1. Breast disease
Dr. A. Basu MD

2. Topic
General concept

4. TDLU

5. D/D of a breast Lump Abscess ( tender) Galactocele
Solid Lump
Cystic Lump
Bilateral
Unilateral
Abscess ( tender)
Galactocele
( History of Pregnancy)
Cyst Breast.
Fibrocystic disease
( Irregular lump)
Fibro adenoma
Cystosarcoma Phyllodes
Breast carcinoma
Fat necrosis

6. Diseases of Breast : lecture topic
Fibrocystic changes of breast: types
Inflammations
Tumors of the Breast

7. Fibrocystic disease of breast
Non Proliferative change
Cyst and fibrosis
Proliferative change
Its is a ‘Premalignant “ condition of the breast
Epithelial Hyperplasia
Sclerosing adenosis

8. Fibrocystic changes

9. Fibrocystic disease (Non Proliferative change)
Gross: Blue dome cyst [ 1to 5 cm]

10. Non Proliferative change : MICRO
Cystic dilation of Glands an ducts
Apocrine metaplasia of the lining epithelium of the duct and glands.

11. Proliferative change Epithelial Hyperplasia Sclerosing adenosis
Subtype: Atypical
Sclerosing adenosis

12. (Atypical) Epithelial Hyperplasia : More chance of carcinoma.
Normal

13. Sclerosing adenosis Excessive fibrosis of beast
Increased number of collapsed gland

14. Sclerosing adenosis clinically mimic malignancy : because it is hard and rubbery on palpation.

15. Clinical : Fibrocystic changes
Lumpy Breast

16. Inflammation of the breast
Acute mastitis ( produce breast abscess).
Mammary Duct ectasia
Traumatic fat necrosis.

17. Acute mastitis ( produce breast abscess).
Etiology : Early week of Nursing and dermatitis.

18. Acute mastitis

19. Mammary Duct ectasia Def : NON-inflammatory lesion.
Age : years , who has children.
Cause : Accumulation of Breast secretion in Main Excretory Duct.

20. Mammary Duct ectasia: Dilated Duct , Fibrosis around the dilated duct
Mammary Duct ectasia: Dilated Duct , Fibrosis around the dilated duct. Presence of PLASMA cells and lymphocytes

21. Mammary Duct ectasia-C/F
Presents as a lump below the nipple.
Cause nipple Retraction : mimic carcinoma

22. Traumatic fat necrosis
Early : Small Tender and localized lump.
Later : Fibrosis and calcification occur.

23. Tumors of the Breast Fibro adenoma Phyllodes Tumors
Intraductal papilloma
Carcinoma of the breast

24. Fibro adenoma : Breast Mouse
Disease involve TDLU
Most common benign tumor in female breast.
Its growth is related to estrogen.
Age : young women ( 3rd Decade)
They have both epithelial and connective tissue elements.

25. Morphology Size : 1 to 10 cm. Tumor more than 10 cm :
Giant fibro adenoma.
Gross: Breast Mouse
Micro: 2 features

26. Gross: Well circumscribed , tan-white

27. 1. Oval round duct space

28. 2. Slit like , star shaped compressed duct

29. Clinical Solitary, discreet, moveable mass ( breast mouse).
Regress after menopause and calcify.
It will never become malignant.

30. Phyllodes ( leaf –like) Tumors

31. Phyllodes ( leaf –like) Tumors
Past name: Cystosarcoma Phylloid
It can become malignant
Usually a big tumor
Contain mainly stromal component.
Morphologically has a “ leaf like” appearance.

32. Morphologically has a “ leaf like” appearance

33. Phyllodes tumor
High-grade lesion behave aggressively and exhibit recurrence.

34. Fibroadenoma Vs Phyllodes tumor
Low cellularity
High cellularity, bulky stroma.
Rare mitosis
High mitosis
No Pleomorphism
Pleomorphism Present
Well circumscribed
Infiltrative border

35. Intraductal papilloma
An Intraductal papilloma may be associated with a serous or bloody nipple discharge .
Location : Subareolar
It’s a benign lesion.

