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Diseases of the breast

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Diseases of the breast

  1. 1. BREAST www.freelivedoctor.com
  2. 2. www.freelivedoctor.com
  3. 3. LYMPHATIC DRAINAGE AXILLARY (MOSTLY) INTERNAL MAMMARY SUPRACLAVICULAR www.freelivedoctor.com
  4. 4. HISTOLOGY <ul><li>LOBE: (10 in whole breast) </li></ul><ul><li>LOBULE: (many per lobe) </li></ul><ul><li>ACINUS/I, aka ALVEOLUS/I: (many per lobule) </li></ul><ul><li>DUCT(S): INTRA- or INTER- LOB(UL)AR, leading to the lactiferous ducts in the nipple </li></ul>www.freelivedoctor.com
  5. 5. LOBE www.freelivedoctor.com
  6. 6. LOBULE www.freelivedoctor.com
  7. 7. www.freelivedoctor.com
  8. 8. THREE NORMALPHASES <ul><li>ACTIVE: about 50-50 Gland/Stroma ratio </li></ul><ul><li>LACTATING: Mostly Glands (like thyroid!!!), >>>50/50 </li></ul><ul><li>ATROPHIC: mostly stroma, <<<50/50 </li></ul>www.freelivedoctor.com
  9. 9. www.freelivedoctor.com
  10. 10. www.freelivedoctor.com
  11. 11. www.freelivedoctor.com
  12. 12. www.freelivedoctor.com
  13. 13. The most important thing to understand breast pathology is to get a solid IMAGE of the “NORMAL” breast lobule----ACINI, STROMA, BOUNDARIES www.freelivedoctor.com
  14. 14. BREAST PATHOLOGY <ul><li>DEVELOPMENTAL: </li></ul><ul><li>DEGENERATION: </li></ul><ul><li>INFLAMMATION: </li></ul><ul><li>NEOPLASM: </li></ul>www.freelivedoctor.com
  15. 15. DEVELOPMENTAL <ul><li>MILKLINE REMNANTS </li></ul><ul><li>ACCESSORY (axillary) BREAST TISSUE </li></ul><ul><li>NIPPLE INVERSION </li></ul><ul><li>MACROMASTIA </li></ul>www.freelivedoctor.com
  16. 16. ACCESSORY (axillary) BREAST TISSUE www.freelivedoctor.com
  17. 17. 1) CONGENITAL 2) ACQUIRED: CARCINOMA 3) ACQUIRED: PIERCING www.freelivedoctor.com
  18. 18. www.freelivedoctor.com Macromastia.
  19. 19. DEGENERATION <ul><li>ATROPHY </li></ul>www.freelivedoctor.com
  20. 20. www.freelivedoctor.com
  21. 21. INFLAMMATION <ul><li>PERIDUCTAL </li></ul><ul><li>DUCT-ECTASIA </li></ul><ul><li>FAT NECROSIS, usually trauma </li></ul><ul><li>LYMPHOCYTIC, i.e., diabetic </li></ul><ul><li>GRANULOMATOUS, sarcoid, TB, etc., but mostly idiopathic </li></ul><ul><li>ACUTE, staph most common </li></ul>www.freelivedoctor.com
  22. 22. ACUTE MASITIS www.freelivedoctor.com
  23. 23. www.freelivedoctor.com Intraductal and periductal inflammatory cells, mostly neutrophils in acute mastitis.
  24. 24. www.freelivedoctor.com Pap smear of nipple exudate in acute mastitis. What are most of these cells?
  25. 25. INFLAMMATION? Peau d’orange www.freelivedoctor.com
  26. 26. www.freelivedoctor.com The tumor cells are INSIDE the skin dermal lymphatic spaces.
  27. 27. PERIDUCTAL INFLAMMATION www.freelivedoctor.com
  28. 28. DUCTESIA www.freelivedoctor.com
  29. 29. Ductesia  CYSTS www.freelivedoctor.com
  30. 30. CUBOIDAL  COLUMNAR  RED COLUMNAR  i.e. “APOCRINE” www.freelivedoctor.com
  31. 31. FAT NECROSIS www.freelivedoctor.com
  32. 32. FAT NECROSIS www.freelivedoctor.com
  33. 33. LYMPHOYCYTIC MASTITIS (DIABETIC MASTOPATHY ) www.freelivedoctor.com
  34. 34. GRANULOMATOUS MASTITIS www.freelivedoctor.com
  35. 35. NEOPLASIA <ul><li>Benign epithelial </li></ul><ul><li>Benign stromal </li></ul><ul><li>Premalignant </li></ul><ul><li>Malignant epithelial (ductal, lobular) (adenocarcinomas) (in-situ, infiltrating) </li></ul><ul><li>Malignant stromal </li></ul>www.freelivedoctor.com
  36. 36. CLINICAL PRESENTATIONS <ul><li>MASS, palpable or mammographic </li></ul><ul><li>NIPPLE DISCHARGE </li></ul><ul><li>PAIN </li></ul>www.freelivedoctor.com
  37. 37. NEOPLASIA <ul><li>BENIGN EPITHELIAL , aka, “FIBROCYSTIC” disease </li></ul><ul><ul><li>NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis </li></ul></ul><ul><ul><li>PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma </li></ul></ul><ul><ul><li>ATYPICAL epithelium </li></ul></ul>www.freelivedoctor.com
  38. 38. CYST www.freelivedoctor.com
  39. 39. www.freelivedoctor.com Breast cyst, filled with fluid, in the ultrasound lab.
