Pathology of the breast

normal anatomy

physiologic changes
developmental abnormalities
inflammations
fibrocystic changes
tumors
benign
malignant
pathology of the male breast

Normal anatomy
before puberty breasts in both sexes ducts
variable degrees of branching, lack lobules
15 to 25 lactiferous ducts
start in the nipple branch
terminal ductal lobular unit (intralobular duct,
multiple lobular ducts, ductules or acini +
intralobular connective tissue)
hormonally responsive

Physiologic changes
at birth

male and female breasts

active secretion (transplacental passage of

maternal hormones)
bilateral breast
enlargement
colostrum-like secretion ("witch's milk")
recedes several months postpartum
after menopause gradual and progressive
involution (lobular atrophy, increased fat,
cystic dilatation of ducts)

Physiologic changes
Macromastia
diffuse enlargement of both breasts
adolescence or pregnancy
exaggerated response to hormonal stimulation
Pubertal (Virginal) Macromastia
1669 - 23-year-old woman - breasts enlarged
"overnight" to a combined weight of 104 pounds
Pregnancy
1 in 100,000 pregnancies - erythematous, edematous,
painful

Developmental
abnormalities
Aplasia and hypoplasia
uncommon associated with overdevelopment of
the contralateral breast
acquired (irradiation chest wall tumors)
unilateral or bilateral amastia (absence of a nipple,
breast ducts, pectoralis major muscle) sex-linked
recessive inheritance

Developmental
abnormalities
Ectopic breast

supernumerary breast (from ectopic breast tissue

along the milk lines (midaxillae normal breasts
medial groin and vulva)
1 6 % of adult women, much less often in men
unilateral axillary breast tissue

Polythelia
areola and underlying mammary ducts

Aberrant Breast
beyond the usual anatomic extent (no nipple or areola)

Inflammatory and reactive

conditions
Fat necrosis
can simulate carcinoma clinically
mammographically

and

history of antecedent trauma, prior surgical

intervention)
histiocytes with foamy cytoplasm
lipidfilled cysts
fibrosis, calcifications, egg shell on mammography

Inflammatory and reactive

conditions
Hemorrhagic necrosis with coagulopathy
Warfarin treatment shortly after initiation
edema, hemorrhage, necrosis (thrombi in small blood
vessels )
protein C deficiency

Breast augmentation
foreign materials (shellac, glazier's putty, spun glass,
epoxy resin, beeswax, and shredded silk, silicone)
thinwalled silicone bag capsule disfiguration

Puerperal mastitis
early stages (2nd and 3rd W) of lactation 5%
stasis of milk in distended ducts + staphylococci
abscess formation (ATB, incision and drainage)

Granulomatous Lobular Mastitis

etiology unknown, suggests carcinoma

Mammary duct ectasia

periductal inflammation, duct sclerosis
intermittent nipple discharge

Tuberculosis
less developed regions - serious condition
lactating breast, innoculation via the lactiferous ducts
slowly growing, solitary, painless mass

Benign proliferative lesions

pathologic spectrum of seemingly related clinically
benign breast abnormalities
palpably irregular and painful breasts
discrete lumps, multiple nodules, cystically dilated
ducts, apocrine metaplasia, interlobular and
intralobular fibrosis
intraductal epithelial proliferation
fibrocystic disease, fibrocystic
extremely common (58% F)

changes

Benign proliferative lesions

Adenosis
elongation of the terminal ductules
caricature of the lobule
sclerosing adenosis
apocrine adenosis
tubular adenosis
nonpalpable lesion, recognized in mammograms
microcalcifications!

Benign tumors
Fibroadenoma
proliferation of epithelial and stromal elements
most common breast tumor in adolescent and young
adult women (peak age = third decade)
higher incidence in black patients
well-circumscribed, freely movable, nonpainful mass
regress with age if left untreated
ducts distorted elongated
slit-like
structures - intracanalicular pattern, ducts not
compressed

Tubular adenoma
far less common than fibroadenomas
young women, discrete, freely movable masses
uniform sized ducts

Lactating Adenoma
enlarging masses during lactation or pregnancy
prominent secretory change

Intraductal papilloma
in the mammary ducts, subareolar lactiferous ducts
periductal inflammation, duct sclerosis
serous or bloody nipple discharge
fibrosis, infarction, squamous metaplasia

Cystosarcoma phyllodes
(phyllodes tumor)
initial description - over 150 years ago - fleshy tumor,
leaf-like pattern and cysts on cut surface
circumscribed, connective tissue and epithelial
elements ( fibroadenomas = greater connective tissue
cellularity), 1-15 cm
less than 1 % of breast tumors
benign, malignant

metastases are hematogenous

low grade
high grade

Proliferative changes
ductal and lobular hyperplasia
atypical ductal and lobular hyperplasia
higher risk for the cancer than "normal" population
associated w. microcalcifications (!mammography!)
incidental histological finding
atypical hyperplasia = precancerous lesion

Breast carcinoma
most frequent malignant tumor in females (followed by
cervix and colon)
highest incidence developed countries
(USA 84,8/100 000F/Y, Western Europe 64,7/100 000F/Y)
2nd killer among cancers (1st = lung ca)
risk factors: genetic predisposition (breast ca in close (1st
degree) relatives), proliferative changes, early menarche, late
menopause, history of ca (breast, ovary, endometrium)
importance of preventive controls! early diagnosis
better prognosis

Breast carcinoma classification

IN SITU

DUCTAL

INVASIVE

LOBULAR

Ductal in situ (intraductal)

Lobular in situ
Ductal invasive
Lobular invasive

+ other types (12)

Carcinoma in situ
preinvasive - does not form a palpable tumor
not detected clinically (only X-ray screening !!!)
multicentricity and bilaterality (namely LCIS)
continuum: bland hyperplasia - increasing atypism carcinoma in situ
no metastatic spread (basement membrane)
risk of invasion depending on grade

Invasive carcinoma
Invasive ductal carcinoma
largest group (65 to 80 % of mammary carcinomas)
mid to late fifties
stellate, white, firm (desmoplasia)
less often circumscribed, soft (medullary ca)
hormonally dependent (estrogen, progesterone)

Invasive lobular carcinoma

uniform cells, infiltrative growth (linear arrangement indian file pattern)

Invasive carcinoma
other types: tubular, mucinous, medullary,
inflammatory together about 10 % of breast ca
metastases: regional lymph nodes (axillary,
parasternal), lungs, liver, bone marrow, brain
treatment: surgery (radical mastectomy, breast
conserving surgery lumpectomy),
radiotherapy
antihormonal therapy (Tamoxifen)
chemotherapy

Pagets disease of the

nipple
result of intraepithelial spread of intraductal
carcinoma
large pale-staining cells within the epidermis of the
nipple
limited to the nipple or extend to the areola
pain or itching, scaling and redness, mistaken for
eczema
ulceration, crusting, and serous or bloody discharge

Pathology of the male

breast

Gynecomastia

most common clinical and pathologic abnormality of the

male breast
increase in subareolar tissue
in 30 to 40 percent of adult males, both breasts are
affected in many cases
associated with hyperthyroidism, cirrhosis of the liver, chronic renal
failure, chronic pulmonary disease, and hypogonadism, use of hormones estrogens, androgens, and other drugs (digitalis, cimetidine, spironolactone,
marihuana, and tricyclic antidepressants)

Carcinoma of the male breast

uncommon < 1 % of all breast cancers