BREASTFK KEDOKTERANUNIVERSITAS METHODIST INDONESIA

Mammary Glands

Parenchymaessential parts of an organ that are concerned with its functionStromaframework/supporting tissue of an organ; contains connective tissue& blood vesselsopposite of parenchyma

ParenchymaStroma

TerminologyExocrine Glanda gland whose secretion reaches an epithelial surface

Secretory cellDuct cellCapillaries Endocrine Gland a gland that secretes directly into the bloodstream

Anatomy of the BreastLobulesInterlobular ductTerminal ductTubular glandAlveolar glandSecretory cellsDuct cells

Ductal / Tubular ArchitectureNippleLactiferous ductLactiferous sinusLactiferous ductInterlobular ductTubular ductAlveolar gland

Development of the BreastBirthrudimentary branching ducts fan out in the region of the nipple and areolaPrepubertyvery slow but progressive growth & branching of mammary ductsgrowth ceases at this stage in the male

Development of the BreastPremenstruationgrowth rate increases; branching of ducts proliferation interductal stroma stimulated by oestrogenducts end blindly (terminal ducts)Menarcheterminal ducts proliferate, giving rise to 30 epithelium-lined ductules acini each terminal duct & ductules form lobule

PregnancyMorphologic maturation & functional developmentinfluenced by oestrogen,progesterone & prolactinoestrogen & progesterone suppress the milk-producing effects of prolactinReversal of usual stromal-glandular relationshipcomposed almost entirely of glands, separated by relatively scant amount of stromaCuboidal epithelium lines the secretory glandssecretory vacuoles of lipid material appear

LactationExpulsion of placenta leads to oestrogen & progesteroneLactogenic effect of prolactin is not longer supressedProlactin stimulates milk production

CONGENITAL ANOMALIESPOLYMASTIA Breast/nipple >2 along the original embryonic breast ridge (milk line).SUPERNUMERARY Accessory breast tissue from nipple to axillaINVERSION OF THE NIPPLE

INFLAMMATIONSACUTE MASTITIS bacterial infection of the breast abscessPost 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 CHANGENON 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.

FIBROSISElastic, mobile.White homogenous.30-35 years.Stromal collagen >>Fibrosis.Gland atrophy.

CYSTICCyst 3-5 cm.Serrous blue brown fluid.45-55 years.Stromal >>.Fibrosis.Gland & epithelial proliferation.Dilated duct cyst.

ADENOSISSclerosing adenosis.Duct hyperplasia.35-45 years.Firm.Blurred borders.Duct hyperplasia.Intraduct papilloma.Gland & stromal proliferation.

BREAST TUMORSBENIGN : - FIBROADENOMA - FIBROMA - INTRADUCTAL PAPILLOMA - CHONDROMAMALIGNANY: - CARCINOMA - SARCOMA

FIBROADENOMA MAMMABenign 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 MAMMAPERICANALICULAR ROUND GLANDS DISPERSED WITHIN FIBROUS STROMA.

FIBROADENOMA MAMMAINTRACANALICULARE FIBROUS TISSUE FORM TUMORCOMPRESS PROLIFERATED DUCTS CURVILINEAR SLITS.

SOME JUVENILE FIBROADENOMAS ATTAIN GREAT SIZE GIANT FIBROADENOMA.

GIANT FAM PHYLLODES TUMOR (CYSTOSARCOMA PHYLLODES)

PHYLLODES TUMORProliferation 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 PAPILLOMASingle 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 BREASTEPIDEMIOLOGY the most common malignancy of women after cervix cancer.PATHOGENESIS : - Genetic Factor history of breast ca in first line degree relatives (mother,sister,daughter).

PATHOGENESISMutations 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.

PATHOGENESISEnvironmental Influences high fat intake.Radiation.Fibrocystic Change.Previous cancer.Viruses.Genomic alterations gene amplification, overexpression & allelic deletion.

CARCINOMA IN SITUINTRADUCTAL CARCINOMA IN SITU: - COMEDOCARCINOMA - NON COMEDO INTRADUCTAL CA

LOBULAR CARCINOMA IN SITU.

PAPILLARY CARCINOMA IN SITU.

INVASIVE CARCINOMA1. 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 FACTORS1. Stage at diagnostic.2. Histological grade degree of glandular differentiation, nuclear atypia and mitotic index.3. Estrogen and progesteron receptor4. Proliferative capacity & ploidy.5. Lymphatic & vascular invasion.6. Oncogene Expression.

TREATMENTEffective 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.

MAMMOGRAM1

Lymphatogenous metastasisHematogenous metastasisMechanism of metastasis4

STAGING OF BREAST CANCER ( TMN )

T0No evidence of primary tumor

TisCarcinoma in situ

T1Tumor 2 cm

T2 Tumor >2 cm but 5 cm

T3 Tumor >5 cm

T4 Extent to chest wall,inflammation, satellite lesions,ulcerations Stage 0Tis N0M0Stage I T1 N0M0 Stage IIA T0 N1M0 T1 N1M0 T2 N0M0Stage IIBT2 N1M0T3 N0M0REGIONAL LYMPH NODES (N)

PRIMARY TUMOR (T)N0No regional lymph nodesN1Metastasis to moveable ipsilateralnodesN2Metastasis to matted or fixed ipsilateral nodesN3Metastasis to ipsilateral internal mammary nodesModified from AJCC 1992DISTANT METASTASIS (M)M0No distant metastasisM1Distant metastasis (includes spreadto ipsilateral supraclavicular nodes) Stage IIIAT0 N2M0T1 N2M0T2 N2M0T3 N1,N2M0Stage IIIBT4 any NM0 any T N3M0Stage IV any T any NM1

PENATALAKSANAAN TUMOR MAMMATUMOR MAMMADIAGNOSABIOPSIASPIRASIEKSISIJINAKGANASSTADIUM KLINIKTHERAPIEKSTIRPASI Kel.Ro Paru Rontgen Paru Scanning Tulang Scanning Hati Fungsi Hati

Breast Self-ExaminationThe 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 InspectionStanding 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 hipsif 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 PALPATIONIf you are able to use both your hands, use your left hand to palpate the right breast, whileholding 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 examinethe outer half of the breast. A woman with small breasts may need only the flat position.

Side-lying positionsLie 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.Lie flat on your back with a pillowor folded towel under the shoulder of the breast to be examined.Flat position

PERIMETER / AREA TO BE EXAMINEDThe 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 yourbreast tissue.Move your fingers in circles about thesize 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 fingerpads 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 becauseof shaking movements, try using the other handto 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.