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Understanding Breast Pathology
- 5. HISTOLOGY ⢠LOBE: (10 in whole breast) ⢠LOBULE: (many per lobe) ⢠ACINUS/I, aka ALVEOLUS/I: (many per lobule) ⢠DUCT(S): INTRA- or INTER- LOB(UL)AR, leading to the lactiferous ducts in the nipple www.freelivedoctor.com
- 9. THREE NORMALPHASES ⢠ACTIVE: about 50-50 Gland/Stroma ratio ⢠LACTATING: Mostly Glands (like thyroid!!!), >>>50/50 ⢠ATROPHIC: mostly stroma, <<<50/50 www.freelivedoctor.com
- 14. The most important thing to understand breast pathology is to get a solid IMAGE of the âNORMALâ breast lobule---- ACINI, STROMA, BOUNDARIES www.freelivedoctor.com
- 15. BREAST PATHOLOGY ⢠DEVELOPMENTAL: ⢠DEGENERATION: ⢠INFLAMMATION: ⢠NEOPLASM: www.freelivedoctor.com
- 16. DEVELOPMENTAL ⢠MILKLINE REMNANTS ⢠ACCESSORY (axillary) BREAST TISSUE ⢠NIPPLE INVERSION ⢠MACROMASTIA www.freelivedoctor.com
- 18. 1) CONGENITAL 2) ACQUIRED: CARCINOMA 3) ACQUIRED: PIERCING www.freelivedoctor.com
- 22. INFLAMMATION ⢠PERIDUCTAL ⢠DUCT-ECTASIA ⢠FAT NECROSIS, usually trauma ⢠LYMPHOCYTIC, i.e., diabetic ⢠GRANULOMATOUS, sarcoid, TB, etc., but mostly idiopathic ⢠ACUTE, staph most common www.freelivedoctor.com
- 24. www.freelivedoctor.com Intraductal and periductal inflammatory cells, mostly neutrophils in acute mastitis.
- 25. www.freelivedoctor.com Pap smear of nipple exudate in acute mastitis. What are most of these cells?
- 27. www.freelivedoctor.com The tumor cells are INSIDE the skin dermal lymphatic spaces.
- 34. LYMPHOYCYTIC MASTITISLYMPHOYCYTIC MASTITIS (DIABETIC MASTOPATHY(DIABETIC MASTOPATHY)) www.freelivedoctor.com
- 36. NEOPLASIA ⢠Benign epithelial ⢠Benign stromal ⢠Premalignant ⢠Malignant epithelial (ductal, lobular) (adenocarcinomas) (in-situ, infiltrating) ⢠Malignant stromal www.freelivedoctor.com
- 37. CLINICAL PRESENTATIONS ⢠MASS, palpable or mammographic ⢠NIPPLE DISCHARGE ⢠PAIN www.freelivedoctor.com
- 38. NEOPLASIA ⢠BENIGN EPITHELIALBENIGN EPITHELIAL, aka, âFIBROCYSTICâ disease â NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis â PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma â ATYPICAL epithelium www.freelivedoctor.com
- 40. www.freelivedoctor.com Breast cyst, filled with fluid, in the ultrasound lab.
- 43. FIBROSIS + CYSTS = FIBROCYSTIC DISEASE www.freelivedoctor.com
- 44. NEOPLASIA ⢠BENIGN EPITHELIALBENIGN EPITHELIAL, aka, âFIBROCYSTICâ disease âNON-proliferative epithelium: i.e., cysts, fibrosis, adenosis âPROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma âATYPICAL epithelium www.freelivedoctor.com
- 47. âCOMPLEXâ SCLEROSING ADENOSIS (RADIAL SCAR) www.freelivedoctor.com
- 49. 1) EXTREMELY WELL DEFINED 2) YOUNGER WOMEN 3) ALWAYS BENIGN 4) CAN FIBROSE OR CALCIFY WITH AGE www.freelivedoctor.com FIBROADENOMA:
- 53. NEOPLASIA ⢠BENIGN EPITHELIALBENIGN EPITHELIAL, aka, âFIBROCYSTICâ disease â NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis â PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma â ATYPICAL epithelium www.freelivedoctor.com
- 54. FEATURES OF âATYPIAâ ⢠LOSS OF STROMA BETWEEN ACINI ⢠âSWISS CHEESEâ HYPERPLASIA* ⢠CRIBRIFORMING** ⢠CELLULAR PLEOMORPHISM ⢠CELLULAR HYPERCHROMASIA ⢠INCREASED/ABNORMAL MITOSES* ⢠âROMANâ BRIDGES*** ⢠NECROSIS*** (âCOMEDO-carcinomaâ) www.freelivedoctor.com
- 55. NORMAL DUCT NORMAL ACINUS ATYPICAL HYPERPLASIA of DUCT ATYPICAL HYPERPLASIA, LOBULE www.freelivedoctor.com
- 59. DCIS, microcalcifications www.freelivedoctor.com Microcalcifications, seen on mammograms, are often the result of necrotic intraductal crud which has calcified.
