Breast Pathology 1 Non neoplastic disorders Soheir Mahfouz

Breast Pathology 1 Non neoplastic disorders Soheir Mahfouz P 174 - 175

BREAST LESIONS INFLAMMATORY Lecture 1 n GROWTH DISTURBANCES n A) NON NEOPLASTIC- HYPERPLASIA B) BENIGN TUMOURS Lecture 2 C) MALIGNANT TUMOURS Lecture 3

Normal breast

LECTURE 1 OUTLINE INFLAMMATION HYPERPLASIA n n n ACUTE MASTITIS & BREAST ABSCESS CHRONIC NON SPECIFIC MASTITIS CHRONIC SPECIFIC MASTITIS PLASMA CELL MASTITIS (DUCT ECTASIA) TRAUMATIC FAT NECROSIS SILICONE GRANULOMA n FIBROCYSTIC DISEASE OF THE BREAST

INFLAMMATION MASTITIS n n n ACUTE MASTITIS & BREAST ABSCESS: usually due to lactation with stasis of milk in abnormally dilated ducts, predisposing to infection. This condition also causes frequent fissuring of the nipple, 2 ry infection & abscess formation CHRONIC NON SPECIFIC MASTITIS: follows acute associated with healing by fibrosis CHRONIC SPECIFIC MASTITIS: TB, syphilis

ACUTE MASTITIS & BREAST ABSCESS: Acute mastitis due to milk stasis is non pyogenic at first but after fissuring of the nipple, 2 ry infection with suppuration & localization i. e. abscess formation occurs n Breast abscess Usually due to lactation with stasis of milk in abnormally dilated ducts, predisposing to pyogenic infection. Acute suppurative inflammation of the breast Organisms: Staph aureus Predisposing Factors: 1. Bad breast hygiene 2. Fissures of the nipple 3. Milk stagnation n

ACUTE MASTITIS & BREAST ABSCESS Pathology n Starts as an acute diffuse inflammation n Breast is swollen (edematous) congested & PAINFUL n When localization occurs we get an abscess (intramammarypremammary or retromammary) n If pus isn't evacuated Chronic abscess

INFLAMMATION MASTITIS n DUCT ECTASIA (PLASMA CELL MASTITIS ): Chronic inflammation with plasma cells (periductal*/granulomatous mastitis) around dilated ducts containing dense secretions. Produces granulomas when ducts release material into tissues,

DUCT ECTASIA (PLASMA CELL MASTITIS) Chronic inflammation with Lymphocytes, plasma cells & macrophages +/- Pnls (periductal mastitis) around dilated ducts containing dense secretions. n Etiology: ? But elevated prolactin levels play a role n 5 th-6 th decades n

DUCT ECTASIA (PLASMA CELL MASTITIS ): GROSS n Firm tender greyish white mass n CS: dilated ducts filled with cheesy material MICROSCOPIC n Granulomatous reaction around dilated ducts n * Plasma cells + lymphocytes, Foamy histiocytes +/- giant cells Pnls n Fibrotic duct wall

INFLAMMATION MASTITIS n n TRAUMATIC FAT NECROSIS is a condition in which painless, round, firm lumps caused by damaged and disintegrating fatty tissues form in the breast tissue. Believed to be due to breast trauma. It occurs in obese pts with pendulous breasts and produces a granuloma which mimics carcinoma SILICONE GRANULOMA: Granulomatous inflammation (describe foreign body granuloma occurring in leaking silicone breast implants

Traumatic fat necrosis n irregular breast mass composed of inflammatory cells with necrosis of fat & many giant cells (may be confused with a malignant mass)

NON NEOPLASTIC hyperplasia of the breast FIBROCYSTIC DISEASE OF THE BREAST (FIBROCYSTIC CHANGE / CYSTIC MASTOPATHY) A breast change suggestive of physiologic variations, reaching their maximum during the late reproductive period, persisting in postmenopause ETIOLOGY: n Exaggeration of menstrual cycle n High levels of estrogens n ? Pituitary tumors affecting ovary

FIBROCYSTIC DISEASE GROSS Single, multiple even bilateral masses & variable in size Ill-defined masses, firm in consistency showing cysts on cut section white in color

FC gross

FIBROCYSTIC DISEASE Microscopic Epithelial hyperplasia (lobular & ductal) n Adenosis + number of glands & size of lobules n Epitheliosis: Large number of cells lining the acini (lobular hyperplasia) – ducts & papillae

