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ANDI & Benign Breast disorders
ANDI & Benign Breast disordersDr. Dileep Ramesh Hoysal
ANDIABERRATION OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI) OF THE BREAST
Normal three phases of physiology of breast(1) Lobular development; (2) Cyclical hormonal modifications; (3) Involution.
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 femalesearly, matured and involution phase of reproductive age group.
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.
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.
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.
Ductal involution Aberration - ductal dilatation and nipple discharge.Later Disease status develops withPeriductal mastitis, Nonlactational breast abscess and Mammary duct fistula. Periductal fibrosis - partial nipple retraction.
Epithelial changes leads into epithelial hyperplasia and atypia.
FIBROADENOMAHyperplasia 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.
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.
Fibroadenoma VariantsJuvenile 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.
2. Complex fibroadenomaIt 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.
Pathological TypesIntracanalicular: large and softmainly cellular. Stroma with distorted duct.Pericanalicular : small and hardmainly fibrous. Stroma with normal duct
Clinical FeaturesPainless swellingSmooth, firm, nontender, well-localised and Moves freely within the breast tissue (mouse in the breast).
Investigations Mammography (well-localised smooth regular shadow). FNAC. Ultrasound (to confirm solid nature).
TreatmentFibroadenoma 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.
Early Reproductive Period(15-25yrs)
PHYLLOIDES TUMORAka 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%)
Gross : Large, Capsulated, Cystic Changes
Cut Curface: Soft, Cystic Spaces
Microscopy: Cystic Spaces With Leaf Like Projections Hence Called Phylloides
CLINICAL FEATURES30-50yrsUnilateralGrows rapidly to attain large sizeBosselated surface with necrosis of skin Swelling is warm, not fixed to skin or chest wall
INVESTIGATIONSULTRASOUNDFNACCHEST XRAY
TREATMENTExcision
Total Mastectomy If Malignant
Mature Reproductive Period (25-40yrs)
Cyclical Mastalgia With NodularityAka Fibrocystadenosis / Fibrocystic Disease Of Breast/ Mammary Dysplasia
Estrogen Dependant
BLUEDOME CYST OF BLOODGOODOne Of The Cyst May Get Enlarged And Become Clinically Palpable
Non Tender, Fluctuant, Transilluminant With Thin Bluish Capsule
Initially Aspirated
Surgical Excision Done If Recurs/ Persists/ Blood Stained/ Residual Lump Remains
Multiple Small Cysts Schimmelbuschs Disease
FIBROCYSTADENOSIS
CLINICAL FEATURESB/L, Diffuse, Painful, Granular Swelling Better Felt With Palpating Fingers
Pain And Tenderness More Just Prior To Menstruatuion
Subsides During Pregnancy/ Lactation/ After Menopause
INVESTIGATIONSFNAC- EPITHELIOSIS (PREMALIGNANT)
USG
MAMMOGRAPHY
TREATMENTCONSERVATIVE ReassuranceOil Of Evening Primrose: Gamolenic Acid NSAIDSVit E And B6Bromocriptine- Prolactin InhibitorTamoxifen- Estrogen AntagonistDanozol- Antigonadotrohin Agent
SURGERYExcision Of Cyst/ Diseased Tissue
D/D: Tietzes Disease Costochondritis Of Second Costal Cartilage
Involution (35-55 yrs)
SCLEROSING ADENOSIS30-50yrs
Present With Breast Lump Or Mastalgia
Smooth, Relatively Mobile Mass
Mimic Carcinoma Clinically, Radiologically And Histologically
DUCT ECTASIADilatation Of Lactiferous Duct Due To Muscular Relaxation Of Duct Wall With Periductal Matitis
Aka Plasma Cell Mastitis
Many Ducts Involved
CLINICAL FEATURESGREENISH NIPPLE DISCHARGE
TENDER INDURATED MASS UNDER THE AREOLAR
EVENTUALLY FORMS ABSCESS AND FISTULA
LATER STAGE- RETRACTION OF NIPPLE
COMMON IN SMOKERS- IN RELATION TO ARTERIAL PATHOLOGY
B/L AND MULTIFOCAL
D/D CARCINOMA BREAST
TREATMENTSTOP SMOKING
CONE EXCISION OF INVOLVED MAJOR DUCTS- HADFIELD OPERATION
ANTIBIOTICS
MASTITISTYPES: (1) SUBAREOLAR MASTITIS- INFECTED GLAND OF MONTGOMERY(2) INTRAMAMMARY MASTITIS -LACTATING ABSCESS - NON LACTATING ABSCESS(3) RETROMAMMARY MASTITIS- TB OF INTERCOSTAL LYMPH NODES
MASTITIS
BREAST ABSCESS
ANTIBIOMA
PREVIOUS HISTORY OF MASTITIS
D/D- CARCINOMA AS IF HARD AND FIXED TO BREAST TISSUE
EXCISION
OTHER BENIGN BREAST CONDITIONSGALACTOCOELE -SEEN IN LACTATING WOMEN -RETENSION CYST IN SUBAREOLAR REGION -BLOCK OF LACTIFEROUS DUCT -MASSIVE ENLARGEMENT OF LACTIFEROUS SINUS
PRESENT AS LARGE, SMOOTH, SOFT, FLUCTUANT LUMP
CAN GET INFECTED
EXCISION
TRAUMATIC FAT NECROSISDIRECT OR INDIRECT TRAUMA
SMOOTH, HARD, NON TENDER, NOT ADHERENT
EXCISION
DUCT PAPILLOMACOMMONEST CAUSE OF BLOODY NIPPLE DISCHARGE
USUALLY SINGLE FROM A SINGLE LACTIFEROUS DUCT
IF MUTIPLE CAN BE PREMALIGNANT
INVESTIGATION- INJECT CONTRAST INTO DUCT (DUCTOGRAM)
MICRODOCHECTOMY: PROBED LACTIFEROUS DUCT IS OPENED AND THE PAPILLOMA EXCISED USING TENNIS RAQUET INCISION
GYNECOMASTIAHYPERTROPHY OF MALE BREAST DUE TO INCREASE IN DUCTAL AND CONNECTIVE TISSUE ELEMENT OFTEN ATTAINING FEATURES OF FEMALE BREAST
U/L OR B/L
CAUSESIDIOPATHICDRUGS: SPIRONOLACTONE. INH, PHENOTHIAZIDES, DIGITALISLIVER FAILURE AND LIVER DISEASELEPROSYTEROTOMA TESTISADRENAL AND PITUITARY DISEASEECTOPIC HORMONE PRODUCTIONKLINEFELTERS
SMALL , WELL LOCALIZED, FIRM SWELLING BELOW THE ARELOAR WHICH IS PAINFUL
WHEN SYMPTOMATIC- EXCISED
THANK YOU