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PATHOLOGY REVIEW OF THE BREAST

For a bunch of boobs

Describe/ draw the normal anatomy of the breast.


What types of pathology are most likely to effect the different regions of
the breast?

Each breast divided into large segments called lobes, and these further
divided into lobules, inside lobules. Together the lobule & its terminal
duct (draining bit) = terminal duct lobular unit. The TDLU is where most
breast cancers arise from.

Check out this sweet boob. Whats up with it? Can you describe the
histology?

This slide shows a normal breast terminal duct lobular unit

Throughout length or lobule, lined by two layers of epithelium


(myoepithelium, and cuboidal epthelium), resting on BM. This is
surrounded by breast stroma.

Before the onset of puberty there is some ducts, but no arangment


of lobes or lobules, accompanied by an overabundance of stroma.

Lobes with acinic, lactiferous ducts become apparent after


menarchy, with changes to stroma, and increased adipose
(note this in top left)

Lactational change in late pregnancy = physiological hyperplasia,


with decreased stroma & ^^^ acini

What are the most common presentations of breast lesions/ bumps?

What is the most common area for cancer?

Whats the deal with mammograms? How do they work? What can
they see?

What are the most common presentations of breast lesions/ bumps?


-Pain (mastalgia) > MC px, but overall, but less common in
malignancy
-Palpable mass (>2cm)
-Nipple discharge

What is the most common area for cancer?


-Upper outer quadrant (50%) > most amount of glandular tissue

Whats the deal with mammograms? How do they work? What can
they see?
-Mammograms are low energy x-rays of the breast. Can pick up
densities (localised) & calcifications (in malignancy usually tiny &
clustered)
-Sensitivity of the test increases with age because of ^ fat &
decreasing stroma :. Dense areas are more clearly seen

Suss mammograms are


investigated using either
FNA, or core biopsies, but
lumpectomies,
mastectomies, and lymph
nodes may also be taken
for histo.

Non Malignant Pathology of


the Breast

a. What are these things?!

a. Hypertrophy of the breast can be unilateral or bilateral. Only


issue is aesthetic. Usually occurs in adolescence.
b. Polythelia supranumery nipples = extra nipples along the milk
line, due to persistence of epithelial remnants. May cause issues
around lactation.
c. Polymastia = accessory breast > dont mistake for axillary lymph
node on exam! Can give rise to cancers.

Whats this? And when does it most commonly occur?


What can be seen on the histology?
Whats the most common causative organism?
If this woman was not breast feeding, what might you consider?

Whats this? And when does it most commonly occur?


Acute mastitis (puerperal abscesses) > usually when breast feeding/ post pregnancy.
Px = discharge, pain, swelling, redness. Cracked nipple provides entry point for
bacteria. Spreads via lymphatics.
What can be seen on the histology?
Neutrophils!
Whats the most common causative organism?
Staph aureus
If this woman was not breast feeding, what might you consider?

Periductal mastitis

Can also get non-puerperal abscess. Has an association with


smoking > possibly due to squamous metaplasia around lactiferous
duct = blockage & bacterial infection. Can cause fistula
communication.

A woman presents to you with a lump in her breast. You perform a


FNA, and this is the result of the histology. Whatchya reckon maayte?
Any risk of this lesion becoming malignant?

A woman presents to you with a lump in her breast. You perform a


FNA, and this is the result of the histology. Whatchya reckon maayte?
Understandable you might confuse this for a tumour, especially due to
the calcifications you might note on mammaogram, and the painless
lump you feel on exam. It is however, fat necrosis due to trauma!
MC in obese women and after menopause due to the increase in
adipose tissue.
Any risk of this lesion becoming malignant? Nah.

A woman presents to you with a lump in her breast. You perform a FNA, and
this is the result of the histology. Whatchya reckon maayte?

Any risk of this lesion becoming malignant?

A woman presents to you with a lump in her breast. You perform a FNA, and this is
the result of the histology. Whatchya reckon maayte?

- A common condition that presents with palpable lump is fibrocystic change.


There are three principal morphological changes that occur, cyst formation,
fibrosis and adenosis. Adenosis is an increase in the number of acini per lobule.
- MC condition in breast in 15-35yrs
- Can appear abnormal on mammogram
Any risk of this lesion becoming malignant?
- Non-proliferative disease > Non-significant risk for ca

A woman presents to you with a lump in her breast. You perform a


FNA, and this is the result of the histology. Whatchya reckon maayte?

Any risk of this lesion becoming malignant?

A woman presents to you with a lump in her breast. You perform a FNA, and this is the
result of the histology. Whatchya reckon maayte?
Fibroadenoma is the most common benign tumour (stromal-epithelial neoplasm) of the
female breast.
-Usually <30yrs
-well circumscribed and consist of stroma which compresses glandular spaces.
-Can appear as popcorn calcifications on mammorgram, but as firm, well circumscribed
borders well defined from surrounding tissue
-Fibrosis of stroma & glandular component > ducts becomes slit-like

A woman presents to you with a lump in her breast. You perform a


FNA, and this is the result of the histology. Whatchya reckon maayte?
Any risk of this lesion becoming malignant?

A woman presents to you with a lump in her breast. You perform a FNA, and this is the
result of the histology. Whatchya reckon maayte?

