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Strength does not come fromStrength does not come from
winning. Struggles & Hardshipwinning. Struggles & Hardship
develop your strength. When you godevelop your strength. When you gothrough hardship and decide not tothrough hardship and decide not to
surrender, that is strengthsurrender, that is strength
Arnold SchwarzeneggerArnold Schwarzenegger
Bodybuilder and ActorBodybuilder and Actor
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Pathology of BreastPathology of BreastCancerCancer
Dr. Venkatesh M. ShashidharDr. Venkatesh M. Shashidhar
Senior Lecturer in PathologySenior Lecturer in Pathology
Fiji School of MedicineFiji School of Medicine
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IntroductionIntroduction
Modified sweat glands.Modified sweat glands.
Lobes and lobules of glandLobes and lobules of gland
in fat tissue stroma.in fat tissue stroma.
Ducts emerge from acini of glandsDucts emerge from acini of glands Smaller ducts join to form lactiferousSmaller ducts join to form lactiferous
ductsducts
Lactiferous ducts merge just beneath theLactiferous ducts merge just beneath thenipple to form a lactiferous sinus.nipple to form a lactiferous sinus.
Then individually open on nippleThen individually open on nipple
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Normal BreastNormal Breast
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Myoepithelial Cells (ipx)Myoepithelial Cells (ipx)
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DisordersDisorders
CongenitalCongenital Aplasia turners, Juvenile hypertrophyAplasia turners, Juvenile hypertrophy
InflammatoryInflammatory
Infections acute/chronic Trauma Fat necrosisInfections acute/chronic Trauma Fat necrosis Duct ectasia discharge, sinusDuct ectasia discharge, sinus Fibrocystic disease common painful lumpsFibrocystic disease common painful lumps
NeoplasticNeoplastic Benign - FibroadenomaBenign - Fibroadenoma Malignant CaMalignant Ca
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Fibrocystic DiseaseFibrocystic Disease
Fibroadenosis, Fibrocystic change, etc.Fibroadenosis, Fibrocystic change, etc. Commonest lump, 10-50% womenCommonest lump, 10-50% women
? Hormonal? Hormonal
Periodic discomfort pain.Periodic discomfort pain.
Eipethilial hyperplasia premalignantEipethilial hyperplasia premalignant
Irregular palpable lumps mimic ca.Irregular palpable lumps mimic ca. Adenosis hyperplasia - cysts papillomatosis Adenosis hyperplasia - cysts papillomatosis
metaplasia fibrosis.metaplasia fibrosis.
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Benign Neoplasms:Benign Neoplasms:
FibroadenomaFibroadenomaDuct PapillomaDuct PapillomaAdenomaAdenoma
Connective tissue tumorsConnective tissue tumors
Features (Fibroadenoma)Features (Fibroadenoma)Young age 3Young age 3rdrd decade.decade. Single, rounded, mobile, painless lumps.Single, rounded, mobile, painless lumps. No scarring or calcification.No scarring or calcification. Slit like glands in Fibrous stromaSlit like glands in Fibrous stroma
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Breast CarcinomaBreast Carcinoma
20% of all cancers in20% of all cancers inwomenwomen
Commonest cause of death -Commonest cause of death -
35-55y35-55y In UK 1 in 10-12 chancesIn UK 1 in 10-12 chances 1 in 8 women in US1 in 8 women in US
Less incidence in AsiaLess incidence in Asia Majority of cancers arise inMajority of cancers arise in
the ducts.the ducts. Very rare before age 25Very rare before age 25
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Risk Factors:Risk Factors:
Female sex..!, Age, Obesity, high fat dietFemale sex..!, Age, Obesity, high fat diet
Maternal relative with breast cancer.Maternal relative with breast cancer.
Longer reproductive span.Longer reproductive span.
Nulliparity, Oral contraceptivesNulliparity, Oral contraceptives
Later age at first pregnancy.Later age at first pregnancy.
Atypical epithelial hyperplasia.Atypical epithelial hyperplasia.
Previous breast cancer/Endometrial Ca.Previous breast cancer/Endometrial Ca. Geographic factors - countryGeographic factors - country
BRCA1 and BRCA2BRCA1 and BRCA2 genesgenes
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Etiology of Breast Carcinoma:Etiology of Breast Carcinoma:
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Clinical Features:Clinical Features:
Physiologic vs Pathologic changesPhysiologic vs Pathologic changes Lump / lumpsLump / lumps
Lumps are much more common than CaLumps are much more common than Ca
Characters ofCharacters oflumplump* and* and ageage**
Discharge in many conditions.Discharge in many conditions.
