Problems of the breast

I. Anatomy

Terminal duct lobular

unit (TDLU) is the basic
functional unit of the breast

II. Benign breast lesions: Non-proliferative, hyperplasia without atypia,

hyperplasia with atypia
1. Non-proliferative
A. Simple breast cyst:
Fluid filled cyst derived from TDLU
Common in women 35 50 years old
Tx: No intervention, if pain, obstruction: needle aspiration
B. Papillary apocrine change
- Ductal epithelial cells with apocrine features
- Eosinophilic cytoplasm
2. Hyperplasia without atypia
A. Usual ductal hyperplasia
Increased number of cells within the ductal space
Cytological features of benign cells
Subsequent breast cancer risk is small. No Tx is needed
B. Intraductal papilloma : monotonous layer of papillary cells that grows from
the wall of the cyst into its lumen. They can be solitary or multiple lesions
+Solitary (single papilloma): Can frequently have bloody nipple discharge.
RR to develop breast cancer is 2.04 higher than the general population
+Multiple lesions (diffuse papillomatosis): minimum of 5 papillomas. Can
have bloody nipple discharge. RR is 3.01 higher
C. Sclerosing adenosis : lobular lesion with increased fibrous tissue
interspersed with glandular cells
Can present as a mass or suspicious finding on mammogram
No Tx is necessary
D. Radial scars: fibroelastic core with radiating duct and lobules
E. Fibroadenoma : Benign solid tumors containing glandular and fibrous
tissue
Etiology: unknown. Maybe related to the menstrual cycle. Hormone?
Commonly found in women between 15 35 years
Firm, rubbery, mobile mass with no increased risk of cancer
No excision necessary after biopsy proven fibroadenoma
3. Hyperplasia with atypia
A. Atypical ductal hyperplasia (ADH): proliferation of uniform epithelial cells
with monomorphic round nuclei , but not the entire involved duct

B. Atypical lobular hyperplasia (ALH) : monomorphic, evenly spaced cells

filling part, but not all of the involved duct
C. Both carry a substantial risk of subsequent breast cancer, RR is 5.3
Tx: Complete surgical excision
Risk prevention: yearly mammography, 2x/yr breast exam, stop HRT,
consider SERM
4. Misc benign lesions
Lipoma: mature fat cells, soft, non-tender, well-circumscribed masses
Fat necrosis: caused by breast trauma, surgery, may mimic malignancy
on imaging
Diabetic mastopathy: Breast mass in women with longstanding DM
type 1. Dense keloid like fibrosis with periductal, perivascular or lobular
lymphocytic infiltration.
Sarcoidosis: firm, hard mass mimicking carcinoma. Biopsy needed to
confirm diagnosis
III. Malignant breast lesions
1. Ductal
A. Ductal carcinoma in situ (DCIS): proliferation of malignant epithelial cells within
the ductal system, no evidence of invasion into the surrounding stroma.
Comedo type: necrosis in the center -> calcification detected on mammogram
Cribriform, micropapillary, papillary type
B. Infiltrating ductal carcinoma : Most common type of invasive breast cancer
Desmoplasia: fibrous response to nests of invasion
Divided into 3 grades: well-differentiated, moderate, poorly differentiated
Goal is complete excision of both DCIS and invasive carcinoma
2. Infiltrating lobular carcinoma : 2nd most common type of invasive breast cancer
Small cells invasion of stroma, adipose tissue individually and in
single file pattern
Minimal fibrous reaction
Usually ER-positive
More favorable prognosis, metastasize later than invasive ductal
3. Other histological types: Tubular, mucinous, medullary, invasive micropapillary,
metaplastic, adenoid cystic, tubulolobular carcinoma
4. Paget disease of the breast:
A special clinical presentation of an underlying breast adenocarcinoma
Pathogenesis: metastasize of the ducts ->invasion of epidermis
->local tissue destruction
Watch out for non-healing nipple ulcer!

IV. Mastitis
1. Non-lactational mastitis
A. Periductal mastitis
Inflammation of the subareolar ducts
Cause is unknown. Majority of patients are smokers
Can have secondary inflammation and infection
B. Idiopathic granulomatous mastitis

Unknown etiology
Biopsy shows granulomatous lesions on breast lobules
Need to send for AFB, sarcoidosis

2. Lactational mastitis

Etiology: Blocked milk duct, pressure on the breast, illness in mother/baby,

maternal malnutrition, nipple cracking
Firm, red, tender, swollen breast, fever >38.3C
Most common: Staph. Aureus, Strept Pyogenes, E.Coli
Tx with symptomatic relief, continue breast feeding, antibiotics

Educational objective

Cellular atypia greatly increase the risk of breast cancer

Most common type of invasive breast cancer is invasive ductal. Invasive
lobular are ER+
Mastitis can be non-lactational or lactation. Continue breastfeeding in
lactational mastitis.