1. Breast Pathology
Dr. M. Griffin

2. The Normal Breast Terminal duct lobular unit Segmental Ducts
Lactiferous ducts and sinuses
Intralobular stroma
Interlobular stroma
Nipple areola complex

3. Diagram of normal breast

4. Normal breast tissue Large duct on the right Lobules to the left
Collagenous stroma extends between
Adipose tissue admixed

5. Terminal duct lobular unit

6. Pathology of breast Disorders of development and growth Inflammations
Fibrocystic change
Proliferative breast disease
Tumours

7. Disorders of development
Supernumerary nipples/ breasts
Accessory axillary breast tissue
Congenital inversion of nipples
Macromastia
Failure of growth eg Turners syndrome

8. Inflammations Acute mastitis Periductal mastitis Duct ectasia
Fat necrosis
Granulomatous mastitis
Silicone breast implants

9. Fibrocystic change/ non proliferative change.
Cyst formation with apocrine metaplasia
Fibrosis

10. Fibrocystic change White tissue represents stromal fibrosis
Multiple cysts are present throughout (arrow)

11. Fibrocystic change 1.Multiple cysts with secretions
2.Arrow indicates microcalcification in one of the cysts
3.Background fibrotic stroma

12. Apocrine metaplasia

13. Proliferative breast Change
Epithelial hyperplasia -
Mild
Moderate
Severe
+/- Atypia
Sclerosing adenosis
Multiple intraduct papillomas

14. Epithelial hyperplasia of usual type
Duct lumina are almost completely filled with proliferating epithelium
No cytologic atypia
present

15. Atypical Ductal Hyperplasia
1 Ducts are filled with markedly atypical cells

16. Proliferative breast disease and risk of Cancer
Atypical epithelial hyperplasia increases the risk by times.
Epithelial hyperplasia of usual type increase risk by times.
Positive family history doubles these risks

17. Breast Tumours Benign Fibroadenoma Phyllodes tumour
Intraduct papilloma
Malignant
Carcinoma
Sarcoma/ Lymphoma/ Metastatic tumour

18. Fibroadenoma 1 circumscribed tumour
2 fibroblastic stoma enclosing glandular structures lined by epithelium

19. Carcinoma of breast Epidemiology and risk factors
Geographic factors
Age / Sex
Genetics and family history
Proliferative breast disease
Radiation exposure
Reproductive/menstrual history
Obesity/ high fat diet/

20. Genetic Predisposition
Positive Family history
5-10% of cancers related to specific inherited gene mutations
BRCA1 and BRCA2 gene mutations
Li Fraumeni syndrome –germline mutation of TP53
Cowden syndrome -germline mutation in PTEN.

21. Carcinoma of breast Etiology and Pathogenesis Age and Sex
Genetic factors
Hormonal influences
Environmental factors
Atypical epithelial hyperplasia

22. Carcinoma of breast Classification
Carcinoma in situ ( carcinoma confined within ducts or acini, may be ductal or lobular)
Invasive carcinoma (carcinoma has breached the basement membrane and infiltrated breast stroma)

23. Carcinoma of Breast Carcinoma in situ (15-30%)
Ductal carcinoma in situ
( including Paget’s disease of the nipple)
Lobular carcinoma in situ

24. Microcalcification on mammogram
1 Ductal carcinoma in situ detected by mammography
2 Pleomorphic microcalcifications
3 Localisation wire in situ – to indicate area for excision
4 lesion is nonpalpable in the majority of cases

25. Ductal carcinoma in situ

26. Paget’s disease of nipple
Large cells in the epidermis represent cancer cells from underlying breast cancer which can be in situ or invasive.
The The

27. Lobular carcinoma in situ
Neoplastic cells filling the acini are small and uniform

28. Carcinoma of Breast Presentation Left breast more often than right
50% affect upper outer quadrant
Painless mass
Skin dimpling, ulceration, nipple retraction or discharge
Peau d’orange/ inflammatory carcinoma
Abnormal mammogram- mass/ density/ pleomorphic microcalcifications

29. Carcinoma of Breast Invasive Carcinoma Ductal carcinoma NOS 79%
Lobular carcinoma %
Tubular/cribriform carcinoma %
Mucoid carcinoma %
Medullary carcinoma %
Papillary carcinoma %

30. Invasive ductal carcinoma- lesion is retracted, infiltrative and stony hard.

31. Carcinoma of breast Triple approach to diagnosis Clinical examination
Imaging – mammogram +/- ultrasound
FNA cytology or core biopsy
GOAL: Non operative diagnosis of mass

32. Mammogram showing 2 invasive carcinomas with intervening DCIS

33. Pre-operative diagnosis
Fine needle aspiration cytology
Core biopsy

34. Invasive ductal carcinoma
1 Small nests and cords of neoplastic cells
2.Dense collagenous stroma in between cells

35. Invasive lobular carcinoma
1.Indian file strands of neoplastic cells
2. Cells are small and uniform
3.Dense stroma

36. Mucinous carcinoma

37. Mucinous carcinoma
1. Abundant bluish staining mucin with small groups of carcinoma cells

38. Tubular carcinoma
1 Normal ducts on the left showing myoepithelial layer (stained brown)
2 Tubular carcinoma on the right, lacking myoepithelail layer

39. Inflammatory carcinoma- tumour in dermal lymphatics

40. Carcinoma of breast Mass- firm, gritty, scirrhous or gelatinous
Circumscribed or infiltrative margins
Microscopy shows a variety of patterns ie glands, cords, or nests of malignant cells infiltrating breast stroma
Invasion of breast stroma, fat. lymphatics or blood vessels

41. Carcinoma of breast Routes of spread Local -skin, nipple , chest wall
Lymphatic- lymph nodes
Blood – lungs, liver, bones

42. Metastatic carcinoma in lymph node and lymphatic

43. Breast cancer prognosis
Stage of disease
T –size of primary tumour
N – nodal status
M - +/_ metastasis

44. AJCC staging for breast cancer
Stage year survival % % % % %

45. Carcinoma of breast Prognostic factors
Lymph node status/ Size /Grade (NPI)
Histologic type
Hormone receptor status
Lymphovascular invasion
Proliferative rate/ DNA content
Oncogene expression eg HER2 NEU
Gene expression profiling

46. Prognostic markers Oestrogen receptor positive
Her2 protein 3+ positive