Hard, soft, inflammationHard, soft, inflammation Skin fixation /Skin fixation / SkinSkin retractionretraction **
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Diagnosis:Diagnosis:
MammorgraphyMammorgraphy UltrasoundUltrasound
Fine Needle Aspiration BiopsyFine Needle Aspiration Biopsy
Core BiopsyCore Biopsy Excision BiopsyExcision Biopsy
Frozen sectionFrozen section
Immunoperoxidase,Immunoperoxidase, Molecular techniques Gene detection.Molecular techniques Gene detection.
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Histological TypesHistological TypesHistologic Type Freq. (UK)
InfiltratingDuctCa 63.6 (75)
Lobular Carcinoma 5.9 (10)
InfiltratingDuctal & Lobular Ca 1.6
Medullary Carcinoma 2.8 (3)
Mucinous (colloid) Carcinoma 2.1 (3)
Comedocarcinoma 1.4
Carcinoma-In-Situ 5%
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Breast CarcinomaBreast Carcinoma
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Breast CarcinomaBreast Carcinoma
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Breast Carcinoma - SchirrousBreast Carcinoma - Schirrous
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Infiltrating Duct Carcinoma: small hardInfiltrating Duct Carcinoma: small hard
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Medullary Carcinoma: Large softMedullary Carcinoma: Large soft
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Infiltrating Duct CarcinomaInfiltrating Duct Carcinoma
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Infiltrating Duct CarcinomaInfiltrating Duct Carcinoma
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Medullary Carcinoma: Inflammation.Medullary Carcinoma: Inflammation.
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Infiltrating Duct Carcinoma: FibrosisInfiltrating Duct Carcinoma: Fibrosis
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Schirrous CarcinomaSchirrous Carcinoma
C iM d ll C i
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Medullary CarcinomaMedullary Carcinoma
Soft, inflammatory cellsSoft, inflammatory cells
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Intraductal in-situ CarcinomaIntraductal in-situ Carcinoma
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Lobular CarcinomaLobular Carcinoma
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Intraduct Carcinoma-in-situIntraduct Carcinoma-in-situ
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Intraduct CarcinomaIntraduct Carcinoma
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Lymphatic spread Peu-de Orange..Lymphatic spread Peu-de Orange..
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Spread of BreastSpread of BreastCarcinoma:Carcinoma:
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Pagets DiseasePagets Disease
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Pagets Disease (Epidermal invasion)Pagets Disease (Epidermal invasion)
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Estrogen Receptor & Prognosis:Estrogen Receptor & Prognosis:
Estrogen receptor expression isEstrogen receptor expression isproportional to differntiation of tumorproportional to differntiation of tumor
inversly proportional to prognosis andinversly proportional to prognosis and
response to tamoxifen (receptor antagonist)response to tamoxifen (receptor antagonist)therapy.therapy.
Demonstrated by ImmunoperoxidaseDemonstrated by Immunoperoxidase
special stain.special stain.
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HER2HER2
The HER2 proto-oncogene encodes a cellThe HER2 proto-oncogene encodes a cellsurface receptor that is overexpressed insurface receptor that is overexpressed in
approximately 25%-30% of breast cancers.approximately 25%-30% of breast cancers.
Trastuzumab (Herceptin) is the firstTrastuzumab (Herceptin) is the firstmonoclonal antibody that targets themonoclonal antibody that targets the
extracelluar domain of the HER2 protein,extracelluar domain of the HER2 protein,
and inhibits growth of breast cancer cellsand inhibits growth of breast cancer cellsthat over express this protein.that over express this protein.
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Estrogen receptor (ER) in nucleiEstrogen receptor (ER) in nuclei
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St 5 7
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St
agDefinition
5-year
Surv (%)
7-year
Surv (%)
I Tumor 2 cm or less without spread 96 92
II
Tumor 2-5cm with regional lymph
node involvement but without distant
metastases, OR > 5 cm in diameterwithout spread
81 71
III
Any size with skin/chest wall fixation,
& axillary or internal mammary
nodal involvement, without distant
metastases
52 39
IV
Tumor of any size with or without
regional spread but with evidence of
di t t t t
18 11
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