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Diseases of the breast

Index

Breast Injuries Breast abscess Normal anatomy & mammography Fibrocystic disease Simple cysts Mammary duct ectasia Breast neoplasms (Classification) Duct papilloma Breast lipoma Fibroadenoma Phylloides tumour Cancer Breast Ductal CA (Path) Lobular CA (Path) Pagets disease Triple assessment Mammography Isotope bone scan Staging of CA breast

Ca breast gross pathology

Breast diseases 2007

Diagnosis of breast masses


Triple assessment

Clinical

Imaging

Histopathology

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Breast Injuries
Blunt breast trauma can produce
1-Breast Hematoma 2-Traumatic Fat Necrosis Following blunt trauma Trauma Fat Necrosis or breast surgery . Release of Fatty Acids F.A. + Ca Ca Soaps (FBG) Old organized Hematoma without Painless irregular hard mass overlying skin bruising with no LN in the axilla with skin is difficult to diagnose tethering and even nipple correctly except by retraction biopsy. Trauma history is a trap, DD cancer breast Mammography is not conclusive DD cancer breast
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Biopsy: Foamy fat laden macrophages Breast diseases 2007

Breast heamatoma following surgery

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Acute Inflammation of the Breast


Breast Abscess
Etiology: organisms, predisposing factors, routes of infect. Pathology: sites: (pre,intra or retromammary)

Stages:
Milk engorgement: Dull ache pain, shivering, low grade fever wedge shaped tender induration no signs of inflammation Cellulites: Burning pain, high grade persistent fever diffuse swelling with tender red induration Pus formation: Throbbing pain ,Hectic fever local signs localized to one sector& overlying skin pitting oedema
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Breast Abscess
Etiology: Organisms: Predisposing factors: Routes of infect:

Sites: Premammary Intramammary Retromammary


Treatment: Early & After pus formation (stop lactation) Hilton method
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Illustration & Mammography of normal breast

A thin skin margin with no retraction of either skin or nipple. The glandular tissue is interspersed with fat and there are relatively regular bands of suspensory ligaments known as Cooper's ligaments. Note that the radiograph shows no dominant or irregular mass and no evidence of any microcalcifications, Breast diseases 2007 8 both are findings which may be observed in carcinomas. Index

Normal mammography (craniocaudal)

The normal mammography image shows a thin, regular skin line with a diffuse, even, soft tissue density of the general glandular tissue and fatty structures organized in a Breast diseases 2007 9 relatively regular way by Cooper's ligaments Index

Normal variations

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Fatty breast
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Dense breast

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Fibrocystic Disease Fibroadenosis


Pathology The disease consists of 4 features that vary in extent and degree Adenosis, Epitheliosis (atypical epithelial hyperplasia), Papillomatosis, Fibrosis sometimesextensive forming hard mass (sclerosing adenosis) simulating cancer. Cyst formation.
Risk of malignancy.

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Fibrocystic Disease

Gross appearance of fibrocystic changes in the breast.


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Fibrocystic disease of the Lt. breast


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Simple cysts

Multiple circumscribed low soft tissue dense lesions seen in both breasts

Ultrasound showing the typical features of a simple cyst: a well defined, anechoic (black) lesion with posterior echoic accentuation (white)

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Index

Breast diseases 2007

Mammary Duct Ectasia


Periductal or plasma cell mastitis What is ectasia?
As a woman approaches menopause the mammary ducts, which are located under the nipple, become dilated . This dilation is called ectasia. Ectasia is a benign (non-cancerous) breast condition. Ectasia can lead to a blockage of the ducts. As a result, fluid may become pooled and leak into the surrounding tissue causing chronic inflammation. If an infection, (also referred to as periductal mastitis) occurs, it may cause scar tissue to develop, thus drawing the nipple inward. In addition, this infection may cause breast pain and thick, sticky nipple discharge
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Index

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Breast Neoplasm Classification

Benign Epithelial
Duct Papilloma Mesenchymal Lipoma Fibroma
Mixed Fibroadenoma
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Malignant
CARCINOMA Lymphoma, Sarcoma

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Duct Papilloma
Pathology Situated in one of the major ducts near its orifice usually single but may be multiple and peripheral (Multiple Papillomatosis) Clinical Picture young adult female (30-45) presenting with blood discharge from the nipple, on examination a fresh drop of
blood is seen on pressure at a certain point or a palpable small fusiform retroareolar mass is felt (retention cyst due to obstruction of the duct by clotted blood) pressure on it produces the discharge.

