Surgical Breast Pathology
Juan C. Cendan, MD
Assistant Professor of Surgery
Objectives of Lecture
• Categorize risk factors for cancer
– Highlight future cancer risk for a given benign
lesion
• Describe diagnostic workup for breast
masses and tools available to the clinician
• Provide up-to-date guidelines in the
screening and diagnosis of breast masses
• Brief review of surgical options and
implications in patients with breast cancer
Assessment of Risk/History
• Four major risks (increase RR by 4x):
– Family history
• 1st degree relatives
• Age at diagnosis, BRCA1/2 risk
– Atypical hyperplasia on prior biopsies
– Personal breast cancer history
– LCIS
Assessment of Risk/History
• Four Minor Risk Factors: 1-2x RR
–
–
–
–
–
Early menarche
Long interval from menarche to 1st child
Nulliparity
Ovarian or endometrial cancer
Estrogen therapy after menopause
Physical Exam
• Be systematic
– Inspection of breasts: sitting up, then
recumbent
• “Strip method”
– Nipples
– Lymph nodes
Clinical Examination of a Patient with Benign Breast Disease
Santen, R. J. et al. N Engl J Med 2005;353:275-285
Common Benign Breast Disorders in Women
Santen, R. J. et al. N Engl J Med 2005;353:275-285
Diagnostics
• Standard screening mammogram
– CC and MLO
• Diagnostic mammogram
– Above, plus compression/additional views
• In either case, 5-10% false negative and
90-95% sensitivity
Cranio-caudal (CC) view and mediolateral oblique (MLO) mammographic view
Atypical Hyperplasia
Histopathological Appearance of Benign Breast Disease (Hematoxylin and Eosin)
Panel A shows nonproliferative fibrocystic changes:the architecture of the terminal-duct lobular unit is distorted by the
formation of microcysts,associated with interlobular fibrosis.Panel B shows proliferative hyperplasia without atypia.
This is adenosis,a distinctive form of hyperplasia characterized by the proliferation of lobular acini,forming crowded
gland-like structures.For comparison,a normal lobule is on the left side.Panel C also shows proliferative hyperplasia
without atypia.This is moderate ductal hyperplasia,which is characterized by a duct that is partially distended by hyperplastic epithelium within the lumen.Panel D again shows proliferative hyperplasia without atypia,but this is florid ductal
hyperplasia:the involved duct is greatly expanded by a crowded,jumbled-appearing epithelial proliferation.Panel E
shows atypical ductal hyperplasia:these proliferations are characterized by a combination of architectural complexity
with partially formed secondary lumens and mild nuclear hyperchromasia in the epithelial-cell population.Panel F
shows atypical lobular hyperplasia:monotonous cells fill the lumens of partially distended acini in this terminal-duct lobular unit.
Hartmann, L. C. et al. N Engl J Med 2005;353:229-237
Diagnostics
• Ultrasound
– Useful in the young
– Useful in pregnant women
– Delineates solid vs cystic
• MRI
– Possibly the future of breast diagnostics,
not there yet, limitations with biopsy
Solid (Suspicious) Breast Mass
Cyst
Fibroadenoma
Biopsy techniques
• Palpable solid mass
– Needle or core biopsy
– Incisional or excisional biopsy
• Non-palpable mass
– Stereotactic core
– Stereotactic “mammotome”
– Needle localized biopsy
Some Benign Conditions
• Nipple Discharge
– Incidence of malignancy when bloody (1015%) and unilateral, though usually
papilloma
– More likely cystic or duct ectasia
– Consider prolactin if bilateral
Benign, con’t
• Fibroadenoma
–
–
–
–
Very common in young women
Freely mobile and smooth
Characteristic u/s appearance
Half of adenomas resolve if <3cm over
5yrs
• Large adenomas should be biopsied to exclude
rare phylloides tumor
Benign, con’t
• Cysts
– Due to relative excess estrogen, usually in
4-5th decades
– Fluctuate with menses
– Aspirate, if bloody then excise, send fluid
for path the first time
Benign, con’t
• Abscess,
–
–
–
–
Usually in lactating women
Painful and erythematous
Usually staph and strep
Drainage and antibiotics indicated
• Rarely, can aspirate and treat with antibiotics
• Caveats, in nonlactating (Ca), non-resolving
(atypical infection), inflammatory cancer
Classification of Benign Breast Lesions on Histologic Examination, According to the Relative
Risk of Breast Cancer
Santen, R. J. et al. N Engl J Med 2005;353:275-285
Risk of Breast Cancer According to Breast Density in Premenopausal and Postmenopausal
Women
Santen, R. J. et al. N Engl J Med 2005;353:275-285
Risk of cancer of benign breast lesions, Hartmann et al,
NEJM 2005
Lesion
RR
Non
1.27
Proliferative
FHx
Age
Weak
Strong
<45
>55
0.9
1.62
1.27
1.31
Proliferative
no atypia
1.88
1.57
2.2
2.27
1.63
Atypia
4.24
2.95
4.0
7
3.37
Gail, J Natl Cancer Inst. 1989 Dec 20;81(24):1879-86.
Race
W
W
W
W
W
Age
45
62
62
62
62
Age 1st
menses
13
13
13
13
13
Age 1st
live birth
21
21
21
21
21
#1a
relatives
0
0
1
1
1
# prior
breast bx
0
0
0
3
3
?Atypia
N
N
N
N
Y
% Risk
per year
.7
1.4
2.9
4.4
8.4
Risk over
life
8.6
6.2
12.8
18.6
32.6
Examples of Outcomes among 100 Women Followed for an Average of 15 Years: Explaining
Relative Risk Calculations to Patients… Start with known risk and “translate” it to an absolute
risk
Elmore, J. G. et al. N Engl J Med 2005;353:297-299
Cancer
• Most women with breast cancer have
no risk factors!
• Role of dietary fat, estrogen
• Breast cancer genes responsible for 35% only
Cancer
• DCIS
– Carcinoma in situ
– Usually found on mammography as
microcalcifications
– Felt to progress to invasive in 30-50% if
untreated
– Subtypes: comedo highest risk
Cancer
• DCIS, con’t
– Treatment
• Non-invasive, so risk of LN disease is minimal
• Must treat the breast, options:
– Excise with large enough margins (>1cm) in a small
tumor
– Or, Excise and radiate
– Or, Mastectomy +/- reconstruction
Cancer
• Invasive Ductal Cancer
– “Garden variety breast cancer”
– More often presents with mass than DCIS
– Treatment:
• BREAST: Excise and RT or mastectomy,
Cannot just excise with margins (30-40% recur)
• Lymph Nodes: Must be sampled for staging
– Sentinel Node vs Axillary Dissection
Cancer
• Chemotherapy
– Recommended for tumors >1cm in most
patients
– Recommended if lymph nodes are positive
– 8 recommended chemo protocols at this
time!!
• ER positivity and Tamoxifen
Cancer
• Survival
Stage
I
II
III
IV
Survival Rate %
96%
82%
53%
18%