PBL CASE 2: B REAST L UMP M ODULE 13: R EPRODUCTIVE S YSTEMC.Thinnakaraen MBBS 2ND Year UniSZA Facillator : Prof. Dr. Parivash 26th DECEMBER 2011

I NFLAMMATORY DISORDERS OFBREAST

Acute mastitis Periductal mastitis Mammary duct ectasia Fat necrosis Lymphocytic mastopathy (sclerosing lymphocytic lobulitis) Granulomatous mastitis

A CUTE

MASTITIS

S. aureus infection Produce localized area of localized inflammationlead abscess formation (single/multiple)

During first month of breastfeedingBreast is erythematous and painful and fever is often present (only one duct system is involved)

Necrotic and neutrophils infiltration

P ERIDUCTAL

MASTITISVariety of names

Recurrent subareolar abscess

Squamous metaplasia of lactiferous dutsLactiferous fistula (zuska disease)

Fistula tunnel forms and opens onto edge of the areola

90 % of the afflictions are due to smokingSymptoms include swelling or subareolar mass, a draining fistula from behind the areola, thick discharge from the nipple, or painful discharge

Inverted nipple (2 to fibrosis & scarring) > contribute to squamous metaplasia of the ducts Surgical removal of the involved duct & contagious fistula tract is curative

M AMMARY

DUCT ECTASIA

Usually in multiparaous women

Palpable perareolar mass white, thick nipple secretions and skin retractionDilatation of the ducts (granular debris deposition + lipid laden macrophages) Inspissation of breast secretions Marked periductal and interstitial chronic granulomatous inflammatory reactions Fibrosis > nipple retraction

Squamous metaplasia of nipple ducts is absentClinical significance mistaken for a carcinoma by palpation

FAT

NECROSIS

Present as painless palpable mass, skin thickening or retraction, a mammographic density/ calicifications Central areas of liquefactive necrosis- intense neutrophilic infiltrate mixed with macrophages Fibroblast proliferations present over the next few daysvascularization & Chronic Inflamamtory cells surround Giant cells, calcification and hemosiderin make their appearance Scar tissue is formed

Walled off by fibrous tissuesClinical significance- confusion with breast carcinoma on palpation

LYMPHOCYTIC MASTHOPATHY

Sclerosing lymphocytic lobulitis Single/ multiple hard palpable masses Bilateral- detected as Mammographic densities

Collegenized stroma surrounding atrophic ducts & lobulesProminent lymphocytic infiltration Common in women with type 1 DM or auto immune thyroid disease autoimmune of breast Clinical significance- must be distinguished from breast cancer

G RANULOMATOUS

MASTITIS

Causes systemic granulomatous diseases (eg: wegener granulomatosis or sarcoidosis), mycobacteria/ fungi Common in immunocompromised patients Foreign objects assertion ( breast prostheses or nipple piercings) Confined to lobules Occurs in parous women- hypersensitivity reaction

B ENIGN E PITHELIAL L ESIONS

Nonproliferative breast changes (fibrocystic changes)Proliferative breast disease without atypia Proliferative breast disease with atypia

Benign tumors Fibroadenomas Duct papillomas Adenomas Connective tissue tumours.

N ONPROLIFERATIVE BREASTCHANGES

Fibrocystic changes -cystic change often with apocrine metaplasia(blue-dome cyst)

-fibrosis > cyst rupture-adenosis physiological /pathological Lactational adenomas- formed by physiological adenosis and lactational changes- hormonal influenced

P ROLIFERATIVE BREASTDISEASE WITHOUT ATYPIA

Epithelial hyperplasia Sclerosing adenosis > acini compressed & distortedmimics invasive carcinoma Complex sclerosing lesion > sclerosing adenosis+ papillomas + epithelial hyperplasia central nidus of entrapped glands Papillomas > multiple branching of fibrovascular cores- growth within dilated ducts, E.hyperplasia & apocrine metaplasia often present Large duct papillomas/ small duct papillomas

P ROLIFERATIVE BREASTDISEASE WITH ATYPIA

Atypical ductal hyperplasia and atypical lobular hyperplasia Atypical ductal hyperplasia histological resemblance to ductal carcinoma in situ (DCIS) Atypical lobular hyperplasia cells identical to lobular carcinoma in situ (LCIS)

C ARCINOMA OF THE BREAST

Invasive Noninvasive

B REAST C YSTS

Definition: harmless (benign) fluid - filled sac of tissue. It can grow right within the breast tissue. Morphology: Feel smooth and squishy

Location: near the surface/ deep (close to the chest wall)- easy to distinguish from other lumps

F IBROADENOMAS

Definition: benign group of cells (fibrous and glandular tissues) Morphology: round breast lump, palpable (hard/firm) and mobile Location: near the surface of the breast

P SEUDOLUMPS

Definition: benign, and may be scar tissue, hardened silicone, necrotic (dead) fat, or a rib bone pressing into breast tissue and compressing it.Morphology: can feel quite hard & usually doesn't change shape/size during a menstrual cycle. It may or may not be movable, depending on what it is actually composed of.

Location: near the surface, deeper, close to the chest wall.

C ANCEROUS

LUMP

Definition: A malignant lump that is made of abnormal breast tissue cells, growing in an uncontrolled way.

Morphology: irregular shape (not round) with a pebbly surface, very hard, not movable.Location: near the surface, deep, close to the chest wall, armpit area

T REATMENT

Chemotherapy Radiotherapy

CHEMOTHERAPYI N T R O D U C T I O N

Refers to the use of drugs to kill or slow the growth of rapidly multiplying cells. A combination of drugs- since this is more effective than a single drug given alone. There are many drug combinations used to treat breast cancer .

H OW

ITS DONE ?

Chemotherapy drugs are given intravenously (directly into a vein) or orally (by mouth). Once the drugs enter the bloodstream, they travel to all parts of the body in order to reach cancer cells that may have spread beyond the breast . Therefore chemotherapy is considered a "systemic" form of breast cancer treatment.

W HEN

ITS DONE ?

Given in cycles of treatment followed by a recovery period. The entire chemotherapy treatment generally lasts for 3-6 months(depending on the type of drugs given). When breast cancer is limited to the breast or lymph nodes. May be given after a lumpectomy or mastectomyadjuvant treatment (may help reduce the chance of breast cancer recurrence). Sometimes given before surgery-neoadjuvant

RADIOTHERAPYI N T R O D U C T I O N

A local treatment- it affects cancer cells only in the treated area. Radiation can come from a machine (external radiation). It can also come from an implant (a small container of radioactive material) placed directly into or near the tumor (internal radiation).

W HAT ARE THE SIDE EFFECTS OF RADIATION THERAPY ?

Depend on the treatment dose and the part of the body that is treated. Most common side effects are tiredness, skin reactions (such as a rash or redness, permanent pigmentation, and scarring) in the treated area, and loss of appetite. Inflammation on the treated areas. Reduced WBC proliferations.

REFERENCES

Robbins and Cotran Pathologic Basis of Disease (8th edition) http://www.medicinenet.com/breast_cancer/arti cle.htm http://www.medicinenet.com/chemotherapy_tr eatment_for_breast_cancer/article.htm

http://www.medicinenet.com/radiation_therapy /article.htm