Non-neoplastic disorders of breast

Dr. Naw May Emerald

Faculty of Medicine & Health Sciences
UCSI University
 LEARNING OUTCOMES

• The students will be able to

1. describe the aetiology, pathogenesis , morphology
and clinical features of mastitis, mammary duct
ectasia and fat necrosis
2. describe briefly the types, pathogenesis,
morphology and clinical features of non
proliferative and proliferative breast lesions and
state their importance.
3. define gynaecomastia and state the causes.
NORMAL ANATOMY OF FEMALE BREAST
Terminal duct lobular unit
Terminal duct lobular unit
NORMAL HISTOLOGY OF BREAST TISSUE
CLINICAL PRESENTATIONS OF BREAST DISEASE
 Clinical Presentations of Breast disease
• The most common symptoms are pain, a palpable
mass, nipple discharge and"lumpiness“ (without a
discrete mass)
• Asymptomatic women with abnormal findings on
mammographic screening also require further evaluation.
I. Pain (mastalgia or mastodynia)
- is a common symptom, may be cyclic or noncyclic.
- Diffuse cyclic pain is related to mentrual cycle and due to
premenstrual oedema
- Noncyclic pain is usually localized to one area of the breast.
• roughly 95% of painful masses are benign
• about 10% of breast cancers are painful.
II. Palpable masses 
• are common
• must be distinguished from the normal nodularity of the
breast.
• The most common palpable lesions are cysts,
fibroadenomas, and invasive carcinomas,
• A breast mass generally becomes palpable when it is at
least 2 cm in size.
• Approximately 50% of carcinomas arise in the upper
outer quadrant, 10% in each of the remaining quadrants,
and about 20% in the central or subareolar region.
III. Nipple discharge

•  is a less common finding

• but it is most worrisome when it is spontaneous and unilateral
(underlying carcinoma)
• A small discharge is often produced by the manipulation of normal
breasts.
• Milky discharges (galactorrhea) are associated with elevated
prolactin levels ( pituitary adenoma) and some other endocrine
disorders. Galactorrhea is not associated with malignancy.
• Bloody or serous discharges - most commonly associated with
benign conditions however in a significant minority of cases can be
a sign of malignancy
 Mammographic screening 

• was introduced in the 1980s ,to detect small,

nonpalpable, asymptomatic breast carcinomas
• The principal mammographic signs of breast
carcinoma are densities and calcifications:
Densities
• produced by radiodense tissue within the breast
• are produced most commonly by benign lesions (rounded
densities) such as fibroadenomas, or cysts, and invasive
carcinomas(irregular masses)
• Most neoplasms are radiologically denser than the
intermingled normal breast tissue.
• Thus small, non palpable cancers can be indentified by
mammography ( can detect the mass < 2cm)
• Calcifications. 
• Calcifications form on secretions, necrotic debris, or
hyalinized stroma.
• Benign calcifications are often associated with clusters of
cysts ( fibrocystic disease), hyalinized fibroadenomas, and
sclerosing adenosis.
• Calcifications associated with malignancy are usually
small, irregular, numerous, and clustered.
• Ductal carcinoma in situ (DCIS) is most commonly
detected as mammographic calcifications
 Breast disease Neoplastic breast lesions
Non-neoplastic breast lesions
Epithelial Stromal

Inflammatory lesions Non-inflammatory lesions

Non neoplastic * Benign

Epithelial lesions
Malignant
Non-proliferative
(Fibrocystic changes)

Proliferative

w/o atypia

w atypia
Incidence of breast disease

Non neoplastic
Epitheial lesions
 Non-neoplastic breast lesions

BENIGN EPITHELIAL LESIONS

• Consequence of an exaggeration and distortion of

cyclic breast changes that occur normally in the
menstrual cycle.
• Age – during reproductive period of life, increases as
menopause gets nearer and persist after menopause
Classified into (3) groups according to the subsequent
risk of developing breast cancer

