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Breast Pathology (Inflammatory Disorders (Acute Mastitis
Acute…
Breast Pathology
Inflammatory Disorders
Acute Mastitis
- Acute inflammation of the breast, typically found in post-partum or pre-menopausal women
- Microbial causes:
- S. aureus: Localised abscess
- Streptococcus spp.: Diffused infection
- Pathogenesis:
- Cracked, inflamed nipple allows entry of microbe
- Proliferation of microbe in stagnant milk
- Acute inflammation - resulting in abscess formation
- Clinical Features:
- Breast appears erythematous, painful
- Fever
- Treatment:
- Incision and drainage
- Antibiotics
- Excision
Periductal Mastitis
- Aka recurrent subareolar abscess, squamous metaplasia of lactiferous ducts or Zuska disease
- Strongly asc with smoking
- Pathogenesis:
- Keratinising squamous metaplasia of the lactiferous ducts
- Keratin sheds and plugs ducts, causing dilation and eventual duct rupture
- Intense chronic inflammation occurs in periductal tissue
- Fistula tract may form to open onto skin at areolar edge
Mammary Duct Ectasia
- Multiparous women, 50-60 yo
- Morphology:
- Dilated ducts containing inspissated secretions
- Marked periductal and interstitial chronic granulomatous inflammation
- No squamous metaplasia of ducts
- Clinical Features:
- Poorly defined palpable periareolar mass
- Thick white nipple secretions
- Skin and nipple retractions due to underlying fibrosis
- Pain and erythema uncommon
- Main significance: Mimics breast carcinoma
Fat Necrosis
- Hx of breast trauma or surgery
- Clinical features:
- Painless palpable mass
- Skin retraction
- Mammographic density
- Main significance: Mimics breast carcinoma
Lymphocytic Mastopathy
- Postulated autoimmune mechanism (commonly seen in Type I DM and autoimmune thyroid diseases)
- Morphology:
- Lymphocytic infiltrate and collagenized storm surrounding atrophic ducts
- Clinical Features:
- Single/multiple, unilateral/bilateral masses
- Main significance: Mimics breast carcinoma
Granulomatous Diseases
- Idiopathic Granulomatous Mastitis:
- Autoimmune disease of unknown etiology targeting secretory products of breast
- Lobulocentric granulomatous inflammation (mainly involves breast lobules, spares stroma)
- Treatment:
- Steroids
- Immunosuppressives
- Surgery
- Non-idiopathic Granulomatous Diseases:
- Granulomatous diseases (Wegener's, sarcoidosis)
- Granulomatous infections (Mycobacterial, fungal)
Breast Implants/Injections
- Types:
- Paraffin injections, implants, autologous tissue
- Pathological Effects:
- Fibrosis around implant
- Foreign body inflammatory reaction to leakages
- Morphology:
- Empty spaces in histological section representing areas of paraffin
- Surrounded by foreign body giant cells and histiocytes
Breast Carcinoma
Risk Factors
- Race (Caucasian, Jew, Parsi)
- Age (Perimenopausal)
- Socioeconomic status (high)
- Weight (obese)
- Previous breast diseases
- Family Hx of breast cancer
- BRCA1 and BRCA2
- DNA repair genes for double strand breaks.
- Mutations account for 25% of familial breast cancers
- Ovarian activity (early menarche, late menopause)
- Exogenous oestrogen (oral contraceptives, hormone replacement therapy)
- Nulliparity
- Lack of breastfeeding
- Proliferative diseases of breast
Classification
- Carcinoma in-situ
- Ductal CIS (+ Paget's disease)
- Lobular CIS
- Invasive carcinoma
- Invasive ductal - wastepaper basket category
- Invasive lobular
- Special types:
- Tubular
- Mucinous
- Medullary
- Lobular
Clinical Presentation
- Palpable mass
- Nipple discharge (serous or bloody)
- Mammographic density and calcifications
- Nipple retraction
- Peau d' orange appearance
- Tumour deposits --> disrupt lymph drainage --> lymphedema --> tethering of skin of breast by Cooper ligaments
- Palpable axillary metastases (LN metastasis)
Prognostic Factors
- Tumour size (<2cm better)
- Tumour grade
- Tumour stage
- Axillary nodes
- Vascular invasion
- Oestrogen receptors
- Present better
- Can treat with tamoxifen (oestrogen antagonists) or aromatase inhibitors
- However, ER+ tumours are less likely to respond to chemotherapy
- HER2/neu/CerbB2 receptor
- Present worse
- Can treat with tyrosine kinase inhibitors (Herceptin aka trastuzumab/lapatinib)
- DNA amount
- Diploid better, aneuploid worse
- Histologic type
- Lobular and special types better
- Ductal worse
Paget's Disease
- Rare manifestation of ductal CIS involving the nipple
- Pathogenesis:
- Extension of DCIS along ducts within the epithelial layer to the area under the skin over nipple
- Appearance:
- Unilateral
- Exfoliation/ulceration of nipple
- Erythematous eruption with a scale crust
- Large, atypical cells with clear cytoplasm
Disease of Male Breast
Gynaecomastia
- Enlargement of the male breast, may be unilateral of bilateral, presenting as a button-like subareolar enlargement
- Causes:
- Drugs (most common cause) - digoxin
- Testicular atrophy (eg. in Klinefelter's syndrome)
- High oestrogen levels:
- Liver cirrhosis
- Oestrogen-secreting tumours of testis or adrenal gland
- Hyperprolactinemia
Carcinoma - extremely rare
- Infiltrating ductal carcinoma
-
Benign Neoplasms
- Fibroepithelial tumour arising from intralobular stroma of breast
Fibroadenoma
- Highest prevalence in young women (peak around 25yo)
- Morphology:
- Gross:
- Firm, well-defined mobile lump (mouse in the breast)
- May be multiple and bilateral
- Histologically:
- Proliferation of glandular and stromal elements
- Pericanalicular or intracanalicular pattern - no prognostic significance
- Cellular, delicate myxoid stroma (resembles normal intralobular stroma of breast)
- Clinical Features:
- Slow-growing tumour
- Risk of malignancy based on degree of epithelial hyperplasia
- Can recur, may occasionally regress spontaneously
Phyllodes Tumour
- Histology:
- Both glandular and stromal components
- Frondlike architecture
- Stroma more cellular than that of fibroadenoma
- Not fully circumscribed: tongues of tumour going into adjacent tissue (hence require 1cm margin in excision to prevent recurrence)
- Clinical Features:
- Higher risk of malignancy than fibroadenoma - in which it will become a sarcoma (proliferating stromal elements overrunning the epithelial components of the original benign tumour)
Clinical Presentation:
- Pain (cyclic, non-cyclic)
- Discrete palpable masses
- Nipple discharge
- Lumpiness
Diagnostic Triad (Triple Test):
- Clinical examination
- Radiology - US, Mammogram, MRI
- Pathology - FNA, core biopsy, excision biopsy