Fibroadenoma cross section

Fibroadenomas are common in women of all ages, but we start seeing them as biopsies in younger, reproductive aged women.  Often these are felt as breast lumps, and are brought to the attention of family physicians and OB-Gyns.  These breast tumors are curious because they are formed from two elements unlike other breast lesions or breast disease.  The fibroadenoma has both stromal and epithelial elements that are integral in its formation.  Most of breast disease, in contrast, is formed by one element, and that is the epithelium or lining of the breast ducts.

Fibroadenoma with large calcifications (dark red-purple)

Fibroadenomas have a fibrous stromal framework that surrounds slit like spaces lined by ductal epithelium.  There are several variations of the epithelial growth pattern within the fibroadenoma, but always there are the two elements.  In younger women the stroma is often looser and may have a bluish “juicy” appearance under the microscope.  I often use the term “succulent” to describe these changes.  As the fibroadenoma ages, the fibrous tissue becomes denser and calcifications may occur.

The fibroadenoma has a characteristic mammographic appearance, and the expert radiologist can often be sure of the diagnosis by its image characteristics.  However, when there is any doubt about the exact diagnosis, a needle core biopsy is recommended.  As you can imagine, until the lesion is sampled by a biopsy, you cannot be certain about the exact nature of the lesion that was felt originally, or found on mammogram.  Biopsy of the lesion can bring relief from uncertainty, and allow for treatment decision planning based on facts.

As a general statement, fibroadenomas are benign and stay benign.  These lesions may occur in sequence, meaning a new one may form after one has been removed.  Both typically are very benign in appearance. Multiple fibroadenoma may occur at the same time in the same breast or both breasts.  Only rarely is the fibroadenoma associated with malignant disease, but it does occur.  The good news is that if this happens, the mammographic image changes, and needle core biopsy is recommended in this situation for diagnosis and clarification.

Treatment options are best discussed with your physician.  In the majority of cases, the woman may decide to “live with” the fibroadenoma and leave it alone, or have it excised.

When a pathologist looks at a breast needle core biopsy, he or she looks over the entire prepared tissue biopsy to survey what is normal and what is abnormal. At low microscopic power, it is like flying over land to look at its various aspects, whether it is meadows, plowed fields, a city or town, or a mountain. This first view is to get an idea of what is normal and abnormal, and what the mammographer saw on mammogram originally to warrant doing the biopsy.

As the pathologist “flies over” the tissue on the slide, in this case, he sees abnormally enlarged ducts that are many times bigger than normal. This requires a closer look, and so the pathologist switches to a higher power lens and focuses on these enlarged ducts.

As you can see, here are clustered large ducts that are filled with many cells. This cellular proliferation or growth remains in the duct or tubule, causing it to expand and enlarge. These malignant cells are all abnormal, and there are no layers.  Normal ducts are lined by two cell layers, and the outer cells are different from those in the inner layer. Please refer to the blog on normal breast in this Show Me series.

Now what about in situ? What does that mean? In situ means in place; the cancer cells are growing in place or inside the duct: non-invasive and in place.  When the malignant cells are growing inside the duct, it is called Ductal Carcinoma In Situ—DCIS.   (Once the cells start to grow outside the duct, they are invading adjacent tissue and are invasive.)

We should remember that malignant cells in general do not have a feed-back regulatory function to stop growth. Malignant cells grow and multiply and don’t stop this process. There is no self control or stopping mechanism. So with DCIS, malignant cells grow “out of control” inside the ducts. The malignant cells grow down the duct system toward the nipple. This is a non-invasive growth because these abnormal cells stay inside the duct, and because of inside-only growth, there is no invasion by definition.

What I am getting ready to tell you is hard to understand and hard to believe. Because the malignant cells stay inside the ducts, and often grow toward the nipple, the extent of the disease may be such that a larger excision is required than for an invasive tumor. The non-invasive disease can grow unchallenged down the duct toward the nipple; without resistance, DCIS can grow over considerable distances sometimes. Here is the hard part: because of its unrestrained growth toward the nipple, non-invasive DCIS may require a larger excision or mastectomy while an invasive tumor is often successfully treated with lumpectomy. It all has to do with extent of disease, and the non-invasive lesion can require more tissue to be removed (bigger surgery) than a purely invasive tumor.

This Show Me series on this blog is going to be a through the microscope adventure for those people who want to learn more about their disease or the disease that afflicting someone they love.  To me as a pathologist, seeing what is going on at the microscopic level allows you to understand more about disease as it affects a human.

Cross section of breast

I need to show and describe normal breast before we start looking at other breast disease.  The breast lobules are collections of small ducts and there are many lobules through out the breast.  When pregnancy ends and lactation begins, these lobules are transformed into the milk producing centers.  Milk secreted from the transformed lobules leaves through larger ducts that empty into still larger ducts until the milk reaches the nipple.  The entire breast produces milk and all of the ducts act as “pipes” to deliver the milk to the nipple and finally to the newborn.

The lobules are thought to be the primary site where breast cancer develops.  Malignant cells first start growing inside these smaller tubules of the lobule.  At this point, the malignant cells will either continue to grow inside the duct and become Ductal Carcinoma in Situ (DCIS), or break through the cell boundary of the duct and begin to invade breast tissues, to become Invasive Carcinoma.

