BREAST

FK KEDOKTERAN
UNIVERSITAS METHODIST INDONESIA

Mammary Glands

 Parenchyma

essential parts of an
organ that are
concerned with its
function

Stroma

Stroma

framework/supporting
tissue of an organ;
contains connective
tissue& blood vessels
opposite of
parenchyma
Parenchyma

Terminology
Exocrine Gland

a gland whose secretion

reaches an epithelial
Capillaries
surface

Duct cell
Secretory cell

Endocrine Gland

a gland that secretes

directly into the bloodstream

Anatomy of the Breast

Interlobular duct
Terminal duct

Duct cells

Lobules

Tubular gland

Secretory
cells

Alveolar
gland

Ductal / Tubular
Architecture
Nipple
Lactiferous duct
Lactiferous sinus
Lactiferous duct
Interlobular duct
Tubular duct
Alveolar gland

Development of the Breast

Birth
rudimentary branching ducts fan out
in the region of the nipple and areola
Prepuberty
very slow but progressive
growth & branching of mammary
ducts
growth ceases at this stage in the
male

Development of the Breast

Premenstruation

growth rate increases; branching of ducts

proliferation interductal stroma
stimulated by oestrogen
ducts end blindly (terminal ducts)

Menarche

terminal ducts proliferate, giving rise to

30 epithelium-lined ductules acini
each terminal duct & ductules form lobule

Pregnancy
Morphologic maturation & functional
development

influenced by oestrogen,progesterone &

prolactin
oestrogen & progesterone suppress
the milk-producing effects of prolactin

Reversal of usual stromal-glandular

relationship

composed almost entirely of glands,

separated by relatively scant amount of stroma

Cuboidal epithelium lines the secretory glands

secretory vacuoles of lipid material appear

Lactation
Expulsion of placenta leads to
oestrogen & progesterone
Lactogenic effect of prolactin
is not longer supressed
Prolactin stimulates
milk production

CONGENITAL ANOMALIES
POLYMASTIA
Breast/nipple >2 along the original
embryonic breast ridge (milk line).
SUPERNUMERARY
Accessory breast tissue from nipple
to axilla
INVERSION OF THE NIPPLE

INFLAMMATIONS
ACUTE MASTITIS bacterial
infection of the breast abscess
Post partum lactating or involuting
breast.
From : - Fissure at Nipple
- Eczema
- Other skin diseases

COMEDOMASTITIS DUCT
ECTASIA
= Plasma Cell Mastitis.
Presence of dilated large and
intermediate ducts of the breast
contain pasty, inspissated material
periductal inflammation and fibrosis.
Micros : dilated ducts, contain
acelluler debris & macrophages,
periductal inflammation, foreign body
granulomas (+).

 FAT NECROSIS
History of trauma hemorrhage
necrosis of adipocytes + inflamm cell
phagocytes lipid debris (limfosit +
giant cell).
GALACTOCELE
Cystic dilatation of terminal ducts
during lactation.

FIBROCYSTIC CHANGE
= Mammary dysplasia fibrocystic
disease.
Hormonal imbalance.
Short menstruation cycle(21-24days)
Estrogen >> Hyperestrism.
50% breast surgery cases in reproductive
period.
Premenstrual pain+lumpy breast.
Stromal and terminal ducts epithelial
proliferation.

FIBROCYSTIC CHANGE
NON PROLIFERATIVE
Discrete mass fibrous connective tissue contain small cysts.
Large cyst (>5 cm) blue color to
the unopened cysts blue-domed
cysts of Bloodgood.

PROLIFERATIVE
FIBROCYSTIC CHANGE
SCLEROSING
ADENOSIS
proliferation of
small ducts &
myoepithelial cells
in terminal duct
lobular unit.

FIBROSIS
Elastic, mobile.
White
homogenous.
30-35 years.
Stromal collagen
>>
Fibrosis.
Gland atrophy.

CYSTIC
Cyst 3-5 cm.
Serrous blue brown
fluid.
45-55 years.
Stromal >>.
Fibrosis.
Gland & epithelial
proliferation.
Dilated duct cyst.

ADENOSIS

Sclerosing adenosis.
Duct hyperplasia.
35-45 years.
Firm.
Blurred borders.
Duct hyperplasia.
Intraduct papilloma.
Gland & stromal
proliferation.

BREAST TUMORS
BENIGN :
- FIBROADENOMA
- FIBROMA
- INTRADUCTAL PAPILLOMA
- CHONDROMA
MALIGNANY:
- CARCINOMA
- SARCOMA

FIBROADENOMA MAMMA
Benign neoplasm of the breast and is
composed of epithelial and stromal
elements that originate from the terminal
duct lobular unit.
Ages : 20-30 years.
Sign : round, rubbery tumor, soliter /
multiple, sharply demarcated, freely
moveable, upper lateral quadrant >>
Macros : encapsulated, gray white.
Micros : proliferation of glands and fibrous
stroma.

