Breast disease
Dr. A. Basu MD
Topic
1. General concept
TDLU
D/D of a breast Lump
Solid Lump
Bilateral
Fibrocystic
disease
( Irregular
lump)
Unilateral
Fibro adenoma
Cystosarcoma
Phyllodes
Breast
carcinoma
Fat necrosis
Cystic Lump
Abscess ( tender)
Galactocele
( History of
Pregnancy)
Cyst Breast.
Diseases of Breast : lecture topic
A. Fibrocystic changes of breast: types
B. Inflammations
C. Tumors of the Breast
Fibrocystic disease of breast
Non Proliferative
change
Cyst and fibrosis
Proliferative change
Epithelial Hyperplasia
Sclerosing adenosis
Its is a
‘Premalignant “
condition of the
breast
Fibrocystic changes
Fibrocystic disease (Non
Proliferative change)

Gross: Blue dome cyst [ 1to 5 cm]
Non Proliferative change : MICRO
Cystic dilation of
Glands an ducts
Apocrine
metaplasia of the
lining epithelium
of the duct and
glands.
Proliferative change
2. Epithelial Hyperplasia
1. Subtype: Atypical
3. Sclerosing adenosis
(Atypical) Epithelial Hyperplasia : More
chance of carcinoma.
Normal
Sclerosing adenosis
1. Excessive
fibrosis of beast
2.Increased
number of
collapsed gland
Sclerosing adenosis clinically mimic
malignancy : because it is hard and rubbery
on palpation.
Clinical : Fibrocystic changes
Lumpy Breast
Inflammation of the breast
1. Acute mastitis ( produce breast
abscess).
2. Mammary Duct ectasia
3. Traumatic fat necrosis.
Acute mastitis ( produce breast
abscess).

Etiology : Early week of Nursing and
dermatitis.
Acute mastitis
Mammary Duct ectasia
Def : NON-inflammatory lesion.
 Age : 40-50 years , who has children.


Cause : Accumulation of Breast
secretion in Main Excretory Duct.
Mammary Duct ectasia: Dilated Duct , Fibrosis
around the dilated duct.
Presence of PLASMA cells and lymphocytes
Mammary Duct ectasia-C/F
Presents as a lump below the nipple.
 Cause nipple Retraction : mimic
carcinoma

Traumatic fat necrosis
Early : Small Tender and localized lump.
 Later : Fibrosis and calcification occur.

Tumors of the Breast
A. Fibro adenoma
B. Phyllodes Tumors
C. Intraductal papilloma
D. Carcinoma of the breast
Fibro adenoma : Breast Mouse
Disease involve TDLU
 Most common benign tumor in
female breast.
 Its growth is related to estrogen.
 Age : young women ( 3rd Decade)
 They have both epithelial and
connective tissue elements.

Morphology
Size : 1 to 10 cm.
 Tumor more than 10 cm :
Giant fibro adenoma.

Gross: Breast Mouse
Micro: 2 features
Gross: Well circumscribed , tan-white
1. Oval round duct space
2. Slit like , star shaped compressed
duct
Clinical
A. Solitary, discreet, moveable mass (
breast mouse).
B. Regress after menopause and
calcify.
C. It will never become malignant.
Phyllodes ( leaf –like) Tumors
Phyllodes ( leaf –like) Tumors
Past name: Cystosarcoma Phylloid
 It can become malignant
 Usually a big tumor
 Contain mainly stromal component.
 Morphologically has a “ leaf like”
appearance.

Morphologically has a “ leaf like”
appearance
Phyllodes tumor

High-grade lesion behave aggressively
and exhibit recurrence.
Fibroadenoma Vs Phyllodes tumor
Low cellularity
High cellularity, bulky
stroma.
Rare mitosis
High mitosis
No Pleomorphism
Pleomorphism
Present
Well circumscribed
Infiltrative border
Intraductal papilloma
1. An Intraductal papilloma may be
associated with a serous or bloody
nipple discharge .
2. Location : Subareolar
3. It’s a benign lesion.
Intraductal papilloma arising in
main lactiferous ducts
Carcinoma Breast

1.
2.
3.
4.
Risk factors
Genetics and family History
Prolonged exposure to exogenous
estrogen and obesity.
Alcohol consumption.
Environmental
Risk factors
6. Proliferative breast diseases
7. Carcinoma of the contra lateral
breast or endometrium.
8. Frequent in nulliparous women.
9. Obesity
Age : Genetics and family
History
Age : uncommon below 35 years
Genetic disease associated with Breast
cancer:
1. Li-Fraumeni syndrome ( multiple
sarcoma and carcinoma).
2. Cowden disease ( multiple
hamartoma syndrome).

