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 ("witch's milk")

recedes several months postpartum

after menopause gradual and progressive involution (lobular atrophy, increased fat, cystic dilatation of ducts)

Physiologic changes
Macromastia
diffuse enlargement of both breasts adolescence or pregnancy exaggerated response to hormonal stimulation Pubertal (Virginal) Macromastia

1669 - 23-year-old woman - breasts enlarged "overnight" to a combined weight of 104 pounds
Pregnancy

1 in 100,000 pregnancies - erythematous, edematous, painful

Developmental abnormalities
Aplasia and hypoplasia
uncommon associated with overdevelopment of the contralateral breast acquired (irradiation chest wall tumors)

unilateral or bilateral amastia (absence of a nipple, breast ducts, pectoralis major muscle) sex-linked recessive inheritance

Developmental abnormalities
Ectopic breast
supernumerary breast (from ectopic breast tissue along the milk lines (midaxillae normal breasts medial groin and vulva) 1 6 % of adult women, much less often in men unilateral axillary breast tissue

Polythelia
areola and underlying mammary ducts

Aberrant Breast
beyond the usual anatomic extent (no nipple or areola)

Inflammatory and reactive conditions

Fat necrosis
can simulate carcinoma clinically and mammographically history of antecedent trauma, prior surgical intervention)

histiocytes with foamy cytoplasm

lipidfilled cysts

fibrosis, calcifications, egg shell on mammography

Inflammatory and reactive conditions

Hemorrhagic necrosis with coagulopathy
Warfarin treatment shortly after initiation

edema, hemorrhage, necrosis (thrombi in small blood vessels )

protein C deficiency

Breast augmentation
foreign materials (shellac, glazier's putty, spun glass, epoxy resin, beeswax, and shredded silk, silicone)

thinwalled silicone bag capsule disfiguration

Puerperal mastitis
early stages (2nd and 3rd W) of lactation 5% stasis of milk in distended ducts + staphylococci abscess formation (ATB, incision and drainage)

Granulomatous Lobular Mastitis

etiology unknown, suggests carcinoma

Mammary duct ectasia

periductal inflammation, duct sclerosis intermittent nipple discharge

Tuberculosis
less developed regions - serious condition lactating breast, innoculation via the lactiferous ducts slowly growing, 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

changes

extremely common (58% F)

Benign proliferative lesions

Adenosis
elongation of the terminal ductules of the lobule caricature

sclerosing adenosis
apocrine adenosis

tubular adenosis
nonpalpable lesion, recognized in mammograms microcalcifications!

Benign tumors
Fibroadenoma
proliferation of epithelial and stromal elements most common breast tumor in adolescent and young adult women (peak age = third decade) higher incidence in black patients

well-circumscribed, freely movable, nonpainful mass

regress with age if left untreated ducts distorted elongated slit-like structures intracanalicular pattern, ducts not compressed pericanalicular growth pattern (little practical value)

Tubular adenoma
far less common than fibroadenomas young women, discrete, freely movable masses

uniform sized ducts

Lactating Adenoma
enlarging masses during lactation or pregnancy prominent secretory change

Intraductal papilloma
in the mammary ducts, subareolar lactiferous ducts periductal inflammation, duct sclerosis serous or bloody nipple discharge fibrosis, infarction, squamous metaplasia

Cystosarcoma phyllodes (phyllodes tumor)

initial description - over 150 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
low grade

metastases are hematogenous

high grade

Proliferative changes
ductal and lobular hyperplasia

atypical ductal and lobular hyperplasia higher risk for the cancer than "normal" population
associated w. microcalcifications (!mammography!) incidental histological finding atypical hyperplasia = precancerous lesion

Breast carcinoma
most frequent malignant tumor in females (followed by cervix and colon)
highest incidence developed countries

(USA 84,8/100 000F/Y, Western Europe 64,7/100 000F/Y)

2nd killer among cancers (1st = lung ca)

risk factors: 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

IN SITU
INVASIVE

DUCTAL
LOBULAR

Ductal in situ (intraductal) Lobular in situ

Ductal invasive
+ other types (12) Lobular invasive

Carcinoma in situ
preinvasive - does not form a palpable tumor not detected clinically (only X-ray screening !!!)

multicentricity and bilaterality (namely LCIS)

continuum: bland hyperplasia - increasing atypism carcinoma in situ no metastatic spread (basement membrane) risk of invasion depending on grade

Invasive carcinoma
Invasive ductal carcinoma
largest group (65 to 80 % of mammary carcinomas) mid to late fifties

stellate, white, firm (desmoplasia)

less often circumscribed, soft (medullary ca) hormonally dependent (estrogen, progesterone)

Invasive lobular carcinoma

uniform cells, infiltrative growth (linear arrangement indian file pattern)

Invasive carcinoma
other types: tubular, mucinous, medullary, inflammatory together about 10 % of breast ca metastases: regional lymph nodes (axillary, parasternal), lungs, liver, bone marrow, brain treatment: surgery (radical mastectomy, breast conserving surgery lumpectomy), radiotherapy antihormonal therapy (Tamoxifen) chemotherapy

Pagets disease of the nipple

result of intraepithelial spread of intraductal carcinoma large pale-staining cells within the epidermis of the nipple limited to the nipple or extend to the areola

pain or itching, scaling and redness, mistaken for eczema

ulceration, crusting, and serous or bloody discharge

Pathology of the male breast

Gynecomastia
most common clinical and pathologic abnormality of the male breast increase in subareolar tissue in 30 to 40 percent of adult males, both breasts are affected in many cases associated with 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)

Carcinoma of the male breast

uncommon < 1 % of all breast cancers