breast lesions and their histo pathology.pptx

breast normal pathology and anatomy and histo pathology

1. Premalignant lesions of the breast PRESENTED BY-DR.JUHI SINGH MODERARTOR-DR.PRANEETA J.SINGH

2. B reast is specialized accessory gland with a mass of glandular, fatty and fibrous tissues on the pectoralis muscles in the chest wall. Attached to chest wall by fibrous strands called COOPERS LIGAMENTS The base of breast extends from 2nd - 6th rib and from the lateral margin of sternum to the mid- axillary line. Glandular tissues of breast consist of lobules, lobes and ducts. Fatty and fibrous tissues surround the milk producing system (lobules and ducts).  Each breast consists of 15 - 20 lobes, which radiate out from the nipple. Lobules drain into ductules and ducts , these in turn drain into c ollecting duct which empties into nipple. Just below the nipple, the ducts are expanded to lactiferous sinuses. The epithelium throughout the duct system is bilayered , consisting of an inner epithelial layer and an outer myoepithelial layer.

3. Lymphatic drainage Majorly to the Axillary nodes Internal mammary and the supraclavicular lymph nodes(parasternal and medial)  Three Lymph Node Levels Axillary lymph nodes defined by pectoralis minor muscle Level I – Lateral and inferior to Pectoralis Minor Level II – Deep to Pectoralis Minor Level III – Medial to Pectoralis Minor Rotter’s Nodes – Between Pectoralis Minor & Major  Nerves Long Thoracic Nerve: Serratus Anterior m. Thoracodorsal Nerve: Latissimus Dorsi Intercostobrachial Nerve : Sensory to medial arm & axilla

4. Epithelial component The entire ductal- lobular epithelial system has bilayered lining : Inner epithelial layer – secretary and absorptive function. Outer myoepithelial layer- supporting system. Immunoreactivity The inner epithelial stains positive for epithelial membrane antigen (EMA) and lactalbumin. Myoepithelial stain positive for smooth muscle antigen(SMA) and S-100.

5. Stromal component Supporting stoma of breast consists of variable amount of loose connective tissues and adipose tissues during different stages of breast.

6. Three normal phases Active (reproductive age): about 50-50% Gland/Stroma ratio. Lactating female: Mostly Glands >> stroma Atrophic (menopausal age): mostly stroma >> gland

7. Nonneoplastic benign epithelial changes affecting the TDLU can be divided broadly into four categories: Metaplastic change within the epithelium (e.g., apocrine metaplasia) Hyperplasia: an increased number of epithelial cells within preexisting glandular components, variously called epithelial hyperplasia, epitheliosis , and papillomatosis An increased number of glandular components, termed adenosis Distortion of preexisting glandular components by the stroma

8. Intraductal Non proliferative Morphological changes(microscopic appearance) Cysts Apocrine metaplasia Fibrosis Calcification Chronic inflammation

9. Cyst Visible grossly or microscopically. Usually contain a cloudy yellow or clear fluid. Some of these cysts have bluish cast when seen from outsides called blue dome cyst or blood good.

10. Microscopically : Epithelial lining of most cyst (especially large cyst ) flattened or absent. Having only thick fibrous wall. Frequently these cysts rupture and elicit inflammatory responses in stroma with abundant foamy macrophages and cholesterol cleft. Cyst no matter how large – arise from TDLU rather than from ducts.

11. Apocrine metaplasia e Very common change. Often seen in dilated and cystic structures but it may appear in normal sized tubules as well. Appearance of lining of cyst is indistinguishable from lining of apocrine sweat gland. Microscopically The individual cells have abundant granular acidophilic cytoplasm, supranuclear vacuoles. Apical protion of cytoplasm shows typical “apical snouts” Nucleus – medium size and nucleolus can be very prominent. PAS stain: shows crescent of coarse glycolipid granules on luminal side.

