Benign breast lesions

Moderated by:- Presented by:-

Dr Neha Banseria Dr Sunil Kumar Patidar
Assistant professor PG student
Department of pathology
Introduction
• The breast is a modified skin appendage.

• Breast lies in the superficial fascia of the

pectoral region.

• A small extension called axillary tail( of

spence) pierces the deep fascia and lies in the
axilla.
Structure of the breast
• Skin- covers the gland and present the followings

• Nipple-
• Present just below the centre of the breast.

• At the level of 4TH ICS.

• Pierced by 15-20 lactiferous ducts.

Areola-
• Skin around the base of the nipple is
pigmented and forms the circular
area.

• It is rich in modified sebaceous

glands.
• Breast is composed of specialized epithelium and
stroma that give rise to both benign and
malignant lesions.

• Six to ten major ductal systems originate at the

nipple.

• Successive branching of the large ducts

eventually leads to the terminal duct lobular unit
(TDLU).
• In the adult woman, the terminal duct
branches into a grapelike cluster of small
acini to form a lobule.
Classification of non neoplastic breast
lesions
• Non proliferative Breast Changes
• Duct ectasia
• Cysts
• Apocrine change
• Mild hyperplasia
• Adenosis
• Fibroadenoma without complex features
• Proliferative Disease Without Atypia
• Moderate or florid hyperplasia
• Sclerosing adenosis
• Papilloma
• Complex sclerosing lesion (radial scar)
• Fibroadenoma with complex features
• Proliferative Disease with Atypia
• Atypical ductal hyperplasia
• Atypical lobular hyperplasia
Normal duct or acinus
It has
• Single basally located
myoepithelial cell layer (cells
with dark, compact nuclei and
scant cytoplasm) and
• A single luminal cell layer
(cells with larger open nuclei,
small nucleoli, and more
abundant cytoplasm).
Mammary Duct Ectasia (Plasma cell
mastitis)
• Dilatation of one or more larger ducts and filled
with inspissated secretions.
• Associated with periductal and interstitial chronic
inflammatory changes.
• The patients may remain asymptomatic or there
may be nipple discharge, retraction of the nipple
and clinically palpable dilated ducts in the
subareolar area.
Grossly,
• The condition appears as a single, poorly-
defined indurated area in the breast with
ropiness on the surface.

• Cut section shows dilated ducts containing

cheesy inspissated secretions.
Histologically
• Dilated ducts with either necrotic or atrophic
lining by flattened epithelium and lumen
containing granular, amorphous, pink debris
and foam cells.

• Periductal and interstitial chronic

inflammation, chiefly lymphocytes, histiocytes
with multinucleate histiocytic giant cells.
• Sometimes, plasma cells are present in
impressive numbers and the condition is
then termed plasma cell mastitis.

• Occasionally, there is obliteration of the

ducts by fibrous tissue and varying
amount of inflammation and is termed
obliterative mastitis.
Intraductal papilloma.
• A central fibrovascular
core extends from the
wall of a duct.

• The papillae arborize

within the lumen and are
lined by myoepithelial
and luminal cells.
Nipple discharge

• Less common presenting symptom but is of

concern when it is spontaneous and unilateral.

• A discharge produced by manipulating the breast

is normal.
A milky discharge (galactorrhea)

Causes
• Increased production of prolactin
• Hypothyroidism,
• Endocrine anovulatory syndromes,
• Patients taking oral contraceptives, TCA,
methyldopa, or phenothiazines.
• Repeated nipple stimulation,
• Milky discharge has not been associated with
malignancy.
Bloody or serous discharges
• Associated with benign lesions but, rarely, can
be due to a malignancy.

• A normal bloody discharge can also occur

during pregnancy, possibly due to the rapid
formation of new lobules.
• The risk of malignancy with bloody
discharge increases with age.

• Discharge is associated with carcinoma

in 7% of women younger than 60 years
and in 30% of women older than 60
years.
ACUTE MASTITIS AND BREAST
ABSCESS
• Acute pyogenic infection of the breast.

• Bacteria such as staphylococci and streptococci

gain entry into the breast by development of
cracks and fissures in the nipple.
• Initially a localized area of acute inflammation,
if not effectively treated, may cause single or
multiple breast abscesses.

• Which my result into Extensive necrosis and

replacement by fibrous scarring of the breast
with retraction of the nipple.
GRANULOMATOUS MASTITIS
It may occur as a result of the following:-
• Systemic non-infectious granulomatous disease
• Infections e.g. tuberculosis
• Silicone breast implants
• Idiopathic granulomatous mastitis
FIBROCYSTIC CHANGE

• Most common benign breast condition.

