The document provides information on common breast problems and their evaluation and diagnosis. It discusses: 1. The most common breast problems women present with are breast pain, nipple discharge, and palpable masses. Evaluation involves a triple assessment using clinical exam, radiology like mammography and ultrasound, and pathology with biopsies. 2. Common benign breast conditions include cysts, fibroadenomas, mastitis, and duct ectasia. Mastitis typically occurs in lactating women while duct ectasia often presents with nipple discharge. 3. Evaluation of breast masses, pain, or discharge involves history, physical exam, imaging like mammography and ultrasound, and pathology through biopsy when needed to arrive at a

1. Breast Tissue Disorders
Gynecology
What Nourishes Me, Also Destroys Me.
Angelina Jolie

2. Interesting Fact:
Do you know that as a fetus in your mums
womb and as newborn you were producing
colostrum. And this is not only in females,
but even males!
Weird ha!

3. Group 2:
1. Abdihakem Muh’ed Abdi.
2. Abdirrahman Mumin Hussain.
3. Abshir Osman Yusuf.
4. Bushra Abdillahi Issa.
5. Khaled Abduaziz Hussain.
6. Suleman Abdurrahman Warsama.

4. Introduction
● Breast problems are a major reason why women visit the
primary care physician
● Breast diseases in women constitute a spectrum of benign
and malignant disorders.
● The most common breast problems for which women consult a physician
are breast pain, nipple discharge and a palpable mass.

5. Anatomy
● The breast is a specialized accessory gland with a mass of glandular, fatty
and fibrous tissues on the pectoralis muscles in the chest wall.
● It is attached to the chest wall by fibrous strands called coopers
ligaments.
● The base of breast extends from 2nd - 6th rib and from the lateral margin of
sternum to the mid axillary line.
● The glandular tissues of the breast consist of lobules, lobes and ducts
● Fatty and fibrous tissues surround the milk producing system (lobules
and ducts).
● Each breast consists of 15 - 20 lobes, which radiate out from the nipple.

7. ● Major hormones responsible for breast
development are estrogen,
progesterone and prolactin.
● The blood supply is through the internal
mammary artery, axillary artery, and
intercostal artery
● Venous drainage is through the Internal
mammary vein, axillary vein and
intercostal veins.

8. ● Lymphatic drainage
○ Majorly to the Axillary nodes
○ Inter mammary and the supraclavicular lymph
nodes (parasternal and medial)
● Three Lymph Node Levels
○ Axillary lymph nodes defined by pectoralis
muscle
■ Level I Lateral and inferior to Pectoralis
Minor
■ Level II Pectoralis – Deep to pectoralis
minor
■ Level III – Medial to Pectoralis Minor
Rotter’s Nodes – Between Pectoralis
Minor & Major
● Nerves
○ Long thoracic nerve – Serratus Anterior M.
○ Thoracodorsal N – Lattisimus Dorsi
○ Intercostobrachial nerves – Sensory to medial
arm and axilla

9. Diagnostic Evaluation of
Breast Diseases

10. Diagnosing Breast Pathology
● Triple Assessment maximises sensitivity of diagnosis:
○ Clinical - history and examination 50-85%
○ Radiology – MMG +/- USS 90%
○ Pathology – FNA or core biopsy 91%
● Sensitivity of triple assessment 99.6% and specificity 93%
● Triple Assessment is positive if any of above is positive but negative when all three
negative.
● Aims:
■ Maximise diagnostic accuracy in breast cancer
■ Maximise preoperative diagnosis in breast cancer
■ Minimise excisional biopsies for diagnosis
■ Minimise proportion of benign excision biopsies for diagnosis

11. History
● Presenting symptoms:
○ Pain
○ Lump
○ Nipple discharge
○ Diffuse swelling
● Onset.
● Age.
● Family history (Cancer).
● Duration.
● Frequency.
● Lump , Nodules Trauma.
● Menstruation (menarche, menopause, contraceptives).

12. Examination
● Both breasts.
● Inspection –
○ sitting, arms either above head or on hips tensing pectoralis
○ size, asymmetry, skin dimpling, nipple retraction, inversion, or excoriation (Paget’s), visible
lumps or ulceration, peau d’orange.
○ Nipples: size and shape, direction of pointing, any rash or ulceration, any discharge.
● Palpation - sitting and supine
○ Features of breast cancer: solitary, hard, irregular, immobile and nontender.
○ Lymph node evaluation axillary, supraclavicular.
● General examination including abdomen.

