Hypothetical Chief Complaint

1
Hypothetical Chief Complaint

• I have left nipple swelling

2
History of Present Illness

• 75 y.o. male was noted to have a painful left
  nipple swelling on 3/15/06. The nurse noted that
  it was an easily palpable lump, with tenderness
  upon palpation. A surgical consult was sought,
  and suggested to perform mammogram and
  ultrasound.

3

• Past Medical History
• Dementia
• HTN
• GERD
• Past Surgical History
• s/p cholecystectomy
• s/p peg (12/05)

4
Medications

• Metoprolol 25 mg BID
• Senna 8.6 mg QHS
• Ranatidine 150 mg BID
• Seraquil 25 mg BID
• Aricept 5 mg QHS
• Tyenol 160mg/5mL Q 6 hours (PRN)
• MVI

5

• Allergies NKDA
• Social History No smoking, drinking, or
  drugs
• Family History No history of cancers

6

• VS T 98.2 P 80 RR 16 BP 100/50
• Gen AAO x 3, NAD
• HEENT NC/AT, PERRLA, EOMI, no LAD, OP clear
• Neck supple, no thyromegaly
• Chest CTA b/l, aw entry, left breast mass,
  palpable at about 12 oclock, tenderness on
  palpation
• CV S1S2 nl, RRR
• Abd soft, NT/ND, BS, no HSM
• Extremities WINL
• Neuro no focal neurological deficit, AAO x 3

7
Labs

• WBC 7.9 Mg 1.8
• H/H 11.7/39.8 Phosphorus 2.8
• Platelets 275 Coags 11.2/25.4/.7
• Na 139 CXR NAPD
• K 4.1 EKG NSR _at_ 100 BPM
• Cl107
• HCO3 29
• BUN 25
• Cr 0.9
• Glucose 78
• Ca 8.9

8
Radiographic Labs

• Mammogram
• Right breast is fatty with some retroareolar
  densities probably representing mild gynecomastia
• Density of left breast, which can represent
  gynecomastia, but mass cant be excluded
• U/S indicated and open excision
• Impression
• Changes consistent with gynecomastia
• R/O mass in left breast approximately at 2
  oclock
• BI-RADS Score
• Right breast 2
• Left breast 0

9
Radiographic Labs

• Ultrasound of Left Breast
• In the periareolar region at 12 oclock, 1-2, 3,
  4-5 and 6 positions, hypoechoic density is seen,
  some borders have mass effect.
• There is a slight vascularity within the lesion,
  which measures 1.5 x .69 cm in the radial plane
  and 1.49 cm in the anteradial plane
• Some compression is seen consistent with
  gynecomastia
• BI-RADS Score
• Left Breast 3

10
Radiographic Labs

• Left Core Biopsy of Breast Mass
• Breast tissue showing extensive foci of atypical
  ductal hyperplasia in the background of
  gynecomastia.

11
Breast Cancer

• Marcella A. Escoto
• St. Barnabas Scholar
• MS III

12
Breast Cancer

• Breast cancer is the most common female cancer in
  the U.S.
• It is the second most common cause of cancer
  death in women.
• Lastly, it is the main cause of death in women
  ages 45 to 55.
• However, male breast cancer is rare in contrast
  to female breast cancer.

13
Epidemiology

• Breast cancer is 100 times more common in females
  than males.
• In males, breast cancer accounts for breast cancer cases in the U.S. and 0.1 of
  cancer mortality in men.
• The American Cancer Society estimated that 1,450
  men would have been diagnosed with breast cancer
  in U.S. and 470 would die from this disease in
  year 2004.
• The incidence of male breast cancer, once thought
  to be relatively stable, now seems substantially
  to be increasing, that has increased from 0.86 to
  1.06 per 100,000 population over the last 26
  years.
• The median age of onset in males is 65-67 years
  of age.
• In females, it is estimated that approximately
  211,240 American women would have been diagnosed
  with breast cancer in year 2005, and 40,410 women
  would have died.
• Breast cancer rates increased by 1.2 per year
  between 1940 and 1980.
• However, the median age of onset in females is
  45-50 years of age, around 10 years younger than
  males.

