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Tumor Breast Diseases

  1. Benign tumors.
    1. Fibroadenoma (it is most common benign breast tumors younger female population)
      1. Usually found in women younger than 35 years.
      2. Rounded in outline mostly 2-3 cm in size and very movable (Breast mouse). They are well-circumscribed, but not encapsulated
      3. About 10% are multiple and bilateral and 10% will disappear per each year.
      4. Fibroadenomas may increase in size during pregnancy and involute after childbirth
      5. Cut surfaces have a lobulated, grey-white myxoid appearance and microscopically they contain epithelial and fibrous components. Branching and budding ducts are surrounded by fibrous tissue.
      6. In the pericanalicular fibroadenoma ductal spaces are round or oval while in the intracanalicular type the ductal lumens are compressed and are slit-like.
      7. The giant fibroadenoma is a large fibroadenoma (> 5 cm). Microscopically they have more cellularity.
      8. It has a long-term risk factor of 2.17 for the subsequent development of breast cancer.
      9. Diagnosis is confirmed by FNAC
      10. Mammographic appearance is: Popcorn appearance. Q
      11. Treatment is excisional biopsy 
    2. Intraductal Papilloma:
      1. Intraductal papilloma usually occurs within a major duct in the subareolar region.
      2. Small (usually smaller than 1 cm.) intraductal growths, having a fibrovascular core. It can be solitary or multiple.
      3. Frequently cause nipple discharge (It often causes bleeding, 50% of all bleeding discharge from the nipple is caused by papillomathat change).  Most common cause of bloody discharge from nipple.
      4. Single papillomas without atypia, probably does not have increased risk for subsequent breast cancer development but multiple papillomas are associated with an increased risk for recurrence and subsequent development of breast carcinoma (Haagensen). Q
      5. The term nipple adenoma or papillomatosis is used for a Papilloma occuring in the nipple. The clinical presentation is bloody, or serous nipple discharge.
      6. Ductography can be done to confirm the diagnosis
      7. Treatment is excision (Microdochectomy). Q 
    3. Phyllodes tumor (Cystosarcoma Phyllodes)
      1. Phyllodes tumor or cystosarcoma phyllodes arise from periductal stroma and show increased cellularity of the stromal components.
      2. Commonly seen after 40 years.
      3. It is a fibroepithelial tumor of unpredictable behavior. Although usually benign but it has malignant potential.
      4. The phyllodes tumor has a lobulated, leaf-like appearance.
      5. In the malignant cystosarcoma phyllodes the epithelial elements are benign, but the stromal tissue is malignant. The clinical behavior of phyllodes tumor is unpredictable. The majority of phyllodes tumors are local problems and do not metastasize. Q   Less than 10-20% of phyllodes tumors metastasize by vascular spread, most commonly to the lung, pleura, and bone. Thus, lymph node dissection is not indicated.
      6. Local recurrence is likely.
      7. A wide local excision is Treatment of choice. For a recurrent or large tumour simple mastectomy can be done. Q
    4. Rare: lipoma, haemangioma, neurinoma, chondroma. 

ANDI Classification of Benign Breast Disorders





Early reproductive years (age 15–25 y)

Lobular development




Nipple inversion

Giant fibroadenoma


Subareolar abscess

Mammary duct fistula

Stromal development

Nipple eversion

Later reproductive years (age 25–40 y)

Cyclical changes of


Cyclical mastalgia


Bloody nipple


Incapacitating mastalgia

Epithelial hyperplasia

of pregnancy

Involution (age 35–55 y)

