Breast-nonmalignant
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Last revised 14 January 2008
Last major update November 2007
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Table of Contents - Breast-nonmalignant
General: primary references, WHO classification, embryology, neonatal, thelarche, normal anatomy, normal histology, pregnancy/lactation, pubertal macromastia
Congenital anomalies: amastia/hypoplasia, accessory glandular tissue, aplasia, athelia, nipple inversion, supernumerary
Procedures: biopsy marking devices, cautery artifact, core biopsy, cytology, open biopsy/frozen section, MRI directed, reduction mammoplasty
Inflammatory / infectious / parasitic: acute mastitis/abscess, duct ectasia, fat necrosis, foreign body reaction, fungi, giant cell arteritis, granulomatous mastitis, hemorrhagic necrosis, infarct, lymphocytic mastitis, Mondor's disease, nephrogenic systemic fibrosis, ossification, parasites, plasma cell mastitis, polyarteritis nodosa, reactive spindle cell nodule, sarcoidosis, silicone implants, tuberculosis
Fibrocystic disease: general, apocrine metaplasia, chronic inflammation, collagenous spherulosis, columnar cell lesion, cystic hypersecretory hyperplasia, cysts, epithelial ductal hyperplasia, fibroadenomatoid change, fibrosis, microcalcifications, pseudolactational hyperplasia, radial scar, sclerosing lobular hyperplasia
Adenosis: general, adenomyoepithelial, blunt duct, microglandular, sclerosing, tubular
Benign (usually) tumors/changes: adenomyoepithelioma, amyloid tumor, angiolipoma, apocrine adenoma, atypical or benign vascular proliferations post-radiation, Carney’s syndrome, chondrolipoma, clear cell “sugar” tumor, cylindroma, ductal adenoma, eccrine spiradenoma, fibroadenoma, fibromatosis, galactocele, granular cell tumor, gynecomastia-like, hamartoma, hemangioma, hemangiopericytoma, inflammatory pseudotumor, juvenile xanthogranuloma, lactating adenoma, leiomyoma, lipoma, lymphangioma, mucocele, myoepithelioma, myofibroblastoma, nipple adenoma/florid papillomatosis, nodular mucinosis, papilloma, phyllodes, pleomorphic adenoma, pseudoangiomatous stromal hyperplasia (PASH), subareolar sclerosing duct hyperplasia, syringomatous adenoma of nipple, tubular adenoma
Atypical hyperplasia: flat epithelial atypia, atypical ductal hyperplasia (ADH), atypical lobular hyperplasia (ALH)
Go to Breast-malignant chapter (DCIS, invasive carcinoma, other malignancies, miscellaneous, children, males)
Primary references for Breast chapter
American Journal of Clinical Pathology (AJCP) [free full text, no registration after 1 year]; January 2000 to November 2007
American Journal of Surgical Pathology (AJSP), March 1977 to October 2007
Archives of Pathology and Laboratory Medicine (Archives) [free full text, no registration always]; January 1976 to October 2007
BMC Clinical Pathology [free full text, no registration always]; December 2003 to 19 September 2007
Cytojournal [free full text, no registration always]; July 2004 to 31 October 2007
Human Pathology (Hum Path), March 1970 to October 2007
Modern Pathology (Mod Path) [free full text, no registration after 1 year]; January 1988 to September 2007
Rosen: Tumors of the Mammary Gland (AFIP Fascicle, 3rd series, volume 7); 1994
Rosai, J: Ackerman’s Surgical Pathology (9th Ed), Mosby, 2004
Sternberg, S: Diagnostic Surgical Pathology (4th Ed); Lippincott Williams & Wilkins, 2004
Websites (images): Digital Atlas of Breast Pathology, Johns Hopkins Breast Center, National Institutes of Health, Online Management of Breast Diseases, PathologyResources.com (online version of AFIP fascicle 3rd Series)
Virtual slides: University of Iowa, USCAP
Journal search terms: “breast” and each topic below
Please refer to these primary references for more detailed discussions and photographs
WHO classification of breast tumors
2003 classification: Table, listing
References: Tavassoli: Tumours of the Breast and Female Genital Organs (WHO, 2003, Volume 4)
Breast is considered an epidermal gland because it develops as diverticula of epidermis into dermis
Breast is also considered a modified and highly specialized apocrine gland
Mammary gland development begins at week 4, when ectoderm and underlying mesoderm proliferate and differentiate into skin