Investigations Benzedine test discharge is


+ve for blood. Galactography using lipiodol shows regular filling defect
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Lipoma in the breast


A large circumscribed radiolucent mass with a thin capsule (arrow) and coarse calcification

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Fibroadenoma

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Fibroadenoma

A benign fibroadenoma of the breast is distinguished by its sharp margins and lack of microcalcifications. There is no skin retraction or extensions into the parenchymal tissue.
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Fibroadenoma

Mammography showed 9 mm solid nodule Ultrasound showed oval, hypoechoic and homogeneous mass, suggesting a benign lesion
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Phylloides Tumour

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Cancer Breast

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Pathology

Ductal Carcinoma
In situ ductal carcinoma Invasive ductal carcinoma

Inflammatory carcinoma
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Index

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Pathology

Lobular carcinoma
Lobular Carcinoma In Situ (LCIS) RR10
premenoposal 1% in biopsies Multicenteric, bilateral

Invasive lobular carcinoma (ILC) 10%


Bilateral in 25% of cases Prognosis remains unaffected when the second tumour is not synchronus.
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Pathology

Pagets Disease

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Index

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Diagnosis of cancer breast

MRI (Indications)
Bone scan (Indications)

Open biopsy with frozen section

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Histopathological assessment:

Fine needle aspiration cytology

True cut tissue biopsy

Open biopsy with frozen section

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Radiological assessment:

Breast US

Breast ultrasound is used as the initial method for evaluating the following symptomatic patients: The young patient under 30 years of age. The pregnant patient. Follow-up of patients with fibrocystic disease (3-6 month intervals).

Breast ultrasound is used as a complementary examination to mammography in the following situations: Evaluation of dense breast tissue. Evaluation of a mass demonstrated on mammography. Breast diseases 2007 28 Guidance of biopsy needle or needle localization (see cyst aspiration image) Index

Radiological assessment:

Mammography

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Index

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Mammography : Cancer breast

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Breast diseases Invasive duct carcinoma giving a speculate mass on mamography 2007 Index

Small (7mm) infiltrative ductal carcinoma

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Mammography demonstrating a focal area of soft tissue density measuring 0.8 x 2.0 cm.
Architectural distortion and microcalcifications are also noted. The mass is categorized as 'highly suspicious' for malignancy

Pathology confirmed an infiltrating, moderately differentiated adenocarcinoma


with an extensive intraductal component
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Index

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Notice the retracted nipple

Malignant masses are often characterized by irregular tented boundaries with retraction of other Breast diseases 2007 33 fibrous structures and may be accompanied by local skin thickening or microcalcifications Index

Mammography showing microcalcification

Close-up view

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Cranio-codal view

Medio-lateral view

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Ductal carcinoma insitu (high grade comedo type) Irregular linear branching microcalcification

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Microcalcifications in intra-duct carcinoma

Cluster of very small microcalcifications with or without increased local density of the breast is an important image finding indicating malignancy. The36 finding merits specific attention even if it is not accompanied by any other of the 2007 Breast diseases Index typical findings in carcinoma such as skin retraction or irregular mass boundary

Mammography : Cancer breast

Large malignant mass with skin retraction

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Isotope bone scan

Normal Vertebral metastasis from cancer breast


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Multiple bone metastasis

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Staging of Breast Cancer


TNM Classification
T = Tumour T0 Carcinoma in situ T1 Less than 2cm T2 Tumor diameter 2-5cm T3 Larger than 5cm T4 Any size invading skin,,chest wall N = Nodes N0 Nonpalpable axillary LN N1 Ipsilateral mobile LN N2 Ipsilateral fixed LN N3 Supraclav.Int mammary contralateral axillary LN M = Metastases M0 No metastases M1 Distant metastases
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Manchester Classification
Stage I Mass confined to the breast, skin involvement over and smaller

Stage II Same + palpable mobile one group of LN in Ipsilateral axilla


Stage III Same + one of the following: 1- Skin invasion larger than size of the mass 2- Mobile more than one group Ax.LN 3- Mass fixed to underlying muscles&fascia Stage IV Same + one of the following: 1-Marked skin affection nodules,ulcer 2-Fixed Ipsilateral.ax.LN. 3- Ipsilateral.supraclavicular LN 4- Mass fixed to chest wall. 5- Distant deposits,other breast,contralateral.axilla Breast diseases 2007 Index

Breast carcinoma

Peau d'orange"

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Breast carcinoma
This is an old specimen and the adipose tissue has become rather dark

It shows an ill defined grayish tumour in the breast, through which run yellow streaks of necrosis.
The nipple is retracted & the tumour is infiltrating the underlying pectoral muscle.
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Index

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Breast carcinoma
Pectoralis muscle

Axillary LNs

Tumour

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Index

Breast diseases 2007