Diseases of the breast

22,274 views

Published on

0 Comments
40 Likes
Statistics
Notes
  • Be the first to comment

No Downloads
Views
Total views
22,274
On SlideShare
0
From Embeds
0
Number of Embeds
52
Actions
Shares
0
Downloads
4,439
Comments
0
Likes
40
Embeds 0
No embeds

No notes for slide
  • Know the 2 major arteries (lateral and internal thoracic) and three lymph node groups which supply the breast.
  • Know the 2 major arteries (lateral and internal thoracic) and three lymph node groups (axillary, internal thoracic (mammary) and supraclavicular) which supply the breast.
  • Confusion between lobe, lobule, acini, alveolus, and duct is rampant in clinical medicine, but should never be confusing for you.
  • Ther are an average of about 10 LOBES per breast. The suspensory ligament separates lobes.
  • A lobule is part of a lobe composed of many acini. Lobules are separated from each other by bands of connective tissue.
  • Acini are also known as alveoli.
  • Active
  • Pregnancy/Lactation
  • Atrophic, i.e., post menopausal
  • Breast tissue that is ~90% glandular and/or looks like “thyoid”, i.e., filled with milk, are lactating breasts
  • Breast tissue ALWAYS extends to the axilla, and when it does form an actual protuberance, it can be called an accessory breast. Breasts are modified apocrine sweat glands embryologically.
  • Nipple retraction can be congenital or acquired, when acquired, it represents suspicion for underlying fibrosis due to neoplasm or inpflammation.
  • Macromastia.
  • Atrophy is a NORMAL feature of postmenopausal breasts (estrogen withdrawal).
  • Stroma>>>>>glands in atrophy, but lobules and acini are still present architecturally.
  • All 4 of the classical signs of inflammation, heat redness, swelling, pain. What the the fifth?
  • Intraductal and periductal inflammatory cells, mostly neutrophils in acute mastitis.
  • Pap smear of nipple exudate in acute mastitis. What are most of these cells?
  • Inflammatory carcinoma with its classic peau d’orange appearance.
  • The tumor cells are INSIDE the skin dermal lymphatic spaces.
  • Most of the inflammation here is PERI- ductal rather than INTRA- ductal. Acute or chronic? Why? Ans: Lymphocytes.
  • Ductesia means dilated ducts.
  • Dilated ducts are the same as cysts.
  • Classic cheesy appearance of fat in fat necrosis. Fat necrosis is usually due to mechanical trauma, surgical or otherwise.
  • Giant cells and hemosiderin are usually easily found in fat necrosis.
  • What is the principal inflammatory cell here? Ans: Lymphocyte.
  • The appearance is 100% exemplary of the diagnosis.
  • “ Fibrocystic disease” is the waste basket term for benign breast disease characterized by fibrosis, cysts, inflammation, and a host of other benign changes. Certain features such as hyperplasia and papillomatosis, put it in a somewhat higher risk category for future carcinoma.
  • Breast cyst, filled with fluid, in the pathology lab.
  • Breast cyst, filled with fluid, in the ultrasound lab.
  • This image speaks for itself.
  • Adenosis is defined as an increased number of acini per lobule.
  • Hence the name, “fibrocystic” disease.
  • “ Benign” hyperplasia is characterized by, NO necrosis, the presence of MYOEPITHELIAL cells, and NO ATYPIA.
  • Sclerosing adenosis is often confused with malignancy. Why? Ans: the “sclerosis” can be mistaken for desmoplasia.
  • VERy very very scary, but 100% benign, lesion.
  • Note the myoepithelial cell. The presence of myoepithelial cells, means, BENIGN!!!
  • Our old friend the papillopma, i.e., a fingerlike proliferation of epithelium, growing over a fibrovascular core.
  • Number 1 commandment in pathology: NEVER diagnosis a malignant papilloma on a frozen section!!!!! NEVER.