FIBROADENOMA MAMMA
PERICANALICUL
AR ROUND
GLANDS
DISPERSED
WITHIN FIBROUS
STROMA.

FIBROADENOMA MAMMA
INTRACANALICU
LARE FIBROUS
TISSUE FORM
TUMORCOMPRES
S PROLIFERATED
DUCTS
CURVILINEAR
SLITS.

 SOME JUVENILE FIBROADENOMAS

ATTAIN GREAT SIZE

GIANT FIBROADENOMA.
GIANT FAM PHYLLODES TUMOR
(CYSTOSARCOMA PHYLLODES)

PHYLLODES TUMOR
Proliferation of stromal element
accompanied by benign growth of
ductal structures.
Benign Phyllodes tumor similar to
FAM, the distinction not made on the
size, but the histological and
cytological characteristic of stromal
component. Micros: stroma hypercell
and has mitotic activity.

PHYLLODES TUMOR

Malignant Phyllodes Tumor

sarcomatous stroma with abundant
mitotic activity, poorly circumscribed,
invasion to surrounding breast tissue

INTRADUCTAL PAPILLOMA
Single tumor.
< 1 cm.
Attached to wall of duct
by fibrovascular stalk.
Situated in large,
subareolar ducts.
Has serrous or bloody
nipple discharge.
Difficult to distinguish
from papillary
carcinoma.

CARCINOMA OF THE
BREAST
EPIDEMIOLOGY the most common
malignancy of women after cervix
cancer.
PATHOGENESIS :
- Genetic Factor history of breast
ca in first line degree relatives
(mother,sister,daughter).

PATHOGENESIS
Mutations of p53 tumor suppressor
gene; BRCA 1 gene (breast ca 1)
located at chromosome 17 (17q21)
and BRCA 2 gene located on
chromosome 13q.
Hormonal status early menarch,
late menopause and older age at first
term pregnancy increased risk.

PATHOGENESIS
Environmental Influences high fat
intake.
Radiation.
Fibrocystic Change.
Previous cancer.
Viruses.
Genomic alterations gene amplification,
overexpression & allelic deletion.

CARCINOMA IN SITU
INTRADUCTAL CARCINOMA IN SITU:
- COMEDOCARCINOMA
- NON COMEDO INTRADUCTAL CA
LOBULAR CARCINOMA IN SITU.
PAPILLARY CARCINOMA IN SITU.

INVASIVE CARCINOMA
1. DUCTAL CARCINOMA.
- The most common form Breast ca.
- Hard, fixed mass(often referred as
scirrhous ca).
- Gross: firm with irregular margin, pale
gray,gritty & flecked yellow chalky
streaks.
- Micros: irregular nests epitheloid cell
within dense fibrous stroma.
Variant ductal caPaget Disease of nipple.

2.LOBULAR CARCINOMA
Micros: single strands of malignant
cells infiltrating between stromal fiber
INDIAN FILING.
+ Signet Ring Caintracelluler mucin
compress nucleus to one side.
+ Pleomorphic Lobular Camarked
nuclear pleomorphism.

3.Colloid
carcinoma
composed of small
clusters of
epithelial cells
forming glands,
floating in pools of
extracell mucin.

4. Tubular
Carcinoma
Well
differentiated ca
composed of
infiltrating, wellformed small ducts
consist one/two
layers of small
regular cells.

5. Medullary
Carcinoma
circumscribed mass
with lacks
calcifications.
Composed sheets
of cells, highly
pleomorphic & high
mitotic index.

6. Metaplastic Carcinoma
a rare invasive variant malignant
epithelium partially differentiation
into either another type of epithelium
or mesenchymal tissue tumor may
show areas of malignant squamous,
fibrous, cartilaginous or bony tissue,
admixed with malignant glandular
component.

PROGNOSTIC FACTORS
1. Stage at diagnostic.
2. Histological grade degree of
glandular differentiation, nuclear
atypia and mitotic index.
3. Estrogen and progesteron receptor
4. Proliferative capacity & ploidy.
5. Lymphatic & vascular invasion.
6. Oncogene Expression.

TREATMENT
Effective treatment of breast ca is
early detection.
Regular self-examination, screening
mammograms decreased mortality
Modified radical mastectomy
treatment of choice.

CANCER OF THE MALE

BREAST
< 1% ALL CASES OF BREAST CA.
LESS FAT IN BREAST INVASION
OF CHEST WALL MUSCLES MORE
FREQUENT.
MUTATION IN BRCA 2 GENE
INCREASE THE RISK OF THIS
TUMOR.