36. Intraductal papilloma arising in main lactiferous ducts

37. Carcinoma Breast Risk factors Genetics and family History
Prolonged exposure to exogenous estrogen and obesity.
Alcohol consumption.
Environmental

38. Risk factors Proliferative breast diseases
Carcinoma of the contra lateral breast or endometrium.
Frequent in nulliparous women.
Obesity

39. Age : Genetics and family History
Age : uncommon below 35 years
Genetic disease associated with Breast cancer:
Li-Fraumeni syndrome ( multiple sarcoma and carcinoma).
Cowden disease ( multiple hamartoma syndrome).

40. Gene and Breast carcinoma
Associate with BRCA 1 and BRCA 2 gene,
Over expression of c-erb –b2. HER2/neu

41. Location of breast tumor
Upper inner 10%
Upper outer: 50%
Central 20
Lower outer outer: 10%
Lower inner: 10%

42. Classification Non Invasive Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (LCIS)
Invasive

43. Invasive Invasive ductal carcinoma ( not otherwise specified ; NOS)
Invasive lobular carcinoma
Medullar carcinoma
Colloid carcinoma
Tubular carcinoma

44. DCIS Vs LCIS Arise from duct Arise from acini.
Associated with micro calcification
Not associate with calcification
High grade DSCI has bad prognosis
Do not produce mass. Good prognosis

45. Duct Carcinoma In Situ : Features
Low grade DCIS : Good prognosis
DCIS with micro invasion
Variant : Comedo carcinoma
Paget disease of nipple: Extension of In situ duct carcinoma cell to the lactiferous duct and the skin of the nipple.

46. Ductal carcinoma in situ (DCIS) : with micro calcification

47. Comedo subtype of DCIS : Central necrosis within the duct.
Comedocarcinoma

48. Paget disease of nipple
Extension of In situ duct carcinoma cell to the lactiferous duct and the skin of the nipple.

49. Paget disease of nipple : Clinically resemble eczema.

50. Paget cells:
These cells have abundant clear cytoplasm and appear in the epidermis either singly or in clusters.

51. Paget cell stain PAS : Indicate presence of Mucin

52. Prognosis of DCIS Excellent 97% long time survival.
DCIS with micro invasion : bad prognosis.

53. Lobular carcinoma in situ

54. All acini of a breast lobe is affected
All acini of a breast lobe is affected. Cells are monomorphic ( similar size)

56. Time for Invasive carcinomas
Invasive ductal carcinoma ( not otherwise specified ; NOS)
Invasive lobular carcinoma
Medullar carcinoma
Colloid carcinoma

57. Invasive ductal carcinoma (Scirrhous carcinoma)- 70-80%
It is carcinoma with no special type ( NOS).
Constitute Majority of Breast carcinoma.
They have desmoplasia (Scirrhous ).
Stony hard mass, fixed to skin , underlying muscles.

58. Invasive ductal carcinoma (Scirrhous carcinoma
Lymph vascular and neural invasion common.
Tumor cells frequently over express ERB B2.
2/3 rd EXPRESS HOEMONE ( ESTROGEN AND PROGESTERONE) RECEPTOR.
Presence of overlying Paget’s disease : Bad prognosis.

59. Gross : IDC ; infiltrative tumor with irregular margin.

60. Gross : IDC ; infiltrative tumor with infiltrating growth .

61. Micro : IDC

62. IDC with extreme desmoplasia

63. Diagnosis
Mammography
Micro calcification [ red alert]
FNAC
Biopsy

64. Inflammatory carcinoma
It a a variant of duct carcinoma ;
Shows swollen , erythematous (red) breast mimic acute inflammation.

65. Invasive lobular carcinoma : Main Features
Tumor cells are monomorphic ( similar size).
Frequently bilateral and multicentric.
More often spread to CSF, serosal surface and ovary.
Frequently clinically silent.
Express hormone receptor.

