Breast Path Flashcards
Signs and symptoms of breast disease
Mass (Nodule)
Nipple changes
Skin changes
Mammographic changes
Breast Cancer
malignant proliferation ofepithelial cells lining the ducts or lobules of the breast.
Epithelialmalignancies of the breast - most common cause of cancer in women (excluding skin cancer), accounting for about one-third of all cancer in women.
improved treatment and earlier detection–>mortality rate from breast cancer has begun to decrease very substantially in the United States.
breast cancer epidemiology
- hormone-dependent disease.
- Women without functioning ovaries who never receive estrogen-replacement therapy do not develop breast cancer.
- a straight-line increase with age but with a decrease in slope beginning at the age ofmenopause.
- three dates in a woman’s life that have a major impact on breast cancer incidence are:
- – age atmenarche,
- – age at first full-term pregnancy
- – age at menopause.
- Length of menstrual life—particularly the fraction occurring before first full-term pregnancy—is a substantial component of the total risk of breast cancer.
- duration of maternal nursing correlates with substantial risk reduction independent of either parity or age at first full-term pregnancy.
breast anatomy and lesions
lobules and terminal ducts: cyst, sclerosing adenosis, small duct papilloma, hyperplasia, atypical hyperplasia, carcinoma
large ducts: duct ectasia, squamous metaplasia of lactiferous ducts, large duct papilloma, Paget disease
intralobular stroma: fibroadenoma, phyllodes tumor
interlobular stroma: fat necrosis, lipoma, fibromatosis, sarcoma
Life cycle changes in breast tissue.
Mammograms in young women: radiodense/ white, making mass-forming lesions or calcifications (which are also radiodense) difficult to detect.
- The density of a young woman’s breast stems from the predominance of fibrous interlobular stroma and the paucity of adipose tissue. Before pregnancy the lobules are small and are invested by loose cellular intralobular stroma.
- During pregnancy, branching of terminal ducts produces more numerous, larger lobules. Luminal cells within lobules undergo lactational change, a precursor to milk formation.
- With increasing age the lobules decrease in size and number, and the interlobular stroma is replaced by adipose tissue.
- Mammograms become more radiolucent with age as a result of the increase in adipose tissue, which facilitates the detection of radiodense mass-forming lesions and calcifications
Disorders of development
Milk line remnants
Accessory Axillary Breast Tissue.
Congenital Nipple Inversion.
Milk line remnants and accessory Axillary breast tissue
Supernumerary nipples (polythelia) and breasts (polymastia) (resulting from the persistence of epidermal thickening along the milk line) can result in painful premenstrual enlargement.
Ectopic breast tissue without the areola-nipple complex can also be present along the milk lines.
These tissues hormone - responsive and can undergo neoplastic (benign or malignant) transformation.
Congenital Nipple Inversion.
present in approximately 3 percent of women ages 19 to 26 without a history of infection, inflammation, trauma, tumor, periareolar surgery, or pregnancy. This condition is usually bilateral.
Congenital nipple inversion results from a failure of the underlying mesenchyme to proliferate and project the nipple papilla outward. Most cases are sporadic but some are associated with inherited genetic disorders such as:
2q37 deletion
Ulnar mammary syndrome
Congenital disorders of glycosylation
Inflammatory breast diseases
Acute Mastitis. Chronic Mastitis. Squamous metaplasia of lactiferous ducts. Duct Ectasia. Fat necrosis.
Acute Mastitis
Sudden infectious inflammation caused by the bacterium staphylococcus aureus and sometimes streptococcus.
First three weeks of nursing.
Irregular nursing contributes to the pathogenesis.
The breast becomes swollen, painful and reddened (sometime abscess with purulent discharge).
Differential diagnosis with inflammatory carcinoma.
Chronic Mastitis
Chronic Mastitis is usually secondary to a systemic infection as tuberculosis, fungal infection or syphilis. Lymphocytic mastitis (associated with Type 1 diabetes and Sjogren syndrome) Idiopathic granulomatous mastitis (possible autoimmune) (sometimes granulomatous inflammation is associated with tuberculosis or connective tissue disease) Plasma cell mastitis (Duct ectasia) usually occurs in multiparous women who have an history of difficult nursing. An hard lump forms below the nipple and might raise the issue of cancer
Squamous Metaplasia of lactiferous ducts.
= recurrent subareolar abscess, periductal mastitis, and Zuska disease.
- painful erythematous subareolar mass that clinically appears to be a bacterial abscess.
- In recurrent cases, a characteristic fistula tract often tunnels under the smooth muscle of the nipple and opens onto the skin at the edge of the areola. Many women have an inverted nipple, most likely as a secondary effect of the underlying inflammation.
** More than 90% of the afflicted are smokers. It has been suggested that a relative deficiency of vitamin A associated with smoking **or toxic substances in tobacco smoke alter the differentiation of the ductal epithelium.
When squamous metaplasia extends deep into a nipple duct, keratin becomes trapped and accumulates. If the duct ruptures, the ensuing intense inflammatory response to keratin results in an erythematous painful mass. A fistula tract may burrow beneath the smooth muscle of the nipple to open at the edge of the areola
Fat Necrosis
The presentations of fat necrosis are protean and can closely mimic cancer—as a painless palpable mass, skin thickening or retraction, or mammographic densities or calcifications. About half of affected women have a history of breast trauma or prior surgery.
Histologically the lesion shows inflammatory reaction, containing “multinucleated giant cells“
Benign epithelial lesions
Non proliferative breast changes.
Proliferative breast disease with atypia.
Proliferative breast disease without atypia.
Benign histological changes.
Non proliferative breast changes.
Fibrocystic changes (Not associated with an increased risk of cancer).
Lumpy breast at palpation.
Radiologically dense with cyst.
Benign histological findings.
Fibrocystic changes
Cysts: Dilated lobules turn into small cyst and might coalesce to form larger cysts; filled with brown or blue fluid (blue-domed cyst). Flat atrophic epithelium or squamous metaplastic epithelium.
Fibrosis: resulting from chronic inflammation secondary to cyst rupture.
Adenosis: increase of number of acini per lobule.
Calcifications are occasionally present within the lumens. The acini are lined by columnar cells, which may appear benign or show nuclear atypia * (“flat epithelial atypia”). Flat epithelial atypia is a clonal proliferation associated with deletions of chromosome 16q. This lesion is thought to be the earliest recognizable precursor of low-grade breast cancers, but does not convey an increased cancer risk, presumably because other steps in cancer development are rate limiting.
Proliferative lesions without atypia.
Lesions characterized by proliferation of epithelial cells, without atypia, are associated with a small increase in the risk of subsequent carcinoma in either breast. They are commonly detected as mammographic densities, calcifications, or as incidental findings in biopsies performed for other reasons. These lesions are not clonal and are not commonly found to have genetic changes. Thus they are predictors of risk but unlikely to be true precursors of carcinoma.
Epithelial Hyperplasia.
Sclerosing adenosis.
Complex Sclerosing Lesion.
Papilloma.
