Transcript
BREAST PATHOLOGYBREAST PATHOLOGYbyby
Dr. Richard RaymondDr. Richard Raymond
MASTITISMASTITIS Acute MastitsAcute Mastits
a)a) Common during lactationCommon during lactationb)b) Organism:Organism: Staphylococcus Staphylococcus
aureusaureus (most common) (most common)
Fat necrosisFat necrosisa)a) Often related to trauma or prior Often related to trauma or prior
surgerysurgeryb)b) May produce a palpable mass or May produce a palpable mass or
lesion on mammographylesion on mammography
There are two types of Mastitis: 1. Cellulitis - which involves an infection of the connective tissue. 2. Adenitis - which is an infection in the milk duct. In either case, mastitis usually affects only one breast.
A patient with inflammatory breast cancer generally presents with a tender, firm and enlarged breast, rather than a discernable mass. This patient was diagnosed with acute mastitis carcinomatosa involving the entire breast.
FIBROCYSTIC CHANGESFIBROCYSTIC CHANGES
Old name: fibrocystic diseaseOld name: fibrocystic disease Age 20 – 50 (i.e., < 50 yrs)Age 20 – 50 (i.e., < 50 yrs) Extremely common and benignExtremely common and benign May produce a palpable mass or May produce a palpable mass or
nodularitynodularity Most often involves the upper outer Most often involves the upper outer
quadrantquadrant ““lumpy – bumpy” and painfullumpy – bumpy” and painful Bloody dischargeBloody discharge
Fibrocystic breast disease is a common and benign change within the breast characterized by a dense irregular and bumpy consistency in the breast tissue. Mammography or biopsy may be needed to rule out other disorders.
Nonproliferative Verus Nonproliferative Verus Proliferative Fibrocystic Proliferative Fibrocystic
ChangesChanges
NonproliferativeNonproliferative Proliferative Proliferative ChangesChanges
FibrosisFibrosis Cysts (blue- Cysts (blue- domed)domed) Apocrine Apocrine metaplasiametaplasia MicrocalcificationsMicrocalcifications
Ductal Ductal hyperplasiahyperplasia
+/- Atypia+/- Atypia Sclerosing Sclerosing adenosisadenosis Small duct Small duct papillomaspapillomas
Relative Risk of Developing Relative Risk of Developing Breast Breast Cancer with Cancer with
Fibrocystic ChangesFibrocystic Changes
RelativeRelative RiskRisk
Fibrocystic ChangesFibrocystic Changes
No increaseNo increase Fibrosis, cysts, apocrine Fibrosis, cysts, apocrine metaplasia, adenosismetaplasia, adenosis
1.5 – 2x1.5 – 2x Sclerosing adenosis, Sclerosing adenosis, ductal hyperplasia, ductal hyperplasia, papillomaspapillomas
4 – 5x4 – 5x Atypical ductal or lobular Atypical ductal or lobular hyperplasiahyperplasia
Features That Features That Distinguish Fibrocystic Distinguish Fibrocystic
Change from Breast CancerChange from Breast Cancer
Fibrocystic Fibrocystic ChangeChange
Breast CancerBreast Cancer
Often bilateral Often bilateral Often UnilateralOften Unilateral
May have multiple May have multiple nodulesnodules
Usually singleUsually single
Menstrual variationMenstrual variation No menstrual variationNo menstrual variation
Cyclic pain & Cyclic pain & engorgementengorgement
No cyclic pain or No cyclic pain or engorgementengorgement
May regress during May regress during pregnancypregnancy
Does not regress Does not regress during pregnancyduring pregnancy
BENIGN NEOPLASMSBENIGN NEOPLASMS FibroadenomaFibroadenoma
a)a) Most common benign breast Most common benign breast tumor in women <35tumor in women <35
b)b) Presentation:Presentation: palpable, round, palpable, round, movable, rubbery massmovable, rubbery mass
c)c) Gross:Gross: well circumscribed, tan, well circumscribed, tan, rubbery mass with small, cleft-rubbery mass with small, cleft-like spaceslike spaces
d)d) Micro:Micro: proliferation of benign proliferation of benign stroma, ducts, & lobulesstroma, ducts, & lobules
Mammogram Gross; cross section
Ultrasound
HU2400 Imaging
Mammography
Phyllodes tumor Phyllodes tumor (cystosarcoma phyllodes)(cystosarcoma phyllodes)
a)a) Fibroadenoma variant usually Fibroadenoma variant usually involves an older patient involves an older patient population population
b)b) Micro:Micro: increased cellularity, increased cellularity, stromal overgrowth, & irregular stromal overgrowth, & irregular marginsmargins
c)c) May locally recur or rarely May locally recur or rarely metastasizemetastasize
Intraductal papillomaIntraductal papilloma
a)a) Commonly presents as a Commonly presents as a bloody nipple dischargebloody nipple discharge
b)b) Micro:Micro: benign papillary growth benign papillary growth within lactiferous ducts or within lactiferous ducts or sinusessinuses
Intraductal papilloma is a benign tumor inside a milk duct. Removal of the duct for biopsy may be recommended to rule out cancer.
