Diseases of

The Breast

DR. MARUF RAZA

Professor of Pathology

ORCID ID: https://orcid.org/0000-0003-0251-4518

Publons/ Web of Science Researcher ID: P-2736-2019
Breast Cancer
BREAST CANCER:
Breast cancer
•
EPIDEMIOLOGY
is the second cause of cancer
deaths in women.

The lifetime risk of a woman developing invasive

breast cancer is 12.6 %.

One out of eight females in the United States

develop breast cancer at some point in her life.
Breast cancer also occurs in men but is rare.
 Breast Cancer: epidemiology
 About 5% invasive breast cancer cases occur
in women aged <40 years.

 Early detection can play a significant role in

reducing its incidence and burden.

 Self Breast Examination (SBE) and

mammography can be done to detected cancer
cases early .
BREAST CARCINOMA – RISK
FACTORS
 Myths & Facts in Breast Cancer
8

 Touching the breasts too often will lead to

tumor/cancer…
 Talking about cancer causes cancer…
 Using illegal drugs causes cancer…
 Herbs can cure breast cancer…
 A bruise on the breast will lead to breast
cancer…
 Incision is made during breast cancer surgery
the cancer will spread…
 Myths & Facts in Breast
9
Cancer
 Getting too many mammograms leads to breast
cancer…
 Breast cancer only affects older women…
 If you have a risk factor for breast cancer,
you're likely to get the disease…
 Using antiperspirants causes breast cancer…
 A breast cancer diagnosis is an automatic
death sentence…
 Prognostic and
predictive factors
 The breast cancer outcome depends on the
biologic features of the carcinoma (molecular
or histologic type).

 The extent to which the cancer has spread

(stage) at the time of diagnosis.
Prognostic and predictive factors

 Prognosis is poor in carcinoma with distant

metastasis and inflammatory carcinoma.

 Prognosis depends on two factors:

i. Major prognostic factors.
ii. Minor Prognostic Factors.
Major prognostic factors
 Invasive carcinoma versus in situ carcinoma.
 Distant metastases (Most Important).
 Lymph node metastases (Important after
Distant Metastasis).
 Tumor size.
 Locally advanced disease.
 Inflammatory carcinoma (Worst prognosis).
Minor Prognostic and Predictive Factors

 Histologic subtype.
 Histologic grade.
 Estrogen and progesterone receptors; ER, PR
positive or negative.
 HER2/neu positive or negative.
 Lymphovascular invasion.
 Proliferative rate.
 Neoadjuvant therapy (Chemo before Surgery)
Prognosis of Breast Cancer
14

Stage 5-Years 10-Years

Survival (%) Survival (%)
Stage 0 95 90
Stage I 85 70
Stage II 70 50
Stage III 55 30
Stage IV 5 2
 Breast Tumour Diagnosis
 By Cytology:
FNAC(Fine Needle Aspiration Cytology); A
fine needle is inserted into the tumour to take
tumour cells.
 By Histopathology:
A Biopsy is done from the tumour and send
with fixatives to the pathology laboratory for
Histopathological Examination.
 Others:
Memmography, Tumour Markers, Gene
Profile, DNA analysis.
CLASSIFICATION OF BREAST
CARCINOMA

 Primary Breast carcinoma

1.Carcinoma in Situ.
2.Invasive (Infiltrating) Carcinoma.

 Secondary or Metastatic carcinoma

CLASSIFICATION OF BREAST
CARCINOMA
CLASSIFICATION OF BREAST
CARCINOMA
 Carcinoma in Situ
 CIS is a malignant proliferation of epithelial
cells limited to ducts and lobules which
doesnot cross the basement membrane.

1. Ductal Carcinoma in Situ (DCIS).

2. Lobular Carcinoma in Situ (LCIS).
Invasive (Infiltrating)
Carcinoma
1. Invasive Ductal Carcinoma.
2. Lobular carcinoma
3.Tubular carcinoma
4. Mucinous carcinoma
5. Medullary carcinoma
6. Papillary carcinoma
7. Metaplastic carcinoma
 Secondary or Metastatic carcinoma

 Metastases to the breasts are rare.

 Metastatic cancer may come from:
i. Contra lateral breast carcinoma.
ii. from malignant melanomas
iii. from Lung cancers.
 Etiology and
Pathogenesis
of
Breast Cancer
 Etiology and
Pathogenesis
 The development of breast cancer is due to
hormonal exposure (estrogen) and genetic
factors.