FC papillae & Apocrine metaplasia

FIBROCYSTIC DISEASE Microscopic Apocrine metaplasia: metaplastic changes of cubical cells to tall columnar large cells with abundant pink cytoplasm & decapitation of their tips (similar to those in sweat glands) Cyst -Duct obstruction by secretion / epitheliosis -papillae → retention of secretions & cysts -Lining cells of these cysts may be: Cubical flat from pressure /metaplastic : apocrine cyst

FIBROCYSTIC DISEASE Microscopic Periductal fibrosis Broad areas of hypocellular FTcontain clusters of dilated ducts. Most of the lobules have disappeared. Commonly the result of ruptured cysts irritation in the surrounding tissue Inflammation

FIBROCYSTIC DISEASE Variants PROLIFERATIVE BREAST DISEASE (review NEJM 353: 229, 2005) Three entities have been removed from the "fibrocystic disease" category because they confer a significant cancer risk (i. e. , mutations have begun accumulating). They are: 1. Epithelial hyperplasia (epitheliosis) ductal/ lobular Typical: Totally benign-looking florid (marked) hyperplasias Atypical : hyperplasias 2. Sclerosing adenosis 3. Small duct papillomas

a) typical ACINAR EXPANSION a) Totally benign-looking hyperplasias

FIBROCYSTIC DISEASE Variants & Complications Typical hyperplasia florid epitheliosis 2 X Atypical hyperplasia 5 X

FIBROCYSTIC DISEASE Variants SCLEROSING ADENOSIS Adenosis + fibrous tissue leading to distortion & compression of the ductules. The appearance is that of small distorted glands in a FT rich stroma giving the appearance of malignant invasion, which may be mistaken for malignancy But there is preservation of lobular architecture and persistent myoepithelial cells

Small duct papillomas n n These small papillomas are usually clinically silent and are probably etiologically distinct from the large duct papillomas associated with nipple discharge discussed later. . . fibrovascular cores extend into small duct lumens and are lined by a normal two cell layer. . .

FIBROCYSTIC DISEASE CHANGES ASSOCIATED WITH CARCINOMA Changes not associated with high risk 1. 2. 3. 4. 5. Fibrosis Cyst formation Inflammation Mild ductal/lobular hyperplasia Apocrine metaplasia Changes associated with high risk Now called proliferative Breast disease 1. Epithelial hyperplasia Typical: Totally benignlooking florid (marked) hyperplasias Atypical : hyperplasias 2. Sclerosing adenosis 3. Small duct papillomas

LECTURE 1 OUTLINE INFLAMMATION HYPERPLASIA n n n ACUTE MASTITIS & BREAST ABSCESS CHRONIC NON SPECIFIC MASTITIS CHRONIC SPECIFIC MASTITIS PLASMA CELL MASTITIS (DUCT ECTASIA) TRAUMATIC FAT NECROSIS SILICONE GRANULOMA n FIBROCYSTIC DISEASE OF THE BREAST

Resources n n n n n BOOKS & Lecture notes � Textbook : Basic Pathology by Kumar, Cotran & Robbins � General & systemic pathology J. C. E Underwood 3 d edition Livingstone� Gamal Nada's General Pathology � Gamal Nada's General Museum of Pathology � Soheir Mahfouz's Guidlelines in General Pathology WEBSITES Important web sites from which many images or text were taken. NB. Those not mentioned may be found on web searches: google , Yahoo & ask. com http: //www. pathmax. com/ http: //www-medlib. med. utah. edu/Web. Path/LABS/LABMENU. html#2 http: //www. med. uiuc. edu/Path. Atlasf/title. Page. html http: //www. medscape. com/pathologyhome http: //www. gwumc. edu/dept/path/2 F. HTM http: //ampat. amu. edu. pl/czasopis/contents. htm http: //www. urmc. rochester. edu/smd/pathres/long. html http: //www. medscape. com/pathology/cme

