ABERRATION IN NORMAL DEVELOPMENT AND INVOLUTION

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1. ABERRATION IN NORMAL DEVELOPMENT AND INVOLUTION

2. Developed and described by Cardiff breast clinic in Wales Wide spectrum of clinicopathological features ranging from near normality to severe disease

3. Endocrine factors 1. Disturbances in the Hypothalamo Pituitary Gonadal steroid axis 2. Altered Prolactin profile – qualitative /quantitative change Non endocrine factors Methyl xanthines, Stress Genetic predisposition to catecholamine supersensitivity  Intra cellular C - AMP mediated events  cellular proliferation 2. Diet rich in saturated fat Altered plasma essential fatty acid profile  receptor supersensitivity to normal levels of Oestrogen & Progesterone 3. Iodine deficiency Receptor supersensitivity to normal levels of Oestrogen & Progesterone Aetiopathogenesis – some theories

4. Physiological stage of the breast Normal Aberration Benign disease Development Duct devt . Lobular devt . Stromal devt . Nipple inversion Fibroadenoma Adolescent hypertrophy Giant fibroadenoma Cyclical change Hormonal activity on gland & stroma Epithelial activity Mastalgia & nodularity Benign papilloma CLASSIFICATION

5. Pregnancy & lactation Epithelial hyperplasia lactation Blood stained discharge galactocele Involution Ductal involution Lobular involution Involutional epithelial hyperplasia Duct ectasia Nipple retraction Cysts, Sclerosing adenosis Hyperplasia & micro papillomatosis Periductal mastitis with suppuration Lobular or ductal hyperplasia with atypia

6. No risk Fibroadenoma Cysts Duct ectasia Mild hyperplasia Slightly increased risk (1.5 – 2 times) Moderately increased risk (5 times) Insufficient data to assign risk Moderate / florid/ solid /papillary hyperplasia Atypical ductal / lobular hyperplasia Radial scar lesion Pathology –relative risk of invasive breast cancer - Gist of American College of Pathologists Consensus Statement

7. Developmental anomalies Athelia -absence of nipple Amazia -absence of breast tissue.asso with poland syndrome POLYMASTIA-common Commonly in axilla Supernumerary nipples-male predominance 1.7:1 Assn. With other syndrome- turne r ,fanconi,ectodermal dysplasia

8. DIFFUSE HYPERTROPHY Occurs in otherwise healthy girls at puberty Alteration in the normal sensitivity of the breast to estrogen Reduction mammoplasty

9. Discrete lump Fibroadenoma Giant fibroadenoma Juvenile fibroadenoma Phyllodes tumours Cysts : macrocysts Nodularity Generalised Localised 1. Lump Age incidence of lumps in the breast

10. Fibroadenoma Types Solitary Few (< 5 / breast ) Multiple (> 5 / breast ) Giant (> 4 / 5 cms) & Juvenile Natural history Majority remain small & static 50% involute spontaneously No future risk of malignancy

11. Phyllodes tumours C omprise less than 1% of all breast neoplasms May occur at any age but usually in 5th decade of life No clinical or histological features to predict recurrence 16 - 30% may be malignant Common sites of metastasis : l ungs , skeleton, heart, and liver

12. 1. Primary treatment L ocal excision with a rim of normal tissue 2. Recurrence Re excision or M astectomy with or without reconstruction Response to chemotherapy and radiotherapy for recurrences and metastases poor Treatment of Phyllodes tumours

13. Cysts Common in the West ( 70 % of women ) 50% are solitary cysts 30% 2 - 5 cysts & rest have > 5 cysts Types Apocrine cysts Lined by secretory epithelium Cyst fluid has a Na : K ratio < 3 Likely to have multiple cysts Likely to develop further cysts Non apocrine cysts Cyst fluid has a Na : K ratio >3 Resembles plasma Mixture of both

14. Management algorithm for c ysts

15. 2. Pain True breast pain Mastalgia Cyclical mastalgia Non cyclical mastalgia True (breast related) Musculoskeletal : costochondral or lateral chest wall Infections Lactational infections Nonlactational infections Central : Periductal mastitis (inflammation, mass, abscess, mammary duct fistula) Peripheral : associated with diabetes, rhuematoid arthritis, steroid usage, trauma etc. Rare : Tuberculosis, Granulomatous mastitis, Diabetic (lymphocytic) mastitis, etc. Skin associated : intertrigo , infected sebaceous cyst, hidradenitis suppurativa etc.

16. Mastalgia Definition : Pain severe enough to interfere with daily life or lasting over 2weeks of menstrual cycle True breast pain Costo Chondral pain Lateral chest wall pain mild True breast pain Musculo skeletal pain

17. Assess type of pain Assess severity of pain ( Pain diary + Visual analogue scale ) Evaluation with Triple assessment Treatment : Reassurance is the key to management Use of supportive undergarments Low fat, Methyl xanthine restricted diet Stop Oral contraceptives / HRT etc Review patient. Sucessful in the majority ( 80 – 85 % ) of patients Start drugs in those not responding to nonpharmacological treatment Review and assess response Management protocol for true mastalgia

18. Drugs of est ablished value in mastalgia

19. Management protocol for musculo skeletal pain

20. Nipple discharge Causes of nipple discharge Benign (common) Malignant (less common) Physiological causes Intraductal pailloma and associated conditions Blood stained nipple discharge of pregnancy Galactorrhoea Periductal Mastitis Duct Ectasia In situ carcinoma (DCIS) Invasive carcinoma

21. Character e stics of nipple discharges

22. Management o f spontaneous nipple discharge

23. Galactorrhoea Management : Estimate PRL levels. If very high, evaluate for pituitary lesion Physiological - Reassurance, cessation of stimulation Drug induced - Stop or change drug if possible Pathological - Cabergoline / Bromocriptine, treat cause if possible ( E.G. Pituitary surgery)

24. 4. Nipple changes Causes : Developmental inversion Acquired inversion Periductal mastitis Duct ectasia (classical slit retraction) Juxta areolar carcinoma with recent & fixed nipple retraction Paget’s disease dry & scaly variety moist & eczematoid erosion of nipple thickening / macroscopically normal nipple 3. Rare problems : adenoma, papilloma etc

25. Management of nipple retraction

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