Breast diseaseBreast disease

Dr. A. Basu MDDr. A. Basu MD

TopicTopic

1.1. General conceptGeneral concept

TDLU

D/D of a breast LumpD/D of a breast Lump

Solid Lump Cystic Lump

Bilateral

Unilateral

Fibrocystic disease

( Irregular lump)

Fibro adenoma

Cystosarcoma Phyllodes

Breast carcinoma

Fat necrosis

Abscess ( tender)

Galactocele

( History of Pregnancy)

Cyst Breast.

Diseases of Breast : lecture Diseases of Breast : lecture topictopic

A.A.Fibrocystic changes of breast: Fibrocystic changes of breast: typestypes

B.B. InflammationsInflammations

C.C.Tumors of the BreastTumors of the Breast

Fibrocystic disease of breastFibrocystic disease of breast

Non Proliferative change

Cyst and fibrosisCyst and fibrosis

Proliferative changeIts is a ‘Premalignant “ condition of the breast

Epithelial Epithelial HyperplasiaHyperplasia

Sclerosing adenosisSclerosing adenosis

Fibrocystic changesFibrocystic changes

Fibrocystic disease (Fibrocystic disease (Non Proliferative change)

Gross: Blue dome cyst [ 1to 5 cm]Gross: Blue dome cyst [ 1to 5 cm]

Non Proliferative change : : MICROMICRO

Cystic dilation of Glands an ducts

Apocrine metaplasia of the lining epithelium of the duct and glands.

Proliferative change

2.2. Epithelial HyperplasiaEpithelial Hyperplasia1.1. Subtype: AtypicalSubtype: Atypical

3.3. Sclerosing adenosisSclerosing adenosis

(Atypical) Epithelial Hyperplasia : (Atypical) Epithelial Hyperplasia : More chance of carcinoma.More chance of carcinoma.

Normal

Sclerosing adenosisSclerosing adenosis

1. Excessive fibrosis of beast

2.Increased number of collapsed gland

Sclerosing adenosis clinically mimic Sclerosing adenosis clinically mimic malignancy : because it is hard and malignancy : because it is hard and

rubbery on palpation.rubbery on palpation.

Clinical : Clinical : Fibrocystic Fibrocystic changeschanges

Lumpy Breast

Inflammation of the breastInflammation of the breast

1.1. Acute mastitis ( produce breast Acute mastitis ( produce breast abscess).abscess).

2.2. Mammary Duct ectasiaMammary Duct ectasia

3.3. Traumatic fat necrosis.Traumatic fat necrosis.

Acute mastitis ( produce Acute mastitis ( produce breast abscess).breast abscess).

Etiology : Early week of Nursing Etiology : Early week of Nursing and dermatitisand dermatitis..

Acute mastitisAcute mastitis

Mammary Duct ectasiaMammary Duct ectasia

Def : NON-inflammatory lesion.Def : NON-inflammatory lesion.Age : 40-50 years , who has Age : 40-50 years , who has

children.children.

Cause : Cause : Accumulation of Breast Accumulation of Breast secretion in Main Excretory Duct.secretion in Main Excretory Duct.

Mammary Duct ectasia: Mammary Duct ectasia: Dilated Duct , Dilated Duct , Fibrosis around the dilated duct.Fibrosis around the dilated duct.

Presence of PLASMA cells and Presence of PLASMA cells and lymphocyteslymphocytes

Mammary Duct ectasia-Mammary Duct ectasia-C/FC/F

Presents as a lump below the Presents as a lump below the nipple.nipple.

Cause nipple Retraction : mimic Cause nipple Retraction : mimic carcinomacarcinoma

Traumatic fat necrosisTraumatic fat necrosis

EarlyEarly : Small Tender and localized : Small Tender and localized lump.lump.

LaterLater : Fibrosis and : Fibrosis and calcificationcalcification occur.occur.

Tumors of the BreastTumors of the Breast

A.A. Fibro adenomaFibro adenoma

B.B. Phyllodes TumorsPhyllodes Tumors

C.C. Intraductal papillomaIntraductal papilloma

D.D. Carcinoma of the breastCarcinoma of the breast

Fibro adenoma : Breast Fibro adenoma : Breast MouseMouse

Disease involve TDLUDisease involve TDLUMost common benign tumor in Most common benign tumor in

female breast.female breast.Its growth is related to estrogen.Its growth is related to estrogen.Age : young women ( 3Age : young women ( 3rdrd Decade) Decade)They have both epithelial and They have both epithelial and

connective tissue elementsconnective tissue elements..