• Producing vague ‘lumpy’ breast rather than
palpable lump.
• Incidence 10-20% in adult women, between
3rd and 5th decades of life.
• Decline in incidence after menopause-role of
estrogen.
Fibrocystic change of the female breast is
characterised by:-
i) Cystic dilatation of terminal ducts.
ii) Relative increase in inter- and intralobular
fibrous tissue.
iii) Variable degree of epithelial proliferation in
the terminal ducts.
The spectrum of histologic changes is divided into
two clinicopathologically relevant groups:
a. Non-proliferative changes: Simple
fibrocystic change.
b. Proliferative changes: Proliferative
fibrocystic change.
NON-PROLIFERATIVE
FIBROCYSTIC CHANGES: SIMPLE
FIBROCYSTIC CHANGE

• Simple fibrocystic change most commonly

includes 2 features—
• Formation of cysts of varying size, and
• Increase in fibrous stroma.
Grossly,
• Cysts are usually multifocal and bilateral.
• The usual cyst is rounded, translucent with
bluish colour prior to opening (blue-dome
cyst).
• Cyst contains thin serous to haemorrhagic
fluid.
Microscopically,
• Cyst formation
• The lining epithelium of cyst is flattened or
atrophic.
• There is apocrine change or apocrine metaplasia in
the lining of the cyst resembling the cells of
apocrine sweat glands.
• Occasionally, there is simultaneous epithelial
hyperplasia forming tiny intra cystic papillary
projections of piled up epithelium.
Fibrosis
• There is increased fibrous stroma
surrounding the cysts and variable
degree of stromal lymphocytic
infiltrate.
PROLIFERATIVE FIBROCYSTIC
CHANGES

• Includes:-
• Epithelial hyperplasia and
• Sclerosing adenosis.
EPITHELIAL HYPERPLASIA or
Epitheliosis
• It is defined as increase in the layers of epithelial
cells over the basement membrane to three or more
layers in the ducts (ductal hyperplasia) or lobules
(lobular hyperplasia).
• Epithelial hyperplasia may be totally benign or
may have atypical features.
• Microscopically,
• Epithelial hyperplasia show various grades of
epithelial proliferations (mild, moderate and
atypical)
1. Mild hyperplasia of ductal epithelium consists
of at least three layers of cells above the
basement membrane, present focally or evenly
throughout the duct.
2. Moderate and florid hyperplasia
• Ductal lumen is filled with proliferated
epithelium.
• It may be focal, forming papillary epithelial
projections called ductal papillomatosis, or
• May be more extensive, termed florid
papillomatosis, or
• May fill the ductal lumen leaving only small
fenestrations in it.
3. Atypical ductal hyperplasia
• Duct lumen is partially filled and produce
irregular micro glandular spaces or cribriform
pattern.
• The individual cells are uniform in shape but
show loss of polarity with indistinct
cytoplasmic margin and slightly elongated
nuclei.
4. Atypical lobular hyperplasia
• It is closely related to lobular carcinoma
in situ but differs by
• Lobular carcinoma has cytologically
atypical cells only in half of the ductules
or acini.
SCLEROSING ADENOSIS
• It is benign proliferation of small ductules or
acini and intralobular fibrosis.
• The lesion may simulate an infiltrating
carcinoma, both clinically and pathologically.
• Unlike carcinomas, the acini are arranged in a
swirling pattern, and the outer border is usually
well circumscribed.
Grossly,
• The lesion may be coexistent with other
components of fibrocystic disease or
• May form an isolated mass which has hard
cartilage-like consistency, resembling an
infiltrating carcinoma.
Microscopically,
• There is proliferation of ductules or acini and
fibrous stromal overgrowth.
• The histologic appearance may superficially
resemble infiltrating carcinoma but
• Differs from the latter in having maintained
lobular pattern and lack of infiltration into the
surrounding fat.
Prognostic Significance
1. Non-proliferative fibrocystic changes -do not
carry any increased risk of developing invasive
breast cancer.