17. Evaluation
a. Radiology:
I. Mammography (Screening):
■ Uses low dose of radiation (0.1 rad), not proven to escalate breast CA
■ Complementary study, can not replace biopsy
■ (+) fine stippling of calcium – suggestive of CA.
■ Annual after the age of 40.
■ Estimated reduction in mortality 15-25%
■ Cardinal features of malignancy
● Mass – spiculated, irregular margins
● Architectural distortion
● Microcalcification with casting or irregularity
● Clustered polymorphic calciification most common finding
● Asymmetry.
■ Sens 63-95% (95% in palpable lesions), Spec 14-90%.

19. II. Ultrasound:
○ Characterize mammographic abnormality.
○ Reliable assessment of tumor size.
○ Particularly useful in dense breasts.
○ First line for a palpable lesion in young pts.
○ Differentiate solid from cystic.
○ Sens 68-97% Spec 74-94%

20. III. MRI:
■ Sens 88-99% Spec 67-94%
■ Specific advantages
■ May detect lobular ca where other radiology is benign
■ Sensitive for multifocal disease
■ Investigation of pts with implants
IV. Nuclear Medicine:
■ Must detect routinely at masses < 10mm.

21. b. Pathology:
I. Fine Needle Aspiration:
■ Cytological diagnosis
■ Can determine hormone receptor status
■ Indications:
● Palpable lesions – done in clinic
● Cystic lesions
● Core biopsy not available
● Impalpable lesions via USS or MMG localization
II. Core Biopsy:
■ Histological diagnosis
■ True cut – large bore needle
■ 14G needle on a spring loaded biopsy gun, core samples under LA
■ Obtain 4-6 cores

22. ■ Indications of core biopsy:
● Calcification on MMG particularly without mass lesion
● Inconclusive FNA (atypical or suspicious)
● Discrepancy between FNA and clinical / radiological features
III. Open Biopsy:
■ Gold Standard.
■ Indications:
● Cytological or histological diagnosis not obtained and still strong
clinical suspicion.
● Result of core biopsy is not consistent with radiological appearance.
● Radial scar - should be localized and excised no matter what
cytology or core results because of a real association with
malignancy.

23. Screening
● 3 components to screening:
○ Breast Self Exam
■ Every month 20 yrs old or older
○ Clinical Breast Exam
■ Detects 3%-45% missed by mammography
■ Sensitivity/specificity are 54% and 94% respectively
■ Every 3 yrs for 20-39 yrs old
■ Every year for 39 and older
○ Screening Mammography
■ Every year >40 yrs old.

24. Classification Based on Clinical Features
● Mastalgia
○ Cyclic
○ Non Cyclic
● Tumors and Masses
○ Nodularity or glandular
○ Cysts
○ Galactoceles
○ Fibroadenoma
○ Sclerosing Adenosis
○ Lipoma
○ Harmatoma
○ Diabetic Mastopathy
○ Cystosarcoma Phylloides
● Nipple discharge
○ Duct ectasia
○ Fibrocystic disease
○ Duct papilloma
○ Galactorrhea
● Breast infections and Inflammation
○ Postpartum engorgement
○ Intrinsic mastitis
○ Lactation mastitis
○ Lactation breast abscess
○ Chronic recurrent subareolar abscess
○ Acute mastitis associated with macrocystic
breasts
○ Extrinsic infections
○ Disease suppurativa.

25. Classification Based on Pathology
● Non Proliferative Lesion
○ Simple Cyst
○ Complex cyst
● Proliferative Lesions – Without Atypia
○ Ductal hyperplasia
○ Fibroadenoma
○ Intraductal papilloma
○ Sclerosing Adenoma
○ Radial Scars
● Atypical Hyperplasia
○ Atypical ductal hyperplasia
○ Atypical lobular hyperplasia

26. 1. Mastalgia
● More common in premenopausal women than in post menopausal women
1. Cyclic Pain ( Physiologic):
■ Usually Bilateral and poorly localized.
■ Occurs in about 60% of premenopausal women except menopausal women on
hormonal replacement therapy.
■ Often described as heaviness , swelling or tenderness that radiates to the arm and
axilla.
■ Associated with menstrual cycle , Most severe before menstruation.
■ Has variable Duration and Resolve spontaneously after menses.
■ Attributed to fibrocystic breast changes.
■ Etiology unknown, thought to be related to Gonadotrophic and ovarian hormones.

