Breast inflammation causes redness, pain and swelling.
Don’t forget that cancer can also cause breast inflammation.
Benign masses tend to be smooth, mobile and soft
Cancerous masses tend to be irregular, fixed and hard.
Fibrocystic Changes refers to benign lumpy bumpy breasts. This is a group of benign “non-proliferative” disorders, meaning the epithelial layer tends to stay 1 -2 layers thick. They tend to occur in young women. Can cause simple cysts, which are bubbles of fluid with a thin wall and no loculations. When cysts rupture, they can cause mild inflammation that leads to stromal fibrosis of the breast. Little association with cancer!
Fibroadenomas are the most common benign breast tumor in young women. It’s full of glands and connective tissues. They are hormone-sensitive, so they grow with estrogen (ovulation, pregnancy) and shrink without it (postmenopausal). They are smooth, mobile and soft.
Sclerosing Adenosis - increase in glands! Increase in connective tissue! Increase in calcifications! So much stuff increases that the glands become compressed.
Epithelial Hyperplasia is an increase in luminal and myoepithelial cells. If the cells develop a disorganized appearance (atypia) then we call it atypical epithelial hyperplasia, which is associated with a risk of cancer.
Intraductal Papillomas are fingerlike growths of epithelium into the mammary ducts. They bleed a lot. They are the most common cause of unilateral bloody nipple discharge.
Phyllodes Tumors are tumors made of connective tissue in the breast. “Phyllodes” is Greek for “leaf like” because it looks like big leafy fronds under the microscope.
Phyllodes tumor
Lobular Carcinomas lack a surface molecule called E-Cadherin, which connects adjacent cells together, sort of like a desmosome. It helps epithelium huddle together to form neat little circular glands. Without E-Cadherin, the cancerous cells grow in a characteristic “cells in a line” formation. This helps lobular carcinomas invade faster.
BREAST CANCER
Breast cancer is the most common cancer in women, and it kills the second highest number of women (lung cancer is first). It usually arises from a structure within the breast called the terminal duct lobular unit.
Risk factors include old age (rarely before menopause), BRCA mutations, high exposure to estrogen (nulliparity, obesity, increased number of periods) and alcohol. In men the risk is increased with BRCA2 and Klinefelter syndrome (because of the high estrogen).
You can screen for breast cancer with a special x-ray of the breast called a mammogram. Mammogram screening begins around 30 or 40, and is repeated every year or two. The mammogram is looking for calcification, a common feature with breast cancer. Mammograms have three downsides: (1) the image is a bit fuzzy and can be difficult to interpret, even for experienced radiologists, (2) lobular breast cancers don’t usually cause calcifications even though we wish they would, and (3) there are several noncancerous breast conditions that cause calcifications, like fat necrosis and sclerosing adenosis. Invasive lobular carcinoma is often asymptomatic, and can only be found incidentally on a biopsy.
The most common sign of breast cancer is a palpable breast mass. Other signs of breast cancer include
Skin dimpling is often cancerous. It’s caused by invasion, inflammation and shortening of the suspensory ligaments of Cooper. Cancer → Inflammation → Fibrosis → Ligamentous shortening (myofibroblasts), which draws the overlying skin inwards. Nipple retraction occurs by the same mechanism.
Peau d’orange is French for “orange peel.” It refers to the combination of skin dimpling, redness and swelling, which actually does look similar to an orange peel. It’s caused by lymphatic blockage. Although the redness and swelling may mimic cellulitis, this is not an infectious process. Rather, it suggests cancerous invasion of the axillary lymph nodes.
Nipple ulceration, aka Paget’s disease of the nipple, suggests a subareolar invasive ductal carcinoma.
Unilateral nipple discharge is common with breast cancer, especially bloody discharge.
Not all breast cancers are treated equally. The treatment depends on which receptors the tumor cells express. Some tumors express estrogen receptors (ER+), and these can be treated with drugs like Tamoxifen that selectively block these estrogen receptors. Tamoxifen can unfortunately also cause uterine cancer. HER2/neu+ responds well to Trastuzumab. Triple negative cancer (ER-, PR-, HER2neu-) is especially aggressive and difficult to treat.
Tamoxifen is Terrible for the uterus. It treats ER+ breast cancer.
Raloxifene Rocks! But it only treats osteoporosis.
GYNECOMASTIA & GALACTORRHEA
Lactation - milk while breastfeeding. Driven by nipple stimulation.
Galactorrhea - milk outside of breastfeeding (either men or women). Driven by the endocrine system. Get a pregnancy test, prolactin and TSH level.
Gynecomastia - breasts on a man
Bloody or unilateral milk is possibly cancerous; however, over 50% of the time is just due to an intraductal papilloma. Get a mammogram or ultrasound.
