1. Invasive ductal carcinoma is the most common type of breast cancer, accounting for 70% of cases. It is characterized by malignant epithelial cells invading the breast stroma. 2. Invasive lobular carcinoma accounts for 5-10% of breast cancers and is characterized by cells resembling those lining the lobules infiltrating in a single-file pattern. 3. Breast cancer prognosis depends on tumor size and spread, with 5-year survival rates ranging from 96% for stage 1 to 18% for stage 4 cancer that has metastasized to distant sites.

1. Breast carcinoma…cont
Dr. Rupinder Kaur

2. Invasive Ductal Carcinoma
► An infiltrative malignant epithelial process
resembling cells lining ducts--most common breast
carcinoma
► Classified according to histologic appearance
as:
1. Carcinoma not otherwise specified : majority
2. Special good prognosis subtype: including
medullary carcinoma, colloid (mucinous)
carcinoma, and tubular carcinoma . . .
3. Poor prognosis : inflammatory carcinoma

3. Invasive Ductal Carcinoma-NOS
► Most common
► Accounts for 70% cases of breast cancer
► Most of these cancers exhibit marked increase in dense,
fibrous tissue stroma giving tumour a hard consistency
(Schirrous carcinoma)
► May have an infiltrative attachment to surrounding
structures with fixation of the tumour to underlying chest
wall, retraction of the nipple and dimpling of the skin

4. Invasive Ductal Carcinoma-NOS
Pathologic changes
► Gross- sharply delimited nodules of stony hard consistency
measuring 1-5 cms
► C/s- pin point foci or streaks of chalky white elastic stroma
► Histologic findings- malignant tumour cells arranged in
cords, solid nests, tubules, or mixture of all these invading
the stroma
► Absence of hormone receptors vary with grade
► Perivascular, perineural, vascular and lymphatic invasion

6. Infiltrating Duct Carcinoma: small hard

9. IDC-NOS

12. Lymphatic spread – Peu-de
Orange..

15. Invasive lobular carcinoma
► Accounts for 5-10% of all breast cancers
► Tend to be bilateral (20%) far more frequently than other
subtypes
► Multicentric within same breast
► Have diffusely invasive pattern which make both primary
and metastasis difficult to detect either by physical
examination or by radiologic studies
► More frequently metastasize to CSF, serosal surfaces,
ovary, uterus and bone marrow than other subtypes

16. Invasive Lobular Carcinoma
► Gross- tumour is rubbery and poorly circumscribed
► Histology- An infiltrating carcinoma resembling cells lining
the lobules (of LCIS)
► Shows classical “Indian file” pattern
► Composed of relatively small cells with scanty cytoplasm,
sometimes vacuolated
► Associated with LCIS in >90% of the cases

18. Lobular Carcinoma

19. Medullary carcinoma
► Variant of ductal carcinoma
► Accounts for 1-5% of all mammary carcinomas
► Occurs in younger age group
► Significantly better prognosis probably because of good
host immune response in the form of lymphoid infiltrate in
the tumour stroma
► Gross-
Large well circumscribed, rounded mass (upto
5cms), soft, fleshy in consistency

20. Medullary carcinoma
► Histologically-
- solid syncitium like sheets (occupying >75%
of the tumour) of large cells with vesicular
pleomorphic nuclei, prominent nucleoli and
frequent mitosis
- moderate to marked lymphoplasmacytic
infiltrate surrounding and within the tumour
- pushing or non infiltrative border

21. Medullary Carcinoma: Large soft

22. Medullary carcinoma- arrows showing
lymphocytes

23. Colloid (mucinous) carcinoma
► Unusual variant (1-6%) , slow growing
► occur in older women, good prognosis
► Gross-
-the tumour is extremely soft having pale,
blue gelatinous consistency, well circumscribed
► Histologically-
- large lakes of light staining mucin dissecting
and extending into contigous tissue spaces
- floating within mucin are small islands and
isolated neoplastic cells at times forming
glands

24. Colloid/Mucinous carcinoma

25. Mucinous carcinoma

26. Tubular carcinoma
► Accounts for only 2-10% of all breast cancers
► Usually detected on mammographic screening as a
spiculated (irregular) masses
► Women tend to be younger (late 40’s)
► Multifocal within one breast (10-56%)
► Bilateral in 9-38%
► Microscopically :simulates a benign condition because of
well differentiated nature of the glands, absent necrosis or
mitosis