  • The asterisked items, are more suspicious than the non-asterisked items. Intraductal NECROSIS is the most suspicious feature of all.
  • Note the INTRADUCTAL NECROSIS.
  • Note the atypia, “swiss cheese” hyperplasia, and early necrosis.
  • Note the extreme artypia.
  • Microcalcifications, seen on mammograms, are often the result of necrotic intraductal crud which has calcified.
  • This type of calcification represents about a 20% chance of malignancy and should be biopsied. This device helps pathologists to sample the areas of greatest concern more heavily.
  • A whole lobule filled with monotono0us cells of the same type can be called LCIS, or lobular carcinoma in situ.
  • A whole lobule filled with monotono0us cells of the same type can be called LCIS, or lobular carcinoma in situ.
  • HER2 is a proto-oncogene located at the long arm of human chromosome 17(17q11.2-q12). Approximately 25-30 percent of breast cancers have an amplification of the HER2/neu gene or overexpression of its protein product. Overexpression of this receptor in breast cancer is associated with increased disease recurrence and worse prognosis. Because of its prognostic role as well as its ability to predict response to trastuzumab , breast tumors are routinely checked for overexpression of HER2/neu. Overexpression also occurs in other cancer such as ovarian cancer and stomach cancer.
  • 90% of infiltrating breast carcinomas are simply called “Infiltrating Ductal Carcinoma” on the pathology report.
  • The “tubular” pattern is somewhat better in behavior.
  • The mucinous variant is also somewhat better in behavior.
  • The medullary variant (i.e., lots of immune calls or lymphocytes) is also somewhat better in behavior.
  • Note that no matter how big a male’s breasts may get, they should never for m lobules, but just end as blunt ducts.
  • Diseases of the breast

    1. 1. BREAST www.freelivedoctor.com
    2. 2. www.freelivedoctor.com
    3. 3. LYMPHATIC DRAINAGE AXILLARY (MOSTLY) INTERNAL MAMMARY SUPRACLAVICULAR www.freelivedoctor.com
    4. 4. HISTOLOGY <ul><li>LOBE: (10 in whole breast) </li></ul><ul><li>LOBULE: (many per lobe) </li></ul><ul><li>ACINUS/I, aka ALVEOLUS/I: (many per lobule) </li></ul><ul><li>DUCT(S): INTRA- or INTER- LOB(UL)AR, leading to the lactiferous ducts in the nipple </li></ul>www.freelivedoctor.com
    5. 5. LOBE www.freelivedoctor.com
    6. 6. LOBULE www.freelivedoctor.com
    7. 7. www.freelivedoctor.com
    8. 8. THREE NORMALPHASES <ul><li>ACTIVE: about 50-50 Gland/Stroma ratio </li></ul><ul><li>LACTATING: Mostly Glands (like thyroid!!!), >>>50/50 </li></ul><ul><li>ATROPHIC: mostly stroma, <<<50/50 </li></ul>www.freelivedoctor.com
    9. 9. www.freelivedoctor.com
    10. 10. www.freelivedoctor.com
    11. 11. www.freelivedoctor.com
    12. 12. www.freelivedoctor.com
    13. 13. The most important thing to understand breast pathology is to get a solid IMAGE of the “NORMAL” breast lobule----ACINI, STROMA, BOUNDARIES www.freelivedoctor.com
    14. 14. BREAST PATHOLOGY <ul><li>DEVELOPMENTAL: </li></ul><ul><li>DEGENERATION: </li></ul><ul><li>INFLAMMATION: </li></ul><ul><li>NEOPLASM: </li></ul>www.freelivedoctor.com
    15. 15. DEVELOPMENTAL <ul><li>MILKLINE REMNANTS </li></ul><ul><li>ACCESSORY (axillary) BREAST TISSUE </li></ul><ul><li>NIPPLE INVERSION </li></ul><ul><li>MACROMASTIA </li></ul>www.freelivedoctor.com
    16. 16. ACCESSORY (axillary) BREAST TISSUE www.freelivedoctor.com
    17. 17. 1) CONGENITAL 2) ACQUIRED: CARCINOMA 3) ACQUIRED: PIERCING www.freelivedoctor.com
    18. 18. www.freelivedoctor.com Macromastia.
