Breast Milk

What crosses from mother to infant?

IgA, Vitamins, enzymes

Cytokines, antioxidants, fibronectin, lysozyme

Drugs, radioactive components, viruses

Lactational amenorrhea

How long can it last?

What causes it?

Resumption of menses = 28 weeks

Correlates with frequency of suckling episodes

Hyperprolactinemia inhibits LH pulsality via effecct on gonadotropin-release hormone secretion

Clinical presentation of breast disease

Pain?

Palpable mass?

Nipple discharge?

Mammography?

Pain(mastodynia) associated with menstrual cycle is almost always a benign sign. 95% of painful masses are benign

Palpable mass 12% have cancer, palpable at 2 cm. Fibroadenomas

Nipple Discharge: Worse when uinlateral & spontaenous

Mammography: Sensitivity & specificy increase with age

 Detected at 1cm (half of palpable)

 DCIS is most commonly detected calcification.

 DCIS has linear and branching calcifications

 Irregular calcification is sign of malignancy

Acute Mastitis

When do I occur?

What causes?

First month of breast feeding(puerperal mastitis)

Cracks allow bacteria in: Staph Aureus; localized acute inflammation may progress to abscesses

Preductal mastitis

Symptoms?

What causes?

Painful erythematous subareolar mass

Inverted nipple secondary to inflammation

Keratinizaing squamous metaplisa of ducts -> dilation -> rupture -> inflammation due to keratin -> infected -> fustula

90% of affected are smokers. also vit A deficiency

Mammary duct ectasia

Occurs in?

Pathology/cause?

Ectasia = dilation or distention of tubular structure

50-60 multiparous women

Dilated ducts are filled by granular debris -> inflammation

Histology shows lymphocytes & macrophages

periolar mass with thick white nipple secretions

mimics carcinoma

Fat Necrosis

What  Casues?

Signs?

History of breast trauma/surgery

Acute = hemoorhage + liquefactive necrosis & neutrophils

Sign is retraction of overlying skin

Mimics carcinoma

Non-proliferative Breast Changes

What is it?

Increase risk of cancer?

Cysts?

Fibrosis?

Adenosis?

Non-proliferatie: Fibrocystic changes: lumpy bumpy breats on palpation

No increased risk of cancer

Cysts: form by dilation and unfolding of lobules(not from ducts)  Calcifications common, lined by metaplastic apocrine cells

Fibrosis: Cysts rupture, and cause inflammatory response

Adenosis: Increase in # of acini per lobule,

 Earliest recognizable precursor of epithelial neoplasia

Intraductal Papilloma

Composed of?

Symptoms?

Composed of branching fibrovascular cores.

Ct axis lined by luminal and myoepithelial cells

Epithelial hyperplasia and apocrine metaplasia

Bloody nipple discharge

Comedocarcinoma

(comedo DCIS)

histology?

Pleomorphic cells with "high-grade" nuclei & central necrosis

Micro calcification.

Marked Necrosis and atypia

Noncomedo DCIS

Histology?

Monomorphic cells, intraluminal calcification

low grade: minimal necrosis or atypia

 Cribiform: cookie cutter look

 Papillary: fibrovascular core extends into duct

 Micropapillary: solid with no core

Paget Disease

What is it/pathology?

Symptoms?

Gentic profile of cancer?

(over expresses/underexpresses)

Paget cells extend from DCIS within ductal system into nipple without crossing basement membrane.

unilateral erythematous with scale crust and pruritis

Exudate from Nipple

ER negative, overexpress HER2/neu

Lobular Carcinoma in situ(LCIS)

Who gets it?

How are lesions detected?

Tx?

Genetics?

Young woman, before menopause

Not associated with calcification

Lesions are detected incidentally, Bilateral 20-40%

Tx: Tamoxifin(most are ER +)

Genetics: Loss of E-cadherin; discohessive on histology

Infiltrating Ductal Carcinoma

Metastases?

Mammography effect?

Symptoms?

Gross histo?

Palpable tumors have axillary lymph node metastases in over 50% of paitents

When mammography detects, only 20% have axillary metastases

Most common cancer.

Nipple retracts when central tumor.

Peau d'orange: lymphadema.

Gross: hard with irregular shapes, gritty when cut

Invasive lobular carcinoma

Histology?

age?

Mammography?

Metastatis?

Genetics?

Histology: Indian file apperance

Median age is over 50

Mammography not sensitive(low % microcalcificaitons)

Hematogenous metastasis: Brain, CNS, peritoneum

Loss of E-cadherin(CDH-1) gives discohesive appearence

Estrogen receptor positive(treat with tamoxifen)

Medullary carcinoma

Occurs in?

Tumor(gross histo) is?

DCIS?

Genetics?

Occurs in old women

Tumor is soft and fleshy, Circumscribed and does not produce fibrosis Lympho-plasmacytic infiltrate

DCIS minimal or absent

Overexpress E-cadherin -> Syncytia

Invasive Carcinomas of breast(excellecent prognosis)

Mucinous(colloid)

Tubular carcinoma

Mucinous:

old women, grows slowly

Tumor cells arranged in clusters within "large lakes" of mucin

Tubular Carcioma

late 40s

no myoepithelial cell involvement

Stage 1: tumor <2cm

Stage 2: tumor >2cm

Stage 3: tumor >5cm

Stage 4: Distant metastases

Fibroadenoma

What is it & gross Histo?

Who gets it?

Mammography?

Common benign tumor of female breast.

Composed of connective tissue(fibro) and glandular(adenoma) elements

Bulging circumscribed, white, firm nodule, rubbery

women 15-30

Mammography shows popcorn calcifications

Phyllodes tumor

How does it spread?

Tx?

Histology?

Spreads hematogenously, so may not need to disect lymph nodes.

Treat with wide margins

Leaflike Architecture histologically

Male Breast Carcinoma

Risks?

What does it present as?

BRCA2 / first degree relatives

Klinefelter syndrome & estrogens.

Men present at higher stage, usually subareolar mass

Nipple discharge is common