Pathology Case Presentation: Prepared by Roll No.s 1-9

Pathology Case Presentation
Prepared by Roll no.s 1-9
Special thanks to Vishal Shrivastava for providing the technical support.

CASE AT A GLANCE
 60 YEARS OLD
WOMAN
 SORENESS & OOZING
FROM NIPPLE OF
LEFT BREAST
 2 CM PALPABLE
MASS UNDERLYING
THE LEFT NIPPLE
REPRESENTATIVE IMAGE ONLY.

REDUNDANCY
 WHENEVER A PATIENT WITH PALPABLE
MASS IN BREAST COMES TO A
CLINICIAN; WHATEVER BE THE
PATHOLOGY HE/SHE MUST ALWAYS
SUSPECT AN UNDERLYING MALIGNANCY.
BEFORE WE BEGIN…..
ISSUES IN OLDER PEOPLE
ONCOLOGY
• Around 50% of cancers occur in 15% of the population: those aged over 65 years.
• Women aged over 65 in the UK are not invited to participate in breast cancer screening but may receive it on
request. Uptake is low despite the increasing incidence with age.
• Presentation may be later for some cancers particularly when symptoms are non specific, patients (and their
doctors) may initially attribute them to age alone.
• The average life expectancy of an 80-year-old woman is 8 years, so cancer may still shorten life and an active
approach therefore remains appropriate.
• Histology, stage at presentation and observation for even a brief period are better guides to prognosis than age
alone.
• Some older patients experience a more indolent course of disease; this is not fully understood but may partly be
due to a reduction in the effectiveness of angiogenesis with age, which may inhibit the development of
metastases.
• Older people respond as well to treatment as younger people; this is well documented for a range of cancers
and for the common modalities of treatment including surgery, radiotherapy, chemotherapy and hormonal
therapy.
• Chronological age is of minor importance in selecting treatment compared to comorbid illness and patient
choice.
• Although older patients can be treated effectively and safely, aggressive intervention with the goal of cure or
long-term remission is not appropriate for all individuals It may be decided that symptom control is all that is
possible or desired by the patient
• When discussing treatment options, it is important that the older patient understands that choosing a non-
aggressive treatment option does not mean a grim, painful death. Reassurance that symptoms can tie
effectively controlled whatever choice is made, is vital.
APPROACH ALGORITHM
Common clinical presentations of
breast diseases
Number of biopsies
120
12
100
10
80
8
60 Benign
Cancer 6 Benign
40 Cancer
4
20
2
0
<40 40's >50
0
<40 40's >50
Age Age
Palpable mass Nipple discharge
Differential Diagnosis
Keeping in mind the age and symptoms we may consider
the following differential diagnoses…..(in order of
decreasing frequency)
•Fibrocystic disease of the breast

•Mammary duct ectasia
•Ductal papilloma
•Ductal carcinoma
•Paget’s disease with invasive carcinoma
Fibrocystic changes of the breast
 A benign epithelial lesions of the breast
 Cysts are the common cause of palpable
mass.
 Are also associated with spontaneous
unilateral nipple discharge.
 Most incidences in third to fifth decade of life
 Dramatic decline in incidence after
menopause
Mammary duct ectasia
 An inflammatory disease of the
breast
 Common in fifth to sixth decade
of life
 Often associated with poorly
defined palpable subareolar
mass, skin retraction, & thick
white nipple secretions
 Characerstic heavy infilteration
of the Plasma cells in some
cases.
 Clinical significance:- irregular
mass can be mistaken for
carcinoma by palpation and
mammography.
Ductal Carcinoma
 Carcinoma of breast arising from ductal
epithelium.
 Produces palpable mass (poorly defined
focus to 3-5 cm mass) in 30-75 % cases
 Nipple discharge in 30 % patients.
Intraductal Papilloma
 A benign papillary tumour.
 Most common occurrence in lactiferous duct or
lactiferous sinus near the nipple.
 Clinically serous or serosanguineous nipple
discharge.
 Most common in third & fourth decades of life.
 Usually solitary, less than 1 cm in diameter
 Commonly located near the nipple.
 Histologically multiple papillary having well developed
fibrovascular stalks covered by cuboidal epithelial
cells
Paget’s disease of nipple
 An eczematoid lesion of nipple
 Often associated with ductal carcinoma
 From minimal nipple erosions to crusted, scaly &
eczematoid lesions found.
 Oozing of serosanguineous fluid.
 About half the patients present with palpable
subareolar mass.
 Paget cells (malignant cells) extend from DCIS within
ductal system into nipple skin.
 Easily detected by nipple biopsy or cytological
preparations of exudate.
Picturesque Representation of Paget disease
Tentative diagnosis
 Without resorting to the investigations it is
quite impossible to reach on a tentative
diagnosis but the postmenopausal status and
the high incidences of assoctiation of
palpable mass, nipple discharge with
increasing age (particularly the alarming
increases in the sixth decades) point towards
the unfortunate diagnosis of carcinoma
breast.(Most probably;Paget Disease with
invasive carcinoma)
Management
Management
Investigations Treatment
Investigations
 Smear examination of
exudate
 FNAC
 Core/Large Needle
Biopsy
 Excisional Biopsy
 Mammography (as
supplement in
diagnosis)
 USG, CT, MRI, Chest
X-ray, bone scan, etc
In decreasing order of preference

FNAC (FINE NEEDLE
ASPIRATION CYTOLOGY)
 Least invasive
technique
 Cost effective
 OPD Procedure
 Very accurate if
cytologist & operator
both are experienced.
FNAC findings
FNAC
Cyst Atypical Cells Malignancy Benign
Disappearance of mass after FNAC

Core Biopsy surgery Excisional biopsy
(Diagnosis + Treatment)
surgery
Excisional biopsy/Core biopsy
 Excisional biopsy done when lump size <2.5
cm and FNAC indicates no malignancy.
Whole of the mass is excised out.
 Core biopsy is indicated when FNAC shows
atypia. Core of tissue is removed with a large
cutting needle.
Treatment Modalities
 Treatment stratgies are defined by findings of
various investigations that determine the
stages & grading of tumour.
 It involves combination of Sugical,
Chemotheraputic & radiological disciplines.
 Palliative treatment includes hormonal
therapies.

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Pathology Case Presentation: Prepared by Roll No.s 1-9

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Pathology Case Presentation

Prepared by Roll no.s 1-9

Special thanks to Vishal Shrivastava for providing the technical support.

REPRESENTATIVE IMAGE ONLY.

•Fibrocystic disease of the breast

In decreasing order of preference

Cyst Atypical Cells Malignancy Benign

Disappearance of mass after FNAC

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