DUCTAL EPITHELIUM OF THE BREAST ROLE OF GYNECOLOGIST:
-very responsive to hormonal cyclic changes - Identify the risk factors during the medical
-follicular phase (parenchymal proliferation of and family history
ducts) - Performing clinical breast examinations
-Luteal phase (dilatation of ductal system and - Offering instructions for breast self-
differentiation of the alveolar cells into the evaluation
secretory cells) - Evaluating all palpable breast masses
-alveolar elements, stroma and myoepithelial cells - Encouraging women to have a routine
(respond to both E/P) screening mammography
-cyclic breast fullness and tenderness (related to - Performing diagnostic procedures or
25-20 ml ave. fluctuation in volume of the referral to those who specialize in breast
premenstrual breasts) disease when clinically indicated
-Full breast development occurs at 18-21 y/o
-surgery for cosmetic results BLOOD SUPPLY
-perforating branches of the internal mammary
BREAST HYPERTROPHY arteries originating from the internal thoracic
-asymmetric artery
-virginal(pubertal), gravid (gestational) -lateral thoracic and thoracoacromial arteries
macromastia, adult types (originate from the axillary artery) and posterior
- surgical management to relieve symptoms 3rd, 4th, 5th intercostal arteries (branches of thoracic
(headache, neck and back pain, upper paresthesias, aorta)
brassiere strap grooving or intertrigo) after 6-12 -inferior and central portion of the breast is the
months of allowing for stable breast size least vascular area
LYMPHATIC DRAINAGE OF THE BREAST BREAST DISEASES
-converge in the subareolar plexus of sappy
-outer quadrants (75% drain to the 30-60 ipsilateral EMBROLOGY AND ANATOMY:
axillary regional nodes) - Development begins in utero at 6th
gestational weeks from the integument
AXILLARY NODES: along the epithelial mammary ridges
Level 1: located lateral to the lateral boarder of the - Ducts and acini (ectoderm); supporting
pectoralis minor muscle tissues (mesenchyme)
Level 2: posterior to the pectoralis minor - Hormonal changes during puberty influence
Level 3: Infraclavicular nodes medial to the the development of the ductal tissue and
pectoralis minor secretory lobules
-Treatment is generally reserved to manage - Milk production is initiated by hormonal
irritation or improve prosthesis changes during after delivery
BREAST
CONGENITAL NIPPLE INVERSION: - Composed of 12-20 varying size triangular
- 2% women (Fhx) lobes radially distributed form the nipple
- Shortening and tethering of breast ducts - Each lobe contains 10-100 lobules with
and develop fibrous bands during alveoli (acini)
intrauterine life - Functional lobules (have epithelial/ductal
- Increase mechanical problems during and stromal components) are affected by
breastfeeding hormonal changes (estrogen, progesterone
- Surgical correction leads to loss of sensation and prolactin) that result in development,
and inability to breastfeed maturation and differentiation
- - Organization of ductal system starts at
puberty
- Flow: secretory cells drain into the alveoli, Lymphatic spread of breast cancer
then into the terminal ducts that then - Orderly fashion within the axillary LN based
collapse into larger coalesce into larger on the anatomic relationship between the
collecting ducts, then terminate at the primary tumor and its associated regional
excretory ducts of the nipple (sentinel nodes)
- Premenstrual breast symptoms (secondary Congenital developmental breast abnormalities
to vascular engorgement and water Nipple
retention with enlargement of lumen and Accessory nipple: occur along the breast or milk
increased ductal and acinar cellular lines.