Week 4: paired ectodermal thickenings called mammary ridges or milk lines develop along ventral embryo and extend in curvilinear convex pattern from axilla to medial thigh; ridges will eventually disappear except at 4th intercostal space on anterior thorax, where mammary gland develops
Week 5: remnant of mammary ridge ectoderm proliferates and is termed primary mammary bud
Week 7: primary mammary bud grows downward into underlying dermis
Week 10: primary mammary bud branches into secondary buds
Week 12: secondary mammary buds start lobule development
Week 20: small lumina develop with mammary buds that coalesce and elongate to form lactiferous ducts
Month 5: areola is formed by ectoderm
References: eMedicine
Identical in males and females
Nipple is small pit in center of areola, becomes everted shortly after birth due to proliferation of mesenchyme underlying the areola
Breast enlargement (uni- or bilateral) is present in up to 70% of neonates due to neonatal prolactin production, caused by falling levels of maternal estrogens; associated with production of “witch’s milk” in males and females
Continued breast stimulation (squeezing or massaging breasts) may cause hypersecretory state to persist
Milk secretion: resembles colostrum; contains water, fat, cellular debris
Micro: duct dilation without acini
Rapid growth of breasts at onset of puberty, usually age 10-11 in females
Signifies entry into Tanner stage II of development (Arch Dis Child 1976;51:170)
Growth is due to fat deposition, periductal connective tissue and elongation and thickening of ductal system; growth may be sporadic
Influenced by estrogens, growth hormone and prolactin, but not progesterone
Excision of initial subareolar disc will lead to amastia after puberty
Premature: if prior to 9 years; may be isolated, or part of precocious puberty if other signs of puberty are present; no lobules present
Gross: initially rubbery subareolar discoid mass; may be asymmetric
Micro: prior to puberty, breasts of both sexes have ducts with variable branching lined by cuboidal epithelium, no lobules, no necrosis (AFIP, p11); at puberty in females, lobules develop
References: Wikipedia
Also called mammary gland
Covered by skin and subcutaneous tissue
Separated from pectoralis muscle by fascia
Composed of terminal duct lobular units (TDLU, terminal duct and lobule, has secretory function) plus 6-10 (AFIP: 15-25) large ducts which drain into lactiferous sinus and collecting duct (below nipple); large ducts subdivide into segmental ducts, subsegmental ducts and then lobules
Montgomery's tubercles: areolar protuberances (10-20), more prominent during pregnancy; composed of collecting lactiferous duct and sebaceous apparatus (Archives 1982;106:60)
TDLU: site of origin of fibrocystic changes, hyperplasia, carcinoma (including most ductal carcinomas)
Ducts: site of origin of solitary papillomas, duct ectasia, rarely ductal carcinoma
Regional lymph nodes: (a) axillary - interpectoral [Rotter’s] nodes and lymph nodes along axillary vein and its tributaries, (b) internal mammary - in the intercostal spaces along the edge of the sternum in the endothoracic fascia; supraclavicular lymph nodes are not considered regional
Lymph nodes: occur normally in any quadrant; but should biopsy in cancer patients (Hum Path 2001;32:178)
Major ducts: lined by pseudostratified columnar epithelium (extralobular) or double layer of cuboidal epithelium (intralobular); extralobular ducts are surrounded by well developed layer of elastic tissue
Terminal duct lobular unit (TDLU): ductules (acini) with lobular architecture and intralobular connective tissue
Ductules (lobular ducts): lined by inner layer of columnar or cuboidal epithelium (secretory and absorptive) and outer basal layer of myoepithelium (myofilaments oriented parallel to long axis of duct)
A continuous basement membrane follows contour of duct and ductules
Occasional neuroendocrine cells are present
Ochrocytes (histiocytes containing lipofuscin pigment) occur in 15-20% (J Pathol 1975;117:39)
Intralobular connective tissue: loose myxomatous stroma with fibroblasts, lymphocytes, macrophages, vessels; hormonally responsive; no elastic fibers
Interlobular connective tissue: denser, more collagenous than intralobular connective tissue; becomes more fatty after age 18 years