1. Hereditary/ Familial Breast Cancer.

2. Sporadic Breast Cancer.
 Hereditary Breast
Cancer
 The inheritance of a susceptibility gene and
mutation of genes is the primary cause of
approximately 5-10% of breast cancers.

 Breast cancer genes are BRCA1 , BRCA2,

p53, CHEK2.

 Mutations in BRCA1 and BRCA2 account for

the majority of cancers.
PATHOGNESIS – GENETIC
FACTORS

Most common genes

implicated in Breast
carcinoma
 Hereditary Breast
Cancer

 Only 5-10% of breast cancers are inherited.

 Families that do have genetic defects in BRCA1

or BRCA2, have a much greater risk of
developing both breast and ovarian cancer.
 Sporadic Breast Cancer
 The sporadic breast cancer are related to
environmental factors and hormone exposure.

 The majority of sporadic cancers occur in

postmenopausal women.
 Sporadic Breast Cancer

 Sporadic Breast Cancer occurs due to

mutations resulting from radiation exposure –
women treated with chest radiation therapy for
lymphoma in childhood or during adolescence.

 Acquired Mutations may also develop due to

exposure of cancer-causing chemicals,
tobacco and charred red meats.
 TREATMENT
29
Surgery:
i. Lumpectomy
ii. Partial or segmental mastectomy
iii. Simple mastectomy
iv. Modified radical mastectomy
v. Sentinel lymph node biopsy
vi. Axillary lymph node dissection
 Radiation therapy
 Chemotherapy
 TREATMENT
30

 Reconstructive surgery

i. Reconstruction with implants

ii. Reconstruction with a tissue flap
iii. Reconstruction of the nipple and
areola
 PREVENTION
31

 LIFE-STYLE FACTORS
i. Taking aspirin
ii. No / limit alcohol, Tobacco.
iii. Maintain a healthy weight
iv. Avoid long-term hormone therapy
v. Stay physically active
vi. Eat foods high in fiber
vii. Emphasize olive oil
viii. Avoid exposure to pesticides
 PREVENTION
32

 Chemoprevention
Tamoxifen (Nolvadex)
Raloxifene (Evista)

 Preventive surgery
Prophylactic mastectomy with reconstruction
Prophylactic oophorectomy
 GYNAECOMASTIA
 Enlargement of male breast.
 Puberty/ Advanced Age/ Hyperestrinism/
Cirrhosis of liver.

 Drugs – alcohol, marijuana, heroin, anabolic

steroids used by athletes & body builders.

 Unilateral or bilateral. Diffuse or Button-like

subareolar enlargement.
Clinical Presentations
of
Breast Disease
Clinical Presentations of Breast
Disease

The most common symptoms are:

 Pain.
 Palpable mass.

 Lumpiness (without a discrete mass).

 Nipple discharge.
Pain (Mastalgia or Mastodynia)

 Most common clinical presentation. Pain may

be cyclic with menses or noncyclical.

 Roughly 95% of painful masses are benign.

 But about 10% of breast cancers are painful.

And these are usually large mass with
advance stage.
 Palpable mass
 A breast mass generally becomes palpable
when it is at least 2 cm in size.

 The most common palpable lesions are

fibroadenoma, cysts and cancer. Likelihood
of a palpable mass being malignant increases
with age.

 Approximately 50% of carcinomas arise in the

upper outer quadrant of breast.
 Nipple discharge
 Nipple discharge is worrisome when it is
bloody and unilateral, might be from an
underlying carcinoma.

 Galactorrhea/ milky discharge is not

associated with malignancy.

 During pregnancy, a bloody discharge can

result from the rapid proliferation of the
breast for lactation.
Benign Epithelial Lesions of breast

Benign epithelial lesions classified into three

groups:

i. Nonproliferative breast changes.

ii. Proliferative breast disease.
iii. Atypical hyperplasia.
Nonproliferative breast changes
 This are often grouped under the term
fibrocystic changes. These lesions are not
associated with an increased risk of breast
cancer.
 Three principal changes:
i. Cystic change.
ii. Fibrosis.
iii. Adenosis.
Proliferative breast disease
 Characterized by proliferation of epithelial
cells of the ducts and lobules of the breast.
Two types:

1. Proliferative breast disease without atypia

2. Proliferative breast disease with atypia
Proliferative breast disease

 Proliferative breast disease without atypia is

associated with 1.5- 2% risk of carcinoma of
breast.