Gene and Breast carcinoma

Associate with BRCA 1 and BRCA 2
gene,

Over expression of c-erb –b2.
HER2/neu
Location of breast
tumor
Upper inner
10%
Upper outer:
50%
Central
20
Lower inner:
10%
Lower outer
outer: 10%
Classification
A. Non Invasive
1. Ductal carcinoma in situ (DCIS)
2. Lobular carcinoma in situ (LCIS)
3. Invasive
Invasive
1. Invasive ductal carcinoma ( not
otherwise specified ; NOS)
2. Invasive lobular carcinoma
3. Medullar carcinoma
4. Colloid carcinoma
5. Tubular carcinoma
DCIS
Vs
LCIS
Arise from duct
Arise from acini.
Associated with
micro calcification
Not associate with
calcification
High grade DSCI
has bad prognosis
Do not produce
mass. Good
prognosis
Duct Carcinoma In Situ : Features
1.
2.
3.
4.
Low grade DCIS : Good prognosis
DCIS with micro invasion
Variant : Comedo carcinoma
Paget disease of nipple: Extension
of In situ duct carcinoma cell to the
lactiferous duct and the skin of the
nipple.
Ductal carcinoma in situ (DCIS)
: with micro calcification
Comedo subtype of DCIS : Central necrosis
within the duct.
Comedocarcinoma
Paget disease of nipple

Extension of In situ duct carcinoma
cell to the lactiferous duct and the
skin of the nipple.
Paget disease of nipple :
Clinically resemble eczema.
Paget cells:
These cells have
abundant clear
cytoplasm and
appear in the
epidermis either
singly or in
clusters.
Paget cell stain PAS : Indicate
presence of Mucin
Prognosis of DCIS


Excellent
97% long time survival.
DCIS with micro invasion : bad
prognosis.
Lobular carcinoma in situ
All acini of a breast lobe is affected.
Cells are monomorphic ( similar size)
Time for Invasive carcinomas
1. Invasive ductal carcinoma ( not
otherwise specified ; NOS)
2. Invasive lobular carcinoma
3. Medullar carcinoma
4. Colloid carcinoma
Invasive ductal carcinoma (Scirrhous
carcinoma)- 70-80%
1. It is carcinoma with no special type
( NOS).
2. Constitute Majority of Breast
carcinoma.
3. They have desmoplasia (Scirrhous ).
4. Stony hard mass, fixed to skin ,
underlying muscles.
Invasive ductal carcinoma (Scirrhous
carcinoma
5.
6.
7.
8.
Lymph vascular and neural invasion
common.
Tumor cells frequently over express
ERB B2.
2/3 rd EXPRESS HOEMONE (
ESTROGEN AND PROGESTERONE)
RECEPTOR.
Presence of overlying Paget’s
disease : Bad prognosis.
Gross : IDC ; infiltrative tumor with
irregular margin.
Gross : IDC ; infiltrative tumor with
infiltrating growth .
Micro : IDC
IDC with extreme desmoplasia
Diagnosis
1.
2.
3.
4.
Mammography
Micro calcification [ red alert]
FNAC
Biopsy
Inflammatory carcinoma
It a a variant of duct carcinoma ;
 Shows swollen , erythematous (red)
breast mimic acute inflammation.