secretory activity) - Run from axilla to the groin
- Menstruation: cause regression of cellular Polythelia: supernumerary or accessory nipples
activity in the alveoli and ducts become - 1% European descent, 6% Asian descent
smaller - Inframammary region (uni/bilateral)
- Both men and women
BREAST TISSUE: - Associated with urologic anomalies and
Amastia: complete absence of both tissue and cardiovascular problems (HPN, and
nipple areola comples conductive or rhythm problems)
- Secondary to regression or failure of
mammary ridge to develop Athelia: complete uni/bilateral absence of nipple or
- Associated with ectodermal defects (cleft areola
palate) - Familial (autosomal dominant)
Polymastia: accessory breast tissue or - Amastia(breast nipple, areola, and breast
supernumerary breasts tissue), Poland syndrome; ectodermal
- 1-2% in women abnormalities (absent pectoral muscle)
- Diagnosed initially at puberty or during - Treatment (nipple and areola
puberty reconstruction- flaps and tattoo)
- Rudimentary or fully developed
Montgomery glands
Tubular breast - 5-20 areolar glands that produce oily
- Tuberous breast secretion to keep the nipple supply and
- Uni/ bilateral congenital anomaly protected (important for breastfeeding)
- Breast diameter is narrow and with - Produce volatile compound that stimulate
constricted base related to glandular the infant’s appetite though olfactory
hypoplasia with deficiency in the pathways
circumferential skin envelop of the breast - Located at the areola and on the nipple
base - Sensitive glands; prone to blockage or
- Surgical correction (augmentation, irritation
mastopexy, or both and tissue expansion - Usually asymptomatic
followed by augmentation) - Subject to normal changes and entire
disease spectrum seen in normal breast
Intermammary or Parasternal nodes - Conservative management; surgery
- Where remaining lymphatics drain (cosmetics); liposuction (to decrease the
- Have direct drainage to the mediastinum, fatty element)
medical quadrants of the opposite breast or
inferior phrenic nodes (provide route for Asymmetric breast development
the metastasis to the liver, ovaries and -common in adolescence and maturity
peritoneum)
-benign, normal variation unless with palpable - Breast pain in the upper outer breast
abnormality quadrants (most tender at the axillary tail)
Clinical classification can be subgrouped as:
- Physiologic swelling and tenderness 2. Adenosis: marked proliferation and
- Nodularity hyperplasia of ducts, ductules and alveolar
- Breast pain (not usually associated with cells
malignancy - Women in 30
- Palpable breast lumps - Multiple breast nodules (2-10mm)
- Nipple discharge including galactorrhea - Premenstrual breast tenderness (less
- Breast infection and inflammation (typically severe)
associated with lactation) - Signs and symptoms (usually prevalent
during premenstrual state)
Phyllodes tumor - Cyclical bilateral breast pain (classic
- Previously termed Cystosarcoma Phyllodes symptom)
- Opposite end of spectrum of fibroepithelial - Clinical signs: increased breast
tumors engorgement and density, excessive breast
- Rare tumors (2.5% of fibroepithelial tumors) nodularity, fluctuation in the size of cystic
- Age onset 40-50 y/o areas, increased tenderness, and frequently
- Benign, borderline or malignant spontaneous nipple discharge
- Present as rapidly growing breast mass, 3. Mastalgia: bilateral, difficult to localize
larger than fibroadenoma or ductal CA - Mostly upper, outer breast quadrants, may
- Histologic findings (stromal elements radiate to the shoulders and upper arms
dominate and invade the ducts in a leafy - Pain is secondary to the cyst formation,
projection- “phyllodes” or “leaf”) may be epithelial and fibrous proliferation and
difficult to distinguish from fibroadenoma, varying degrees of fluid retention
benign or malignant cystosarcoma
phyllodes Differential Diagnosis (breast pain)
- Referred pain from dorsal radiculitis or
Cystic phase: women in 40’s inflammation of the CCJ (Tietze syndrome)-
- No breast tenderness (unless a cyst rapidly not cyclic and unrelated to the menstrual
increase in size with pain, point tenderness cycle
and lumping)
- Cyst (tender to palpation) Fibrocystic changes:
- Microscopic size to 5mm - Previously termed fibrocystic disease
- Complex cysts (internal septations, debris or - Common, natural maturation of the breast
solid components- CORE NEEDLE BIOPSY if tissue over time
stability cannot be determined) - Fibrosis or adenosis
- Fluid aspirate (straw colored, dark brown or - Lobular changes, involutional changes are
green) due to hormonal response of the breast
- Subdivided pathologically by their potential
Breast Carcinoma future cancer risk
- Most common malignancy of women - Nonproliferative disorders: no increased
- Present in two ways (clinical symptoms or risk
screening evaluation- BSE or CBE) - Proliferative disorders without atypia: mild
to moderate increase risk
3 general clinical stages of Fibrocystic change - Atypical hyperplasia: substantial increase in
1. Mazoplasia (mastoplasia): associated with risk (5x)
intense stromal proliferation - Locally aggressive and require local incision
- Occurs in early reproductive years (20) with 1cm margins and should be shelled out
during surgical removal (to avoid - Has extensive list of symptoms and
recurrence) terminology (>35 different names and
- 25% risk for malignancy, > 20% local terms)
recurrence rate - ICD 10: diffuse cystic mastopathy
- Metastatic hematogenously - Common in reproductive age (20-50 y/o)
Fat necrosis Fibroadenomas
- Wide variety of presentations on - Fibrous and epithelial elements
mammography. Utz, and mri - Most common benign breast neoplasms
- 2.75 % of all breast lesions (50 years) (15-20%)