Nipple: contains numerous sebaceous glands independent of hair follicles, dense fibrous stroma containing erectile smooth muscle tissue, stratified squamous epithelium resembling skin but with increased melanin pigment, Toker cells (clear cells basally located in the epidermis); lactiferous sinuses often appear irregularly corrugated; stratified squamous epithelium extends into duct lumens for short distance
Areola: contains sebaceous glands
Menstrual cycle: proliferative phase breast has small lobules with few terminal duct structures, rare mitotic figures, condensed intralobular stroma; secretory phase breast has larger lobules, more terminal duct structures, basal epithelial cell proliferation and vacuolization, stromal edema (breast fullness), increased mitotic figures; stromal lymphocytes increase at end of secretory phase; followed by desquamation, apoptosis, atrophy, shrinkage (AJSP 1986;10:382)
Pregnancy related changes and lactation: see below
Clear cell change: clear cytoplasm contains glycogen, may represent metaplastic change towards eccrine sweat glands
Post-menopausal: largely adipose tissue with few residual ducts, acini or vessels; atrophy of glandular component is normal with age, may be microcystic (but not considered fibrocystic disease); in elderly women, residual estrogenic stimulation maintains vestigial remnants of lobules; elastosis (excess elastic fibers) found in 50% of women age 50+ years without breast disease, either diffusely in stroma, around vessels or around ducts; marked perivascular elastosis is suggestive of malignancy (Archives 1991;115:1241)
Males: testosterone causes involution of male mammary gland, except in testicular feminization syndrome (no testosterone receptors)
Normal histology of breast (continued)
Positive stains (epithelium): CK 8/18, CK 19, EMA (apical region of active secretory cells), milk fat globule membrane antigen, lactalbumin, E-cadherin
Positive stains (myoepithelial cells): smooth muscle actin, CK5/6, CK14, CK17, S100, p63 (nuclear staining, AJSP 2001;25:1054),
CD10 (Mod Path 2002;15:397), E-cadherin and P-cadherin (J Pathol 1993;169:245), calponin, smooth muscle myosin heavy chain, maspin, type IV collagenase
Positive stains (basement membrane): laminin, type IV collagen, reticulin
Negative stains (myoepithelial cells): EMA, ER, PR, p53, HER2 (AJCP 2003;120:161)
Pregnancy / lactation - breast
See also lactating adenoma, pseudolactational hyperplasia
Changes usually begin at time of first missed menstrual period (gestational week 4)
Due to progesterone, estrogens, prolactin, placental lactogen secretion in third trimester
Causes intralobular ducts to form buds that become secretory alveoli with grape-like clusters and scant stroma; epithelial cells accumulate cytoplasmic organelles to sustain postpartum lactation; glands have dilated lumina, contain lipid secretory vacuoles with large, apical nuclei resembling Arias Stella reaction; may have clear cell change in ductal or lobular epithelium; these changes may also occur without pregnancy or hormonal manipulation (see pseudolactational hyperplasia)
Prolactin stimulates alveolar epithelium to produce and secrete casein, alpha-lactalbumin and lipids
Lactation: increase in number of lobules and number of acini within each lobule; reduction in interlobular and intralobular stroma; myoepithelial cells are present but difficult to identify; luminal epithelial cells are secretory and have cytoplasmic vacuoles; after lactation ends, lobules involute over several months and are infiltrated by lymphocytes and plasma cells
Crying or suckling causes hypothalamus to produce oxytocin, causing contraction of myoepithelial cells, which expels milk
When nursing stops, prolactin level drops, causing milk production to stop
May cause macromastia - erythematous, edematous, painful breasts with variable ulceration of overlying skin; usually recurs with subsequent pregnancies
Micro: acinar proliferation with minimal intra- and interlobular connective tissue
Pubertal (virginal) macromastia
Occasionally breasts undergo rapid and massive enlargement at puberty, instead of development over several years
If unilateral, usually due to multiple fibroadenomas
Treatment: reduction mammoplasty usually needed
Clinical: diffusely enlarged breasts with flattening of nipples
Micro: abundant connective tissue separating ducts, usually poorly developed or no lobules; may resemble gynecomastia
Congenital anomalies of breast
Amastia / hypoplasia of breast tissue
Uncommon
Unilateral or bilateral
Amastia: no glandular tissue (breast bud), nipple or areola
