Breast%20disease

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Breast disease

• Dr. A. Basu MD

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Topic

• General concept

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TDLU
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D/D of a breast Lump
Solid Lump
Cystic Lump
Bilateral
Unilateral
Abscess ( tender) Galactocele ( History of
Pregnancy) Cyst Breast.
Fibrocystic disease ( Irregular lump)
Fibro adenoma Cystosarcoma Phyllodes Breast
carcinoma Fat necrosis
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Diseases of Breast lecture topic

• Fibrocystic changes of breast types
• Inflammations
• Tumors of the Breast

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Fibrocystic disease of breast
Non Proliferative change Cyst and fibrosis
Proliferative change Its is a Premalignant condition of the breast Epithelial Hyperplasia Sclerosing adenosis
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Fibrocystic changes
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Fibrocystic disease (Non Proliferative change)

• Gross Blue dome cyst 1to 5 cm

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Non Proliferative change MICRO
Cystic dilation of Glands an ducts Apocrine
metaplasia of the lining epithelium of the duct
and glands.
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Proliferative change

• Epithelial Hyperplasia
• Subtype Atypical
• Sclerosing adenosis

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(Atypical) Epithelial Hyperplasia More chance
of carcinoma.
Normal
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Sclerosing adenosis

1. Excessive fibrosis of beast
2. Increased number of collapsed gland

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Sclerosing adenosis clinically mimic malignancy
because it is hard and rubbery on palpation.
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Clinical Fibrocystic changes
Lumpy Breast
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Inflammation of the breast

1. Acute mastitis ( produce breast abscess).
2. Mammary Duct ectasia
3. Traumatic fat necrosis.

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Acute mastitis ( produce breast abscess).

• Etiology Early week of Nursing and dermatitis.

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Acute mastitis
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Mammary Duct ectasia

• Def NON-inflammatory lesion.
• Age 40-50 years , who has children.
• Cause Accumulation of Breast secretion in Main
  Excretory Duct.

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Mammary Duct ectasia Dilated Duct , Fibrosis
around the dilated duct.Presence of PLASMA cells
and lymphocytes
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Mammary Duct ectasia-C/F

• Presents as a lump below the nipple.
• Cause nipple Retraction mimic carcinoma

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Traumatic fat necrosis

• Early Small Tender and localized lump.
• Later Fibrosis and calcification occur.

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Tumors of the Breast

• Fibro adenoma
• Phyllodes Tumors
• Intraductal papilloma
• Carcinoma of the breast

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Fibro adenoma Breast Mouse

• Disease involve TDLU
• Most common benign tumor in female breast.
• Its growth is related to estrogen.
• Age young women ( 3rd Decade)
• They have both epithelial and connective tissue
  elements.

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Morphology

• Size 1 to 10 cm.
• Tumor more than 10 cm
• Giant fibro adenoma.
• Gross Breast Mouse
• Micro 2 features

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Gross Well circumscribed , tan-white
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1. Oval round duct space
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2. Slit like , star shaped compressed duct
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Clinical

1. Solitary, discreet, moveable mass ( breast
   mouse).
2. Regress after menopause and calcify.
3. It will never become malignant.

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Phyllodes ( leaf like) Tumors
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Phyllodes ( leaf like) Tumors

• Past name Cystosarcoma Phylloid
• It can become malignant
• Usually a big tumor
• Contain mainly stromal component.
• Morphologically has a leaf like appearance.

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Morphologically has a leaf like appearance
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Phyllodes tumor

• High-grade lesion behave aggressively and exhibit
  recurrence.

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Fibroadenoma Vs Phyllodes tumor
Low cellularity High cellularity, bulky stroma.
Rare mitosis High mitosis
No Pleomorphism Pleomorphism Present
Well circumscribed Infiltrative border
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Intraductal papilloma

• An Intraductal papilloma may be associated with a
  serous or bloody nipple discharge .
• Location Subareolar
• Its a benign lesion.