MorphologyMorphology

Size : 1 to 10 cm.Size : 1 to 10 cm.Tumor more than 10 cm : Tumor more than 10 cm :

Giant fibro adenoma.Giant fibro adenoma.

Gross: Breast MouseGross: Breast Mouse

Micro: 2 featuresMicro: 2 features

Gross: Well circumscribed , tan-Gross: Well circumscribed , tan-whitewhite

1. Oval round duct space1. Oval round duct space

2. Slit like , star shaped 2. Slit like , star shaped compressed ductcompressed duct

Clinical Clinical

A.A.Solitary, discreet, moveable Solitary, discreet, moveable mass ( breast mouse).mass ( breast mouse).

B.B.Regress after menopause and Regress after menopause and calcify. calcify.

C.C. It will never become malignant.It will never become malignant.

Phyllodes ( leaf –like) Phyllodes ( leaf –like) TumorsTumors

Phyllodes ( leaf –like) Phyllodes ( leaf –like) TumorsTumors

Past namePast name: : Cystosarcoma Cystosarcoma PhylloidPhylloid

It can become malignantIt can become malignantUsually a big tumorUsually a big tumorContain mainly stromal Contain mainly stromal

component.component.Morphologically has a “ leaf like” Morphologically has a “ leaf like”

appearance. appearance.

Morphologically has a “ Morphologically has a “ leaf leaf likelike” appearance” appearance

Phyllodes tumorPhyllodes tumor

High-grade lesion behave High-grade lesion behave aggressively and exhibit aggressively and exhibit recurrence.recurrence.

Fibroadenoma Vs Phyllodes Fibroadenoma Vs Phyllodes

tumortumor Low cellularity Low cellularity High cellularity, High cellularity,

bulky stroma.bulky stroma.

Rare mitosisRare mitosis High mitosisHigh mitosis

No Pleomorphism No Pleomorphism Pleomorphism Pleomorphism PresentPresent

Well circumscribedWell circumscribed Infiltrative borderInfiltrative border

Intraductal papillomaIntraductal papilloma

1.1. An Intraductal papilloma may An Intraductal papilloma may be associated with a serous or be associated with a serous or bloody nipple discharge .bloody nipple discharge .

2.2. Location : SubareolarLocation : Subareolar

3.3. It’s a benign lesion.It’s a benign lesion.

Intraductal papilloma arising Intraductal papilloma arising in in main lactiferous ductsmain lactiferous ducts

Carcinoma BreastCarcinoma Breast

Risk factorsRisk factors

1.1. Genetics and family HistoryGenetics and family History

2.2. Prolonged exposure to Prolonged exposure to exogenous estrogen and exogenous estrogen and obesity.obesity.

3.3. Alcohol consumption.Alcohol consumption.

4.4. Environmental Environmental

Risk factorsRisk factors

6.6. Proliferative breast diseasesProliferative breast diseases

7.7. Carcinoma of the contra lateral Carcinoma of the contra lateral breast or endometrium.breast or endometrium.

8.8. Frequent in nulliparous women.Frequent in nulliparous women.

9.9. ObesityObesity

Age : Genetics and family Age : Genetics and family HistoryHistory

Age : uncommon below 35 yearsAge : uncommon below 35 years

Genetic disease associated with Genetic disease associated with Breast cancer:Breast cancer:

1.1. Li-Fraumeni syndrome ( multiple Li-Fraumeni syndrome ( multiple sarcoma and carcinoma).sarcoma and carcinoma).

2.2. Cowden disease ( multiple Cowden disease ( multiple hamartoma syndrome).hamartoma syndrome).

Gene and Breast carcinomaGene and Breast carcinoma

Associate with BRCA 1 and BRCA Associate with BRCA 1 and BRCA 2 gene,2 gene,

Over expression of c-erb –b2. Over expression of c-erb –b2. HER2/neuHER2/neu

Central

20

Upper outer: 50%

Upper inner 10%

Lower inner: 10%

Lower outer

outer: 10%

Location of breast tumor

Classification Classification

A.A. Non InvasiveNon Invasive

1.1. Ductal carcinoma in situ (DCIS)Ductal carcinoma in situ (DCIS)

2.2. Lobular carcinoma in situ (LCIS)Lobular carcinoma in situ (LCIS)

3.3. InvasiveInvasive

InvasiveInvasive

1.1. Invasive ductal carcinoma ( not Invasive ductal carcinoma ( not otherwise specified ; NOS) otherwise specified ; NOS)

