1. Breast
Dr. Raid Jastania

7. Breast
Definitions: Lactiferous ducts, Duct, Lobule, Terminal duct lobular unit
Common presentations of diseases
Lump, mass, pain, skin changes
Mammography: fibrous thickening and calcifications
Triple test: Clinical, mammography, biopsy

9. Rare conditions Supernumerary nipples and breast
Congenital inversion of nipple
Galactocele

10. Fibrocystic Change Present as mass or lump Hormonal related, Estrogen
Types
Proliferative fibrocystic change
Non-proliferative fibrocystic change

11. Fibrocystic Change Non-Proliferative fibrocystic change Fibrosis
Apocrine metaplasia

13. Fibrocystic Change Non-Proliferative fibrocystic change
Multifocal, bilateral
Nodularity, fibrosis
Cysts 1-5 com, Blue dome cysts, lined by benign epithelium, myoepithelial cells present,
Apocrine metaplasia
Calcification

14. Fibrocystic Change Proliferative fibrocystic change
Epithelial hyperplasia
Sclerosing adenosis

15. Fibrocystic Change Proliferative fibrocystic change
Epithelial hyperplasia
Types: Ductal, Lobular
Grades: Mild, moderate, severe (florid), atypcial
Sclerosing adenosis

18. Fibrocystic Change Proliferative fibrocystic change
Epithelial hyperplasia
Sclerosing adenosis
Hard, rubbery
Fibrous stroma
Proliferation of small ducts (adenosis) with marked compression of the fibrous stroma (sclerosing)

19. Fibrocystic Change Risk of Cancer: Family history: double the risk
No Risk
Non-proliferative FC, mild hyperplasia
Risk of x
Moderate-florid hyperplasia, sclerosing adenosis, papillomatosis
Risk of 5 x
Atypical hyperplasia

20. Carcinoma Second to lung cancer as a cause of death
¼ of women with the disease die
Lifetime risk is 1 in 8 women in US
Increasing incidence
75% of patients are older than 50 y
5% are younger than 40 y

21. Carcinoma L > R (slightly) 4% bilateral Upper outer quadrant: 50%
Central zone: 20%
All other quadrants: 10% each

22. Carcinoma Classification Carcinoma In-situ Invasive carcinoma
Ductal (DCIS)
Lobular (LCIS)
Invasive carcinoma
Ductal carcinoma (Scirrhous carcinoma)
Lobular carcinoma
Others: medullary, colloid, tubular…

23. Ductal Carcinoma In-Situ DCIS
Terminal duct lobular unit
Large malignant cells, monotonous, within ducts
Pattern
Solid
Cribriform
Papillary
Micropapillary
Comedo: central necrosis

28. Ductal Carcinoma In-Situ DCIS
Presentation
Mammography: calcifications
Can be palpable
Prognosis: 97% survival
1/3 of cases progress to invasive cancer if untreated
Recurrence in 20-25%

29. Lobular Carcinom In-Situ LCIS
Terminal duct lobular unit
Uniform, monomorphic, bland, discohesive cells, some with vacuoles (signet-ring)
1/3 will develop invasive cancer, the risk is to both sides of breast
LCIS is a marker of increased risk
Presentation: incidental, not palpable, no calcification

32. Invasive Ductal Carcinoma (NOS) or (NST)
70-80% of invasive carcinoma
Associated with DCIS
Hard, palpable mass, irregular borders
Nipple retraction, Peau d’ orange
fixation to the chest wall

34. Invasive Ductal Carcinoma (NOS) or (NST)
Invasive adenocarcinoma
Irregular glands lined by malignant cells
Grading: tubular formation, nuclear grade, mitosis
2/3 ER/PR +
1/3 HER2/NEU over expression

39. Invasive Lobular carcinoma
20% of invasive cancer cases
2/3 are associated with LCIS
Most are palpable, but can be occult
More frequent multifocal, multicentric (10-20%)

40. Invasive Lobular carcinoma
Single cells, indian file, targetoid arrangement
Signet-ring cells, intracytoplasmic lumina
Matastasize to serosal surfaces and CNS, ovary
All ER/PR +
HER2/NEU over expression is rare

44. Medullary Carcinoma Well circumscribed mass, pushing borders
Large anaplastic cells
Mixed with inflammatory cells
Cases of BRCA1 show medullary carcinom-like features
Lack ER/PR
HER2/NEU negative

45. Colloid carcinoma (mucinous)
Well circumscribed mass
Pools of mucus
Malignant cells floating in mucus
ER/PR +
HER2/NEU negative

47. Tubular carcinoma Small <1cm Irregular densities on mammography
Prognosis is excellent
ER/PR +
HER2/NEU negative

49. Inflammatory Carcinoma
Usually ductal carcinoma NOS
Clinical: enlarged swollen, erythematous breast
Cancer seen in lymphatic channels in skin
Poor prognosis

