Breast Tumors (PDF)

Tumors of the female breast BY DR. HUSAMELDIN OMER. M. OMER  Benign Epithelial tumors of the breast 1) Fibroadenoma: It can be described as focal areas of lobular hyperplasia rather than true neoplasm. Hyperplasia involves both epithelial and connective tissues...

Tumors of the female breast BY DR. HUSAMELDIN OMER. M. OMER  Benign Epithelial tumors of the breast 1) Fibroadenoma: It can be described as focal areas of lobular hyperplasia rather than true neoplasm. Hyperplasia involves both epithelial and connective tissues. Fibroadenoma may present at any age after puberty but are most common in young women. It present as small (often less than 3 cm), firm, whitish, well defined, highly mobile lump. Occasionally it may be multiple smooth surface , and it easily enucleated at surgery, it is not truly encapsulated (pseudocapsule).  Microscopically there is either a pericanalicular pattern consists of small hyperplastic ducts/ductules surrounded by reactive loose myxomatous stroma or intracanalicular pattern with higher proliferation (hyperplasia) in connective tissue element comparing to the epithelial elements (ducts/ductules) and so the last epithelial components looked compressed by the surround stroma. Fibroadenomas are completely benign with pseudo capsule of compressed fibrous tissue and they usually have no tendency to malignant changes. MULTIPLE FIBROADENOMAS (gross section)  Fibroadenoma microscopic pattern. Pericanalicular pattern Intracanalicular pattern 2) Duct papilloma: Are considerably less common than fibroadenomas. They more frequently arise in middle aged women. They are the commonest cause of nipple discharge and this discharge is often stained with blood. A mass can often be felt. Duct papilloma is usually a solitary lesion arises within a large duct from its lining epithelium. Solitary duct papillomas are not premalignant and often less than 3 CM in diameter. However rarely multiple ductal papillomas occur. These tend to occur in a younger age group and they show tendency for malignant change. INTRADUCT PAPILLOMA 3) Adenomas: Are much rarer than fibroadenomas and duct papillomas. There are three subtypes a) Tubular adenomas: They are well circumscribed tumors between 10 and 40 mm in diameter, occurring mainly in women in their early twenties. They are most commonly but not exclusively located at the upper outer quadrant of the breast They are composed of closely packed, uniform tubular structures with little stromal tissue in between. b) Lactating adenomas: Are originally tubular adenomas which undergo secretary changes during pregnancy. Tubular and lactating adenomas Tubular adenoma Lactating adenoma  c) Nipple adenomas: Occur as a small nodule under the nipple, usually less than 15 mm in diameter. They affect women of any age. They consist of a haphazardly arranged mass of proliferating elongated tubular structures composed of epithelial and myoepithelial cells with varying amounts of fibrous stroma of cells and surrounded with dense stroma. The overlying skin is often ulcerated and there may be a blood stained discharge, so this tumor may be mistaken for Paget`s disease. Nipple adenoma  Malignant epithelial tumors of the breast Mammary carcinoma is the commonest type of malignancy in women worldwide The classification of mammary carcinomas A-Carcinomas arising within or from the ducts I) Intraduct (in situ) carcinoma II) Infiltrating duct carcinoma which is either: a) Infiltrating duct carcinoma not other -wise specified (NOS) b) Medullary mammary carcinoma  c) Mucoid (colloid) mammary carcinoma d) Tubular mammary carcinoma e) Papillary mammary carcinoma f) Paget`s disease of the breast B) Carcinomas from the lobules I) Lobular carcinoma in situ II) Infiltrating lobular carcinoma Intra duct carcinoma: A rare slowly growing small hard mass that usually causes bloody or serous nipple discharge. The lumens of the large or medium sized mammary ducts are filled with masses of polyhydral malignant cells. There is no infiltration of basement membrane of the ducts. Prognosis is good so long as the tumor cells do not infiltrate the basement membrane INTRA-DUCT CARCINOMA  Infiltrating duct carcinoma (NOS) Is the commonest type forming up to 75% of all mammary carcinomas. The tumor more commonly arises in the upper outer quadrant of the breast. Appears as a hard mass with ill-defined border. The size of the tumor varies between patients. Tumor can occur in both pre and