Benign and Malignant Breast Diseases Flashcards
What are the 5 major groups of benign breast disease?
- Inflammatory conditions
- Non - proliferative breast changes
- Proliferative breast disease without atypia
- Proliferative breast disease with atypia
- Benign neoplastic lesions/tumours
What is the clinical presentation of benign breast disease?
- Pain
- Palpable mass
- Nipple discharge or skin changes
What are the 2 categories of inflammatory conditions?
- Infectious - uncommon, usually seen with lactation
e. g. acute pyogenic mastitis - Non - infectious
e. g. mammary duct ectasia and fat necrosis
What is acute pyogenic mastitis?
- Acute inflammatory condition
- Very painful
- Usually occurs first few weeks after delivery
Describe the clinical presentation of acute pyogenic mastitis?
- There is rubor, calor, tumor and dolor
- Purulent nipple discharge in severe cases
- If untreated can progress to abscess formation
What causes mastitis?
- S. aureus, common
- S. pyrogens
Describe the aetiopathogenesis of acute pyogenic mastitis?
- Portal of entry = crack in nipple with lymphatic spread
- bacteria causes widespread inflammation with systemic effects
- Duct obstruction by a keratotic plug (hair follicles get clogged with dead skin cells and keratin) contributes
- Usually localised to one segment with spread to others in some cases
What other infections can cause acute pyogenic mastitis?
tuberculosis
How does TB cause APM?
Usually haematogenous spread from a focus in the lung
- Can occur as part of miliary TB
What is the clinical presentation for APM caused by TB?
- Caseous mass in the breast
- Complicated cases can form sinuses
- Clinically can mimick cancer hence need for a biopsy
Name the oppurtunistic infections of immunocompromised patients that can lead to APM?
Localised or as part of systemic infection
- histoplasmosis, cryptococcus, mucormycosis - fungal
- Atypical mycobacteria
- Actinomycosis
What is mammary duct ectasia?
subareolar periductal inflammation with dilated mammary glands
- Involves larger ducts
- Severe cases can extend to smaller ducts
- Common in perimenopause and menopause
- has no relationship to malignancy
What is the clinical presentation of MDE?
- nipple discharge : when blood stained can mimick cancer
- nipple retraction due to fibrosis around ducts
- mass
What is the pathology of MDE?
- Dilated ducts filled with sticky/viscous material
- Periductal chronic inflammation: lymphocytes, plasma cells, macrophages
- Periductal fibrosis
What is fat necrosis?
a benign condition that most commonly develops after an injury or trauma to the breast tissue
- Frequently seen in obese people and after menopause
Describe the clinical presentation of fat necrosis?
Presents as a discrete lump therefore mimicking cancer
Describe the macroscopic presentation of fat necrosis?
yellow haemorrhagic tissue with calcifications
Describe the microscopic morphology of fat necrosis?
- necrotic adipocytes,
- chronic inflammation,
- foamy macrophages
- fibrosis
What are non-proliferative breast changes?
breast fibrocystic change characterized by the absence of epithelial cell hyperplasia
- No increase in risk of cancer compared to the proliferative diseases
Non proliferative breast changes can present with?
- Palpable mass
- Nipple discharge
- Mammographic densities or calcifications
What are the 3 principal patterns of morphologic change in non proliferative breast disease?
- cyst formation
- fibrosis
- adenosis
Describe cyst formation in NPBD?
- Small to large cysts (blue-dome cysts)
- Aprocrine metaplasia present
- Calcifications
Describe fibrosis in NPBD?
Secondary to cyst rupture with subsequent inflammation and fibrosis
Describe adenosis in NPBD?
- Increase in number of acini per lobule
- Acini not distorted, no epithelial hyperplasia
Proliferative breast disease without atypia is characterised by?
- Proliferation of ductal epithelium and/stroma
- No epithelial atypia
- Can form palpable masses, majority of cases do not
- Commonly detected as mammographic densities
What is the microscopic morphology of proliferative breast disease without atypia?