27. Tubular carcinoma
► Clue to diagnosis-
- haphazard arrangement of glands in the stroma with
absence of any organoid confugration
- invasion of the fat at the periphery of the lesion
- Cellular stroma
- Irregular and angulated contours of glands
- Lack of myoepithelial cells

28. Tubular carcinoma

31. Spread
► Direct: skin, pec major, seratus anterior, chest
wall
► Lymphatic: skin (Peau d’orange), axillary,
internal thoracic. Later to supraclavicular,
abdominal, mediastinal, groin, contralateral
nodes.
► Blood stream: lungs, liver, bones (sites of red
bone marrow) brain, ovaries, adrenal glands.
► Trans-coelomic: pleural (effusion) and
peritoneal (ascites) in advanced disease

32. Spread of
Breast
Carcinoma:

33. Tumour Grade (Histological)
► Modified Bloom-Richardson system:
• TUBULES (1-3) +
• PLEOMORPHISM (1-3) +
• MITOSES (1-3)
• Grade 1 = 3-5
• Grade 2 = 6-7
• Grade 3 = 8-9

34. Staging
► Stage 1 - Tumour less than 2cm in diameter
with no LN involvement
► Stage 2 - Tumour 2-5cm with or without LN
involvement
► Stage 3 - Tumour cells spread to axillary LN’s
but not to other parts of the body
► Stage 4 - The cancer cells spread to other
parts of the body

35. St
ag
Definition
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
diameter without 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
distant metastases
18 11

36. High-Risk
► Prior breast cancer
► Family history of breast cancer
 Ovarian cancer
 BRCA-1 or BRC-2 gene
► Prior mantle radiation
► Biopsy proven of atypia or LCIS

37. Diagnosis:
► Mammography
► Ultrasound
► Fine Needle Aspiration Biopsy
► Core Biopsy
► Excision Biopsy
► Frozen section
► Immunohistochemistry ( ER,PR, Her2neu)
► Molecular techniques – Gene detection ( BRCA1,2, p53
loss).

38. Screening
► Prior breast cancer or atypia
 Annual mammography
 6 mo CBE
► Family Hx
 10 yrs younger than relative’s diagnosis
 6 mo CBE
► BRCA
 25 yr – annual mammography
 6 mo CBE

39. Prognostic Factors of Breast Cancer
► Size of primary tumor
► Lymph node involvement and extent
► Grade
► Histologic type
► To a lesser extent, estrogen/progesterone receptors

40. ER/PR
► Expression of oestrogen and progesterone receptors is a
very powerful and useful predictor.
► The response rate to hormonal treatment in breast cancer
is associated with the presence of oestrogen and
progesterone receptors
► Assessment of the receptor expression profile allows for
prediction of breast cancer response to hormonal
treatment.
► The higher the content of ER and PR in breast cancer, the
greater the likelihood of response to hormonal therapy

41. Microphotograph showing positive nuclear staining of progesterone receptor
in invasive ductal carcinoma (IDC)

42. Treatment
► Modern treatment based on multimodal approach
combining surgery, chemo, RT and HT
► Chemotherapy (CMF) / Radiotherapy
► Tamoxifen (if ER +ve)
► Arimidex (if ER +ve, postmenopasual and contraindication
to Tamoxifen)
► Herceptin (if HER2 positive)

43. Treatment
► Breast conserving surgery (BCS)
- Wide local excision (WLE)
- +/- axillary sampling (at least four nodes) or
axillary clearance
Contra-indications to BCS
► – Pregnancy
► – Previous irradiation to breast
► – Multifocal/diffuse disease (including carcinoma in situ)
► – Positive margins/residual disease after BCS
► – Tumours >5cm*
► – Very large or very small breasts*

45. Gynecomastia
► Button-like subareolar swelling, bilateral,
► Histologically corresponding to intraductal epithelial
hyperplasia and increased periductal stromal cellularity and
edema
► Associated with relative estrogen excess, cirrhosis of liver,
Klinefelter’s, estrogen secreting tumor, estrogen therapy,
and digitalis therapy
► Physiological gynecomastia most common in puberty and
old age
► No clear cut association with development of carcinoma

46. Gynecomastia

47. Male Breast Carcinoma
► Rare, ratio of male to female breast cancer 1:125
► Occurs in advanced age
► Identified in peri-nipple/areolar region
► Presents in advanced stage
► Resembles morphologically and biologically
invasive carcinomas of the female breast