ANDI & benign breast disorders

aberrations of normal development and involution and benign breast disorders - presentation for MBBS students

1. ANDI & Benign Breast disorders Dr. Dileep Ramesh Hoysal

2. ANDI ABERRATION OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI) OF THE BREAST

3. Normal three phases of physiology of breast— (1) Lobular development; (2) Cyclical hormonal modifications; (3) Involution.

4. First coined by LE Hughes at Cardiff breast clinic in 1987 ANDI includes variety of benign breast disorders occurring at different periods of reproductive periods in females—early, matured and involution phase of reproductive age group.

5. Early reproductive age group (15-25 years) Normal lobule formation may cause aberration as fibroadenoma . >5 cm - Giant fibroadenoma as a diseased status. It is AND of a lobule. Normal stroma may develop juvenile hypertrophy as aberration and multiple fibroadenoma as diseased status.

6. Mature reproductive age group (25-40 years): Normal cyclical hormonal effects on glands and stroma get exaggerated by aberration causing generalised enlargement . Its disease is cyclical mastalgia with nodularity also called as fibrocystadenosis .

7. Involution age group (40-55 years): Lobular involution with microcysts , fibrosis, adenosis , apocrine metaplasia and eventual aberrations as macrocysts and cystic disease of breast. Macrocyst is an aberration of normal involution (ANI). Sclerosing adenosis is also a type of aberration.

8. Ductal involution Aberration - ductal dilatation and nipple discharge. Later Disease status develops with Periductal mastitis, Nonlactational breast abscess and Mammary duct fistula. Periductal fibrosis - partial nipple retraction. Epithelial changes leads into epithelial hyperplasia and atypia .

9. FIBROADENOMA Hyperplasia of a single lobule of the breast (AND). Most common benign tumour of the breast. Encapsulated tumour common in young females. Bilateral in 20% of cases. 20% are multiple.

10. Progression 30% of fibroadenomas may disappear or reduce in size in 2-4 years. 10 -15% will increase in size progressively. It does not occur after menopause unless women are on hormones.

11. Fibroadenoma Variants Juvenile fibroadenoma Occurs in adolescent girls. Even though it shows rapid growth with stromal and epithelial hyperplasia, it does not show any alteration in stromal epithelial balance or cellular atypia or periductal cellular concentration. Mimic phyllodes tumour .

12. 2. Complex fibroadenoma It occurs in older age group. Having typical fibroadenoma with fibrocystic changes like apocrine metaplasia , cyst formation, sclerosing adenosis . 15% of proven fibroadenomas are complex. Occasionally it may turn into malignancy unlike usual fibroadenomas .

13. Pathological Types Intracanalicular : large and soft—mainly cellular. Stroma with distorted duct. Pericanalicular : small and hard—mainly fibrous. Stroma with normal duct

14. Clinical Features Painless swelling Smooth, firm, nontender , well- localised and Moves freely within the breast tissue ( mouse in the breast ).

15. Investigations Mammography (well- localised smooth regular shadow). FNAC. Ultrasound (to confirm solid nature).

16. Treatment Fibroadenoma which is small (< 3 cm)/single/age < 30 years can be left alone with regular follow-up with USG at 6 monthly interval. Indications for surgery are: Size > 3 cm. Multiple. Giant type. Recurrence. Cosmesis . Complex type.

17. Early Reproductive Period(15-25yrs)

18. PHYLLOIDES TUMOR Aka Cystosarcoma Phylloides Or Serocystic Disease Of Brodie This Is A Giant Fibroadenoma Which Shows A Wide Spectrum Of Activity From A Benign Condition (85%) To Locally Aggressive To Metastatic Tumor (15%)

19. Gross : Large, Capsulated, Cystic Changes Cut Curface : Soft, Cystic Spaces Microscopy: Cystic Spaces With Leaf Like Projections Hence Called “ Phylloides ”

20. CLINICAL FEATURES 30-50yrs Unilateral Grows rapidly to attain large size Bosselated surface with necrosis of skin Swelling is warm, not fixed to skin or chest wall

21. INVESTIGATIONS ULTRASOUND FNAC CHEST XRAY

22. TREATMENT Excision Total Mastectomy If Malignant

23. Mature Reproductive Period (25-40yrs)

24. Cyclical Mastalgia With Nodularity Aka Fibrocystadenosis / Fibrocystic Disease Of Breast/ Mammary Dysplasia Estrogen Dependant

25. BLUEDOME CYST OF BLOODGOOD One Of The Cyst May Get Enlarged And Become Clinically Palpable Non Tender, Fluctuant, Transilluminant With Thin Bluish Capsule