MAMMOGRAM

Hematogenous
metastasis
Lymphatogenou
s metastasis

Mechanism of metastasis

Modified
from AJCC STAGING OF
1992
PRIMARY TUMOR (T)
T0

No evidence of primary tumor

Tis

Carcinoma in situ

T1

Tumor 2 cm

T2

Tumor >2 cm but 5 cm

T3
T4

Stage IIB

N0
N1

No regional lymph nodes

Metastasis to moveable ipsilateral
nodes
Metastasis to matted or fixed
ipsilateral nodes
Metastasis to ipsilateral internal
mammary nodes

N3

DISTANT METASTASIS (M)

Extent to chest wall,

inflammation, satellite lesions,
ulcerations

Tis
T1
M0
M0
T2
T2
T3

TMN )

REGIONAL LYMPH NODES (N)

N2

Tumor >5 cm

Stage 0
Stage I
Stage IIA T0 N1
T1 N1

BREAST CANCER (

M0
M1

N0
N0

M0
M0

Stage IIIA

N0
N1
N0

M0
M0
M0

Stage IIIB
Stage IV

No distant metastasis
Distant metastasis (includes spread
to ipsilateral supraclavicular nodes)

T0
T1
T2
T3
T4
any T
any T

N2
N2
N2
N1,N2
any N
N3
any N

M0
M0
M0
M0
M0
M0
M1

PENATALAKSANAAN TUMOR MAMMA

TUMOR MAMMA
DIAGNOSA

ASPIRASI

BIOPSI

EKSISI
GANAS

JINAK
Kel.Ro Paru

STADIUM KLINIK

Rontgen Paru
Scanning Tulang
Scanning Hati
Fungsi Hati

THERAPI

EKSTIRPASI

Breast Self-Examination
The American Cancer Society recommends that
women perform a breast self-examination once
a month.
The best time to do a breast self-exam is one
week after your period so that your breasts will
be less tender and you will be more likely to
notice any changes in their look or feel.

After menopause, do breast self-exams on

the first day of each month.

Breast self-exam

Visual Inspection
Standing or sitting in front of a mirror as
illustrated. In each position look for :
Changes in color or shape of breast
Changes in color or texture of the skin
Changes in nipple shape or texture
Evidence of nipple discharge
Dimpling or puckering anywhere on chest
If your eyesight is limited, making it difficult
for you to do the visual inspection yourself
perhaps a close friend, spouse, an attendant
or family member could help you with this.

make it easy for you to notice any changes

in the way your breasts look or feel.

If you cannot easily stand, you can

do the visual inspection in a
seated position, if you have a full
length mirror, for example on the
back of a door.

Arms relaxed at side

Hands on hips with your thumbs

facing forward,push down on
your hips

if you cannot place your hands on your hips,

try clasping your hands together in front of you,
to tighten your chest muscles

Arms raised above head

Bending forward

POSITIONS FOR PALPATION

If you are able to use both your hands, use
your left hand to palpate the right breast, while
holding your right arm up with the elbow bent.
Repeat the procedure on the other side sidelying position allows a woman, especially one
with large breasts, to most effectively examine
the outer half of the breast. A woman with
small breasts may need only the flat position.

Side-lying positions
Lie on the opposite side of the breast of be examined.
Place a pillow or rolled up towel under your shoulder blade.
Rotate the shoulder back to the flat surface.
Use the side-lying position to examine the outer half of your
breast.

Flat position
Lie flat on your back with a pillow
or folded towel under the
shoulder of the breast to be
examined.

PERIMETER / AREA TO BE EXAMINED

The exam area is bounded by the line which extends down

from the middle of the armpit to just beneath the breast,
continues across the underside of the breast to the middle
of the breast bone, then moves up and along the collar bone
and back to the middle of the armpit. Most breast cancers
occur in the upper outer area of the breast
(the shaded area).

If you can use only one hand, use that for checking both breasts,
and examine the breast on that side as well as you can.

PALPATION WITH PADS OF FINGERS

Use the pads of three fingers to examine every inch of your
breast tissue.Move your fingers in circles about the
size of a dime.

Do not lift your fingers from your breast between palpations.

You can use powder or lotion to help your fingers glide from
one spot to the next.

If you have difficulty using or feeling with the finger

pads of one or both hands, try using the thumb,
the palm of your hand or the back of your fingers.
If it is difficult to control one or both hands because
of shaking movements, try using the other hand
to stabilizethe hand examining the breast.

PRACTICE WITH FEEDBACK

It is important that you perform breast
self examination (BSE) while your
instructor watches you to be sure you
are doing it correctly Practice your skills
until you feel comfortable and confident.