27. 2. Non-cyclic:
■ Most common in women 40 to 50 yrs of age.
■ Often unilateral.
■ Usually described as sharp, burning pain localized in the breast.
■ Occasionally secondary to the presence of Fibroadenoma and or cyst.
■ Menstrual irregularity, emotional stress, trauma, MSK, scars from previous biopsies
and medications have been associated.
■ Also can be due to breast size and stretching forces of the fibrous bands.
3. Extramammary pain:
■ Referred pain from sources other than the breasts.
■ In some studies done in primary care and certain breast clinic settings, it has been
found that women presenting with breast pain more often have extramammary
pain rather than true mastalgia.
■ Extramammary pain may be from musculoskeletal sources such as the chest wall,
spinal or paraspinal disorders, trauma, or scarring from prior biopsy.
■ It may also be related to medical problems such as biliary, pulmonary, esophageal,
or cardiac disease.

28. ● Management:
○ Reassurance that it’s not malignancy is important + Physical support.
○ Pharmacological Treatment
■ NSAIDs
■ OCPs
■ Danazol 100- 400mg per day
■ 75% of women with non cyclic pain will be symptom free
■ Tamoxifen 10mg
■ Bromocriptine – prolactin antagonist
○ Surgery has no role in management of breast pain.

29. The Question is:
If a lady tells you she’s experiencing breast pain what’s the first
thing that will come to your mind??

31. 2. Breast Inflammation and Infection
a. Mastitis:
○ Most common in lactating female.
○ Dry, cracked fissured areola/nipple complex
provides portal for infection.
○ Usually caused by Staph/Strep organisms.
○ Rule out malignancy
○ Treat with heat, continued breast feeding,
■ Antibiotics for 10-14 days to cover staph
and strep infections.
b. Abscesses:
○ May present with breast swelling,
tenderness and fever
○ On PE, breast is tender , warm and fluctuant,
may also have purulent discharge.
○ Treated by: surgical drainage + Abx.

32. c. Retromammary Mastitis:
○ It is commonly due to tuberculosis of the intercostal lymph nodes or ribs beneath or
suppuration of the intercostal lymph nodes.
○ Empyema necessitans or infected hematoma in the chest wall cal also is the cause.
○ Presentations: Pain and swelling in the chest wall deep to breast which is nonmobile.
○ Investigations: Hematocrit, ESR, peripheral smear; Chest X-ray; US of breast and chest
wall. But CT scan chest is ideal.
○ Treatment: Cause has to be treated. Drainage through submammary/retromammary
incision is done.

33. d. Mondor’s Disease:
○ Phlebitis of the thoracoepigastric and lateral thoracic vein
○ Palpable, visible, skin retraction over tender extending to chest wall
○ Spontaneous or related to trauma
○ Ultrasound may be helpful in confirming this diagnosis.
○ Treatment self-limited, can use NSAIDs.
○ Mammogram if over 35yo to r/o malignancy.
e. Chronic Subareolar Abscess:
○ Occurs at base of lactiferous duct, and squamous metaplasia of duct may occur.
○ Sinus tract to areola develops.
○ Treatment requires complete excision of sinus tract.
○ Recurrence is common.

34. f. Mastitis Neonatorum:
○ B/L or unilateral enlargement of breasts. In 50%,
swelling is later accompanied by secretion of
creamy fluid similar to colostrum,
which is called ‘Witch’s Milk’.
○ Occurs on the 3rd or 4th day of birth.
○ Response to mothers hormone exposure
(prolactin, estrogen).
○ Resolves spontaneously after 2 weeks when
the estrogen level automatically.
○ Occasionally becomes infected.

35. g. Fat necrosis:
○ Fat necrosis of the breast is a benign condition that most
commonly occurs as the result of breast trauma or
surgical intervention.
○ Fat necrosis can be confused with a malignancy on physical
○ examination and may mimic malignancy on radiologic studies.
○ It is sometimes necessary to biopsy these lesions to confirm the diagnosis, although
experienced radiologists can usually determine that a lesion represents fat necrosis
based on mammographic and ultrasound findings such as oil cysts (collections of
liquefied fat).
○ Once the diagnosis is established, excision is not necessary and there is no increased risk
of subsequent breast cancer.

