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THE BREAST

ANATOMY  Pain (mastalgia or mastydonia)


 Palpable mass (≥2cm in size)
 Consists of 6-10 lobes o Most common
 Keratinizing squamous epithelium- nipple and  Invasive carcinomas
areola  Fibroadenomas
 Double-layered cuboidal epithelium- ducts  Cysts
 Colostrum – produced by luminal cells of the o Malignancy increases with age
lobules
 Nipple discharge
Anatomic Origins of Common Breast Mass o Bloody discharge- MC in benign tumors
 Terminal duct o Milky d/c – increase in Prl
o Lobular unit
 Cyst Mammography - @ age 40
 Scerosing Adenosis Densities and calcifications – principal signs of breast
 Small duct papilloma cancer
 Hyperplasia  Densities – MC prod by
 Atypical hyperplasia o Carcinoma
 Carcinoma o Fibroadenoma
o Lobular duct o Cysts
 Fibroadenoma  Calcification – MC prod by
 Phyllodes tumor o Apocrine cyst
o Large ducts and lactiferous sinuses o Hyalinized fibroadenoma
 Duct ectasia o Sclerosing adenosis
 Recurrent subareolar abcesses
 Solitary ductal papilloma Inflammatory disorders
 Paget disease
o Interlobular stroma  Acute Mastitis-
 Fat necrosis  MC cause – S. aureus – single/multiple focal
 Lipoma abscesses
 Fibrous tumor  S. epidermidis – diffuse abscess, involves the
 Fibromatosis entire breast
 Sarcoma  Periductal Mastitis
 Subareolar abscess, Zuska disease
DISORDERS OF DEVELOPMENT  Associated with smoking
 Non-proliferative Breast change (Fibrocystic
 Milk line remnants- change)
o supernumerary nipples  Cyst- blue dome cyst
 Accessory Axillary Breast Tissue  Fibrosis
o Ductal system extends to SC tissue of the chest  Adenosis- inc # of acini/ lobule
wall or the axillary fossa  Proliferative Breast Disease without atypia
 Congenital Nipple Inversion  Epithelial hyperplasia
o Correct spontaneously  Sclerosing adenosis
o Acquired nipple retraction- may indicate  Complex sclerosing lesion
presence of an invasive cancer or an  Papillomas
inflammatory disorder  Proliferative Breast Disease with Atypia
 Associated with radiologic calcifications
CLINICAL PRESENTATION OF A BREAST DISEASE  Cellular proliferation resembling carcinoma in
situ
Most common symptoms: Pain  Atypical ductal hyperplasia
Palpable mass or Lumpiness  Atypical lobular hyperplasia
Nipple discharge
 Carcinoma in situ
Carcinoma of the Breast  Ductal (DCIS)
 Comedocarcinoma- high grade
MC non-skinmalignancy in women  Cribriform DCIS – cookie cutter-like
Majority are ER-positive  Solid DCIS
ER negative tumors – basal-like  Papillary DCIS
HER2/neu positive – in young women  Microcapillary DCIS- bulbous protrusions,
BRCA1 or BRCA2 – hereditary breast cancer gene arranged in complex intraductal patterns
 Paget disease – maybe mistaken as
 Risk Factors erythema, with palpable nodules and have
o Gender – most important RF underlying invasive carcinoma
o Age – peaks at age 75-80  DCIS with microinvasion- invasion through
o Age at menarche the basement membrane into the stroma
o Age at first live birth measuring no more than 0.1 cm
o First degree relatives with breast ca Treatment – MASTECTOMY
o Atypical hypeplasia
o Race/Ethnicity  Lobular Carcinoma In Situ (LCIS)
o Estrogen Exposure  Atypical lobular hyperplasia
o Breast Density  Invasive lobular hyperplasia
o Radiation exposure
o Carcinoma of the contralateral breast or Mucin positive signet-ring cells are
endometrium commonly present
o Geographic influence
o Diet  Invasive Carcinoma
o Obesity  Associated with axillary lymph node metastases
o Exercise  Peau d’ orange
o Breastfeeding
o Environmental toxin  Invasive Carcinoma, No Special type (NST; Invasive
o Tobacco Ductal Carcinoma)
 Majority of Carcinomas
Etiology and Pathogenesis
Major RF for the development of breast cancer are
 Invasive Lobular Carcinoma
Hormonal and Genetic
 Dyscohesive infiltrating tumor cells
 Signet ring cells containing mucin droplets
 Hereditary Breast CA
o Mutations in BRCA1 and BRCA2
 Medullary Carcinoma
o BRCA1 – assoc with ovarian ca
 Sporadic Breast CA  Soft, fleshy, and well circumscribed tumor
o Major RF for sporadic breast ca are related to  Poorly differentiated
hormone exposure  Better prognosis than NST carcinomas
o Hormonal exposure- inc the num of potential  Mucinous (Colloid) Carcinoma
target cells by stimulating breast growth during  Tumor is soft and rubbery
puberty  Appears like pale gray-blue gelatin
o Estrogen- play direct role in carcinogenesis
 Tubular Carcinoma
Classification of Breast Carcinoma  Consist exclusively of well-formed tubules and
MC malignancies are ADENOCARCINOMAS, divided into are sometimes mistaken for benign sclerosing
in situ carcinomas and invasive carcinoma lesions.
 Excellent prognosi
Carcinoma In situ- limited to ducts and lobules by the
basement membrane  Invasive Papillary Carcinoma
Invasive ca- infiltrating ca, has penetrated to the stroma  ER positive,
 Have favourable prognosis
 Metaplastic Carcinoma
 Includes rare types of breast cancer
 Prognosis are generally poor

Prognostic and Predictive Factors

 Distant metastases – once present, cure is unlikely


 Lymph node metastases – most important
prognostic factor for invasive carcinoma in the
absence of distant metastasis
 Tumor size – second most important prognostic
factor
 Locally advanced disease
 Inflammatory carcinoma – breast ca presenting with
breast swelling and skin thickening due to dermal
lymphatic involvement have particularly poor
prognosis

STROMAL TUMORS

Fibroadenoma – most common benign tumor of the


female breast
 Popcorn calcifications – large lobulated
calcifications

Phyllodes Tumor
 Cystosarcoma phyllodes
 “leaflike”
 Only stromal component metastasizes

Benign Stromal Lesions


 Abnormal presence of B- catenin in the nucleus
– diagnostic feature

Malignant Stromal tumors


 Angiosarcoma, rhabdomyosarcoma,
liposarcoma, leiomyosarcoma,
chondrosarcoma, and osteosarcoma
 Bulky palpable masses
 Spread to the lungs is commonly seen

THE MALE BREAST

Gynecomastia
 In association with liver cirrhosis – due to
abnormality in metabolism of estogen

Carcinoma
 Almost same as in female