this pathology lecture covered various pathologies of the female breast. first we covered normal breast histoanatomy and physiology: breast tissue is made up of on a microscopic level of different cells such as luminal epithelial cells and myoepithelial cells, which produce milk and assist in milk ejection during lactation, respectively. "lobules" are formations of cells that are involved in milk production that are largely absent prepuberty and after menopause but appear during puberty and are copious during pregnancy. breast tissue structure and growth is directed by hormonal influences, in particular estrogen (stimulating duct elongation, branching and elasticity, as well as increased connective tissue and fat) and progesterone (lobule formation).
breast tissue is subject to various congenital anomalies: amastia is absence of breast tissue, nipple or areola, while amazia is absent mammary glands with normal outer anatomy. supernumerary nipple is an extra nipple in an ectopic location and supernumerary breast tissue is ectopic breast tissue, generally along the milk line. inverted nipple can be physiological in a small percentage of women, but can be pathological in cases of breast cancer.
galactorrhea is nipple discharge and can be simply from hormonal dysregulation or a side effect from drugs, or can be cause for concern if unilateral or accompanied by a breast mass. mastitis is an inflammation of the breast tissue parenchyma, called puerperal mastitis in lactating mothers. infectious mastitis can be caused from staph or strep epidermitis, and periductal mastitis is characterized by a painful mass in the sub-areolar area with an overlying erythema. periductal mastitis also has a strong correlation with smoking and nipple inversion.
mammary duct ectasia results from the dilation of sub-areolar ducts that appears histologically as dilated lactiferous ducts with granular debris such as lipid laden macrophages. it presents in the 5th or 6th decade of life, generally unilateral, with a palpable peri-areolar mass, thick nipple secretion, breast pain, and erythema. 30-40% of cases are associated with nipple inversion.
fibrocystic breast disease is an extremely common disorder and is the number one cause of surgical breast procedures. it is a non cancerous fibrotic change of breast tissue that results in lumps and cords and discomfort that can be exacerbated by hormonal or lifestyle influences. it will present during 20-40 years old and generally affect the upper outer quadrant of the breast. mammography will be interfered with because of the dense nature of the fibrotic tissue.
fat necrosis of the breast occurs in response to injury or surgery: rupture of adipocytes causes hemorrhage into the affected tissue, leading to lipolysis, conversion to fatty acids and glycerol, fibroblastic proliferation and walling off / vascularization of damaged tissue. it presents as a painless mass or area of skin accompanied by breast tissue retraction and skin thickening, and may show areas of high density (from fat) or calcifications on a mammogram.
lymphocytic mastopathy is characterized by single or multiple masses which are made up of collagenized / fibrotic stromal tissue that surrounds atrophic ducts and lobules. histologically, lymphocytic infiltrates surround the epithelium and blood vessels of the affected tissue. there is a strong correlation between lymphocytic mastopathy and type 1 DM and autoimmune thyroiditis and in general a sense that LM might be related to autoimmune dysfunction.
the last breast disorder in this lecture is granulomatous mastopathy, a mastitis characterized by giant cell / epitheloid cell granulomas with an idiopathic origin. this disorder can be seen in conjunction with other diseases such as breast carcinoma or TB, in which case the granulomas are caseating. in immunocompromised patients, granulomatous mastopathy is likely due to mycobacterial or fungal infection.
questions
normal breast anatomy...
1. how many ducts does the lactiferous duct system of the breast generally consist of?
2. what makes up the remainder of the non-milk producing breast tissue?
3. what are the two cell types in the lactiferous ducts and lobules and what do they do?
4. where does lymph from the breast flow to?
5. describe the changes that occur on the histological level during breast development through puberty.
6. what happens to the breast tissue on a histological level during a woman's 3rd decade of life and after menopause?
7. what effect does estrogen have on breast tissue?
8. what effect does progesterone have on breast tissue?
9. what are Montgomery tubercles?
congenital breast conditions...
10. what is amastasia?
11. what is amazia?
12. what is a supernumerary nipple? how common is it?
13. what is supernumerary breast tissue? where is it generally located?
14. what is inverted nipple and what is it caused by?
15. the diagnosis of a patient with inverted nipple must rule out what?
various pathologies...
16. what is galactorrhea and what is it caused by?
17. when might galactorrhea be a cause for concern?
18. what is mastitis?
19. what is "puerperal mastitis"?
20. cases of infectious mastitis are found to be due to which microorganisms?
21. what is periductal mastitis?
22. more than 90% of periductal mastitis patients are...
23. what is a common sequelae for periductal mastitis?
24. ∂escribe the histomorphology of periductal mastitis.
mammary duct ectasia...