36. h. Diabetic Mastopathy:
○ Also known as lymphocytic mastitis or lymphocytic mastopathy, is seen occasionally
in premenopausal women who have longstanding type 1 diabetes mellitus.
○ The typical presentation is a nontender suspicious breast mass with a dense
mammographic pattern.
○ Core biopsy is recommended for diagnostic confirmation.
○ Pathology shows dense keloid-like fibrosis and periductal, lobular, or perivascular
lymphocytic infiltration.
○ The pathogenesis is unknown, but it may represent an autoimmune reaction as the
histologic features are similar to those seen in other autoimmune diseases.
○ Once the diagnosis is established, excision is not necessary and there is no
increased risk of subsequent breast cancer.

37. 3. Nipple Discharge:
a. Physiological cause:
○ During pregnancy and lactation.
b.Intraductal Papilloma:
○ Benign growth within ductal system.
○ Presents as a bloody nipple discharge.
○ Excision is the only way to differentiate from carcinoma.
c. Coloured Opalescent Discharge:
○ Wide range of color and consistency.
○ Creamy, purulent, yellow, brown, green and black.
○ No increased cancer risk.
○ Common in late reproductive life.
○ Most common pathology Duct Ectasia.
○ Sometimes due to underling cyst.

38. d. Galactorrhea:
○ Secretion of milk not related to pregnancy or lactation.
○ Stress & mechanical stimulation of breast.
○ Side-effect of drugs that enhances dopamine activity e.g. chlorpromazine,
metoclopromide & methyldopa.
○ Hyperprolactinaemia due to prolactin-secreting tumor or from a secondary
source of bronchogenic carcinoma.
○ It could be due to hypothalamic / pituitary stalk lesions.
○ Obtain prolactin level. If normal, simple reassurance.
○ Stop mechanical stress or ingestion of drugs.
○ Treatment of prolactin-secreting tumor or bronchogenic carcinoma.

39. e. Duct Ectasia / Periductal Mastitis:
○ Dilatation of the breast ducts, which is often associated with periductal inflammation.
○ Etiopathogenesis is obscure , the disease is much more common in smokers.
○ Periductal inflammation is the primary condition.
○ Cl. F: Nipple discharge (of any colour), subareolar mass or abscess, mammary duct fistula
and/or nipple retraction.
○ Mgmt:
■ In the case of a mass or nipple retraction, a carcinoma must be excluded by
obtaining a mammogram and negative histology.
■ Any suspicion remains the mass should be excised.
■ Antibiotic therapy may be tried,
• Co-amoxiclav or flucloxacillin and metronidazole.
■ If single duct is invovled: microdochectomy.

40. ● Evaluation:
○ H&P.
○ Mammography.
○ Galactography.
○ Ultrasound.
○ Ductal Lavage.
○ Fiberoptic ductography.
○ Exfoliative cytology.
● Management:
○ In case of lump- treat according to lump, disregard discharge.
○ No lump present- treat the underlying cause.

42. 4. Breast Masses
a. Cysts:
I. Cystic Breast Mass:
■ Common cause of dominant breast mass.
■ May occur at any age, but uncommon in
postmenopausal women.
■ Fluctuates with menstrual cycle.
■ Well demarcated from the surrounding
tissue.
■ Characteristically firm and mobile.
■ May be tender.
■ Difficult to differentiate from solid mass.
■ FNA is both diagnostic and therapeautic.
■ If it disappears and cytology is benign no
further workup is needed.

43. II. Fibrocystic Breast Disease:
■ Most common of all benign breast disease.
■ It is due to Aberration of Normal Development
and Involution(ANDI) of breast causing
changes in the breast.
■ Most common between ages 20- 50.
■ 50% of women with Fibrocystic changes
have clinical symptoms.
■ 53% have histologic changes.
■ Believed to be associated the Imbalance of
progesterone and estrogen.
■ May present with bilateral cyclic pain, breast
swelling, palpable mass and heaviness.

44. ○ P/E: Ten, Incr engorgement and more dense breast, Incr lumpiness /
glandular, Occasional spontaneous nipple discharge
○ Dx: MMG, USS, FNA (both diagnostic and therapeautic)
○ Tx:
■ pain relieve + comfortable bra,
■ warm/cold compresses,
■ dietary changes i.e limiting caffeine intake.
■ aspiration (If recurrent).

46. b. Fibroadenomas:
○ Most common benign tumor of breast.
○ WHO Definition- Discrete benign tumor
showing evidence of connective tissue
and epithelial proliferation.
○ Histological Variants- Hyper cellularity
or Atypia.
○ Stromal element is the key to classification.
○ Stroma with low cellularity and low
cytology.
○ Clinical Variants- Large size or
Rapid Growth.