14
Back to BasicsANATOMY

• Basic Structure
• Composed of glandular, fibrous, and adipose
  tissue.
• Lies within layers of superficial pectoral
  fascia.
• Each mammary gland consists of approximately 15
  to 20 lobules, each of which has a lactiferous
  duct that opens on the areola.
• The breast has ligaments that extends from the
  deep pectoral fascia to the superficial dermal
  fascia that provide structural support referred
  to as Coopers ligaments.
• The skin dimpling in breast cancer is due to
  traction on Coopers ligaments.
• The breast frequently extends into axilla as the
  axillary tail of Spence.
• The breast is also partitioned into 4 quadrants
  by vertical and horizontal lines across the
  nipple
• Upper inner quadrant (UIQ)
• Lower inner quadrant (LIQ)
• Upper outer quadrant (UOQ)
• Lower outer quadrant (LOQ)

15
Breast Anatomy
16
Quadrants of the Breast
17
Blood and Nerve Supply to the Breast

• Blood Supply
• Arterial
• It is supplied by the axillary artery via the
  lateral thoracic and thoracoacromial branches
• The internal mammary artery via its perforating
  branches
• Adjacent intercostal arteries
• Venous
• It tends to follow the arterial supply axillary,
  internal mammary, and intercostal veins
• The axillary vein is responsible for the majority
  of venous drainage
• The venous drainage is largely responsible for
  metastases to the spine through Batsons plexus.
• Nerve Supply
• The breast is supplied by 4 main nerves
• Long thoracic nerve
• Thoracodorsal nerve
• Medial and lateral pectoral nerves
• Intercostobrachial nerve

18
Lymphatic Drainage to the Breast

• The lymphatic drainage of the breast is important
  because of its role in the metastasis of breast
  cancer.
• Lymph tends to pass from the nipple, areola, and
  lobules of the gland to the subareolar lymphatic
  plexus.
• Most lymph (more than 75), especially from the
  lateral quadrants drain to the axillary lymph
  nodes.
• The axillary lymph nodes are sub-divided into
  levels
• Level I (low) lateral border of pectoralis minor
• Level II (middle) deep to pectoralis minor
• Level III (high) medial border of pectoralis
  minor
• Rotters node these nodes lie between the
  pectoralis major and minor muscles.
• Most of the remaining lymph, particularly from
  the medial quadrants, drains to the parasternal
  nodes or to the opposite breast, while lymph from
  the lower quadrants passes deeply to the inferior
  phrenic nodes.

19
Back to Basics.ANATOMY
20
Risk Factors for Breast Cancer

• Females
• Early menarche
• Late menopause
• Nulliparity or 1st pregnancy 30 y.o.a.
• White race
• Old age
• Family history of breast cancer
• Genetic predisposition (BRCA 1, BRCA 2, Li
  Fraumeni Syndrome)
• Prior personal history of breast cancer
• DCIS or LCIS
• Atypical ductal or lobular hyperplasia

• Males
• Testicular Abnormalities
• Undescended testes
• Congenital inguinal hernia
• Orchitis
• Testicular injury
• Infertility
• Positive family history
• Klinefelter Syndrome
• Elevated endogenous estrogen
• Previous irradiation
• Trauma
• Jewish ancestry

21
Screening for Breast Cancer

• Breast screening is a method of detecting breast
  cancer at a very early age.
• There are several methods for to screen for
  breast cancer, and it can begin at a very early
  age.
• The simple ways to begin to screen for breast
  cancer are
• Breast Self Examination
• Mammography
• Ultrasound

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Breast Self Examination

• Breast Self Examination
• All women should perform a self breast
  examination monthly after the menstrual period,
  when breast swelling and fibrocystic changes are
  less likely to interfere with the detection of a
  lump or mass.
• This is also followed by a yearly clinical breast
  exam.
• HOW TO DO THE EXAM
• First, lift your right hand and place it behind
  your head.
• Keep the first 3 fingers of your hand firmly
  together.
• Press the outermost point of your right breast
  (near armpit) firmly in a little circular motion
  with the pads of your fingers. Then continue in a
  large circle all around your breast.
• Move your finger an inch closer to the nipple and
  feel another circle around the breast. Continue
  circling until you have felt every part of the
  breast, including the nipple.
• Squeeze the nipple gently to see if any fluid
  comes out.
• Now change hands and repeat the procedure for the
  other breast.

