Surgical Breast Pathology

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Surgical Breast Pathology

• Juan C. Cendan, MD
• Assistant Professor of Surgery

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Objectives of Lecture

• Categorize risk factors for cancer
• Highlight future cancer risk for a given benign
  lesion
• Describe diagnostic workup for breast masses and
  tools available to the clinician
• Provide up-to-date guidelines in the screening
  and diagnosis of breast masses
• Brief review of surgical options and implications
  in patients with breast cancer

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Assessment of Risk/History

• Four major risks (increase RR by 4x)
• Family history
• 1st degree relatives
• Age at diagnosis, BRCA1/2 risk
• Atypical hyperplasia on prior biopsies
• Personal breast cancer history
• LCIS

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Assessment of Risk/History

• Four Minor Risk Factors 1-2x RR
• Early menarche
• Long interval from menarche to 1st child
• Nulliparity
• Ovarian or endometrial cancer
• Estrogen therapy after menopause

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Physical Exam

• Be systematic
• Inspection of breasts sitting up, then recumbent
• Strip method
• Nipples
• Lymph nodes

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Clinical Examination of a Patient with Benign
Breast Disease
Santen, R. J. et al. N Engl J Med 2005353275-285
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Common Benign Breast Disorders in Women
Santen, R. J. et al. N Engl J Med 2005353275-285
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Diagnostics

• Standard screening mammogram
• CC and MLO
• Diagnostic mammogram
• Above, plus compression/additional views
• In either case, 5-10 false negative and 90-95
  sensitivity

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Atypical Hyperplasia
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Histopathological Appearance of Benign Breast
Disease (Hematoxylin and Eosin)
Panel A shows nonproliferative fibrocystic
changesthe architecture of the terminal-duct
lobular unit is distorted by the formation of
microcysts,associated with interlobular
fibrosis.Panel B shows proliferative hyperplasia
without atypia. This is adenosis,a distinctive
form of hyperplasia characterized by the
proliferation of lobular acini,forming
crowded gland-like structures.For comparison,a
normal lobule is on the left side.Panel C also
shows proliferative hyperplasia without
atypia.This is moderate ductal hyperplasia,which
is characterized by a duct that is partially
distended by hyper- plastic epithelium within the
lumen.Panel D again shows proliferative
hyperplasia without atypia,but this is florid
ductal hyperplasiathe involved duct is greatly
expanded by a crowded,jumbled-appearing
epithelial proliferation.Panel E shows atypical
ductal hyperplasiathese proliferations are
characterized by a combination of architectural
complexity with partially formed secondary lumens
and mild nuclear hyperchromasia in the
epithelial-cell population.Panel F shows atypical
lobular hyperplasiamonotonous cells fill the
lumens of partially distended acini in this
terminal-duct lob- ular unit.
Hartmann, L. C. et al. N Engl J Med
2005353229-237
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Diagnostics

• Ultrasound
• Useful in the young
• Useful in pregnant women
• Delineates solid vs cystic
• MRI
• Possibly the future of breast diagnostics, not
  there yet, limitations with biopsy

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Solid (Suspicious) Breast Mass
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Cyst
Fibroadenoma
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Biopsy techniques

• Palpable solid mass
• Needle or core biopsy
• Incisional or excisional biopsy
• Non-palpable mass
• Stereotactic core
• Stereotactic mammotome
• Needle localized biopsy

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Some Benign Conditions

• Nipple Discharge
• Incidence of malignancy when bloody (10-15) and
  unilateral, though usually papilloma
• More likely cystic or duct ectasia
• Consider prolactin if bilateral

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Benign, cont

• Fibroadenoma
• Very common in young women
• Freely mobile and smooth
• Characteristic u/s appearance
• Half of adenomas resolve if lt3cm over 5yrs
• Large adenomas should be biopsied to exclude rare
  phylloides tumor

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Benign, cont

• Cysts
• Due to relative excess estrogen, usually in 4-5th
  decades
• Fluctuate with menses
• Aspirate, if bloody then excise, send fluid for
  path the first time

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Benign, cont

• Abscess,
• Usually in lactating women
• Painful and erythematous
• Usually staph and strep
• Drainage and antibiotics indicated
• Rarely, can aspirate and treat with antibiotics
• Caveats, in nonlactating (Ca), non-resolving
  (atypical infection), inflammatory cancer

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Classification of Benign Breast Lesions on
Histologic Examination, According to the Relative
Risk of Breast Cancer
Santen, R. J. et al. N Engl J Med 2005353275-285
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Risk of Breast Cancer According to Breast Density
in Premenopausal and Postmenopausal Women
Santen, R. J. et al. N Engl J Med 2005353275-285
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Risk of cancer of benign breast lesions, Hartmann
et al, NEJM 2005
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Gail, J Natl Cancer Inst. 1989 Dec
2081(24)1879-86.
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Examples of Outcomes among 100 Women Followed for
an Average of 15 Years Explaining Relative Risk
Calculations to Patients Start with known risk
and translate it to an absolute risk
Elmore, J. G. et al. N Engl J Med 2005353297-299
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Cancer

• Most women with breast cancer have no risk
  factors!
• Role of dietary fat, estrogen
• Breast cancer genes responsible for 3-5 only

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Cancer

• DCIS
• Carcinoma in situ
• Usually found on mammography as
  microcalcifications
• Felt to progress to invasive in 30-50 if
  untreated
• Subtypes comedo highest risk

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Cancer

• DCIS, cont
• Treatment
• Non-invasive, so risk of LN disease is minimal
• Must treat the breast, options
• Excise with large enough margins (gt1cm) in a
  small tumor
• Or, Excise and radiate
• Or, Mastectomy /- reconstruction

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Cancer

• Invasive Ductal Cancer
• Garden variety breast cancer
• More often presents with mass than DCIS
• Treatment
• BREAST Excise and RT or mastectomy, Cannot just
  excise with margins (30-40 recur)
• Lymph Nodes Must be sampled for staging
• Sentinel Node vs Axillary Dissection

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Cancer

• Chemotherapy
• Recommended for tumors gt1cm in most patients
• Recommended if lymph nodes are positive
• 8 recommended chemo protocols at this time!!
• ER positivity and Tamoxifen

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Cancer

• Survival

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