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 at birth male and female breasts
active secretion (transplacental passage of maternal hormones) bilateral breast enlargement
colostrum-like secretion ("witch's milk")
recedes several months postpartum
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
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
supernumerary breast (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
Polythelia
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 – disfiguration

9. Granulomatous Lobular Mastitis Mammary duct ectasia
Puerperal mastitis
early stages (2nd and 3rd 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. Intraductal papilloma
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/ F/Y, Western Europe 64,7/ F/Y)
2nd killer among cancers (1st = lung ca)
risk factors: genetic predisposition (breast ca in close (1st 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
+ other types (12)
Lobular invasive

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