乳房病病理学-课件

,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,DISEASES OF THE BREAST,1,DISEASES OF THE BREAST1,Lecture Objectives,At the end of the lecture the student should be able to:,1. Discuss the etiology/pathologic features of,different forms of benign non-neoplastic and,neoplastic breast disease.,2. List the benign breast diseases that increase a,patients risk of developing breast cancer and,classify these conditions by the degree of risk.,2,Lecture Objectives 2,Lecture Objectives,At the end of the lecture the student should be able to:,3. Outline other risk factors predisposing to breast,cancer & incidence/prevalence of breast cancer.,4. Classify breast cancer into histologic subtypes,and describe the pathologic features of each.,5. List the prognostic factors for breast cancer.,3,Lecture ObjectivesAt,CLINICAL PRESENTATION,Palpable lump,Inflammatory mass,Nipple discharge,Non-palpable abnormality,4,CLINICAL PRESENTATION Palpable,METHODS OF DIAGNOSIS,FNAC,Incisional biopsy,Excisional biopsy,Image-guided,biopsy,5,METHODS OF DIAGNOSIS FNAC5,Jamaican Breast Disease Study 2000-2,Clinical Findings,6,Jamaican Breast Disease Study,BENIGN BREAST DISEASE,7,BENIGN BREAST DISEASE7,INFLAMMATION,Acute Mastitis,Most clinically important form of,mastitis,Breast-feeding,cracks/fissures,in the nipples,bacterial infection,(esp. Staph. aureus),8,INFLAMMATION Acute Mastitis 8,INFLAMMATION,Acute Mastitis,Usually unilateralacute inflammation in the breast can lead to abscess formation,Treatment = surgical drainage (often under general anesthesia) and antibiotics,9,INFLAMMATION Acute Mastitis9,INFLAMMATION,Mammary Duct Ectasia,5th and 6th decades,Affects mainly large ducts,Periductal chronic inflammation,destruction and dilation of,the ducts with fibrosis,The underlying cause is unknown,10,INFLAMMATION Mammary Duct Ect,INFLAMMATION,Mammary Duct Ectasia,Poorly defined periareolar mass; can be confused clinically/radiologically with carcinoma,Can also present as a thick, cheesy nipple discharge +/- mass,Periductal fibrosis,skin retraction,11,INFLAMMATION Mammary Duc,INFLAMMATION,Fat Necrosis,Uncommon lesion; may be a history,of trauma, prior surgical,intervention or radiation therapy,Characterized by a central focus of,necrotic fat cells with lipid-laden,macrophages and neutrophils,12,INFLAMMATION Fat Necrosis12,INFLAMMATION,Fat Necrosis, C,hronic inflammation with lymphs and multinucleated giant cells,Major clinical significance is its possible confusion with carcinoma (e.g. fibrosis,clinically palpable mass / Ca,2+,seen on mammography),13,INFLAMMATION Fat Necrosis13,NON-PROLIFERATIVE (“FIBROCYSTIC”) CHANGES,Most common breast disorder,Alterations present in most women,No associated risk of progression,or cancer,? Due to hormonal imbalances,14,NON-PROLIFERATIVE (“FIBROCYSTI,NON-PROLIFERATIVE (“FIBROCYSTIC”) CHANGES,Pathologic features:,Cystic change,Apocrine metaplasia,Adenosis,Fibrosis,15,NON-PROLIFERATIVE (“FIBROCYSTI,16,16,17,17,NON-PROLIFERATIVE (“FIBROCYSTIC”) CHANGES,Usually diagnosed 20 to 40 years,Present as palpable lumps, nipple,discharge or mammographic,densities/calcifications,O,ften multifocal and bilateral,general “lumpiness”,18,NON-PROLIFERATIVE (“FIBROCYSTI,PROLIFERATIVE DISEASE WITHOUT ATYPIA,Epithelial Hyperplasia,number of layers of cells lining,ducts and acini,Involved ducts and acini are,filled with overlapping,proliferating