Lobular involution


Sclerosing lesions

Duct ectasia

Nipple retraction

Epithelial hyperplasia

Periductal mastitis

Epithelial hyperplasia

with atypia

Duct involution



Epithelial turnover

  1. Breast Cancer
    1. ​​​​Risk Factors: Increasing Age is the most important risk factors.
      1. Female gender: The incidence of breast cancer in women exceeds that in men by 100:1. Overall, 1 of every 8 American women develops breast cancer in her lifetime.
      2. 20% decrease in risk for each year that menarche is delayed.
      3. Risk is delayed by early menopause.
      4. First late pregnancy (after 30 yrs) have 2-5 folds increased risk.
      5. Nulliparous women have greater risk.
      6. Increased risk with long term users of oral contraceptives.
      7. Environmental: American> Japanese.
      8. Dietary: Increased risk with fat.
      9. Irradiation: Increased risk.
      10. The Genetics of Breast Cancer
        Most cases of breast cancer, about 90%, are due to sporadic, somatic mutations The other 10% are associated with germline, or inherited mutations. Q Both BRCA1 and BRCA2 are tumor suppressor genes, and when mutations alter or inactivate this function, cancer is more likely to develop. With BRCA1 mutation risk of breast cancer is 35-85% in females and 5% with males 5%. With BRCA2 mutation it is 45-85% and 6% lifetime risk of male breast cancer.  
    2. Other genetic breast syndromes are:
      1. BRCA1: (Chromosome 17) Autosomal dominant with increased cancer incidence of breast and ovary.
      2. BRCA: (Chromosome 13) Autosomal dominant with increased cancer incidence of Breast, ovarian, prostate and pancreatic cancer.
      3. Li-Fraumeni syndrome: Autosomal dominant (TP53 Gene) with increased cancer incidence of Breast, brain, soft tissue sarcomas, leukemia, adrenocortical etc.
      4. Peutz-Jegher syndrome: Autosomal dominant with increased cancer incidence of GI, breast Hamartomatus polyps of bowel and pigmentation of buccal mucosa.
      5. Ataxia-telangiectasia: Autosomal dominant (ATM Gene) with increased cancer incidence of leukemia, lymphoma, cerebella ataxia, immune deficiency, telangiectasias
      6. Muir-Torre syndrome: Basal cell carcinoma, benign and malignant GI tumours.
      7. Cowden Syndrome: Facial trichilemmomas, papillomatosis of lips and oral mucosa, acral keratosis, GI polyps and uterine leiomyomas.  




Bkgrd Risk





Year Discovered




Year Isolated








Breast cancer




Ovarian cancer


< 10%


Male Breast cancer




Other cancers




Hereditary Syndromes
  1. Paget's Disease (Pd. Of The Breast & Nipple is rare, with a reported incidence of 0.5-2% of patientswith breast cancer.
    1. It is a superfacial manifestation of the underlaying breast cancer.
    2. The characteristic changes are erythema and eczematous changes of the nipple. Ulceration, crusting and serous or bloody discharge characterize more advanced cases.
    3. Exfoliative cytology with demonstration of Paget's cells is useful, but a negative finding does not exclude PD. Surgical biopsy is the diagnostic standard.
    4. Majority of these hve underlying infiltrating ductal carcinoma 90%. Paget’s disease is anatomical precursor of underlying DICS or invasive ductal carcinoma.
    5. The epidermotropic theory holds that Paget's cells are ductal carcinoma cells that have migrated from the underlying breast parenchyma. According to the in situ transformation theory, Q the Paget's cells arise as malignant cells in the nipple epidermis independent from any other pathologic process within the breast parenchyma.
  2. Paget's cells express heregulin receptors, including HER2/Neu, which exert a chemotactic effect resulting in migration into the epidermis. Fifty to sixty percent of patients have a palpable tumor in the breast. An invasive carcinoma was detected in 75-90%. Q
    1. Microscopically, the characteristic feature is the presence of adenocarcinoma cells (Paget's cells) in the keratinizing epithelium of the epidermis.
    2. These cells occur singly in superficial epidermal layers. They are more likely to form clusters in the basal portions of the epidermis. Isolated Paget's cells appear to lie in vacuoles.
    3. The cytoplasm is pale or clear, and it may contain mucin secretion vacuoles. Nuclei tend to have prominent nucleoli.
    4. The most common differential diagnoses are malignant melanoma, squamous or basal cell Ca.
    5. The extramammary forms of PD occur predominantly as vulvar or perianal disease. Primary vulvar PD is a localized carcinoma of sweat duct origin.
    6. The extravulvar form presents in the perianal areas as metastatic disease from sites that may include the rectum or urinary bladder
    7. PD of the breast often is estrogen- and progesterone-receptor negative.
    8. The prognosis of patients is determined by the extent of the associated carcinoma.
    9. Treatment is mastectomy. Some patients without a palpable mass may be candidates for breast-conservation therapy. 
According to TNM classification in breast carcinoma, involvement of supraclavicular lymph nodes, indicates: 
(AIIMS Nov 08)
A.  IIIa                              B. IIIb                      C. IIIc                       D. IV

Ans. C. IIIc

T0:  no evidence of primary tumor
Tis:  carcinoma in situ
T1:  < 2cm
T1a:  < 0.5cm
T1b:  0.5-1cm
T1c:  1-2cm
T2:  2-5cm
T3:  >5cm
T4:  any size, extension to skin or chest wall (excluding pectoralis musclE.
T4a:  extension to chest wall
T4b:  skin edema, ulceration or satellite nodules
T4c:  both a and b
T4d:  inflammatory carcinoma
N0:  no regional lymph node metastasis
N1:  cancer in movable nodes, same side
N2a:  axillary nodes fixed / matted, ipsilateral.
N2b:  Ipsilateral Internal mammary lympnode involved.
N3a:  Ipsilateral apical & axillary group of lymph node.
N3b: cancer in internal mammary nodes & axillary node on same side
N3c: involved supraclavicular nodes, same side
M0:  no metastasis
M1:  distant metastasis


