Breast Pathology

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Breast Pathology

• Dr. M. Griffin

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The Normal Breast

• Terminal duct lobular unit
• Segmental Ducts
• Lactiferous ducts and sinuses
• Intralobular stroma
• Interlobular stroma
• Nipple areola complex

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Diagram of normal breast
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Normal breast tissue

1. Large duct on the right
2. Lobules to the left
3. Collagenous stroma extends between
4. Adipose tissue admixed

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Terminal duct lobular unit
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Pathology of breast

• Disorders of development and growth
• Inflammations
• Fibrocystic change
• Proliferative breast disease
• Tumours

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Disorders of development

• Supernumerary nipples/ breasts
• Accessory axillary breast tissue
• Congenital inversion of nipples
• Macromastia
• Failure of growth eg Turners syndrome

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Inflammations

• Acute mastitis
• Periductal mastitis
• Duct ectasia
• Fat necrosis
• Granulomatous mastitis
• Silicone breast implants

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Fibrocystic change/ non proliferative change.

• Cyst formation with apocrine metaplasia
• Fibrosis

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Fibrocystic change

• White tissue represents stromal fibrosis
• Multiple cysts are present throughout (arrow)

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Fibrocystic change

• 1.Multiple cysts with secretions
• 2.Arrow indicates microcalcification in one of
  the cysts
• 3.Background fibrotic stroma

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Apocrine metaplasia
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Proliferative breast Change

• Epithelial hyperplasia -
• Mild
• Moderate
• Severe
• /- Atypia
• Sclerosing adenosis
• Multiple intraduct papillomas

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Epithelial hyperplasia of usual type

• Duct lumina are almost completely filled with
  proliferating epithelium
• No cytologic atypia
• present

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Atypical Ductal Hyperplasia

• 1 Ducts are filled with markedly atypical cells
  

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Proliferative breast disease and
risk of Cancer

• Atypical epithelial hyperplasia increases the
  risk by 4 - 5 times.
• Epithelial hyperplasia of usual type increase
  risk by 1.5 -2 times.
• Positive family history doubles these risks

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Breast Tumours

• Benign
• Fibroadenoma
• Phyllodes tumour
• Intraduct papilloma
• Malignant
• Carcinoma
• Phyllodes tumour
• Sarcoma/ Lymphoma/ Metastatic tumour

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Fibroadenoma

• 1 circumscribed tumour
• 2 fibroblastic stoma enclosing glandular
  structures lined by epithelium

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Carcinoma of breast Epidemiology and risk factors

• Geographic factors
• Age / Sex
• Genetics and family history
• Proliferative breast disease
• Radiation exposure
• Reproductive/menstrual history
• Obesity/ high fat diet/

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Genetic Predisposition

• Positive Family history
• 5-10 of cancers related to specific inherited
  gene mutations
• BRCA1 and BRCA2 gene mutations
• Li Fraumeni syndrome germline mutation of TP53
• Cowden syndrome -germline mutation in PTEN.

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Carcinoma of breast

• Etiology and Pathogenesis
• Age and Sex
• Genetic factors
• Hormonal influences
• Environmental factors
• Atypical epithelial hyperplasia

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Carcinoma of breast

• Classification
• Carcinoma in situ ( carcinoma confined within
  ducts or acini, may be ductal or lobular)
• Invasive carcinoma (carcinoma has breached the
  basement membrane and infiltrated breast stroma)

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Carcinoma of Breast

• Carcinoma in situ (15-30)
• Ductal carcinoma in situ
• ( including Pagets disease of the nipple)
• Lobular carcinoma in situ

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Microcalcification on mammogram

• 1 Ductal carcinoma in situ detected by
  mammography
• 2 Pleomorphic microcalcifications
• 3 Localisation wire in situ to indicate area
  for excision
• 4 lesion is nonpalpable in the majority of cases

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Ductal carcinoma in situ
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Pagets disease of nipple
Large cells in the epidermis represent cancer
cells from underlying breast cancer which can be
in situ or invasive.
The The
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Lobular carcinoma in situ
Neoplastic cells filling the acini are small and
uniform
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Carcinoma of Breast

• Presentation
• Left breast more often than right
• 50 affect upper outer quadrant
• Painless mass
• Skin dimpling, ulceration, nipple retraction or
  discharge
• Peau dorange/ inflammatory carcinoma
• Abnormal mammogram- mass/ density/ pleomorphic
  microcalcifications

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Carcinoma of Breast

• Invasive Carcinoma
• Ductal carcinoma NOS 79
• Lobular carcinoma
  10
• Tubular/cribriform carcinoma 6
• Mucoid carcinoma
  2
• Medullary carcinoma
  2
• Papillary carcinoma
  1

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Invasive ductal carcinoma- lesion is retracted,
infiltrative and stony hard.
Invasive
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Carcinoma of breast

• Triple approach to diagnosis
• Clinical examination
• Imaging mammogram /- ultrasound
• FNA cytology or core biopsy
• GOAL Non operative diagnosis of mass

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Mammogram showing 2 invasive carcinomas with
intervening DCIS
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Pre-operative diagnosis
Fine needle aspiration cytology
Core biopsy
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Invasive ductal carcinoma

• 1 Small nests and cords of neoplastic cells
• 2.Dense collagenous stroma in between cells

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Invasive lobular carcinoma

• 1.Indian file strands of neoplastic cells
• 2. Cells are small and uniform
• 3.Dense stroma

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Mucinous carcinoma
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Mucinous carcinoma

• 1. Abundant bluish staining mucin with small
  groups of carcinoma cells

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Tubular carcinoma

• 1 Normal ducts on the left showing myoepithelial
  layer (stained brown)
• 2 Tubular carcinoma on the right, lacking
  myoepithelail layer

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Inflammatory carcinoma- tumour in dermal
lymphatics
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Carcinoma of breast

• Mass- firm, gritty, scirrhous or gelatinous
• Circumscribed or infiltrative margins
• Microscopy shows a variety of patterns ie glands,
  cords, or nests of malignant cells infiltrating
  breast stroma
• Invasion of breast stroma, fat. lymphatics or
  blood vessels

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Carcinoma of breast

• Routes of spread
• Local -skin, nipple , chest wall
• Lymphatic- lymph nodes
• Blood lungs, liver, bones

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Metastatic carcinoma in lymph node and lymphatic
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Breast cancer prognosis

• Stage of disease
• T size of primary tumour
• N nodal status
• M - /_ metastasis

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AJCC staging for breast cancer

• Stage 5 year
  survival
• 0
  92
• 1
  87
• 2
  75
• 3
  46
• 4
  13

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Carcinoma of breast

• Prognostic factors
• Lymph node status/ Size /Grade (NPI)
• Histologic type
• Hormone receptor status
• Lymphovascular invasion
• Proliferative rate/ DNA content
• Oncogene expression eg HER2 NEU
• Gene expression profiling

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Prognostic markers
Oestrogen receptor positive
Her2 protein 3 positive