The Breast Flashcards
The breasts are lined by two cells type, what and what??
Myoepithelial cells - contractile cells with myoflaments that lies of the basement membrane and help in milk ejection
Luminal cells; only those in terminal ducts and mobiles produce milk
Two different stromas of the breast
Interlobular - dense fibrous connective tissue admixed with adipose tissue
Intra lobular - breast specific hormonay respsonsive, delicate, myxomatosis stroma that contains a scattering of lymphocytes
At the beginning of menarche, what changes in the breast occur?
- Terminal duct gives rise to lobules
- Inter lobular stroma increases in volume
- Paucity of Adipose tissue (radio dense breast)
Changes in the breast in the follicular phase
- Cell proliferation and increase in the number of acini per lobule
- vacuolization of epithelial cells
- Markedly edematous intralobular stroma
Sense of fullness in follicular phase is from the stimulatory effect of progesterone and estrogen combined
Breast changes in Menstrual phase
- fall in hormones leads to epithelial cell apoptosis
- a disappearance of stromal edema
- regression of the size of the lobules
When does the breast achieve its complete morphological maturation and functional activity?
During pregnancy
- lobules increase in both number and size
- Breast composed of almost entirely lobules and scant stroma
- Montgomery tubercles; nipple lubrication
- secretory vacuole of lipid material are found in the TDLU epithelial cells. Milk production is inhibited by progesterone
Lactation changes in the breast ?
Immediately after birth, breast produces colostrum (high in protein)
- so within 10 days (charges to milk -higher in calories and fat)
- IgA , neutrophils, lymphocytes and macrophages, cytokines, fibronectin, lysozyme are transferred to the baby
- postpartum health of the mother can influence lactating child (radiation)
Involution of the breast involves?
- After the third decade, lobules and their stroma start to involute
- Radiodense fibrous imterlobular stroma of the young female breast is progressively replaced by radioluscent adipose tissue.
Disorders of the breast
Macromastia - juvenile hypertrophy (reduction mammoplasty removed breast tissue but preserves the nipple
Congenital Nipple inversion
Milk line remnants; extends from axilla to perineum (supernumerary nipples)sThe
Inflammatory condition of the breast ?
Acute mastitis
Periductal mastitis
Mammary duct ecstasies
Fat necrosis
Lymphocytic mastopathy
Granulomatous mastitis
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Acute mastitis is caused by?
- Staph aureus, streptococcus species
During lactation
-erythematous painful breast, fever - at onset, only 1 duct system is involved. Can progress without treatment
- treated with antibiotics and complete drainage of milk from the breast
Morphology of acute mastitis
Staph aureus
- An area Acute inflammation and multiple abscesses
Strep infection
- diffuse spreading infection that involves the entire breast
- necrosis, neutrophil infiltration.
Periductal mastitis can also be called?
- Zuska disease
- Recurrent Subareolar abscess
- Squamous metaplasia of lactiferous ducts
Periductal mastitis morphology and epidemiology?
- Seen in both men and women
- Painful erythematous subarealola mass
- seen mostly among smokers
- fistula may form and open at the edge of areola
- many present with inverted nipple secondary to fibrosis and scarring
- condition may contribute to squamous metaplasia of the duct
- may be related to vitamin A deficiency in smokers with alter the ductal epithelium
- keratin plug may be formed
Fat necrosis may present as which ways?
- painless palpable mass
- slim thicikening or retraction
- Mammogrpahic density
- mammographic retraction
History of trauma or prior surgery
Lymphocytic mastopathy features
- presents with single or multiple hard palpable mass (extremely hard lesions)
- collagenized stroma surrounding atrophic ducts and lobules
- BM is often thickened
- lymphocytic infiltrates
- common in women with type 1 DM
- autoimmune disease of the breast
Granulomatous mastitis Is associated with which diseases ?
- Wegeners granulomatosis
- sarcoidosis
- mycobacterial infection/fungal infection (breast prosthesis or nipple piercing)
- granulomas involving the lobular epithelium
- only parous women are affected
- may be an hypersensitivity reactions
MONDOR’S DISEASE ?
- Thrombophlebitis of the superficial veins of the chest wall
- cordlike induration if the breast
- resolves spontaneously
IgG4 related mastopathy?
- Due to proliferation of IgG4 lymphocytes
- associated with the following?
• Granulomatous mastitis
• retroperitoneal fibrosis
• salivary gland inflammation (sialadenitis)
Benign diseases can be classified as ?
- Non-proliferative
- Proliferative
- Atypical hyperplasia
Fibrocystic change;
- non proliferative benign disease
- exaggerated and uncoordinated response of the mammary ducts and stroma to hormone stimulation
Main histological change - Fibrosis, cystic dilatation and adenosis
Changes that occur in each histological fibrocystic change
Fibrosis
- Dense Interlobular fibrous tissue expands into the lobules replacing the loose Intralobular connective tissue
Cystic dilation
- strands of fibrous tissue constrict ducts (blocked normal secretions)
- distal dialatation of these terminal ducts
Adenosis
- changes resulting from proliferation of terminal ducts cells that are group around the centrally dilated ducts
Apocrine metaplasia
- Ducts are lined by cell with granular eosinophilic cytoplasm and small nuclei
- presence usually suggest benign lesion
Epithelial hyperplasia features?