1. Non- proliferative breast changes (Fibrocystic

change)–
Includes cyst and/or fibrosis without epithelial
hyperplasia (Simple fibrocystic change)
2. Proliferative breast disease without atypia
3. Atypical hyperplasia (Proliferative breast disease
with atypia)
 Aetiology & pathogenesis
Ovarian hormones participate in the causation of
fibrocystic change
When time period nearer to menopause
 Failure of ovulation increases
 Relative imbalance between estrogen and
progesterone in each menstrual cycle
 Disturbances in the interaction of pituitary and
ovaries.
 Abnormal responsiveness of breast tissue to the
hormonal influences
 Non proliferative change

Fibrocystic change (Cysts and fibrosis)

• Most common type
• Characterized by an increased in fibrous stroma with
dilatation of ducts and formation of cysts of various
sizes.
• Clinically lumpy-bumpy breast on palpation
• Radiologist – a dense breast with cyst
• Pathologist- benign histologic finding

• Are not associated with increased risk of breast

cancer
FIBROCYSTIC CHANGES
• Morphology –
• Gross –
• single or multifocal lesions, not well demarcated
lesions, Size varies from 1 -5 cm
• Often bilateral
Three principle morphologic changes-
1. Cystic change,
2. fibrosis
3. adenosis
I. Cysts - Small cysts formed by dilation of lobules,
may unite to form larger cysts
• Contain turbid , semi-translucent fluid of a brown to
blue colour thus called blue dome cyst
• Calcifications are common& can be detected by
mammography.
II. Fibrosis – Cysts ruptured, releasing secretory material
into stroma resulting in chronic inflammation and
fibrosis contribute to palpable firmness of breast.
III. Adenosis – increase in the number of acini per lobule.
Lactational adneoma : a palpable mass in pregnancy or
lactating women, not proven to be neoplastic, represent
an exaggerated local response to gestational hormones
Fibrocystic change
Fibrosis
Fibrosis
Fat

Blue dome cyst Fat

Fibrosis

Scattered poorly demarcated white areas represent foci of fibrosis

red arrow – transected opened cyst
blue arrow – unopened blue dome cyst
 Fibrocystic change -
Non-proliferative lesion
 Proliferative breast disease without atypia

• Lesions characterized by proliferation of epithelial

cells, without atypia,
• Associated with a mild increased in the risk of
subsequent carcinoma in either breast
• Commonly detected as mammographic densities,
calcifications & incidental findings in biopsies
• Predictors of risk but not true precursor of carcinoma
 Morphology
1.Epithelial hyperplasia-
• Normal breast ducts and lobules are lined by 2 cell
layers- myoepithelial & luminal cells
• Increased number of both luminal and myoepithelial
cells fill and distend the ducts and lobules

Normal mammary ducts)

 • 2. Sclerosing adenosis – number of acini per terminal
duct is increased with stromal fibrosis

Normal mammary lobule with terminal duct

• 3.Complex sclerosing lesion - features of

components of sclerosing adenosis, papillomas and
epithelial hyperplasia
3. Papillomas – composed of multiple branching
fibrovasculr cores lined by luminal and myoepithelial
cells. ( large duct papilloma produce nipple
discharge)
 2. Proliferative breast disease with atypia
( Atypical hyperplasia)
• the histological features resemblance of carcinoma
in-situ
• Associated with moderate increased risk of
carcinoma
• Includes 2 forms -
• Atypical ductal hyperplasia
• Atypical lobular hyperplasia
• Grossly – the lesion is not distinct, dominated by
fibrous & cystic change.
• Histologically – there is a spectrum of proliferative
alterations.
• Atypical ductal hyperplasia – multiple layers of
proliferated epithelial cells showing cellular and
nuclear atypia, filling the dilated duct.
• Atypical lobular hyperplasia – proliferation of
lobular cells showing cellular and nuclear atypia
with retained acini structures.
• s/t contains calcifications produces
microcalcifications on mammography.
ADH ALH
PROLIFERATIVE BREAST LESION
CLINICAL SIGNIFICNCE OF BENIGN EPITHELIAL CHANGES**
( Proliferative and non-proliferative lesions )
• Association with invasive cancer of breast
1. non proliferative (fibrocystic) changes do not increase
the risk of cancer
2. Proliferative disease without atypia is associated with
mild increase in risk (1.5-two- fold increased risk)
3. Proliferative disease with atypia confers the moderate
increase in risk .( four to five-fold increased risk)
4. Both breast are at increased risk, althou’ the risk of
ipsilateral breast may be higher
5. A family history of carcinoma may increase the risk of
all categories. ( about 10 folds with atypical
hyperplasia.)
 Key Concept
Benign Epithelial Lesions
■ Benign epithelial lesions usually do not cause symptoms
but are frequently detected as mammographic calcifications or
densities.
■ These lesions are classified according to the subsequent
risk of cancer in either breast.
■ The majority are not precursors of cancer.
■ Although risk reduction can be achieved by surgery or
chemoprevention, the majority of women will not develop
cancer and many women choose surveillance instead of
intervention.
 Inflammatory disorders of breast

