BREAST DISEASE
Ed Friedlander, M.D., Pathologist
scalpel_blade@yahoo.com

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Welcome to Ed's Pathology Notes, placed here originally for the convenience of medical students at my school. You need to check the accuracy of any information, from any source, against other credible sources. I cannot diagnose or treat over the web, I cannot comment on the health care you have already received, and these notes cannot substitute for your own doctor's care. I am good at helping people find resources and answers. If you need me, send me an E-mail at scalpel_blade@yahoo.com Your confidentiality is completely respected. No texting or chat messages, please. Ordinary e-mails are welcome.

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Especially if you're looking for information on a disease with a name that you know, here are a couple of great places for you to go right now and use Medline, which will allow you to find every relevant current scientific publication. You owe it to yourself to learn to use this invaluable internet resource. Not only will you find some information immediately, but you'll have references to journal articles that you can obtain by interlibrary loan, plus the names of the world's foremost experts and their institutions.

Alternative (complementary) medicine has made real progress since my generally-unfavorable 1983 review. If you are interested in complementary medicine, then I would urge you to visit my new Alternative Medicine page. If you are looking for something on complementary medicine, please go first to the American Association of Naturopathic Physicians. And for your enjoyment... here are some of my old pathology exams for medical school undergraduates.

I cannot examine every claim that my correspondents share with me. Sometimes the independent thinkers prove to be correct, and paradigms shift as a result. You also know that extraordinary claims require extraordinary evidence. When a discovery proves to square with the observable world, scientists make reputations by confirming it, and corporations are soon making profits from it. When a decades-old claim by a "persecuted genius" finds no acceptance from mainstream science, it probably failed some basic experimental tests designed to eliminate self-deception. If you ask me about something like this, I will simply invite you to do some tests yourself, perhaps as a high-school science project. Who knows? Perhaps it'll be you who makes the next great discovery!

Our world is full of people who have found peace, fulfillment, and friendship by suspending their own reasoning and simply accepting a single authority that seems wise and good. I've learned that they leave the movements when, and only when, they discover they have been maliciously deceived. In the meantime, nothing that I can say or do will convince such people that I am a decent human being. I no longer answer my crank mail.

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Courtesy of CancerWEB

LEARNING OBJECTIVES

We have often seen in the breast a tumor exactly resembling the animal the crab. Just as the crab has legs on both sides of his body, so in this disease the veins extending out from the unnatural growth take the shape of a crab's legs. We have often cured this disease in its early stages, but after it has reached a large size no one has cured it without operation. In all operations we attempt to excise a pathological tumor in a circle in the region where it borders the healthy tissue.

KCUMB Students
"Big Robbins" -- Breast
Lectures follow Textbook

QUIZBANK

Breast / Heme (?!)
Taiwanese pathology site
Good place to go to practice

Breast
Surgical Pathology Atlas
Nice photos, hard-core

Archive of Histologic Images
of Gynecologic & Breast Path
Greek, minimal commentary

Breast Images
University of Washington
Pictures and comments

Gynecologic and Breast Pathology
Photomicrograph collection
In Portuguese

Breast Slides
Iowa Virtual Microscopy
Have fun

Breast

Chaing Mi, Thailand

Breast Diseases
Nice pathology photos
Recommended

breast-cancer.ca (?!)
Popular site
Amazingly good
pathology section

Breast
Photos, explanations, and quiz
Indiana U.

Breast
Brown Digital Pathology
Some nice cases

Breast Exhibit
Virtual Pathology Museum
University of Connecticut

Digital Atlas of Breast Pathology
Meenakshi Singh, MD
Outstanding resource

Breast
Photo Library of Pathology
U. of Tokushima

Breast
"Pathology Outlines"
Nat Pernick MD

REVIEW OF ORIGIN, ANATOMY, PHYSIOLOGY

{47710} {47732} {47725}

{20793} normal breast
{11769} normal breast, histology
{11770} normal breast, histology
{10748} pregnant lady's breast

Normal breast

WebPath Photo -- comments are down right now

Normal breast

WebPath Photo -- comments are down right now

Pregnant lady's breast

WebPath Photo -- comments are down right now


{49361} supernumerary nipple
{12439} supernumerary nipple

DEVELOPMENTAL PROBLEMS

{49360} giant fibroadenoma in a teen

{49359} hypoplasia of breast

INFLAMMATIONS: Not common.

{49350} lipogranuloma from ruptured polyethylene breast implant

Breast -- non-neoplastic
From Chile
In Spanish

Mastitis / Fat Necrosis
From Chile
In Spanish

"FIBROCYSTIC CHANGE OF THE BREAST" (don't call it mammary dysplasia, chronic cystic mastitis, etc.)

