OBAFEMI AWOLOWO UNIVERSITY ILE-IFE, NIGERIA

DEPARTMENT OF MORBID ANATOMY & FORENSIC MEDICINE

LECTURE NOTES ON BREAST PATHOLOGY, 7
TH
FEBRUARY,
2011.
BY
DR A.E OMONISI
Ou!"#$
1) The Normal Breast
i) Normal Anatomic Position and Relations
ii) Microanatomy
iii)Physiology of the Breasts
2).Develomental and Physiologic A!normalities of the Breast.
"). #linical Manifestations of Breast Disease
$).%nflammatory Disorders
i).Ac&te Mastitis and Breast A!scess
ii).#hronic Mastitis
iii).Perid&ctal Mastitis
iv).Mammary D&ct 'ctasia
().)ymhocytic Mastoathy
vi).*at Necrosis
+) A!normalities of the Breast d&e to Ne&ro,endocrine
disorders.
-T&mo&rs of the Breasts
i).Benign Breast Diseases
ii).#arcinoma of the Breast

B%&'()*u#+.
.ne of the ma/or disting&ishing feat&res of h&mans from other
animals is the level of develoment of the !reasts0 1hich serve
as a so&rce of !reast mil2 rod&ction0 transfer of
imm&noglo!&lin to the offsring and also serve as one of the
second se3&al characteristics.
The disorders of the !reast are !est &nderstood in the conte3t of
its normal anatomy.
N*),%! A#%*,- *. /$ B)$%0.
The !reast is a modified s1eat gland covered !y a s2in and
s&!c&taneo&s tiss&e. %t rests on the ectoralis m&scle0 from
1hich it is searated !y a fascia. %ts manifests in h&man as a
aired str&ct&re on the chest 1all.
L*&%"*# 1 A#%*,"& B*u#+%)"$0.
The ad&lt !reast lies !et1een the second and the si3th ri!s in the
vertical lane and !et1een the sternal edge medially and
mida3illary line laterally.
The average !reast meas&res 14,12cm in diameter0 and thic2ness
centrally is 5,-cm.%t is concentric 1ith a lateral ro/ection into
the a3illa0 referred to as the a3illary tail of 6ence.
A thin layer of mammary tiss&e e3tends from the clavicle a!ove
to the seventh or eighth ri!s !elo1 and from the midline to the
edge of the latissim&s dorsi osteriorly.
M"&)*%#%*,-
The ad&lt !reast consists of three ma/or str&ct&res7 s2in0
s&!c&taneo&s fatty tiss&e and !reast tiss&e 8arenchyma and
stroma).The s2in contains of hair follicles0 se!aceo&s glands and
eccrine s1eat glands.
The gland&lar !reast is divided into 15,24 segments 8lo!es) that
converge at the nile in a radial arrangement. These lo!es are
made & of 24,$4 lo!&les. 'ach lo!&le in t&rn consists of 14,144
alveoli 8t&!&losacc&lar secretory &nits).#ollecting mil2 d&cts0
meas&ring aro3imately 2mm in diameter0 drain each segment.
Bet1een five to ten ma/or collecting mil2 oen at the nile into
s&!areolar lactifero&s sin&ses0 1hich are a!o&t +,9mm in
diameter.
The morhof&ctional &nit of the organ is the single gland0 a
comle3 !ranching str&ct&re that is comosed of t1o ma/or
arts in the terminal d&ct lo!&lar &nit 8TD):) and the large d&ct
system.
The s&erficial ectoral fascia envelos the !reast and is
contin&o&s 1ith the s&erficial a!dominal fascia of #amer.
The &nders&rface of the !reast lies on the dee ectoral fascia.
#ooer s&sensory ligaments rovide s&orts for the !reast and
are fi!ro&s !ands connecting the t1o fascial layers.
N"22!$1A)$*!%
The eidermis of the nile 8mammary ailla) and areola is
igmented and 1rin2ed and consists of 2eratini;ing0 stratified
s<&amo&s eitheli&m. %t is 15,+4mm in diameter. These are
!&ndles of smooth m&scle fi!res that are circ&mferentially
arranged in dense connective tiss&e and are resonsi!le for the
contractile f&nction and erection of the nile.
T1o recetor,tye nerve endings 8R&ffini,li2e !odies and end
!&l! of =ra&se) are resent on the nile and are associated 1ith
the tactile recetor of stretch and ress&re.
The Areola has no hair follicles. %t has se!aceo&s glands0
aocrine s1eat glands and accessory areolar glands
8Montgomery glands).Montgomery glands are intermediate
!et1een tr&e mammary glands and s1eat glands and oen on the
s&rface of the areola as small elevations called Morgagni
t&!ercles.
T/$ 3%0&u!%) 0u22!- %#+ 3$#*u0 +)%"#%($.
The arterial !lood s&ly to the !reasts is derived from the
1.%nternal thoracic artery
2. )ateral thoracic artery
".Thoracoacromial artery
$. Posterior intercostal arteries
Both se3es have a large concentration of !lood vessels and
nerves in their niles. The niles of !oth 1omen and men can
!ecome erect in resonse to se3&al stim&li to to&ch and to cold
(eno&s drainage
The veno&s drainage of the !reast is mainly to the a3illary vein
!&t there is some drainage to the internal thoracic vein and the
intercostal veins.
I##$)3%"*#0 *. /$ 4)$%0
The !reast is innervated !y the anterior and lateral c&taneo&s
!ranches of the fo&rth thro&gh si3th intercostal nerves. The
nile is s&lied !y the T$ dermatome.
