DUCTAL EPITHELIUM OF THE BREAST
-very responsive to hormonal cyclic changes
-follicular phase (parenchymal proliferation of
ducts)
-Luteal phase (dilatation of ductal system and
differentiation of the alveolar cells into the
secretory cells)
-alveolar elements, stroma and myoepithelial cells
(respond to both E/P)
-cyclic breast fullness and tenderness (related to
25-20 ml ave. fluctuation in volume of the
premenstrual breasts)
-Full breast development occurs at 18-21 y/o
-surgery for cosmetic results
BREAST HYPERTROPHY
-asymmetric
-virginal(pubertal), gravid (gestational)
macromastia, adult types
- surgical management to relieve symptoms
(headache, neck and back pain, upper paresthesias,
brassiere strap grooving or intertrigo) after 6-12
months of allowing for stable breast size
LYMPHATIC DRAINAGE OF THE BREAST
-converge in the subareolar plexus of sappy
-outer quadrants (75% drain to the 30-60 ipsilateral
axillary regional nodes)
AXILLARY NODES:
Level 1: located lateral to the lateral boarder of the
pectoralis minor muscle
Level 2: posterior to the pectoralis minor
Level 3: Infraclavicular nodes medial to the
pectoralis minor
-Treatment is generally reserved to manage
irritation or improve prosthesis
CONGENITAL NIPPLE INVERSION:
- 2% women (Fhx)
- Shortening and tethering of breast ducts
and develop fibrous bands during
intrauterine life
- Increase mechanical problems during
breastfeeding
- Surgical correction leads to loss of sensation
and inability to breastfeed
- - Organization of ductal system starts at
ROLE OF GYNECOLOGIST:
- Identify the risk factors during the medical
and family history
- Performing clinical breast examinations
- Offering instructions for breast self-
evaluation
- Evaluating all palpable breast masses
- Encouraging women to have a routine
screening mammography
- Performing diagnostic procedures or
referral to those who specialize in breast
disease when clinically indicated
BLOOD SUPPLY
-perforating branches of the internal mammary
arteries originating from the internal thoracic
artery
-lateral thoracic and thoracoacromial arteries
(originate from the axillary artery) and posterior
3rd, 4th, 5th intercostal arteries (branches of thoracic
aorta)
-inferior and central portion of the breast is the
least vascular area
BREAST DISEASES
EMBROLOGY AND ANATOMY:
- Development begins in utero at 6th
gestational weeks from the integument
along the epithelial mammary ridges
- Ducts and acini (ectoderm); supporting
tissues (mesenchyme)
- Hormonal changes during puberty influence
the development of the ductal tissue and
secretory lobules
- Milk production is initiated by hormonal
changes during after delivery
BREAST
- Composed of 12-20 varying size triangular
lobes radially distributed form the nipple
- Each lobe contains 10-100 lobules with
alveoli (acini)
- Functional lobules (have epithelial/ductal
and stromal components) are affected by
hormonal changes (estrogen, progesterone
and prolactin) that result in development,
maturation and differentiation
puberty
 - Flow: secretory cells drain into the alveoli,
then into the terminal ducts that then
collapse into larger coalesce into larger
collecting ducts, then terminate at the
excretory ducts of the nipple
- Premenstrual breast symptoms (secondary
to vascular engorgement and water
retention with enlargement of lumen and
increased ductal and acinar cellular
secretory activity)
- Menstruation: cause regression of cellular
activity in the alveoli and ducts become
smaller
BREAST TISSUE:
Amastia: complete absence of both tissue and
nipple areola comples
- Secondary to regression or failure of
mammary ridge to develop
- Associated with ectodermal defects (cleft
palate)
Polymastia: accessory breast tissue or
supernumerary breasts
- 1-2% in women
- Diagnosed initially at puberty or during
puberty
- Rudimentary or fully developed
Tubular breast
- Tuberous breast
- Uni/ bilateral congenital anomaly
- Breast diameter is narrow and with
constricted base related to glandular
hypoplasia with deficiency in the
circumferential skin envelop of the breast
base
- Surgical correction (augmentation,
mastopexy, or both and tissue expansion
followed by augmentation)
Intermammary or Parasternal nodes
- Where remaining lymphatics drain
- Have direct drainage to the mediastinum,
medical quadrants of the opposite breast or
inferior phrenic nodes (provide route for
the metastasis to the liver, ovaries and
peritoneum)
Lymphatic spread of breast cancer
- Orderly fashion within the axillary LN based
on the anatomic relationship between the
primary tumor and its associated regional
(sentinel nodes)
Congenital developmental breast abnormalities
Nipple
Accessory nipple: occur along the breast or milk
lines.
