BREAST

FIBROCYSTIC CHANGES
NON PROLIFERATIVE
Cysts and fibrosis

PROLIFERATIVE
Innocuous/atypical ductular epithelial cell hyperplasia
Sclerosing adenosis

CYSTS AND FIBROSIS

Dilation of ducts + formation of cysts + increase in fibrous stroma

Morphology
Ill defined 1-5 cm diameter
Discrete nodularity
Microcalcification
Lining – columnar, cuboidal cells
Apocrine metaplasia – polygonal eosinophilic cells with granular cytoplasm
Stroma – fibrous
Inflammatory infiltrate may be present

EPITHELIAL HYPERPLASIA
Mild and orderly
Ducts filled by orderly cuboidal cells and small glandular pattern within
Ductal papillomatosis
Atypical lobular hyperplasia
Monomorph8ic cells with complex architectural patterns

Dosent often produce discrete breast mass. But produce microcalcifications

SCLEROSING ADENOSIS
Gross
Hard rubbery similar to ca breast
Microscopy
Proliferation of lining epithelial cells and myoepithelial cells in small ducts
Glandular pattern within fibrous stroma
Stromal fibrosis
Can resemble invasive scirrhous ca breast

RISK FOR CA IN THESE CASES

Fibrosis and cysts
Apocrine metaplasia 0 risk
Mild hyperplasia
Fibroadenoma

Moderate florid hyperplasia

Ductal papillomatosis 1.5-2 times risk
Sclerosing adenosis

Atypical hyperplasia 5 times

Multifocal

INFLAMMATIONS
ACUTE MASTITIS
Early wks of nursing and various dermatitis

Fissures in nipples

Inspisation of secretions

Staph/ strep colonization

Morphology
Staph
Single/multiple abscesses
Scarring
Strep
Entire breast
No scarring

MAMMARY DUCT ECTASIA

Non bacterial chronic inflammation due to inspissition of breast secretion in main
excretory ducts and their dilation and rupture

Morphology
Confined to area drained by one excreatoryduct
Firm dilated ropelike structures
Cheesy white secretions containing granular debri of lipid laden macrophages, plasma
cells and lymphocytes
Occational granulomas in periductal stroma

Cause induration of breast substance

TRAUMATIC FAT NECROSIS

Initially small tender mall which later becomes a mass of scar tissue

Morphology
Central necrotic fat cells
Surrounded by neutrophils and lipid filled macrophages
Fibrous tissue and lymphocytes

TUMORS
BENIGN
TUMOR CAUSE MORPHOLOGY C/F
FIBROADENOMA Increased Gross Monoclonal
estrogen Firm, freely movable cells
level nodule(1-10 cm) Never become
White on cut section with malignant
yellow specs of glandular area
Micro
Loose fibroblastic stroma with
duct like epithelial lined specs
Pericanalicular- open duct
space
Intracanalicular- slit like duct
space
PHYLLODES Periductal Gross Benign
TUMOR stroma Large Localized and
proliferation Leaf like clefts and slits on cured by
section due to lobulation and excision
cysts Most
Increased stromal cellularity, malignant may
anaplasia and mitotic activity metastasise
INTRADUCTAL Principal Small, solitary Benign
PAPILLOMA lactiferous Multiple papillae- Multiple
ducts/sinuses Central connective tissue papillomas in
Cuboidal or columnar cell several ducts
lining and absence of
Frequently double layered myoepithelium
epith, basal layer- indicates
myoepithelial malignancy

CARCINOMA
CAUSES
Hormone replacement therapy for osteoporosis
OCPs
Ionizing radiations
Genetic
HER2/NEU
RAS, MYC amplification
RB, p53 mutation
5 subtypes based on gene profiling
Luminal A - estrogen receptor positive
Luminal B - estrogen receptor positive
HER2/NEU overexpressing - estrogen receptor negative
Basal like - estrogen receptor and HER2/NEU negative
Normal breast like
CLASSIFICATION
Non invasive
DCIS
LCIS
Invasive
IDC (Scirrous tumor)
ILC
Medullary carcinoma
Colloid carcinoma
Tubular carcinoma
Other types

NON INVASIVE
DCIS LCIS
Origin Terminal duct lobular unit Terminal duct lobular unit
Gross Fill distort, unfold lobules involved and Expand, but dosent alter the
appear to involve duct like spaces underlying str
Histology Wide variety of appearance Uniform
Solid, comedo, cribriform, papillary, Loosely cohesive clusters
micropapillary, clinging Signet ring cells
Nuclear Low and high Low
grade
Hormone Positive -----
receptors
Prognosis Excellent High chance for invasive
carcinoma and developing
in both breasts
Treatment Simple mastectomy Clinical and radiological
Antiestrogenic therapy, tamoxifilin follow up
Aromatase inhibitors Bilateral prophylactic
mastectomy
C/F Palapable mass or nipple discharge Often incidential finding
No masses or calcification

PAGETS DISEASE
Extension of DCIS to lactiferous ducts and contiguous skin around nipple
Disrupt epidermal barrier
Unilateral crusting
INVASIVE CARCINOMA
TYPE MORPHOLOGY PROGNOSIS RECEPTORS
DUCTAL Gross Vary according 2/3 have
Produce desmoplastic to type. But hormone
response generally poor receptors
Microscopy 1/3 have
Heterogeneous HER2/NEU
INFLAMMATORY Enlarged, swollen, Poor ----
erythematous due to
blockage of lymphatics.
No true inflammation.
Poorly differentiated
carcinoma
LOBULAR Gross Metastasise Hormone
Bilateral and multicentric more frequently receptors
more frequently than to CSF, ovary,
others serosa, uterus,
Microscopy GIT, BM
Cells identical to LCIS
Allined in strands or
chains
Bulls eye pattern
occationally
MEDULLARY Gross -------- No receptors
Well circumscribed and BRCA1
mistaken for mutations seen
fibroadenoma
Micro
Sheets of large anaplastic
cells with well
circumscribed borders and
lymphoplasmacytic
ingiltrate
TUBULAR Gross Excellent Hormone
No palpable mass. Only receptors
mammographic densities
Well formed tubrles with
low grade nuclei

COMMON FEATURES
Tendency to become adherent to pectoral fascia, muscles and skin
Dimpling of skin, lymphedema

SPREAD
Lymphatic and hematogenous
Metastasis mainly to lungs, skeleton, adrenals, liver and less commonly to brain and
pituitary

COURSE
Solitary, movable painless mass
2-3 cm when palpable and 1 cm when just detectable by mammography

PROGNOSIS
TNM
Grade – well differentiated, moderate differentiated, poorly differentiated based on
Tubule formation
Nuclear grade
Mitotic rate
Histology
Presence of hormone receptors is a slightly better prognosis
Proliferation rate
Aneuploidy
Overexpression of HER2NEU is bad prognosis

STAGING
STAGE 1 Invasive carcinoma <=2 cm without nodes 87%
Carcinoma insitu with micro invasion
STAGE 2 Invasive carcinoma <=5 cm with 3 axillary lymph nodes 75%
>5 cm without lymph nodes
STAGE 3 Invasive carcinoma <=5 cm with >4 lymph nodes 46%
Invasive carcinoma >5 cm with nodal involvement
Invasive carcinoma of any size with > 10 nodes
Invasive carcinoma of any size with ipsilater IMN involvement
Invasive carcinoma of any size with skin involvement
Inflammatory carcinoma
STAGE 4 Distant metastasis 13%