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