cells,19,PROLIFERATIVE DISEASE WITHOUT,20,20,PROLIFERATIVE DISEASE WITHOUT ATYPIA,Sclerosing Adenosis,Characterized by,#acini +,stromal fibrosis within lobules,Can be assoc with calcifications,which may be detected on,mammography,21,PROLIFERATIVE DISEASE WITHOUT,ATYPICAL HYPERPLASIA,Epithelial hyperplasia characterized,atypical architectural and/or,cytologic features,Can affect ductsatypical ductal,hyperplasia, or lobulesatypical,lobular hyperplasia,22,ATYPICAL HYPERPLASIA Epitheli,ATYPICAL HYPERPLASIA,Atypical features resemble but fall short of in-situ cancer,No diagnostic clinical or radiologic features, I,ncidence with,use of screening mammography and,number of breast biopsies,23,ATYPICAL HYPERPLASIAAtypical f,BENIGN TUMOURS,Fibroadenoma,Most common benign tumour,Circumscribed lesion composed,of both proliferating glandular,and stromal elements,24,BENIGN TUMOURS Fibroadenoma24,25,25,26,26,BENIGN TUMOURS,Fibroadenoma,Patients usually present 30 years,Classic presentation is that of a firm,mobile lump (“breast mouse”),Giant forms can occur, especially in,younger patients,27,BENIGN TUMOURS Fibroadenoma27,BENIGN TUMOURS,Fibroadenoma,Can be associated with proliferative,changes in the adjacent breast tissue,Approx. 20% of lesions are,complex,fibroadenomas,characterized by,certain specific,histologic features,28,BENIGN TUMOURS Fibroadenoma28,BENIGN TUMOURS,Duct Papilloma,Benign papillary epithelial tumour;,occurs mainly in large ducts,Papillae are fibrovascular stalks lined,by layers of proliferating epithelial,and myoepithelial cells,Most patients present with a serous or,bloody nipple discharge,29,BENIGN TUMOURS Duct Pa,30,30,RELATIVE RISK FOR INVASIVE BREAST CANCER FOR BENIGN BREAST LESIONS,31,RELATIVE RISK FOR INVASIVE BRE,RISK FOR INVASIVE BREAST CANCER,v,No Increased Risk (NIR),Mastitis,Fat necrosis,Mammary duct ectasia,Non-proliferative,(“fibrocystic”) disease,Fibroadenoma (simple),32,RISK FOR INVASIVE BREAST CANCE,RISK FOR INVASIVE BREAST CANCER,v,Slightly,Risk (SIR),=,Risk 1.5-2 Times,Moderate/florid hyperplasia,Sclerosing adenosis,Fibroadenoma (complex),Duct papilloma,33,RISK FOR INVASIVE BREAST CANCE,RISK FOR INVASIVE BREAST CANCER,v,Moderately,Risk (MIR),=,Risk 4-5 Times,Atypical ductal hyperplasia,Atypical lobular hyperplasia,34,RISK FOR INVASIVE BREAST CANCE,Jamaican Breast Disease Study 2000-2,Biopsy Results (46.1% patients),35,Jamaican Breast Disease Study,CARCINOMA OF THE BREAST,36,CARCINOMA OF THE BREAST36,EPIDEMIOLOGY,Commonest malignancy in women worldwide,:,Breast cancer 18%,Cervical cancer 15%,Colonic cancer 9%,Stomach cancer 8%,37,EPIDEMIOLOGY Commonest malig,EPIDEMIOLOGY,Incidence rates are highest in North,America, Australia and Western,Europe; intermediate in South,America, the Caribbean and Eastern,Europe and lowest in China, Japan,and India,Most common invasive tumour of Jamaican women,38,EPIDEMIOLOGYIncidence rates ar,RISK FACTORS,Age,Incidence of breast cancer,ses,with age,Uncommon before age 25 years;,incidence,ses to the time of,menopause and then slows,39,RISK FACTORS Age39,RISK FACTORS,Family History,Approx 10% of breast cancer is due to,inherited genetic predisposition,A woman whose mother or sister has,had breast cancer is at,relative risk 2,to 3 times compared to other women,40,RISK FACTORS Family History,RISK FACTORS,Family History,At least two genes that predispose to,breast cancer have been identified,BRCA 