Common Benign Disorders

and Diseases of the Breast

By
royacostagumban
 Common Benign Disorders and
Diseases of the Breast
• Aberrations of Normal Development and Involution
(ANDI)
– basic principles

• benign breast disorders and diseases are related to the

normal processes of reproductive life and to involution

• there is a spectrum of breast conditions that ranges

from normal to disorder to disease

• encompasses all aspects of the breast condition,

including pathogenesis and the degree of abnormality
 ANDI Classification of Benign Breast Disorders
Normal Disorder Disease
Early reproductive years Lobular development Fibroadenoma Giant fibroadenoma
(age 15–25)
Stromal development Adolescent hypertrophy Gigantomastia

Nipple eversion Nipple inversion Subareolar abscess

Mammary duct fistula

Later reproductive years Cyclical changes of Cyclical mastalgia Incapacitating mastalgia

(age 25–40) menstruation
Nodularity

Epithelial hyperplasia of Bloody nipple discharge

pregnancy
Involution (age 35–55)  Lobular involution Macrocysts

Sclerosing lesions

Duct involution
–Dilatation Duct ectasia Periductal mastitis
–Sclerosis Nipple retraction
Epithelial turnover Epithelial hyperplasia Epithelial hyperplasia
with atypia
 Aberrations of Normal Development
and Involution (ANDI)

• Early Reproductive Years

• Later Reproductive Years

• Involution
 Early Reproductive Years
• Fibroadenomas are seen in younger women
age 15 to 25 years

• Grow to 1 or 2 cm in diameter and then are

stable, but may grow to a larger size
 Early Reproductive Years
• Small fibroadenomas (1 cm in size or less) are
considered normal

• Larger fibroadenomas (up to 3 cm) are disorders

• Giant fibroadenomas (larger than 3 cm) are disease

• Multiple fibroadenomas (more than five lesions in one

breast) are very uncommon and are considered
disease
 Early Reproductive Years
• Nipple inversion

– a disorder of development of the major ducts,

which prevents normal protrusion of the nipple

– predisposes to major duct obstruction

• leading to recurrent subareolar abscess and mammary
duct fistula
 Later Reproductive Years
• Cyclical mastalgia and nodularity

– usually associated with premenstrual enlargement

of the breast

– normal
 Later Reproductive Years
• Cyclical pronounced mastalgia and severe painful
nodularity

– viewed differently than are physiologic discomfort

and lumpiness

– Painful nodularity that persists for more than 1 week

of the menstrual cycle is considered a disorder

• Epithelial hyperplasia of pregnancy, papillary

projections sometimes give rise to bilateral
bloody nipple discharge
 Involution
• Involution of lobular epithelium

– dependent on the specialized stroma around it

– not always seen and disorders of the process are

common
 Involution
• When the stroma involutes too quickly, alveoli
remain and form microcysts, which are
precursors of macrocysts
 Involution
• Macrocysts
– common
– often subclinical in nature
– do not require specific treatment

• Sclerosing adenosis
– considered a disorder of both the proliferative and
the involutional phases of the breast cycle
 Involution
• Duct ectasia (dilated ducts) and periductal mastitis are
other important components of the ANDI classification

• Periductal fibrosis
– sequela of periductal mastitis
– may result in nipple retraction

• Atypical proliferative diseases include ductal and

lobular hyperplasia
– both of which display some features of carcinoma in situ
 Cancer Risk Associated with Benign Breast Disorders and In
Situ Carcinoma of the Breast
Abnormality Relative Risk

Nonproliferative lesions of the breast No increased risk

Sclerosing adenosis No increased risk

Intraductal papilloma No increased risk

Florid hyperplasia 1.5 to 2-fold

Atypical lobular hyperplasia 4-fold

Atypical ductal hyperplasia 4-fold

Ductal involvement by cells of atypical ductal 7-fold

hyperplasia
Lobular carcinoma in situ 10-fold

Ductal carcinoma in situ 10-fold

 Common Benign Disorders and
Diseases of the Breast
• Of paramount importance for the optimal
management of benign breast disorders and
diseases

– Is the histologic differentiation of benign, atypical,

and malignant changes
 Common Benign Disorders and
Diseases of the Breast
• Classification system developed by Page
separates the various types of benign breast
disorders and diseases into three clinically
relevant groups:

– nonproliferative disorders

– proliferative diseases without atypia

– proliferative disorders with atypia

 Classification of Benign Breast Disorders
Nonproliferative disorders of the breast 
Cysts and apocrine metaplasia
Duct ectasia
Calcifications
Fibroadenoma and related lesions
Proliferative breast disorders without atypia 
Sclerosing adenosis
Radial and complex sclerosing lesions
Ductal epithelial hyperplasia
Intraductal papillomas
Atypical proliferative lesions 
Atypical lobular hyperplasia (ALH)
Atypical ductal hyperplasia (ADH)
 Pathology of Nonproliferative
Disorders
• account for 70% of benign breast conditions

• carry no increased risk for the development of

breast cancer
 Pathology of Nonproliferative
Disorders
• This category includes
– Cysts
– Duct ectasia
– Periductal mastitis
– Calcifications
– Fibroadenomas and related lesions
 Pathology of Nonproliferative
Disorders
• Breast macrocysts

