BREAST

BY
DR H. JOKO S. LUKITO,SpPA
Mammary Glands
 Parenchyma
essential parts of
an organ that are Stroma
concerned with its
function
Stroma
framework/support
ing tissue of an
organ;
contains
connective tissue&
blood vessels
Parenchyma
opposite of
parenchyma
 Terminology
Exocrine Gland
a gland whose secretion
reaches an epithelial
surface Capillaries

Duct cell

Secretory cell

Endocrine Gland
a gland that secretes
directly into the bloodstream
 Anatomy of the Breast
Interlobular duct

Terminal duct
Duct cells

Lobules

Alveolar
Secretory
cells gland
Tubular gland
 Ductal / Tubular
Architecture
Nipple

Lactiferous duct

Lactiferous sinus

Lactiferous duct

Interlobular duct

Tubular duct

Alveolar gland
 Development of the Breast
Birth
rudimentary branching
ducts fan out in the region
of the nipple and areola
Prepuberty
very slow but progressive
growth & branching of
mammary ducts
growth ceases at this stage
in the male
Development of the Breast

Premenstruation
growth rate increases; branching of
ducts proliferation interductal stroma
stimulated by oestrogen
ducts end blindly (terminal ducts)

Menarche
terminal ducts proliferate, giving rise
to 30 epithelium-lined ductules acini
each terminal duct & ductules form
lobule
 Pregnancy
Morphologic maturation & functional
development
influenced by oestrogen,progesterone &
prolactin
oestrogen & progesterone suppress
the milk-producing effects of prolactin
Reversal of usual stromal-glandular
relationship
composed almost entirely of glands,
separated by relatively scant amount of
stroma
Cuboidal epithelium lines the secretory
glands
secretory vacuoles of lipid material appear
 Lactation

Expulsion of placenta leads to

oestrogen & progesterone
Lactogenic effect of prolactin
is not longer supressed
Prolactin stimulates
milk production
 CONGENITAL ANOMALIES
POLYMASTIA
Breast/nipple >2 along the original
embryonic breast ridge (milk line).
SUPERNUMERARY
Accessory breast tissue from nipple
to axilla
INVERSION OF THE NIPPLE
 INFLAMMATIONS
ACUTE MASTITIS bacterial
infection of the breast abscess
Post partum lactating or involuting
breast.
From : - Fissure at Nipple
- Eczema
- Other skin diseases
 COMEDOMASTITIS DUCT
ECTASIA
= Plasma Cell Mastitis.
Presence of dilated large and
intermediate ducts of the breast
contain pasty, inspissated material
periductal inflammation and fibrosis.
Micros : dilated ducts, contain
acelluler debris & macrophages,
periductal inflammation, foreign body
granulomas (+).
 FAT NECROSIS
History of trauma hemorrhage
necrosis of adipocytes + inflamm cell
phagocytes lipid debris (limfosit +
giant cell).

GALACTOCELE
Cystic dilatation of terminal ducts
during lactation.
 FIBROCYSTIC CHANGE
= Mammary dysplasia fibrocystic
disease.
Hormonal imbalance.
Short menstruation cycle(21-24days)
Estrogen >> Hyperestrism.
50% breast surgery cases in reproductive
period.
Premenstrual pain+lumpy breast.
Stromal and terminal ducts epithelial
proliferation.
 FIBROCYSTIC CHANGE
NON PROLIFERATIVE

Discrete mass fibrous connec-

tive tissue contain small cysts.
Large cyst (>5 cm) blue color to
the unopened cysts blue-domed
cysts of Bloodgood.
 PROLIFERATIVE
FIBROCYSTIC CHANGE

SCLEROSING
ADENOSIS
proliferation of
small ducts &
myoepithelial cells
in terminal duct
lobular unit.
 FIBROSIS
Elastic, mobile.
White
homogenous.
30-35 years.
Stromal collagen
>>
Fibrosis.
Gland atrophy.
 CYSTIC
Cyst 3-5 cm.
Serrous blue brown
fluid.
45-55 years.
Stromal >>.
Fibrosis.
Gland & epithelial
proliferation.
Dilated duct
cyst.
 ADENOSIS
Sclerosing
adenosis.
Duct hyperplasia.
35-45 years.
Firm.
Blurred borders.
Duct hyperplasia.
Intraduct
papilloma.
Gland & stromal
proliferation.
 BREAST TUMORS
BENIGN :
- FIBROADENOMA
- FIBROMA
- INTRADUCTAL PAPILLOMA
- CHONDROMA
MALIGNANY:
- CARCINOMA
- SARCOMA
 FIBROADENOMA MAMMA
Benign neoplasm of the breast and is
composed of epithelial and stromal
elements that originate from the terminal
duct lobular unit.
Ages : 20-30 years.
Sign : round, rubbery tumor, soliter /
multiple, sharply demarcated, freely
moveable, upper lateral quadrant >>
Macros : encapsulated, gray white.
Micros : proliferation of glands and fibrous
stroma.
 FIBROADENOMA MAMMA
PERICANALICUL
AR ROUND
GLANDS
DISPERSED
WITHIN FIBROUS
STROMA.
 FIBROADENOMA MAMMA
INTRACANALICU
LARE FIBROUS
TISSUE FORM
TUMORCOMPRES
S PROLIFERATED
DUCTS
CURVILINEAR
SLITS.
 SOME JUVENILE FIBROADENOMAS
ATTAIN GREAT SIZE
GIANT FIBROADENOMA.