26. Initially Aspirated Surgical Excision Done If Recurs/ Persists/ Blood Stained/ Residual Lump Remains Multiple Small Cysts – Schimmelbusch’s Disease

27. FIBROCYSTADENOSIS

28. CLINICAL FEATURES B/L, Diffuse, Painful, Granular Swelling Better Felt With Palpating Fingers Pain And Tenderness More Just Prior To Menstruatuion Subsides During Pregnancy/ Lactation/ After Menopause

29. INVESTIGATIONS FNAC- EPITHELIOSIS (PREMALIGNANT) USG MAMMOGRAPHY

30. TREATMENT CONSERVATIVE Reassurance Oil Of Evening Primrose: Gamolenic Acid NSAIDS Vit E And B6 Bromocriptine - Prolactin Inhibitor Tamoxifen - Estrogen Antagonist Danozol - Antigonadotrohin Agent

31. SURGERY Excision Of Cyst/ Diseased Tissue D/D: Tietze’s Disease Costochondritis Of Second Costal Cartilage

32. Involution (35-55 yrs)

33. SCLEROSING ADENOSIS 30-50yrs Present With Breast Lump Or Mastalgia Smooth, Relatively Mobile Mass Mimic Carcinoma Clinically, Radiologically And Histologically

34. DUCT ECTASIA Dilatation Of Lactiferous Duct Due To Muscular Relaxation Of Duct Wall With Periductal Matitis Aka Plasma Cell Mastitis Many Ducts Involved

35. CLINICAL FEATURES GREENISH NIPPLE DISCHARGE TENDER INDURATED MASS UNDER THE AREOLAR EVENTUALLY FORMS ABSCESS AND FISTULA LATER STAGE- RETRACTION OF NIPPLE

36. COMMON IN SMOKERS- IN RELATION TO ARTERIAL PATHOLOGY B/L AND MULTIFOCAL D/D –CARCINOMA BREAST

37. TREATMENT STOP SMOKING CONE EXCISION OF INVOLVED MAJOR DUCTS- HADFIELD OPERATION ANTIBIOTICS

38. MASTITIS TYPES: (1) SUBAREOLAR MASTITIS- INFECTED GLAND OF MONTGOMERY (2) INTRAMAMMARY MASTITIS -LACTATING ABSCESS - NON LACTATING ABSCESS (3) RETROMAMMARY MASTITIS- TB OF INTERCOSTAL LYMPH NODES

39. MASTITIS

40. BREAST ABSCESS

41. ANTIBIOMA

42. PREVIOUS HISTORY OF MASTITIS D/D- CARCINOMA AS IF HARD AND FIXED TO BREAST TISSUE EXCISION

43. OTHER BENIGN BREAST CONDITIONS GALACTOCOELE -SEEN IN LACTATING WOMEN -RETENSION CYST IN SUBAREOLAR REGION -BLOCK OF LACTIFEROUS DUCT -MASSIVE ENLARGEMENT OF LACTIFEROUS SINUS

44. PRESENT AS LARGE, SMOOTH, SOFT, FLUCTUANT LUMP CAN GET INFECTED EXCISION

45. TRAUMATIC FAT NECROSIS DIRECT OR INDIRECT TRAUMA SMOOTH, HARD, NON TENDER, NOT ADHERENT EXCISION

46. DUCT PAPILLOMA COMMONEST CAUSE OF BLOODY NIPPLE DISCHARGE USUALLY SINGLE FROM A SINGLE LACTIFEROUS DUCT IF MUTIPLE – CAN BE PREMALIGNANT

47. INVESTIGATION- INJECT CONTRAST INTO DUCT (DUCTOGRAM) MICRODOCHECTOMY : PROBED LACTIFEROUS DUCT IS OPENED AND THE PAPILLOMA EXCISED USING TENNIS RAQUET INCISION

48. GYNECOMASTIA HYPERTROPHY OF MALE BREAST DUE TO INCREASE IN DUCTAL AND CONNECTIVE TISSUE ELEMENT OFTEN ATTAINING FEATURES OF FEMALE BREAST U/L OR B/L

49. CAUSES IDIOPATHIC DRUGS: SPIRONOLACTONE. INH, PHENOTHIAZIDES, DIGITALIS LIVER FAILURE AND LIVER DISEASE LEPROSY TEROTOMA TESTIS ADRENAL AND PITUITARY DISEASE ECTOPIC HORMONE PRODUCTION KLINEFELTERS

50. SMALL , WELL LOCALIZED, FIRM SWELLING BELOW THE ARELOAR WHICH IS PAINFUL WHEN SYMPTOMATIC- EXCISED

51. THANK YOU