47. ● Types of fibroadenomas:
○ Simple:
■ Benign solid tumors containing glandular as well as fibrous tissue .
■ Usually present as well defined, mobile mass.
■ Commonly found in women between the ages of 15 and 35 years.
■ Cause is unknown, thought to be due to hormonal influence.
■ May increase in size during pregnancy or with estrogen therapy.
○ Giant:
■ Fibroadenomas over 10cm in size.
■ Excision is recommended.

48. ○ Juvenile:
■ Variant of fibroadenomas.
■ Found in young women between the ages of 10 -18.
■ Vary in size from 5 - 20cm in diameter. Usually painless, solitary,
unilateral masses.
■ Excision is recommended.
○ Complex:
■ Complex fibroadenomas contain other proliferative changes such as
sclerosing adenosis, duct epithelial Hyperplasia, epithelial calcification.
■ Associated with slightly increased risk of cancer.
● Investigations:
○ Triple assessment.
○ Sonography.
○ Cytology – FNA.

49. ● Management:
○ Overall Conservative.
○ Reassurance
○ Once tissue diagnosis has been obtained patient can be observed
○ Offer exicision
■ if >3cm / rapid increase
■ Symptomatic
■ Patients choice, patients satisfaction.
○ Surgical- If within 3cm of nipple, periareolar incision.
○ Alternative- Laser Ablation, Cryosurgery
○ Hormonal- Tamoxifen. Not favored due to unwanted side effects.

50. c. Phylloides Tumors:
○ Rapidly growing.
○ One in four malignant.
○ One in Ten Metastasize.
○ Create bulky tumors that distort the
breast.
○ May ulcerate through the skin due to
pressure necrosis.
○ Treatment consists of wide excision
unless metastasis has occurred.

51. d. Galactocele:
○ Milk filled cyst from over distension of a lactiferous duct.
○ Presents as a firm non tender mass in the breast,
○ Commonly in upper quadrants beyond areola.
○ Diagnostic aspiration is often curative.
e. Gynecomastia:
○ Benign growth of the glandular tissue of the male breast.
○ Due to an imbalance in the estrogen to androgen activity.
○ May be unilateral or bilateral.
○ Common in infancy, adolescence and adult life.
○ Pseudogynecomastia may be seen obese individuals.
○ Causes include; drugs, chronic dxs, metabolic, pubertal,
○ Hormonal, tumors, idiopathic, hypogonadism.
○ TX: stop any meds, tx underlying cause, pharmacotherapy i.e androgens, surgery.

53. Breast Carcinoma
If you ever watched a
horror movie then this
is one of them!!

54. Introduction
● Globally, breast cancer is the second most frequently diagnosed
malignancy just behind lung cancer, accounting for over two million cases
each year.
● It is more common in developed, Western countries. In African-American
women, it is more aggressive.
● It is more common after middle age, but can occur at any age group, after
20 years.
● It can be familial in 2-5% cases, but the vast majority of cases are sporadic
without family history.
● Breast cancer is more common in women but can also occur in males.

55. Etiopathogenesis
● Mutation of tumour suppressor genes BRCA1/BRCA2 is thought to be involved
with high-risk of breast carcinoma. (BRCA means Breast CArcinoma).
● BRCA1 mutationis having more risk (35-45%) than BRCA2 mutation.
● Occasionally mutation of BRCA3 and p53 suppressor gene is also involved.
● Attaining early menarche and late menopause have high-risk of breast
malignancy.
● Risk is 3-5 times more if 1st degree relative is having breast cancer. Risk is
more if 1st degree relative is younger or premenopausal or having bilateral
breast cancers.
● Cowden's syndrome – or Li-Fraumen's syndrome (LFS) can be associated.

56. ● It is often associated with ataxia telangiectasia.
● Previous therapeutic radiation (thoracic) may predispose carcinoma
breast especially when RT is given at younger age mainly for Hodgkin's
lymphoma.
● It is more common in individuals who are on oral contraceptive pills (not
proved) and hormone replacement therapy (HRT) for more than 5 years.
● Some breast cancers are associated with mutations in ERBB2 gene which
increase in the expression of HER2 receptors, thus promote cell division.

57. Risk Factors
● Age.
● Early menarche and late menopause.
● Hormonal factors.
● Parity???
● Diet and obesity.
● Family history.
● Prior breast biopsy.
● Socioeconomic status.
● Decreased risk have been noted
with:
○ Early pregnancy.
○ Longer time of breastfeeding.

