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 and
mammographically
• history of antecedent trauma, prior surgical
intervention)
• histiocytes with foamy cytoplasm
• lipid–filled 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)
• thin–walled 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 changes

• extremely common (58% F)
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
pericanalicular growth pattern (little practical value)
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 low grade

high grade
• metastases are hematogenous
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
+ other types (12)
Lobular invasive
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
Paget‘s 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