2.2. Invasive lobular carcinomaInvasive lobular carcinoma

3.3. Medullar carcinomaMedullar carcinoma

4.4. Colloid carcinoma Colloid carcinoma

5.5. Tubular carcinoma Tubular carcinoma

DCIS Vs LCISDCIS Vs LCIS

Arise from ductArise from duct Arise from acini.Arise from acini.

Associated with Associated with micro micro calcificationcalcification

Not associate Not associate with with calcificationcalcification

High grade DSCI High grade DSCI has bad has bad prognosisprognosis

Do not produce Do not produce mass. Good mass. Good prognosisprognosis

Duct Carcinoma In Situ : Duct Carcinoma In Situ : FeaturesFeatures

1.1. Low grade DCISLow grade DCIS : Good : Good prognosisprognosis

2.2. DCIS with micro invasionDCIS with micro invasion

3.3. VariantVariant : Comedo carcinoma : Comedo carcinoma

4.4. Paget disease of nipplePaget disease of nipple: : Extension of In situ duct Extension of In situ duct carcinoma cell to the lactiferous carcinoma cell to the lactiferous duct and the skin of the nipple. duct and the skin of the nipple.

Ductal carcinoma in situ (DCIS)Ductal carcinoma in situ (DCIS): with : with micro calcificationmicro calcification

Comedo subtypeComedo subtype of DCIS : Central of DCIS : Central

necrosis within the duct.necrosis within the duct.

Comedocarcinoma

Paget disease of nipplePaget disease of nippleExtension of In situ duct Extension of In situ duct

carcinoma cell to the carcinoma cell to the lactiferous lactiferous ductduct and the skin of the nipple. and the skin of the nipple.

Paget disease of nipple : Paget disease of nipple : Clinically resemble Clinically resemble eczema.eczema.

Paget cells:

These cells have abundant clear cytoplasm and appear in the epidermis either singly or in clusters.

Paget cell stain PAS : Indicate Paget cell stain PAS : Indicate presence of Mucinpresence of Mucin

Prognosis of DCISPrognosis of DCIS

ExcellentExcellent 97% long time survival.97% long time survival.

DCIS with micro invasionDCIS with micro invasion : bad : bad prognosis.prognosis.

Lobular carcinoma in situLobular carcinoma in situ

All acini of a breast lobe is All acini of a breast lobe is affected. affected. Cells are monomorphic Cells are monomorphic

( similar( similar size) size)

Time for Invasive carcinomasTime for Invasive carcinomas

1.1. Invasive ductal carcinoma ( not Invasive ductal carcinoma ( not otherwise specified ; NOS) otherwise specified ; NOS)

2.2. Invasive lobular carcinomaInvasive lobular carcinoma

3.3. Medullar carcinomaMedullar carcinoma

4.4. Colloid carcinoma Colloid carcinoma

Invasive ductal carcinoma Invasive ductal carcinoma ((Scirrhous carcinomaScirrhous carcinoma)- 70-80%)- 70-80%

1.1. It is carcinoma with no special It is carcinoma with no special type ( NOS).type ( NOS).

2.2. Constitute Majority of Breast Constitute Majority of Breast carcinoma.carcinoma.

3.3. They have desmoplasia They have desmoplasia (Scirrhous(Scirrhous ) )..

4.4. Stony hard mass, fixed to skin , Stony hard mass, fixed to skin , underlying muscles. underlying muscles.

Invasive ductal carcinoma Invasive ductal carcinoma (Scirrhous carcinoma(Scirrhous carcinoma

5.5. Lymph vascular and neural Lymph vascular and neural invasion common.invasion common.

6.6. Tumor cells frequently Tumor cells frequently over over express ERB B2.express ERB B2.

7.7. 2/3 rd EXPRESS HOEMONE 2/3 rd EXPRESS HOEMONE ( ESTROGEN AND ( ESTROGEN AND PROGESTERONE) RECEPTOR.PROGESTERONE) RECEPTOR.

