Dr. Nazar Jawhar- Department of Pathology
BREAST TUMORS: One of the most important lesions of the female breast. Since breast tissue consists of both epithelial and connective tissue elements, then 2 major groups of tumor can arise from the breast:Dr. Nazar Jawhar- Department of Pathology
Stromal tumors: Arise from connective tissue, mainly from hormone- responsive intralobular stroma, example: - Fibroadenoma. - Phyllodes tumor. - Soft tissue tumor ( benign & sarcomas). Epithelial tumors: - Tubular adenoma. - Carcinoma.Dr. Nazar Jawhar- Department of Pathology
Fibroadenoma: It is the most common benign tumor of the breast. A mixed tumor that composed of both fibrous and glandular elements. Age: Mostly in young age group ( before 30 years).Dr. Nazar Jawhar- Department of Pathology
Morphology: Gross: -Well circumscribed encapsulated spherical-oval firm mass. Variable size (1-10cm).Dr. Nazar Jawhar- Department of Pathology
Morphology: M.I: - Dual proliferation of benign-looking glands in a background of loose fibroblastic stroma.Dr. Nazar Jawhar- Department of Pathology
Clinically: Painless, firm, very slowly growing.freely mobile mass ( breast mouse). Diagnosis: Clinical, FNA, Mammogram (pop corn calcification).
Dr. Nazar Jawhar- Department of Pathology
Phyllodes tumor:A low grade malignant tumor, may recur locally but only rarely metastasize. Affects older age group. Gross: Size: M.i: Malignant variant.
Dr. Nazar Jawhar- Department of Pathology
Incidence & epidemiology: Most common: 2nd killer: Incidence increases with age (at 90years risk is 1:8). Incidence is rising: Screening programs:Breast carcinoma:
Dr. Nazar Jawhar- Department of Pathology
Breast carcinoma: Incidence and epidemiology: - It is the most common malignancy of the breast and it is the most common malignant tumor of female breast and only second to lung cancer as a cause of cancer-related death. - The incidence increases with age. A women who lives to the age of 90 has a one in 8 chance of developing the breast CA ( in USA).Dr. Nazar Jawhar- Department of Pathology
Incidence and epidemiology cont…- The incidence is increasing over the last 30 years, either related to some unindentified environmental causes or mostly due to increase no. of cases detected by screening programs (breast exam and mammogram). Howevere, the mortality rate from CA breast starts to decline slightly over the last 10 years due to increased no. of cases detected at a curable state ( in situ and low stage).Dr. Nazar Jawhar- Department of Pathology
RISK FACTORS: Include the following: Geographical influence: More common among women form Europe & North America than those from Africa & Asia. Age: Rare before 25, average age is 64 year.Dr. Nazar Jawhar- Department of Pathology
Genetic factors & family history of breast CA: -. -, Familial cancers: BRCA1 and BRCA2:Dr. Nazar Jawhar- Department of Pathology
Menstrual & reproductive history: Related to hormonal imbalance, mostly excessive exposure to ER ( and PR), evidence: - . . . . . .Dr. Nazar Jawhar- Department of Pathology
Breast feeding: Proliferative breast disorders: Carcinoma of the contralateral breast or endometrium:Dr. Nazar Jawhar- Department of Pathology
Radiation exposure: Especially if the exposure occurs in early age & heavy dose. Obesity: Increases the risk in postmenopause (due to increase ER synthesis in subcutaneous fat) but not in young women. Dietary & life style: -. - -.Dr. Nazar Jawhar- Department of Pathology
Distribution: Lt breast affected more than Rt breast. 50% of cases arise in the upper outer quadrant ( 10% in the remaining quadrants and 20% central subareolar). Ca is bilateral in 4% of cases.20%
10%
10%
10%
50%
Dr. Nazar Jawhar- Department of Pathology
Classification: Ca is divided into: Non-invasive ( Ca in situ): Definition: Classified into ductal and lobular (DCIS & LCIS) on the basis of the resemblance of the involved space to ducts & lobules. In the past the incidence of in situ Ca was 5%, now it is raised to 15-30% WHY?.Dr. Nazar Jawhar- Department of Pathology
Invasive carcinoma: -Definition: - Classified into several types depending on the architectural pattern:Dr. Nazar Jawhar- Department of Pathology
Total CancersPer Cent
In Situ Carcinoma
15-30
Ductal carcinoma in situ
80
Lobular carcinoma in situ
20
Invasive Carcinoma
70-85
No special type carcinoma ("ductal")
79
Lobular carcinoma
10
Tubular/cribriform carcinoma
6
Mucinous (colloid) carcinoma
2
Medullary carcinoma
2
Papillary carcinoma
1
Metaplastic carcinoma
<1
Distribution of Histologic Types of Breast Cancer
Dr. Nazar Jawhar- Department of Pathology
Morphology: Non-invasive ( Ca in situ):- Types: ductal/lobular,,,, comedo/ non-comedo.- Paget’s disease of the nipple.
Dr. Nazar Jawhar- Department of Pathology
Non-invasive ( Ca in situ): - Her the ducts or lobules become filled by malignant cells (showing all features of malignancy), but they are limited by the basement membrane of the ducts or lobules.Dr. Nazar Jawhar- Department of Pathology
Non-invasive ( Ca in situ): - Classified into several types depending on the morphological architecture ( e.g diffuse, cribriform, papillary..).Dr. Nazar Jawhar- Department of Pathology
Non-invasive ( Ca in situ): Comedo carcinoma:Dr. Nazar Jawhar- Department of Pathology
Non-invasive ( Ca in situ):Paget’s disease of the nipple:- Rare, seen in 1-2% of cases.- Definition:Dr. Nazar Jawhar- Department of Pathology
Non-invasive ( Ca in situ):Paget’s disease of the nipple:- Clinically:Dr. Nazar Jawhar- Department of Pathology
Note: About 25-30% of in situ carcinoma (DCIS & LCIS) well eventually develop into invasive carcinoma.