MALIGNANTMALIGNANT NEOPLASMSNEOPLASMS
Carcinoma of the breastCarcinoma of the breasta)a) EpidemiologyEpidemiology
i.i. Most common cancer in Most common cancer in females (1 in 9 women in the females (1 in 9 women in the U.S.)U.S.)
1.1. > 50 yrs.> 50 yrs.
ii.ii. Second most common cause Second most common cause of cancer deathof cancer death
iii.iii. United States > JapanUnited States > Japaniv.iv. Incidence is increasingIncidence is increasing
b)b) Risk FactorsRisk Factors
i.i. Incidence increases with ageIncidence increases with age
ii.ii. First-degree relative with breast First-degree relative with breast cancercancer
iii.iii. Hereditary (5-10% of breast Hereditary (5-10% of breast cancers)cancers) BRCA1 chromosome 17q21BRCA1 chromosome 17q21 BRCA2 chromosome 13q12-13BRCA2 chromosome 13q12-13 P53 germ-line mutation: Li P53 germ-line mutation: Li
Fraumeni syndromeFraumeni syndrome
The TP53 gene is a tumor suppressor gene. When an individual inherits a mutation in this type of gene from one of his or her parents, there is an increased risk for developing certain kinds of cancer. Females with LFS have an increased risk for developing breast cancer.
Pedigree of family with Li-Fraumeni syndrome. (Redrawn from Malkin D, Li FP, Strong LC, et al. Germ line p53 mutations in a familial syndrome of breast cancer, sarcomas, and other neoplasms. Science 1990;250:1233-1238.)
iv.iv. Prior breast cancerPrior breast cancer
v.v. Long length of reproductive Long length of reproductive lifelife
vi.vi. NulliparityNulliparity
vii.vii. ObesityObesity
viii.viii. Exogenous estrogensExogenous estrogens
ix.ix. Proliferative fibrocystic Proliferative fibrocystic changes, especially atypical changes, especially atypical hyperplasiahyperplasia
c)c) Clinical PresentationClinical Presentationi.i. Mammographic calcifications or Mammographic calcifications or
architectural distortionarchitectural distortionii.ii. Physical exam: solitary painless Physical exam: solitary painless
massmassiii.iii. Nipple retraction or skin Nipple retraction or skin
dimplingdimplingiv.iv. Fixation to the chest wallFixation to the chest wallv.v. Most common in upper outer Most common in upper outer
quadrantquadrantd)d) Gross:Gross: stellate, white-tan, gritty stellate, white-tan, gritty
massmass
e)e) Histologic variantsHistologic variants
i.i. PreinvasivePreinvasive1.1.Ductal carcimona Ductal carcimona in situin situ
(DCIS)(DCIS)
2.2. Lobular carcinoma in situ Lobular carcinoma in situ (LCIS)(LCIS)
Range of Ductal Carcinoma in situ (DCIS)
Image - Lobular Carcinoma in situ (LCIS)
Normal breast with lobular carcinoma in situ (LCIS) in an enlarged cross–section of the lobule.Breast profile:A ductsB lobulesC dilated section of duct to hold milkD nippleE fatF pectoralis major muscleG chest wall/rib cage
Enlargement:A normal lobular cellsB lobular cancer cellsC basement membrane
Lobular Carcinoma in situ (LCIS)
b)b) Invasive (infiltrating) ductal Invasive (infiltrating) ductal carcinomacarcinoma
i.i. Most common (>80%)Most common (>80%)ii.ii. Micro:Micro: tumor cells form ducts tumor cells form ducts
within a desmoplastic stromawithin a desmoplastic stromac)c) Invasive (infiltrating) lobular Invasive (infiltrating) lobular
carcinomacarcinomai.i. Some 5-10% of casesSome 5-10% of casesii.ii. Micro:Micro: small, bland tumor cells small, bland tumor cells
