Vijesh Patel Breast diseases Breast extends from the subcutaneous tissue and the pectoralis muscles Anatomy

o Divided into 4 quadrants: **Upper outer quadrant** is the most likely place that a tumor will form o Breast contains: Lobules contain terminal duct and its ascini These lobules are found within lobes Lobes contain single lactiferous ducts and it branches which empty into the nipple o TDLU (Terminal duct lobular unit) consists of the acini, lobule & terminal ducts **Most cancers are situated here** Histology o Ducts and lobules lined by cuboidal cells (inner) and myoepithelial cells (outer) and an outer basement membrane Normally 2 cell layer Some of these epithelial cells are estrogen receptor positive; thus undergo changes during menstruation o Stromal tissue contains dense fibrous tissue + scattered adipose tissue Changes with puberty o Pre-pubertal: the ducts are immature w/ no terminal differentiation (no lobes + no lobules) o Post-pubertal: the ducts are mature; small glands make up 1 lobule which drain into a lactiferous duct Changes with menstruation o Proliferative: proliferation of the epithelial cells under the influence of estrogen + progesterone Can be induced by OCP o Late secretory: progesterone cause more edema + vacuolization of cells Pain + sense of fullness o Pregnancy: proliferation of epithelial cells + secretions found in vacuoles Physiologic hyperplasia of the ascinar cells Clinical presentation of breast lesions Pain (mastalgia) most common If it is painless = may be malignant; If it is painful = may be benign Palpable mass most significant Palpable if it reaches 2 cm in size o Lower risk of malignancy for younger patients <40 years 10% malignant o Higher risk of malignancy for older patients >50 years 60% malignant Nipple discharge Mammography Use to find non-palpable breast tumors Use for a screening test for women after 40 years and every 2 years after that (Family history = start at younger age) Compress the breast between two plates and see if there are any abnormal findings in densities + calcifications o Sensitivity increases as the patient gets older b/c of adipose tissue + brous ssue

Vijesh Patel
Epi Non-neoplastic breast disease Hypertrophy Polythelia Polymastia (Accessory breast) Breast implants Pathogenesis / Antibodies Enlargement of the breast Supernumerary nipples Extra breast found 1) Dense fibrous tissue surrounding implants 2) Rupture of the implants results in a granulomatous response 3) Calcification 4) T4 HSR (SLE, scleroderma) S/S *

May swell + undergo lactation

Mostly found in the axilla - This can have breast cancer

Giant cells found around foreign material

Benign Acute mastitis 1. Puerperal abscess

2. Non-puerperal abscess (Periductal mastitis) Mammary duct ectasia (dilation) (Plasma cell mastitis) Fat necrosis of breast

Smoking association - Can lead to squamous metaplasia

Breast feeding leads to cracks + fissures which can be infected - Staph aureus Subareolar region - Staph aureus + anerobes Heavy inflammation - Plasma cells + M - Granulomas Trauma Early stage = hemorrhage Late stage = liquifactive necrosis - Granulomas + foamy M - Calcification + fibrosis

No mass - Pain - Fever - Discharge

Periareolar mass - Thick nipple secretions Painless palpable mass - DDX: Cancer this has truama

Benign breast epithelial lesions

Palpable lump - Diffuse solid, firm & cystic - Densities / calcification on mammogram No risk of cancer Child bearing age Risk: - Caffeine, ovarian dysfunction Mammographic calcifications Cystic change & apocrine metaplasia Blue dome cyst - Unopened cysts w/ turbid fluid - Sweat gland epithelium - Apical snouts - Calcifications

Disappears w/ fine needle aspiration

1. Non-proliferative breast disease a. Fibrocystic disease

Rx OCP may balance out their cycle

b. Fibrosis c. Adenosis 2. Proliferative breast disease w/o atypia a. Epithelial hyperplasia b. Sclerosing adenosis c. Complex sclerosing lesions (Radial scar) d. Intra ductal papillomas 3. Proliferative breast disease w/ atypia a. Atypical ductal hyperplasia b. Atypical lobular hyperplasia 4. Carcinoma in situ Stromal- Epithelial neoplasms Fibroadenoma Breast mouse Phyllodes tumor (Benign cystosarcoma phyllodes) (Giant fibroadenoma)

Firm nodules Increase in acini / lobule Mild risk of cancer Greater than 2 layers 2x increase in acini - Fibrosis + calcification Central stellate scar - Tear drop shaped glands Papillary growth w/in dilated duct

Mammographic calcifications NO TRUAMA

Blood nipple discharge - If large ducts are affected

**High risk of malignancy** - If small ducts are affected

Moderate risk of cancer Mammographic calcifications Proliferation of ductal cells - No alteration in N/C ratio Proliferation of acini of lobule Cookie cutter appearance - cribriform pattern Bilateral

Substantial risk of cancer Benign Mammographic calcifications Benign Hormonally responsive Solitary rubbery firm lump - Discrete - Freely movable (slip :. mouse) Huge breast enlargement - Leaf like projections of stromal cells Not a cancer precursor

Fibrous stroma may become malignant (rare)