GIANT FAM PHYLLODES TUMOR

(CYSTOSARCOMA PHYLLODES)
 PHYLLODES TUMOR
Proliferation of stromal element
accompanied by benign growth of
ductal structures.
Benign Phyllodes tumor similar to
FAM, the distinction not made on the
size, but the histological and
cytological characteristic of stromal
component. Micros: stroma hypercell
and has mitotic activity.
 PHYLLODES TUMOR

Malignant Phyllodes Tumor

sarcomatous stroma with abundant
mitotic activity, poorly circumscribed,
invasion to surrounding breast tissue
 INTRADUCTAL PAPILLOMA
Single tumor.
< 1 cm.
Attached to wall of
duct by fibrovascular
stalk.
Situated in large,
subareolar ducts.
Has serrous or bloody
nipple discharge.
Difficult to distinguish
from papillary
carcinoma.
 CARCINOMA OF THE
BREAST
EPIDEMIOLOGY the most common
malignancy of women after cervix
cancer.
PATHOGENESIS :
- Genetic Factor history of breast
ca in first line degree relatives
(mother,sister,daughter).
 PATHOGENESIS
Mutations of p53 tumor suppressor
gene; BRCA 1 gene (breast ca 1)
located at chromosome 17 (17q21)
and BRCA 2 gene located on
chromosome 13q.
Hormonal status early menarch,
late menopause and older age at first
term pregnancy increased risk.
 PATHOGENESIS
Environmental Influences high fat
intake.
Radiation.
Fibrocystic Change.
Previous cancer.
Viruses.
Genomic alterations gene amplification,
overexpression & allelic deletion.
 CARCINOMA IN SITU
INTRADUCTAL CARCINOMA IN SITU:
- COMEDOCARCINOMA
- NON COMEDO INTRADUCTAL CA

LOBULAR CARCINOMA IN SITU.

PAPILLARY CARCINOMA IN SITU.

 INVASIVE CARCINOMA
1. DUCTAL CARCINOMA.
- The most common form Breast ca.
- Hard, fixed mass(often referred as
scirrhous ca).
- Gross: firm with irregular margin, pale
gray,gritty & flecked yellow chalky
streaks.
- Micros: irregular nests epitheloid cell
within dense fibrous stroma.
Variant ductal caPaget Disease of nipple.
2.LOBULAR CARCINOMA
Micros: single strands of malignant
cells infiltrating between stromal
fiber INDIAN FILING.
+ Signet Ring Caintracelluler mucin
compress nucleus to one side.
+ Pleomorphic Lobular Camarked
nuclear pleomorphism.
3.Colloid
carcinoma
composed of small
clusters of
epithelial cells
forming glands,
floating in pools of
extracell mucin.
4. Tubular
Carcinoma
Well differentiated
ca composed of
infiltrating, well-
formed small ducts
consist one/two
layers of small
regular cells.
5. Medullary
Carcinoma
circumscribed
mass with lacks
calcifications.
Composed sheets
of cells, highly
pleomorphic & high
mitotic index.
6. Metaplastic Carcinoma
a rare invasive variant malignant
epithelium partially differentiation
into either another type of epithelium
or mesenchymal tissue tumor may
show areas of malignant squamous,
fibrous, cartilaginous or bony tissue,
admixed with malignant glandular
component.
 PROGNOSTIC FACTORS
1. Stage at diagnostic.
2. Histological grade degree of
glandular differentiation, nuclear
atypia and mitotic index.
3. Estrogen and progesteron receptor
4. Proliferative capacity & ploidy.
5. Lymphatic & vascular invasion.
6. Oncogene Expression.
 TREATMENT
Effective treatment of breast ca is
early detection.

Regular self-examination, screening

mammograms decreased mortality

Modified radical mastectomy

treatment of choice.
 CANCER OF THE MALE
BREAST
< 1% ALL CASES OF BREAST CA.