12. Proliferative Changes Usual Ductal Hyperplasia Characterized by epithelial proliferation more than its normal double layer without architectural abnormalities or cytologic atypia . Mild hyperplasia : of ductal epithelial consists 2-4 layers of cells above the basement membrane. Moderate hyperplasia : proliferation of 4 or more layers of benign ductal epithelium over basement membrane. Florid hyperplasia : tendency to fill the ductal lumen with proliferated epithelium

13. Epithelial hyperplasia Normal breast ducts and lobules are lined by a double-layer of myoepithelial cells and luminal cells Increased numbers of both luminal and myoepithelial cell types fill and distend ducts and lobules.

14. Low-power features characteristic of UDH include the following: 1. Luminal spaces between the proliferating cells are irregular and often slitlike . 2. Micropapillary projections, if present, are elongated (often tapering) or tuftlike 3. Cells are arranged in a haphazard to streaming pattern. Nuclei are crowded, overlap, and appear to “touch.”

15. Sclerosing adenosis Average age of occurrence 30-40 years. Gross: Small, disk like multinodular configuration. Cuts with resistance. Microscopically : Retains round to oval lobular configuration. More cellular centrally than peripherally. Elongated and compressed proliferating tubules lines by two cell types. ADENOSIS- Term applied to any hyperplastic process that primarily involves glandular component of breast.

16. Atypical ductal hyperplasia Present in 5% to 17% of specimens from biopsies performed for calcifications. Histologic resemblance to ductal carcinoma in situ (DCIS). It distinguished from DCIS, that it only partially fills involved duct. Individual cells are relatively monomorphic and ovoid to rounf nuclei and formation of micropapillae, tufts, bridges or solid and /or cribriform pattern within the involved space. Some of the spaces are round and regular, the peripheral spaces are irregular and slit like.

17. Atypical ductal hyperplasia. A few adjacent ducts are partially involved by a lowgrade monotonous proliferation that is forming rigid bridges and early micropapillary structures (lower center).

18. Atypical lobular hyperplasia Consists of cells identical to those of lobular carcinoma in situ, but the cells do not fill or distend more than 50% of the acini within a lobule. Atypical lobular cells may lie between the ductal basement membrane and overlying normal luminal cells .

19. Population of monomorphic small, round, loosely cohesive cells partially fills a lobule.

20. Intraductal papilloma Median Age : 48 years. Arise in large or small ducts Grossly soft and fragile, and may have areas of hemorrhage Papilloma can give rise to bloody nipple discharge and may be palpable in a subareolar location. The presence of two cell types (luminal and myoepithelial), oval nuclei, Scanty mitotic activity. Necrosis is nearly always absent.

21. Fibroadenoma Common benign breast lesion Age: between 20 and 35 years. Grossly: Sharply demarcated, firm mass, usually no more than 3 cm in diameter. C/s : solid, grayish white, and bulging, with a whorl-like pattern and slit-like spaces.

22. Microscopically : They are divided into two subtypes 1) Intracanalicular : When the connective tissue invaginates into the glandular space 2) Pericanalicular : When the regular round to oval configuration of gland is preserved. The glands are composed of cuboidal to low columnar cells with round regular nuclei resting on a myopeithelial layer. Stroma is usually made up of loose connective tissue rich in mucopolysaccharides , but may be partially or completely composed of a dense fibrous type stroma.

23. Juvenile Fibroadenoma It grows rapidly and may produce marked distortion of the breast. Microscopic examination juvenile fibroadenomas usually have a pericanalicular growth pattern. Epithelial hyperplasia is a more prominent feature. Stromal cellularity is less

24. Juvenile fibroadenoma. Fibroadenoma with mildly hypercellular stroma, a predominantly pericanalicular growth pattern, and micropapillary-type usual ductal hyperplasia.

25. 2. Phyllodes Tumor : Muller (1838) gave the name to a large huge tumour of breast ( Phyllodes - Greek-leaf like ) Age ; 30- 70 yrs. Gross : round, oval ,bosselated, Partially capsulated. Cut Surface : solid and gray–white, cleft like areas, areas of hemorrhage and necrosis & degenerative changes.

26. Microscopic : There is increased stromal cellularity, Stromal glandular overgrowth, Typical leaflike architecture Phyllodes tumors can be benign, borderline, or malignant It depend on stromal cellularity, infiltration at the tumor's edge, and mitotic activity.

27. TDLU(Terminal duct lobular unit)