Nipple Discharge & Benign Breast Conditions & Special Neoplasms😍

Nipple Discharge

Duct Ectasia

• Most common pathological cause for nipple discharge

• Dilated duct + greenish discharge

• A/w smoking

• Discharge Characteristics:
• Greenish or bluish discharge (from multiple ducts).
• Periareolar abscess or sinuses (aerobic or anaerobic).

• Management (Mx):
• Initial: Antibiotics.
• If Antibiotics Fail: Major duct excision
• Hadfield procedure/cone excision of ducts

• Mnemonic: Field (Hadfield) → Greenery (Greenish d/d → Periductal mastitis/ Duct ectasia)

Periductal Mastitis (Zuska’s Disease)

• Seen in perimenopausal (associated with smoking)

• Presents with pain + greenish discharge

• Periareolar abscess/sinuses (Aerobic + anaerobic)

• Investigation (IOC): 
• Ultrasound

• Management:
• Antibiotics

• If not responding:
• Surgical Hadfield procedure (Cone excision of all affected ducts)

Duct Papilloma

• Has central fibrovascular core + papillary projections
• Epithelium and myoepithelial cells

• Most common cause of bloody nipple discharge (from single duct)

Types:

• Solitary Papilloma: 
• Relative Risk (RR) of cancer → 1.5-2

• Papillomatosis: 
• 5 papillomas
• RR → 3

• Juvenile Papillomatosis: 
• Multiple papillomas (Swiss cheese disease)

Investigation: 

• USG (Dilated duct + intraductal growth)

• Diagnosis: Galactogram

Management: 

• Microdochectomy
• Single affected duct + lump removed
• Probe is inserted into the duct → making a tennis racquet incision → dissecting the flap to reach the duct, and finally excising the duct

Paget’s Disease vs. Eczema

• Clinical Presentation: 
• Crusting in nipple-areola complex.
• Looks like a dermatology condition.
• 70% patients have underlying lump
• DCIS (Most Common),
• invasive ductal cancer (Rare)

• ER and PR negative

• CEA Positive

• Mnemonic: CEO (CEA) took Clear (clear cell) Page (Pagets) → rubbed in her breast → NAC destroyed

Diagnosis: Punch biopsy

• Biopsy shows clear cells (Paget cells) in skin.

• Similar to Paget's vulva

• Distinct from Paget's disease of the bone.

Benign Breast Conditions

Mastalgia

• Most Common Cause: 
• Fibrocystic disease/fibroadenosis

• Clinical Features: 
• Cyclical mastalgia
• increases before menses,
• settles after periods
• breast nodularity

• Assessment: 
• Cardiff-Lucknow scale for nodularity

• Management:
• Maintain pain diary
• Reassurance that it is not malignancy
• Flaxseed/evening primrose oil (no benefit after 2 months)

• Treatment of Pain + Nodularity:
• (Most Common Used)
• Tamoxifen
• Ormeloxifen
• Danazol

Fibrocystic Disease

Mammogram

• Tea cup calcification

Features:

• Fibrosis

• Blue dome cysts

• Apocrine cells (pinkish color cells)
• Pink secretions called snout secretions

Breast Cyst

Mondor’s Disease

• Clinical Features: 
• Mastalgia, on examination:
• cord-like swelling

• Description: Thrombophlebitis of chest veins

• Important Note: Always rule out carcinoma

 

• Risk: Increased in smokers

• Management: Anti-inflammatory agents (settles in a few weeks)

Radial Scar

• Features:
• Star-shaped or central stellate scar.
• Star projections microscopically.

• Importance: Premalignant.

Stellate terms	Seen in
Stellate cells	• Cirrhosis • NAFLD • Chronic pancreatitis • Young stella → alcoholic → liver and pancreas
Stellate Keratin Precipitates	• Herpetic uveitis • Toxoplasmosis • Fuchs Heterochromia Iridocyclitis • Young stella → Fucked () by Toxic () Herpes () Guy
Stellate Granuloma	• Cat Scratch Disease • LGV • Leprosy • Syphillis • Stella granny → has a Cat, Lgtv, has leprosy and syphillis
Stellate scar	• Kidney → Oncocytoma, Chromophobe RCC • Liver → Focal Nodular Hyperplasia, Fibrolamellar Carcinoma • Pancreas → Serous Cystadenocarcinoma • Breast → Radial Scar: Premalignant

Fibroadenoma

• Radiology: Shows popcorn calcification.

• Clinical: "Breast mouse" (high mobility).

• FNAC:
• Staghorn clusters.
• Bare nuclei.

• Biopsy Patterns:
• Intracanalicular Fibroadenoma:
• Ducts appear compressed ('I' shape).
• Pericanalicular Fibroadenoma:
• Ducts appear open ('P' shape).

• Prognosis:
• No difference between patterns.

• Mnemonic: mouse with a staghorn (Staghorn clusters on FNAC) eating popcorn

Benign lesion/Fibroadenoma → Imaging

• Phyllodes and fibroadenoma
• Intralobular stroma -MED12 mutation
• common origin

• Wider > Taller

• Macrocalcification

• Chunky / Popcorn calcification

• Corresponds to BIRADS 2.

Other benign calcifications

FibroadenomaLipoma / Hamartoma

• Breast in breast appearance

Ductal Carcinoma In Situ (DCIS)

• Nature: Precancerous condition.

• Basement Membrane:
• Still present around every duct.

