Pathology of the Female Breast I PDF

Pathology of the female reast I BY DR. HUSAMELDIN OMER  Congenital anomalies Amastia: congenital absence of one or both breasts. Polymastia: abnormal number of breasts. Athelia: absence of the nipple. Polythelia: more than two nipples. Anatomical structures &...

Pathology of the female reast I BY DR. HUSAMELDIN OMER  Congenital anomalies Amastia: congenital absence of one or both breasts. Polymastia: abnormal number of breasts. Athelia: absence of the nipple. Polythelia: more than two nipples. Anatomical structures & lesions Normal breast tissue  Main clinical presentations A) Breast pain: Although the vast majority of patients with pain have a benign etiology, up to 10% of patients with cancer have associated pain. Breast pain can be either cyclic or noncyclic. Cyclic pain usually is maximal pre- menstrually and relieved with the onset of menses. It either unilateral or bilateral. Noncyclic pain have various causes, including hormonal fluctuations, firm adenomas, macrocysts, duct ectasia and trauma. B) Nipple discharge: It is a common presenting complaint. It is divided into three main groups 1- Physiological discharge: This is usually bilateral and serous in nature. Not associated with underlying disease 2-Galactorrhea discharge: Is also bilateral, but with a milky character. Galactorrhea may have a variety of causes including prolong usage of oral contraceptives, certain other drugs and endocrine diseases e.g. prolactinoma 3- pathologic discharge: Unlike the previous two types, this discharge is unilateral and localized to a single duct Commonly the pathologic discharge is caused by benign breast diseases even if it contains blood. However any patient with an associated mamographic abnormality or palpable mass should be biopsied. Breast carcinoma accounts for only 5% of pathologic discharge, and 3% to 11% of women with breast cancer have an associate nipple discharge. causes include papilloma, duct ectasia, and fibrocystic changes C)Mastitis: acute mastitis 1- Puerperal mastitis: an acute cellulitis of the breast in a lactating mother. The affected tissue is red, warm and very tender. Usually there is no purulent discharge from the nipple because the infection is around rather than within the duct system. High fevers and chills as well as flulike body ache is common. Staphylococcus aureus is the most common organism. If it is not treated urgently, an abscess may be formed 2- Non puerperal mastitis: usually appears as an abscess which is often sub- areolar with an area of tenderness and erythema. Usually no systematic symptoms Chronic mastitis: not common. Either specific e.g. of tuberculosis or non specific following acute mastitis with marked fibrosis, so it may be mistaken for cancer. D) Tumor like lesions: 1- Breast cysts: can be found in pre- or post menopausal women. Physical examination often can not distinguish cysts from solid masses. Ultrasound and cyst aspiration for cytology can be diagnostic. Galactocele Is special cystic swelling of a lactiferous duct which develops during lactation. It follows obstruction of that duct. It contains creamy (milky) fluid which gradually becomes watery. It may become infected or it may induce a granulomatous inflammatory reaction Large Breast galactocele 2- Traumatic fat necrosis: This lesion is caused by injury in the fatty tissue of an obese breast. It occurs more commonly in the sub-areolar region. The lesion becomes heavily infiltrated by foamy macrophages. Crystal of lipid may be deposited and stimulate a granulomatous foreign body giant cell reaction. Calcification may also be found. The lesion presents as a firm, ill defined, painless BREAST FAT NECROSIS poorly mobile with associated nipple retraction so it sometimes needs considered efforts to be differentiated from mammary carcinoma 3-Mammary duct ectasia: Consists of progressive dilatation of large or intermed- iate duct for unknown reason. There is a surrounding chronic granulomatous inflammatory reaction with large number of plasma cells and polymorphs. The dilated. Duct-ectasia ducts contain cheese like fatty material and they are rich in foam macrophages. This disease is often symptomless but nipple discharge may be a feature. Nipple retraction sometimes presence and raises a suspicion of breast carcinoma. 4-Fibrocystic changes (fibroadenosis) A common breast lesion. It occurs mainly in women between the age of 35 and 50 years. However it occurs in a considered percentage of women younger than age 21 years. The lesion is often bilateral and multifocal but this is not a constant rule. Macroscopically the lesion consists of firm, ill defined, grayish to white fibrous tissue with cysts of different sizes. The cysts contain yellowish serous, or brown haemorrhagic fluid. Microscopically the lesion characterizes with epithelial, glandular and fibrous hyperplasia and it shows the following criteria a- Adenosis: Formation of many new small ducts that seen as variable sized glandular structures. b- Epitheliosis: There will be hyperplasia in the epithelium lining of the ducts and it forms papillary processes or small solid areas of epithelial cells. c- Cyst formation: The ducts and ductules dilated and show cystic changes. These cysts are distended with serous fluid. The lining cells may change into columnar cells with a convex free margin and strongly eosinophilic cytoplsm. This metaplastic change is called apocrine metaplasia. d- Fibrosis: Increase proliferation of the peri-ductal fibrous connective tissue it may be loose or dense. Fibrocystic disease of the breast Fibrocystic disease of the breast The true etiology of fibrocystic change is not definite but it is assumed to be caused by a hormonal imbalance in the form of increased oestrogen and decrease progesterone with the following breast tissue hyperplasia. Sometimes the epithelial hyperplasia is atypical with abnormal increase in mitotic activity and abnormal increase in lining layers. This is considered as a pre – malignant condition. FIBROCYSTIC DISEASE OF THE BREAST with epitheliosis &atypical epithelial hyperplasia