Benign Breast Diseases Flashcards
How does the breast develop embryologically?
Mammary ridges that run along ‘milk line’ which goes from axilla to the groin
Primary buds form initially which becomes more and more complex forming secondary buds and eventually forms a rudimentary duct system which stay the way it is until puberty.
What triggers development and differentiation of breast during pubery?
Hormonal influx triggers development of a terminal milk-producing lobule, the terminal duct lobular unit, TDLU
What is the terminal duct lobular unit? What are the components of the TDLU?
The TDLU is the milk producing unit of the breast.
The TDLU has a basement membrane, a layer of myoepithelial cells, and a layer of epithelial cells.
What surrounds TDLU?
A cuff of loose intralobular stroma.
TDLUs are separated by interlobular stroma that are variably fibrofatty.
Where does milk move when going from TDLUs to the nipple?
TDLUs -> extralobular ducts -> Interlobular ducts -> Lactiferous ducts -> Lactiferous sinus -> orifice at the nipple
Where does the breast lymphatic drainage drain the breasts?
Axillary lymph nodes -> Supraclavicular lymph nodes
Internal mammary
What does the nipple-areolar complex consist of?
Nipple - 5 - 9 duct openings
Areola surrounds the nipple (Sebaceous glands provide lubrication during lactation)
How can breast development go wrong?
Ectopic breast tissue can develop anywhere along the milk line.
What happens to the breast during pregnancy / breast feeding?
TDLU undergoes terminal differentiation
What is the significance of the ratio of parenchymal and stromal components?
It is unique to the individual and changes with age.
Cancer risk is affected
Has implications for screening (more stroma is harder to visualize)
How does breast disease present clinically?
16% of women present with breast condition over a 10 year period.
2 ways:
Screen detected (BreastScreen WA)
Symptomatic (Breast lump, pain, nipple discharge, skin changes, etc)
Most symptomatic and screen detected abnormalities are benign
What happens during breast screening?
Targets 50 - 74 year old asymptomatic women.
2 yearly mammograms; 5% are often recalled for assessment and the next tests are:
triple test: Clinical, additional radiological and pathological examination.
What percentage of screens find malignancy?
0.6% of screens and 10% of triple test assessments
How is mammography conducted?
Gentle compression of breast between digital X-ray detector plates.
Low dose X-ray which is converted to images and finds abnormalities using tissue densities.
What do MMG abnormalities look like?
Calcifications
Distortions
Densities/masses
What are the limitations of mammographies?
Small (and cumulative radiation risk)
Not all carcinomas are visible (small false negative rate)
How are abnormaliteis investigated using US?
High frequency sound used to show masses and cysts.
Not all carcinomas are visible and there is no radiation risk.
How do breast diseases present with symptoms?
The major clinical presentations of disease are:
Discrete mass (lump) / lumpiness
Pain
Nipple changes/discharge
Skin changes (tethering, peau d’orange, ulceration
Other (Metastases shows distant manifestations)
What does work-up of breast symptoms in clinical practice require?
Experience and judgement
A multidisciplinary approach with triple test
What are the risk factors for a palpable mass being malignant?
Age: 6% diagnosed in women under 40 are malignant. >70% diagnosed in women over 50 are malignant
Features of the mass: Soft, rubbery, mobile - low risk. Hard, fixed, axilla lump - high risk.
Benign lesions can cause malignancy (Fibroadenoma, FCC, cysts, fat necrosis)
What does pain tell us about a palpable breast mass?
Only 2% of women presenting with pain will have diagnosis of cancer (75% of these also have a mass)
How does pain present with benign breast conditions?
Cyclical/diffuse manner
No structural abnormality, cyclical mastalgia, infection/inflammation mastitis)
What causes galactorrhoea from the nipple?
Often hormonal or drug related
What can cause serous/bloody discharge from the nipple?
Cysts, intraduct papilloma, DCIS
What causes excoriation, crusting, and itching of the nipple?
Eczema
Dermatophytes
Pagets disease
Breast cancer invading skin
What are the most important inflammatory breast diseases?
Acute mastitis (infection of static milk typically by staph species (rarely strep) which enter through cracks in nipple)
Subareolar abscess (squamous metaplasia of lactiferous ducts (SMOLD) resulting in obstruction, dilation and rupture with granulomatous reaction)
Mammary duct ectasia (Dilated subareolar ducts, uncertain aetiology)
Fat necrosis
Lymphocytic lobulitis
Granulomatous mastitis
How does acute mastitis present?
Almost always occurs during lactation.
Red, hot, swollen and painful breast/lump +/- generally unwell.
What does histology show in acute mastitis?
Inflammation with neutrophils +/- necrosis +/- abscess
How should acute mastitis be managed?
Breast feeding/pumping
Analgesia
Antibiotics
+/- surgery
What is the clinical presentation of subareolar abscess?
90% are smokers
Red, hot, swollen, subareolar mass +/- draining fistula (to adjacent tissue)
what does a subareolar abscess show on histology?
Ruptured squamous lined ducts with mixed inflammation, foreign body response +/- abscess
How is a subareolar abscess managed?
Smoking cessation
Antibiotics
Surgery (in most cases necessary)
How does mammary duct ectasia present clinically?