Dr. Nazar Jawhar- Department of Pathology
Invasive Carcinoma: Her malignant cells had extended & invaded beyond the basement membrane of the ducts or lobules into the adjacent stroma, where they incite desmoplastic reaction.Dr. Nazar Jawhar- Department of Pathology
Gross: Firm-hard whitish greyish mass with irregular invasive outlines. - Scirrhous carcinoma?Dr. Nazar Jawhar- Department of Pathology
M.I: Depending on the microscopical appearance, invasive carcinoma can be classified into several types:Invasive Carcinoma
70-85%
No special type carcinoma ("ductal")
79
Lobular carcinoma
10
Tubular/cribriform carcinoma
6
Mucinous (colloid) carcinoma
2
Medullary carcinoma
2
Papillary carcinoma
1
Metaplastic carcinoma
<1
They have better prognosis than ductal & lobular
Dr. Nazar Jawhar- Department of Pathology
M.I: Invasive ductal carcinoma (NOS): - This the most common type. - Malignant cells arrange in the form of glands, islands, and cords with surrounding dense fibroblastic reaction.Dr. Nazar Jawhar- Department of Pathology
M.I: Invasive lobular carcinoma: Less common type. Malignant cells arrange in the form of lines of single cells called Indian fill appearance. It characterized by high incidence of bilaterality & multicentricity.Dr. Nazar Jawhar- Department of Pathology
Grading of invasive carcinoma: 3 grades depending on cytological & architectural features. Grade I Grade II Grade IIIDr. Nazar Jawhar- Department of Pathology
Spread of invasive carcinoma:Either by: Local spread into overlying skin & underlying muscle & chest wall. Lymphatic: - Axillary LN (commonest 50%).- Supraclavicular LN.- Internal mammary LN Hematogenous: To bones, lung&pleura, liver, ovary, adrenal, CNS,….etc.Dr. Nazar Jawhar- Department of Pathology
Staging of invasive carcinoma: Staging is important for determination of treatment and prognosis. Of the commonly used staging system is that devised by the AJC on breast cancer. (There is also TNM staging)Dr. Nazar Jawhar- Department of Pathology
StageMass
Lymph node
Metastasis
0
DCIS &LCIS
Nil
Nil
I
<2cm
Nil
Nil
II
<5cm
<3 axillary
Nil
or
>5cm
Nil
Nil
III
>5cm
Positive
Nil
or
<5cm
>4 axill LN
Nil
or
Any size
Fixed axill. LN
or
Ca invading chest wall, or skin, or inflam Ca
-/+
Nil
or
Any size
int.mammary LN
Nil
IV
Any
Any
Positive
Dr. Nazar Jawhar- Department of Pathology
The TNM classification of breast cancer: Tumor size: T0 - no primary tumor found Tis - in situ (tumor has not invaded other tissue) T1 - < 2 cm T1mic ≤ 0.1 cm (microinvasive) T1a > 0.1 to 0.5 cm T1b > 0.5 to 1 cm T1c > 1 to 2 cm T2 > 2 to 5 cm T3 > 5 cm T4 Chest wall /skin T4a - Chest wall T4b - Skin edema (peau d'orange), ulceration, or satellite skin modules T4c - Both 4a and 4b T4d - Inflammatory carcinomaDr. Nazar Jawhar- Department of Pathology
Lymph nodes: N0 - No lymph nodes N1 - Movable axillary N2a - Fixed axillary N2b - Internal mammary clinically apparent N3a - Infraclavicular N3b - Internal mammary clinically apparent with axillary lymph node involvement N3c - Supraclavicular lymph nodes Distant metastasis: M0 - No M1 - YesDr. Nazar Jawhar- Department of Pathology
Stage grouping: Stage 0: Tis Stage I: T1,N0,M0 Stage IIA: T0-1,N1,M0 or T2,N0,M0 Stage IIB: T2,N1,M0 or T3,N0,M0 Stage IIIA: T3,N1,M0 or T0-3,N2,M0 Stage IIIB: T4,any N,M0 Stage IIIC: any T,N3,M0 Stage IV: any T,any N,M1Dr. Nazar Jawhar- Department of Pathology
Clinical presentation: Palpable mass: Painless, irregular, hard, mobile or fixed. Skin or nipple retraction: Peau’d orange: Inflammatory carcinoma: Evidence of metastasis: hemoptysis, pathological #,…..Dr. Nazar Jawhar- Department of Pathology
Investigation:Manual examination:Mammogram & US:FNA:Frozen section:Excisional biopsy:Immunohistochemistry:Genetic tests:Detection of mets: CXR,CT, bone scan,….Dr. Nazar Jawhar- Department of Pathology
TreatmentSurgery Chemotherapy Radiotherapy Hormonal therapy
Dr. Nazar Jawhar- Department of Pathology
Prophylactic therapy
Dr. Nazar Jawhar- Department of Pathology
Prognosis: Lymph node mets: Size of the primary tumor: Distant mets: Locally advanced disease: Tumor grade: Inflammatory CA: Histologic subtypes: ER & PR receptor status: Overexpression of HER2 (c-erb-B2): OtherDr. Nazar Jawhar- Department of Pathology
Survival:Stage I : 5 year survival 87% Stage II : 5 year survival 75% Stage III : 5 year survival 46% Stage IV: 5 year survival 13%