  40. 40. CYST, GROSS CYST, MICROSCOPIC www.freelivedoctor.com
  41. 41. ADENOSIS www.freelivedoctor.com
  42. 42. FIBROSIS + CYSTS = FIBROCYSTIC DISEASE www.freelivedoctor.com
  43. 43. NEOPLASIA <ul><li>BENIGN EPITHELIAL , aka, “FIBROCYSTIC” disease </li></ul><ul><ul><li>NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis </li></ul></ul><ul><ul><li>PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma </li></ul></ul><ul><ul><li>ATYPICAL epithelium </li></ul></ul>www.freelivedoctor.com
  44. 44. DUCTALHYPERPLASIA www.freelivedoctor.com
  45. 45. “ SCLEROSING” ADENOSIS www.freelivedoctor.com
  46. 46. “ COMPLEX” SCLEROSING ADENOSIS (RADIAL SCAR) www.freelivedoctor.com
  47. 47. SCLEROSING ADENOSIS www.freelivedoctor.com
  48. 48. 1) EXTREMELY WELL DEFINED 2) YOUNGER WOMEN 3) ALWAYS BENIGN 4) CAN FIBROSE OR CALCIFY WITH AGE www.freelivedoctor.com FIBROADENOMA:
  49. 49. PAPILLOMA www.freelivedoctor.com
  50. 50. PAPILLOMA www.freelivedoctor.com
  51. 51. PAPILLOMA www.freelivedoctor.com
  52. 52. NEOPLASIA <ul><li>BENIGN EPITHELIAL , aka, “FIBROCYSTIC” disease </li></ul><ul><ul><li>NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis </li></ul></ul><ul><ul><li>PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma </li></ul></ul><ul><ul><li>ATYPICAL epithelium </li></ul></ul>www.freelivedoctor.com
  53. 53. FEATURES OF “ATYPIA” <ul><li>LOSS OF STROMA BETWEEN ACINI </li></ul><ul><li>“ SWISS CHEESE” HYPERPLASIA* </li></ul><ul><li>CRIBRIFORMING** </li></ul><ul><li>CELLULAR PLEOMORPHISM </li></ul><ul><li>CELLULAR HYPERCHROMASIA </li></ul><ul><li>INCREASED/ABNORMAL MITOSES* </li></ul><ul><li>“ ROMAN” BRIDGES*** </li></ul><ul><li>NECROSIS*** (“COMEDO-carcinoma ”) </li></ul>www.freelivedoctor.com
  54. 54. NORMAL DUCT NORMAL ACINUS ATYPICAL HYPERPLASIA of DUCT ATYPICAL HYPERPLASIA, LOBULE www.freelivedoctor.com
  55. 55. DCIS www.freelivedoctor.com
  56. 56. DCIS www.freelivedoctor.com
  57. 57. DCIS www.freelivedoctor.com
  58. 58. DCIS, microcalcifications www.freelivedoctor.com Microcalcifications, seen on mammograms, are often the result of necrotic intraductal crud which has calcified.
  59. 59. DCIS, microcalcifications www.freelivedoctor.com
  60. 60. NORMAL lobule www.freelivedoctor.com
  61. 61. www.freelivedoctor.com A whole lobule filled with monotono0us cells of the same type can be called LCIS, or lobular carcinoma in situ.