post- menopausal women. The tumor usually gives a gritty sensation during cutting due to the presence of excess reactive fibrous stroma (hence it named, scirrhous carcinoma). The nipple is retracted due the excess reactive fibrous stroma. The skin covering the tumor simulates the peel of an orange “peau d’orange”. This is due to blockage of the superficial lymphatics by the malignant cells with the following oedema which raises the skin except at the point of attachment to the sweat and sebaceous glands. Later the tumor becomes fixed to the skin and the underlying deep fascia and pectoralis muscles. Microscopically small groups or cords of malignant large rounded or polygonal cells are seen separated by abundant fibrous stroma. The nuclear cytoplasmic ratio is high and the nuclei are hyperchromatic. The mitoses are frequent.  Mammary carcinoma ulceration +involvement of axillary lymph nodes Mammary carcinoma + nipple retraction Mammary carcinoma + peau d’orange and nipple retraction Invasive duct carcinoma Medullary carcinomas: account for approximately 3% of invasive carcinomas. They are well defined and soft, measuring between 10 and 40 mm in diameter. Mixed with excess lymphocytes and has relatively good prognosis Tubular carcinomas: rare tumors amounting to about 2% of invasive carcinomas. They are small (usually less than 1cm in diameter), and firm. These tumors tend to be of low-grade malignancy Medullary and tubular carcinomas Medullary carcinoma Tubular carcinoma Mucoid (colloid) carcinomas: are rare (less than 1% of invasive carcinomas). Characteristically they have a well defined gelatinous gross appearance. Histologically the tumor composed of clumps of small, regular malignant cells Papillary breast cancer is very rare that only accounts for fewer than 1% of all breast cancers. It consists of finger like projections.  Mucoid and papillary breast carcinomas Mucoid carcinoma papillary carcinoma Paget`s disease of the breast: is always accompanied by an underlying ductal carcinoma in situ. This extends along major ducts as far as the nipple, then groups of malignant cells enter the deeper layer of the epidermis and spread within it. The affected skin of the nipple and areola shows reactive inflammatory changes in the dermis like itching, redness and sometimes superficial small ulcers. Paget’s disease of the breast Lobular mammary carcinomas Lobular carcinoma in situ: is much less common than ductal carcinoma in situ and is usually an incidental finding Infiltrating lobular carcinoma: account for about 10% of all invasive carcinomas. Microscopically this tumor is composed of small, regular epithelial cells with infrequent mitoses. Classically the relatively small malignant cells infiltrate as strands or linear cords that consist only of one cell in width and separated by fine collagen bands. This pattern is called targetoid or (Indian file) pattern. The tumor is often multicentric and sometimes it is bilateral. Prognosis is better than invasive duct carcinoma. Intralobular carcinoma Invasive lobular carcinoma targetoid or (Indian file) pattern The risk factors of mammary carcinoma include these ❖ Risk increases with age. ❖ Long interval between menarche and menopause. ❖ Older age at first full-term pregnancy ❖ Obesity and high fat diet. ❖ Genetic factors and family history of breast cancer. ❖ Geographic and environmental factors. ❖ Atypical hyperplasia in previous breast biopsy. ❖ Multiple ductal papillomas  Non epithelial breast tumors Phyllodes tumor (giant Fibroadenoma) : These tumors are uncommon and occur predominantly after the age of 40. Their diameter is usually more than 5 CM. Under the microscope the epithelial component characterized by proliferation of the ducts forming leaf-like structures. The stroma either to be benign, resembling that of fibroadenoma, or occasionally shows malignant features with sarcomatous pattern and abundant mitotic activity. Other stromal benign breast tumors like lipomas Other malignant tumors like sarcomas or lymphomas. Phyllodes tumor  Spread of mammary malignant tumors 1) Direct local spread: To skin (which may be ulcerated), deep fascia, pectoral muscles, ribs and pleura and then it will be highly fixed 2) Lymphatic spread (metastasis): To the axillary, internal mammary, mediastinal and supraclavicular lymph nodes. Lymphatic permeation may form small malignant nodules under the skin. 3) Blood spread (metastasis): To the lungs, bones, brain, liver and adrenals