59. Presentation
● Lump in the breast which is hard, painless (most common).
● Nipple discharge is the second common presentation.
● Ulceration and fungation.
● Axillary lymph node enlargement; supraclavicular lymph node
enlargement.
● Chest pain and haemoptysis.
● Bone pain, tenderness, and pathological fracture.
● Pleural effusion, ascites.
● Liver secondaries, secondary ovarian tumor.
● Pain in the lump in 10% cases.

60. ● Most common site is upper outer
quadrant (60%) because breast
tissue is more in this quadrant.
● Cutaneous manifestations include:
○ Peau d'orange.
○ Dimpling of skin.
○ Retraction of nipple.
○ Ulceration, discharge from the nipple
and areola.
○ Skin ulceration and fungation.
○ Cancer-en-cuirasse.
○ Tethering to skin.

62. Classification
● Cancer cells are in situ or invasive depending on whether or not they invade
through the basement membrane.
● Can also be classified according the site they arise from:
○ Ductal
○ Lobular
● Can also be classified by their histologic expression of certain receptors like
ER, Pr or HER2:
a. ER +ve & PR +ve and HER2 –ve
b. ER +/-ve & PR +/-ve and HER2 +ve
c. ER –ve & PR –ve and HER2 –ve.

64. 1. DCIS (Ductal Carcinoma In Situ)
● It is intraductal carcinoma (proliferation of malignant mammary ductal
epithelial cells) without any invasion into the basement membrane.
● It is 5-20% common.
● It can be high grade DCIS or low grade DCIS.
● It can be comedo DCIS (more malignant and more likely to be invasive
later) or noncomedo OCIS (less malignant).
● In 20%of cases synchronousinvasive carcinoma in duct is seen.
● Untreated DCIS becomes invasive in > 50% cases (5 fold).

65. ● Types of DCIS:
a. Solid type, Ductal Carcinoma in situ:
■ The tumour cells completely fill the involved ducts.
b. Cribriform type, Ductal Carcinoma in situ:
■ The tumour cells do not completely fill the ducts. The pattern has little
holes and slits, similar to a sieve.
c. Papillary and micropapillary types, Ductal Carcinoma in situ:
■ These two types have fern-like projections of cells into the centre of the
duct. The micropapillary type projections are smaller than
those seen with the papillary type.

66. d. Comedo type Ductal Carcinoma in situ:
■ It tends to be slightly more aggressive than the other forms of DCIS.
■ Appearance under the microscope:
● The individual cells look more abnormal
● The centre of the duct is plugged up with dead cellular debris, known
as necrosis.
■ Also seen very often in mammograms the areas of necrosis are
microcalcifications – small abnormal calcium deposits in the areas of
necrosis.

68. 2. LOBULAR CARCINOMA IN SITU (LCIS)
● Originates from the terminal duct
lobular units and develops only in
the female breast.
● Characterized by distension and
distortion of the terminal duct
lobular units by cells.
● Characterized by dyscohesive cells
lacking E-cadherin adhesion
protein.

69. ● Malignant proliferation of cells in lobules with no invasion of the
basement membrane.
● Does not produce a mass or calcifications; usually discovered incidentally
on biopsy.
● Often multifocal and bilateral.
● The true incidence in the general population is unknown, due to lack of
clinical and mammographic signs.
● The mean age at diagnosis is between 44 and 46 years of age, and 80 to
90 percent of cases occur in premenopausal women.

70. ● Histologic typing:
○ Classic type:
■ solid proliferation of small cells, with small, uniform, round-to-oval nuclei and
variably distinct cell borders.
■ The cells typically show cytologic dyshesion.
■ LCIS is usually present in the terminal duct lobular units and distends and distorts
the involved spaces; the extralobular ducts may also be involved.
○ Non-classic types:
■ Pleomorphic:
● consists of larger cells that demonstrate marked nuclear pleomorphism but
otherwise demonstrate the same characteristics of the classical type.
■ Florid:
● The only one which can present with calcifications and can be seen in
mammographic.

72. 3. PAGET’S DISEASE OF THE NIPPLE
● Frequently presents as a chronic,
eczematous eruption of the nipple,
which may be subtle but may
progress to an ulcerated, weeping
lesion.
● Usually is associated with extensive
DCIS, may be associated with an
invasive cancer.