Resources n n n n n http: //www. mic. ki. se/Diseases/C 23. html http: //dir. yahoo. com/Health/medicine/pathology/ http: //www. iaphomepage. org/ http: //search. msn. com/results. aspx? q=Pathology+lectures+on+line&FORM=QBRE 2 http: //dpalm. med. uth. tmc. edu/faculty/bios/hunter/pathlinks. htm http: //www. pathmax. com/main. html http: //www. pathguy. com http: //www. emedicine. com/oncology/ http: //www. thedoctorsdoctor. com/diseases/liposarcoma. htm#histo http: //www. humpath. com/article. php 3? id_article=3532 http: //www. ec. upstate. edu/path/ http: //peir. net/ http: //medstat. med. utah. edu/Web. Path/webpath. html ATLAS http: //www. emedicine. com/asp/image_search. asp? query=actinomycosis&offset=12 http: //erl. pathology. iupui. edu/C 604/INDEX. HTM http: //www. path. uiowa. edu/virtualslidebox/

Resources n n n http: //www. mic. ki. se/MEDIMAGES. html#G 02. 403. 776. 600 http: //www. palms. med. usyd. edu. au/pathology_museum/ http: //www. med. uiuc. edu/Path. Atlasf/title. Page. html http: //images. google. com/imgres? imgurl=http: //www. images. md/intermedia/imgagen t/mediaget/getwatermarked/ACNCR 01 -09 -55001&imgrefurl=http: //www. images. md/users/explore_chapter. asp%3 FID%3 DACNC R 01 -09 -55%26 col. ID%3 DACNCR 0109%26 coltitle%3 DBreast%2 BCancer&h=80&w=120&sz=11&tbnid=EZu 7 ub. DWDd. UUI M: &tbnh=55&tbnw=83&hl=en&start=67&prev=/images%3 Fq%3 DFine%2 BNeedle%2 B Aspiration%2 Bof%2 BBreast%26 start%3 D 60%26 svnum%3 D 10%26 hl%3 Den%26 lr%3 D%26 sa%3 DN http: //images. google. com/imgres? imgurl=http: //www. hopkinsbreastcenter. org/path ology/benign/1 j. jpg&imgrefurl=http: //www. hopkinsbreastcenter. org/library/educati onal_information/benign. shtml&h=380&w=492&sz=289&tbnid=NTEc. MCp 3 m. Ru. Zb. M: & tbnh=98&tbnw=127&hl=en&start=1&prev=/images%3 Fq%3 DFine%2 BNeedle%2 BAspi ration%2 Bof%2 BBreast%26 svnum%3 D 10%26 hl%3 Den%26 lr%3 D http: //images. google. com/imgres? imgurl=http: //www. webpathology. com/slides/thum bnails/Testes_Sex. Cord_Granulosa. Cell. Tumor 2 TN. jpg&imgrefurl=http: //www. webpat hology. com/case. cfm%3 Fcase%3 D 38&h=76&w=101&sz=6&tbnid=yup 1 zv. PUIS 1 u 3 M: &t bnh=58&tbnw=78&hl=en&start=21&prev=/images%3 Fq%3 Dgranulosa%2 Bcell%2 Btum our%2 Bovary%26 start%3 D 20%26 svnum%3 D 10%26 hl%3 Den%26 lr%3 D%26 sa%3 DN

Resources n n n http: //screening. iarc. fr/index. php http: //web. med. unsw. edu. au/pathology/Pathmus/pathmus. htm#Interactive. Images http: //www. hopkinsbreastcenter. org/library/educational_information/benign. shtml http: //eulep. anat. cam. ac. uk/Search_Pathbase/index. php? actiontype=search&mpath= http: //www. diesis. com/fabrizio/atlas/ n n Dermatopath http: //www. derm. ubc. ca/pathology/micrneurann. htm http: //tray. dermatology. uiowa. edu/DPTutor. htm n n n Reproductive http: //images. google. com/imgres? imgurl=http: //www. path. sunysb. edu/coursemat/re proimages/thumbs/4 thumb. jpg&imgrefurl=http: //www. path. sunysb. edu/coursemat/r eproslides. htm&h=86&w=120&sz=5&tbnid=a. VSQELIji. Wf. BAM: &tbnh=59&tbnw=83&h l=en&start=25&prev=/images%3 Fq%3 Dgranulosa%2 Bcell%2 Btumour%2 Bovary%26 st art%3 D 20%26 svnum%3 D 10%26 hl%3 Den%26 lr%3 D%26 sa%3 DN Respiratory http: //iris. nyit. edu/~edoran/Course/Resp 1 lect 01. htm#NORMAL%20 ANATOMY%20 LUNGS