23
Breast Self Exam (BSE)
24
Mammography

• 2. Mammogram
• Mammograms are the most important tools doctors
  have to diagnose and evaluate women who have
  breast cancer.
• It tends to identify 5 cancers/ 1,000 women
• It is 85-90 sensitive
• Gives false positives 10, false negatives 6-8
• Mammograms are more useful in ages 30 secondary
  to the large proportion of fibrous tissue in
  younger womens breast make more difficult to
  interpret.
• Recommendation for annual mammograms start at the
  age of 40 however, women with risk factors for
  breast carcinoma should have yearly mammograms
  at an earlier age.
• The American College of Radiology Diagnostic Code
  interprets the mammograms from negative to highly
  suggestive of malignancy.

25
Mammography

• American College of Radiology Diagnostic
  Code
• BI-RADS SCORE
• 0 incomplete assessment, needs additional
  imaging
• 1 negative
• 2 benign finding
• 3 probably benign recommend short term follow
  up
• 4 suspicion abnormality consider biopsy
• 5 highly suggestive of malignancy

26
Ultrasonography

• Ultrasound is frequently used to evaluate breast
  abnormalities that are found with screening
  mammography or during a physician performed
  breast examination.
• Ultrasound allows significant freedom in
  obtaining images of the breast from almost any
  direction.
• However, it is not FDA approved as a screening
  tool for breast cancer. Yet, it is used as a
  first tool in women under 30 years of age when a
  breast abnormality is found secondary to the
  large amount of fibrous tissue found in women of
  this age.
• Advantages
• They are good for identifying cystic disease
• Can assist in therapeutic aspiration
• It has excellent contrast resolution
• Disadvantages
• It lacks spatial resolution (fine detail)
• It cannot detect most calcium deposits on breast
  tumors
• It cannot document how much breast tissue has
  been imaged
• Will not identify lesions

27
Diagnostic Tools for Breast Cancer

• While physical breast exam, mammography,
  ultrasound, and other breast imaging methods can
  help detect a breast abnormality, biopsy followed
  by pathological analysis is the only definitive
  way to determine if cancer is present.
• Depending on a number of factors, including how
  suspicious the abnormality appears the size, the
  shape and the location of the abnormality many
  different methods of biopsy can be performed,
  such as
• Fine Needle Aspiration Biopsy (FNA)
• Core Needle Biopsy
• Vacuum-Assisted Biopsy (Mammatome or MIBB)
• Large Core Surgical (ABBI)
• Open Surgical (Excisional or Incisional)

28
Fine Needle Aspiration Biopsy

• Fine Needle Aspiration Biopsy (FNA)
• It is a percutaneous (through the skin)
  procedure that uses a fine gauge needle (22 or 25
  gauge) and a syringe to sample fluid from a
  breast cyst or remove clusters of cells from a
  solid mass.
• Advantages
• Fastest and easiest method of biopsy, where the
  results are easily available.
• It is excellent for confirming breast cysts
• Has a low morbidity
• Only 1-2 false-positive rate
• Disadvantages
• The procedure only removes very small samples of
  tissues or cells from breast
• If the sample is benign fluid, then the procedure
  is ideal. However, if the tissue is solid or a
  cloudy sample, the small number of cells removed
  by FNA only allow for a cytologic (cell)
  diagnosis.
• False negatives rate up to 10
• May miss deep masses

29
Core Needle Biopsy

• 2. Core Needle Biopsy
• It is also a percutaneous procedure that involves
  removing small samples of breast tissue using a
  hollow core needle.
• This procedure is usually for palpable lesions.
• It differs from FNA in that is also uses a larger
  gauge needle (16,14 or 11).
• Advantages
• Core needle biopsy usually allows for a more
  accurate assessment of a breast mass than FNA
  because the larger core needle usually removes
  enough tissue for the pathologist to evaluate
  abnormal cells.
• Disadvantages
• Still a chance of sampling error
• Again, like FNA it only removes a sample of the
  mass and not the entire area of concern.