    19. 19. DEGENERATION <ul><li>ATROPHY </li></ul>www.freelivedoctor.com
    20. 20. www.freelivedoctor.com
    21. 21. INFLAMMATION <ul><li>PERIDUCTAL </li></ul><ul><li>DUCT-ECTASIA </li></ul><ul><li>FAT NECROSIS, usually trauma </li></ul><ul><li>LYMPHOCYTIC, i.e., diabetic </li></ul><ul><li>GRANULOMATOUS, sarcoid, TB, etc., but mostly idiopathic </li></ul><ul><li>ACUTE, staph most common </li></ul>www.freelivedoctor.com
    22. 22. ACUTE MASITIS www.freelivedoctor.com
    23. 23. www.freelivedoctor.com Intraductal and periductal inflammatory cells, mostly neutrophils in acute mastitis.
    24. 24. www.freelivedoctor.com Pap smear of nipple exudate in acute mastitis. What are most of these cells?
    25. 25. INFLAMMATION? Peau d’orange www.freelivedoctor.com
    26. 26. www.freelivedoctor.com The tumor cells are INSIDE the skin dermal lymphatic spaces.
    27. 27. PERIDUCTAL INFLAMMATION www.freelivedoctor.com
    28. 28. DUCTESIA www.freelivedoctor.com
    29. 29. Ductesia  CYSTS www.freelivedoctor.com
    30. 30. CUBOIDAL  COLUMNAR  RED COLUMNAR  i.e. “APOCRINE” www.freelivedoctor.com
    31. 31. FAT NECROSIS www.freelivedoctor.com
    32. 32. FAT NECROSIS www.freelivedoctor.com
    33. 33. LYMPHOYCYTIC MASTITIS (DIABETIC MASTOPATHY ) www.freelivedoctor.com
    34. 34. GRANULOMATOUS MASTITIS www.freelivedoctor.com
    35. 35. NEOPLASIA <ul><li>Benign epithelial </li></ul><ul><li>Benign stromal </li></ul><ul><li>Premalignant </li></ul><ul><li>Malignant epithelial (ductal, lobular) (adenocarcinomas) (in-situ, infiltrating) </li></ul><ul><li>Malignant stromal </li></ul>www.freelivedoctor.com
    36. 36. CLINICAL PRESENTATIONS <ul><li>MASS, palpable or mammographic </li></ul><ul><li>NIPPLE DISCHARGE </li></ul><ul><li>PAIN </li></ul>www.freelivedoctor.com
    37. 37. NEOPLASIA <ul><li>BENIGN EPITHELIAL , aka, “FIBROCYSTIC” disease </li></ul><ul><ul><li>NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis </li></ul></ul><ul><ul><li>PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma </li></ul></ul><ul><ul><li>ATYPICAL epithelium </li></ul></ul>www.freelivedoctor.com
    38. 38. CYST www.freelivedoctor.com
    39. 39. www.freelivedoctor.com Breast cyst, filled with fluid, in the ultrasound lab.