form a single-file patternform a single-file patterniii.iii. High incidence of multifocal & High incidence of multifocal &
bilateral diseasebilateral disease
Range of Ductal Carcinoma in situ (DCIS)
Normal breast with invasive lobular carcinoma (ILC) in an enlarged cross–section of the lobule.Breast profile:A ductsB lobulesC dilated section of duct to hold milkD nippleE fatF pectoralis major muscleG chest wall/rib cage
Enlargement:A normal cellsB lobular cancer cells breaking through the basement membraneC basement membrane
Invasive Lobular Carcinoma (ILC)
d)d) Mucinous (colloid) carcinomaMucinous (colloid) carcinomai.i. Micro:Micro: clusters of bland tumors clusters of bland tumors
float within pools of mucinfloat within pools of mucinii.ii. Better prognosisBetter prognosis
e)e) Tubular carcinoma: rarely Tubular carcinoma: rarely metastasizesmetastasizes
f)f) Medullary carcinomaMedullary carcinomai.i. Micro:Micro: Pleomorphic tumor cells Pleomorphic tumor cells
from syncytial group, from syncytial group, surrounded by a dense surrounded by a dense lymphocytic host responselymphocytic host response
ii.ii. Better prognosisBetter prognosis
g)g) Inflammatory carcinomaInflammatory carcinoma
i.i. Red, warm, edematous skinRed, warm, edematous skin
ii.ii. Peau d’ orange: thickened Peau d’ orange: thickened skin resembles an orange skin resembles an orange peelpeel
iii.iii. Extensive dermal lymphatic Extensive dermal lymphatic invasion by tumorinvasion by tumor
The image is an example of peau d'orange, the orange-peel texture often associated with inflammatory breast cancer.
Inflammatory breast cancer of the left breast showing peau d’orange and inverted nipple.
Normal breast with cancer cells invading the lymph channels and blood vessels in the breast tissue.A blood vesselsB lymphatic channels
Enlargement:A normal duct cellsB cancer cellsC basement membraneD lymphatic channelE blood vesselF breast tissue
PrognosisPrognosisa)a) Axillary lymph node statusAxillary lymph node statusb)b) Size of tumorSize of tumorc)c) Histological type & grade of Histological type & grade of
tumortumord)d) ER/ PR receptor statusER/ PR receptor status
i.i. ERER1.1. due to due to plasma estrogen (e.g.,post menopausal) plasma estrogen (e.g.,post menopausal)
e)e) Overexpression of c-erbB2 Overexpression of c-erbB2 (HER2/neu)(HER2/neu)
f)f) Flow cytometry S-phase & DNA Flow cytometry S-phase & DNA ploidyploidy
TreatmentTreatment
a)a) Local diseaseLocal disease
i.i. Mastectomy or lumpectomy Mastectomy or lumpectomy with radiationwith radiation
ii.ii. Axillary dissectionAxillary dissection
b)b) Metastatic diseaseMetastatic disease
i.i. TamoxifenTamoxifen
ii.ii. ChemotherapyChemotherapy
OTHEROTHER MALIGNANCIESMALIGNANCIES
Paget disease of the nipplePaget disease of the nipple
a)a) Ulceration, oozing, crusting, & Ulceration, oozing, crusting, & fissuring of the nipple & areolafissuring of the nipple & areola
b)b) MicroMicro
i.i. Intraepidermal spread of tumor Intraepidermal spread of tumor cells (Paget cells)cells (Paget cells)
ii.ii. Tumor cells occur singly or in Tumor cells occur singly or in groupsgroups
iii.iii. Often have a clear halo Often have a clear halo surrounding the nucleussurrounding the nucleus
c)c) Commonly associated with an Commonly associated with an underlying invasive or underlying invasive or in situin situ ductal carcinomaductal carcinoma
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