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Intraductal papilloma arising in main lactiferous
ducts
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Carcinoma Breast

• Risk factors
• Genetics and family History
• Prolonged exposure to exogenous estrogen and
  obesity.
• Alcohol consumption.
• Environmental

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Risk factors

• Proliferative breast diseases
• Carcinoma of the contra lateral breast or
  endometrium.
• Frequent in nulliparous women.
• Obesity

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Age Genetics and family History

• Age uncommon below 35 years
• Genetic disease associated with Breast cancer
• Li-Fraumeni syndrome ( multiple sarcoma and
  carcinoma).
• Cowden disease ( multiple hamartoma syndrome).

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Gene and Breast carcinoma

• Associate with BRCA 1 and BRCA 2 gene,
• Over expression of c-erb b2. HER2/neu

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Location of breast tumor
Upper inner 10
Upper outer 50
Central 20
Lower outer outer 10
Lower inner 10
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Classification

• Non Invasive
• Ductal carcinoma in situ (DCIS)
• Lobular carcinoma in situ (LCIS)
• Invasive

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Invasive

• Invasive ductal carcinoma ( not otherwise
  specified NOS)
• Invasive lobular carcinoma
• Medullar carcinoma
• Colloid carcinoma
• Tubular carcinoma

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DCIS Vs LCIS
Arise from duct Arise from acini.
Associated with micro calcification Not associate with calcification
High grade DSCI has bad prognosis Do not produce mass. Good prognosis
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Duct Carcinoma In Situ Features

1. Low grade DCIS Good prognosis
2. DCIS with micro invasion
3. Variant Comedo carcinoma
4. Paget disease of nipple Extension of In situ
   duct carcinoma cell to the lactiferous duct and
   the skin of the nipple.

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Ductal carcinoma in situ (DCIS) with micro
calcification
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Comedo subtype of DCIS Central necrosis within
the duct.
Comedocarcinoma
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Paget disease of nipple

• Extension of In situ duct carcinoma cell to the
  lactiferous duct and the skin of the nipple.

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Paget disease of nipple Clinically resemble
eczema.
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Paget cells These cells have abundant clear
cytoplasm and appear in the epidermis either
singly or in clusters.
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Paget cell stain PAS Indicate presence of Mucin
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Prognosis of DCIS

• Excellent
• 97 long time survival.
• DCIS with micro invasion bad prognosis.

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Lobular carcinoma in situ
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All acini of a breast lobe is affected. Cells are
monomorphic ( similar size)
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Time for Invasive carcinomas

• Invasive ductal carcinoma ( not otherwise
  specified NOS)
• Invasive lobular carcinoma
• Medullar carcinoma
• Colloid carcinoma

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Invasive ductal carcinoma (Scirrhous carcinoma)-
70-80

1. It is carcinoma with no special type ( NOS).
2. Constitute Majority of Breast carcinoma.
3. They have desmoplasia (Scirrhous ).
4. Stony hard mass, fixed to skin , underlying
   muscles.

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Invasive ductal carcinoma (Scirrhous carcinoma

1. Lymph vascular and neural invasion common.
2. Tumor cells frequently over express ERB B2.
3. 2/3 rd EXPRESS HOEMONE ( ESTROGEN AND
   PROGESTERONE) RECEPTOR.
4. Presence of overlying Pagets disease Bad
   prognosis.

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Gross IDC infiltrative tumor with irregular
margin.
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Gross IDC infiltrative tumor with
infiltrating growth .
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Micro IDC
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IDC with extreme desmoplasia
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Diagnosis

• Mammography
• Micro calcification red alert
• FNAC
• Biopsy

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Inflammatory carcinoma

• It a a variant of duct carcinoma
• Shows swollen , erythematous (red) breast mimic
  acute inflammation.

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Invasive lobular carcinoma Main Features

1. Tumor cells are monomorphic ( similar size).
2. Frequently bilateral and multicentric.
3. More often spread to CSF, serosal surface and
   ovary.
4. Frequently clinically silent.
5. Express hormone receptor.