- 62. www.freelivedoctor.com A whole lobule filled with monotono0us cells of the same type can be called LCIS, or lobular carcinoma in situ.
- 64. LCIS ⢠Usually hangs around MANY MANY years before it infiltrates, in contrast to DCIS ⢠The BEST management may be judicious neglect, i.e., observation ⢠If it does infiltrate, however, it is at least as bad as DCIS infiltrating, or probably WORSE, showing âindianâ files www.freelivedoctor.com
- 65. BREAST CANCER RISK FACTORS⢠Age ⢠Menarche Age, early menarche is a risk ⢠First Live Birth ⢠First-Degree Relatives with Breast Cancer ⢠Breast Biopsies ⢠Race ⢠Estrogen Exposure ⢠Radiation Exposure ⢠Carcinoma of the Contralateral Breast or Endometrium ⢠Geographic Influence ⢠Diet ⢠Obesity ⢠Exercise ⢠Breast-Feeding, less breast feeding is a risk ⢠Environmental Toxins ⢠Tobacco ⢠ABORTIONS? www.freelivedoctor.com
- 66. BREAST CANCER PROGNOSTIC FACTORS ⢠AGE ⢠GENERAL HEALTH and IMMUNITY ⢠Histologic degree of differentiation, i.e., GRADING ⢠ERA/(PRA) ⢠Her2, aka Her2-Neu ⢠STAGING, especially POS or NEG lymph nodes, TNM, etc. www.freelivedoctor.com
- 67. STAGING, TNM, based on biologic behavior ⢠IN-SITU ⢠EARLY disruption of the basal lamina, i.e., basement membrane ⢠STROMAL infiltration ⢠LYMPHATIC vessels ⢠SENTINAL lymph node metastasis ⢠MORE lymph node metastases ⢠Adjacent structures, skin, ie, âinflammatoryâ ⢠DISTANT, METASTASES, LIVER, BONE, LUNGS, BRAIN, EVERYWHERE www.freelivedoctor.com
- 68. Total Cancers Per Cent In Situ Carcinoma 15â30 Ductal carcinoma in situ, DCIS 80 Lobular carcinoma in situ, LCIS 20 Invasive Carcinoma 70â85 No special type carcinoma ("ductal") 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) www.freelivedoctor.com
- 69. HISTOLOGIC TIDBITS ⢠INFILTRATING DUCTAL ⢠INFILTRATING LOBULAR (INDIAN FILE) ⢠TUBULAR (LOOKS LIKE SCLEROSIS, BUT NO BASEMENT MEMBRANE) ⢠MUCINOUS (COLLOID) ⢠MEDULLARY (LOTS of LYMPHOCYTES) www.freelivedoctor.com
- 71. INFILTRATING LOBULAR CA.,INDIANâ FILE PATTERNINFILTRATING LOBULAR CA.,INDIANâ FILE PATTERN www.freelivedoctor.com
- 72. INFILTRATING DUCTAL CA., âTUBULARâ PATTERN or TYPEINFILTRATING DUCTAL CA., âTUBULARâ PATTERN or TYPE www.freelivedoctor.com
- 73. INFILTRATING DUCTAL CA., MUCINOUS (COLLOID) PATTERN or TYPEINFILTRATING DUCTAL CA., MUCINOUS (COLLOID) PATTERN or TYPE www.freelivedoctor.com
- 74. INFILTRATING DUCTAL CA., MEDULLARY PATTERN or TYPEINFILTRATING DUCTAL CA., MEDULLARY PATTERN or TYPE www.freelivedoctor.com
- 75. NEOPLASIA, STROMAL Cysto-âSARCOMAâ PHYLLODES (aka, PHYLLODES TUMOR), Looks like a giant fibroadenoma, really NOT a sarcoma SARCOMAS, true, are RARE!!!! www.freelivedoctor.com
- 77. MALE BREAST ⢠GYNECOMASTIA (related to hyperestrogenism) ⢠CARCINOMA (1% of â ) www.freelivedoctor.com
Hinweis der Redaktion
- Know the 2 major arteries (lateral and internal thoracic) and three lymph node groups which supply the breast.
- Know the 2 major arteries (lateral and internal thoracic) and three lymph node groups (axillary, internal thoracic (mammary) and supraclavicular) which supply the breast.
- Confusion between lobe, lobule, acini, alveolus, and duct is rampant in clinical medicine, but should never be confusing for you.
