BENIGN BREAST DISEASES

Dr. B.NareshPost graduate - S4

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BREAST DEVELOPMENT AND FUNCTION

Initiated by a variety of hormonal stimuli

EstrogenProgesteroneProlactinOxytocinThyroid hormoneCortisolGrowth hormone

HORMONAL REGULATION

HYPOTHALAMUS+/- GnRH

ANTERIOR PITUITARY`basophilic cells

FSHLH

OVARIESEstrogen Progesterone

INACTIVE Breast ACTIVE Breast

HORMONAL EFFECTS ON BREAST TISSUE

EstrogenDuctal development

ProgesteroneEpithelial differentiationLobular development

ProlactinLactogenesis

@ 10 YEARS OF AGE

BREAST BUD (or) MOUND

Mammary tissue grow beneath the areola, producing the characteristic protuberence on the chest wall.

@ 12 YEARS OF AGE

TRUE NIPPLES develop

By further areolar growth and formation of bulk of breast tissue.

may be asymmetrical

@ PUBERTY

attains the CLASSICAL SHAPE

by hormonal influence

by further areolar recession & pigmentation

MENSTUAL CYCLE

Substantial histological changes – different phases

Retention of fluid occurs – luteal phase

DURING PREGNANCY

ADENOSIS Lobular – Alveolar growthnew Secretory units develop

Capillary growthVenous engorgmentMyoepithelial cell proliferate

Colostrum formationDoubling of breast weight

From 200g to 400g

Areola – darkensMontgomery glands - prominent

Increased conc. OfLuteal hormonesPlacental sex hormonesPlacental LactogensHCG

DURING LACTATION

DURING LACTATION

TRUE MILK - after 2 days of parturitionAlveoli - source of milk production.

Milk let down reflex

NEURAL REFLXES –Nipple Areolar complex

Production of PROLACTINOXYTOCIN

DURING WEANING

POST LACTATIONAL INVOLUTION

Prolactin & oxytocin decreases

Dormant milk - increase pressure within ducts

Atrophy of alveoli epithelium

Lymphocytic infiltration & Hyalinization - lobules

DURING MENOPAUSE

Estrogen & Progesterone secretion decreases

Involution of ducts & alveoli

Breast tissue – replaced – Adipose tissue.Fibrous connective tissue increase in density

MALE BREAST

GYNAECOMASTIA

Enlargement of ductal andstromal tissue of male breast.

Physiological (or) Pathological

increased Estrogen : Androgen ratio

PHYSIOLOGICAL (PRIMARY) GYNAECOMASTIA

Neo – natal Placental estrogen

AdolescenceEstradiol > Testosterone

SenescenceCirculating testosterone - falls

PATHOLOGICAL (SECONDARY) GYNAECOMASTIA

Estrogen excess state

Androgen deficiency states

Drug – related

Systemic diseases with idiopathic mechanism

PATHOLOGICAL (SECONDARY) GYNAECOMASTIAEstrogen excess state

Gonadal originTrue hermaphroditismTesticular tumour

Non – germinal neoplasmGerm cell tumour

Non – Testicular tumourAdrenal cortical neoplasmLung carcinomaHepatocellular carcinoma

Endocrine disorder

Liver disease

Nutrition alteration

PATHOLOGICAL (SECONDARY) GYNAECOMASTIA

Androgen deficiency statesHypogonadism

Primary testicular failureKlinefelter’s syndromeKallmann’s syndromeReifenstein’s syndromeKennedy’s diseaseEunuchoidal malesACTH deficiency

Secondary testicular failureTraumaOrchitisIrradiation

Renal failure

PATHOLOGICAL (SECONDARY) GYNAECOMASTIA

Drug relatedwith Estrogenic activity

Digitalis, Estrogens, Steroids, Marijuana

enhance Estrogen synthesisHuman chorionic gonadotropin

inhibit Testosterone synthesisCimetidine, ketoconazole, phenytoin, frusemide, antineoplastic agents, spironolactone, diazepams.

GYNAECOMASTIA – CLINICAL FEATURES

Unilateral / Bilateral

Painless, sometimes little pain

On Palpation – nontender, & movable

Psychological problem may accompany

Associated – various breast pathologies.

GYNAECOMASTIA - CLASSIFICATION

GRADE

I Mild breast enlargement (-) Skin redundancy

IIa Moderate enlargement (-) Skin redudancy

IIb Moderate enlargement (+) Skin redudancy

III Marked enlargement (+) Skin redudancy & Ptosis, simulates a female breast

BENIGN BREAST DISEASESBreast – physiologically dynamic structure,

in which cyclic variations are super-imposed on changes of development and involution, throughout the women’s life.

-- Clinico pathological features, range from near normal to severe disease

-- 30 % of woman suffer from this condition.

BENIGN BREAST DISEASES -CLASSIFICATION

No completely satisfactory classification

Poor co-relation between clinical, pathological and radiological features in any particular disease.

Yet, 3 classifications are described,

based on Symptoms

based on Pathogenesis – ANDI classification

based on histological differentiation.