L-,2/%"& +)%"#%($
)ymhatic drainage A!o&t -5 ercent of lymh from the !reast
travels to the isilateral a3illary lymh nodes The rest travels to
arasternal nodes to the other !reast or a!dominal lymh nodes
The a3illary nodes incl&de the ectoral s&!sca&lar and h&meral
gro&s of lymh nodes These drain to the central a3illary lymh
nodes then to the aical a3illary lymh nodes The lymhatic
drainage of the !reasts is artic&larly relevant to oncology since
!reast cancer is a common cancer and cancer cells can !rea2
a1ay from a t&mo&r and sread to other arts of the !ody
thro&gh the lymh system !y metastasis
BREAST PHYSIOLOGY
1. Menstr&al #ycle> The mammary arenchyma &ndergoes
changes d&ring the menstr&al cycle arallel to0 al!eit less
rono&nced than comara!le changes in the 'ndometri&m.
These changes are reflected redominantly in lo!&lar d&cts and
in the intralo!&lar stroma. )o!&lar d&cts !ecome increasingly
n&mero&s d&ring the oestrogenic hase of the cycle0 res&lting in
an increase in lo!&lar si;e. (ac&olation of myoeitheli&m
!ecomes more consic&o&s d&ring the menstr&al hase of the
cycle.
2. Pregnancy> Mammary enlargement 1ith increased firmness is
one of the earliest signs of regnancy. This is attri!&ta!le to
roliferation of terminal lo!&lar d&cts0 res&lting in lo!&lar
enlargement0 rogressive effacement of interlo!&lar stroma0 and
comromise of interlo!&lar stroma. Pregnancy ?li2e hyerlasia
or so,called se&dolactational changes have !een associated
1ith hyerrolactinaemia as 1ell as henothia;ines0 hormonal
and anti,hyertensive agents.
D$3$!*2,$#%! %#+ P/-0"*!*("& A4#*),%!""$0 *. /$ B)$%0
Tr&e develomental a!normalities of the !reast are &ncommon.
Accessory niles are more common than a!sent !reast and
malositions.
Develomental defects of the !reasts incl&de>
a).Amastia> This is a congenital a!normality consisting of
a!sence of a nile0 !reast d&cts0 and occasionally the ectoralis
ma/or m&scle. Amastia is ro!a!ly a manifestation of
congenital ectodermal dyslasia0 !ased &on se3,lin2ed
recessive inheritance0 1hereas isolated !ilateral a!sence of the
!reasts reresents a&tosomal recessive transmission. %ts may
occ&r 1ith T&rner@s syndrome0 ovarian agenesis0 congenital
adrenal hyerlasia or delayed menarche.
!).Ayolasia> This may !e defined as lac2 of mat&ration of the
!reast .Bhile a modest degree of asymmetry of the !reasts
sho&ld !e considered normal0 &nilateral hyolasia is an
&ncommon develomental occ&rrence0 often associated 1ith
overdeveloment of the contralateral !reast. Ayolasia may
also !e ac<&ired a!normalities0 often attri!&ta!le to irradiation
of intrathoracic or chest 1all t&mo&rs in the re&!ertal atients.
This condition may occ&r in association 1ith an &nderdeveloed
ectoralis m&scle. Ayolasia of the !reast may !e associated
1ith other congenital a!normalities0 esecially renal
a!normalities. Breast asymmetry may necessitate corrective
s&rgery.
c).Macromastia7 the si;e of the !reast is largely determined !y
!ody ha!it&s and age0 its stores fat. Massive !reast enlargement
8macromastia) may !e res&lt from intrinsic lesion0 s&ch as a
neglected or raidly gro1ing malignant neolasm or0 esecially
in adolescents0 from a so,called /&venile fi!roadenoma or
m&ltile fi!roadenomas. %n s&ch instances only one of the
!reasts is &s&ally involved. %n contrast 0diff&se enlargement of
!oth !reasts0 &nassociated 1ith any discerna!le mass0 resents
most often in adolescence or regnancy. The aetiology is
&n2no1n. %t is conceiva!le that the !reast might !e the seat of
a!normal Ctarget resonse Cto normal hormonal stim&lation.
#ases have !een descri!ed from =enya0 6&dan and Nigeria.
d).6&ern&merary Breast 8Mil2line Remnants)> 6&ern&merary
!reast arise from ectoic !reast tiss&e along the mil2 lines 1hich
e3tend !ilaterally from mida3illae thro&gh the normal !reasts
inferiorly to the medial groin and v&lva. 6&ern&merary !reasts
develo from ortions of the mil2 ridges that fail to atrohy.
6&ern&merary !reast tiss&e is s&!/ect to changes that occ&r in
the !reast 1ith hormonal stim&lation0 as in regnancy and
lactation.
e).Accessory A3illary Breast Tiss&e> This is not &ncommon in
Nigeria. The normal d&ctal system e3tends into the a3illary tail
of 6ence or the s&!c&taneo&s tiss&e of the chest 1all. :s&ally0
no niles are seen. The &s&al cyclical changes occ&r0 a ala!le
mass may !e alated or its may give rise to carcinomas o&tside
the !reast roer.
f).%nfantile Breast and P&!erty> At !irth male and female !reasts
may have active secretion ca&sed !y the translacental assage
of maternal hormones. %n some infants0 this res&lts in !ilateral
!reast enlargement 1ith ela!oration of a colostr&ms li2e
secretion termed D1itch@s mil2E. Microscoically0 this is
associated 1ith d&ct dilatation 1itho&t acin&s formation.
g).#ongenital Nile %nversion> may !e d&e to the fail&re of the
nile to evert d&ring develoment and is &nilateral. Nile
inversion may !e a sign of malignancy or an inflammatory
disorder in an ac<&ired setting. #ongenital inverted niles
&s&ally correct d&ring regnancy0 or can sometimes !e everted
!y simle traction.
h).A!errant Breast> is defined as mammary gland&lar
arenchyma fo&nd !eyond the &s&al anatomic e3tent of the
!reast or mil2 line. A!errant tiss&e does not form a nile or
areola0 and is rarely clinically aarent &nless it !ecomes the
sites of a athologic rocess
#linical Manifestations of Breast Disease.