66. Invasive lobular carcinoma: monomorphic round cells

67. Invasive lobular carcinoma : microscopy : single indian file

68. Bulls eye pattern of invasion

69. Colloid carcinoma Age : Older women Growth : Slow growing,
Prognosis ; Prognosis is better than for non-mucinous, invasive carcinomas.
Most express hormone receptors.
Gross: Soft gelatinous.

70. Colloid carcinoma :Note the abundant bluish Mucin.

71. Medullar carcinoma-2%
Incidence : Less than 5% of breast cancers ( occur with BRCA1)
Morphology :
Gross : 2-5 cm, fleshy masses .
Micro : Sheets and nests of cells are surrounded by a lymphoid plasmacytic stroma with no desmoplasia.

72. Medullar carcinoma

73. Medullary carcinoma
Prognosis : Better than for infiltrating ductal or lobular carcinoma.
Lack hormone receptors.

74. Topic now Tubular carcinoma Sarcoma of breast
Features of invasive tumor
Spread of breast carcinoma
Staging of breast carcinoma
Clinical course and prognosis
Management
Male Breast
Miscellaneous lesions

75. Tubular carcinoma : features
Small mass , rarely palpable( 1cm size).
Excellent Prognosis
Lympnnode metastasis is rare.
Express hormone receptor.
Micro : Well formed tubules and low grade nuclei.

76. Morphology

77. Sarcoma of Breast All types of sarcoma can occur
But angiosarcoma is common.

78. Features of invasive tumor
Fixation to the tissue ( skin, muscle)
Retraction of nipple.
Inflammatory carcinoma.
Dimpling of the skin.
Lymph edema : caused by Tumor emboli in the dermal blood vessels.

79. Retraction of nipple

80. Inflammatory carcinoma: common in pregnancy (but no inflammatory cells present)

81. Tumor emboli in the dermal blood vessels: the cause of Lymphedema

82. Lymphedema following radical mastectomy: Thickened skin

83. Spread Local Lymph nodes Lung, Skeleton ( osteolytic) Brain ( CSF)
Metastasis may occur even after 15 years.

84. Internal mammary Lymph nodes Axillary Lymph nodes
Upper outer: 50%
Upper inner 10%
Central 20
Lower outer outer: 10%
Lower inner: 10%

85. 11 Prognostic factors The size of the primary tumor
Invasive Ca < 2 cm = excellent
Lympnnode and number of LN involvement.
Most important factor related to the prognosis of breast cancer
Histological type
NOS : Duct carcinoma = bad prognosis
Specialized Ca : good prognosis

86. Prognostic factors Grade Well differentiate tumor = better prognosis.
Presence of both estrogen / progesterone receptor
Slightly better prognosis.

87. Prognostic factors Aneuploidy If present - worse prognosis.
Over expression of ERB B2
Poorer Prognosis.
Increased mitosis.
Bad prognosis

88. Prognostic factors Angiogenesis +++ More chance of metastasis Protease
If increased more chance of invasion.

89. Hercepctin Monoclonal Antibody to Gene ERBB2.
It is an antitumor antibody.
If response to this antibody is GOOD = GOOD prognosis.

90. Management Lumpectomy Mastectomy or breast Preservation
Hormonal and Chemotherapy.
Inhibition of angiogenesis.

91. Post mastectomy Tumor deposit on scar area.

92. Breast self examination; best way to save life

93. Thank you
We will now move on to Male Breast.

94. Male Breast
Gyenecomastia ( Greek word) : enlargement of the male breast.

95. Proliferation of ducts in hyalinized fibrous tissue with periductal edema

96. Causes Puberty Tumors ( Leydig cell tumor of testis)
Genetic disorders ( kilnefelter syndrome)
Chronic liver disease (cirrhosis)
Female hormone exposure

97. Carcinoma of male breast : rare : usually duct carcinoma.

98. Thank you