8.8. Presence of overlying Paget’s Presence of overlying Paget’s disease : disease : Bad prognosis.Bad prognosis.

Gross : IDC ; infiltrative tumor Gross : IDC ; infiltrative tumor with irregular margin.with irregular margin.

Gross : IDC ; infiltrative tumor Gross : IDC ; infiltrative tumor with infiltrating growth .with infiltrating growth .

Micro : IDCMicro : IDC

IDC with extreme IDC with extreme desmoplasiadesmoplasia

Diagnosis Diagnosis

1.1. MammographyMammography

2.2. Micro calcification [ red alert]Micro calcification [ red alert]

3.3. FNACFNAC

4.4. BiopsyBiopsy

Inflammatory carcinomaInflammatory carcinoma

It a a variant of duct carcinoma ;It a a variant of duct carcinoma ;Shows Shows swollen , erythematous swollen , erythematous

(red) breast(red) breast mimic acute mimic acute inflammation.inflammation.

Invasive lobular carcinoma Invasive lobular carcinoma : : Main FeaturesMain Features

A.A. Tumor cells are monomorphic Tumor cells are monomorphic ( similar size).( similar size).

B.B. Frequently bilateral and Frequently bilateral and multicentric.multicentric.

C.C. More often spread to CSF, More often spread to CSF, serosal surface and ovary.serosal surface and ovary.

D.D. Frequently clinically silent.Frequently clinically silent.

E.E. Express hormone receptor.Express hormone receptor.

Invasive lobular carcinoma: Invasive lobular carcinoma: monomorphic round cellsmonomorphic round cells

Invasive lobular carcinoma : Invasive lobular carcinoma : microscopy : single indian filemicroscopy : single indian file

Bulls eye pattern of invasionBulls eye pattern of invasion

Colloid carcinomaColloid carcinoma

Age : Age : Older womenOlder womenGrowth : Growth : Slow growing, Slow growing, Prognosis ; Prognosis ; Prognosis is better Prognosis is better

than for non-mucinous, invasivethan for non-mucinous, invasive carcinomascarcinomas..

Most express hormone Most express hormone receptorreceptorss..

Gross: Soft gelatinous.Gross: Soft gelatinous.

Colloid carcinoma :Note the Colloid carcinoma :Note the abundant bluish Mucin.abundant bluish Mucin.

Medullar carcinoma-2%Medullar carcinoma-2%

A.A. IncidenceIncidence : : Less than 5% of Less than 5% of breast cancers ( occur with breast cancers ( occur with BRCA1) BRCA1)

B.B. Morphology :Morphology :

1.1. Gross Gross : : 2-5 cm, fleshy masses2-5 cm, fleshy masses . .

2.2. MicroMicro : : Sheets and nests of cells Sheets and nests of cells are surrounded by a are surrounded by a lymphoid lymphoid plasmacytic stromaplasmacytic stroma with no with no desmoplasia.desmoplasia.

Medullar carcinomaMedullar carcinoma

Medullary carcinomaMedullary carcinoma

C.C. PrognosisPrognosis : : Better than for Better than for infiltrating ductal or lobular infiltrating ductal or lobular carcinoma.carcinoma.

D.D. Lack hormone receptors. Lack hormone receptors.

Topic now Topic now

1.1. Tubular carcinomaTubular carcinoma2.2. Sarcoma of breastSarcoma of breast3.3. Features of invasive tumorFeatures of invasive tumor4.4. Spread of breast carcinomaSpread of breast carcinoma5.5. Staging of breast carcinomaStaging of breast carcinoma6.6. Clinical course and prognosisClinical course and prognosis7.7. ManagementManagement8.8. Male BreastMale Breast9.9. Miscellaneous lesionsMiscellaneous lesions

Tubular carcinoma : featuresTubular carcinoma : features

1.1. Small mass , rarely Small mass , rarely palpable( 1cm size).palpable( 1cm size).

2.2. Excellent PrognosisExcellent Prognosis

3.3. Lympnnode metastasis is rare.Lympnnode metastasis is rare.

4.4. Express hormone receptor.Express hormone receptor.

5.5. MicroMicro : : Well formed tubules and Well formed tubules and low grade nuclei.low grade nuclei.

MorphologyMorphology

Sarcoma of BreastSarcoma of Breast

All types of sarcoma can occurAll types of sarcoma can occurButBut angiosarcoma angiosarcoma is common. is common.