The manner of clinical manifestation of !reast disease may
rovide &sef&l cl&es that are ertinent to the secific diagnosis.
Breast disease may resent 1ith one of the follo1ings>
1. Breast Pain> also 2no1n as mastalgia or mastodynia is a very
common 1ay of manifestation of !reast disease in o&r setting.
The ain may !e associated 1ith menstr&al cycle !&t sometimes
they are not. As a r&le of the th&m!0 ma/ority of ainf&l masses
are !enign.
2. Nile Discharge7 deending on the colo&r and the <&antity
of the discharge0 its may !e a ointer to an &nderlying
malignancy. Mil2y discharges seen in galatorrhea are &s&ally
associated 1ith elevated rolactin levels associated 1ith
conditions li2e hyothyroidism0 endocrine anov&latory
syndromes0 it&itary adenoma and in atients on dr&gs for
e3amles oral contracetives0 tricyclic antideressants and
methyldoa.
Bloody or sero&s discharges altho&gh are often associated 1ith
!enign conditions0 they sometimes may !e associated 1ith
malignancies.
=indly note that the ris2 of malignancy 1ith discharge increases
1ith age.
". Pala!le mass> is most common mode of manifestation of
!reast disease in o&r setting. Most ala!le masses in the yo&ng
are most li2ely to !e fi!roadenoma and in most cases are
&nilateral.
6ometimes these masses are ointers to &nderlying invasive
carcinomas or cystic diseases. These masses m&st ho1ever !e
differentiated from the normal l&miness of the !reast. The
ro!a!ility of a mass !eing malignant increases 1ith age.
I#.!%,,%*)- %#+ R$%&"3$ C*#+""*#0 *. /$ B)$%0
%nflammation of the !reast is called mastitis. The imortant
tyes of mastitis seen in o&r environment are> ac&te mastitis and
!reast a!scess0 chronic mastitis0 mammary d&ct 'ctasia also
2no1n as lasma cell mastitis0 tra&matic fat necrosis and
galactocele.
1. Ac&te Mastitis and Breast A!scess> ac&te yogenic infection
of the !reast occ&rs mainly d&ring the early hase of lactation. A
!acteria gains entry into the !reast !y develoment of crac2s and
fiss&res in the nile. #ommon !acterial agents resonsi!le for
the infection are stahylococc&s a&re&s and stretococc&s
yogenic.
The end res&lt of the esta!lished infection is the formation of a
locali;ed area of ac&te inflammation 1hich if not treated0 may
ca&se single or m&ltile !reast a!scesses.
2. #hronic mastitis> chronic inflammation affecting the !reast is
called chronic mastitis. %t co&ld !e f&rther divided into chronic
non,secific mastitis 1hich is relatively &ncommon and chronic
gran&lomato&s inflammation.
#hronic gran&lomato&s disease in the !reast may occ&r as a
res&lt of the follo1ing>
i). 6ystemic gran&lomato&s disease e.g. as art of systemic
sarcoidosis.
ii).%nfections> this is artic&larly imortant in the troics.
%nfections s&ch as t&!erc&losis and f&ngal infection of the !reast
may occ&r in imm&nocomromised atients.
These conditions may !e misdiagnosed as !reast cancer
esecially t&!erc&losis of the !reast o1ing to a3illary nodal
involvement. T&!ercle !acilli reach the !reast via the
hematogeno&s0 lymhatic or direct sread. Pathologically0
tyical caseating t&!ercles 1ith discharging sin&ses thro&gh the
s&rface of the !reast are fo&nd.
iii).6ilicone !reast imlants> imlant on either !reast after
mastectomy or as !reast a&gmentation cosmetic s&rgery may
r&t&re or silicone may slo1ly lea2 into the s&rro&nding !reast
tiss&e. This incites chronic inflammatory reaction.
iv).%dioathic gran&lomato&s mastitis> the aetiology is &n2no1n.
This is an &ncommon form of reaction aro&nd lo!&les and d&cts.
The e3act athogenesis is &n2no1n !&t it have !een s&ggested
that l&minal secretion of the !reast eitheli&m d&ring lactation
may !e the trigger factor.
". Perid&ctal Mastitis> also 2no1n as F&s2a disease or rec&rrent
s&!areolar a!scess or s<&amo&s metalasia of lactifero&s d&cts.
This condition has a strong association 1ith cigarette smo2ing.
Patients 1ith this lesion may resent 1ith a ainf&l
erythemato&s s&!areolar mass or have an inverted nile and in
rec&rrent cases a fist&la tract may !e seen.
The hallmar2 of diagnosis is 2eratini;ing s<&amo&s metalasia
of the nile d&cts 1ith ca&sing dilation of the d&ctal system
d&e to acc&m&lation of 2eratin l&gs. 6illage of these 2eratins
into the erid&ctal tiss&e may res&lt in an intense chronic and
gran&lomato&s inflammation resonse aro&nd the erid&ctal
tiss&e leading to erid&ctal mastitis.
$. Mammary D&ct 'ctasia> this is also 2no1n as lasma cell
mastitis. This is a condition in 1hich one or more of the larger
d&cts of the !reast are dilated and filled 1ith insissated
secretions. D&ct 'ctasia affects 1omen in their $
th
to -
th
decades
of life. The aetiolgy is &n2no1n !&t its aears to !egin 1ith
erid&ctal inflammation follo1ed !y destr&ction of the elastic
tiss&e to ca&se ectasia and erid&ctal fi!rosis. Grossly0 the
condition aears as a single0 oorly,defined ind&rated area in
the !reast 1ith roiness of the s&rface. #&t section sho1s dilated
d&cts containing cheesy insissated secretions.