{21062} fibrocystic changes, breast
{25567} fibrosis of breast
{25568} fibrosis of breast
{25569} cystic change of breast

Fibrocystic change

WebPath Photo -- comments are down right now

Fibrocystic change of breast

KU Collection

Breast cyst

WebPath Photo -- comments are down right now

Fibrocystic change
Microcalcification
WebPath Photo -- comments are down right now

Fibrocystic change

WebPath Photo -- comments are down right now

Sclerosing Adenosis
Dino Laporte's PathosWeb

Sclerosing adenosis

WebPath Photo -- comments are down right now

Hyperplasia

WebPath Photo -- comments are down right now

Hyperplasia

WebPath Photo -- comments are down right now

Atypical hyperplasia

WebPath Photo -- comments are down right now

PROLIFERATIVE BREAST DISEASE (review NEJM 353: 229, 2005)

{25570} sclerosing adenosis

RADIAL SCAR is a star-shaped fibrosing lesion that looks like a typical crablike cancer on mammography but that proves utterly benign on excisional biopsy and confers no increased cancer risk. A larger version is called COMPLEX SCLEROSING LESION. See Am. J. Surg. 180: 428, 2000.

Radial scar of breast
AFIP. Quite benign.
Wikimedia Commons

* Don't worry about the baffling "collagenous spherulosis" or a host of other benign lesions.

FIBROADENOMA (pathology: Am. J. Clin. Path. 115: 736, 2001)

{08461} fibroadenoma, gross
{08942} fibroadenoma, histology
{08943} fibroadenoma, histology
{08944} fibroadenoma, histology

Fibroadenoma of breast
Great labels
Romanian Pathology Atlas

Fibroadenoma

KU Collection

Fibroadenoma

WebPath Photo -- comments are down right now

Fibroadenoma

WebPath Photo -- comments are down right now

Fibroadenoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Phyllodes tumor

WebPath Photo -- comments are down right now

LARGE DUCT PAPILLOMA

{20230} intraductal papilloma

Papilloma

WebPath Photo -- comments are down right now

INTRODUCING CARCINOMA OF THE BREAST ("breast cancer").

Breast Tumors I
From Chile
In Spanish

Breast Tumors II
From Chile
In Spanish

Breast Tumors III
From Chile
In Spanish

Breast Cancer
Dino Laporte's PathosWeb

Breast Cancer
Australian Pathology Museum
High-tech gross photos

Breast cancer
Ed Uthman
Wikimedia Commons

{00120} breast carcinoma, gross, skin dimpling
{00126} breast carcinoma, gross, recurrent at mastectomy site
{07561} breast carcinoma, gross
{10924} breast carcinoma, gross
{10928} breast carcinoma, gross
{12441} breast carcinoma, gross
{12533} breast carcinoma, infiltrating, gross
{49362} breast carcinoma
{49352} breast carcinoma
{24600} breast carcinoma
{10749} breast carcinoma
{00123} breast carcinoma, cytology

NONINVASIVE ("IN SITU") CARCINOMA

Cancerization of lobules
Breast
Wikimedia Commons

{10931} Paget's disease of breast, gross
{24449} Paget's disease of breast

Paget's

WebPath Photo -- comments are down right now

Paget's

WebPath Photo -- comments are down right now

Paget's
PAS stain
WebPath Photo -- comments are down right now

{12527} intraductal breast carcinoma, comedocarcinoma pattern
{12530} intraductal breast carcinoma, comedocarcinoma of breast pattern
{15498} intraductal breast carcinoma

{15525} lobular carcinoma in situ
{15526} lobular carcinoma in situ

Lobular carcinoma

WebPath Photo -- comments are down right now

Breast cancer
Ed Lulo's Pathology Gallery

Cribriform cancer

WebPath Photo -- comments are down right now

Comedocarcinoma

WebPath Photo -- comments are down right now

Comedocarcinoma
Dystrophic calcification
WebPath Photo -- comments are down right now

Breast cancer
Inked margins
WebPath Photo -- comments are down right now

Fine needle aspiration

WebPath Photo -- comments are down right now

Scirrhous cancer

WebPath Photo -- comments are down right now

Breast cancer
Microcalcifications
WebPath Photo -- comments are down right now

infiltrating breast cancer
Microcalcification
WebPath Photo -- comments are down right now

Breast cancer
Both phases
WebPath Photo -- comments are down right now

Scirrhous cancer

WebPath Photo -- comments are down right now

Scirrhous cancer

WebPath Photo -- comments are down right now

Scirrhous cancer

WebPath Photo -- comments are down right now

Breast cancer
Both phases
WebPath Photo -- comments are down right now

Scirrhous cancer

WebPath Photo -- comments are down right now

Cribriform breast adenocarcinoma
Classic drawing
Adami & McCrae, 1914

Breast Adenocarcinoma
Text and photomicrographs. Nice.
Human Pathology Digital Image Gallery