Hypoplasia: small rudimentary breasts
Both are associated with Poland syndrome (musculoskeletal deformities of chest wall and ipsilateral upper extremity, OMIM 173800), also surgery or radiation that affects breast bud (Acta Oncol 1989;28:519)
References: eMedicine
Accessory glandular tissue of breast
See supernumerary nipples / breasts below
Nipple and areola present, but no glandular tissue
Associated with Poland syndrome (musculoskeletal deformities of chest wall and ipsilateral upper extremity, OMIM 173800)
Breast glandular tissue, but no nipple or areola
Very rare
Associated with Poland syndrome (musculoskeletal deformities of chest wall and ipsilateral upper extremity, OMIM 173800)
Case reports: female infant who died shortly after birth (Am J Med Genet A 2007;143:1231), bilateral athelia and congenital jejunal atresia (Clin Dysmorphol 2006;15:37)
Affects males and females
Occurs in 3% of women, 87% are bilateral (Aesthetic Plast Surg 1999;23:144)
Familial in 50%
Usually caused by fibrous bands and hypoplastic ductal system tethering nipple in inverted position
Also associated with large, pendulous breasts
Interferes with nursing, may be confused with cancer
Grade I, II or III (Plast Reconstr Surg 1999;104:389)
Treatment: surgery (Plast Reconstr Surg 2007;119:1178), continuous elastic outside distraction (Ann Plast Surg 2005;54:120)
Supernumerary nipples / breasts
Also called pseudomamma
Persistent epidermal thickenings along milk line from axilla to perineum/vulva due to clusters of primordial breast cells that fail to involute
Ectopic tissue may be combinations of breast glandular tissue and nipple
Often not noticed until pregnancy
Polythelia (3+ nipples) is more common than polymastia (ectopic breast tissue)
Polythelia occurs in 2-6% of females and 1-3% of males; may be more common on left side and in males (Eur J Pediatr 1998;157:821)
Sites (nipples): thorax or abdomen (65%), axilla (20%); back, buttock, face, neck are less common
Sites (glandular tissue): axilla most common
May undergo same disease or physiologic processes as other breast tissue, including lactation (J Reprod Med 1994;39:657)
Associated with renal disease in some studies (7% vs. 0.7% in controls, Int J Dermatol 1996;35:349, but not all, Pediatr Dermatol 2001;18:291); also associated with hematologic disorders (Pediatr Hematol Oncol 2004;21:461), mitral valve prolapse (Am J Cardiol 2000;86:695)
Case reports (disease in supernumerary nipples or breast): carcinoma in vulva (Cancer 1976;38:2570), fibroadenoma (J BUON 2007;12:285), hamartoma (Breast 2006;15:135), metaplastic carcinoma (South Med J 2002;95:462), mucinous adenocarcinoma of vulva (Archives 2002;126:1216), Paget’s disease (Virchows Arch 1998;432:289), secretory carcinoma (Archives 2001;125:1372)
unusual sites - face (J Pediatr Surg 1997;32:1377), foot (Dermatol Online J 2006;12:7), male perineum (Urology 1997;50:122)
occurrence in three generations (Eur J Pediatr 2001;160:375)
Micro: supernumerary nipple has same features as regular nipple, including hyperpigmentation, slight hyperkeratosis, pilosebaceous structure of Montgomery tubercles, smooth muscle, Toker cells (J Cutan Pathol 2003;30:256), possibly breast lobules and ducts
References: eMedicine
Procedures involving breast
Devices mark the site of radiographic biopsies for future localization and resection
Either pellets of resorbable polylactic acid/polyglycolic acid copolymers or plugs of bovine collagen; both contain metallic clips for long-term radiographic marking; pellets are placed within biopsy cavity to fix clip in place and reduce clip migration away from biopsy site; collagen plugs may also promote hemostasis
Gross: pellets resemble soft grains of rice; collagen plugs are spongiform with variable hemorrhagic changes
Micro:
pellets - initially hypocellular fibrotic reaction around empty spaces (processing dissolves the polymer), then multinucleated giant cell reaction with eosinophilic material in marker core
collagen plugs - eosinophilic, hyalinized, acellular material with lymphocytic and eosinophilic infiltrate that gradually penetrates into the core; no prominent multinucleated giant cell reaction; may resemble amyloidosis
References: AJSP 2005;29:814, AJR Am J Roentgenol 2003;181:1295
Electrocautery instruments reduce bleeding and risk of hematoma
