Pathology of the Breast: Benign and Premalignant

Question 1

Benign Lesions of the Breast

Answer 1

• Fibrocystic Changes (nonproliferative)
• Proliferative Changes
• Intraductal Papilloma

Question 2

Benign Lesions of the Breast - Fibrocystic Changes (nonproliferative)

Answer 2

•include

• cysts
• apocrine metaplasia
• fibrosis
• adenosis
• THE most common breast disorder and the #1 cause for biopsy
• painful
• FCC represents a clinical problem as many as 50% of women, generally between ages 20 -45
• Etiology: Hormonal imbalance and/or abnormal end-organ sensitivity
• no increased risk of breast cancer

Question 3

Benign Lesions of the Breast - Fibrocystic Changes (nonproliferative) - Cysts abd Apocrine Metaplasia

Answer 3

Question 4

Benign Lesions of the Breast - Fibrocystic Changes (nonproliferative) - Fibrosis

Answer 4

Question 5

Benign Lesions of the Breast - Fibrocystic Changes (nonproliferative) - Adenosis

Answer 5

•Increase in the number of glands(acini) per lobule

Question 6

Benign Lesions of the Breast - Proliferative Changes

Answer 6

• Moderate or florid epithelial hyperplasia (>4 cell layers)
• Sclerosing adenosis (at least 2X normal acini in terminal duct)
• Radial scar

Question 7

Benign Lesions of the Breast - Proliferative Changes - Floral Ductal Hyperplasia

Answer 7

Question 8

Benign Lesions of the Breast - Proliferative Changes - Sclerosing Adenosis

Answer 8

• Radiologic findings

• Microcalcifications
• Area of architectural distortion
• Mass

• Histologic findings

• Lobulocentric
• Increased numbers of glands with sclerotic intralobular stroma
• Distorted, elongated &/or obliterated glands & tubules

Question 9

Benign Lesions of the Breast - Proliferative Changes - Radial Scar

Answer 9

•Radiologic findings

-Stellate or spiculated lesions with radiolucent central area

Question 10

Benign Lesions of the Breast - Proliferative Changes - Radial Scar Histologic Findings

Answer 10

• Central zone of fibroelastosis from which ducts & lobules radiate
• Benign ducts and lobules with dual cell layer

Question 11

Benign Lesions of the Breast - Intraductal Papilloma

Answer 11

• Clinical presentation: Clear or bloody nipple discharge.
• Morphology: Grows in major lactiferous ducts just deep to nipple. Composed of fibrovascular cores lined by benign epithelium.
• Significance: Rule out carcinoma
• Solitary
• Lactiferous sinuses of nipple
• 80% spontaneous unilateral nipple discharge
• <1 cm diameter
• No well defined increased RR

Question 12

Biphasic Tumors

Answer 12

The 2 breast specific biphasic tumors arise from glands and stroma of lobule.

• Fibroadenoma
• Phyllodes Tumor

Question 13

Biphasic Tumors - Fibroadenoma

Answer 13

• Most common benign tumor of female breast; can be bilateral & multiple
• Frequently <30 years, premenopausal
• Presents as palpable mobile mass in young women
• Waxes and wanes during menstrual cycle since hormonally sensitive
• Gross: Well-circumscribed, rubbery, grayish white
• Morphology: even distribution of glands and stroma. Delicate, often myxoid stroma enclosing glandular and cystic spaces lined by bilayered epithelium; stroma becomes hyalinized with aging

•Treatment: Simple excision.

-No well-defined risk of breast cancer

Question 14

Biphasic Tumors - Fibroadenoma Radiologic and Gross

Answer 14

Question 15

Biphasic Tumors - Fibroadenoma Histologic

Answer 15

Question 16

Biphasic Tumors - Phyllodes Tumor

Answer 16

• Rare tumor
• Most present in 6th decade
• Presents as Fast growing palpable mass
• Gross: Few cm to huge, bulbous protrusions and slit-like spaces (phyllodes is Greek for “leaflike”)
• Morphology: Stroma overgrows glandular component. Categorized as benign, borderline and malignant based upon: cellularity, mitotic rate and nuclear atypia, tumor margins: circumscribed or infiltrative
• Most are benign and indolent but rarely can behave aggressive with features of soft tissue sarcoma
• Treatment: Wide excision to prevent local recurrence

Question 17

Biphasic Tumors - Phyllodes Tumor Radiologic

Answer 17

• Bulky mass with rapid growth

Question 18

Gynecomastia

Answer 18

• Clinical: Unilateral or bilateral subareolar enlargement due to conditions leading to a decrease in testosterone compared to estrogen (medications, drugs, liver failure, tumors etc.)
• Morphology: Proliferation of breast ducts and stroma.
• Significance: Not associated with cancer

Question 19

Gynecomastia - Physiologic

Answer 19

• Puberty
• Senescence, with a relative ↑ in adrenal E aa androgen function from testis ↓’s

Question 20

Gynecomastia -Endocrine

Answer 20

• Klinefelter Syndrome

Question 21

Gynecomastia - Systemic

Answer 21

• Cirrhosis since liver is responsible for metabolizing E
• Chronic renal failure

Question 22

Gynecomastia - Toxicity/ Medications

Answer 22

• Alcohol
• Cannabis
• Thiazide diuretics/Sprinolactone/Cimetidine/Omeprazole/Digoxin
• Anabolic steroids

Question 23

Gynecomastia - Tumors

Answer 23

• testis
• adrenal
• pituitary

Question 24

Benign Breast Changes - Inflammatory Conditions

Answer 24

• acute mastitis
• periductal mastitis
• fat necrosis
• duct ectasia

Question 25

Benign Breast Changes - Inflammatory Conditions - Acute Mastitis

Answer 25

* Acute mastitis is essentially limited to the lactating breast. * It presents with a painful, erythematous breast, usually with fever. * Staphylococcus aureus or streptococci are the usual bacteria and are responsive to antibiotics. * Inflammatory breast cancer can mimic acute mastitis and should be suspected in any nonlactating woman with the clinical appearance of mastitis

Question 26

Benign Breast Changes - Inflammatory Conditions - Periductal Mastitis

Answer 26

* Periductal mastitis (recurrent subareolar abscess) presents as a painful erythematous subareolar mass that often recurs. * More than 90% of patients are smokers. * The morphology is duct rupture with intense chronic and granulomatous inflammation in response to spilled entrapped keratin that accumulates from keratinizing squamous epithelium extending to an abnormal depth in the nipple ducts. * Treatment is surgical although antibiotics may be indicated if there is superimposed infection.

Question 27

Benign Breast Changes - Inflammatory Conditions - Fat Necrosis

Answer 27

•Fat necrosis can present as a painless palpable mass or mammographic abnormality with calcifications that can be confused with breast cancer. May have a history of trauma.

Question 28

Benign Breast Changes - Inflammatory Conditions - Mammary Duct Ectasia

Answer 28

* Mammary duct ectasia occurs in the 5th- 6th decades, in multiparous women and presents with painful periareolar redness and induration, often with thick white nipple secretions. * It is not associated with cigarette smoking. * Treatment is surgical drainage or excision. Need to rule out carcinoma.