Breast
Ductal CIS
Wikimedia Commons

INFILTRATING (INVASIVE) BREAST CARCINOMA

Invasive ductal carcinoma of the breast
Great labels
Romanian Pathology Atlas

{15488} carcinoma of breast, colloid type

Mucinous / colloid cancer

WebPath Photo -- comments are down right now

{15484} carcinoma of breast, infiltrating lobular type
{15485} carcinoma of breast, infiltrating lobular type

Indian Files
David Barber MD -- KCUMB

Breast cancer
Indian files
KU Collection

Infiltrating lobular carcinoma

WebPath Photo -- comments are down right now

Lobular carcinoma
Indian files
WebPath Photo -- comments are down right now

AFTER THE DIAGNOSIS OF BREAST CANCER IS MADE...

{04607} metastatic breast carcinoma in brain, scan

{24707} post-mastectomy, post-radiation with lymphedema
{12442} reconstruction after mastectomy

Adenoid cystic carcinoma
of the breast
Pittsburgh Illustrated Case

DISEASES OF THE MALE BREAST

{49363} gynecomastia
{12512} gynecomastia, histology
{49434} gynecomastia, 5 year old male, some kind of hormonal problem

Gynecomastia

WebPath Photo -- comments are down right now

{24603} carcinoma of breast, man

OTHER CANCERS

THE BREAST IMPLANT FIASCO: The U.S. public pays for willful ignorance of the fundamental methods of science and rational decision-making, with ordinary decent women, as usual, the big losers (NEJM 326: 1696, 1992; NEJM 342: 781, 2000).

Silicone implant

WebPath Photo -- comments are down right now

Silicone implant
In place
WebPath Photo -- comments are down right now

Silicone leak
Granulomas
WebPath Photo -- comments are down right now

* In April 1992, the FDA banned the use of silicone breast implants except in studies, even for women with mastectomies (NEJM 326: 1713, 1992). In previous years, about 120,000 women per year got breast implants for breast augmentation (i.e., "to look better"), and 30,000 got the implants for reconstruction after mastectomy.

* The "scientific rationale" was slim but not altogether lacking. We do know that silicone slowly leaks out through the capsule of the implant. There was a series of four women with implants who then got scleroderma (Ann. Int. Med. 111: 377, 1989). One other patient with a ruptured implant got "scleroderma" and it resolved (!) when the implant was removed (Arch. Derm. 126: 1198, 1990). Somebody was impressed enough to coin the term "human adjuvant disease", conjecturing that the gel was causing people to get sensitized to their own proteins, and the rest is history.

* Shortly after the ban, a California study found anti-nuclear antibodies in 11 women with implants plus scleroderma (most common), lupus, or some overlap syndrome; there was no typical serologic picture, but the study related disease onset to traumatic rupture of the implants (Lancet 340: 1304, 1992). The most interesting work I've seen so far was 3 cases from South Carolina, in which silicone was demonstrated at sites of connective tissue disease, and the illness remitted after removal of the implants (Arch. Derm. 129: 63, 1993). A Danish mega-review found only 32 cases of all connective tissue disease, mostly scleroderma (Kjoller et. al., 93134723, abstract), "much less than you'd expect by chance" (gee whiz), but was impressed by anecdotes of disease clearing on removal of the implants. A big review found no increase in connective tissue disease in implant recipients: NEJM 332: 1666, 1995; the only recent "study" that found a link took women's self-reports and made no attempt to confirm them (i.e., if an implant recipient said she had lupus, then she had lupus). Updates: NEJM 334: 1505 & 1513, 1996; Neurology 46: 308, 1996 ("neuromythology of silicone breast implants"); Plast. Recon. Surg. 99: 1362, 1997; Br. Med. J. 316: 147, 1998 seems to have finished the "connective tissue disease" claim off. Most recently, there was an essentially negative study in Am. J. Epidem. 160: 691, 2004. "Antipolymer antibody"'s existence remains unsubstantiated by the general scientific community. The link with fibromyalgia (which is a real disease / syndrome but one that a pathologist cannot exhibit) remains a public concern and I think with some reason. The FDA did a survey of recipients' health and x-rayed to see if the silicone had leaked. When the obvious confounders were controlled for, everything pretty much disappeared except for a link between implant rupture and "fibromyalgia". Nobody's reproduced this surprising finding yet, previous studies were negative (J. Rheum. 27: 2237, 2000) or extremely weak (the Wichita group suggested that psychological factors contribute both to fibromyalgia and to getting implants), and the folks in Denmark found that whether or not the implants have ruptured seems to have no effect on how Danish women say they feel (Plast. Rec. Surg. 111: 723, 2003). A huge meta-analysis found nothing except people misinterpreting foreign-body reactions as evidence of systemic disease, and examining flaws in the previous work: Plast. Rec. Surg. 120: 625, 2007. Flow cytometry and sub-subclassification of circulating lymphocytes shows no differences ("no pro-inflammatory effect") in implant patients (Plast. Rec. Surg. 121: 25, 2008).