25. what is mammary duct ectasia?
26. when does mammary duct ectasia generally affect women?
27. is mammary duct ectasia unilateral or bilateral?
28. what is the characteristic clinical presentation of mammary duct ectasia?
29. how common is nipple inversion associated with mammary duct ectasia?
30. what are the histologic findings of mammary duct ectasia?
fibrocystic breast disease...
31. what is fibrocystic breast disease?
32. fibrocystic tissue changes may cause...
33. how common is fibrocystic breast disease?
34. what age is fibrocystic breast disease generally diagnosed?
35. where are fibrocystic breast changes most often found?
36. why is mammography of limited value in diagnosing fibrocystic breast disease?
fat necrosis...
37. how does fat necrosis of the breast present?
38. what are the common causes of FN?
39. describe the pathogenesis of FN in breast tissue.
40. what is deposited within the affected area of FN?
41. what does mammography of the affected FN area reveal?
lymphocytic mastopathy...
42. what is lymphocytic mastopathy?
43. what are the histologic features of lymphocytic mastopathy?
44. why is it hypothesized that LM is an autoimmune disease?
granulomatous mastopathy...
45. what is granulomatous mastopathy?
46. what is the etiology of most granulomatous mastopathy?
47. granulomas may be seen in association with...
48. caseating granulomas of the breast may be due to...
49. breast granulomas in immunocompromised patients is likely due to...
answers
1. 4-18 ducts (modified sweat glands that lactate)
2. adipose, connective tissue, ligamentous tissue.
3. luminal epithelial cells (produce milk) and myoepithelial cells (assist in milk ejection during lactation, maintain normal structure and function of lobule and basement membrane)
4. 3/4 to the axillary lymph system, the rest to the para-sternal lymph, abdominal lymph, other breast.
5. before puberty: large ductal system, minimal lobules. after menarch: terminal ducts give rise to lobules, marked increase in interlobular stoma.
6. lobules and stromal tissues begin to involute, then lobules almost completely disappear after menopause.
7. estrogen stimulates duct elongation and branching, increased volume and elasticity of connective tissue, increased deposition of adipose tissue, increased elasticity of ducts. [more CT, fat, elastic ducts]
8. progesterone stimulates lobule formation.
9. glands on areola that aid in lubrication of the nipple.
10. absent breast tissue, nipple, or areola.
11. absent mammary glands but nipple and areola present.
12. presence of one or more additional nipple. 2-6% females and 1-3% males.
13. breast tissue in an ectopic location, generally along the milk line.
14. nipple that points into the breast, caused by fibrous bands of tissue.
15. breast cancer.
16. nipple discharge from hormonal dysregulation, or drug side effect.
17. if it is unilateral, bloody, or associated with a breast mass.
18. inflammation of the parenchyma of mammary gland.
19. mastitis of lactating mothers.
20. staph or strep epidermitis.
21. a painful mass in the sub-areolar area with an overlying skin erythema.
22. smokers.
23. nipple inversion.
24. keratinizing squamous epithelium, chronic granulomatous inflammation.
25. dilatation of sub-areolar ducts.
26. 5th or 6th decade of life.
27. unilateral.
28. palpable but poorly defined peri-areolar mass, thick nipple secretion, breast pain, maybe erythema.
29. 30-40% of cases.
30. dilated lactiferous ducts filled with granular debris (such as lipid laden MØ's).
31. fibrous, non-cancerous lumps and cords in the breast tissue.
32. discomfort related to hormonal cycles or life style influences.
33. single most common disorder of breast, accounts for more than half of surgical procedures for breast.
34. between 20-40.
35. upper outer quadrant.
36. because the dense fibrotic tissue will interfere with proper visualization of the breast tissue.
37. painless mass or area of skin, with breast tissue retraction, skin thickening.
38. prior breast trauma, surgery.
39. rupture of adipocytes and hemorrhage into affected area, followed by lipolysis and conversion to fatty acids and glycerol, followed by fibroblastic proliferation and increased vascularization walling off affected area.
40. calcium, hemosiderin.
41. central radiolucent, high density fat, possible calcifications at periphery.
42. single or multiple hard masses made of collagenized stroma surrounding atrophic ducts/lobules.
43. thickened/fibrotic stromal tissue, lymphocytic infiltrates surrounding epithelium and blood vessels.
44. because of its association with type 1 DM or AI thyroiditis.
45. mastitis characterized by granulomas formed by epitheloid cells and giant cells.
46. idiopathic.
47. breast carcinoma.
48. tuberculosis. (uncommon)
49. mycobacterial or fungal infection.
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