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Invasive lobular carcinoma monomorphic round
cells
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Invasive lobular carcinoma microscopy single
indian file
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Bulls eye pattern of invasion
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Colloid carcinoma

• Age Older women
• Growth Slow growing,
• Prognosis Prognosis is better than for
  non-mucinous, invasive carcinomas.
• Most express hormone receptors.
• Gross Soft gelatinous.

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Colloid carcinoma Note the abundant bluish
Mucin.
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Medullar carcinoma-2

• Incidence Less than 5 of breast cancers (
  occur with BRCA1)
• Morphology
• Gross 2-5 cm, fleshy masses .
• Micro Sheets and nests of cells are surrounded
  by a lymphoid plasmacytic stroma with no
  desmoplasia.

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Medullar carcinoma
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Medullary carcinoma

• Prognosis Better than for infiltrating ductal
  or lobular carcinoma.
• Lack hormone receptors.

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Topic now

1. Tubular carcinoma
2. Sarcoma of breast
3. Features of invasive tumor
4. Spread of breast carcinoma
5. Staging of breast carcinoma
6. Clinical course and prognosis
7. Management
8. Male Breast
9. Miscellaneous lesions

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Tubular carcinoma features

1. Small mass , rarely palpable( 1cm size).
2. Excellent Prognosis
3. Lympnnode metastasis is rare.
4. Express hormone receptor.
5. Micro Well formed tubules and low grade nuclei.

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Morphology
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Sarcoma of Breast

• All types of sarcoma can occur
• But angiosarcoma is common.

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Features of invasive tumor

• Fixation to the tissue ( skin, muscle)
• Retraction of nipple.
• Inflammatory carcinoma.
• Dimpling of the skin.
• Lymph edema caused by Tumor emboli in the
  dermal blood vessels.

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Retraction of nipple
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Inflammatory carcinoma common in pregnancy (but
no inflammatory cells present)
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Tumor emboli in the dermal blood vessels the
cause of Lymphedema
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Lymphedema following radical mastectomy
Thickened skin
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Spread

1. Local Lymph nodes
2. Lung, Skeleton ( osteolytic)
3. Brain ( CSF)
4. Metastasis may occur even after 15 years.

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Internal mammary Lymph nodes
Axillary Lymph nodes
Upper outer 50
Upper inner 10
Central 20
Lower outer outer 10
Lower inner 10
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Prognostic factors
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The size of the primary tumor Invasive Ca lt 2 cm excellent
Lympnnode and number of LN involvement. Most important factor related to the prognosis of breast cancer
Histological type NOS Duct carcinoma bad prognosis Specialized Ca good prognosis
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Prognostic factors
Grade Well differentiate tumor better prognosis.
Presence of both estrogen / progesterone receptor Slightly better prognosis.
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Prognostic factors
Aneuploidy If present - worse prognosis.
Over expression of ERB B2 Poorer Prognosis.
Increased mitosis. Bad prognosis
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Prognostic factors
Angiogenesis More chance of metastasis
Protease If increased more chance of invasion.
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Hercepctin

• Monoclonal Antibody to Gene ERBB2.
• It is an antitumor antibody.
• If response to this antibody is GOOD GOOD
  prognosis.

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Management

• Lumpectomy
• Mastectomy or breast Preservation
• Hormonal and Chemotherapy.
• Inhibition of angiogenesis.

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Post mastectomy Tumor deposit on scar area.
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Breast self examination best way to save life
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Thank you

• We will now move on to Male Breast.

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Male Breast

• Gyenecomastia ( Greek word) enlargement of the
  male breast.

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Proliferation of ducts in hyalinized fibrous
tissue with periductal edema
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Causes

1. Puberty
2. Tumors ( Leydig cell tumor of testis)
3. Genetic disorders ( kilnefelter syndrome)
4. Chronic liver disease (cirrhosis)
5. Female hormone exposure

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Carcinoma of male breast rare usually duct
carcinoma.
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Thank you