Dr. Sura Obay Al-Dewachi Breast Dr. Sura Obay Al-Dewachi

Carcinoma Breast cancer is the most common cancer in women. Risk factors Age, rare before 25 years Early menarche and late menopause Age at 1st pregnancy First-degree relatives with breast cancer Prior breast biopsies with atypical hyperplasia Additional risk factors Hormone replacement therapy. Radiation exposure Carcinoma of the contralateral breast or endometrium

Additional risk Factors Diet Over weight Lack of exercise Lack of breast feeding Environmental toxins smoking

Pathogenesis of breast cancer Genetic influence: approximately 5-10% of breast cancer are hereditary, meaning that there is a known genetic mutation causing increased cancer risk in the patient’s family. 25% are attributed to mutations in two supressor genes (BRCA1, BRCA2). Other genes mutations form 10%. Remaining 65% of familial breast cancers are unexplained.

Hormonal influence: risk of breast cancer increase with life time estrogen exposure, so hormonal imbalance (endogenous estrogens excess) play a significant role. Role of estrogen in breast cancer Its metabolites can cause mutation or generate DNA-damaging free radicals Via its hormonal action, it directly stimulates proliferation of epithelial cells

Classification of breast carcinoma The chief forms of carcinoma of breast can be classified as follow: Non invasive (in situ)(cancer not penetrate the limiting basemet membrane): Ductal carcinoma in situ (DCIS) (intraductal carcinoma) Lobular carcinoma in situ (LCIS)

Invasive (infiltrating) Invasive ductal carcinoma Invasive lobular carcinoma Medullary carcinoma Colloid carcinoma (mucinous carcinoma) Tubular carcinoma

Ductal carcinoma in situ (DCIS) Forms up to 30% of all carcinomas. Presents as Vague palpable mass Nipple discharge Mammographic calcifications or densities Incidental in a biopsy for another lesion Majority of cases cannot be detected by palpation or visual inspection Morphology (Comedocarcinoma, solid, cribriform, papillary, micropapillary) Many cases will progress to invasive carcinoma Mastectomy is curative in 95% of cases

DCIS, comedo pattern

Comedo carcinoma DCIS, solid pattern

DCIS, cribriform pattern

DCIS, papillary pattern

Paget disease of nipple It is caused by extension of DCIS up to lactiferous ducts and in to the contiguous skin of the nipple. The clinical appearance is unilateral erythematous pruritic eruption , crusting exudate over the nipple and areolar skin. About half of cases, an underlying invasive carcinoma will be found , and presented with palpable mass.

Paget disease of nipple

Lobular Carcinoma In Situ (LCIS) Always an incidental finding in a biopsy performed for another reason More common in young women bilateral in up to 40% of cases Management include Bilateral prophylactic mastectomy Tamoxifen Close clinical follow-up and mammo-graphic screening

LCIS

Invasive Carcinoma Almost always presents as a palpable mass

Invasive duct carcinoma

Invasive lobular carcinoma

Spread of breast cancer : Direct : It invades the breast tissue & overlying skin with ulceration & nipple retraction . It may invade the underlying muscle & chest wall . Lymphatics : Permeation of the local dermal lymphatics by tumour cause blockage of lymphatics & oedema of the skin producing a Peau d orange. Dermal lymphatic invasion may produce multiple tumour nodules with thickening of skin . Invasion of axillary lymph nodes . Invasion of internal mammary lymph nodes . Invasion of supraclavicular lymph nodes . Blood : spread to lung , liver & bones .

Major prognostic factors In situ versus invasive carcinoma distant metastasis lymph node metastases primary tumor size locally advanced disease inflammatory carcinoma Invasion of chest wall Skin ulceration

THE MALE BREAST

Gynaecomastia : It is enlargement of the breast tissue of males ,which is usually caused by proliferation of connective tissue & ducts of the breast. It may be unilateral or bilateral . Aetiology : Endocrine disturbances : due to increase estrogen Testicular tumors e.g. teratoma. estrogen therapy e.g. for carcinoma of the prostate Cirrhosis : Due to failure of detoxification of estrogen . Drugs : e.g. digitalis , tricyclic compounds.

Gynecomastia Gynecomastia