30
Vacuum-Assisted Biopsy

• 3. Vacuum-Assisted Biopsy (Mammotome)
• This is a relatively new biopsy that is
  percutaneous procedure that relies on
  stereotactic mammography or ultrasound imaging.
• Stereotactic mammography involves using computers
  to pinpoint the exact location of a breast mass
  based on mammograms taken from two different
  angles.
• Vacuum-assisted biopsy is minimally invasive
  procedure that allows for the removal of multiple
  tissue samples.
• It has been becoming more common that open
  surgical biopsies due to its advantages.
• Advantages
• Minimally invasive
• Usually no significant scarring
• Does not require stitches
• No breast deformity
• Procedure takes less than hour
• Cost effective

31
Large Core Surgical

• 4. Large Core Surgical (ABBI)
• It is a surgical technique that involves removing
  an entire intact breast lesion under image
  guidance.
• It requires the use of a prone biopsy table and a
  stereotactic mammography.
• It can remove 5 mm to 20 mm of breast tissue.
• However, this technique is not widely accepted
  and has bought controversy secondary to that in
  large core biopsy it requires the removal of a
  significant portion of normal breast tissue just
  to reach the lesion.

32
Open Surgical Biopsy

• 5. Open Surgical Biopsy
• Traditional open surgical biopsy is the gold
  standard to which other methods of breast
  biopsies are compared.
• It tends to require a 1.5 cm to 2 cm incision in
  the breast.
• Excisional Biopsy The surgeon will attempt to
  completely remove the area of concern, often
  along with the surrounding margin of normal
  breast tissue.
• Incisional Biopsy Similar to excisional biopsy
  except that the surgeon removes only part of the
  breast lesion, usually performed on large
  lesions.
• Advantages
• Yields the largest breast tissue sample of all
  breast biopsy methods
• Gold standard the accuracy is close to 100 for
  a diagnosis
• Disadvantages
• Requires stitches and leaves a scar
• Chances of bleeding, infection, or problems with
  wound healing
• Mortality risk associated with anesthesia

33
Staging of Breast Cancer

• TNM Staging for Breast Cancer
• Tx Cannot assess primary tumor
• T0 No evidence of primary tumor
• T1
• T2
• T3 5cm
• T4 any size, with direct extension into the
  chest wall or with skin edema or ulceration
• Nx Cannot assess lymph nodes
• N0 No nodal metastasis
• N1 Movable ipsilateral axillary nodes
• N2 Fixed ipsilateral axillary nodes
• N3 Ipsilateral internal mammary nodes
• Mx Cannot assess metastasis
• M0 No metastasis
• M1 Distant metastasis or supraclavicular nodes

34
Staging System for Breast Cancer
35
Treatment

• The primary goal of local therapy is to provide
  optimal control of the disease in the breast and
  regional tissue while providing the best possible
  cosmetic result.
• The different types of treatment may include
  surgery, radiation therapy, adjuvant
  chemotherapy, adjuvant endocrine therapy, or a
  combination of modalities.

36
Surgical Treatment

• The optimal surgical approach is determined by
  the following factors
• Disease stage
• Tumor size
• Tumor location
• Breast size and configuration
• Number of tumors in the breast

37
Surgical Treatment

• Radical mastectomy Resection of all breast
  tissue, axillary nodes, and pectoralis major and
  minor muscles.
• Modified radical mastectomy Same as radical
  mastectomy except pectoralis muscles left intact.
• Simple mastectomy Resection of all the breast
  tissue, except pectoralis muscle left intact and
  no axillary node dissection.
• Lumpectomy and axillary node dissection
  Resection of mass with rim of normal tissue and
  axillary node dissection good cosmetic result.
• Sentinel node biopsy Recently developed
  alternative to complete axillary node dissection.
• Lymph nodes are identified on pre-operative
  scintigraphy and blue dye is injected in the
  periareolar area.
• Axilla is opened and inspected for blue and/or
  hot nodes identified by a gamma probe.
• When sentinel node is positive, an axillary
  dissection is completed.
• When sentinel node is negative, axillary
  dissection is not performed unless axillary
  lymphadenopathy identified.

38
Breast Cancer

• There are many different types of breast cancers,
  and they can be distinguished by the following
• Infectious/Inflammatory Disease
• Mastitis
• Fat Necrosis
• Benign Disease
• Fibroadenoma
• Cystosarcoma Phyllodes
• Intraductal Papilloma
• Gynecomastia
• Atypical Ductal Hyperplasia
• Pre-Malignant Disease
• Ductal Carcinoma In Situ (DCIS)
• Lobular Carcinoma In Situ (LCIS)
• Malignant Disease
• Infiltrating Ductal Carcinoma
• Infiltrating Lobular Carcinoma
• Paget Disease (of the Nipple)