Aistologically0 the feat&res are>
i). Dilated d&cts 1ith either necrotic or atrohic lining !y
flattening eitheli&m and l&men containing gran&lar0
amorho&s0 in2 de!ris and foam cells.
ii).Mar2ed erid&ctal and interstitial chronic gran&lomato&s
inflammatory resonse0 chiefly lymhocytes0 histiocytes 1ith
m&ltin&cleated giant cells. 6ometimes0 lasma cells are resent
in imressive n&m!ers and the condition is then termed lasma
cell mastitis.
iii)..ccasionally0 there may !e o!literation of the d&cts !y
fi!ro&s tiss&e and varying amo&nt of inflammation0 this is
referred to o!literative mastitis.
Please note that the ma/or disting&ishing feat&re !et1een &re
erid&ctal mastitis and mammary ectasia is that s<&amo&s
metalasia of the nile d&cts is a!sent.
5. )ymhocytic Mastoathy> this is also 2no1n as scleosing
lymhocytic lo!&litis. The masses are &s&ally hard and may !e
solitary or m&ltile at resentation. The e3act aetiology is
&n2no1n !&t there are e3lanations of ossi!le a&toimm&ne
aetiology as the lesion is mostly seen in 1omen 1ith tye 1
8ins&lin ?deendent).
+. *at Necrosis> *at necrosis of the !reast ass&mes imortance
!eca&se it can sim&late carcinoma !oth clinically and
mammagrahically.
Bhile a history of antecedent tra&ma may !e o!tained0 may also
res&lts from rior s&rgical intervention or radiation theray
follo1ing !reast conserving treatment of a carcinoma. Grossly0
the e3cised l&m has central ale cystic area of necrosis.
Aistologically0 there is disr&tion of the reg&lar attern of
liocytes 1ith formation of liid,filled saces s&rro&nded !y
ne&trohils0 lymhocytes0 lasma cells and histiocytes having
foamy cytolasm and fre<&ent foreign !ody cell formation. %n
late stage0 there is relacement fi!rosis and even calcification.
Ne&roendocrine Disorders
Ne&roendocrine disorders s&ch as may occ&r in =linefelter@s
syndrome 8HHY disease)0 adrenal hyerlasia and the vario&s
degrees of hyogonadism may ca&se an aarently normal
!reast to develo a!normally. .ther rare ca&ses are adrenal
t&mo&rs0 gran&losa cell t&mo&rs and !rain t&mo&rs in the
hyothalam&s.
.
*i!rocystic #hange
%t 1as revio&sly termed fi!rocystic disease !&t is c&rrently
considered as an e3aggerated hysiological henomena and not
a disease.
Many other names have !een roosed over the years for this
disorder> cystic disease0 cystic mastoathy0 cystic hyerlasia0
mammary dyslasia0 Recl&s disease0 !enign !reast disease0 and
others.
*i!rocystic change is an e3tremely imortant lesion !eca&se of
its high fre<&ency and the a!ility of some of its s&!tyes to
sim&late the clinical0 radiograhic0 gross0 and microscoic
aearance of carcinoma7 and the ossi!le relationshi of some
of its forms to carcinoma.
%t is the most common !enign !reast condition rod&cing vag&e
Cl&my@ !reast rather than ala!le l&m in the !reast of ad&lt
1omen. %ts incidence has !een reorted to range from 14,24I in
ad&lt 1omen. Most of the atients 1ith fi!rocystic change are
!et1een "
rd
and 5
th
decades of life0 1ith dramatic decline in its
incidence after menoa&se &nless atient is on hormone
relacement theray s&ggesting the role of oestrogen in the
athogenesis.
This disorder affects rimarily the Terminal D&ct )o!&lar :nit
8TD):).
The morhological changes seen in !reasts 1ith fi!rocystic
change incl&de the follo1ings>
1. *ormation of cysts
2. Aocrine metalasia
". *i!rosis of the stroma
$. #alcification
5. #hronic inflammation
+. 'ithelial hyerlasia
-. *i!roadenomatoid change
%n recent times0 the sectr&ms of microscoic changes seen in
fi!rocystic change are divided into t1o #linicoathological
gro&s>
A.Proliferative changes7 feat&ring eithelial hyerlasia and
sclerosing adenosis.
B. Non,roliferative changes7 feat&ring cyst formation and
fi!rosis.
The roliferative changes 1ith or 1itho&t cell&lar atyia are
associated 1ith increase in the ris2 of !reast cancer.
F"4)*$2"/$!"%! N$*2!%0,
These are clinically and athologically discrete t&mo&rs that
manifest roliferation of eithelial and stromal elements. .f
imortant to &s in this lect&re is fi!roadenoma.
F"4)*%+$#*,%
*i!roadenomas are the most common !reast t&mo&r in
adolescent and yo&ng ad&lt 1omen0 1ith a ea2 age incidence in
the third decade. They acco&nt for the ma/ority of all lesions
1hich occasion !reast !iosy in this age gro&0 resenting as
1ell,circ&mscri!ed0 freely mova!le0 nonainf&l masses. The
t&mo&r are often solitary7 ho1ever0 as many as 25 ercent of
atients have m&ltile in one or !oth !reasts and they develo
s&!se<&ent t&mo&rs. There is a higher incidence in !lac2
atients.
The aetiology is &n2no1n !&t several genetic factors incl&ding
BR#A 1 and BR#A 2 increase the ris2.
Pathologic changes>
Grossly0 tyical fi!roadenoma is a small 82,$cm diameter)0
solitary ro&nd to oval0 r&!!ery0 firm masses and 1ell
encas&lation. The circ&mscrition allo1s them to !e Cshelled
o&t@ !y the s&rgeon.