- Run from axilla to the groin
Polythelia: supernumerary or accessory nipples
- 1% European descent, 6% Asian descent
- Inframammary region (uni/bilateral)
- Both men and women
- Associated with urologic anomalies and
cardiovascular problems (HPN, and
conductive or rhythm problems)
Athelia: complete uni/bilateral absence of nipple or
areola
- Familial (autosomal dominant)
- Amastia(breast nipple, areola, and breast
tissue), Poland syndrome; ectodermal
abnormalities (absent pectoral muscle)
- Treatment (nipple and areola
reconstruction- flaps and tattoo)
Montgomery glands
- 5-20 areolar glands that produce oily
secretion to keep the nipple supply and
protected (important for breastfeeding)
- Produce volatile compound that stimulate
the infant’s appetite though olfactory
pathways
- Located at the areola and on the nipple
- Sensitive glands; prone to blockage or
irritation
- Usually asymptomatic
- Subject to normal changes and entire
disease spectrum seen in normal breast
- Conservative management; surgery
(cosmetics); liposuction (to decrease the
fatty element)
Asymmetric breast development
-common in adolescence and maturity
-benign, normal variation unless with palpable
abnormality
Clinical classification can be subgrouped as:
- Physiologic swelling and tenderness
- Nodularity
- Breast pain (not usually associated with
malignancy
- Palpable breast lumps
- Nipple discharge including galactorrhea
- Breast infection and inflammation (typically
associated with lactation)
Phyllodes tumor
- Previously termed Cystosarcoma Phyllodes
- Opposite end of spectrum of fibroepithelial
tumors
- Rare tumors (2.5% of fibroepithelial tumors)
- Age onset 40-50 y/o
- Benign, borderline or malignant
- Present as rapidly growing breast mass,
larger than fibroadenoma or ductal CA
- Histologic findings (stromal elements
dominate and invade the ducts in a leafy
projection- “phyllodes” or “leaf”) may be
difficult to distinguish from fibroadenoma,
benign or malignant cystosarcoma
phyllodes
Cystic phase: women in 40’s
- No breast tenderness (unless a cyst rapidly
increase in size with pain, point tenderness
and lumping)
- Cyst (tender to palpation)
- Microscopic size to 5mm
- Complex cysts (internal septations, debris or
solid components- CORE NEEDLE BIOPSY if
stability cannot be determined)
- Fluid aspirate (straw colored, dark brown or
green)
Breast Carcinoma
- Most common malignancy of women
- Present in two ways (clinical symptoms or
screening evaluation- BSE or CBE)
3 general clinical stages of Fibrocystic change
1. Mazoplasia (mastoplasia): associated with
intense stromal proliferation
- Occurs in early reproductive years (20)
- Breast pain in the upper outer breast
quadrants (most tender at the axillary tail)
2. Adenosis: marked proliferation and
hyperplasia of ducts, ductules and alveolar
cells
- Women in 30
- Multiple breast nodules (2-10mm)
- Premenstrual breast tenderness (less
severe)
- Signs and symptoms (usually prevalent
during premenstrual state)
- Cyclical bilateral breast pain (classic
symptom)
- Clinical signs: increased breast
engorgement and density, excessive breast
nodularity, fluctuation in the size of cystic
areas, increased tenderness, and frequently
spontaneous nipple discharge
3. Mastalgia: bilateral, difficult to localize
- Mostly upper, outer breast quadrants, may
radiate to the shoulders and upper arms
- Pain is secondary to the cyst formation,
epithelial and fibrous proliferation and
varying degrees of fluid retention
Differential Diagnosis (breast pain)
- Referred pain from dorsal radiculitis or
inflammation of the CCJ (Tietze syndrome)-
not cyclic and unrelated to the menstrual
cycle
Fibrocystic changes:
- Previously termed fibrocystic disease
- Common, natural maturation of the breast
tissue over time
- Fibrosis or adenosis
- Lobular changes, involutional changes are
due to hormonal response of the breast
- Subdivided pathologically by their potential
future cancer risk
- Nonproliferative disorders: no increased
risk
- Proliferative disorders without atypia: mild
to moderate increase risk
- Atypical hyperplasia: substantial increase in
risk (5x)
- Locally aggressive and require local incision
with 1cm margins and should be shelled out
 during surgical removal (to avoid
recurrence)
- 25% risk for malignancy, > 20% local
recurrence rate
- Metastatic hematogenously
Fat necrosis
- Wide variety of presentations on
mammography. Utz, and mri
- 2.75 % of all breast lesions (50 years)
- Most commonly the result of trauma,
radiotherapy, anticoagulation, breast
procedures and infection
- Rare causes (polyarteritis nodusa, weber-
christian disease, and granulomatous
angiopanniculitis)
Benign breast disorders: classification describes
emphasis to clinical signs, symptoms or histologic
findings
1. Aberrations of normal development and
involution(ANDI)
2. Pathologic classification
3. Clinical classification
4. Classification based on the risk for
malignancy
Intraductal papilloma
- Broad based or pedunculated polypoid
epithelial lesions (may obstruct and distend
the involved duct)
- Perimenopausal women
- Classical clinical presentation- intermittent
but spontaneous discharge from one nipple
involving one or two ducts (watery, serous,
or bloody of variable volume)
- Located beneath the areola (75%)