39
Infectious/Inflammatory Breast Disease

• Mastitis
• It is usually caused by S. aureus or
  Streptococcus spp.
• It commonly occurs during early weeks of breast
  feeding, in which there is focal tenderness with
  erythema and warmth of overlapping skin.
• Diagnosis Ultrasound can be used to localize an
  abscess
• Treatment Continue breast feeding and recommend
  breast pump as an alternative.
• If cellulitis would perform wound care and IV
  antibiotics, and if abscess would do incision and
  drainage followed by IV antibiotics.
• Fat Necrosis
• It usually presents as a firm, irregular mass of
  varying tenderness, with a history of a local
  trauma elicited in 50 of patients.
• The exam represents irregular mass with no
  discrete borders that may or may not be tender.
• Diagnosis and Treatment Excisional biopsy with
  pathologic evaluation for carcinoma.

40
Mastitis Fat Necrosis
41
Benign Breast Disease

• Fibroadenoma
• It is a fibrous stroma surrounds duct-like
  epithelium and forms a benign tumor that is
  grossly smooth, white, and well-circumscribed.
• It typically more common in blacks, and occurs in
  the late teens to early 30s.
• This disease is also estrogen-sensitive, which
  has increased tenderness during pregnancy.
• The breast exam shows smooth, discrete, circular
  and mobile mass
• Diagnosis FNA
• Treatment Observation

42
Benign Breast Disease

• Cystosarcoma Phyllodes
• It is a variant of fibroadenoma, in which the
  majority are benign
• The patients tend to present later than those
  with fibroadenoma
• They tend to be indistinguishable from
  fibroadenoma by ultrasound or mammogram, but can
  only be distinguished on their histologic
  features (phyllodes has more mitotic activity).
• The breast exam shows large, freely movable mass
  with overlying skin changes.
• Diagnosis Biopsy with pathologic evaluation
• Treatment
• Small Tumors Wide local excision with a least a
  1 cm margin
• Larger Tumors Simple mastectomy

43
Cystosarcoma Phyllodes
44
Benign Breast Disease

• Intraductal Papilloma
• It is a benign local proliferation of ductal
  epithelial cells, that has unilateral
  serosanguineous or bloody nipple discharge.
• Patients usually present with subareolar mass
  and/or spontaneous nipple discharge.
• In examination one must radially compress breast
  to determine which lactiferous duct express fluid
• Diagnosis Definitive diagnosis by pathologic
  evaluation of resected specimen.
• Treatment Excise affected duct

45
Benign Breast Disease

• Gynecomastia
• It is the development of female-like breast
  tissue in males, which can either be physiologic
  or pathologic.
• There is at least a 2 cm of excess subareolar
  breast tissue present to make the diagnosis.
• The causes can be medications, illicit drugs,
  liver failure, increased estrogen, and/or
  decreased testosterone.
• Treatment Treat underlying cause if specific
  cause identified if normal physiology is
  responsible, only surgical excision.

46
Benign Breast Disease

• Atypical Ductal Hyperplasia (ADH)
• It is the name given to a condition that can
  occur in the lining of the milk ducts in the
  breast.
• This typically is benign in both males and
  females but can be at risk for developing cancer
  hence, further studies are needed.
• In women, this disease rarely proceeds on towards
  cancer, and it is not cancer.
• In men however, when ADH is diagnosed with a
  background of gynecomastia there is a 4-5 times
  increased risk for the development of invasive
  breast carcinoma.
• Diagnosis Biopsy
• Treatment Observation, or surgical resection

47
Atypical Ductal Hyperplasia
48
Pre-Malignant Disease

• Ductal Carcinoma In Situ (DCIS)
• It is the proliferation of ductal cells that
  spread through the ductal system but lack the
  ability to invade the basement membrane. It
  arises from the inner layer of epithelial cells
  in major ducts.
• More than ½ the cases occur after menopause, in
  which there is a palpable mass some of the times.
• Diagnosis Clustered microcalcifications on
  mammogram, malignant epithelial cells in breast
  duct on biopsy.
• Risk of invasive cancer There is increased risk
  in ipsilateral breast, usually same quadrant
  where infiltrating ductal carcinoma is most
  common histologic type.
• Treatment
• If small (follow-up or radiation
• If large ( 2 cm) Lumpectomy with 1 cm margins
  and radiation
• If breast diffusely involved Simple mastectomy

49
Ductal Carcinoma In Situ
50
Pre-Malignant Disease

• Lobular Carcinoma In Situ (LCIS)
• It is a multi-focal proliferation of acinar and
  terminal ductal cells, which arises from cells of
  the terminal duct-lobular unit.
• The vast majority of the cases occur prior to
  menopause, and one usually does not feel a
  palpable mass.
• Diagnosis Typically a clinically occult lesion
  undetectable by mammogram and incidental on
  biopsy.
• Risk of invasive cancer There is an equally
  increased risk in either breast, infiltrating
  ductal carcinoma associated with simultaneous
  LCIS in the contralateral breast in over ½ the
  cases.
• Treatment None, bilateral mastectomy an option
  if patient is at high risk.