– involutional disorder

– high frequency of occurrence

– often multiple
 Pathology of Nonproliferative
Disorders
• Duct ectasia
– a clinical syndrome

– describes dilated subareolar ducts that are

palpable

– often associated with thick nipple discharge

 Pathology of Nonproliferative
Disorders
• Duct ectasia
– a primary event, which led to

• stagnation of secretions

• epithelial ulceration

• leakage of duct secretions (containing chemically irritant

fatty acids) into periductal tissue

– This sequence was thought to produce a local

inflammatory process with periductal fibrosis and
subsequent nipple retraction
 Pathology of Nonproliferative
Disorders
• Periductal mastitis

– An alternative theory considers to be the primary

process, which leads to

• weakening of the ducts and secondary dilatation

 Pathology of Nonproliferative
Disorders
• It is possible that both processes occur and
together explain the wide spectrum of problems
seen, which include

– nipple discharge

– nipple retraction

– inflammatory masses

– abscesses
 Pathology of Nonproliferative
Disorders
• Calcium deposits

– most are benign

– caused by cellular secretions and debris or by

trauma and inflammation
 Pathology of Nonproliferative
Disorders
• Calcifications that are associated with cancer
include
– Microcalcifications

• which vary in shape and density

• less than 0.5 mm in size

– fine, linear calcifications,

• may show branching

•
 Pathology of Nonproliferative
Disorders
• Fibroadenomas

– abundant stroma with histologically normal

cellular elements

– show hormonal dependence

 Pathology of Nonproliferative
Disorders
• Adenomas of the breast

– well circumscribed

– composed of benign epithelium with sparse stroma,

• the histologic feature that differentiates them from

fibroadenomas

– divided into tubular adenomas and lactating

adenomas
 Pathology of Nonproliferative
Disorders
• Adenomas of the breast

– Tubular adenomas
• present in young nonpregnant women

– Lactating adenomas
• present during pregnancy or during the postpartum
period
 Pathology of Nonproliferative
Disorders
• Hamartomas

– discrete breast tumors

– usually 2 to 4 cm in diameter

– firm

– sharply circumscribed
 Pathology of Nonproliferative
Disorders
• Adenolipomas

– circumscribed nodules of fatty tissue

– contain normal breast lobules and ducts

 Pathology of Nonproliferative
Disorders
• Fibrocystic Disease

– Nonspecific

– frequently, it is used as a diagnostic term

• to describe symptoms
• to rationalize the need for breast biopsy
• to explain biopsy results
 Pathology of Nonproliferative
Disorders
• Fibrocystic Disease
– Synonyms include
• fibrocystic changes
• cystic mastopathy
• chronic cystic disease
• chronic cystic mastitis
• Schimmelbusch's disease
• Mazoplasia
• Cooper's disease
• Reclus' disease
• fibroadenomatosis
 Pathology of Nonproliferative
Disorders
• Fibrocystic Disease

– refers to a spectrum of histopathologic changes

that are best diagnosed and treated specifically
 Pathology of Proliferative Disorders
Without Atypia
• Sclerosing adenosis

– prevalent during the childbearing and perimenopausal years

– has no malignant potential

– Histologic changes are both

• proliferative (ductal proliferation)
• involutional (stromal fibrosis, epithelial regression) in nature

– characterized by distorted breast lobules and usually occurs in

the context of multiple microcysts, but occasionally presents as
a palpable mass
 Pathology of Proliferative Disorders
Without Atypia
• Radial scars and complex sclerosing lesions of
the breast
– Is characterize by

• central sclerosis and varying degrees of epithelial

proliferation

• apocrine metaplasia

• papilloma formation
 Pathology of Proliferative Disorders
Without Atypia
• Radial scars

– lesions up to 1 cm in diameter

• Complex sclerosing lesions

– are larger lesions

 Pathology of Proliferative Disorders
Without Atypia
• Mild ductal hyperplasia

– presence of three or four cell layers above the

basement membrane

• Moderate ductal hyperplasia

– presence of five or more cell layers above the

basement membrane
 Pathology of Proliferative Disorders
Without Atypia
• Florid ductal epithelial hyperplasia

– occupies at least 70% of a minor duct lumen

– found in more than 20% of breast tissue

specimens, is either solid or papillary

– carries an increased cancer risk

 Pathology of Proliferative Disorders
Without Atypia
• Intraductal papillomas

– arise in the major ducts

– usually in premenopausal women

– less than 0.5 cm in diameter but may be as large as 5

cm

– common presenting symptom is nipple discharge

• may be serous or bloody
 Pathology of Proliferative Disorders
Without Atypia
• Intraductal papillomas

– Grossly
• pinkish tan, friable, and are usually attached to the wall
of the involved duct by a stalk

– rarely undergo malignant transformation

– presence does not increase a woman's risk of

developing breast cancer
 Pathology of Proliferative Disorders
Without Atypia
• Multiple intraductal papillomas

– occur in younger women

– less frequently associated with nipple discharge

– susceptible to malignant transformation

 Pathology of Atypical Proliferative
Diseases
• Have some of the features of carcinoma in situ
(CIS) but either lack a major defining feature
of CIS or have the features in less than fully
developed form
End...