• Presents with erythematous swollen painful breast

• Can mimic inflammatory breast cancer
• Non-lactating women with the clinical appearance
of mastitis should always be suspected of
inflammatory cancer.
• Inflammatory disorders include
1. Acute mastitis
2. Periductal mastitis
3. Mammary duct ectasia
4. Fat necrosis
5. Sclerosing lymphocytic lobulitis
6. Granulomatous mastitis
 Acute mastitis (Acute pyogenic matitis)
• develops when bacteria, usually Staphylococcus
aureus, gain access to the breast tissue through the
ducts.
• The vast majority of cases arise during the early weeks
of nursing, when the skin of the nipple is vulnerable to
the development of fissures
• Clinically, staphylococcal infections induce typical acute
inflammatory changes, can progress to form single or
multiple abscesses
• Manifests with pain and tenderness of the breast
• heal with residual foci of scarring – palpable as
localized areas of induration
 Mastitis caused by other infections

Tuberculosis
• results from haematogenous spread from other source
• Fibrocaseous mass with the formation of sinuses
• Marked fibrous reaction giving rise firm mass that will mimic a
carcinoma.
Actinomycosis
• A rare infection
• Extension from lung through thoracic cage or
• Occurs as primary
• Hard lump beneath the nipple, may be painful but no
temperature change, mimicking a tumour
• Results in abscess formation
 Mammary duct ectasia (plasma cell mastitis)

• is a nonbacterial chronic inflammation of the breast

associated with inspissation of breast secretions in
the main excretory ducts.
• Ductal dilation and eventual rupture leads to reactive
changes in the surrounding tissue
• may present as a poorly defined periareolar mass
with nipple retraction, mimicking the changes
caused by some cancers.
• It is an uncommon condition usually encountered in
parous women between 40 and 60 years of age.
 Traumatic fat necrosis
• Uncommon,
• due to antecedent trauma to the breast in some women
• Produces mass
Morphology-
• small, often tender, rarely > 2cms, sharply localized
• Histology - Consist of central focus of necrotic fat cells
surrounded by neutrophils and lipid filled macrophages
• The focus is replaced by scar tissue ,debris becomes
encysted within the scar.
• calcification may develop.
Disorder of male breast
Gynaecomastia
 Gynaecomastia
• Is enlargement of male breast
• Only benign lesion seen in the male breast
• Presents with button-like subareolar enlargement
Morphology – a firm, mobile disc beneath the
nipple
• May be unilateral or bilateral, unilateral in 70% of
cases
Histology-
Normal histology of male breast - contains only
ductular structures with no acini, similar to
prepubertal female breast
Gynaecomastia In gynaecomastia -

- Increased in dense
collageneous connective
tissue stroma associated with
epithelial hyperplasia
of the duct lining with
characteristic micropapillae

- Stroma around the duct is

oedematous and myxoid

-Lobule formation is almost

never observed
Causes –
• Due to hormonal imbalance between estrogen and
androgen
• Estrogen stimulate breast tissue and androgen
counteract these effects
• May appear during puberty, very aged & adult when
there is hyperestrinism e.g. cirrhosis of liver.
• Drugs: alcohol, marijuana, heroin, antiretroviral therapy
& anabolic steroids have been associated with
gynaecomastia
• Functioning testicular neoplasms ( Sartoli or Leydig cell
tumours)
• Occurs as part of Klinefelter syndrome
Risk of cancer - may be associated with small increased risk
of breast cancer
THANK YOU