73. ● Nipple biopsy specimen shows
a population of cells that are
identical to the underlying
DCIS cells (pagetoid features
or pagetoid change).
● Pathognomonic of this cancer
is the presence of large, pale,
vacuolated cells (Paget cells)
in the rete pegs of the
epithelium.

74. Invasive Carcinomas of the Breast
a. Invasive Ductal Carcinoma:
○ Occurs most frequently in perimenopausal or
postmenopausal women in the
fifth to sixth decades of life.
○ Presents as a solitary, firm mass with
poorly defined margins.
○ Broad spectrum of histologic types with
variable cellular and nuclear grades.
○ Cut surfaces show a central stellate
configuration with chalky white or
yellow streaks extending into
surrounding breast tissues.

75. b. Medullary Carcinoma:
○ 4% of all invasive breast cancers.
○ Frequent phenotype of BRCA1 hereditary breast cancer.
○ Gross characteristics:
■ Soft and haemorrhagic
■ A rapid increase in size may occur secondary to necrosis and haemorrhage.
c. Mucinous (Colloid) Carcinoma:
○ 2% of all invasive breast cancers.
○ Typically presents in the elderly population as a bulky tumour.
○ Cut surface is glistening and gelatinous.
○ Fibrosis is variable, and when abundant, imparts a firm consistency to the cancer.
○ Microscopically defined by extracellular pools of mucin surrounding aggregates of low
grade cancer cells.

76. d. Papillary Carcinoma:
○ Generally presents in the seventh decade of life.
○ Occurs in a disproportionate number of non-white women.
○ Typically small, rarely attain a size of 3 cm in diameter.
○ Defined by papillae with fibrovascular stalks and multilayered epithelium.
e. Tubular Carcinoma:
○ 2% of all invasive breast cancers.
○ Diagnosed in the perimenopausal or early menopausal periods.
○ Under low-power magnification, a haphazard array of small, randomly arranged tubular
elements are seen.
○ Distant metastases are rare.
○ Long-term survival approaches 100%.

77. f. Lobular Carcinoma:
○ 10% of breast cancers.
○ Presentation: Varies from clinically
inapparent carcinomas to those that
replace the entire breast with a poorly
defined mass.
○ Frequently multifocal, multicentric,
and bilateral.

78. g. Inflammatory carcinoma:
○ Most aggressive type of carcinoma breast.
○ It is 2% common.
○ It is common in lactating women or pregnancy.
○ It mimics acute mastitis because of its short duration, pain, warmth and tenderness.
○ Clinically, it is a rapidly progressive tumour of short duration, diffuse, painful, warm often
involving whole of breast tissue with occurrence of peau d' orange, often extending to the
skin of chest wall also.
○ Mammography may not show any finding except skin thickening. Inflammatory
carcinoma of breast is a clinical diagnosis. FNAC confirms the diagnosis.
○ It has got worst prognosis.

81. Diagnosis

82. Investigation of Breast Carcinoma
● TO CONFIRM THE DIAGNOSIS:
○ Imaging:
■ Mammography:
● 2 views – (i) Mediolateral oblique and (ii) Craniocaudal.
● Indications:
○ Screening: Asymptomatic women of more than 40 years
○ Diagnostic: Women with pain in the breast, mass, discharge,
family history of breast cancer.
■ USG:
● Particularly useful in young women with dense breasts in whom
mammograpy is difficult to interpret.
● Can distinguish between solid and cystic lesions.

84. ■ MRI:
● Can be useful to distinguish scar from recurrence in women who have had
previous breast conservation therapy for cancer.
● Best imaging modality for the breasts of women with implants
○ Biopsy:
■ FNAC
● More than 95% accuracy.
● False negative 15%.
● Invasiveness of cancer cannot be determined.
■ Trucut biopsy
● Histological diagnosis of invasive or non invasive carcinoma may be made.
● Tumour grade and any lymphovascular invasion may be assessed.
● ER/PR and Her2-neu status may also be assessed.

85. ● Other investigations:
○ TO STAGE THE DISEASE – METASTATIC WORK UP
■ CT scan chest.
■ X-ray.
■ Whole body bone scan.
■ Upper abdominal USG with LFT.
■ Sentinel node biopsy.
○ TO KNOW THE GENERAL CONDITION
■ Complete haemogram with ESR.
■ Serum albumin, sugar, urea, creatinine.
■ ECG, Echo and Pulmonary function test for elder patients.

