Malignant Breast Diseases

Breast Cancer

• Most common site-specific cancer in women• Leading cause of death from cancer 20-59

years• Primary Breast Cancer– 80% productive fibrosis that involves epithelial

and stromal tissue– Skin retraction – shortening of Cooper’s

suspensory ligaments – Ulceration – invasion of the skin

Metastasis

• Axillary Lymph Node Metastasis– Via lymphatics– Level 1 (low) > level II (apical) > Level III (axillary)– Axillary LN status – most important prognostic

correlate of disease free and overall survival• Distant Metastasis– Neovascularization– Batson’s plexus of veins or axillary and intercostal

veins– Bone>lung>pleura>soft tissue>liver

Carcinoma In Situ

• Does not invade basement membrane

Lobular CIS

• Lobular CIS– Usually incidental finding– (-) calcification– Younger women– Histo

• Distention and distortion terminal duct lobular units• Cytoplasmic mucoid globules

– Almost always ER and PR (+)– Higher propensity to be bilateral– Sx: (B) prophylactic mastectomy, tamoxifen

Ductal CIS

• Ductal CIS– 15-30%– Mammogram calcification

• Papillary growth pattern• Cribiform growth pattern• Solid growth pattern• Comedo growth pattern

– Anatomic precursor of invasive ductal CA– 5x increase for invasive breast CA– Mastectomy – curative in 95% but BCT is SOC

BRCA1 vs BRCA 2

• BRCA1– Only females– Poorer differentiation– Aggressive clinical

course– Do not express hormone

receptors – Over expression of Her 2

ne

• BRCA2– Both males and females– Poor differentiation– ER (+)

Invasive Breast CA

• Paget’s Disease of the Nipple• Invasive Ductal Carcinoma– Adenocarcinoma with productive fibrosis 80%– Medullary carcinoma– Muinous carcinoma– Papillary carcinoma– Tubular carcinoma

• Invasive Lobular Carcinoma• Rare cancers (adenoid cyst, squamous cell,

apocrine)

Paget’s Disease of the Nipple

• Unilateral chronic eczematous eruption• Ulcerated weeping lesion• Associated with extensive DCIS• Pathognomonic sign: large vacuolated cells

(Paget Cells) in the Rete pegs of the epithelium

• Sx: lumpectomy, mastectomy, MRM

Invasive Ductal CA

• Most common• Poorest prognosis

IDC: Adenocarcinoma with productive fibrosis

• 60% of axillary lymph node metastasis• Perimenopausal/postmenopausal – 5th to 6th

decades• Solitary firm mass, poorly defined margins• Central satellite configuration with chalky

white or yellow streaks

IDC: Medullary Carcinoma

• BRCA1• Soft and hemorrhagic• Rapid increase in size -> necrosis and

hemorrhage• Bulk, well circumscribed and often positioned

deep within the breast• 50% are associated with DCIS

IDC: Mucinous Carcinoma

• Elderly • Bulky tumor• Histo– Extracellular pools of mucin, which surround aggregates of

low grade cancer cells– Glistening and gelatinous

• 66% have hormone receptors• 33% have lymph node mets• 5 year survival – 73%• 10 year survival – 59%

IDC: Papillary Carcinoma

• 7th decade of life• Small <3cm• With papillae with fibrovascular stalks and

multilayered epithelium

IDC: Tubular Carcinoma

• Perimenopausal or early menopausal• Histo:– Haphazard array of small randomly arranged

tubular elements• Distant metastases are rare• Only 10% have lymph node metastases

Histologic grading system for Invasive Breast CA

Invasive Lobular Carcinoma

• 2nd most frequent type (5-10%)• Replaces the entire breast with poorly define

mass• Multifocal, multicentric, bilateral• Hallmark– single file pattern• Bone mets more common (mets to

leptomeninges, peritoneum, GI tract and reproductive organs)

Phyllodes Tumors

• Benign, borderline, malignant• Sharply demarcated• Bulk is connective tissue with mixed

gelatinous, solid and cystic areas• Cut surface: leaf life appearance• Rare axillary LN mets

Inflammatory Breast CA

• Stage IIIB• Skin changes:– Brawny induration, erythema with a raised edge

and edema (peau d’orange)• Frequent distant mets