    40. 40. CYST, GROSS CYST, MICROSCOPIC www.freelivedoctor.com
    41. 41. ADENOSIS www.freelivedoctor.com
    42. 42. FIBROSIS + CYSTS = FIBROCYSTIC DISEASE www.freelivedoctor.com
    43. 43. NEOPLASIA <ul><li>BENIGN EPITHELIAL , aka, “FIBROCYSTIC” disease </li></ul><ul><ul><li>NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis </li></ul></ul><ul><ul><li>PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma </li></ul></ul><ul><ul><li>ATYPICAL epithelium </li></ul></ul>www.freelivedoctor.com
    44. 44. DUCTALHYPERPLASIA www.freelivedoctor.com
    45. 45. “ SCLEROSING” ADENOSIS www.freelivedoctor.com
    46. 46. “ COMPLEX” SCLEROSING ADENOSIS (RADIAL SCAR) www.freelivedoctor.com
    47. 47. SCLEROSING ADENOSIS www.freelivedoctor.com
    48. 48. 1) EXTREMELY WELL DEFINED 2) YOUNGER WOMEN 3) ALWAYS BENIGN 4) CAN FIBROSE OR CALCIFY WITH AGE www.freelivedoctor.com FIBROADENOMA:
    49. 49. PAPILLOMA www.freelivedoctor.com
    50. 50. PAPILLOMA www.freelivedoctor.com
    51. 51. PAPILLOMA www.freelivedoctor.com
    52. 52. NEOPLASIA <ul><li>BENIGN EPITHELIAL , aka, “FIBROCYSTIC” disease </li></ul><ul><ul><li>NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis </li></ul></ul><ul><ul><li>PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma </li></ul></ul><ul><ul><li>ATYPICAL epithelium </li></ul></ul>www.freelivedoctor.com
    53. 53. FEATURES OF “ATYPIA” <ul><li>LOSS OF STROMA BETWEEN ACINI </li></ul><ul><li>“ SWISS CHEESE” HYPERPLASIA* </li></ul><ul><li>CRIBRIFORMING** </li></ul><ul><li>CELLULAR PLEOMORPHISM </li></ul><ul><li>CELLULAR HYPERCHROMASIA </li></ul><ul><li>INCREASED/ABNORMAL MITOSES* </li></ul><ul><li>“ ROMAN” BRIDGES*** </li></ul><ul><li>NECROSIS*** (“COMEDO-carcinoma ”) </li></ul>www.freelivedoctor.com
    54. 54. NORMAL DUCT NORMAL ACINUS ATYPICAL HYPERPLASIA of DUCT ATYPICAL HYPERPLASIA, LOBULE www.freelivedoctor.com
    55. 55. DCIS www.freelivedoctor.com
    56. 56. DCIS www.freelivedoctor.com
    57. 57. DCIS www.freelivedoctor.com
    58. 58. DCIS, microcalcifications www.freelivedoctor.com Microcalcifications, seen on mammograms, are often the result of necrotic intraductal crud which has calcified.
    59. 59. DCIS, microcalcifications www.freelivedoctor.com
    60. 60. NORMAL lobule www.freelivedoctor.com
    61. 61. www.freelivedoctor.com A whole lobule filled with monotono0us cells of the same type can be called LCIS, or lobular carcinoma in situ.
    62. 62. LCIS www.freelivedoctor.com
    63. 63. LCIS <ul><li>Usually hangs around MANY MANY years before it infiltrates, in contrast to DCIS </li></ul><ul><li>The BEST management may be judicious neglect, i.e., observation </li></ul><ul><li>If it does infiltrate, however, it is at least as bad as DCIS infiltrating, or probably WORSE, showing “indian” files </li></ul>www.freelivedoctor.com