The c&t s&rface is firm0 greyish,1hite0 slightly my3oid and may
sho1 slit,li2e saces formed !y comressed d&cts. .ccasionally0
m&ltile fi!roadenoma may form art of fi!rocystic disease and
is termed fi!roadenomatosis. )ess commonly0 a fi!roadenoma
may !e fairly large in si;e0 & to 15cm in diameter0 and is called
giant fi!roadenoma.
Microscoically0 there is !enign roliferation of !oth d&cts and
fi!rocollageno&s stroma. The fi!ro&s tiss&e comrises most of
fi!roadenoma.The arrangements !et1een fi!ro&s overgro1th
and d&cts may rod&ce t1o tyes of atterns 1hich may coe3ist
in the same t&mo&r. These are intracanalic&lar and
ericanalic&lar atterns. The intracanalic&lar attern is the one in
1hich the stroma comresses the d&cts into a slit,li2e saces
1hile the ericanalic&lar attern is characteri;ed !y encircling
masses of fi!ro&s stroma aro&nd the atent or dilated d&cts.
.vertime the lesion may &ndergo fi!rosis and calcification. A
/&venile variant may !e larger and more cell&lar. D&ring
regnancy they may &ndergo raid gro1th.
The s&!/ect of ossi!le increased ris2 of !reast cancer in 1omen
1ith a history of fi!roadenoma is controversial. Altho&gh most0
!&t not all a&thorities !elieve that 1omen 1ith a history of
fi!roadenoma are at a slightly increased ris2 of the develoment
of !reast cancer.
Gynaecomastia 8Ayertrohy of male !reast)
:nilateral or !ilateral enlargement of the male !reast is 2no1n
as gynaecomastia. 6ince the male !reast does not contain
secretory lo!&les0 the enlargement is mainly d&e to roliferation
of d&cts and increased erid&ctal stroma.
Gynaecomastia occ&rs in resond to hormonal stim&lation
artic&larly oestrogen. 6&ch e3cessive oestrogen activity in
males is seen in yo&ng !oys !et1een 1" and 1- years of age
8&!ertal gynaecomastia).
#a&ses>
1. 'ndocrine diseases associated 1ith increase oestrogen
secretion or red&ction in androgenic activity e.g. in liver
cirrhosis0 testic&lar t&mo&rs0 it&itary t&mo&rs0 carcinoma of the
l&ngs.
2. '3ogeno&s oestrogen administration> As a form of theray in
atients 1ith rostatic carcinoma.
". %dioathic> 'nlargement 1itho&t any o!vio&s ca&se termed
idioathic gynaecomastia.
#arcinoma of the Breast
Breast carcinoma is the most common malignant t&mo&r and the
leading ca&se of carcinoma death in 1omen in !oth the
ind&striali;ed and the develoing co&ntries.
The earliest recorded history of !reast t&mo&r came from
ancient 'gyt in 1+44 B# in a Par&s o!tained !y 'd1in 6mith
81922,1J4+).6ince then0 thro&gh the classical Gree2 eriod0 the
Medieval and Renaissance eriod different efforts 1ere made to
manage the entity no1 called !reast cancer
%t is also the commonest malignancy in Nigeria. %t is estimated
that aro3imately one in 12 1omen 1ill develo !reast cancer
in their lifetime.
The ma/ority of !reast cancers 8J5I) are soradic7 only a small
roortion0 artic&larly those diagnosed in yo&ng 1omen are
d&e to a highly enetrant a&tosomal ?dominant trait.
'idemiology
)iterat&re is relete 1ith claims a!o&t differences in
eidemiology0 !iology and o&tcome of treatment in !reast
cancer comaring Non,Aisanic 1hite and African
Americans on the one hand0 and 1ith Africans on the other
These differences incl&de ? raidly increasing incidence0
earlier age of onset0 more advanced disease at diagnosis0
higher revalence of oor redictive and rognostic
mar2ers0 and oorer o&tcome of treatment
There are vario&s st&dies in Nigeria that doc&mented the
eidemiological and the histoathological atterns of !reast
cancer in Nigeria.
Ma/ority of !reast cancer cases in Nigeria 1ere of high grade
and carried a very oor rognosis .Most of atients resent 1ith
the advanced stage of the disease.
The %le,%fe '3erience
.ne of the earliest st&dies on !reast diseases in %le,%fe 1as !y
.l&1ole et al. They revie1ed cases of !reast diseases seen in
%le,%fe !et1een 1J-- and 1J9+.The findings sho1ed 21 I of all
the atients 1ith !reast disease had !reast cancer.
Adel&sola et al in the year 1JJ+ st&died 2"+ cases of
histologically diagnosed !reast cancers in %le,%fe. They recorded
t1o ea2 age incidences 1hich 1ere $4,$J years and +4,+J
years.1J$ cases 892.2I) had the diagnosis of infiltrating d&ctal
carcinoma 8N.6).
%n 1JJ- Adeni/i et al analy;ed cases of !reast cancer in %le,%fe
over a eriod of nineteen years and only fo&nd ten cases
occ&rring in men giving an incidence rate of 1.JI.
This agreed 1ith the general glo!al 2no1ledge that !reast
cancer is rare in men.
Ades&n2anmi et al in same %le,%fe0 sho1ed in their series that the
atterns of !reast cancer had not changed m&ch over the year.
Titiloye et al in a st&dy s&ervised !y .moniyi,'san and
Adel&sola in 2449 analysed "4$ cases 1ith age range of 24,9J
years. They fo&nd o&t that the male> female 1as 1>"-0 ositivity
for oestrogen and rogesterone recetors 1ere lo1 and 1as seen
in "9.$5I and 2".JI resectively.Aer2Kne& ositivity 1as seen
in only 9.2I.Ma/ority of their cases 1ere trile negative.