  62. 62. LCIS www.freelivedoctor.com
  63. 63. LCIS <ul><li>Usually hangs around MANY MANY years before it infiltrates, in contrast to DCIS </li></ul><ul><li>The BEST management may be judicious neglect, i.e., observation </li></ul><ul><li>If it does infiltrate, however, it is at least as bad as DCIS infiltrating, or probably WORSE, showing “indian” files </li></ul>www.freelivedoctor.com
  64. 64. BREAST CANCER RISK FACTORS <ul><li>Age </li></ul><ul><li>Menarche Age, early menarche is a risk </li></ul><ul><li>First Live Birth </li></ul><ul><li>First-Degree Relatives with Breast Cancer </li></ul><ul><li>Breast Biopsies </li></ul><ul><li>Race </li></ul><ul><li>Estrogen Exposure </li></ul><ul><li>Radiation Exposure </li></ul><ul><li>Carcinoma of the Contralateral Breast or Endometrium </li></ul><ul><li>Geographic Influence </li></ul><ul><li>Diet </li></ul><ul><li>Obesity </li></ul><ul><li>Exercise </li></ul><ul><li>Breast-Feeding, less breast feeding is a risk </li></ul><ul><li>Environmental Toxins </li></ul><ul><li>Tobacco </li></ul><ul><li>ABORTIONS? </li></ul>www.freelivedoctor.com
  65. 65. BREAST CANCER PROGNOSTIC FACTORS <ul><li>AGE </li></ul><ul><li>GENERAL HEALTH and IMMUNITY </li></ul><ul><li>Histologic degree of differentiation, i.e., GRADING </li></ul><ul><li>ERA/(PRA) </li></ul><ul><li>Her2, aka Her2-Neu </li></ul><ul><li>STAGING, especially POS or NEG lymph nodes, TNM, etc. </li></ul>www.freelivedoctor.com
  66. 66. STAGING, TNM, based on biologic behavior <ul><li>IN-SITU </li></ul><ul><li>EARLY disruption of the basal lamina, i.e., basement membrane </li></ul><ul><li>STROMAL infiltration </li></ul><ul><li>LYMPHATIC vessels </li></ul><ul><li>SENTINAL lymph node metastasis </li></ul><ul><li>MORE lymph node metastases </li></ul><ul><li>Adjacent structures, skin, ie, “inflammatory” </li></ul><ul><li>DISTANT, METASTASES, LIVER, BONE, LUNGS, BRAIN, EVERYWHERE </li></ul>www.freelivedoctor.com
  67. 67. www.freelivedoctor.com Total Cancers Per Cent In Situ Carcinoma 15–30 Ductal carcinoma in situ, DCIS 80 Lobular carcinoma in situ, LCIS 20 Invasive Carcinoma 70–85 No special type carcinoma (&quot;ductal&quot;) 79 Lobular carcinoma 10 Tubular/cribriform carcinoma (Better prognosis than average) 6 Mucinous (colloid) carcinoma (Better prognosis than average) 2 Medullary carcinoma (Better prognosis than average) 2 Papillary carcinoma 1 Metaplastic carcinoma, (Squamous)
  68. 68. HISTOLOGIC TIDBITS <ul><li>INFILTRATING DUCTAL </li></ul><ul><li>INFILTRATING LOBULAR (INDIAN FILE) </li></ul><ul><li>TUBULAR (LOOKS LIKE SCLEROSIS, BUT NO BASEMENT MEMBRANE) </li></ul><ul><li>MUCINOUS (COLLOID) </li></ul><ul><li>MEDULLARY (LOTS of LYMPHOCYTES) </li></ul>www.freelivedoctor.com
  69. 69. INFILTRATING DUCTALCARCINOMA www.freelivedoctor.com
  70. 70. INFILTRATING LOBULAR CA.,INDIAN” FILE PATTERN www.freelivedoctor.com
  71. 71. INFILTRATING DUCTAL CA., “TUBULAR” PATTERN or TYPE www.freelivedoctor.com
  72. 72. INFILTRATING DUCTAL CA., MUCINOUS (COLLOID) PATTERN or TYPE www.freelivedoctor.com
  73. 73. INFILTRATING DUCTAL CA., MEDULLARY PATTERN or TYPE www.freelivedoctor.com
  74. 74. NEOPLASIA, <ul><li>STROMAL </li></ul><ul><li>Cysto-”SARCOMA” PHYLLODES </li></ul><ul><li>(aka, PHYLLODES TUMOR), </li></ul><ul><li>Looks like a giant fibroadenoma, really NOT a sarcoma </li></ul><ul><li>SARCOMAS, true, are RARE!!!! </li></ul>www.freelivedoctor.com
  75. 75. FIBROADENOMA www.freelivedoctor.com
  76. 76. MALE BREAST <ul><li>GYNECOMASTIA (related to hyperestrogenism) </li></ul><ul><li>CARCINOMA (1% of ♀ ) </li></ul>www.freelivedoctor.com
  77. 77. GYNECOMASTIA (NO lobules) www.freelivedoctor.com

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