 Proliferative breast disease with atypia is

associated with 4- 5% risk of carcinoma of
breast.
 STROMAL TUMORS
 The two types of stroma in the breast,
intralobular and interlobular give rise to
distinct types of neoplasms.

 Types:
i.Fibroadenoma
ii.Phyllodes Tumor
Fibroadenoma

 This is the most common benign tumor of the

female breast. Most occur in women in
between 20 years and 30 years age.

 They are usually single but in 20% cases are

multiple and bilateral.

 Their usual size is 1 to 3 cm but vary in size to

large tumors.
Fibroadenoma
 Young women usually present with a palpable
mass which is usually sharply demarcated,
firm and freely movable.

 They feel like little marbles in the breast tissue

and often move during palpation examination
("breast mouse“).

 It increases in size during pregnancy and

tends to regress as patients age increases.
Fibroadenoma
Inflammatory Disorders of Breast

 Acute mastitis
 Squamous metaplasia of lactiferous ducts

 Duct ectasia

 Fat necrosis

 Lymphocytic mastopathy

 Granulomatous mastitis
Mammary Duct Ectasia
 Duct ectasia is a inflammatory condition of the
breasts, tends to occur in the fifth or sixth
decade of life.

 Palpable periareolar mass that is often

associated with nipple secretions and with
skin retraction.

 Duct ectasia mimics the clinical and

radiographic appearance of an invasive
carcinoma.
 Fat Necrosis
 Fat necrosis refers to the localized areas of fat

destruction.
 Fat necrosis is of two types:

i. Enzymatic fat necrosis

ii. Traumatic fat necrosis

 Enzymatic fat necrosis occurs in acute pancreatitis

which destroy pancreatic and peritoneal fat.

 Traumatic fat necrosis occurs in weight bearing

areas like shoulder of a day laborer and also
occurs in the breasts.
Fat Necrosis in breasts

 About half of affected women with fat necrosis

have a history of breast trauma or prior breast
surgery.

 Painless palpable mass, skin thickening or

skin retraction, or mammographic densities or
calcifications indicates fat necrosis in breasts.
Sentinel lymph node
 A sentinel lymph node is defined as the first
lymphnode in a regional lymphatic system that
receives lymph flow from the primary tumor.
 Biopsy of sentinel nodes helps to identify
presence or absence of metastatic lesions in
the lymph nodes.

 It is done to avoid surgical morbidity

associated with a full axillary lymph node
dissection.
Mammographic screening
 Mammography is a non invasive procedure
and currently the most commonly used
screening test for breast cancer.

 The principal mammographic signs of breast

carcinoma are densities and calcifications.

 However approximately 10% of invasive

carcinomas are not detected by
mammography.
 Mammography
 Mammography use a low-dose x-ray system to
examine breasts.
 It converts x-rays into electrical signals and
produce images on a computer screen (similar
to digital cameras)
 Mammography can show changes in the breast
up to two years before a physician can feel
them.
 Neoadjuvent Chemotherapy
 Chemotherapy uses drugs to destroy cancer
cells, stop their growth, to reduce symptoms.

 Neoadjuvant (also called preoperative or

primary) chemotherapy, drug treatment taken
before surgical extraction of a tumor.

 Neoadjuvant chemotherapy is usually given in

breast, colorectal and lung cancers.
Neoadjuvant therapy
for Breast Cancer

Diagnosis and Staging

Neoadjuvant systemic
therapy

Surgical Resection

Chemo and radio therapy

 Neoadjuvent
Chemotherapy
 Allow patients to start treatment earlier.
 Reduce the extent of surgery required in breast
and axilla.
 Make tumours more operable, increase the rate
of breast conserving surgeries.
 Improve prognosis of certain disease subtypes
(i.e. HER2+)
Developmental Disorders of
Breast
 Milk Line Remnants
 Accessory Axillary Breast Tissue

 Congenital Nipple Inversion

Milk Line Remnants/Accessory Axillary
Breast Tissue
 Congenital Nipple Inversion

 The failure of the nipple to evert during

development is a common condition in
female.

 Congenitally inverted nipples may correct

spontaneously during pregnancy or can be
everted by simple traction.

 Acquired nipple retraction of an aged women

may indicate presence of an invasive cancer
or an inflammatory nipple disease.
Thank You All