Aetiology
Desite the vario&s research and st&dies carried o&t in the field
of !reast cancer0 its e3act aetiology of !reast cancer remains
el&sive. Ao1ever0 some redisosing factors or ris2ed factors
are considered significant in its aetiology>
1. Genetic factors. 6ome &!lished 1or2s have sho1n the
infl&ence of family history and inherited m&tations in !reast
cancer>
i. *amily history> *irst degree relatives 8mother0 sister0 and
da&ghter) of 1omen 1ith !reast cancer have 2 to +,fold higher
ris2 of develoment of !reast cancer.
The ris2 is roortionate to any of these factors>
a).N&m!er of !lood relatives 1ith !reast cancer
!).Yo&nger age at the time of develoment of !reast cancer
c).Bilateral cancers
d).Aigh ris2 cancer families having !reast and ovarian
carcinomas.
ii. Genetic m&tation> A!o&t 14I !reast cancers have !een fo&nd
to have inherited m&tations. These m&tations incl&de the
follo1ings>
a).BR#A genes> These are the most imortant s&sceti!ility
genes in inherited !reast cancer. There are BR#A 1 and BR#A 2
genes.
BR#A 1 gene is located on chromosome 1-0a DNA reair gene0
is resonsi!le for !oth !reast and ovarian cancer in inherited
cases. The deletion of this gene is seen in a!o&t t1o,third of
1omen 1ith inherited !reast cancer having family history !&t
BR#A 1 m&tation is &ncommon in soradic cases. Men 1ho
have m&tated BR#A 1 have increased ris2 of develoing
rostate cancer !&t not of male !reast.
BR#A 2 gene is ho1ever located on chromosome 1"0 also a
DNA reair gene0 in its m&tated form0 has a similarly higher
incidence of inherited cancer of the !reast 8one,third cases) and
its confers a smaller ris2 for ovarian carcinoma in females.
B#A1 and BR#A 2 carriers are also at higher ris2 of
develoment of other eithelial cancers0 s&ch as rostatic and
ancreatic carcinomas.
!).M&tation in P5" t&mo&r s&ressor gene on chromosome 1-
as an ac<&ired defect acco&nts for $4I cases of soradic !reast
cancer in 1omen !&t rarely in 1omen 1ith family history of
!reast cancer.P5" m&tation is also seen in )i,*ra&meni
syndrome having m&ltile cancers incl&ding !reast cancer in
yo&ng 1omen7 others are t&mo&rs of the !rain0 sarcomas0 and
adrenal cortical t&mo&rs.
c)..ther m&tations seen less commonly in !reast cancer>
i.Ata3ia telangiectasia gene
ii. PT'N 8Phoshate and tensin) t&mo&r s&ressor gene.
2. Geograhy. Breast cancer incidence rates in the develoed
1orld are a!o&t si3 times higher than the develoing co&ntries0
1ith a nota!le e3cetion in Laan. These geograhic differences
are considered to !e d&e to 1estern life style 1hich is
characteri;ed !y a highly caloric diet0 rich in fats0 refined
car!ohydrates and animal roteins 1ith lo1 hysical activity.
" Aigh state of .estrogen. There is s&fficient evidence to
s&ggest that e3cess endogeno&s oestrogen or e3ogeno&sly
administered oestrogen or e3ogeno&sly administered oestrogen
for rolonged d&ration is an imortant factor in the develoment
of !reast cancer. These evidences incl&de some of the
follo1ings>
i.Bomen 1ith rolonged rerod&ctive life0 1ith menarche
setting in at an early age and menoa&se relatively late have
greater ris2.
ii. Aigher ris2 in &nmarried and n&lliaro&s 1omen than in
married and m&ltiaro&s 1omen.
iii. Bomen 1ith first child!irth at a late age 8over "4 years) are
at greater ris2.
iv. )actation is said to red&ce the ris2 of !reast cancer on the
long r&n.
v. .estrogen relacement theray administered to
ostmenoa&sal 1omen may res&lt in increased ris2 of !reast
cancer.
vi. Men 1ho have !een treated 1ith oestrogen for rostatic
cancer have increased ris2 of develoing cancer of the male
!reast.
The mechanism of oestrogen e3cess>
Normal !reast eitheli&m ossesses oestrogen and rogesterone
recetors. The !reast cancer cells secrete many gro1th factors
1hich are oestrogen,deendent. %n this 1ay0 the ma/ority of high
circ&lating levels of oestrogen0 oestrogen recetors and gro1th
factors !ring rogression of !reast cancer.
$. 'nvironmental and dietary factors.
These incl&de large cons&mtion of animal fats0 high calorie
foods0 cigarette smo2ing0 radiation e3os&re to the chest and
alcohol.
5. Atyical d&ctal hyerlasia.
A history of rior !reast !iosies0 esecially if revealed atyical
hyerlasia0 increases the ris2 of invasive carcinoma.
#lassification of Breast #arcinoma
Ma/ority of the carcinoma of the !reast are adenocarcinomas0
1hich comosed of>
i.#arcinoma,in,sit&
ii. %nvasive carcinoma.
i.#arcinoma,in,sit&> The neolastic roliferation is confined
1ithin the d&ct or lo!&le. The malignant cells do not e3ceed the
!asement mem!rane.
The t&mo&r initially !egins 1ith atyical hyerlasia of d&ctal
eitheli&m follo1ed !y filling of the d&ct 1ith t&mo&r
cells.#linically0 it rod&ces a ala!le mass in "4,-5I of cases
and resence of nile discharge in a!o&t "4I atients.
Pathology changes.
