Chapter 21: The Breast

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acinus (acini)

glandular (milk-producing) component of the breast lobule. Each breast has hundreds of lobules, each of which contains one or several acini



overgrowth of the stromal and epithelial elements of the acini within the terminal ductal lobular unit (TDLU) of the breast; a component of a fibrocystic condition



without echoes; simple cyst on ultrasound should be anechoic



plane of imaging on ultrasound of the breast that is perpendicular to the radial plane of imaging. The radial plane of imaging uses the nipple as the center point of an imaginary clock face imposed on the breast, such that the radial 12 o’clock plane is a line extending upward toward the top of the breast. Similarly, the radial 9 o’clock plane extends straight out to the right aspect of the breast, and so on. Three-dimensional measurements of a breast mass can be recorded using sagittal/transverse or radial/antiradial planes


apocrine metaplasia

form of fibrocystic change in the breast in which the epithelial cells of the acini undergo alteration (metaplasia); the epithelial cells assume a columnar shape similar to sweat (apocrine) glands. This process can lead to cyst formation, hyperplasia, and other fibrocystic changes



the pigmented skin surrounding the breast nipple



without symptoms; in the case of breast cancer screening, asymptomatic women are eligible for a screening mammogram—a fast, low-cost mammogram examination. A screening mammogram is different from a diagnostic mammogram, which is a more extensive examination for evaluation of a specific symptom or an abnormal finding


atypical hyperplasia

abnormal proliferation of cells with atypical features involving the TDLU, with an increased likelihood of evolving into breast cancer; in atypical ductal hyperplasia (ADH), the pathologist recognizes some, but not all, of the features of ductal carcinoma in situ (DCIS); atypical lobular hyperplasia (ALH) shows some, but not all, of the features of lobular carcinoma in situ (LCIS); ALH and LCIS are now grouped by some authors under the term lobular neoplasia



armpit; the axilla contains the lymph nodes that drain most of the breast tissue; in cases of invasive breast cancer, the lymph nodes are sampled to stage the cancer and direct further treatment



differentiated apocrine sweat gland with the functional purpose of secreting milk during lactation


breast cancer (breast carcinoma)

breast cancer involves two main types of cells: ductal and lobular. Ductal cancer, accounting for approximately 85% of breast cancer cases, includes many subtypes, such as medullary, mucinous, tubular, apocrine, and papillary types. In addition, very early, or preinvasive, breast cancer is generally ductal in type. This preinvasive breast cancer is also called in situ, noninvasive, or intraductal breast cancer. Another commonly used term for this early type of cancer is ductal carcinoma in situ, or DCIS


breast cancer screening

screening for breast cancer involves annual screening mammography (starting at age 40), monthly breast self-examination (BSE), and regular clinical breast examination (CBE)


breast imaging reporting and data system (BI-RADS)

trademark system created by the American College of Radiology (ACR) to standardize mammographic reporting terminology; to categorize breast abnormalities according to the level of suspicion for malignancy; and to facilitate outcome monitoring. BI-RADS was made a mandatory part of mammogram reports by federal legislation (Mammography Quality Standards Act of 1994)


breast self-examination (BSE)

part of breast cancer screening; every woman is encouraged to perform breast self-examination monthly starting at age 20; BSE is usually best performed at the end of menses


clinical breast examination (CBE)

examination of the breast by a health care provider as part of breast cancer screening. Every woman is encouraged to have a thorough CBE in conjunction with her routine health care assessment. Between ages 20 and 40, CBE is advised every 3 years. From age 40 on, CBE should be performed by the woman’s regular health care provider annually.


Cooper’s ligaments

connective tissue septa that connect perpendicularly to the breast lobules and extend out to the skin; considered the fibrous “skeleton” supporting the breast glandular tissue



fluid-filled sac of variable size. Cysts in the breast usually result from obstruction of the terminal duct draining the normal fluid secretions from the acinar units of the lobule, or from overproduction of fluid from the acini. Cysts are typically simple (anechoic, sharply marginated) or complex (thick, irregular wall, internal debris, internal echoes, intracystic mass)


cyst aspiration

common diagnostic and interventional breast procedure that involves placing a needle through the skin of the breast into a cystic mass and pulling fluid out of the cyst through the needle. In the case of a palpable cyst, this procedure can be performed in a physician’s office. In the case of a small, complex, or nonpalpable cyst, image guidance (usually with ultrasound) can be used to facilitate the aspiration


diagnostic breast imaging

also called consultative, workup, or problem-solving mammography or breast imaging; this type of breast imaging examination is more intensive than routine screening mammography. Diagnostic breast imaging is usually directed toward a specific clinical symptom of possible breast cancer, or toward an abnormal finding on a screening mammogram. The goal of diagnostic breast imaging is to categorize the abnormality according to the level of suspicion for cancer (see Breast Imaging and Reporting System [BI-RADS])


epithelial hyperplasia

proliferation (hyperplasia) of epithelial cells lining the terminal duct-lobular unit