Invasive lobular carcinoma
: Main Features
A. Tumor cells are monomorphic (
B.
C.
D.
E.
similar size).
Frequently bilateral and
multicentric.
More often spread to CSF, serosal
surface and ovary.
Frequently clinically silent.
Express hormone receptor.
Invasive lobular carcinoma:
monomorphic round cells
Invasive lobular carcinoma : microscopy :
single indian file
Bulls eye pattern of invasion
Colloid carcinoma
Age : Older women
 Growth : Slow growing,
 Prognosis ; Prognosis is better than
for non-mucinous, invasive
carcinomas.
 Most express hormone receptors.
 Gross: Soft gelatinous.

Colloid carcinoma :Note the
abundant bluish Mucin.
Medullar carcinoma-2%
A. Incidence : Less than 5% of breast
cancers ( occur with BRCA1)
B. Morphology :
1. Gross : 2-5 cm, fleshy masses .
2. Micro : Sheets and nests of cells are
surrounded by a lymphoid
plasmacytic stroma with no
desmoplasia.
Medullar carcinoma
Medullary carcinoma
C. Prognosis : Better than for
infiltrating ductal or lobular
carcinoma.
D. Lack hormone receptors.
Topic now
1.
2.
3.
4.
5.
6.
7.
8.
9.
Tubular carcinoma
Sarcoma of breast
Features of invasive tumor
Spread of breast carcinoma
Staging of breast carcinoma
Clinical course and prognosis
Management
Male Breast
Miscellaneous lesions
Tubular carcinoma : features
1. Small mass , rarely palpable( 1cm
2.
3.
4.
5.
size).
Excellent Prognosis
Lympnnode metastasis is rare.
Express hormone receptor.
Micro : Well formed tubules and low
grade nuclei.
Morphology
Sarcoma of Breast
All types of sarcoma can occur
 But angiosarcoma is common.

Features of invasive tumor
1.
2.
3.
4.
5.
Fixation to the tissue ( skin, muscle)
Retraction of nipple.
Inflammatory carcinoma.
Dimpling of the skin.
Lymph edema : caused by Tumor
emboli in the dermal blood vessels.
Retraction of nipple
Inflammatory carcinoma: common in
pregnancy (but no inflammatory cells present)
Tumor emboli in the dermal blood
vessels: the cause of Lymphedema
Lymphedema following radical
mastectomy: Thickened skin
Spread
1. Local Lymph nodes
2. Lung, Skeleton (
osteolytic)
3. Brain ( CSF)
4. Metastasis may occur
even after 15 years.
Internal
mammary
Lymph
nodes
Axillary
Lymph
nodes
Upper outer:
50%
Upper inner
10%
Central
20
Lower inner:
10%
Lower outer
outer: 10%
Prognostic factors
11
The size of the
primary tumor
Invasive Ca < 2 cm =
excellent
Lympnnode and
number of LN
involvement.
Histological type
Most important factor related
to the prognosis of breast
cancer
NOS : Duct carcinoma =
bad prognosis
Specialized Ca : good
prognosis
Prognostic factors
Grade
Presence of both
estrogen /
progesterone
receptor
Well differentiate
tumor = better
prognosis.
Slightly better
prognosis.
Prognostic factors
Aneuploidy
If present - worse
prognosis.
Over expression of Poorer Prognosis.
ERB B2
Increased mitosis. Bad prognosis
Prognostic factors
Angiogenesis
+++
More chance of
metastasis
Protease
If increased more
chance of invasion.
Hercepctin
Monoclonal Antibody to Gene ERBB2.
 It is an antitumor antibody.
 If response to this antibody is GOOD =

GOOD prognosis.
Management
Lumpectomy
 Mastectomy or breast Preservation
 Hormonal and Chemotherapy.
 Inhibition of angiogenesis.

Post mastectomy Tumor deposit on
scar area.
Breast self examination; best way to
save life
Thank you

We will now move on to Male Breast.
Male Breast

Gyenecomastia ( Greek word) :
enlargement of the male breast.
Proliferation of ducts in hyalinized fibrous
tissue with periductal edema
Causes
1. Puberty
2. Tumors ( Leydig cell tumor of testis)
3. Genetic disorders ( kilnefelter
syndrome)
4. Chronic liver disease (cirrhosis)
5. Female hormone exposure
Carcinoma of male breast : rare :
usually duct carcinoma.
Thank you