Minarcik robbins 2013_ch23-breast
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BREASTBREAST
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LYMPHATIC DRAINAGE
AXILLARY (MOSTLY)palpable
INTERNAL MAMMARYnon-palpable
SUPRACLAVICULAR?palpable
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HISTOLOGY• LOBE: (10 in whole breast)• LOBULE: (many per lobe)• ACINUS/I, aka ALVEOLUS/I:
(many per lobule)• DUCT(S): INTRA- or INTER-
LOB(UL)AR, leading to the lactiferous ducts in the nipple
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L
O
B
E
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LOBULE
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One single
ACINUS(alveolus)
Epithelial cells
MYO-epithelial cells
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THREE NORMALPHASES
• ACTIVE: about 50-50 Gland/Stroma ratio
• LACTATING: Mostly Glands (like thyroid!!!), >>>50/50
• ATROPHIC: mostly stroma, <<<50/50
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QUIZ ???
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The most important thing to understand breast pathology is to get a solid IMAGE of the
“NORMAL” breast lobule----ACINI, STROMA, BOUNDARIES
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BREAST PATHOLOGY
• DEVELOPMENTAL:
• DEGENERATION:
• INFLAMMATION:
•NEOPLASM:
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DEVELOPMENTAL• MILKLINE REMNANTS
• ACCESSORY (axillary) BREAST TISSUE
• NIPPLE INVERSION (fibrosis)
• MACROMASTIA
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ACCESSORY
(axillary)
BREAST
TISSUE
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1) CONGENITAL
2) ACQUIRED: CARCINOMA
3) ACQUIRED: PIERCING
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DEGENERATION•ATROPHY
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INFLAMMATION• ACUTE, staph most common
• PERIDUCTAL
• DUCT-ECTASIA
• FAT NECROSIS, usually trauma
• LYMPHOCYTIC, i.e., diabetic
• GRANULOMATOUS, sarcoid, TB, etc., but mostly idiopathic
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ACUTE
MASTITIS
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INFLAMMATION?
Peau d’orange
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PERIDUCTAL INFLAMMATION
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DUCTESIA
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Ductesia CYSTS
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CUBOIDAL
COLUMNARRED COLUMNAR
i.e. “APOCRINE”
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FAT NECROSIS
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FAT NECROSIS
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LYMPHOYCYTIC MASTITISLYMPHOYCYTIC MASTITIS
(DIABETIC MASTOPATHY)(DIABETIC MASTOPATHY)
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GRANULOMATOUS MASTITIS
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NEOPLASIA• Benign epithelial
• Benign stromal
• Premalignant
• Malignant epithelial (ductal, lobular) (adenocarcinomas) (in-situ, infiltrating)
• Malignant stromal
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CLINICAL PRESENTATIONS
•MASS, palpable
or mammographic• NIPPLE DISCHARGE• PAIN
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NEOPLASIA• BENIGN EPITHELIALBENIGN EPITHELIAL, aka,
“FIBROCYSTIC” disease
–NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis
–PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma
–ATYPICAL epithelium
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CYST
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CYST, GROSS
CYST, MICROSCOPIC
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ADENOSIS ↑ acini/lobule
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FIBROSIS + CYSTS = FIBROCYSTIC DISEASE
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NEOPLASIA• BENIGN EPITHELIALBENIGN EPITHELIAL, aka,
“FIBROCYSTIC” disease
–NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis
–PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma
–ATYPICAL epithelium
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DUCTAL
HYPERPLASIA
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“SCLEROSING” ADENOSIS
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“COMPLEX” SCLEROSING ADENOSIS
(RADIAL SCAR)
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“SCLEROSING” ADENOSIS
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FIBROADENOMA:
1) EXTREMELY WELL DEFINED
2) YOUNGER WOMEN
3) ALWAYS BENIGN
4) CAN FIBROSE OR CALCIFY WITH AGE
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PAPILLOMA
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PAPILLOMA
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PAPILLOMA