LESS FAT IN BREAST INVASION

OF CHEST WALL MUSCLES MORE
FREQUENT.
MUTATION IN BRCA 2 GENE
INCREASE THE RISK OF THIS
TUMOR.
 1

MAMMOGRAM
 4

Hematogenous
metastasis

Lymphatogenou
s metastasis

Mechanism of metastasis
Modified
from AJCC STAGING OF BREAST CANCER ( TMN )
1992
PRIMARY TUMOR (T) REGIONAL LYMPH NODES (N)
T0 No evidence of primary tumor N0 No regional lymph nodes
N1 Metastasis to moveable ipsilateral
Tis Carcinoma in situ nodes
N2 Metastasis to matted or fixed
T1 Tumor 2 cm ipsilateral nodes
N3 Metastasis to ipsilateral internal
T2 Tumor >2 cm but 5 cm mammary nodes

T3 Tumor >5 cm
DISTANT METASTASIS (M)
M0 No distant metastasis
T4 Extent to chest wall,
M1 Distant metastasis (includes spread
inflammation, satellite lesions,
ulcerations to ipsilateral supraclavicular nodes)

Stage 0 Tis N0 M0 Stage IIIA T0 N2 M0

Stage I T1 N0 M0 T1 N2 M0
Stage IIA T0 N1 M0 T2 N2 M0
T1 N1 M0 T3 N1,N2 M0
T2 N0 M0 Stage IIIB T4 any N M0
Stage IIB T2 N1 M0 any T N3 M0
T3 N0 M0 Stage IV any T any N M1
 PENATALAKSANAAN TUMOR MAMMA

TUMOR MAMMA
ASPIRASI

BIOPSI
DIAGNOSA

EKSISI

GANAS JINAK

Kel.Ro Paru
Rontgen Paru
STADIUM KLINIK EKSTIRPASI
Scanning Tulang
Scanning Hati
Fungsi Hati
THERAPI
Breast Self-Examination
The American Cancer Society recommends that
women perform a breast self-examination once
a month.

The best time to do a breast self-exam is one

week after your period so that your breasts will
be less tender and you will be more likely to
notice any changes in their look or feel.

After menopause, do breast self-exams on

the first day of each month.
Breast self-exam
 Visual Inspection
Standing or sitting in front of a mirror as
illustrated. In each position look for :

Changes in color or shape of breast

Changes in color or texture of the skin
Changes in nipple shape or texture
Evidence of nipple discharge
Dimpling or puckering anywhere on chest
If your eyesight is limited, making it difficult
for you to do the visual inspection yourself
perhaps a close friend, spouse, an attendant
or family member could help you with this.
make it easy for you to notice any changes
in the way your breasts look or feel.
If you cannot easily stand, you
can do the visual inspection in a
seated position, if you have a full
length mirror, for example on the
back of a door.

Arms relaxed at side

 Hands on hips with your thumbs
facing forward,push down on
your hips

if you cannot place your hands on your hips,

try clasping your hands together in front of you,
to tighten your chest muscles
Arms raised above head

Bending forward
POSITIONS FOR PALPATION

If you are able to use both your hands, use

your left hand to palpate the right breast, while
holding your right arm up with the elbow bent.
Repeat the procedure on the other side side-
lying position allows a woman, especially one
with large breasts, to most effectively examine
the outer half of the breast. A woman with
small breasts may need only the flat position.
Side-lying positions
Lie on the opposite side of the breast of be examined.
Place a pillow or rolled up towel under your shoulder blade.
Rotate the shoulder back to the flat surface.
Use the side-lying position to examine the outer half of your
breast.

Flat position

Lie flat on your back with a pillow

or folded towel under the
shoulder of the breast to be
examined.
 PERIMETER / AREA TO BE EXAMINED

The exam area is bounded by the line which extends down

from the middle of the armpit to just beneath the breast,
continues across the underside of the breast to the middle
of the breast bone, then moves up and along the collar bone
and back to the middle of the armpit. Most breast cancers
occur in the upper outer area of the breast
(the shaded area).

If you can use only one hand, use that for checking both breasts,
and examine the breast on that side as well as you can.
PALPATION WITH PADS OF FINGERS
Use the pads of three fingers to examine every inch of your
breast tissue.Move your fingers in circles about the
size of a dime.

Do not lift your fingers from your breast between palpations.

You can use powder or lotion to help your fingers glide from
one spot to the next.
 If you have difficulty using or feeling with the finger
pads of one or both hands, try using the thumb,
the palm of your hand or the back of your fingers.

If it is difficult to control one or both hands because

of shaking movements, try using the other hand
to stabilizethe hand examining the breast.
PRACTICE WITH FEEDBACK

It is important that you perform breast

self examination (BSE) while your
instructor watches you to be sure you
are doing it correctly Practice your skills
until you feel comfortable and confident.