Thermal distortion may make it difficult to distinguish hyperplasia and DCIS, assess histologic grade or interpret immunostaining
References: Am J Surg 2001;182:384 (laser treatment), Ann Surg 1986; 204: 612
Percutaneous large core needle biopsy using stereotactic mammography or ultrasound guidance is routinely used to evaluate clinically occult breast lesions, and is an alternative to open biopsy for many patients
Overall high level of inter-pathologist agreement, but less consensus for ADH, DCIS and lobular neoplasia (AJSP 2004;28:126)
Core biopsy results are comparable to excisional specimens (Int J Cancer 2008;122:468) but tumor grade in invasive carcinoma may differ (AJSP 2003;27:11)
Core biopsy is favored over fine needle aspiration due to ability to evaluate cytologic and architectural characteristics and definitely diagnose invasive carcinoma (Diagn Cytopathol 2007;35:681); imprint cytology may be useful for rapid diagnosis (Cytopathology 2007 Oct 22; [Epub ahead of print])
Not associated with significant bleeding in patients on anticoagulant therapy (AJR Am J Roentgenol 2000;174:245)
First generation: computer-assisted stereotactic mammography or ultrasound used to localize target lesion, then automated spring-loaded biopsy gun, usually with 14-gauge cutting needle
Second-generation: includes Mammotome (Breast Cancer 2007;14:292, World J Surg Oncol 2007;5:83); uses vacuum assistance to draw tissue into the needle and permits use of larger-caliber needles (8 to 11 gauge) and more thorough sampling of lesions (thicker, longer, multiple specimens with single needle insertion)
Processing: should routinely obtain 3-5 deeper levels; 5 levels recommended to detect ADH and atypical proliferations, (Archives 2001;125:1055) or minimally invasive carcinoma (Archives 2004;128:996); see also Mod Path 2001;14:350
Reducing false negatives: need radiologic-histologic correlation - must determine if histologic results provide a sufficient explanation for the imaging features - if not, lesion may not have been adequately sampled; follow up imaging is also helpful (Radiographics 2007;27:79)
Some recommend routine radiologic examination of cores for microcalcifications and deeper levels if microcalcifications are not in slide
Minimal invasion in core biopsies (1 mm or less) is usually associated with invasive tumors 1 cm or more at excision (Archives 2004;128:996)
Rarely, mastectomy (or excisional biopsy) after malignant core biopsy will show no cancer (Mod Path 1997;10:1209)
Immunostains for ER, PR and HER2 show 85-95% concordance with excision specimens (Acta Oncol 2007 Jun 11:1 [Epub ahead of print], Pathology 2007;39:391)
Core biopsy of breast lesions (continued)
Complications: seeding/displacement of normal epithelium along needle tract, particularly with papillary lesions, which may simulate malignancy (Archives 2005;129:1465), seeding of tumor cells along needle tract (Breast Cancer Res Treat 2007 Aug 3; [Epub ahead of print]), particularly intracystic papillary carcinoma (J Clin Pathol 2002;55:780), reactive spindle cell proliferation (see below), epidermal inclusion cysts
Reporting system of UK National Health Service Screening Programme (J Clin Pathol 2004;57:897)
- B1 - normal tissue/inadequate sample (comment on microcalcifications and specimen adequacy)
- B2 - benign lesion (specify)
- B3 - uncertain malignant potential (includes radial scar, some papillary lesions, ADH, lobular neoplasia)
- B4 - suspicious of malignancy (suggestive but not diagnostic due to scanty material or artifacts)
- B5 - malignant; specify if invasive or not, if possible; indicate grade of DCIS
References: eMedicine, Breast fine needle aspiration cytology and core biopsy; a guide for practice 2004
See also cytology sections under specific breast lesions
Usually refers to fine needle aspiration (FNA); also imprints of core biopsies (Cytopathology 2007 Oct 22; [Epub ahead of print]) or cytology touch imprints for evaluating margins (quick, easy, inexpensive, no frozen section artifacts, don’t sacrifice tissue, can sample entire margin, Archives 2002;126:846)
Relatively quick with minimal equipment needed
Uses 23 or 27 gauge needles (Breast 2006;15:567)
Nipple secretion aspiration: little value due to lack of sensitivity and specificity, but (a) presence of epithelial cells in nipple aspirate fluid is associated with higher risk for subsequent breast cancer (Breast Cancer Res Treat 2006;98:63), (b) may be useful in distinguishing benign versus malignant lesions in patients with unilateral, spontaneous nipple discharge (Int Surg 2003;88:83)