     Breast Cancer – Staging:  TMN Universal Classification for Breast Cancer
Thanks to early detection through breast self-examination, yearly doctor examination and mammography, up to half the breast cancers now detected are DCIS. Treatment for DCIS may be lumpectomy plus radiation (breast conserving therapy) or total mastectomy. If the DCIS is multi-focal (multiple sites within one quadrant) or multi-centric (in more than one quadrant), it may mitigate for total mastectomy. Tamoxifen may also be added.    
Stage 0 Tis N0 M0
Stage I T1 N0 M0
Stage II A T0 N1 M0
  T1 N1 M0
  T2 N0 M0
Stage IIB T2 N1 M0
  T3 N0 M0
Stage IIIA T0 N2 M0
  T1 N2 M0
  T2 N2 M0
  T3 N1,N2 M0
Stage IIIB T4 any N M0
  any T N3 M0
Stage IV any T any N M1
Stage 0 is very early cancer at a pre-invasive level
called carcinoma in situ. It most often originates in the
ducts (ductal carcinoma in situ, DCIS) and less
commonly in the glandular lobules (lobular carcinoma
in situ, LCIS).
The former by definition has not spread, is usually
detected early by mammography and is highly
curable. The latter is also called lobular neoplasia and
is not technically considered a cancer, but it is
associated with a high incidence (25% in 25 years from
diagnosis) of invasive cancer developing in either
breast. DCIS is often difficult to differentiate
microscopic ally from LCIS, and a second expert opinion
is sometimes beneficial.    
After LCIS has been diagnosed by excisional biopsy, treatment may consist of close surveillance alone. Although
there is a significantly increased risk of developing a subsequent infiltrating cancer in either breast, the majority of
women (75%) will not. The other option is prophylactic bilateral total mastectomy if 1st degree family history of breast cancer in premenopausal age group. Tamoxifen, has been shown
to greatly reduce (40%) the risk of recurrent cancer.
Stage I cancer is an invasive (usually ductal) cancer less than 2 cm in size with no nodal or distant spread, i.e.
localized to the breast. Stage I disease is also highly curable.   
The treatment of stage I disease is either breast-conserving therapy or modified radical mastectomy. Breast
conserving therapy includes removal of the tumor with a safe margin of normal tissue around it (lumpectomy,
segmentectomy or quadrantectomy), axillary sampling and adjuvant radiotherapy after the surgical wound
has healed (2-3 weeks). Modified radical mastectomy eliminates the need for radiation. Tamoxifen is added to
many treatment regimens if the tumor is ER/PR positive because of its potential to reduce recurrence. If nodal
metastasis is found on axillary sampling, it changes the stage from a clinical stage I to a pathological stage II. 
Stage II is the presence of a small tumor (<2 cm) with isolated nodal metastasis, a moderate size (2-5 cm) tumor
with or without scattered nodal metastasis, or the presence of a large tumor (>5cm) without nodal
metastasis. Stage II is divided into A and B depending on the combination of features.      
The treatment options for stage II disease are similar to those for stage I, with the combination of local (surgery,
radiotherapy) and systemic (chemotherapy, hormonal therapy). The choices are based on the character and
extent of a particular patient's disease within the confines of the stage II parameters. A large tumor, for example
may mitigate for mastectomy; multiple involved lymph nodes may mitigate for more radical chemotherapy.      
Stage III is disease that is spread beyond the breast. The three features that, by themselves, establish stage III are:
Matted, fixed axillary nodal metastasis (N2) or
• Involvement of the chest wall or the skin (T4) by tumor, or
• The presence of internal mammary (N3) lymph node metastasis. 
These features may be combined with any other T or N category. A large (T3/>5 cm) tumor with mobile nodal metastasis (N1), also is a stage III. Stage III is also divided into A and B. Stage IIIB is either an extensive tumor or internal mammary node involvement with any combination of the other features.    
Treatment of stage IIIA usually includes modified radical or radical mastectomy in combination with radiation, chemotherapy and possibly hormonal therapy. The chemotherapy may also be given preoperatively (neo-adjuvant) to reduce the extent of disease. Radical chemotherapy may also be indicated. Stage IIIB disease usually involves diagnosis by biopsy with systemic therapy playing the primary treatment role. Surgery may be done later to try and gain local control. Inflammatory breast cancer (T4D. is a grave, special case not classified by stage, but is also treated in this way.  
Stage IV is distant metastasis (including supraclavicular lymph nodes on the same side as the primary tumor). 
Breast cancer most commonly spreads to bone, lungs, brain and liver. Diagnosis of metastasis may be made by bone scan, brain scan, X-ray, abdominal CT and lab tests. Stage IV disease is treated systemically with the goal of retarding the progress of the disease. Mastectomy may be used for local control.      

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