CLASSIFICATION -- SYMPTOMS

Breast Pain (Mastalgia)

Breast Lumps

Disorders of Nipple & Periareolar region

Breast Infection

BREAST PAIN (MASTALGIA)

Cyclical

Non CyclicalMusculo skeletalCervical root painSclerosing adenosisPost - operative

Cyclical Non - cyclicalMedian age 35 years of age 45 years of age

Features Wax and Wane not always bilateral

Chronicunilateral

Localized Poorly Trigger spot zones

Located Upper, outer quadrants Medial quadrantPeri areolar regions

Type of pain Heaviness of breast Burning Dragging

Aetiology Hormonal (estrogen ; prolactin)Excessive caffeineInadequate EFAPsychoneurosis

UnclearDuctal ectasiaLumpsPost operativeSurrounding structures

CYCLICAL MASTALGIA

Discomfort lasting 2-3 days before menstruation

----- disorder (cyclical mastalgia)

Pain lasting throughout the cycle, with relief only during menstruation

------ disease (Incapacitating mastalgia)

NON CYCLICAL MASTALGIA

Musculo – skeletal (Tiet’z syndrome)

Usually unilateral

Pain @ the Lateral wall of chestCosto – chondral junction

Reffered cervical root pain

Usually in elderly people

BREAST LUMPSFibroadenomaGiant FibroadenomaPhyllodes tumourCyclical nodularityCysts GalactoceleSclerosing adenosisFat necrosisLipomaChronic abscessDuct papillomaHaematoma

FIBROADENOMA

Derived from the Breast Lobule

Aberration of normal lobular development

Proliferation of both connective tissue & epithelium

due to Localized Hypersensitivity of Estrogen.

Blacks are more Prone than whites

FIBROADENOMA

Solitary / Multiple (10%)

Painless, Smooth, Encapsulated lump of size 1 to 3 cm

Spherical / Multinodular / Irregular

On section, uniform greyish white, fleshy, homogenous with fibrous whorls, tend to bulge from capsule

Occurs mostly in upper and outer quadrants

FIBROADENOMA

FIBROADENOMAPeri Canalicular variety (Hard Fibroadenoma)

15 – 30 years of ageFirmer, smaller, movable -- “Breast Mouse”

Intra Canalicular variety (Soft Fibroadenoma)

30 – 50 years of ageLess Firmer, Grows rapidly and largerCompresses the glandular and ductal system due to proliferation hence “Intraductal myxoma”

Both patterns can co-exist within the same tumour

GIANT FIBROADENOMABimodal age presentation

14 - 18 yrs of age ---- Juvenile Fibroadenoma45 – 50 yrs of age

Rapid growth .

Size > 5 cms in diameter

Painful

Blacks have greater propensity

GIANT FIBROADENOMA

GIANT FIBROADENOMA

Histologically, typical hypocellular stromaepithelial components showing mild degree of hyperplasia and atypia, with mitoses.

ClinicallyBreast enlarged, Nipple displacement,Shiny skin with dilated veinsSkin necrosis may occur

PHYLLODES TUMOUR

Serocystic disease of Brodie

Vary from Benign – Locally invasive – Metastatic

Predominant in pre menopausal women , around 40

Grow rapidly, to large size,involves almost entire breast

Metastasis via blood

PHYLLODES TUMOUR

Clinically,Unevenly bosselated surface with projectionsSkin – warm, red, shiny with dilated veinsPressure necrosis – skin ulceration

Cut – section,Soft brown in colorExhibit cysts, necrosis or haemorrhageLeaf – like appearance

Histologically,Hypercellular, much atypia, numerous mitoses.

DISORDERS OF NIPPLE & PERIAREOLAR

Nipple Inversion

Nipple Retraction

Nipple Discharge

Mammary fistula

Duct ectasia / Periductal mastitis

Skin - eczema

NIPPLE INVERSION

NIPPLE RETRACTIONNot congenital

Due to

Duct ectasia

Carcinoma

Post surgical retraction

NIPPLE RETRACTION

NIPPLE DISCHARGE

ECZEMA --- SKIN

BREAST INFECTIONIntramammary mastitis (acute / chronic)

Subareolar mastitis (acute / chronic)

Retromammary abscess

TuberculosisSyphillisActinomycosis / BlastomycosisHidradenitis suppurativa

Mondor’s disease

INTRA MAMMARY ABSCESS

Lactating breast --- Nursing Mother

AetiologyDevelopment of cracks and bruises in the nippleBlockade of one or more lactiferous ductulesRetracted nipple

Infectious organismStaphylococcus aeurusstreptococcus

INTRA MAMMARY ABSCESSCellulitic stage

RednessOedemaTendernessBrawny indurationExtremely painful

Abscess formation

Chronic abscess

Antibioma

SUBAREOLAR ABSCESS

RETROMAMMARY ABSCESS

Arises from the tissue deep to breast

Infected haematoma

Emphyema

TB of rib and spine

Osteomyelitis of rib

TUBERCULOSIS -- BREAST

SYPHILIS -- BREAST

MONDOR’S DISEASE

ABERRATION OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI)

NORMAL DISORDER DISEASEEarly Reproductive yrs (age 15 - 25)

Lobular development

Stromal development

Nipple Eversion

Fibroadenoma

Adol. Hypertrophy

Nipple inversion

Giant fibroadenoma

Gigantomastia

Sub areolar abscessMammary. duct . fistula

Late Reproductive yrs(age 25 - 40)

Cyclical changes of menstruation

Epithelial hyperplasia of pregnancy

Cyclical mastalgiaNodularity

Bloody nipple dischrge

In-capactitating. mastalgia

Involution (age 35 - 55)

Lobular involution

Ductal involution(dilatation / sclerosis)

Epithelial turnover

MacrocystsSclerosing leisonsDuct ectasiaNipple retraction

Epithelial hyperplasia

Peri ductal mastitis

Atypical Epithelial . . . hyperplasia

CLASSIFICATION – HISTOLOGICAL DIFFERENTIATION

Non Proliferativedisorders of breast

Cysts and apocrine metaplasiaDuct ectasiaCalcificationsFibroadenoma and related leisons

Proliferative breast disorders without atypia

Sclerosing adenosisRadial and complex sclerosing leisonsDuctal epithelial hyperplasiaIntraductal papillomas

Atypical proliferative leisons

Atypical lobular hyperplasia (ALH)Atypical ductal hyperplasia (ADH)

Thank you