Macroscoically0 the t&mo&r may vary from a small oorly,
defined foc&s to ",5cm diameter mass. .n c&t section0 the
involved area sho1s #ystically dilated d&cts containing cheesy
necrotic material 8comedo attern)0or the intrad&ctal t&mo&r
may !e olyoid and fria!le resem!ling intrad&ctal ailloma
8aillary attern).
Aistologically0 the roliferating t&mo&r cells 1ithin the d&ctal
l&mina may have $ tyes of atterns in different com!inations>
comedo0 solid0 aillary and cri!riform.
ii. %nvasive 8%nfiltrating) #arcinoma.
%n the develoing co&ntries li2e o&rs0 atients 1ith invasive
carcinoma of the !reasts almost al1ays resent 1ith ala!le
mass. Any of the follo1ings may also !e seen> a3illary lymh
nodes involvement0 dimling of the s2in d&e to fi3ing of larger
t&mo&r to the chest 1all0 retraction of the niles 1hen the
central ortion of the !reast is involved and lymoedema 1hen
the lymhatics are !loc2ed.
The invasive !reast cancer has vario&s morhologic tyes 1hich
have clinical and rognostic correlates.
a).%nvasive D&ctal #arcinoma,N.6
%nvasive D&ctal #arcinoma,N.6 8Not .ther1ise 6ecified) is
the classic !reast cancer and is the most common Aistologic
attern acco&nting for -4I to 94I cases of !reast cancer. %n
fact0 this is the attern of cancer for 1hich the terms Ccancer@
and Ccarcinoma@ 1ere first coined !y Aiocrates. #linically0
ma/ority of infiltrating d&cts carcinomas have a hard consistency
d&e to dense collageno&s stroma 8scirrho&s carcinoma).They are
fo&nd more fre<&ently in the left !reast0 often in the &er o&ter
<&adrant.
Pathologic changes.
Macroscoically0 the t&mo&r is irreg&lar0 1,5cm in diameter0
hard cartilage ?li2e mass that c&ts 1ith a grating so&nd. The
sectioned s&rface of the t&mo&r is grey,1hite to yello1ish 1ith
chal2y strea2s.
Aistologically0 as the N.6 s&ggests0 the t&mo&r is different from
other secial tyes in lac2ing a reg&lar and &niform attern
thro&gho&t the t&mo&r.
!).%nvasive )o!&lar #arcinoma
#omrises of a!o&t 5I of all !reast cancers. This morhologic
form differs from other invasive cancers in !eing more
fre<&ently !ilateral7 and 1ithin the same !reast0 it may have
m&lticentric origin.
Aistologically0 a characteristic single file 8%ndian file) linear
arrangement of stromal infiltration !y the t&mo&r cells 1ith very
little tendency to gland formation is seen.
c).Med&llary carcinoma
%s a variant of d&ctal carcinoma and comrises a!o&t 1I of all
!reast cancers. The t&mo&r has a significant !etter rognosis
than the &s&al infiltrating d&ctal carcinoma. This is d&e to the
good host imm&ne resonse in the form of lymhoid infiltrate in
the t&mo&r stroma.
d).#olloid 8M&cino&s)#arcinoma
This slo1,gro1ing attern is commonly seen in the older
atients and is relatively &ncommon. #olloid carcinoma has
!etter rognosis than the &s&al infiltrating d&ct carcinoma.
Aistologically0 colloid carcinoma contains large amo&nt of
e3tracell&lar eithelial m&cin and acini filled 1ith m&cin.
#&!oidal to tall col&mnar t&mo&r cells0 some sho1ing m&c&s
vac&olation0 are seen floating in large la2es of m&cin.
e).Paillary #arcinoma
This is a very rare variety of infiltrating d&ct carcinoma in 1hich
the stromal invasion is in form of aillary str&ct&res. %nvasive
aillary carcinomas are &s&ally 'R ositive and have a
favo&ra!le rognosis.
f).T&!&lar #arcinoma
This is another rare variant of invasive d&ctal carcinoma 1hich
has more favora!le rognosis.
Aistologically0 the t&mo&r is highly 1ell differentiated and has
an orderly attern. The t&mo&r cells are reg&lar and form a
single layer in 1ell ?defined t&!&les. The t&!&les are <&ite 1ell
even and distri!&ted in dense fi!ro&s stroma.
g) Metalastic #arcinoma
Rarely0 infiltrating d&ctal carcinomas may have vario&s tyes of
Metalastic alterations s&ch as s<&amo&s metalasia0
cartilagino&s and osseo&s metalasia0 or their com!ination. They
are 'R,PR,A'R2Kne& Dtrile negativeE often e3ress
myoeithelial roteins and aear to !e related to the !asal,li2e
carcinomas.
i) .thers incl&de7 Adenoid cystic 8%nvasive #ri!riform)
#arcinoma0 6ecretory 8L&venile)#arcinoma and %nflammatory
#arcinoma.
Grading0 6taging and Prognosis.
Aistologic grading and #linical staging of !reast cancer
determine the o&tcomes of atients 1ith !reast cancers.
A. Aistologic Grading> Breast cancers are s&!divided into
vario&s Aistologic grades deending &on the follo1ing
arameters>
1. Aistologic tye of the t&mo&r7
i. Non,metastasi;ing, %ntrad&ctal and lo!&lar carcinoma in sit&
ii. )ess commonly metastasi;ing,Med&llary0 colloid0 aillary0
t&!&lar0 adenoid cystic and secretary 8/&venile) carcinomas.
iii. #ommonly metastasi;ing,%nfiltrating d&ct0 invasive lo!&lar
and inflammatory carcinomas.
2.Microscoic grade>
#&rrently0 the most 1idely &sed system for microscoic grading
system is the Nottingham Aistological Grading 6ystem81hich is
the modification of the Bloom,Richardson 6ystem).