51. Paget Diseas of nipple
Extension of DCIS upto lactiferous ducts and skin of nipple
50% associated with invasive carcinoma
Extramammary Paget disease
Common in perineum, but can be in any site

53. Case

55. 49-year-old woman who has come to the doctor for evaluation of a lump in her right breast. She says she first noticed it two weeks ago while she was taking a shower. She hasn't noticed any nipple discharge, skin changes, or alteration in the lump's size. She is perimenopausal. Her mother died at age 45 from "a breast tumor." Five years previously, the patient had a biopsy of her left breast

57. Physical examination reveals a nontender, slightly moveable, 2
Physical examination reveals a nontender, slightly moveable, 2.0-cm mass in the upper outer quadrant of her right breast. In addition, several smaller nodules and ill-defined firm areas are present in both breasts. The nipple and skin appear normal. The lower right axilla contains a 1.5-cm moveable nodule
A mammogram shows an irregular mass with stippled calcifications in the upper outer quadrant of the right breast.

58. Gross examination of the lumpectomy specimen shows a 2
Gross examination of the lumpectomy specimen shows a 2.0-cm, grey, scirrhous mass in the central portion of the specimen
The margins of the lumpectomy specimen are free of tumor.
Serial sections of the sentinal lymph node reveal metastatic ductal carcinoma ,thus, a completion axillary dissection is performed a week later, revealing 2 additional positive lymph nodes out of 15.
Special studies reveal the tumor to be estrogen and progesterone receptor positive with a high proliferative rate and a diploid DNA histogram. The tumor is HER2 positive. The patient is given chemotherapy and radiotherapy.

62. Cancer Spread Lymph nodes 40% of cases
Axillary nodes, internal mammary nodes, supacalvicular nodes
Lung, liver, BM, adrenal
Metastasis can be many years after the primary resection (10-15 years)

63. Cancer Spread Stage Size, L.N. involvement, metastasis (TNM)
Poor prognostic findings
Chest wall invasion, skin ulceration, inflammatory carcinoma

64. Cancer Spread Stage: Stage 0: DCIS, LCIS, survival 97%
Stage 1: invasive <2cm, survival 87%
Stage 2: invasive 2 – 5 cm, survival 75%
Stage 3: invasive >5 cm + L.N., survival 46%
Stage 4: metastatic disease, survival 13%

65. Risk Factors
Environmental
Host
Changeable
Non changeable

66. Risk Factors Host Changeable Non changeable
Age: uncommon <30 years, increase with age till menopause
Early menarche
Late menopause
Nulliparous

67. Risk Factors Host Changeable Non changeable Genetic
5-10% of cancer is related to inhereted gene
Suspected in young, bilateral cancer, with ovarian tumor
BRCA1, Ch 17q
BRCA2, Ch 13q
Li Fraumeni syndrome (P53 mutation)
Cowden disease (PTEN)
Ataxia-telangeictasia

68. Risk Factors Host Changeable Non changeable
Prolonged exogenous estrogen postmenopausally
Hormone replacement therapy
Oral contraceptives
Non changeable

69. Risk Factors Environmental Geographic variations Radiation Others
US>Asia, Africa
US 5x of Japan
Radiation
Early age during breast development <30y
Others
Obesity, high-fat diet, alcohol, smoking

70. Pathogenesis Genetic Overexpression of HER2/NEU (ERBB2)
Found in 30% of cases
Poor prognosis
Amplification of Ras gene, Myc
Mutations of P53, RB1

71. Pathogenesis Hormonal
Estrogen excess (early menarche, late menopuse, nulliparity)
Ovarian tumor secreting estrogen

72. Prognosis Tumor stage (size, LN, metastasis) Grade Type
Lymphovascular invasion
ER. PR.
Proliferation rate
Aneuploidy
HER2/NEU over expression

73. Inflammation of Breast

74. Inflammation of Breast
Tender, painful, Fever…
Acute mastitis
Nursing
Staph : single, multiple
Mammary duct ectasia
Non bacterial, year old
Duct dilation, rupture, reactive changes
Traumatic fat necrosis
Mass, small, tender
Fat necrosis, acute inflammation, foamy histiocytes

75. Fibroadenoma Most common benign tumor of the breast Young female 30y
Estrogen ?
Findings
Discrete, freely mobile, firm, tan-white 1-10cm
Pericanalicular, intracanalicular

79. Phyllodes Tumor Stromal tumor Usually large, leaf-like cleft and slits
Most are benign
Can be malignant
Stromal cellularity, atypia, mitosis, invasion

82. Intraductal Papilloma
Solitary, affect large lactiferous ducts
Present: bloody nipple discharge, subareolar mass, rarely nipple retraction
Findings:
Dilated duct with branching tumor
Papillary, double layers of cells
Intraductal papillomatosis

86. Male Breast Gynecomastia Carcinoma Enlargement of male breast Estrogen
Klinefelter syndrome
Estrogen secreting tumors
Digitalis
Physiologic in puberty
Carcinoma
Rare M:F ratio 1:125