1,and,BRCA 2,Mutations in these tumour-suppressor,genes also predispose affected women,to ovarian cancer,41,RISK FACTORS Family History,RISK FACTORS,Benign Breast Disease,Certain types of benign breast disease,History of Other Cancer,A history of cancer in the other breast,or a history of ovarian or endometrial,cancer,42,RISK FACTORS Benign Breast Di,RISK FACTORS,Hormonal Factors,levels of estrogen,risk:,Early age at menarche,Late age at menopause,Nulliparity,Late age at first child-birth,Obesity,43,RISK FACTORS Hormonal Factors,RISK FACTORS,Environmental Factors,High fat intake,Excess alcohol consumption,Ionizing radiation,44,RISK FACTORS Environmental Fa,ETIOLOGY,The etiology of breast cancer in most women is unknown,Most likely due to a combination of risk factors i.e. genetic, hormonal and environmental factors,45,ETIOLOGY The etiology of breas,HISTOLOGIC CLASSIFICATION,Breast Cancer, ,Ductal,Lobular, , ,DCIS,IDC,LCIS ILC,(,15%,) (,75%,) (,5%,) (,5%,),46,HISTOLOGIC CLASSIFICATION,Ductal Carcinoma In-situ,sed incidence with,sed use of,mammographic screening and,early cancer detection,50% screen-detected cancers,Can also produce palpable mass,47,Ductal Carcinoma In-situ se,Ductal Carcinoma In-situ,Characterized by proliferating,malignant cells within ducts that do,not breach the basement membrane,Different patterns e.g.,comedo,(central,necrosis,);,cribiform,(cells arranged,around “punched-out” spaces);,papillary,and,solid,(cells fill spaces),48,Ductal Carcinoma In-situCharac,49,49,50,50,51,51,Ductal Carcinoma In-situ,Different grades i.e. low, intermediate,and high gradecomedo DCIS is,classically high grade,Often,multifocal,malignant,population can spread widely through,the duct system,52,Ductal Carcinoma In-situ Diff,Ductal Carcinoma In-situ,Women with DCIS are at risk of:,Recurrent DCIS following Rx,Invasive cancer (rel. risk 8 to 10,times) especially in the same,breast,53,Ductal Carcinoma In-situ Women,Lobular Carcinoma In-situ,Relatively uncommon lesion,Malignant proliferation of small,uniform epithelial cells within,the lobules,Also at marked,sed relative risk,for invasive cancer (8 to 10 times),in either breast,54,Lobular Carcinoma In-situ Re,55,55,Invasive Ductal Carcinoma,Commonest form of breast cancer especially in poorer populations,sing incidence of s,creendetected,cancer in developed countries,(usually smaller; much better,prognosis),56,Invasive Ductal Carcinoma Comm,Invasive Ductal Carcinoma,Clinical presentation:,Hard, irregular palpable lump,Peau dorange,(lymphatic obstruction,thickening/dimpling of the skin),Pagets disease,of the nipple,(ulceration/inflammation due to,intraductal spread to the nipple),57,Invasive Ductal Carcinoma C,Invasive Ductal Carcinoma,Clinical presentation:,Tethering of the skin,Retraction of the nipple,Axillary mass (spread to regional,lymph nodes),Distant mets (lung, brain, bone),58,Invasive Ductal CarcinomaClini,59,59,Invasive Ductal Carcinoma,Different histologic types exist,The most common is,scirrhous,carcinoma,(IDC of no special type),This type is characterized grossly by an,irregular, hard mass,Histology shows infiltrating clusters of,malignant cells in a dense, fibrous stroma,60,Invasive Ductal CarcinomaDiffe,61,61,Invasive Ductal Carcinoma,Special histologic types of IDC:,Medullary carcinoma,= circumscribed,tumour; sheets of malignant cells in,dense lymphoid stroma,Tubular