LYMPHATIC DRAINAGE AXILLARY (MOSTLY) INTERNAL MAMMARY SUPRACLAVICULAR

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1 BREAST

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3 LYMPHATIC DRAINAGE AXILLARY (MOSTLY) INTERNAL MAMMARY SUPRACLAVICULAR

4 HISTOLOGY LOBE: (10 in whole breast) LOBULE: (many per lobe) ACINUS/I, aka ALVEOLUS/I: (many per lobule) DUCT(S): INTRA- or INTER- LOB(UL)AR, leading to the lactiferous ducts in the nipple

5 L O B E

6 LOBULE

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8 One single ACINUS (alveolus) Epithelial cells MYO-epithelial cells

9 THREE NORMAL PHASES ACTIVE: about Gland/Stroma ratio LACTATING: Mostly Glands (like thyroid!!!), >>>50/50 ATROPHIC: mostly stroma, <<<50/50

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14 The most important thing to understand breast pathology is to get a solid IMAGE of the NORMAL breast lobule----acini, STROMA, BOUNDARIES

15 BREAST PATHOLOGY DEVELOPMENTAL: DEGENERATION: INFLAMMATION: NEOPLASM:

16 DEVELOPMENTAL MILKLINE REMNANTS ACCESSORY (axillary) BREAST TISSUE NIPPLE INVERSION MACROMASTIA

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19 ACCESSORY (axillary) BREAST TISSUE

20 1) CONGENITAL 2) ACQUIRED: CARCINOMA 3) ACQUIRED: PIERCING

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22 DEGENERATION ATROPHY

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24 INFLAMMATION ACUTE, staph most common PERIDUCTAL DUCT-ECTASIA FAT NECROSIS, usually trauma LYMPHOCYTIC, i.e., diabetic GRANULOMATOUS, sarcoid, TB, etc., but mostly idiopathic

25 ACUTE MASTITIS

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28 INFLAMMATION? Peau d orange

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31 PERIDUCTAL INFLAMMATION

32 DUCTESIA

33 Ductesia CYSTS

34 CUBOIDAL RED COLUMNAR COLUMNAR i.e. APOCRINE

35 FAT NECROSIS

36 FAT NECROSIS

37 LYMPHOYCYTIC MASTITIS (DIABETIC MASTOPATHY)

38 GRANULOMATOUS MASTITIS

39 Benign epithelial Benign stromal Premalignant Malignant epithelial (ductal, lobular) (adenocarcinomas) (insitu, infiltrating) Malignant stromal

40 CLINICAL PRESENTATIONS, palpable or mammographic NIPPLE DISCHARGE PAIN

41 BENIGN EPITHELIAL, aka, FIBROCYSTIC disease NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma ATYPICAL epithelium

42 CYST

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44 CYST, GROSS CYST, MICROSCOPIC

45 ADENOSIS acini/lobule

46 FIBROSIS + CYSTS = FIBROCYSTIC DISEASE

47 BENIGN EPITHELIAL, aka, FIBROCYSTIC disease NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma ATYPICAL epithelium

48 DUCTAL HYPERPLASIA

49 SCLEROSING ADENOSIS

50 COMPLEX SCLEROSING ADENOSIS (RADIAL SCAR)

51 SCLEROSING ADENOSIS

52 FIBROADENOMA: 1) EXTREMELY WELL DEFINED 2) YOUNGER WOMEN 3) ALWAYS BENIGN 4) CAN FIBROSE OR CALCIFY WITH AGE

53 PAPILLOMA

54 PAPILLOMA

55 PAPILLOMA

56 BENIGN EPITHELIAL, aka, FIBROCYSTIC disease NON-proliferative epithelium: i.e., cysts, fibrosis, adenosis PROLIFERATIVE epithelium: hyperplasia, sclerosing adenosis, papilloma, fibroadenoma ATYPICAL epithelium

57 FEATURES OF ATYPIA LOSS OF STROMA BETWEEN ACINI SWISS CHEESE HYPERPLASIA* CRIBRIFORMING** CELLULAR PLEOMORPHISM CELLULAR HYPERCHROMASIA INCREASED/ABNORMAL MITOSES* ROMAN BRIDGES*** NECROSIS*** ( COMEDO-carcinoma )

58 NORMAL DUCT NORMAL ACINUS ATYPICAL HYPERPLASIA of DUCT ATYPICAL HYPERPLASIA, LOBULE

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61 DCIS

62 DCIS, microcalcifications

63 DCIS, microcalcifications

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65 DCIS, ROMAN BRIDGES

66 NORMAL lobule

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68 CIS

69 Usually hangs around MANY MANY years before it infiltrates, in contrast to DCIS The BEST management may be judicious neglect, i.e., observation If it does infiltrate, however, it is at least as bad as DCIS infiltrating, or probably WORSE, showing indian files

70 BREAST CANCER RISK FACTORS Age Menarche Age, early menarche is a risk First Live Birth First-Degree Relatives with Breast Cancer Breast Biopsies Race (caucasian the highest) Estrogen Exposure, prolonged, early menarche, late menopause Radiation Exposure Carcinoma of the contralateral breast or endometrium Geographic Influence Diet (high fat diet is riskiest) Obesity Exercise Lack of breast feeding is a risk, Lack of prior pregnancy is a risk. Environmental Toxins Tobacco ABORTIONS?

71 BREAST CANCER PROGNOSTIC FACTORS STAGING, especially POS or NEG lymph nodes, TNM, etc. AGE GENERAL HEALTH and IMMUNITY Histologic degree of differentiation, i.e., GRADING ERA/(PRA) Her2, aka Her2-Neu

72 STAGING, TNM, based on biologic behavior IN-SITU EARLY disruption of the basal lamina, i.e., basement membrane STROMAL infiltration LYMPHATIC vessels SENTINAL lymph node metastasis MORE lymph node metastases Adjacent structures, skin, ie, inflammatory DISTANT, METASTASES, LIVER, BONE, LUNGS, BRAIN, EVERYWHERE

73 Total Cancers Per Cent In Situ Carcinoma * Ductal carcinoma in situ, DCIS 80 Lobular carcinoma in situ, LCIS 20 Invasive Carcinoma No special type carcinoma ("ductal") 79 Lobular carcinoma 10 Tubular/cribriform carcinoma (Better prognosis than average) Mucinous (colloid) carcinoma (Better prognosis than average) Medullary carcinoma (Better prognosis than average) 2 Papillary carcinoma 1 Metaplastic carcinoma, (Squamous) 6 2

74 HISTOLOGIC TIDBITS INFILTRATING DUCTAL INFILTRATING LOBULAR (INDIAN FILE) TUBULAR (LOOKS LIKE SCLEROSIS, BUT NO BASEMENT MEMBRANE) MUCINOUS (COLLOID) MEDULLARY (LOTS of LYMPHOCYTES)

75 INFILTRATING DUCTAL

76 INFILTRATING LOBULAR CA., INDIAN FILE PATTERN

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78 INFILTRATING DUCTAL CA., TUBULAR PATTERN or TYPE

79 INFILTRATING DUCTAL CA., MUCINOUS (COLLOID) PATTERN or TYPE

80 INFILTRATING DUCTAL CA.,

81 NEOPLASIA, STROMAL Cysto- SARCOMA PHYLLODES (aka, PHYLLODES TUMOR), Looks like a giant fibroadenoma, really NOT a sarcoma SARCOMAS, true, are RARE!!!!

82 FIBROADENOMA

83 MALE BREAST GYNECOMASTIA (related to hyperestrogenism) CARCINOMA (1% of )

84 GYNECOMASTIA (NO lobules)