Breast 2 Neoplastic

8/8/2019 Breast 2 Neoplastic

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The Breast

Breast

Normal

Pathology

Developmental

Anomalies

Clinical features

InflammationsBenign Epithelial

lesions

Carcinoma Male Breast


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Breast Carcinoma

Arise from epithelial cells,one in nine women develops breast cancer during her life-time (1/3 fatal);

Risk Factors-

1. strong family history first-degree relatives with cancer,

2. Specific genes linked to genetic inheritance , p53 -Li-Fraumeni syndrome, ATM -ataxia-

telangiectasia; BRCA1 and 2 (Genetic inheritance is in < 10% of all breast cancer cases)3. age (rare


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Breast Carcinoma Classified as: in situ (noninvasive) - 15 to 30% of all cancers: can be ( DCIS

(intraductal carcinoma), LCIS (lobular carcinoma); invasive (invasive) MC is invasive ductal carcinoma (80%)

Ductal carcinoma in situ (DCIS) - proliferations of tumor cells within ducts and lobules

confined by the basement membrane, spread from lactiferous ducts into the contiguous skin of

the nipple - Paget disease of the nipple (nipple -eczematous or ulcerated, not detected on the

mammogram; 1/3 can develop carcinoma over time if untreated; Lobular carcinoma in situ- proliferation of small, uniform cells within ducts and lobules that

fill, distend or distort at least 50% of the acinar units of a single lobule; always an incidental

finding ,never forms a mass , calcifications are rare, invasive carcinoma develops in 25 to 30%

, ,

Invasive ductal carcinoma (IDC) MC type - or cannot be classified or no special type(NST); malignant cells with a dense stromal reactionhard consistency (scirrhous carcinoma)

Invasive Lobular Ca.-5 to 10% of invasive carcinomas, multifocal and bilateral diffusely

invasive - difficult to detect clinically and mammographically; composed of small, uniform

cells forming strands of infiltrating tumor cells, sometimes arranged concentrically about ducts

(bull's eye lesions); Behavior- frequently metastasize to CSF (carcinomatous meningitis),serosal surfaces, ovary and uterus, bone marrow

Medullary carcinoma - younger age; with BRCA1 mutations ; Grossly- large, soft, well

circumscribed ; no desmoplasia, a moderately dense lymphoblastic infiltrate,

Others- Colloid (mucinous) ca. Tubular (cribriform) ca. Papillary carcinoma - have

good prognosis


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Paget disease


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Lobular carcinoma

Lobular carcinoma in situ Invasive Lobular carcinoma


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Breast carcinoma

Excess stromal proliferation. Desmoplasia


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Medullary carcinoma


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Colloid (mucinous) carcinoma


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Stromal Tumors

1. Fibroadenoma (Br. Mouse) - MC benign tumor of the female breast, during thereproductive period; cyclosporine A therapy; Clinically- well circumscribed

palpable masses or mammographic densities, (during pregnancy- grow in size and

sometimes infarct), in older women- calcify, Benign & associated with proliferative

changes; slightly increased risk of cancer; Grossly-solitary white, rubbery nodules

from 1 to 10 cm in diameter; Histologically -biphasic (stroma and epithelium

lining cystic spaces)

-

women 50 70 yrs. (10 to 20 years older than fibroadenomas) & cellularity,mitotic activity, stromal overgrowth and invasiveness Behavior-Most - benign &

cured by local excision, few recur; few are highly malignant

3. Sarcomas -rare, can leiomyo, chondros and osteosarcoma; Sarcomatousdifferentiation inphyllodes tumors and carcinomas -metaplastic carcinomas;

Lymphangio-sarcomas if arise after radiation therapy for breast cancer or skin of a

chronically edematous arm in a post- mastectomy patient- Stewart-Treves

syndrome


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Fibroadenoma (Br. MOUSE)


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Mammographic Changes

1. Densities - most Neoplasms - radiologically denser than the intermingledconnective and adipose tissue of the normal breast; Invasive carcinomas-

spiculated density with irregular borders ; Benign lesions - well-circumscribed

densities with smooth borders

2. Calcifications - DCIS is the MC malignancy associated with calcifications;

malignancy - small, irregular, numerous and clustered or linear and branching,

-

comparison of sequential mammograms for developing densities, architecturaldistortion or increased in the number of calcifications

4. Limitations of Mammography-some carcinomas (even if palpable) may not be

detected by mammography due to surrounding dense stroma (esp. in youngerwomen), absence of calcification, small size, close to the chest wall in the

periphery of the breast


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Mammogram of Young Beast


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Mammogram of aged Beast


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Multiple small Irregular clusters

Cause?