87. TNM Staging
● T: means the size of the tumor and whether it has grown in nearby areas.
● N: degree to which the cancer has spread to nearby lymph nodes.
● M: presence of distant metastases.
● Staged from O to 4, with 4 being the most severe.
● Then are grouped in combination of these factors for treatment
purposes.

91. Treatment:
● Treatment modalities include:
○ Surgery
○ Chemotherapy
○ Radiotherapy
○ Hormonal Therapy
● The choice between these modalities depend on the type, stage and
pattern of receptors expressed.
● Surgery is the mainstay treatment when ever possible. And are followed
by different methods like radiation, chemotherapy, endocrine therapy
and targeted therapy toward specific receptors expressed by tumor cells.

92. ● Medications used after surgery is called adjuvant therapy and those used
prior to surgery are called neoadjuvant therapy.
● The surgical approach of the primary tumor depends on the: size of the
tumor, the size of the breast and whether the disease is multifocal or not.
● In breast conserving therapies i.e lumpectomy, only the affected area is
removed and followed by adjuvant radiotherapy.
● In mastectomy the whole breast is removed either +/- adjuvant
radiotherapy.
● Nearby lymph nodes should be if the cancer had metastasized to them.
● Radiotherapy can be given as external beam radiotherapy or
brachytherapy.

93. ● Following surgery some individuals may get adjuvant therapy.
○ Premenopausal women with ER+ low risk cancer can be given tamoxifen as an
adjuvant therapy. N.B: women should be on some type of contraception.
○ Premenopausal women with high risk cancer should get exemestance as an
adjuvant therapy, as well as surgery and meds like leuprolide or goserelin.
○ Postmenopausal women with ER+ tumor should get an aromatase inhibitor i.e
exemestane, anastrozole, as an adjuvant therapy.
○ HER2 +ve cancers gets treated with trastuzumab alone or in combination with
chemo if the tumor is bigger than 1cm.

94. ○ Finally triple negative breast cancer that’s bigger than 0.5cm generally gets
adjuvant chemotherapy as therapy. One of the most common regimens is
called “AC” and it combines cyclophophomide with doxorubicin.
● Most individuals with advanced, inoperable breast cancer should get
neoadjuvant systemic therapy and then have their cancer restaged to see
if it’s resectable.
● Most indivituals who need neoadjuvant therapy get chemotherapy.
● For tumors who are HER2 +ve trastuzumab should be added to the
chemotherapy regimen.

95. ● Metastatic breast cancers are unlikely to be cured. So individuals with
hormone receptor positive disease are first treated with targeted therapy.
● If the tumor progresses despite being on multiple endocrine therapies
than chemotherapy is tried.
● If the metastatic disease is triple negative disease then chemotherapy is
used right away.
● Some cases may get local treatments i.e surgery or radiotherapy, to help
prevent or treat symptoms or complications of cancer.
● Patients who have received full course neoadjuvant chemotherapy
before surgery need not receive adjuvant chemotherapy.

96. Prognosis
● Spread to the axillary nodes is the most important prognostic indicator.
● Younger age has worse prognosis.
● CA male breast has worse prognosis than CA female breast. But why???
● Stage 1 & 2 of carcinoma of breast has better prognosis than stage 3 & 4.
● ER +ve & PR +ve tumours have better prognosis.
● HER-2/neu +ve tumours have poor prognosis.
● p53 tumour suppressor gene shows bad prognosis.
● Inflammatory carcinoma has worst prognosis.
● Tumour size less than 1cm has better prognosis.

97. Complications of Breast Cancer
● Complications of the breast cancer can be due to result of the
disease itself or the result of the treatment approaches.
● Most common complications include
1. May cause local inflammation causing damage of the suspensory ligaments
resulting in their fibrosis.
2. Can invade to the nearby tissues like pectoral muscles below or skin above.
3. Can also block lymphatic vessels and result in severe lymphedema.
4. Can also spread and metastasize via blood to other sites like spine, brain,
lungs, liver or the heart. And where do you think is the most common site of
distant metastasis of BC?

98. References:
● UpToDate.
● Kaplan Medical Notes and Videos.
● Boards and Boards Medical Resouces.
● SRB Manual of Surgery 6th Edition.
● Osmosis Medical Resources.
● Slideshare resources.
● Pinterest and Google Images.
● Healthline.
● Jeffcoate’s Principles of Gynaecology, 8th Ed.

99. That’s all.
Thanks for Listening.