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Breast Pathology

Breast Pathology. Dr. M. Griffin. The Normal Breast. Terminal duct lobular unit Segmental Ducts Lactiferous ducts and sinuses Intralobular stroma Interlobular stroma Nipple areola complex. Diagram of normal breast. Large duct on the right Lobules to the left

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Breast Pathology

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  1. Breast Pathology Dr. M. Griffin

  2. The Normal Breast • Terminal duct lobular unit • Segmental Ducts • Lactiferous ducts and sinuses • Intralobular stroma • Interlobular stroma • Nipple areola complex

  3. Diagram of normal breast

  4. Large duct on the right Lobules to the left Collagenous stroma extends between Adipose tissue admixed Normal breast tissue

  5. Terminal duct lobular unit

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

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

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

  9. Fibrocystic change/ non proliferative change. • Cyst formation with apocrine metaplasia • Fibrosis

  10. White tissue represents stromal fibrosis Multiple cysts are present throughout (arrow) Fibrocystic change

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

  12. Apocrine metaplasia

  13. Proliferative breast Change • Epithelial hyperplasia - Mild Moderate Severe +/- Atypia • Sclerosing adenosis • Multiple intraduct papillomas

  14. Duct lumina are almost completely filled with proliferating epithelium No cytologic atypia present Epithelial hyperplasia of usual type

  15. 1 Ducts are filled with markedly atypical cells Atypical Ductal Hyperplasia

  16. 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

  17. Breast Tumours • Benign Fibroadenoma Phyllodes tumour Intraduct papilloma • Malignant Carcinoma Phyllodes tumour Sarcoma/ Lymphoma/ Metastatic tumour

  18. 1 circumscribed tumour 2 fibroblastic stoma enclosing glandular structures lined by epithelium Fibroadenoma

  19. 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/

  20. 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.

  21. Carcinoma of breast Etiology and Pathogenesis Age and Sex Genetic factors Hormonal influences Environmental factors Atypical epithelial hyperplasia

  22. 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)

  23. Carcinoma of Breast Carcinoma in situ (15-30%) Ductal carcinoma in situ ( including Paget’s disease of the nipple) Lobular carcinoma in situ

  24. 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 Microcalcification on mammogram

  25. Ductal carcinoma in situ

  26. Paget’s disease of nipple Large cells in the epidermis represent cancer cells from underlying breast cancer which can be in situ or invasive. The The

  27. Lobular carcinoma in situ Neoplastic cells filling the acini are small and uniform

  28. 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 d’orange/ inflammatory carcinoma • Abnormal mammogram- mass/ density/ pleomorphic microcalcifications

  29. 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%

  30. Invasive ductal carcinoma- lesion is retracted, infiltrative and stony hard. Invasive

  31. Carcinoma of breast Triple approach to diagnosis Clinical examination Imaging – mammogram +/- ultrasound FNA cytology or core biopsy GOAL: Non operative diagnosis of mass

  32. Mammogram showing 2 invasive carcinomas with intervening DCIS

  33. Pre-operative diagnosis Fine needle aspiration cytology Core biopsy

  34. 1 Small nests and cords of neoplastic cells 2.Dense collagenous stroma in between cells Invasive ductal carcinoma

  35. 1.Indian file strands of neoplastic cells 2. Cells are small and uniform 3.Dense stroma Invasive lobular carcinoma

  36. Mucinous carcinoma

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

  38. 1 Normal ducts on the left showing myoepithelial layer (stained brown) 2 Tubular carcinoma on the right, lacking myoepithelail layer Tubular carcinoma

  39. Inflammatory carcinoma- tumour in dermal lymphatics

  40. 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

  41. Carcinoma of breast Routes of spread Local -skin, nipple , chest wall Lymphatic- lymph nodes Blood – lungs, liver, bones

  42. Metastatic carcinoma in lymph node and lymphatic

  43. Breast cancer prognosis • Stage of disease • T –size of primary tumour • N – nodal status • M - +/_ metastasis

  44. AJCC staging for breast cancer • Stage 5 year survival • 0 92% • 1 87% • 2 75% • 3 46% • 4 13%

  45. 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

  46. Prognostic markers Oestrogen receptor positive Her2 protein 3+ positive

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