Features of invasive tumorFeatures of invasive tumor

1.1. Fixation to the tissue ( skin, Fixation to the tissue ( skin, muscle)muscle)

2.2. Retraction of nipple.Retraction of nipple.

3.3. Inflammatory carcinoma.Inflammatory carcinoma.

4.4. Dimpling of the skin.Dimpling of the skin.

5.5. Lymph edema : Lymph edema : caused by Tumor caused by Tumor emboli in the dermal blood vessels.emboli in the dermal blood vessels.

Retraction of nippleRetraction of nipple

Inflammatory carcinoma: common in Inflammatory carcinoma: common in pregnancy (but no inflammatory cells pregnancy (but no inflammatory cells

present)present)

Tumor emboli in the dermal Tumor emboli in the dermal blood vessels: the cause of blood vessels: the cause of

LymphedemaLymphedema

Lymphedema following radical Lymphedema following radical mastectomy: mastectomy: Thickened skinThickened skin

Spread Spread

1.1. Local Lymph nodesLocal Lymph nodes

2.2. Lung, Skeleton Lung, Skeleton ( osteolytic)( osteolytic)

3.3. Brain ( CSF)Brain ( CSF)

4.4. Metastasis may occur Metastasis may occur even after 15 years.even after 15 years.

Central

20

Upper outer: 50%Upper

inner 10%

Lower inner: 10%

Lower outer

outer: 10%

Axillary Lymph nodes

Internal mammary Lymph nodes

Prognostic factorsPrognostic factors

The size of the The size of the primary tumorprimary tumor

Invasive Ca Invasive Ca < 2 cm< 2 cm = = excellentexcellent

Lympnnode and Lympnnode and number of LN number of LN involvement.involvement.

Most important factor related to the prognosis of breast cancer

Histological Histological typetype

NOS : Duct carcinoma NOS : Duct carcinoma = bad prognosis= bad prognosis

Specialized Ca : good Specialized Ca : good prognosisprognosis

11

Prognostic factorsPrognostic factors

GradeGrade Well differentiate Well differentiate tumor = better tumor = better prognosis.prognosis.

Presence of both Presence of both estrogen / estrogen / progesterone progesterone receptorreceptor

Slightly better Slightly better prognosis.prognosis.

Prognostic factorsPrognostic factors

Aneuploidy Aneuploidy If presentIf present - - worse prognosis.worse prognosis.

Over expression Over expression of ERB B2of ERB B2

Poorer Poorer Prognosis.Prognosis.

Increased Increased mitosis.mitosis.

Bad prognosisBad prognosis

Prognostic factorsPrognostic factors

Angiogenesis Angiogenesis ++++++

More chance of More chance of metastasismetastasis

ProteaseProtease If increased more If increased more chance of invasion.chance of invasion.

HercepctinHercepctin

Monoclonal Antibody to Gene ERBB2Monoclonal Antibody to Gene ERBB2.. It is an antitumor antibody.It is an antitumor antibody. If response to this antibody is GOOD If response to this antibody is GOOD

= = GOOD prognosis.GOOD prognosis.

ManagementManagement

LumpectomyLumpectomyMastectomy or breast Mastectomy or breast

PreservationPreservationHormonal and Chemotherapy.Hormonal and Chemotherapy.Inhibition of angiogenesis.Inhibition of angiogenesis.

Post mastectomy Tumor deposit Post mastectomy Tumor deposit on scar area.on scar area.

Breast self examination; best Breast self examination; best way to save lifeway to save life

Thank you Thank you

We will now move on to Male Breast.We will now move on to Male Breast.

Male BreastMale Breast

Gyenecomastia ( Greek word) : Gyenecomastia ( Greek word) : enlargement of the male breast.enlargement of the male breast.

Proliferation of ducts in hyalinized Proliferation of ducts in hyalinized fibrous tissue with periductal edemafibrous tissue with periductal edema

Causes Causes

1.1. Puberty Puberty

2.2. Tumors ( Leydig cell tumor of Tumors ( Leydig cell tumor of testis)testis)

3.3. Genetic disorders ( kilnefelter Genetic disorders ( kilnefelter syndrome)syndrome)

4.4. Chronic liver disease (cirrhosis)Chronic liver disease (cirrhosis)

5.5. Female hormone exposureFemale hormone exposure

Carcinoma of male breast : rare : Carcinoma of male breast : rare : usually duct carcinoma.usually duct carcinoma.

Thank youThank you