Fine needle aspiration (FNA): 90% sensitive, 95%+ specific; false positives are often florid epithelial hyperplasia; difficult to differentiate ADH or invasive carcinoma from DCIS, papillary carcinoma from fibroadenoma (Archives 2000;124:1667)
FNA is less sensitive for tumors with extensive fibrosis, DCIS, tubular carcinoma, cribriform carcinoma or for small tumors
Negative FNA should not rule out biopsy if clinical suspicion of malignancy persists, but negative cytology, negative clinical examination and negative radiologic findings together have a negative predictive value close to 100% (Breast J 2004;10:487)
Breast aspiration fluid-CEA concentration may be helpful in determining malignancy (Archives 2004;128:1251)
p63 immunostaining may be useful to categorize cases problematic by Pap staining (AJCP 2007;128:80)
FNA artifacts: displaced epithelium which simulates stromal and vascular invasion (AJSP 1994;18:896, Mod Path 1995;8:380), hemorrhage, infarction, necrosis, hemosiderin deposition (AJSP 1994;18:1039)
Cytology: malignancy - detailed analysis of a single morphologic characteristic has limited diagnostic value (Cancer 2005;105:152)
helpful features are cohesive clusters of tumor cells with irregular margins; pleomorphic cells with enlarged and hyperchromatic nuclei, mitotic figures, necrosis, microcalcifications, usually no naked nuclei, usually no apocrine metaplasia
DD of malignancy: gynecomastia with chemoradiation induced atypia (Archives 2002;126:613)
References: JCAHO protocol instructions for fine needle aspirations (Cytojournal 2007;4:19)
Open biopsy and frozen section of breast
Perform excisional biopsies for tumors 2.5 cm or less; incisional biopsies for diagnosis if tumors are larger
Historically, open biopsy with positive frozen section led to mastectomy; currently, even if frozen section is positive, there is a delay after biopsy to give patient time to evaluate options
First priority of open biopsy or frozen section is accurate histologic diagnosis - sufficient tissue must be obtained (for permanent sections) for this purpose
If diagnosis for frozen section is suspicious for DCIS, use all remaining tissue for diagnostic purposes (i.e. for permanent sections)
Don’t do frozen section if mass is 1 cm or less or if calcifications only/no mass (Cancer 1997;80:75), because frozen block may contain artifacts and no tissue will be left for permanent sections without artifacts
Frozen section can be helpful to evaluate margins (Ann Surg Oncol 2007;14:2953), to confirm a cytologic diagnosis, or to assess sentinel lymph nodes (World J Surg Oncol 2006;4:26); probably not helpful if grossly benign (Mod Path 1994;7:762)
False positives with frozen section: sclerosing lesions (radial scar, sclerosing adenosis, ductal adenoma), ductal hyperplasia, papillary lesions, fat necrosis; often cannot exclude invasion in DCIS
False negatives with frozen section: post-chemotherapy tumor, well differentiated papillary carcinoma, lobular carcinoma, tubular carcinoma (Chin Med J (Engl) 2007;120:630)
References: Archives 2005;129:1565
Magnetic resonance imaging (MRI) is used to screen high risk women for breast cancer (AJR Am J Roentgenol 2003;181:619, Cancer 2005;103:1898) and to evaluate extent of disease
MRI cannot verify that suspicious lesion is in specimen (unlike traditional radiography), because MRI requires IV injection of gadolinium and uptake into suspicious area, which cannot be done after specimen has been excised
Low (87%) sensitivity for diagnosing mammographically detected microcalcifications (AJR Am J Roentgenol 2006;186:1723)
Recommended to submit entire specimen for microscopic examination because most malignancies have no associated gross finding (Hum Path 2007 Sep 12; [Epub ahead of print])
43% had close/positive margins for DCIS but not invasive carcinoma, as MRI is more sensitive at detecting invasive carcinoma than DCIS (J Am Coll Surg 2005;200:527)
References: eMedicine
Also spelled mammoplasty
Common surgical procedure performed for cosmetic purposes or relief of pain
Must examine tissue carefully since most have some pathologic change (Plast Reconstr Surg 2005;115:729)