- Small and soft, often difficult to palpate (1-
3mm)
- Excisional biopsy and surveillance (3-4
months intervals)
Fibrocystic change
- Most common along all benign breast
conditions
- Represent as a spectrum of changes
throughout a woman’s reproductive age
with significant patient variation
- Has extensive list of symptoms and
terminology (>35 different names and
terms)
- ICD 10: diffuse cystic mastopathy
- Common in reproductive age (20-50 y/o)
Fibroadenomas
- Fibrous and epithelial elements
- Most common benign breast neoplasms
(15-20%)
- Accidentally noticed while bathing
- Mostly on adolescents and women in 20’s
(15-20)
- Aberration in normal lobular development
- Hormonal dependence, lactate during
pregnancy and involute (replaced by hyaline
connective tissue) during perimenopause
Management:
- Dependent on signs and symptoms
- Include appropriate use of diagnostic
imaging
- Lifestyle modification
- Medical management: diuretics, OC’s or
progestins, Danazol and Tamoxifen
Mastitis and inflammatory disease:
- Lactational (1st 6 weeks of breastfeeding),
non lactational (cyst or cyst rupture) and
post surgical
- S. aureus ( most common cause of overall
incidence)
- Idiopathic granulomatous mastitis is rare,
present with mass, abscess, inflammations
or granuloma formation
- Chronic inflammatory disease (lupus,
sarcoid, wegner granulomatosis) are rare
and should be suspected with unresponsive
treatment with antibiotics
- Diagnostcs: tissue biopsy, core needle
biopsy
- Treatment during pregnancy (as non
pregnancy state)
- Mastectomy, breast conserving therapy,
and systemic therapy
- Radiation (contraindicated)
- Radical mastectomy is the most common
surgery, breast conserving therapy is an
 option if radiation therapy can be delayed
to the postpartum period
Inset Table 15.1 ANDI classification of BBD
Insert table 15.15 BI-RAD classification of
mammographic lesions
Inflammatory breast Cancer
- Rare (1-5% of breast cancers)
- Recognized clinically as a rapidly growing
malignant carcinoma with highly angiogenic
and angioinvasive characteristics
- Most inflammatory breast cancers are
diagnosed as either stage 3 or 4
- Most are invasive ductal carcinomas
- Infiltration of malignant cells into the
dermal lymphatics of the skin (looks like a
skin infection)
- Breast is firm, warm and enlarged with
thickened, erythematous, peau d’ orange
skin changes
- Dermal lymphatic invasion by malignant
cells is noted histologically
Insert table 15.2 risk factors for breast Ca
Lobular Carcinoma in Situ
- Non-invasive lesion (from the lobules and
terminal ducts of the breast)
- Found with an invasive carcinoma (5% of
malignant breast specimens)
- Increase risk of developing breast cancer
- Premenopausal women (80-90%)
- Greater tendency to be bilateral and
multifocal
- Lesions diagnosed on an excisional biopsy,
obtaining histologically negative margins is
not mandatory as LCIS is frequency
multicentric
- Breast cancer chemoprevention with a
SERM or an aromatase inhibitor maybe
indicated for women diagnosed with LCIS
Insert Table 15.4
Insert Box 15.3
Infiltrating lobular carcinoma
- 10-15% of invasive lesions
- 2nd most common type of invasive breast
cancer
- Characteristic uniformly of the small round
neoplastic cells that infiltrate the stroma
and the adipose tissue in a single file
fashion
- Multicentric origin in the same breast and
tends to involve both breast and are more
frequently ER positive
- Excised breast tissue frequently has a
normal consistency and no mass lesion is
grossly evident
- Histologic findings (subdivisions of
infiltrating lobular carcinoma include small
cell, round cell, and signet cell carcinoma
Insert table 15.15 staging of breast cancer
Breast cancer during pregnancy
- Not frequently diagnosed during pregnancy
- <5% of breast cancers diagnosed before the
age 50 are during pregnancy or in the
postpartum
- Mostly poorly differentiated, ER/PR
negative, ALN positive and have a large
primary tumor size
- Diagnosis is frequently delayed in 2 months
or longer
- Similar to nonpregnant women, in pregnant
or postpartum women a breast mass is
usually the presenting sign (mass that
persists for more than 2 weeks)
- Mammography is not contraindicated in
pregnancy (abdominal shielding is
recommended)
- Breast utz can also be used to better define
a mass or guide biopsy
- Clinically suspicious mass should be
biopsied either by FNA or CNB
- Staging studies (tailored to minimized fetal
exposure to radiation
Paget’s Disease
- 1-3% of new breast carcinomas
- Lesion has an innocent appearance and
looks like eczema or dermatitis of the nipple
- Scaly, raw or ulcerated lesion of the nipple
and areola (infiltrating ductal carcinoma
that invades the epidermis)
 - Punch biopsy or a full thickness wedge of
the nipple is used for diagnosis
- Intraepithelial adenocarcinoma cells/
pagets cells (singly or in small groups within
the epidermis of the nipple seen
histologically)

Ductal Carcinoma in Situ

- Non-invasive lesion
- Perimenopausal and postmenopausal
- Mammography
- CNB: stereotactic guided (confirmatory)
- Goal of treatment (prevent development to
invasive Ca)
- Surgery (mastectomy: 98% curative), RT,
adjuvant endocrine therapy,
chemoprevention,

Insert table 15.8

Box 15.2