Postmenopausal parous women
Painful
Erythematous
Subareolar mass
+/- fistula
+/- discharge
What does histology of mammary duct ectasia show?
Dilated ducts, periductal fibrosis and chronic inflammation
How is mammary duct ectasia managed?
Conservative or surgery
How does fat necrosis present clinically?
Necrotic fat and fibrous tissue
Hard mass, skin retraction, screen detected calcification
May stimulate cancer
Often site of prior injection
Can be caused by: Surgery, trauma, or radiation
What does histology show with fat necrosis?
Necrotic adipose tissue
Foamy macrophages
Multinucleated giant cells
Chronic inflammation
Hemosiderin
Fibrosis
Calcification
What is hemosidirin?
Hemosiderin or haemosiderin is an iron-storage complex. It is only found within cells (as opposed to circulating in blood) and appears to be a complex of ferritin, denatured ferritin and other material. The iron within deposits of hemosiderin is very poorly available to supply iron when needed
What is lymphocytic lobulitis?
Diabetic mastopathy (attracts inflammatory tissue around it)
What is fibrocystic change?
A non-neoplastic change in breast epithelium, particularly post-menopause.
Does not cause a significant risk of carcinoma
What are the clinical symptoms of fibrocystic change?
Non-specific
Lump/lumpiness
Pain
Calcifications on screening
What are the histopatholoigical features of fibrocystic change?
Cysts
Apocrine metaplasia
Fibrosis
How is fibrocystic change managed?
Harmless condition so conservative measures taken (only assurance of diagnosis)
What are the types of benign proliferative conditions of the breast?
Epithelial: Usually hyperplasia and columnar cell change (hyperplasia is only benign when there are no atypia)
Stroma: PseudoAngiomatous Stromal Hyperplasia (PASH)
Both elements:
Sclerosing adenosis
Complex sclerosing lesion/radial scar
Papilloma
Fibroadenoma
What is epithelial hyperplasia of the breast?
Proliferation of epithelial cells within ducts and lobules
How are epithelial hyperplasia and columnar cell change classified?
Presence or absence of atypia:
Atypia present = moderate risk of malignancy
No-atypia = mildly elevated risk of BC (compared to normal breast)
What are the clinical symptoms of epithelial hyperplasia?
Asymptomatic
Comes up as calcifications on screening
What are the histopathological features of epithelial hyperplasia?
Multilayering of small cells, rounded and oval, jumbled-up, irregular slits between cells, rare mitotic figures.
How is mild, moderate, and florid hyperplasia distinguished?
Mild - 2 - 4 epithelial layers
Mod - 4 layers
Florid - Fills ducts
How are epithelial hyperplasia and columnar change treated?
No atypia, nothing is done.
What happens in columnar cell change?
Metaplastic proliferation of columnar cells (similar to hyperplasia of epithelium)
What are the histological features of columnar cell change?
Columnar cells lining ducts and lobules
Apical snouts luminal secretions (+/- calcs)
Cellular multilayering
What is sclerosing adenosis?
Increased glandular element and stromal formation
What are the clinical symptoms of sclerosing adenosis?
Asymptomatic
Mass
Calcifications
Distortion on screening
What is the risk of cancer like with sclerosing adenosis? How does this affect treatment?
No cancer risk no need for treatment.
What are the histopathological features of sclerosing adenosis?
Lobular architecture
Increased glands
Compression by stroma
Myoepithelial layer/basement membrane maintained
Can mimic cancer
What is a complex sclerosing lesion?
Increased glandular elements compressed by fibroelastotic stroma into a stellate arrangement.
What kind of lesion is a complex sclerosing lesion/radial scar; benign or malignant?
It is benign but it is associated with another adjacent sinister lesion.
What are the clinical features of a complex sclerosing lesion/radial scar?
Can be asymptomatic
Can form a mass
Calcifications or distortion on screening
What are the histopathological features of a complex sclerosing lesion/radial scar?
Stellate architecture
Increased glands
Compression by stroma
Myoepithelial layer/basement membrane maintained
Can mimic cancer
How is a complex sclerosing lesion/radial scar treated?
Conservative excision
What causes an intraductal papilloma?
Intraductal proliferation of epithelial and myoepithelial cells overlying fibrovascular stalks.
What kind of lesion is an intraductal papilloma; benign or malignant?
It is benign but, like complex sclerosing lesions, it is associated with adjacent sinister lesions.
If there is multiple or associated atypia it has moderate risk of malignancy.
What are the clinical features of a intraductal papilloma?
Mass
Discharge
Incidental
Calcifications on screening
How is an intraductal papilloma treated?
If there is one it is excised conservatively.
If there are multiple it is closely followed up.
What are the clinical features of a fibroadenoma?
It is well circumscribed, rubbery, mobile
What are the histopathological features of a fibroadenoma?
Circumscribed nodule of ducts and expanded stroma.
How are fibroadenomas managed?
If its small - follow up and surgery if symptomatic.
If enlarging, symptomatic, provoking anxiety, and having atypical biopsy findings then it is treated with surgery
Must exclude phyllodes tumour.
What is phyllodes tumour?
Tumour related to a fibroadenoma. Its behaviour ranges from benign to malignant.
What is pseudoangiomatous stromal hyperplasia (PASH)?
A benign proliferation of stromal elements that form asymptomatic, occassionally mass forming, lesions.
