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Breast

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  • 1. Pathology of the breast
    • normal anatomy
    • physiologic changes
    • developmental abnormalities
    • inflammations
    • fibrocystic changes
    • tumors
      • benign
      • malignant
    • pathology of the male breast
  • 2. 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
  • 3. 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)
  • 4. 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
  • 5. 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
  • 6. 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 )
  • 7. 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
  • 8. 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
  • 9.
    • 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
  • 10. 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)
  • 11. 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 !
  • 12. 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)
  • 13.
    • 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
  • 14. 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
  • 15. 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
  • 16. 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
  • 17. Breast carcinoma - classification
    • IN SITU
    • INVASIVE
    • DUCTAL
    • LOBULAR
    Ductal in situ (intraductal) Lobular in situ Ductal invasive Lobular invasive + other types (12)
  • 18. 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
  • 19. 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)
  • 20. 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
  • 21. 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
  • 22. 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

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