Carcinomas present in 0.5 to 1.5% (usually microscopic), ADH/ALH in 1-2%, moderate/florid hyperplasia, sclerosing adenosis or papilloma in 10% (AJCP 2003;120:377)
References: eMedicine
Inflammatory / infectious / parasitic lesions of breast
Associated with lactation and cracks in nipple
Mastitis occurs in 5-15% of post-partum primiparous women, 3% with mastitis have an abscess (BJOG 2004;111:1378)
Also associated with eczema, nipple dermatoses and post-reduction mammoplasty
Bacteria often not isolated from culture
Pregnancy related infections usually due to Staphylococcus; usually unilateral, often MRSA (Arch Surg 2007;142:881)
Streptococcus usually causes diffuse infections leading to scarring, but is uncommon today
Nonpregnancy related infections are usually polymicrobial; may be associated with acute tubulo-interstitial nephritis and uveitis (TINU) syndrome (Acta Paediatr 2004;93:135)
May cause fistulous tract between lactiferous duct and surface of areola
Zuska’s disease: periareolar abscess associated with squamous metaplasia of lactiferous ducts (J Am Coll Surg 1994;178:29)
Case reports: post-partum presentation with widespread symmetrical inflammatory polyarthropathy and marked synovitis (Scand J Rheumatol 2000;29:133), Brucellosis (Breast J 2006;12:375), Enterococcus faecalis (Indian J Pathol Microbiol 2005;48:507), Fusarium (Indian J Med Microbiol 2005;23:198), Gordonia bronchialis (J Clin Microbiol 2005;43:3009), Prevotella (Int J Syst Evol Microbiol 2007;57:883), Streptococcus group B abscess (Archives 1987;111:74)
Treatment of abscesses: incision and drainage, but may recur (Gynecol Obstet Fertil 2007;35:645); also ultrasound guided treatment (Radiology 2004;232:904)
Micro: central cavity with neutrophils and secretory material surrounded by inflammatory cells and eventually fibrosis
References: Wikipedia
Also called periductal mastitis, although some believe they are different entities (Br J Surg 1996;83:820)
Usually women in reproductive years; may be a response to stagnant colostrum
Painful, erythematous, subareolar mass, may have fistulous tract; associated with smoking (Int J Clin Pract 2005;59:1045), possibly pituitary adenomas and increased prolactin levels (AJSP 1988;12:130)
Recurrences may cause nipple inversion or discharge, resembling carcinoma
Late stage is ductitis obliterans or mastitis obliterans with total occlusion of ducts (Breast J 2007;13:599)
Case reports: causing bloody nipple discharge in 2 year old boy (Turk J Pediatr 2005;47:379), 13 year old girl (J Natl Med Assoc 2004;96:543); associated with Bechet’s disease (Saudi Med J 2001;22:1030)
Treatment: excise duct and fistulous tract in continuity
Gross: nipple discharge in 20%; skin retraction from fibrosis may mimic cancer; dilated large ducts with fatty (cheesy) material in lumen
Micro: dilated large ducts with fibrous thickening of wall, elastic fibers in wall and foamy macrophages in lumen; often calcifications; keratin goes deep within ductal system causing dilation and rupture of duct with intense chronic and granulomatous inflammation; may have associated epithelial hyperplasia or apocrine metaplasia
Cytology: paucicellular, with few scattered, cohesive clusters of ductal epithelial cells with mild atypia and peripheral myoepithelial cells; also CD68+ macrophages with finely vacuolated cytoplasm (Acta Cytol 2001;45:1027)
Simulates carcinoma clinically and mammographically
May be associated with duct ectasia, fibrocystic change, trauma (including surgery), brachytherapy or radiation (Int J Radiat Oncol Biol Phys 2007;69:724), injections of Depixol (J BUON 2002;7:281), low molecular weight heparin (Age Ageing 2005;34:193) or methylene blue dye (Int Semin Surg Oncol 2005;2:26)
Frozen sections difficult to obtain due to high fat content of specimen
Gross: opaque, bright yellow
Micro: partially necrotic adipose tissue with foamy macrophages, multinucleated giant cells and chronic inflammatory cells; often hemosiderin deposits, fibrosis and calcification; occasional metaplastic squamous epithelium
Foreign body reaction of breast
See also fat necrosis, reactive spindle cell nodule of breast, silicon breast implants
Also called biopsy site changes
Usually localized, 1-2 weeks after trauma, surgery or radiation
Clinically resembles carcinoma due to skin retraction
Case reports: injections - carbon for biopsy tracking (Clin Radiol 1998;53:845), hydrophilic polyacrylamide gel injection augmentation mammoplasty (