* Under a 1976 law, manufacturers had to prove their devices were "safe and effective". Of course, that doesn't mean risk-free. The FDA merely had to decide that the benefits outweighed any demonstrated risks. Unfortunately, because the benefits of breast augmentation are subjective, the FDA acted as if there were no benefits (NEJM 326: 1695, 1992). Internal memos from manufacturers of the implants painted a less-than-edifying portrait of corporate America. "Consumer advocates" who have always tolerated alcohol and tobacco (including all those tobacco advertisements directed at young girls) presented anecdotes and scare-stories designed to terrify the two-million-plus women with implants. Militant feminists were divided between "a woman's right to make decisions about her own body" and the need to oppose the "sexist" pressures that makes some women feel they needed breast augmentation in the first place. (It seems to your lecturer that a reasonable person can say "no" to the latter while still supporting the former.) The result was a media circus that led to the ban, as well as around $4 billion dollars in liability payments; the whole thing may end up costing $40-$60 billion (Science 276: 1564, 1997). See also Cleveland Clinic J. Med. 59: 539, 1992; Plast. Rec. Surg. 90: 1102, 1992; CMAJ 147: 772, 1127 & 1141, 1992; Arthr. Rheum. 39: 1615, 1996. It was ironic, in mid-1994 in the wake of the (expected) studies showing no serious risk (NEJM 330: 1697, 1994 was best-known), to hear the same investigative journalists turn wildly indignant against the FDA's ban ("Government interference in our private lives!") A psychologist explains how this sort of thing contributes to public ill-health by making people somatize: Ann. Rheum. Dis. 60: 653, 2001. We need a word to go with "iatrogenic disease" to describe people who develop real (though subjective) symptoms because of pop claims about things that are probably harmless (other people's perfume, other people eating peanuts on the airplane, etc.) The FDA decided in late 2003 not to allow the devices to be reintroduced, then reversed itself in late 2006, and fourteen years after their withdrawal, they are available again (Br. Med. J. 333: 1139, 2006). I've given up trying to make sense of this.

KNOW: In late 2008, a Dutch group reported a tiny-sample association between the very-rate ALK-negative anaplastic large T-cell lymphoma and implants (JAMA 300: 2030, 2008). Cases of lymphoma in the implant capsule pop up from time to time, though they are thankfully still very rare; they are generally of the anaplastic large T-cell type (Plast. Recon. Surg. 126: 39e, 2010; Cancer 117: 1478, 2011; Plast. Recon. Surg. 127: 2141, 2011; Plast. Recon. Surg. 128: 629 & 112e, 2011). You'll need to warn patients of this very rare risk, which is probably real.

By the way: "Women who undergo breast augmentation with silicone implants have a lower risk of breast cancer than the general population. This finding suggests that these women are drawn from a population already at low risk and that the implants do not substantially increase the risk (NEJM 326: 1649, 1992)". Well, looking at the statistics again, there probably isn't any real effect one way or the other (NEJM 332: 1535, 1995; Plast. Rec. Surg. 120(S1): 70-S, 2008). For some reason that I cannot explain, nobody seems to have looked at bust size as a natural risk factor for breast cancer.

* In Isaac Bashevis Singer's famous short story Gimpel the Fool, one of the characters dies of cancer of the breast. The story deals with a simple baker's struggle to be a good person in a world full of deceit. Highly recommended.

BIBLIOGRAPHY / FURTHER READING

*SLICE OF LIFE REVIEW

{11770} breast, normal
{14992} mammary gland (prepubertal), normal
{14992} mammary gland (prepubertal), normal
{14993} mammary gland (prepubertal), normal
{14993} mammary gland (prepubertal), normal
{14994} mammary gland (secreting), normal
{14994} mammary gland (secreting), normal
{14995} mammary gland (secreting), normal
{14995} mammary gland (secreting), normal
{14996} mammary gland (ct stain), normal
{14996} mammary gland (ct stain), normal
{14997} mammary alveolus (active), normal
{14997} mammary alveolus (active), normal
{14998} mammary ducts (mature), normal
{14998} mammary ducts (mature), normal
{14999} mammary ducts (mature), normal
{14999} mammary ducts (mature), normal
{17489} breast, normal
{20293} breast, normal
{20690} mammary gland, normal
{20690} mammary gland, normal
{20691} mammary gland, gland epithelium
{20693} mammary gland, gland epithelium
{20694} mammary gland, gland epithelium
{20793} mammary gland
{20794} mammary gland
{20968} mammary gland
{20969} mammary gland, alveolus
{50571} breast, normal duct
{50572} breast, normal duct

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