Chapter 18 Breast
COMMON CLINICAL PROBLEMS FROM BREAST DISEASE
Pathological basis of breast signs and symptoms
Sign or symptom | Pathological basis |
---|---|
Lump | |
Fibrosis, epithelial hyperplasia and cysts in fibrocystic change | |
Neoplasm or solitary cyst | |
Benign neoplasm (usually fibroadenoma) | |
Invasive neoplasm (carcinoma) | |
Skin features | |
Impaired lymphatic drainage due to carcinoma | |
Invasion of skin by carcinoma | |
Increased blood flow due to inflammation or tumour | |
Nipple | |
Tethering by invasive carcinoma | |
Paget’s disease of nipple or eczema | |
Breast pain | |
Benign breast changes | |
Inflammatory lesion (e.g. mastitis) | |
Microcalcification (on mammography) | Dystrophic calcification associated with benign changes, e.g. cysts, sclerosing adenosis, or in situ or invasive carcinoma |
Axillary node enlargement | Often due to metastatic breast carcinoma |
Bone pain or fracture | Possibly due to metastatic breast carcinoma or associated with hypercalcaemia |
NORMAL STRUCTURE AND FUNCTION
Development
Structure
The main function of the breast is the production and expression of milk (Fig. 18.2).
Lobules
The lobules are the secretory units of the breast. Each lobule consists of a variable number of acini, or glands, embedded within loose connective tissue and connecting to the intralobular duct (Fig. 18.3). Each acinus is composed of two types of cell, epithelial and myoepithelial. The epithelial cells are secretory. Although synthesising milk only during the later stages of pregnancy and post-partum, they continuously secrete a variety of glycoproteins into the glandular lumens. They are surrounded by myoepithelial cells which contact with the basement membrane and may directly or indirectly control luminal cell function. The intralobular duct connects with the extralobular duct and this, together with the lobule, is called the terminal ductal lobular unit.
Ducts
The extralobular ducts within the same area link together to form subsegmental ducts, which link in turn to form segmental ducts. These drain into the lactiferous ducts and sinuses (Fig. 18.2) which empty on to the surface of the nipple through separate orifices. There are 15 to 20 lactiferous ducts, each draining a segment of breast. The ducts are lined by epithelial cells surrounded by myoepithelial cells. The connective tissue in which they lie is denser than that of the lobules, and they are surrounded by elastic tissue which helps in the drainage function of the ducts.
Cyclical variations
The breast undergoes minor changes during each menstrual cycle but these will vary if there is a failure of ovulation or if pregnancy intervenes. The breast is sensitive to changes in the levels of sex steroids during the different phases (Fig. 18.4). The lobular stroma becomes oedematous during the secretory phase, due to the effects of oestrogens, and this accounts for the breast fullness often felt in the premenstrual phase. An increase in the number of cells in mitosis occurs at days 22–24 of the cycle, coincident with the high peaks of oestrogen and progesterone; however, the numbers are never very high. A loss of cells occurs by apoptosis (Ch. 5) at the end of the cycle, due to a fall in hormone levels, so that an overall balance is maintained. In view of the changes that can occur in the breast in the second half of the menstrual cycle, it is better to examine clinically the breasts of a pre-menopausal woman in the first half of the cycle.
Pregnancy and lactation
During pregnancy, the lobules undergo controlled proliferation and enlargement in preparation for the synthetic and secretory activity of lactation. By the third trimester the number of acini in each lobule and the overall size of the lobules have markedly increased. The epithelial cells have become differentiated and they synthesise and secrete milk (Fig. 18.5). The various components of milk (casein, alpha-lactalbumin and milk fat globule membranes derived from the luminal surface of breast cells) are useful markers of the state of differentiation of breast cells, and because of this they have been extensively studied in breast disease.
Oestrogens, progesterone and prolactin, together with other hormones shown in Figure 18.1, are important in the development of the breast during pregnancy; however, once delivery occurs, the levels of sex steroids fall and it is prolactin that is necessary for the initiation of lactation. When breast feeding ceases there is a rapid involution of the differentiated lobular structure, and the breast returns to the pre-pregnancy structure.
Involution
Changes occur in the breast with increasing age; these involutional changes relate to the altered sex steroid levels that accompany decreasing ovarian function. The connective tissue of the lobules changes from a loose to a dense structure, the basement membranes around acini become thicker, and the lining cells of the acini are lost. These changes start in the pre-menopausal period and continue past the menopause; they often occur at an uneven rate, producing clinically palpable lumps. In elderly women, the major component of the breast is adipose tissue.
CLINICAL FEATURES OF BREAST LESIONS
Most pathological lesions of the breast present as a lump or lumps. These can vary in their nature depending on their cause: well-circumscribed or ill-defined; single or multiple small nodules; soft or firm; mobile or attached to skin or underlying muscle. These features assist in the clinical distinction between benign breast lesions and breast carcinomas, but they are relatively weak discriminators on their own. Below the age of about 35, benign breast lumps are much more common than carcinomas. Most women with breast cancer are peri- or post-menopausal. The most likely type of lesion will vary with the age of the patient, although overlaps occur (Table 18.1). However, there can be exceptions and histological examination is mandatory for a definite diagnosis.
Table 18.1The probable pathological causes of presenting clinical lesions at different ages in women
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DIAGNOSTIC METHODS
Fine-needle aspiration cytology
This technique is used in the clinic. A needle is inserted into the lump or area in the breast with the abnormality (guided if necessary by ultrasonography or mammography). Cells are aspirated, and after staining are examined by a pathologist; if the sample is adequate a diagnosis can be made. Women with benign conditions can be reassured and surgery may not be necessary. It is possible to prepare slides and a report while the patient is in the clinic.
INFLAMMATORY CONDITIONS
Mammary duct ectasia
The aetiology is unknown but the affected women are usually parous. The ducts are dilated and filled with white–green viscid matter; this material may be discharged from the nipple. The matter can usually be seen with the naked eye in excised tissue. The tissue around the ducts contains lymphocytes, plasma cells and macrophages, with a significant degree of fibrosis. Due to the inflammatory reaction, the condition is sometimes known as periductal mastitis.
Fat necrosis
Histologically, the appearances are the same as those of any adipose tissue that undergoes necrosis (Ch. 6): collections of macrophages and giant cells containing lipid material may be seen, and there is an associated reaction with lymphocytes, fibroblasts and small vascular channels. The necrotic fat acts as a persistent irritant, resulting in a chronic inflammatory process and hence fibrous tissue formation.
PROLIFERATIVE CONDITIONS OF THE BREAST
Fibrocystic change
Clinical and gross features
Proliferative lesions and their associated tissue responses generally occur between the ages of 30 and 55, with a marked decrease in incidence after the menopause. The incidence reaches a maximum in the years just before the menopause (Fig. 18.6).
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Fig. 18.6 Incidence rates of benign proliferative breast changes occurring in women at different ages.
Surgery for benign conditions is now uncommon. If undertaken it is more common to find nodules of soft pink or grey tissue, up to 3 mm in diameter in younger women, whereas in women nearer the menopause cysts are frequently seen. These cysts can vary in size from 2 to 20 mm (Fig. 18.7) and, rarely, a solitary large cyst can be seen. The small cysts are often multiple. They frequently have a dark blue surface and, on opening, contain clear, yellowish or blood-stained fluid. The intervening tissue is usually firm due to the increase in fibrous tissue but the softer foci of epithelial proliferation can be seen and felt.