Phyllodes tumour (cystosarcoma phyllodes)


- MC in 6th decade.
- Biphasic tumour with the stromal component determining the behaviour of the lesion,
and devided into low and high grade based on the appearance of the stroma
- Can be massive size w prominent superficial veins > can be confused for malignancy
- leaf-like on histology > similar to fibroadenoma on histo, but ducts less slit-like, and
fibrosis more rounded & leaf like
- can be resected, but often recur & this confers an increased risk fr malignancy
occurring

Pts usually px with blood stained nipple discharge. Under category of proliferative
disease can progress to malignancy.
Can occur in lactiferous ducts = low potential for malignancy, smaller ducts =
higher risk

Malignant Breast Lesions


Some (less than) fun facts:
-Breast ca is the most common malignancy in women, and 2nd most common
cause of death
-1/10 women at 80 have (had) breast ca
-risk factors: FHx (7-8x in first degree family member, though familial BCa is only
5-10% these cancers), alcohol, obesity, radiation, ^oestrogen ie. early menarche,
no prenancies, late menopause, HRT etc. (pregnancy is also protective due to
terminal differentiation of epithelium in preparation for lactation)
Aspects to be considered when diagnosing breast lesions:
- Physiological changes must be distinguished from pathological lesions
menstrual cycle and pregnancy
- Family history is essential
- The age of the patient is important for diagnosis below the age of 35 benign
breast lumps are more common than carcinomas
- Common presentation is a lump or lumps single or multiple, well
circumscribed or ill-defined, mobile or attached to skin or muscle
- Nipple discharge duct papilloma
- Nipple ulceration or eczema Pagets disease

Malignant Breast Lesions


Clinical Features that may help to distinguish benign and malignant breast
lumps:
It is usually a combination of factors and not a single criterion that makes one
suspicious that the lump is malignant.
- Mobility benign lumps tend to be more mobile whereas malignant are
more often fixed.
- Definition benign well defined, malignant ill-defined
- Texture malignant are hard due to the stromal desmoplastic reaction
- Size rapid increase in size may suggest malignant growth
Pagets disease
- Pain whilst both benign and malignant lesions can be painless,
unremitting pain suggests malignancy
- Metastases enlarged axillary nodes may indicate metastatic spread,
explain the significance of sentinel lymph nodes and how they are identified.

Malignant shizzle
Classification of breast carcinoma:
-Insitu (non-invasive): Carcinoma in situ occurs when the neoplastic cells are
confined to the ducts and lobules (there is no penetration of the basement
membrane). It is divided into lobular carcinoma in situ (LCIS) and ductal
carcinoma in situ (DCIS).
-Invasive carcinoma (defined as those which breach the basement
membrane & extend into the underlying stroma).
- Divided into ductal, lobular, medullary, tubular, and mucinous
carcinomas.
- Ductal & lobular are most common
- Types are graded using three features: number of mitoses, nuclear
pleomorphism, and tubular formation. Receptor status (ER
esostrogen receptor, PR progesterone receptor and HER2 human
epidermal growth factor receptor 2) plays a role in determining the
treatment.

I am bilateral with 80 to 90% occurring in premenopausal women.

WHO AM I??

Breast profile:
A: ducts
B: lobules
C: dilated section of duct to hold milk
D: nipple
E: fat
F: pectoralis major muscle
G: chest wall/ rib cage
Enlargement:
A: normal lobular cells
B: lobular cancer cells
C: basement membrane

LCIS is usually bilateral with 80 to 90% occurring in premenopausal women.


Table 1. Lobular carcinoma in situ (LCIS)

Normal breast with lobular carcinoma in situ (LCIS) in an enlarged cross


section of the lobule.
Breast profile:
A: ducts
B: lobules
C: dilated section of duct to hold milk
D: nipple
E: fat
F: pectoralis major muscle
G: chest wall/ rib cage
Enlargement:
A: normal lobular cells
B: lobular cancer cells
C: basement membrane

DCIS is often detected mammographically. The treatment requires surgical


excision. 83% of Insitu carcinomas are ductal.
Breast profile:
A: ducts
B: lobules
C: dilated section of duct to hold milk
D: nipple
E: fat
F: pectoralis major muscle
G: chest wall/rib cage
Enlargement:
A: normal duct cells
B: ductal cancer cells
C: basement membrane
D: lumen (centre of duct)

Who am I?
I often have a stony hard consistency, with small calcifications. On resection Im
usually chalky white, and poorly circumscribed.

Another clue?
My histology is quite varied. I can have well differentiated glands, or perhaps solid
sheets of cells, with no clear pattern. Thus I am often described as NST no
specific type

You are correct!


Invasive ductal carcinoma the most
common invasive breast cancer!

Who am I?
Im more common in post-menoupausal women.
I commonly px bilaterally.
I am palpable often as a vague thickened area of the breast rather than stony hard.

Who
am
I?
My histology is quite typical as neoplastic sheets of cells in single (indian) file
arrangement.
I also have a weird mode of metastasis with a odd fetish for peritoneum, meninges
and ovary!

Yeeah, lobular invasive


carcinomaaa

Why am I bumpy? And look like an orange?

Peau dorange! Often a sign advanced breast malignancy > lymphatic


involvement = lymphatic oedema of skin w dimpling due to anchoring around
suspensory ligaments of cooper BUT can also occur in acute mastitis

What up with this weird nipple?

Pagets disease
- * NOT the pagets
disease of bone
- deep intraductal
adenocarcinomas &
transport via lactiferous
ducts to outer skin
surrounding nipple
- not invasive > travel
along existing
architecture
- pagets cells - rounded,
often mucin positive
- px: scaly lesion around
nipple - can be confused
for eczema etc