- Most commonly the result of trauma, - Accidentally noticed while bathing
radiotherapy, anticoagulation, breast - Mostly on adolescents and women in 20’s
procedures and infection (15-20)
- Rare causes (polyarteritis nodusa, weber- - Aberration in normal lobular development
christian disease, and granulomatous - Hormonal dependence, lactate during
angiopanniculitis) pregnancy and involute (replaced by hyaline
connective tissue) during perimenopause
Benign breast disorders: classification describes
emphasis to clinical signs, symptoms or histologic Management:
findings - Dependent on signs and symptoms
1. Aberrations of normal development and - Include appropriate use of diagnostic
involution(ANDI) imaging
2. Pathologic classification - Lifestyle modification
3. Clinical classification - Medical management: diuretics, OC’s or
4. Classification based on the risk for progestins, Danazol and Tamoxifen
malignancy
Mastitis and inflammatory disease:
Intraductal papilloma - Lactational (1st 6 weeks of breastfeeding),
- Broad based or pedunculated polypoid non lactational (cyst or cyst rupture) and
epithelial lesions (may obstruct and distend post surgical
the involved duct) - S. aureus ( most common cause of overall
- Perimenopausal women incidence)
- Classical clinical presentation- intermittent - Idiopathic granulomatous mastitis is rare,
but spontaneous discharge from one nipple present with mass, abscess, inflammations
involving one or two ducts (watery, serous, or granuloma formation
or bloody of variable volume) - Chronic inflammatory disease (lupus,
- Located beneath the areola (75%) sarcoid, wegner granulomatosis) are rare
- Small and soft, often difficult to palpate (1- and should be suspected with unresponsive
3mm) treatment with antibiotics
- Excisional biopsy and surveillance (3-4 - Diagnostcs: tissue biopsy, core needle
months intervals) biopsy
- Treatment during pregnancy (as non
Fibrocystic change pregnancy state)
- Most common along all benign breast - Mastectomy, breast conserving therapy,
conditions and systemic therapy
- Represent as a spectrum of changes - Radiation (contraindicated)
throughout a woman’s reproductive age - Radical mastectomy is the most common
with significant patient variation surgery, breast conserving therapy is an
option if radiation therapy can be delayed - 2nd most common type of invasive breast
to the postpartum period cancer
- Characteristic uniformly of the small round
Inset Table 15.1 ANDI classification of BBD neoplastic cells that infiltrate the stroma
Insert table 15.15 BI-RAD classification of and the adipose tissue in a single file
mammographic lesions fashion
- Multicentric origin in the same breast and
Inflammatory breast Cancer tends to involve both breast and are more
- Rare (1-5% of breast cancers) frequently ER positive
- Recognized clinically as a rapidly growing - Excised breast tissue frequently has a
malignant carcinoma with highly angiogenic normal consistency and no mass lesion is
and angioinvasive characteristics grossly evident
- Most inflammatory breast cancers are - Histologic findings (subdivisions of
diagnosed as either stage 3 or 4 infiltrating lobular carcinoma include small
- Most are invasive ductal carcinomas cell, round cell, and signet cell carcinoma
- Infiltration of malignant cells into the
dermal lymphatics of the skin (looks like a Insert table 15.15 staging of breast cancer
skin infection)
- Breast is firm, warm and enlarged with Breast cancer during pregnancy
thickened, erythematous, peau d’ orange - Not frequently diagnosed during pregnancy
skin changes - <5% of breast cancers diagnosed before the
- Dermal lymphatic invasion by malignant age 50 are during pregnancy or in the
cells is noted histologically postpartum
- Mostly poorly differentiated, ER/PR
Insert table 15.2 risk factors for breast Ca negative, ALN positive and have a large
primary tumor size
Lobular Carcinoma in Situ - Diagnosis is frequently delayed in 2 months
- Non-invasive lesion (from the lobules and or longer
terminal ducts of the breast) - Similar to nonpregnant women, in pregnant
- Found with an invasive carcinoma (5% of or postpartum women a breast mass is
malignant breast specimens) usually the presenting sign (mass that
- Increase risk of developing breast cancer persists for more than 2 weeks)
- Premenopausal women (80-90%) - Mammography is not contraindicated in
- Greater tendency to be bilateral and pregnancy (abdominal shielding is
multifocal recommended)
- Lesions diagnosed on an excisional biopsy, - Breast utz can also be used to better define
obtaining histologically negative margins is a mass or guide biopsy
not mandatory as LCIS is frequency - Clinically suspicious mass should be
multicentric biopsied either by FNA or CNB
- Breast cancer chemoprevention with a - Staging studies (tailored to minimized fetal
SERM or an aromatase inhibitor maybe exposure to radiation
indicated for women diagnosed with LCIS
Paget’s Disease
Insert Table 15.4 - 1-3% of new breast carcinomas
Insert Box 15.3 - Lesion has an innocent appearance and
looks like eczema or dermatitis of the nipple
Infiltrating lobular carcinoma - Scaly, raw or ulcerated lesion of the nipple
- 10-15% of invasive lesions and areola (infiltrating ductal carcinoma
that invades the epidermis)
- Punch biopsy or a full thickness wedge of
the nipple is used for diagnosis
- Intraepithelial adenocarcinoma cells/
pagets cells (singly or in small groups within
the epidermis of the nipple seen
histologically)
Ductal Carcinoma in Situ
- Non-invasive lesion
- Perimenopausal and postmenopausal
- Mammography
- CNB: stereotactic guided (confirmatory)
- Goal of treatment (prevent development to
invasive Ca)
- Surgery (mastectomy: 98% curative), RT,
adjuvant endocrine therapy,
chemoprevention,
Insert table 15.8
Box 15.2
