Pathology of the breast

normal anatomy

physiologic changes developmental abnormalities inflammations fibrocystic changes tumors benign malignant pathology of the male breast

Normal anatomy
before puberty breasts in both sexes ducts variable degrees of branching, lack lobules 15 to 25 lactiferous ducts start in the nipple branch terminal ductal lobular unit (intralobular duct, multiple lobular ducts, ductules or acini + intralobular connective tissue hormonally responsive

Physiologic changes
at birth male and female breasts active secretion (transplacental passage of maternal hormones bilateral breast enlargement colostrum!like secretion ("#itch$s milk" recedes several months postpartum after menopause gradual and progressive involution (lobular atrophy, increased fat, cystic dilatation of ducts

Physiologic changes
%acromastia
diffuse enlargement of both breasts adolescence or pregnancy exaggerated response to hormonal stimulation &ubertal ('irginal %acromastia 1669 - 23-year-old woman - breasts enlarged "overnight" to a combined weight of 104 pounds &regnancy 1 in 1((,((( pregnancies ! erythematous, edematous, painful

Developmental abnormalities
)plasia and hypoplasia
uncommon associated #ith overdevelopment of the contralateral breast ac*uired (irradiation chest #all tumors unilateral or bilateral amastia (absence of a nipple, breast ducts, pectoralis ma+or muscle sex!linked recessive inheritance

Developmental abnormalities
,ctopic breast
supernumerary breast (from ectopic breast tissue along the milk lines (midaxillae normal breasts medial groin and vulva 1 - . of adult #omen, much less often in men unilateral axillary breast tissue

&olythelia
areola and underlying mammary ducts

)berrant /reast
beyond the usual anatomic extent (no nipple or areola

Inflammatory and reactive conditions

0at necrosis
can simulate carcinoma clinically mammographically and

history of antecedent trauma, prior surgical intervention histiocytes #ith foamy cytoplasm lipidfilled cysts fibrosis, calcifications, egg shell on mammography

Inflammatory and reactive conditions

1emorrhagic necrosis #ith coagulopathy
2arfarin treatment shortly after initiation edema, hemorrhage, necrosis (thrombi in small blood vessels protein 3 deficiency

/reast augmentation
foreign materials (shellac, gla4ier$s putty, spun glass, epoxy resin, bees#ax, and shredded silk, silicone thin#alled silicone bag capsule disfiguration

&uerperal mastitis
early stages (2nd and 5rd 2 of lactation 5. stasis of milk in distended ducts + staphylococci abscess formation ()6/, incision and drainage

7ranulomatous 8obular %astitis

etiology unkno#n, suggests carcinoma

%ammary duct ectasia

periductal inflammation, duct sclerosis intermittent nipple discharge

6uberculosis
less developed regions ! serious condition lactating breast, innoculation via the lactiferous ducts slo#ly gro#ing, solitary, painless mass

Benign proliferative lesions

pathologic spectrum of seemingly related clinically benign breast abnormalities palpably irregular and painful breasts discrete lumps, multiple nodules, cystically dilated ducts, apocrine metaplasia, interlobular and intralobular fibrosis intraductal epithelial proliferation fibrocystic disease, fibrocystic extremely common (59. 0

changes

Benign proliferative lesions

)denosis
elongation of the terminal ductules caricature of the lobule sclerosing adenosis apocrine adenosis tubular adenosis nonpalpable lesion, recogni4ed in mammograms microcalcifications:

Benign tumors
0ibroadenoma
proliferation of epithelial and stromal elements most common breast tumor in adolescent and young adult #omen (peak age ; third decade higher incidence in black patients #ell!circumscribed, freely movable, nonpainful mass regress #ith age if left untreated ducts distorted elongated slit!like structures ! intracanalicular pattern, ducts not compressed

6ubular adenoma
far less common than fibroadenomas young #omen, discrete, freely movable masses uniform si4ed ducts

8actating )denoma
enlarging masses during lactation or pregnancy prominent secretory change

<ntraductal papilloma
in the mammary ducts, subareolar lactiferous ducts periductal inflammation, duct sclerosis serous or bloody nipple discharge fibrosis, infarction, s*uamous metaplasia

Cystosarcoma phyllodes (phyllodes tumor)

initial description ! over 15( years ago ! fleshy tumor, leaf!like pattern and cysts on cut surface circumscribed, connective tissue and epithelial elements (= fibroadenomas ; greater connective tissue cellularity , 1!15 cm less than 1 . of breast tumors benign, malignant
lo# grade high grade

metastases are hematogenous

Proliferative changes
ductal and lobular hyperplasia atypical ductal and lobular hyperplasia higher risk for the cancer than "normal" population associated #> microcalcifications (:mammography: incidental histological finding atypical hyperplasia ; precancerous lesion

Breast carcinoma
most fre*uent malignant tumor in females (follo#ed by cervix and colon highest incidence developed countries (?@) 9A,9B1(( (((0BC, 2estern ,urope -A,DB1(( (((0BC 2nd killer among cancers (1st ; lung ca risk factorsE genetic predisposition (breast ca in close (1st degree relatives , proliferative changes, early menarche, late menopause, history of ca (breast, ovary, endometrium importance of preventive controls: early diagnosis better prognosis

Breast carcinoma - classification

<F @<6? <F')@<', G?36)8 8H/?8)I

Guctal in situ (intraductal 8obular in situ Guctal invasive 8obular invasive + other types (12

Carcinoma in situ
preinvasive ! does not form a palpable tumor not detected clinically (only J!ray screening ::: multicentricity and bilaterality (namely 83<@ continuumE bland hyperplasia - increasing atypism carcinoma in situ no metastatic spread (basement membrane risk of invasion depending on grade

Invasive carcinoma
<nvasive ductal carcinoma
largest group (-5 to 9( . of mammary carcinomas mid to late fifties stellate, #hite, firm (desmoplasia less often circumscribed, soft (medullary ca hormonally dependent (estrogen, progesterone

<nvasive lobular carcinoma

uniform cells, infiltrative gro#th (linear arrangement ! indian file pattern

Invasive carcinoma
other typesE tubular, mucinous, medullary, inflammatory together about 1( . of breast ca metastasesE regional lymph nodes (axillary, parasternal , lungs, liver, bone marro#, brain treatmentE surgery (radical mastectomy, breast conserving surgery lumpectomy , radiotherapy antihormonal therapy (6amoxifen chemotherapy

Pagets disease of the nipple

result of intraepithelial spread of intraductal carcinoma large pale!staining cells #ithin the epidermis of the nipple limited to the nipple or extend to the areola pain or itching, scaling and redness, mistaken for ec4ema ulceration, crusting, and serous or bloody discharge

Pathology of the male breast

7ynecomastia
most common clinical and pathologic abnormality of the male breast increase in subareolar tissue in 5( to A( percent of adult males, both breasts are affected in many cases associated #ith hyperthyroidism, cirrhosis of the liver, chronic renal
failure, chronic pulmonary disease, and hypogonadism, use of hormones ! estrogens, androgens, and other drugs (digitalis, cimetidine, spironolactone, marihuana, and tricyclic antidepressants

3arcinoma of the male breast

uncommon K 1 . of all breast cancers