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NEOPLASIA• BENIGN EPITHELIALBENIGN EPITHELIAL, aka,
“FIBROCYSTIC” disease
–NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis
–PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma
–ATYPICAL epithelium
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FEATURES OF “ATYPIA”• LOSS OF STROMA BETWEEN ACINI
• “SWISS CHEESE” HYPERPLASIA*
• CRIBRIFORMING**
• CELLULAR PLEOMORPHISM
• CELLULAR HYPERCHROMASIA
• INCREASED/ABNORMAL MITOSES*
• “ROMAN” BRIDGES***
• NECROSIS*** (“COMEDO-carcinoma”)
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NORMAL
DUCT
NORMAL
ACINUS
ATYPICAL HYPERPLASIA
of DUCTATYPICAL HYPERPLASIA, LOBULE
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DCIS
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DCIS
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DCIS
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DCIS, microcalcifications
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DCIS, microcalcifications
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DCIS, ROMAN BRIDGES
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NORMAL lobule
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LCIS
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LCIS• Usually hangs around MANY MANY
years before it infiltrates, in contrast to DCIS
• The BEST management may be judicious neglect, i.e., observation
• If it does infiltrate, however, it is at least as bad as DCIS infiltrating, or probably WORSE, showing “indian” files
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BREAST CANCERRISK FACTORS
• Age• Menarche Age, early menarche is a risk• First Live Birth• First-Degree Relatives with Breast Cancer• Breast Biopsies• Race (caucasian the highest)• Estrogen Exposure, prolonged, early menarche, late menopause • Radiation Exposure • Carcinoma of the contralateral breast or endometrium • Geographic Influence • Diet (high fat diet is riskiest)• Obesity • Exercise • Lack of breast feeding is a risk, Lack of prior pregnancy is a risk.• Environmental Toxins • Tobacco
• ABORTIONS?
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BREAST CANCERPROGNOSTIC FACTORS
•STAGING, especially POS or NEG lymph nodes, TNM, etc.
• AGE• GENERAL HEALTH and IMMUNITY• Histologic degree of differentiation, i.e., GRADING
• ERA/(PRA)• Her2, aka Her2-Neu
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STAGING, TNM,based on biologic behavior
• IN-SITU• EARLY disruption of the basal lamina, i.e.,
basement membrane• STROMAL infiltration• LYMPHATIC vessels• SENTINAL lymph node metastasis• MORE lymph node metastases• Adjacent structures, skin, ie, “inflammatory”• DISTANT, METASTASES, LIVER, BONE, LUNGS,
BRAIN, EVERYWHERE
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Total Cancers Per Cent
In Situ Carcinoma 15–30Ductal carcinoma in situ, DCIS 80
Lobular carcinoma in situ, LCIS 20
Invasive Carcinoma 70–85No special type carcinoma ("ductal") 79
Lobular carcinoma 10
Tubular/cribriform carcinoma (Better prognosis than average)
6
Mucinous (colloid) carcinoma (Better prognosis than average)
2
Medullary carcinoma (Better prognosis than average) 2
Papillary carcinoma 1
Metaplastic carcinoma, (Squamous)
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HISTOLOGIC TIDBITS• INFILTRATING DUCTAL
• INFILTRATING LOBULAR (INDIAN FILE)
• TUBULAR (LOOKS LIKE SCLEROSIS, BUT NO BASEMENT MEMBRANE)
• MUCINOUS (COLLOID)
• MEDULLARY (LOTS of LYMPHOCYTES)
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INFILTRATING DUCTAL
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INFILTRATING LOBULAR CA.,INFILTRATING LOBULAR CA.,
““INDIAN” FILE PATTERNINDIAN” FILE PATTERN
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INFILTRATING DUCTAL CA., INFILTRATING DUCTAL CA.,
““TUBULAR” PATTERN or TYPETUBULAR” PATTERN or TYPE
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INFILTRATING DUCTAL CA., INFILTRATING DUCTAL CA.,
MUCINOUS (COLLOID) PATTERN or TYPEMUCINOUS (COLLOID) PATTERN or TYPE
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INFILTRATING DUCTAL CA., INFILTRATING DUCTAL CA.,
MEDULLARY PATTERN or TYPEMEDULLARY PATTERN or TYPE
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NEOPLASIA,STROMAL
Cysto-”SARCOMA” PHYLLODES
(aka, PHYLLODES TUMOR), Looks like a giant fibroadenoma, really NOT a sarcoma
SARCOMAS, true, are RARE!!!!
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FIBROADENOMA
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MALE BREAST•GYNECOMASTIA (related to hyperestrogenism)
•CARCINOMA (1% of ♀ )
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GYNECOMASTIA (NO lobules)