Pathology of the Female Breast I Quiz

Pathology of the Female Breast I

• Congenital Anomalies:
  • Amastia: Absence of one or both breasts.
  • Polymastia: Abnormal number of breasts.
  • Athelia: Absence of the nipple.
  • Polythelia: More than two nipples.

Anatomical Structures & Lesions

• Anatomical Structures:
  • Ductules/Acinus
  • Lobule
  • Terminal duct
  • Adipose tissue
  • Segmental duct
  • Lactiferous duct
  • Lactiferous sinus
  • Nipple
• Lesions:
  • Nipple adenoma
  • Paget's disease
  • Papillomas
  • Traumatic fat necrosis
  • Hyperplasia
  • Most carcinomas
  • Fibroadenoma
  • Cysts

Normal Breast Tissue

• Images of normal breast tissue are presented.

Main Clinical Presentations

• Breast pain:

  • Most breast pain has a benign cause, but ~10% of breast cancers are associated with pain.
  • Pain can be cyclic (maximal premenstrually, relieved with menses, can be unilateral or bilateral) or non-cyclic (various causes, e.g., hormonal fluctuations, benign tumors, cysts, duct ectasia and trauma).

• Nipple discharge:

  • A common complaint classified into three main groups:
    • Physiological: Usually bilateral, serous, not associated with disease
    • Galactorrhea: Bilateral milky discharge; various causes (oral contraceptives, other drugs, endocrine disorders such as prolactinoma)
    • Pathological: Unilateral, localized to a single duct, often cause by benign conditions even if blood is present. Breast cancer accounts for only 5% of cases, with a range of 3-11% of women with breast cancer having associated nipple discharge.

Mastitis

• Acute Mastitis:
  • Puerperal Mastitis:
    • Acute cellulitis (inflammation) of the breast in lactating mothers.
    • Affected area is red, warm, and tender.
    • Usually no purulent discharge (pus) from the nipple as the infection is around the duct system, not within it.
    • High fever and chills, flu-like body aches are common.
    • Staphylococcus Aureus is the most common bacteria.
  • Non-Puerperal Mastitis:
    • Commonly appears as an abscess (pus-filled cavity) that is often subareolar (under the areola) with tenderness and erythema (redness.)
    • Usually without systemic symptoms.

Chronic Mastitis

• Relatively uncommon. Possible causes include tuberculosis or non-specific conditions (following acute mastitis with marked fibrosis, potentially mistaken for cancer).

Tumour-like Lesions

• Breast Cysts:

  • Common in pre- and postmenopausal women.
  • Physical examination often cannot distinguish cysts from solid masses.
  • Imaging (ultrasound) and aspiration are often necessary for diagnosis.

• Galactocele:

  • A special cystic swelling of a lactiferous duct that occurs during lactation.
  • It follows obstruction of the duct.
  • It contains creamy (milky) fluid, which may become watery and infected.
  • May induce a granulomatous inflammatory response.

• Traumatic fat necrosis:

  • Results from injury to the fatty tissue of the breast (commonly in obese individuals in the sub-areolar region.)
  • Characterized by foam macrophages, lipid crystals, granulomatous reaction (especially foreign body giant cell reaction.), and calcification.
  • Firm, ill-defined, painless mass.

• Mammary duct ectasia:

  • Progressive dilation of large or intermediate ducts for unknown reasons.
  • Surrounding chronic granulomatous inflammatory reaction with many plasma cells and polymorphs.

• Fibrocystic changes (fibroadenosis):

  • Common, occurring predominantly in women aged 35-50, though sometimes earlier.
  • Often bilateral, multifocal, not always constant.
  • Macroscopically: Firm, ill-defined, grayish to white fibrous tissue with cysts of varying sizes .
  • Microscopically: Cysts contain yellowish serous, or brown hemorrhagic fluid. Epithelial linings of the ducts and ductules are dilated and show cystic changes, sometimes with abnormal epithelial cell changes (such as apocrine metaplasia). Fibrosis also present--fibrous proliferation of peri-ductal connective tissue which can be loose or dense.

• The true cause of fibrocystic changes is hormonal imbalance (increased estrogen and decreased progesterone). Sometimes, the epithelial hyperplasia is atypical with abnormal increase in mitotic activity. This may be a pre-malignant condition.