2. Proliferative fibrocystic changes-associated with

1.5 to 2 times increased risk for development of
invasive breast cancer.
3. Multifocal and bilateral proliferative
changes in the breast pose increased risk to
both the breasts equally.
4. Within the group of proliferative fibrocystic
changes, atypical hyperplasia in particular,
carries 4 to 5 times increased risk to develop
invasive breast cancer later.
Fibrocystic change Non proliferative Proliferative
fibrocystic change fibrocystic change
Fibroadenoma
• Fibroadenoma is a benign tumour of fibrous and
epithelial elements.
• It is the most common benign tumour of the
female breast.
• Most common age of presentation 15 to 30 years
of age.
• Clinically, fibroadenoma generally appears as a
solitary, discrete, freely mobile nodule within the
breast.
Grossly,
• Typical fibroadenoma is a small (2-4 cm
diameter), solitary, well encapsulated, spherical or
discoid mass.

• The cut surface is firm, grey-white, slightly

myxoid and may show slit-like spaces formed by
compressed ducts.
Microscopically,
• Fibrous tissue comprises most of a fibroadenoma.
• The arrangements between fibrous overgrowth and
ducts may produce two types of patterns.
• These are intracanalicular and pericanalicular
patterns: ”.
Intracanalicular pattern
The stroma compresses the ducts so that they
are reduced to slit-like clefts lined by ductal
epithelium or

May appear as cords of epithelial elements

surrounding masses of fibrous stroma. ”
Peri canalicular pattern
Characterised by encircling masses of fibrous
stroma around the patent or dilated ducts.

The fibrous stroma may be quite cellular, or there

may be areas of hyalinised collagen.
Morphologic variants of
fibroadenomas
1. Tubular adenoma.
• If the tumour is predominantly composed of
closely-packed ductular or acinar
proliferation and fibrous tissue element in the
tumour is scanty.
2. lactating adenoma
• If an adenoma is composed of acini with
secretory activity,
• Seen during pregnancy or lactation.
Juvenile fibroadenoma
• Uncommon variant
• It is larger and rapidly growing mass seen in
adolescent girls
• It does not recur after excision.
PHYLLODES TUMOUR
(CYSTOSARCOMA PHYLLODES)

• Cystosarcoma phyllodes was the nomenclature given

by Müller in 1838 to an uncommon bulky breast
tumour with leaf-like gross appearance
(phyllodes=leaf-like) having an aggressive clinical
behaviour.
• Most patients are between 30 to 70 years of age.
• The tumour resembles a giant fibroadenoma.
• Later, the WHO classification of breast tumours has
proposed the term ‘phyllodes tumour’.
• Phyllodes tumour can be classified into benign,
borderline and malignant on the basis of histologic
features of stromal cells.
• Local recurrences are much more frequent than
metastases.
Grossly,
• The tumour is generally large, 10-15 cm in
diameter, round to oval, bosselated, and less fully
encapsulated than a fibroadenoma.
• The cut surface is grey-white with cystic cavities,
areas of hemorrhages, necrosis and degenerative
changes
Histologically,
• The phyllodes tumour is composed of an extremely
hypercellular stroma, accompanied by benign ductal
structures.
• Thus, phyllodes tumour resembles fibroadenoma except for
marked stromal overgrowth.
• The histologic criteria considered to distinguish benign,
borderline and malignant categories of phyllodes tumour are
based on following cellular features of stroma:
• i) frequency of mitoses;
• ii) cellular atypia;
• iii) cellularity; and
• iv) infiltrative margins.
Complex sclerosing
lesion (radial scar).
There is a central nidus
consisting of small
tubules entrapped in a
densely fibrotic stroma
surrounded by radiating
arms of epithelium
GYNAECOMASTIA
(HYPERTROPHY OF MALE BREAST)

• Unilateral or bilateral enlargement of the male breast is

known as gynecomastia.
• Since the male breast does not contain secretory
lobules, the enlargement is mainly due to proliferation
of ducts and increased periductal stroma.
• Gynecomastia occurs in response to hormonal
stimulation, mainly estrogen.
FAT NECROSIS

• It is generally initiated by trauma

• The condition presents as a well-defined mass with
indurated appearance.
Grossly,
• The excised lump has central pale cystic area of
necrosis.
Histologically,
• There is disruption of the regular pattern of
lipocytes with formation of lipid-filled spaces
surrounded by neutrophils, lymphocytes, plasma
cells and histiocytes having foamy cytoplasm and
frequent foreign body giant cell formation.
• In late stage, there is replacement fibrosis and
even calcification.
GALACTOCELE

• It is cystic dilatation of one or

more ducts during lactation.
• The mammary duct is
obstructed and dilated to form
a thin-walled cyst filled with
milky fluid.
• Rarely, the wall of galactocele
may get secondarily infected.
Thank
you…………..