Fig.19.22Originsofbreastdisorders.Benignepitheliallesionsincludeintraductalpapillomasthatgrowinsinusesbelowthenippleandepithelialhyperplasiathatarisesinlobules.Malignantepitheliallesionsaremainlybreastcarcinomas,whichmayremaininsituorinvadeintothebreastandspreadbymetastasis.Specializedintralobularstroma(green) cellsmaygiverisetofibroadenomasandphyllodestumors,whereasinterlobularstroma(green) maygiverisetoavarietyofrarebenignandmalignanttumors.Luminal cells (blue) Myoepithelial cells (black) Intralobular stroma (green) Interlobular stroma (red) NORMAL Fibroadenoma Hemangioma Angiosarcoma Papilloma DCIS Epithelial hyperplasia Invasive carcinoma Phyllodes tumor Nipple BENIGN MALIGNANT Normal lobule ing the origins, presentations, and treatment of breast disease
A SYMPTOMS OF PATIENTS Nipple discharge Inflammation 7% are cancers 5% are cancers 5% are cancers <1% are cancers 1% are cancers Palpable mass Lumpiness or other symptoms Pain
Fig.19.23Presentingsymptomsofbreastdisease.(A)Commonbreast-relatedsymptomsthatbringpatientstoclinicalattention.(B)Presentationsofbreastcancer.
inflammation is “inflammatory” breast carcinoma (discussed later).
Nipple discharge may be normal when small in quantity and bilateral. The most common benign lesion producing a nipple discharge is a papilloma arising in the large ducts below the nipple (
Fig. 19.22 ). Discharges that are spontaneous, unilateral, and bloody are of greatest concern for malignancy.
Lumpiness, or a diffuse nodularity throughout the breast, is usually a result of normal glandular tissue. When pronounced, imaging studies may help to determine whether a discrete mass is present.
Palpable masses can arise from proliferations of stromal cells or epithelial cells and are generally detected when they are 2 to 3 cm in size (
Fig. 19.22 ). Most (~95%) are benign; these tend to be round to oval and to have circumscribed borders. In contrast, malignant tumors usually invade across tissue planes and have irregular borders. However, because some cancers grow deceptively as circumscribed masses, all palpable masses require evaluation.
Gynecomastia is the only common breast symptom in males. There is an increase in both stroma and epithelial cells resulting from an imbalance between estrogens, which stimulate breast tissue, and androgens, which counteract these effects.
Regardless of presenting symptom, the likelihood of malignancy increases with age. For example, the risk of nipple discharge being due to cancer increases from 7% in women younger than 60 years of age to 30% in women older than 60. Similarly, only 10% of palpable masses in women younger than 40 years of age are carcinomas, as compared to 60% in women older than 50.
Mammographic screening was introduced in the 1980s as a means to detect early, nonpalpable asymptomatic breast carcinomas before metastatic spread has occurred. Mammography has met this promise, as the average size of invasive carcinomas detected by mammography is about 1 cm (significantly smaller than cancers identified by palpation), and only 15% will have metastasized to regional lymph nodes at the time of diagnosis. In the United States, most cancers in women more than 50 years of age are now detected by mammography (