most common benign solid tumor of the breast, consisting predominantly of fibrous and epithelial (adenomatous) tissue elements. These masses tend to develop in young women (even teenagers), tend to run in families, and can be multiple. The usual appearance of a fibroadenoma is a benign-appearing mammographic mass (round, oval, or gently lobular and well circumscribed) with a correlating sonographic mass that is well defined and demonstrates homogeneous echogenicity


fibrocystic condition (FCC)

also called fibrocystic change or fibrocystic breast, this condition represents many different tissue processes within the breast that are all basically normal processes, which in some patients become exaggerated to the point of raising concern for breast cancer. The main fibrocystic tissue processes are adenosis, epitheliosis, and fibrosis. These processes can cause symptoms, such as lumps and pain, and changes on the mammogram that mimic cancer. They can also cause mammographic changes, such as cysts, microcalcifications, distortion, and masslike densities. Common pathologic changes of FCC include apocrine metaplasia, microcystic adenosis, sclerosing adenosis, and many others. Only a few fibrocystic tissue processes are associated with increased risk of subsequent development of breast cancer. See atypical hyperplasia



refers to vibrations produced by phonation and felt through the chest wall during palpation; a technique used in conjunction with power Doppler to identify the margins of a lesion



hypertrophy of residual ductal elements that persist behind the nipple in the male, causing a palpable, usually tender lump. Generally, no lobular (glandular) tissue is present in the male patient. A breast mass resulting from gynecomastia must be distinguished from male breast cancer



echo texture that is more echogenic than the surrounding tissue. Hyperechoic masses in the breast are nearly always benign



having relatively weak echoes. Most solid breast masses (including cancer) are hypoechoic


infiltrating (invasive) ductal carcinoma

cancer of the ductal epithelium; most common general category of breast cancer, accounting for approximately 85% of all breast cancers. This cancer usually arises in the terminal duct in the terminal ductal lobular unit (TDLU). If the cancerous cells remain within the duct without invading the breast tissue beyond the duct wall, this is ductal carcinoma in situ (DCIS). If the cancerous cells invade breast tissue (invasive ductal carcinoma, or IDC), the cancer may spread into the regional lymph nodes and beyond. Of the many subtypes of IDC, the most common is infiltrating ductal carcinoma, not otherwise specified (IDC-NOS).


infiltrating (invasive) lobular carcinoma (ILC)

cancer of the lobular epithelium of the breast, arises at the level of the TDLU; accounts for 12% to 15% of all breast cancers



echo texture that resembles the surrounding tissue. In the breast, isoechoic masses can be difficult to identify



near the chest wall (thorax)


lobular neoplasia

a term preferred by many authors to replace atypical hyperplasia and lobular carcinoma in situ (LCIS); it is neither considered a true cancer nor treated as such


mammary layer

the middle of three layers of breast tissue recognized on breast ultrasound between the skin and the chest wall that contains the ductal, glandular, and stromal portions of the breast


multicentric breast cancer

breast cancer that occurs in different quadrants of the breast at least 5 cm apart; multicentric cancers are more likely to be of different histologic types than is multifocal cancer


multifocal breast cancer

breast cancer that occurs in more than one site within the same quadrant or the same ductal system of the breast



cannot be felt on clinical examination; a nonpalpable breast mass is one that is usually identified on screening mammogram and is too small to be felt as a breast lump on BSE or CBE


Paget’s disease

surface erosion of the nipple (reddened area with flaking and crusting) that results from direct invasion of the skin of the nipple by underlying breast cancer



can be felt on clinical examination; a palpable breast lump is one that is identified on CBE or BSE


peau d’orange

French term that means skin of the orange; descriptive term for skin thickening of one breast that, on clinical breast examination, resembles the skin of an orange. Such an appearance can result from an inflammatory breast condition (mastitis), simple edema, or skin involvement from underlying breast cancer. The thickening results when the pores of the skin open to allow edema to directly evaporate through the skin; this occurs because inflammatory disease has blocked the lymphatic drainage of fluids building up in those tissues



plane of imaging on ultrasound of the breast; see antiradial


retromammary layer

deepest of the three layers of the breast noted on breast ultrasound. The retromammary layer is predominantly fatty and can be thin. The retromammary layer separates the active breast glandular tissue from the pectoralis fascia overlying the chest wall muscles


sentinel node

represents the first lymph node along the axillary node chain. This is the node chain the surgeon identifies for evidence of metastasis



finger-like extension of a malignant tumor; usually appears as a small line that radiates outward from the margin of a mass


subcutaneous layer

most superficial of the three layers of the breast identified on breast ultrasound, the subcutaneous layer is mainly fatty; it is located immediately beneath the skin and superficial to the mammary layer. The subcutaneous layer can be very thin and difficult to recognize


tail of Spence

a normal extension of breast tissue into the axillary or armpit region


terminal ductal lobular unit (TDLU)

smallest functional portion of the breast involving the terminal duct and its associated lobule, containing at least one acinus (tiny milk-producing gland). The TDLU undergoes significant monthly hormone-induced changes and radical changes during pregnancy and lactation. The TDLU is the site of origin of nearly all significant pathologic processes involving the breast, including all elements of fibrocystic condition, fibroadenoma, and in situ and invasive breast cancer, both lobular and ductal