Three breast lobules

What we need to understand is the breast has a tubular or pipe-like system that is designed to deliver milk after pregnancy.  This same pipe-like system is where in later years, malignant cells can begin to grow.  These cells will either stay inside the pipes or tubules, or begin to invade adjacent breast tissue.

In a later blog, we will look more at how the malignant cells grow and what that means to the patient.

A pathologist is a physician (MD or DO) who examines tissues and is responsible for the accuracy of laboratory tests. Pathologists interpret the results of these examinations and tests—information that is important for the patient’s diagnosis and recovery. The pathologist and the patient’s other doctors consult on which tests to order, interpretation of test results, and appropriate treatments. Pathologists play a vital role on the patient’s primary health care team.  Pathologists are problem-solvers, fascinated by the process of disease and eager to unlock medical mysteries, like AIDS and diabetes, using the tools of laboratory science and its sophisticated instruments and methods. Today, with advances in biomedical science, more than 2,000 laboratory tests on blood and body fluids are available.  Many require specialized professional interpretation by an expert, usually a pathologist.  Pathologists work in many areas of the medical laboratory, and a pathologist usually serves as Director of the Laboratory. In the blood bank, pathologists and medical technologists ensure that the blood or blood products you receive are safe. In microbiology, microorganisms that can cause infections – bacteria, viruses, fungi, and parasites – are identified so the most effective drugs to treat an infection can be selected.  Autopsy, while an important tool in medicine, represents only a small part of the typical pathologist’s practice.

A clinical pathologist oversees laboratory tests conducted on body fluids such as blood and urine.

An anatomic pathologist assists surgeons during operations by providing immediate diagnoses on biopsies—specially treated tissues removed in surgery and rushed to the lab. A forensic pathologist uses the science of the laboratory to answer questions about evidence collected for criminal and civil cases. Other pathologists conduct research in pathology, developing new tests and new instruments to better diagnose diseases.

The above statement was copied directly from the American Society of Clinical Pathologists, http://www.ascp.org/pdf/ThePathologist.aspx

Blog Note:  The above description pretty much covers the specialty of pathology.  It is a very broad based medical practice and you can see from the above details, pathologists can busy themselves in many practice areas, in academia, in private practice, in the military, in legal matters and finally in many aspects of research.

What we discuss in future blogs are the breast pathologists and how their practice affects your diagnosis and treatment.

The answer to this question relates to who is looking at your mammograms.  In the best places, the radiologist specializes in breast imaging, and that is all that he or she looks at day after day.  As you can imagine, these specialists develop a keen, eagle like ability to see small abnormalities that others might not recognize.  This ability to see subtleties in breast imaging takes years to acquire.  Such specialization allows these physicians to practice in breast centers, and offer early detection services to the women in the community.

The National Consortium of Breast Centers recognizes these breast centers as the optimal way to screen for breast disease.  If you visit the website www.breastcare.org you can read about the activities of such breast centers across the United States.  You will learn there are different levels of breast center services available to you.

The word dedicated means that these specially trained physicians are only performing studies on women’s breasts.  They are not examining bones, kidneys or lungs like other radiologists do in most places.  These physicians also participate in weekly conferences where surgeons, pathologists and medical and radiation oncologists meet to discuss newly diagnosed women with breast disease problems.  One woman at a time is discussed and her options for treatment reviewed.  Such meetings improve communication amongst treating physicians and the direct beneficiary is you, the patient.

For more information on dedicated breast radiologists, please visit the guest article written by my colleague, Dr. Stephen Rose.  It is located in the Guest Commentary section.

The purpose of this new blog is to discuss activities behind the scenes in an anatomic pathology laboratory in a community hospital setting.  This laboratory has been involved in the evolution of changes that have occurred since our comprehensive breast center was established in 1996.  Patients know that their biopsies and larger resections will be handled in an optimal manner when their specimens come to our lab.  But few patients have ever met their pathologist or talked with them about their diagnosis and how it was made.  So this website, www.breastpath.com, and this blog is for women who want to know more about their pathology report, and how the diagnosis was made.  This blog also allows you to converse directly with a pathologist who has been deeply involved in a comprehensive breast center for 14 years and practicing for 37 years.

A detailed study of women in a two-county area in Sweden has shown that it is more important to offer extensive mammogram screening rather than adjuvant chemotherapy or hormonal therapy to reduce breast cancer mortality. Research headed by László Tabár, M.D., professor of radiology at the University of Uppsala School of Medicine in Sweden, revealed that a dramatic 60 percent reduction in breast cancer mortality occurs in patients who actually receive mammographic screening compared with those who are not screened.

The important message in Dr. Tabar’s studies is that mortality from invasive breast cancer is reduced by detecting these cancers when they are “babies,” being in their infancy.  Three problems exist however: 1. breast cancers begin as non-palpable (better prognosis) when smaller; 2. smaller tumors have fewer metastases (better prognosis); 3 breast cancers may appear between the time of last mammogram and current mammogram (interval cancer) and these cancers usually behave more aggressively.

The most effective way to achieve the goal of small, non-palpable breast cancer detection is yearly mammography.  This yearly mammographic approach will also find many “interval cancers” earlier and shorten their growth span.

Yearly mammographic screening is the answer. It is how Dr. Tabar’s studies achieved a 60% mortality reduction in breast cancer patients.