Pathology Of Breast Carcinoma

“Strength does not come from winning. Struggles & Hardship develop your strength. When you go through hardship and decide not to surrender, that is strength” Arnold Schwarzenegger Bodybuilder and Actor

Pathology of Breast Cancer Dr. Venkatesh M. Shashidhar Senior Lecturer in Pathology Fiji School of Medicine

Introduction Modified sweat glands.  Lobes and lobules of gland  in fat tissue stroma.  Ducts emerge from acini of glands  Smaller ducts join to form lactiferous ducts  Lactiferous ducts merge just beneath the nipple to form a lactiferous sinus.  Then individually open on nipple 

Normal Breast

Myoepithelial Cells (ipx)

Disorders 

Congenital 



Inflammatory   



Aplasia – turners, Juvenile hypertrophy Infections acute/chronic – Trauma Fat necrosis Duct ectasia discharge, sinus Fibrocystic disease – common – painful lumps

Neoplastic  

Benign - Fibroadenoma Malignant – Ca

Fibrocystic Disease      

Fibroadenosis, Fibrocystic change, etc. Commonest lump, 10-50% women ? Hormonal Periodic discomfort – pain. Eipethilial hyperplasia – premalignant Irregular palpable lumps – mimic ca. 

Adenosis – hyperplasia - cysts – papillomatosis – metaplasia – fibrosis.

Benign Neoplasms:  Fibroadenoma  Duct Papilloma  Adenoma  Connective tissue tumors  Features (Fibroadenoma) Young age 3rd decade.  Single, rounded, mobile, painless lumps.  No scarring or calcification.  Slit like glands in Fibrous stroma

Breast Carcinoma 



   



20% of all cancers in women Commonest cause of death 35-55y In UK 1 in 10-12 chances 1 in 8 women in US Less incidence in Asia Majority of cancers arise in the ducts. Very rare before age 25

Risk Factors:         

Female sex..!, Age, Obesity, high fat diet Maternal relative with breast cancer. Longer reproductive span. Nulliparity, Oral contraceptives Later age at first pregnancy. Atypical epithelial hyperplasia. Previous breast cancer/Endometrial Ca. Geographic factors - country BRCA1 and BRCA2 genes

Etiology of Breast Carcinoma:

Clinical Features:       

Physiologic vs Pathologic changes Lump / lumps Lumps are much more common than Ca Characters of lump* and age* Discharge in many conditions. Hard, soft, inflammation Skin fixation / Skin retraction *

Diagnosis:        

Mammorgraphy Ultrasound Fine Needle Aspiration Biopsy Core Biopsy Excision Biopsy Frozen section Immunoperoxidase, Molecular techniques – Gene detection.

Histological Types

Histologic Type

Freq. (UK)

Infiltrating Duct Ca

63.6 (75)

Lobular Carcinoma

5.9 (10)

Infiltrating Ductal & Lobular Ca

1.6

Medullary Carcinoma

2.8 (3)

Mucinous (colloid) Carcinoma

2.1 (3)

Comedocarcinoma

1.4

Carcinoma-In-Situ

5%

Breast Carcinoma

Breast Carcinoma

Breast Carcinoma - Schirrous

Infiltrating Duct Carcinoma: small hard

Medullary Carcinoma: Large soft

Infiltrating Duct Carcinoma

Infiltrating Duct Carcinoma

Medullary Carcinoma: Inflammation.

Infiltrating Duct Carcinoma: Fibrosis

Schirrous Carcinoma

Medullary Carcinoma Soft, inflammatory cells

Intraductal in-situ Carcinoma

Lobular Carcinoma

Intraduct Carcinoma-in-situ

Intraduct Carcinoma

Lymphatic spread – Peu-de Orange..

Spread of Breast Carcinoma:

Pagets Disease

Pagets Disease (Epidermal invasion)

Estrogen Receptor & Prognosis: 





Estrogen receptor expression is proportional to differntiation of tumor inversly proportional to prognosis and response to tamoxifen (receptor antagonist) therapy. Demonstrated by Immunoperoxidase special stain.

HER2 



The HER2 proto-oncogene encodes a cell surface receptor that is overexpressed in approximately 25%-30% of breast cancers. Trastuzumab (Herceptin®) is the first monoclonal antibody that targets the extracelluar domain of the HER2 protein, and inhibits growth of breast cancer cells that over express this protein.

Estrogen receptor (ER) in nuclei

Immunoperoxidase Positivity Neg 1+

2+

3+

St ag

5-year Surv (%)

7-year Surv (%)

96

92

Tumor 2-5cm with regional lymph node involvement but without distant II 81 metastases, OR > 5 cm in diameter without spread

71

I

Definition Tumor 2 cm or less without spread

Any size with skin/chest wall fixation, & axillary or internal mammary III 52 nodal involvement, without distant metastases Tumor of any size with or without IV regional spread but with evidence of 18 distant metastases

39

11