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Breast
 

Breast

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    Breast Breast Presentation Transcript

    • 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
      • a t birth male and female breasts
      • active secretion ( transplacental passage of maternal hormones ) bilateral breast enlargement
      • colostrum - like secretion ( "witch's milk" )
      • recedes several months postpartu m
      • 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
      • s upernumerary b reast ( 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
      • Po lythelia
      • 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
      • lipid–filled 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 )
      • thin–walled silicone bag – capsule – disfigur ation
      • Puerperal mastitis
      • early stages (2 nd and 3 rd 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 caricature of the lobule
      • 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
      • metastases are hematogenous
      low grade 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)
      • 2 nd killer among cancers (1 st = lung ca)
      • risk factors: genetic predisposition (breast ca in close (1 st 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 Lobular invasive + other types (12)
    • 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
    • Paget‘s 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