    64. 64. BREAST CANCER RISK FACTORS <ul><li>Age </li></ul><ul><li>Menarche Age, early menarche is a risk </li></ul><ul><li>First Live Birth </li></ul><ul><li>First-Degree Relatives with Breast Cancer </li></ul><ul><li>Breast Biopsies </li></ul><ul><li>Race </li></ul><ul><li>Estrogen Exposure </li></ul><ul><li>Radiation Exposure </li></ul><ul><li>Carcinoma of the Contralateral Breast or Endometrium </li></ul><ul><li>Geographic Influence </li></ul><ul><li>Diet </li></ul><ul><li>Obesity </li></ul><ul><li>Exercise </li></ul><ul><li>Breast-Feeding, less breast feeding is a risk </li></ul><ul><li>Environmental Toxins </li></ul><ul><li>Tobacco </li></ul><ul><li>ABORTIONS? </li></ul>www.freelivedoctor.com
    65. 65. BREAST CANCER PROGNOSTIC FACTORS <ul><li>AGE </li></ul><ul><li>GENERAL HEALTH and IMMUNITY </li></ul><ul><li>Histologic degree of differentiation, i.e., GRADING </li></ul><ul><li>ERA/(PRA) </li></ul><ul><li>Her2, aka Her2-Neu </li></ul><ul><li>STAGING, especially POS or NEG lymph nodes, TNM, etc. </li></ul>www.freelivedoctor.com
    66. 66. STAGING, TNM, based on biologic behavior <ul><li>IN-SITU </li></ul><ul><li>EARLY disruption of the basal lamina, i.e., basement membrane </li></ul><ul><li>STROMAL infiltration </li></ul><ul><li>LYMPHATIC vessels </li></ul><ul><li>SENTINAL lymph node metastasis </li></ul><ul><li>MORE lymph node metastases </li></ul><ul><li>Adjacent structures, skin, ie, “inflammatory” </li></ul><ul><li>DISTANT, METASTASES, LIVER, BONE, LUNGS, BRAIN, EVERYWHERE </li></ul>www.freelivedoctor.com
    67. 67. www.freelivedoctor.com Total Cancers Per Cent In Situ Carcinoma 15–30 Ductal carcinoma in situ, DCIS 80 Lobular carcinoma in situ, LCIS 20 Invasive Carcinoma 70–85 No special type carcinoma (&quot;ductal&quot;) 79 Lobular carcinoma 10 Tubular/cribriform carcinoma (Better prognosis than average) 6 Mucinous (colloid) carcinoma (Better prognosis than average) 2 Medullary carcinoma (Better prognosis than average) 2 Papillary carcinoma 1 Metaplastic carcinoma, (Squamous)
    68. 68. HISTOLOGIC TIDBITS <ul><li>INFILTRATING DUCTAL </li></ul><ul><li>INFILTRATING LOBULAR (INDIAN FILE) </li></ul><ul><li>TUBULAR (LOOKS LIKE SCLEROSIS, BUT NO BASEMENT MEMBRANE) </li></ul><ul><li>MUCINOUS (COLLOID) </li></ul><ul><li>MEDULLARY (LOTS of LYMPHOCYTES) </li></ul>www.freelivedoctor.com
    69. 69. INFILTRATING DUCTALCARCINOMA www.freelivedoctor.com
    70. 70. INFILTRATING LOBULAR CA.,INDIAN” FILE PATTERN www.freelivedoctor.com
    71. 71. INFILTRATING DUCTAL CA., “TUBULAR” PATTERN or TYPE www.freelivedoctor.com
    72. 72. INFILTRATING DUCTAL CA., MUCINOUS (COLLOID) PATTERN or TYPE www.freelivedoctor.com
    73. 73. INFILTRATING DUCTAL CA., MEDULLARY PATTERN or TYPE www.freelivedoctor.com
    74. 74. NEOPLASIA, <ul><li>STROMAL </li></ul><ul><li>Cysto-”SARCOMA” PHYLLODES </li></ul><ul><li>(aka, PHYLLODES TUMOR), </li></ul><ul><li>Looks like a giant fibroadenoma, really NOT a sarcoma </li></ul><ul><li>SARCOMAS, true, are RARE!!!! </li></ul>www.freelivedoctor.com
    75. 75. FIBROADENOMA www.freelivedoctor.com
    76. 76. MALE BREAST <ul><li>GYNECOMASTIA (related to hyperestrogenism) </li></ul><ul><li>CARCINOMA (1% of ♀ ) </li></ul>www.freelivedoctor.com
    77. 77. GYNECOMASTIA (NO lobules) www.freelivedoctor.com

    ×