Breast Study Notes

Developmental Problems
- inverted nipples are common and may make nursing more dificult; if a previously-normal nipple inverts, you have a problem, i.e., something has retracted underneath, and it's the stroma of a cancer until proven otherwise
- vaginal hypertrophy - very large breasts developing around puberty; really hyperplasia; 
- hypomastia - almost complete failure of breast development

Inflammations: not common
- acute mastitis and breast abscess: usually occurs during early lactation, less often in pts with dermatitis; usually S. aureus, less often strep
- fat necrosis: a solid mass, often in a fat breast, caused by a blow or other injury; necrotic fat cells surrounded by mixed inflammatory infiltrate, later with calcification, foreign body reaction, and scarring
- duct ectasia - an uncommon cause of a breast mass, usually in older women, usually tender and with nipple retraction; chronic inflammation and fibrosis around ducts are typical
- galactocele - one or more ducts became plugged during lactation

Fibrocystic Disease of the Breast
- commonest disease of the breast; a lump or lumps
- unopposed estrogen is a known factor; est-progest pills pts get less incidence
- four patterns occur seperately or together - fibrosis, cyst formation, sclerosing adenosis, ductal epithelial hyperplasia
- cysts - dilated ducts containing cloudy serous fluid; likely to be tender during menses and after drinking coffee
- fibrosis - dense collagenization distorting and compressing the epithelial structures
	- most common in upper outer quadrants
- sclerosing adenosis - proliferation of small ductules and sometimes even acini in a fibrous stroma
- epithelial hyperplasia - includes such entities as ductal papillomas and atypical hyperplasia; probably premalignant

Fibroadenoma
- the most common benign breast tumor, occurs at any time during reproductive life, most often under age 30
- presents as a small, sharply circumscribed, freely movable nodule within the breast substance
- a loose stroma surrounds ducts that are often crushed flat
- cystosarcoma phyllodes - a bad term for worrisome fibroadenoma which exhibits metaplastic and/or anaplastic stroma and rapid growth; phyllodes tumor
	
Papilloma
- a less than 1 cm lesion in a major duct just below the nipple
- produces blood discharge, and occasionally nipple retraction
- one in 100 is a papillary carcinoma

Carcinoma of the Breast
- this is the commonest cancer in women, and still the most feared
- rare before age 25, more common with increasing age
- 1 woman in 9 will develop breast cancer
- usually a dominant, painless mass
- risk factors:
	- female gender
	- Jewish ancestry
	- increasing age
	- obesity
	- menarche before age 13 or menopause after 50
	- nulliparous women or those having their first child at a late age
	- not having lactated places a woman a slightly increased risk for pre-menopausal breast cancer
	- family history of breast cancer
		- probably due to anti-oncogene BRCA1 deletion syndrome on 17q
		- Li-Fraumeni and Cowden's are also considered important
	- history of high-dose radiation 
	- history of epithelial hyperplasia variant of fibrocystic disease
	- previous breast cancer
	- previous cancer of the endometrium
- cigarette smoking is not a risk factor
- tumor types:
	- carcinoma arising in mammary ducts
		- non-infiltrating (intraductal)
			- comedocarcinoma and other variants of carcinoma in situ
			- intraductal papillary carcinoma
		- infiltrating ductal carcinoma (90%)
			- scirrous carcinoma (75%)
				- very hard; cells arranged in Indian files in a desmoplastic stroma
			- medullary carcinoma
				- big, bulky, and soft; plentiful lymphocytes
			- mucinous carcinoma
				- clumps of cells in lakes of mucin; gelatinous mass; good prognosis
			- tubular carcinoma
				- best prognosis; well-formed glands one cell layer thick
			- Paget's disease of the nipple
				- intraepithelial growth of cancer cells in the nipple
				- most often an underlying duct carcinoma
	- carcinoma arising in mammary lobules
		- non-infiltrating lobular carcinoma
			- distinctive proliferation of the ductules and acini
			- associated with a high incidence of subsequent infiltrating ductal or 		lobular carcinoma
		- infiltrating lobular carcinoma
			- also produces Indian files
			- cells are small and lack much anaplasia
			- often bilateral; biopsy of the upper outer quadrant of opposite breast 
- the lesion is usually a dominant mass in a breast, and is almost always painless
- when examining look for:
	- nipple retraction
	- calcification
	- retraction and dimpling of skin
	- lymphedema
	- ulceratoin of overlying skin
	- inflammatory carcinoma
- prognosis
	- the presence or absence of metastatic tumor in the axillary lymph nodes is more important
	- favorable factors: detected by self examination, tiny cancers on mammography, presence of estrogen receptors and esp. progesterone receptors, diploidy, and tumor grade
	- unfavorable factors: findings on physical exam noted above, polyploidy, four or more positive axillary lymph nodes, positive internal mammary nodes, and if the disease has metastasized systemically, the disease in incurable
- course
	- breast cancer is often indolent; late recurrences common
- therapies
	- mastectomy with or without reconstruction
	- surgery with breast conservation
	- tylectomy
	- radiation
	- chemotherapy
	- hormonal manipulation

Diseases of the Male Breast
- gynecomastia
	- proliferation of a man's ducts and stroma, unilateral or bilateral
	- can be idiopathic, or due to hyperestrinism
	- other drugs are digitalis and spirolactone
- carcinoma of the male breast
	- uncommon, but very lethal
	- almost always an infiltrating ducal carcinoma, usually without much desmoplasia

The Breast Implant Fiasco