51
Lobular Carcinoma In Situ
52
Malignant Disease

• Infiltrating Ductal Carcinoma
• This is the most common invasive cancer in both
  males and females (80 of cases).
• It is the most common in perimenopausal and
  postmenopausal women.
• Presentation A hard, fixed mass, peau d
  orange overlying the skin, ulceration of
  overlying skin, bloody nipple discharge, inverted
  or retracted nipple.
• The ductal cells tend to invade stroma in various
  histologic forms described as scirrhous,
  medullary, comedo, colloid, papillary, or
  tubular.
• Medullary Invasive breast cancer that forms a
  distinct boundary between tumor tissue and normal
  tissue.
• Colloid Formed by mucus producing cancer cells
• Can have metastasis to axilla, bones, lungs,
  liver and brain.

53
Infiltrating Ductal Carcinoma
54
Malignant Disease

• Infiltrating Lobular Carcinoma
• It is the second most common type of invasive
  breast cancer (10 of cases).
• It originates from terminal ducts cells and, like
  LCIS, has a high likelihood of being bilateral.
• 20 of infiltrating lobular carcinoma have
  simultaneous contralateral breast cancer.
• Tends to present as an ill-defined thickening of
  the breast.
• Like LCIS, lacks microcalcifications and is often
  multi-centric
• Tends to metastasize to the axilla, meninges, and
  serosal surfaces.

55
Infiltrating Lobular Carcinoma
56
Malignant Disease

• Paget Disease (of the Nipple)
• It is usually 2 of invasive breast cancers
• They are usually associated with underlying LCIS
  or ductal carcinoma extending within the
  epithelium of the main excretory ducts to skin of
  nipple and areola.
• Presentation Tender, itchy nipple with or
  without a bloody discharge with or without a
  subareolar palpable mass
• Treatment Usually requires a modified radical
  mastectomy.

57
Paget Disease of the Nipple
58
Metastasis

• Breast cancer tends to metastasize to the
  following places
• Lymph nodes (most common)
• Lung/pleura
• Liver
• Bones
• Brain

59
Prognosis

• Approximately 50 of patients with operable
  breast cancer develop recurrent disease unless
  they receive adjuvant chemotherapy or hormone
  therapy. Prognostic factors include
• Tumor size Tumors larger than 5 cm are
  associated with a decreased survival rate and
  increased recurrence rate.
• Axillary node status
• Histopathology
• Hormone receptor status
• Oncogenic expression

60
5 Year Survival Rate According to Stage
61
Summary

• Breast cancer is the most common female cancer,
  in contrast to male where it is rare, with a
  ratio of 1001.
• When performing an initial evaluation of patients
  with possible breast disease
• Remember to have a complete medical history,
  including risk factors, such as
• Ask when first menarche, first child, any history
  of breast cancer, when did menopause happen, how
  old is the patient, any previous breast biopsy,
  etc.
• Be sure to inquire about any history of nipple
  discharge, or any changes in the size, shape,
  symmetry, or contour of the breasts.
• Remember to inspect and palpate all four
  quadrants of the breast, the axillary lymph
  nodes, and the nipple-areolar complex for any
  discharge.
• Screening test of choice Mammogram
• Diagnostic Test Biopsies
• Treatments Surgical, Hormonal, Adjuvant Therapy
  Chemotherapy, Radiation Therapy

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Surgical Specimen of Left Mastectomy

• Gynecomastia with atypical ductal hyperplasia
• Note
• The breast shows duct hyperplasia with periductal
  edema
• Some ducts show atypical micropapillary
  hyperplasia
• Few ducts show disorderly proliferation of
  epithelial cells nearly fills the duct
• Focal duct dilation and apocrine metaplasia are
  also present