- Proliferating Breast changes without Atypia
- presence of more than two cell layers
- moderate to florid (> 4 cell layers)
- cells fill and distends the ducts and lobules
- can form fenestrations
Papillomas features ?
- Small duct papillomas are usually multiple deep in ductal system. Increased risk of breast carcinoma
- Large duct papillomas are usually solitary in lactiferous duct of the nipple
- multiple branching fibrovascular cores
Other proliferative disease without Atypia ?
- Endothelial hyperplasia
- Papillomas
- Sclerosing adenosis
- Complex Sclerosing lesions
- Fibroadenoma with complex figures
Examples of proliferative disease with Atypia ?
Atypical ductal hyperplasia (ADH)
Atypical lobular hyperplasia (ALH)
- resembles ductal carcinoma in situ or LCIS
- no features of carcinoma
Atypical ductal hyperplasia
- associated with calicufications
- adjacent to anothe calcifying lesion
- resembles DCIS (with round lamina, regular cell placement, monomorphic cell population)
Atypical lobular hyperplasia (ALH)
- Resembles LCIS
- cells do not distend more than 50% of the acini within the lobules
- can extend into the ducts, increase sef risk of invasive carcinoma
Clinical significance of ADH and LH
1) Proliferative dx with Atypia - moderate increase in risk for carcinoma
2) carcinoma in situ (DCIS, LCIS) - substantial risk for carcinoma if not tested
3) proliferative dx without Atypia - mild risk
4) non proliferative dx - no risk
Fibroadenoma
- benign breast tumor
- elongated ducts surrounded by loose fibrous stroma
- well circumscribed, movable mass
- 20-35year age group
Phyllodes tumor
- stroma shows increased cellularity and Anaplasia
- most are benign
- metastasizing malignant tumor is rare
- malignant phyllodes is locally invasive and may recur after incomplete excision
Intraductal papillomas
- being tumors of the main lactiferous ducts
- can be easily torn away and lead to bleeding from nipple
The most common malignant tumor
- breast cancer
- second most common cause of cancer mortality in women
Risk factors for breast cancer ?
Aging
family history X2-9
Menstrual history X2
Nulliparity X 3
Proliferative breast disease and hyperplasia X2
Atypical hyperplasia - X4
Carcinoma In situ - X8
Carcinoma of contralateral breast
Breast feeding
Geographic influence
Breast biopsies
Most common locations for breast cancer
Upper outer quadrant - 50%
Central area - 20%
Others - 30%
Classification or breast cancer
Site of origin
- Ductal (90%)
- lobular
- other
Based of invasion
- invasive
- non invasive
Intraductal carcinoma
- DCIS
- pre-invasive form of breast carcinoma
- mammography
- most common form of newly diagnosed breast cancer
- most ominous are comedo-carcinoma
Lobular carcinoma in situ ?
- pre-invasive form of lobular carcinoma
- less common
- lesion are often bilateral
- LCIS should be taken
Most Breast cancers are ?
Adenocarcinomas
Histologic type of DCIS?
Comedo type
Micro papillary
Cribiform
Pagers disease
Prognostic factors in breast carcinoma ?
- Distant metastasis
- Invasive carcinoma
- Lymph node metastasis
- tumor size
- Locally advanced disease
- Inflammatory carcinoma
- macrometastasis
- HER2/neu or HER2 receptors
- Lymphobascualr invasion
- proliferative rate
- DNA content
- Estrogen and progesterone receptors
Most common breast lesions detected as densities are ?
- Fibroadenoma
- invasive carcinomas
- cysts
The most common malignancy associated with calcifications ?
DCIS
Benign calcifications
- Sclerosing adenomas
- hyalinized Fibroadenomas
- apocrine cysts
Diagnostic methods for breast lesions
Mammography and ultrasound
- basis of screening
- less value in young women due to dense breast
- ultrasound is of value in young women
Fine-needle aspiration cytology
- needle inserted, cells aspirated and stained
- need adequate sample for diagnosis
Core biopsy
- when infufficient sample is obtained at FNA
- to obtain samples for markers studies
- follow up for recurrence
Frozen section
Core imprints
Male breast cancer
- palpable subareaolar mass, 2-3cm in diameter
- nipple discharge is common
- ulceration through the skin is common
- dissemination follows same pattern in women (axillary lymph nodes)
- prognosis is better in men than women when they are matched by stage
- treated locally with mastectomy and axillary node dissection
- papillary carcinomas are common
- Estrogen receptor +Ve is more common in men (81%)
- incidence of ER positive tumors does not increase with age unlike women
Zuska disease ?
- Periductal mastitis
- seen in smokers
- inverted nipple
Which Brest lesion is associated with Tyoe 1 diabetes ?
Lymphocytic mastopathy
Cord like induration of the breast is seen in?
- Mondors disease
- Thrombophlebitis of the superficial veins in the chest wall