carcinoma,= infiltrating,tubular structures on histology,62,Invasive Ductal Carcinoma ,Invasive Ductal Carcinoma,Special histologic types of IDC:,Mucinous/colloid carcinoma,=,malignant cells in pools of mucin,Papillary carcinoma,=,papillary,formations like papilloma +,invasion,63,Invasive Ductal Carcinoma ,Invasive Lobular Carcinoma,Much less common than IDC,Can present with similar features,More likely to be,bilateral,and/or,multicentric,(multiple lesions,within the same breast),64,Invasive Lobular Carcinoma Mu,Invasive Lobular Carcinoma,Classic histology = small, uniform cells arranged as:,Strands/columns within a fibrous stroma,(“Indian-file”),Around uninvolved ducts,( “bulls-eye” pattern),Metastasize more frequently to CSF, serosal surfaces and pelvic organs,65,Invasive Lobular CarcinomaClas,66,66,PROGNOSIS,Stage,Staging systems inc.TNM and the,Manchester classification,Tumour size,and,axillary node status,are important parameters,10-year survival rate for lymph node,neg disease is 80% vs 35% for tumours,with positive nodes,67,PROGNOSIS Stage67,PROGNOSIS,Tumour Grade,Different grading systems exist,tumour grade = worse prognosis,Histologic Subtypes,68,PROGNOSIS Tumour Grade68,PROGNOSIS,Hormone Receptors,Estrogen receptors,Progesterone receptors,Molecular Markers,Inc. c-erb-B2, c-myc and p53,69,PROGNOSIS Hormone Receptors69,TREATMENT OPTIONS,Surgery,Mastectomy,Breast conservation,+/- Axillary dissection,Radiation therapy (local control),Chemotherapy (systemic control),Hormonal Rx (systemic control),70,TREATMENT OPTIONS Surgery 70,PHYLLODES TUMOUR,Stromal tumour arising from the,intralobular stroma,Range in size from a few cm to,massive lesions,Classically have a “leaf-like”,configuration,71,PHYLLODES TUMOUR Stromal tumou,PHYLLODES TUMOUR,Most are low-grade lesions that can,recur locally but do not metastasize,Others are of high-grade and exhibit,aggressive clinical behaviour e.g.,spread to distant sites (cystosarcoma,phyllodes),72,PHYLLODES TUMOUR Most are low-,THE MALE BREAST,Gynecomastia,Enlargement of the male breast due to,hormonal imbalance (rel.,estrogens):,Physiologic,; seen at puberty or old age,Pathologic;,associated with cirrhosis,functional testicular tumours, certain,drugs (alcohol, marijuana and anabolic,steroids),73,THE MALE BREAST Gynecoma,THE MALE BREAST,Gynecomastia,Can be unilateral/bilateral; present as,diffuse enlargement /defined mass,Most important clinically as a marker,of hyperestrinism,Neoplasia needs to be excluded in,certain cases,74,THE MALE BREAST Gynecom,THE MALE BREAST,Carcinoma,Very rare occurrence; female cancer,to male cancer ratio approx 100:1,Pathology and behavior is similar to,cancers seen in women although with,less breast tissue, skin involvement is,more frequent,75,THE MALE BREAST Carcinoma75,Lecture ObjectivesCan you?,1. Discuss the etiology/pathologic features of,different forms of benign non-neoplastic and,neoplastic breast disease.,2. List the benign breast diseases that increase a,patients risk of developing breast cancer and,classify these conditions by the degree of risk.,76,Lecture ObjectivesCan you?1.,Lecture ObjectivesCan you?,3. Outline other risk factors predisposing to breast,cancer & incidence/prevalence of breast cancer.,4. Classify breast cancer into histologic subtypes,and describe the pathologic features of each.,5. List the prognostic factors for breast cancer.,77,Lecture ObjectivesCan you?3.,