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Large density With Irregular Border

Cause ?


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Features common to all invasive carcinomas

Local invasion into adjacent structures produces tissue fixation, retraction of thenipple and dimpling of the skin,

Extensive lymphatic blockage by tumor can result in Lymphedema, causing the

breast skin to resemble an orange peal (peau d'orange)

Inflammatory carcinomas present as a markedly enlarged erythematous and

,

1/3rd of breast carcinomas present with lymph node metastases, can metastasize to

axillary, supraclavicular or internal mammary nodes (tumors ofouter quadrant -

metastasize to axillary nodes, ofinner quadrants and center to internal mammary

nodes)


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Prognostic indicators in Breast carcinomas

Tumor size; larger the tumor the worse the prognosis

Locally advanced disease; locally advanced disease (invasion into

skin or chest wall) - poor prognosis,

lymph node metastases; Lymph node metastases -most important

prognostic factor, ( no involvement, 10 year survival - 70 to 80%,if 10 are involved it is 10 to 15%);

distant metastases;

a specia su types ave a etter prognosis w en compare to NSTcancers, (tubular and colloid ca. - best prognosis),

Poorly differentiated ca. - worse prognosis;

carcinomas with hormone receptors have a slightly better prognosis

(Rx. with less toxic hormonal therapies);

Lymphovascular invasion - poor prognostic ;

involvement of dermal lymphatics (inflammatory carcinoma) poor

prognosis


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Prognostic indicators in Breast carcinomas

Tumor size; larger the tumor the worse the prognosis

Locally advanced disease; locally advanced disease (invasion into

skin or chest wall) - poor prognosis,

lymph node metastases; Lymph node metastases -most important

prognostic factor, ( no involvement, 10 year survival - 70 to 80%,if 10 are involved it is 10 to 15%);

distant metastases;

a specia su types ave a etter prognosis w en compare to NSTcancers, (tubular and colloid ca. - best prognosis),

Poorly differentiated ca. - worse prognosis;

carcinomas with hormone receptors have a slightly better prognosis

(Rx. with less toxic hormonal therapies);

Lymphovascular invasion - poor prognostic ;

involvement of dermal lymphatics (inflammatory carcinoma) poor

prognosis


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Breast carcinomas contd.

Poor prognostic indicators; - Increased angiogenesis, DNA content if abnormal,increased levels of proliferation markers, expression of Oncogenes (ex. c-erb-B2)

and loss of expression of tumor-suppressor genes, proteases

Current therapy includes -local and regional control using combinations ofsurgery (mastectomy or breast conservation - lumpectomy) and postoperative

radiation and systemic control using hormonal treatment, chemotherapy or both,

newer strategies include inhibition (by pharmacologic agents or specific antibodies)

o mem rane- oun growt receptors ex. c-er - , stroma proteases,

angiogenesis

Cytological features of malignancy Hyperchromatic nuclei dark staining, in

DNA content, N: C ratios large nucleoli, Irregular nuclear membrane, Atypical

mitosis, Pleomorphic large and small cells all mixed & not producing any

recognizable pattern


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Male breast-

Gynecomastia - enlargement of the male breast, key indicator -

imbalance between estrogens and androgens, (during puberty, in

Klinfelter's syndrome, manifestation of hormone-producing tumors -

ex. Leydig cell or Sertoli cell tumors) ; Cirrhosis; side effect of drugs(ex. marijuana, anabolic steroids, some psychoactive agents);

Histologically - proliferation of both epithelial and stromal

com onents

Carcinoma of the male breast -risk factors, prognostic factors are

similar to those of women, male breast cancer is strongly associated

with BRCA2 in some families the same histological types of breastcancer are found in men and women, because the scant amount of

surrounding breast tissue in men, carcinomas tend to invade the skin

and chest wall earlier and present at higher stages


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Carcinoma of BreastCytological features of malignancy

Hyperchromatic nuclei dark staining

in DNA content

N:C ratios largenuc eo

Irregular nuclearmembrane

Atypical mitosis

Pleomorphic large andsmall cells all mixed in

Not producing anyrecognizable pattern


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The Breast Pathology

Carcinoma of Breast

LymphangiosarcomaST syndrome

Breast cancer

Huge breast cancerMetastasis in her axilla is almost as big as thebreast cancerDied within a few days of the picture


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Gynecomastia

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Breast 2 Neoplastic