乳房病病理学

DISEASESOFTHEBREASTLectureObjectivesAttheendofthelecturethestudentshouldbeableto:1.Discusstheetiology/pathologicfeaturesofdifferentformsofbenignnon-neoplasticandneoplasticbreastdisease.2.Listthebenignbreastdiseasesthatincreaseapatient’sriskofdevelopingbreastcancerandclassifytheseconditionsbythedegreeofrisk.LectureObjectivesAttheendofthelecturethestudentshouldbeableto:3.Outlineotherriskfactorspredisposingtobreastcancer&incidence/prevalenceofbreastcancer.4.Classifybreastcancerintohistologicsubtypesanddescribethepathologicfeaturesofeach.5.Listtheprognosticfactorsforbreastcancer.CLINICALPRESENTATIONPalpablelumpInflammatorymassNippledischargeNon-palpableabnormalityMETHODSOFDIAGNOSISFNACIncisionalbiopsyExcisionalbiopsyImage-guidedbiopsyJamaicanBreastDiseaseStudy2000-2ClinicalFindings5%15%80%MalignantUncertainBenignBENIGNBREASTDISEASEINFLAMMATIONAcuteMastitisMostclinicallyimportantformofmastitisBreast-feedingcracks/fissuresinthenipplesbacterialinfection(esp.Staph.aureus)INFLAMMATIONAcuteMastitisUsuallyunilateral—acuteinflammationinthebreastcanleadtoabscessformationTreatment=surgicaldrainage(oftenundergeneralanesthesia)andantibioticsINFLAMMATIONMammaryDuctEctasia5thand6thdecadesAffectsmainlylargeductsPeriductalchronicinflammationdestructionanddilationoftheductswithfibrosisTheunderlyingcauseisunknownINFLAMMATIONMammaryDuctEctasiaPoorlydefinedperiareolarmass;canbeconfusedclinically/radiologicallywithcarcinomaCanalsopresentasathick,cheesynippledischarge+/-massPeriductalfibrosisskinretractionINFLAMMATIONFatNecrosisUncommonlesion;maybeahistoryoftrauma,priorsurgicalinterventionorradiationtherapyCharacterizedbyacentralfocusofnecroticfatcellswithlipid-ladenmacrophagesandneutrophilsINFLAMMATIONFatNecrosisChronicinflammationwithlymphsandmultinucleatedgiantcellsMajorclinicalsignificanceisitspossibleconfusionwithcarcinoma(e.g.fibrosisclinicallypalpablemass/Ca2+seenonmammography)NON-PROLIFERATIVE(“FIBROCYSTIC”)CHANGESMostcommonbreastdisorderAlterationspresentinmostwomenNoassociatedriskofprogressionorcancer?DuetohormonalimbalancesNON-PROLIFERATIVE(“FIBROCYSTIC”)CHANGESPathologicfeatures:CysticchangeApocrinemetaplasiaAdenosisFibrosisNON-PROLIFERATIVE(“FIBROCYSTIC”)CHANGESUsuallydiagnosed20to40yearsPresentaspalpablelumps,nippledischargeormammographicdensities/calcificationsOftenmultifocalandbilateralgeneral“lumpiness”PROLIFERATIVEDISEASEWITHOUTATYPIAEpithelialHyperplasianumberoflayersofcellsliningductsandaciniInvolvedductsandaciniarefilledwithoverlapping,proliferatingcellsPROLIFERATIVEDISEASEWITHOUTATYPIASclerosingAdenosisCharacterizedby#acini+stromalfibrosiswithinlobulesCanbeassocwithcalcificationswhichmaybedetectedonmammographyATYPICALHYPERPLASIAEpithelialhyperplasiacharacterizedatypicalarchitecturaland/orcytologicfeaturesCanaffectducts—atypicalductalhyperplasia,orlobules—atypicallobularhyperplasiaATYPICALHYPERPLASIAAtypicalfeaturesresemblebutfallshortofin-situcancerNodiagnosticclinicalorradiologicfeaturesIncidencewithuseofscreeningmammographyandnumberofbreastbiopsiesBENIGNTUMOURSFibroadenomaMostcommonbenigntumourCircumscribedlesioncomposedofbothproliferatingglandularandstromalelementsBENIGNTUMOURSFibroadenomaPatientsusuallypresent30yearsClassicpresentationisthatofafirm,mobilelump(“breastmouse”)Giantformscanoccur,especiallyinyoungerpatientsBENIGNTUMOURSFibroadenomaCanbeassociatedwithproliferativechangesintheadjacentbreasttissueApprox.20%oflesionsarecomplexfibroadenomas—characterizedbycertainspecifichistologicfeaturesBENIGNTUMOURSDuctPapillomaBenignpapillaryepithelialtumour;occursmainlyinlargeductsPapillaearefibrovascularstalkslinedbylayersofproliferatingepithelialandmyoepithelialcellsMostpatientspresentwithaserousorbloodynippledischargeRELATIVERISKFORINVASIVEBREASTCANCERFORBENIGNBREASTLESIONSRISKFORINVASIVEBREASTCANCERvNoIncreasedRisk(NIR)MastitisFatnecrosisMammaryductectasiaNon-proliferative(“fibrocystic”)diseaseFibroadenoma(simple)RISKFORINVASIVEBREASTCANCERvSlightlyRisk(SIR)=Risk1.5-2TimesModerate/floridhyperplasiaSclerosingadenosisFibroadenoma(complex)DuctpapillomaRISKFORINVASIVEBREASTCANCERvModeratelyRisk(MIR)=Risk4-5TimesAtypicalductalhyperplasiaAtypicallobularhyperplasiaJamaicanBreastDiseaseStudy2000-2BiopsyResults(46.1%patients)10%66%24%[NB.10%Allpatients]MalignantSIR/MIRNIRCARCINOMAOFTHEBREASTEPIDEMIOLOGYCommonestmalignancyinwomenworldwide:Breastcancer18%Cervicalcancer15%Coloniccancer9%Stomachcancer8%EPIDEMIOLOGYIncidenceratesarehighestinNorthAmerica,AustraliaandWesternEurope;intermediateinSouthAmerica,theCaribbeanandEasternEuropeandlowestinChina,JapanandIndiaMostcommoninvasivetumourofJamaicanwomenRISKFACTORSAgeIncidenceofbreastcancerseswithageUncommonbeforeage25years;incidencesestothetimeofmenopauseandthenslowsRISKFACTORSFamilyHistoryApprox10%ofbreastcancerisduetoinheritedgeneticpredispositionAwomanwhosemotherorsisterhashadbreastcancerisatrelativerisk2to3timescomparedtootherwomenRISKFACTORSFamilyHistoryAtleast