- Ther are an average of about 10 LOBES per breast. The suspensory ligament separates lobes.
- A lobule is part of a lobe composed of many acini. Lobules are separated from each other by bands of connective tissue.
- Acini are also known as alveoli.
- Active
- Pregnancy/Lactation
- Atrophic, i.e., post menopausal
- Breast tissue that is ~90% glandular and/or looks like âthyoidâ, i.e., filled with milk, are lactating breasts
- Breast tissue ALWAYS extends to the axilla, and when it does form an actual protuberance, it can be called an accessory breast. Breasts are modified apocrine sweat glands embryologically.
- Nipple retraction can be congenital or acquired, when acquired, it represents suspicion for underlying fibrosis due to neoplasm or inpflammation.
- Macromastia.
- Atrophy is a NORMAL feature of postmenopausal breasts (estrogen withdrawal).
- Stroma&gt;&gt;&gt;&gt;&gt;glands in atrophy, but lobules and acini are still present architecturally.
- All 4 of the classical signs of inflammation, heat redness, swelling, pain. What the the fifth?
- Intraductal and periductal inflammatory cells, mostly neutrophils in acute mastitis.
- Pap smear of nipple exudate in acute mastitis. What are most of these cells?
- Inflammatory carcinoma with its classic peau dâorange appearance.
- The tumor cells are INSIDE the skin dermal lymphatic spaces.
- Most of the inflammation here is PERI- ductal rather than INTRA- ductal. Acute or chronic? Why? Ans: Lymphocytes.
- Ductesia means dilated ducts.
- Dilated ducts are the same as cysts.
- Classic cheesy appearance of fat in fat necrosis. Fat necrosis is usually due to mechanical trauma, surgical or otherwise.
- Giant cells and hemosiderin are usually easily found in fat necrosis.
- What is the principal inflammatory cell here? Ans: Lymphocyte.
- The appearance is 100% exemplary of the diagnosis.
- âFibrocystic diseaseâ is the waste basket term for benign breast disease characterized by fibrosis, cysts, inflammation, and a host of other benign changes. Certain features such as hyperplasia and papillomatosis, put it in a somewhat higher risk category for future carcinoma.
- Breast cyst, filled with fluid, in the pathology lab.
- Breast cyst, filled with fluid, in the ultrasound lab.
- This image speaks for itself.
- Adenosis is defined as an increased number of acini per lobule.
- Hence the name, âfibrocysticâ disease.
- âBenignâ hyperplasia is characterized by, NO necrosis, the presence of MYOEPITHELIAL cells, and NO ATYPIA.
- Sclerosing adenosis is often confused with malignancy. Why? Ans: the âsclerosisâ can be mistaken for desmoplasia.
- VERy very very scary, but 100% benign, lesion.
- Note the myoepithelial cell. The presence of myoepithelial cells, means, BENIGN!!!
- Our old friend the papillopma, i.e., a fingerlike proliferation of epithelium, growing over a fibrovascular core.
- Number 1 commandment in pathology: NEVER diagnosis a malignant papilloma on a frozen section!!!!! NEVER.
- The asterisked items, are more suspicious than the non-asterisked items. Intraductal NECROSIS is the most suspicious feature of all.
- Note the INTRADUCTAL NECROSIS.
- Note the atypia, âswiss cheeseâ hyperplasia, and early necrosis.
- Note the extreme artypia.
- Microcalcifications, seen on mammograms, are often the result of necrotic intraductal crud which has calcified.
- This type of calcification represents about a 20% chance of malignancy and should be biopsied. This device helps pathologists to sample the areas of greatest concern more heavily.
- A whole lobule filled with monotono0us cells of the same type can be called LCIS, or lobular carcinoma in situ.
- A whole lobule filled with monotono0us cells of the same type can be called LCIS, or lobular carcinoma in situ.
- HER2 is a proto-oncogene located at the long arm of human chromosome 17(17q11.2-q12). Approximately 25-30 percent of breast cancers have an amplification of the HER2/neu gene or overexpression of its protein product. Overexpression of this receptor in breast cancer is associated with increased disease recurrence and worse prognosis. Because of its prognostic role as well as its ability to predict response to trastuzumab, breast tumors are routinely checked for overexpression of HER2/neu. Overexpression also occurs in other cancer such as ovarian cancer and stomach cancer.
- 90% of infiltrating breast carcinomas are simply called âInfiltrating Ductal Carcinomaâ on the pathology report.
- The âtubularâ pattern is somewhat better in behavior.
- The mucinous variant is also somewhat better in behavior.
- The medullary variant (i.e., lots of immune calls or lymphocytes) is also somewhat better in behavior.
- Note that no matter how big a maleâs breasts may get, they should never for m lobules, but just end as blunt ducts.