- Epithelial hyperplasia: moderate or florid
- Sclerosing adenosis
- Complex sclerosing lesion (radial scar)
- papillomas
Compare normal breast tissue vs breast with epithelial hyperplasia?
- In normal breast: one epithelial cell layer and one myoepithelial cell layer
- In EP: presence of more than 2 cell layers
- Referred to as moderate to florid when there are more than 4 cell layers
Describe epithelial hyperplasia in PBDW/A?
- There is proliferation of epithelial and myoepithelial cells and basement membrane is intact.
- Cells fill and distend ducts and lobules
Describe sclerosing adenosis?
- Increase in number of acini
- Variable cellular hyperplasia with prominence of myoepithelial cells.
- Acini in the centre are compressed and distorted, those at periphery are dilated
- Fibrosis
- Calcifications
Describe complex sclerosing lesions?
- Also called stellate lesions
- Contain central area of hyalinised stroma with entrapped glands
- Great mimic of cancer both radiologically or morphologically
- No cellular atypia
Describe papillomas?
- Commonly present as palpable masses
- Can involve large or small ducts
- Composed of multiple fibrovascular cores lined by proliferating epithelial and myoepithelial cells.
- Apocrine metapasia is present
- Expands and dilates a duct
Proliferative breast disease with atypia includes?
- Atypical duct hyperplasia (ADH)
2. Atypical lobular hyperplasia (ALH)
What is proliferative breast disease with atypia?
Atypical cellular proliferation/ hyperplasia but lacking sufficient features for duct carcinoma in situ (DCIS) or lobular carcinoma in situ (LCIS)
- DCIS and LCIS are pre-invasive lesions for breast cancer
Describe benign tumours?
- Common is the fibroadenoma
- No malignant potential
- Present as a palpable mass
- Lesions are hormonally responsive and lesions may increase in late menstrual cycle.
Describe the epidemiology of benign tumours?
Seen in young females: adolescents and early reproductive age group
Describe the macroscopic morphology of fibroadenoma?
- Sharply circumscribed and encapsulated
- Freely movable in the breast: breast mice
Describe the microscopic morphology of fibroadenoma?
proliferation of stroma and epithelial components (ducts)
What is breast cancer?
Carcinoma of the breast is most common form of breast cancer
- Common problem worldwide and in Malawi
What are the major risk factors of breast cancer?
- hormonal
2. genetic (family history BRCA 1 and 2 mutations)
Describe the role of oestrogen in causing breast cancer?
Metabolites of oestrogen causes
- Mutations
- Generate DNA damaging free radicals
- Via its hormonal actions, oestrogen drives the proliferation of premalignant lesions and the cancer itself
How to treat hormonal breast cancer causes by oestrogen?
giving anti-oestrogen drugs eg Tamoxifen
Describe age a risk factor for breast cancer?
- rarely found before age 25 except in familial cases
- Common in older women
Describe how age at menarche is a risk factor?
young age at menarche have increased risk compared to late menarche
Describe how first live birth is a risk factor for breast cancer?
Full term pregnancy at young age < 20 have half the risk of nulliparous women
Describe risk factors of breast cancer?
First degree relative with breast cancer portends an increased risk
Previous atypical hyperplasia
Race: Younger black women (40) at more risk than whites
Oestrogen exposure
Radiation exposure
Obesity
Carcinoma of contralateral breast and endometrium
Diet: rich in fat; controversial though
Breast feeding: longer durations of breast feeding reduces risk
Environmental toxins with oestrogenic effects on humans eg organochlorine pesticides
Describe the progression of cancer?
- Starts with pre-malignant lesions and progress to invasive cancer
- Common premalignant lesion is DCIS precursor of infiltrating duct carcinoma (IDC)
- IDC is the most common carcinoma (70-80%)
Name other types of breast cancer?
- Lobular carcinoma
- Mucinous carcinoma
- Medullary carcinoma