• Patterns:
• Cribriform DCIS: Looks like a sieve or chimney with holes.
• Comedo Necrosis: Shows dirty material inside (like a comedone).
• Mnemonic: DCIS → De seive → Sieve → Deceiving Van (Van nuys) [SCAM]

Van Nuys

• Size, Margin, Class, Age

• To plan management
• Excision alone
• Excision + RT
• Mastectomy

Squamous Metaplasia of Breast

• Benign condition

• Normal breast tissue cells → squamous cell type

• Not a risk factor for developing breast cancer

Special Breast Neoplasms

Locally Advanced Breast Cancer (LABC)

Definition:

• ≥ 5 cm with Nodes

• T3 N1 M0 →

• with M0
• Any T4
• Any N2
• Any N3

Management: 

• Neoadjuvant chemotherapy → MRM/BCS → RT

Pregnancy-Associated Breast Cancer

• Occurrence: Develops during pregnancy or within 1 year of delivery

• Characteristics: Aggressive tumours (Usually ER, PR -)

• Investigation: Core biopsy (Diagnostic)

Management:

• Surgery:
• MRM in 1st trimester
• BCS only in 2nd/3rd trimester (RT after delivery)

• Chemotherapy:
• Contraindicated in 1st trimester
• Best to give in 2nd trimester

• Hormonal Rx + Radiotherapy: 
• Contraindicated in all trimesters

Phyllodes Tumour/Cystosarcoma Phyllodes

• Phyllodes and fibroadenoma
• Intralobular stroma -MED12 mutation
• common origin

• Meaning: "Phyllodes" means leaf-like (microscopic pattern).

• Types: Benign, borderline, malignant.

Differentiation (based on mitosis per 10 high power fields (HPF)):

Note:

Clinical Features:

• 3rd/4th decade

• Rapidly enlarging breast lump

• Dilated veins over chest wall

Spread:

1. <10% metastasize to LN
• So no role for SNLB

2. Hematogenous spread (if malignant):
• Lungs (Most Common)

Histopathology (HPE): 

• Arborizing pattern

• slit-like cystic areas

Management:

1. Lumpectomy

2. Simple mastectomy
• for malignant phyllodes or recurrence

Mucinous or Colloid Carcinoma

• Key Feature: Lots of mucin.

• FNAC: Mucin background with chicken wire blood vessel appearance.

• Biopsy: Pools of mucin with tumor cells floating.

NOTE: Chicken Wire Appearance, Fried egg, Diens and Mycoplasma

Pattern	Appearance Type	Condition/Location
Fried Egg	Hairy cell leukemia	Bone marrow biopsy
Fried Egg	Seminoma	Testis
Fried Egg	Dysgerminoma	Ovary
Fried Egg	Mycoplasma colonies	Microbiology
Fried Egg colonies on SDA with Olive Oil	Malassezia furfur	Fungus
Chicken Wire	Chicken wire blood vessels.	Oligodendroglioma
Chicken Wire	Chicken wire calcification	Chondroblastoma (bone tumor)
Chicken Wire	Chicken wire blood vessels	Mucinous/Colloid carcinoma of the breast → FNAC
Chicken Wire	Chicken wire fibrosis	Alcoholic liver disease (liver pathology)

• Mnemonic:
• We cannot eat fied egg because it has
1. Fur ()
2. Hair ()
3. Germs (dysgerminoma)
4. Semen (seminoma)
5. Blood (Mycoplasma) in it

• Mnemonic:
• Chicken Breast piece (Breast Ca) um cartilage (Chondroblastoma) um Kallum (Colloid carcinoma, Alcoholic LD)

Mnemonic:

• for Mycoplasma
• Atypical Walking (walking pneumonia) people (PPLO agar) with CAT (Cold agglutination test) → Eat (Eaton agent) fried egg (fried egg colonies) and Dine (Diens stain) → No walls (cell wall deficient) and take steroids (steroid in cell membrane)

• for Diens
• Diens phenomenon → Proteus
• Diens stain → Mycoplasma

Inflammatory Breast Carcinoma

• TNM Stage: 4d

• Inflammatory cancer > 1/3rd of breast surface area

• Looks like inflammation, but is cancer.
• local rise of temperature
• mobile lump

Peau d'orange appearance

• If only Peau d'orange appearance → T4b

• Due to cancer cells in subdermal lymphatics.

Invasive Lobular Carcinoma (ILC)

• Cause:
• Loss of E-cadherin.

• Microscopic Feature:
• Cancer cells in a straight line → Indian file pattern.

• Mnemonic: LIC (ILC → Inv Lob C) officil File () eduthond varunna pennine kadich (CDH)

CDH gene (E-cadherin):

• Chromosome 16

• "Glue" for cell-to-cell connection.

Loss/mutation

• Mnemonic: Kadich (CDH) → Breastlum Vyarilum

• "Golu" tumors/Kadicha tumors
1. Diffuse Gastric Cancer

Lauren's Classification	Intestinal Lauren's Classification	Diffuse Lauren's Classification
Epidemiological	Environmental	Familial
Pathology	Gastric atrophy, intestinal metaplasia	Blood Group A
Sex	m > F	F > M
Age	↑ Incidence with ↑Age	Younger age
Morphology	Gland formation Round glands	Poorly differentiated
Cell Type	ㅤ	• Gross: Linitis plastica  ("leather bottle appearance"). • Microscopy: Signet ring cells.
Genetics	APC gene mutations, Microsatellite instability p53, p16 inactivation	Loss of E-cadherin (↓ E-cadherin) p53, p16 inactivation
Invasion	Hematogenous spread	Transmural/Lymphatic spread

2. Lobular Carcinoma Breast
• Indian File/Single File Pattern

• Mnemonic: File (Indian file) of Breast Ca patients
3. Claudin low → EMT positive breast cancer

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• Krukenberg tumor
• Stomach > Breast/ Colon
• Signet Ring Cells
• Retrograde lymphatic spread

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NOTE: Miscellaneous one liners