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Benign Breast Lesions

Lt Col Deep Kumar Raman., MD., DNB.,

Classified Specialist (Pathology)

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I ntroduction

Mammary glands ± Breasts

Distinguish Mammalia from all other Animals

Modified Sweat glands!!!

Important function for the newbornProvide complete nutritionImmunological support

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28 d 6w

6w 12 w birth

Emb ryology

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D evelop m ent

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D evelop m ent

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N orm al Anato m y

Skin and subcutaneous tissueNipple and areola15 ± 20 lactiferous ducts thatstart in the nipple1 lactiferous duct = 1 Breast lobe

Breast ductsBreast lobulesTerminal Duct lobular unit

Collagen and connective tissue Adipose tissue

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N orm al Anato m y

Basic functional unit ± Terminal Duct Lobular Unit (TDLU)

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H istology

Nipple, areola and initial lactiferous ducts ±squamous epithelium.Large ducts ± two layered cuboidal

TDLU ± two cell typesCuboidal luminal (secretory) cellsFlattened peripheral myoepithtelial cells

StromaµLoose¶ Hormone responsive intralobular stromaDense Interlobular stroma

Adipose tissue

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H istology

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D evelop m ental D isorders

Milkline remnantsSupernumerary Nipples / BreastsHormone sensitive

Painful premenstural engorgementCan be foci of other normal benignlesions of breast

Accessory axillary Breast tissue

Axillary tail of SpenceCan develop lactational change /carcinomas

Congenital nipple inversion

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Acquired disorders - Benign

Inflammatory DisordersBenign Epithelial Lesions

Non-proliferative Breast lesionsProliferative breast lesions w ithout AtypiaProliferative breast lesions w ith Atypia

Benign Stromal LesionsFibroadenomaPhyllodes tumour Other stromal lesions

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I nflamm atory D isorders

Periductal MastitisSub-areolar Abscess, Zuskadisease

90% smokersPainful erythematous sub-areolar mass + fistulaDue to sq metaplasia of lactiferous ducts block accumulation of secretions

Abscess FistulaRemove involved duct

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I nflamm atory D isorders

Mammary duct ectasia5-6 decade of life, multiparous womenPoorly defined palpable periareolar massThick whitish nipple secretionsDilated ducts with inspissated secretionsMorphology

Dilated ducts with debrisNumerous lipid laden macrophages inductsIntense periductal and interductalinflammatory infiltrate of lymphocytes andmacrophagesNo squamous metaplasia of ducts

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I nflamm atory D isorders

Fat necrosisPainless palpable mass, skin retractionMammographic densities / calcifications

Prior history of trauma / breast surgeryMorphology

Acute lesions ± haemorrhagic withliquifactive fat necrosisOlder lesions ± ill-defined, firm greyishwhite area with chalky white depositsNecrotic fat cells surrounded byinflammatory cells

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I nflamm atory D isorders

Lymphocytic mastopathyHard palpable masses, may be bilateral

Assoc with Type 1 DM and Autoimmune thyroiditis

Collagenised stroma surrounded by atrophic ducts

Granulomatous MastitisTB! TB!! TB!!!

Systemic granulomatous disordersForeign bodies / fungi / chronic infectionsGranulomatous lobular mastitis - ? autoimmune

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F ib rocystic disease

Umbrella term for non-proliferative benign lesions ±no risk of progression to cancer Clincally ± ³lumpy bumpy´ breast.

MorphologyCysts

Turbid fluid ± blue domed cysts Apocrine metaplasia

CalcificationFibrosis - with or without chronic inflammation

Adenosis ± increased acini per lobule; µBlunt duct adenosis¶

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F ib rocystic disease

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P roliferative Lesions ² N o atypia

Epithelial Hyperplasia (Epitheliosis)More than 2 cell thick ducts / lobulesProliferation of both cell types that fills and

distends ducts.Irregular compressed peripheral lumen

Sclerosing adenosisPalpable mass / radiological density

More than twice the normal acini per lobuleCentral distortion of ducts by dense stromaMyoepithelial cells may be prominent

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P roliferative Lesions ² N o atypia

Complex Sclerosing lesions Admixture of sclerosing adenosis,epitheliosis and papillomatosis

Radial Scar Type of complex sclerosing lesionHard palpable lumpCan mimic Ca clinically, radiologically andhistologically

Central nidus of entrapped compressedglands in a dense hyalinised stromaLong radiating projections into theadjacent areas

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P roliferative Lesions ² N o atypia

Intraductal PapillomasPresent as nipple discharge / subareolar lumpDilated ducts filled by multiplebranching papillaeCentral fibrovascular cores with atwo cell liningEpithelial hyperplasia andapocrine metaplasia may bepresentSmall duct papillomas present asmultiple smaller deeper situatedlesions

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P roliferative Lesions with Atypia

Atypical Ductal Hyperplasia5-15 % of biopsies for calcification / lumpsResembles DCISRelatively monomorphic proliferation of regularly spaced cells with irregular cribriform

spacesLimited extent and partial filling of ducts

Atypical Lobular hyperplasiaIncidental finding; <5 % of biopsiesResembles LCIS ± proliferation of cells in the

lobular aciniCells do not fill or distend more than 5 0% of theacini within a lobuleMay show pagetoid spread

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S tro m al Tu m ours

FibroadenomaPhyllodes tumour

OthersLipomaHamartomaPseudoangiomatous stromal hyperplasia

MyofibroblastomaFibromatosis

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F ib roadeno m a

Most common benign breast tumour Women in 20 s and 3 0 sPresent as lump breast / rarely as mammographic

calcificationSpherical firm rubbery nodules that are freely mobile(³Breast mouse´)Vary in size from tiny to very large.

Hormone responsive and show menstrual variationsUndergo lactational changes during pregnancy andcan increase in size.

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F ib roadeno m a

GrossRubbery well circumscribed greyish whitenodulesBulge on cutting

Thin slit like spaces

MicroscopyProliferation of glands and stroma.

Thin slit like compressed glands with twocell typesSurrounded by looses cellular myxoidinteralobular type stroma

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P hyllodes Tu m our

Arise from intralobular stroma Age ± 1 0 -20 yrs later than fibroadenomasUsually present as palpable massesVary in size from a few cms to very largeBulbous protusions / cyst formation may be seenHistologically similar to fibroadenomas but are

More cellular Increased mitotic rateNuclear pleomorphismInfiltrative patterns / margins

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P hyllodes Tu m our

Most are benign, but some may recur locallyRare distant metastasis

Wide local excision / mastectomy is themanagement of choice.High grade lesions have been assoc withamplification of EGFR gene

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