%t is !ased on " feat&res>
i.T&!&le formation
ii.N&clear formation
iii.Mitotic co&nt
". T&mo&r si;e
There is generally an inverse relationshi !et1een diameter of
rimary !reast cancer at the time of mastectomy and long,term
s&rvival.
$. A3illary lymh node metastasis
The s&rvival rate of the atient is sometimes !ased on the
n&m!er and level of lymh nodes involved !y metastasis .The
more the n&m!er of loco,regional lymh nodes involved0 the
1orse 1ill !e the s&rvival rate of the atient.
The identification and dissection of sentinel lymh node
follo1ed !y histoathologic e3amination has attained immense
rognostic val&e. 86entinel lymh node is the first node in the
vicinity to receive drainage from rimary cancer i.e. Csentinel@
over the t&mo&r).
5. .estrogen and Progesterone Recetors.
.estrogen is 2no1n to romote the !reast cancer. Presence or
a!sence of oestrogen recetors on the t&mo&r cells can hel in
redicting the resonse of !reast cancer to endocrine theray.
Accordingly0 atients 1ith high levels of oestrogen recetors on
!reast t&mo&r cells have a !etter rognosis. A rec&rrent t&mo&r
that is recetor ositive is more li2ely to resond to anti,
oestrogen theray than one that is recetor, negative.
+. DNA #ontent
T&mo&r cell s&!o&lations 1ith ane&loid DNA content as
eval&ated !y flo1 have a 1orse rognosis than &rely diloid
t&mo&rs.
B. #linical 6taging.
The American Loint #ommittee 8AL#) on cancer staging has
modified the TNM 8rimary T&mo&r0 Nodal0 and distant
Metastasis) staging roosed !y :%##8:nion %nternational for
#ontrol of #ancer).
AL# #linical 6taging of Breast #ancer
6tage T%6> %n sit& carcinoma
6tage % > T&mo&r 2cm or less in diameter
No nodal sread
6tage %% > T&mo&r M 2cm in diameter
Regional lymh nodes involved
6tage %%% A> T&mo&r M or N 5cm in diameter
Regional lymh node involved on same side
6tage %%% B> T&mo&r M or N 5cm in diameter
6&raclavic&lar and infraclavic&lar lymh nodes
involved.
6tage %( > T&mo&r of any si;e
Bith or 1itho&t regional sread !&t 1ith distant
metastasis.


Prognostic and Predictive *actors
Prognostic information is cr&cial in co&nseling atients of their
chances of s&rvival. The ma/or determinants of rognosis in any
atient 1ith !reast cancers are the histoathological
characteristics of the rimary t&mo&r and the a3illary lymh
nodes.
The ma/or rognostic factors are>
1. %nvasive carcinoma vers&s in sit& disease> Prognosis is !etter
in carcinoma in sit&.
2. Distant metastasis> #&re is &nli2ely in the setting 1ith
evidence of metastasis.
". T&mo&r si;e> The larger the si;e of the t&mo&r the higher the
chances of metastasis. )arger t&mo&rs are &s&ally associated
1ith oorer rognosis.
$. )ocally advanced t&mo&r> )ocally invasive cancers e3tending
into the s&rro&nding str&ct&res are &s&ally larger and may !e
diffic&lt to !e resected comletely.
5. )ymh node stat&s> A3illary lymh node stat&s is the gold
standard for invasive carcinoma in the a!sent of any clear
evidence of metastasis.
Minor rognostic factors>
1. Proliferative inde3> Proliferation is conventionally meas&red
&sing the mitotic co&nts as art of the microscoic grading .B&t
1ith the introd&ction of imm&nohistochemistry cell&lar roteins
s&ch cyclins0 =i+- have !een &sef&l in assessing the inde3. A
high roliferative inde3 1ill confer a oor rognosis and the
reverse.
2. Aer2Kne&> Aer2Kne& over e3ression is redictive of a oorer
o&tcome.
". )ymhovasc&lar invasion> %nvasion of lymhovasc&lar saces
!y t&mo&r cells is strongly associated 1ith oorer rognosis.
$. .estrogen and rogesterone recetors> 'R and PR ositive
t&mo&rs resond to hormonal treatment and hence confer !etter
rognosis.
5. Positive resonse to neoad/&vant theray> The e3tent to 1hich
t&mo&rs resond to cytoto3ic dr&gs and other medications
!efore s&rgery is a rognostic signal in some t&mo&rs.
+. DNA content> Ane&loid t&mo&rs are associated 1ith 1orst
rognosis.
-. Aistologic variant> T&!&lar0 m&cino&s0 aillary0 med&llary
and lo!&lar carcinomas are associated 1ith favo&ra!le rognosis
1hen comared 1ith the other variants of invasive carcinoma.
9. Aistologic grade> Nottingham Aistologic grade % and %% are
associated 1ith slightly good rognosis 1hen comared 1ith
grade %%% t&mo&rs.
J. Molec&lar rofiling of t&mo&rs> Molec&lar rofiling of
t&mo&rs rovide a vast amo&nt of information a!o&t
carcinomas .The genes e3ressed !y these carcinomas may
correlate 1ell in some cases 1ith the rognosis.

Male Breast #arcinoma
The occ&rrence of this condition in the males is said to !e very
rare. The redisosing factors are !asically same 1ith that
o!taina!le in the females.
The males !reast are smaller 1hen comared 1ith the females0
this ma2es most male atients 1ith !reast cancer to resent 1ith
ala!le s&!areolar mass. Bloody nile discharge is a common
symtom in them.
The same histologic variants of invasive cancer are resent0 !&t
the aillary s&!tye is commonly seen in the males.
The modalities of treatment are essentially same for !oth men
and 1omen 1ith !reast carcinoma.
'ND