aberration in normal development and involution
DESCRIPTION
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ABERRATION IN NORMAL DEVELOPMENT AND INVOLUTION
Developed and described by Cardiff breast clinic in Wales
Wide spectrum of clinicopathological features ranging from near normality to severe disease
Endocrine factors
1. Disturbances in the Hypothalamo Pituitary Gonadal steroid axis
2. Altered Prolactin profile – qualitative /quantitative change
Non endocrine factors
1. 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
Physiological stage of the breast
Normal Aberration Benign disease
Development Duct devt.
Lobular devt.Stromal devt.
Nipple inversionFibroadenomaAdolescent hypertrophy
Giant fibroadenoma
Cyclical change
Hormonal activity on gland & stromaEpithelial activity
Mastalgia & nodularity
Benign papilloma
CLASSIFICATION
Pregnancy & lactation
Epithelial hyperplasia
lactation
Blood stained discharge
galactocele
Involution Ductal involution
Lobular involution
Involutional epithelial hyperplasia
Duct ectasiaNipple retractionCysts, Sclerosing adenosisHyperplasia & micro papillomatosis
Periductal mastitis with suppuration
Lobular or ductal hyperplasia with atypia
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
Developmental anomalies
Athelia-absence of nippleAmazia-absence of breast tissue.asso with
poland syndrome POLYMASTIA-common Commonly in axillaSupernumerary nipples-male
predominance 1.7:1Assn. With other syndrome-
turner,fanconi,ectodermal dysplasia
DIFFUSE HYPERTROPHY
Occurs in otherwise healthy girls
at puberty Alteration in the
normal sensitivity
of the breast to estrogen
Reduction mammoplasty
Discrete lump Fibroadenoma
Giant fibroadenoma Juvenile fibroadenoma
Phyllodes tumours Cysts : macrocysts
Nodularity Generalised Localised
1. Lump
Age incidence of lumps in the breast
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
Phyllodes tumours
Comprise 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 : lungs, skeleton, heart, and liver
1. Primary treatment
Local excision with
a rim of normal tissue
2. Recurrence Re excision
or
Mastectomy with or without reconstruction Response to
chemotherapy and radiotherapy for recurrences and metastases poor
Treatment of Phyllodes tumours
Cysts
Common in the West ( 70 % of women )
50% are solitary cysts 30% 2 - 5 cysts & rest have > 5 cysts
Types
Apocrine cystsLined 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
Management algorithm for cysts
No routine followup
No residual massNo cyst recurrence
Surgical biopsy
Residual massCyst recurrence (X3)
Non blood stained aspirate
FNAC/Surgical biopsy
Blood stained aspirate
Fine needle aspiration
Cyst(C linical diagnosis)
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.
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
• 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
Drugs of established value in mastalgia Drug Dose Clinical response Side
effects
Comments
Evening
primrose oil
3 g / day Cyclical mastalgia 44 %
Non cyclical mastalgia
27%
Low ( 2% ) Efficacy as medicine
questioned. Marketing
authority withdrawn.
Danazol 200mg / day reduced to
100 mg on alternate
days (low dose regime)
Cyclical mastalgia 70%
Non cyclical mastalgia
30%
High (22%) More effective in Cyclical
mastalgia.
Some side effects may be
permanent.
Bromocriptine 2.5 mg twice / day
(incremental dose
regime)
Cyclical mastalgia 47%
Non cyclical mastalgia
20%
High (45%) Not recommended due to
serious side effects
Tamoxifen 10 mg / day Cyclical mastalgia 94%
Non cyclical mastalgia
56%
High (21%) Not licensed for use in
Mastalgia.
Used in Refractory
mastalgia & relapse
Goserelin 3.75 mg / month
intramuscular depot
injection
Cyclical mastalgia 91%
Non cyclical mastalgia
67%
High Major loss of trabecular
bone limits use in Refractory
mastalgia & relapse
ReassuareParacetamol
Mild
Review
Oral NSAID
Moderate
Review&
repeat if necessary
1% lignocaine+
40 mg methyl prednisoloneas local injection
Severew ith trigger points
Non cyclical mastalgiaMusculo skeletal type
Management protocol for musculo skeletal pain
Nipple discharge Causes of nipple discharge
Benign (common) Malignant (less common)
Physiological causesIntraductal pailloma and associated conditionsBlood stained nipple discharge of pregnancyGalactorrhoeaPeriductal MastitisDuct Ectasia
In situ carcinoma (DCIS) Invasive carcinoma
Characterestics of nipple discharges
Non significant nipple discharge Significant nipple discharge
Elicited Spontaneous
Age < 40 years Age > 60 years (new symtom)
Bilateral Unilateral
Intermittent Persistent
Thick Watery
Non troublesome Troublesome
Multiductal Uniductal
Negative test for blood (reagent stick test for
blood)
Positive test for blood
Total duct excision
Distressing symptoms
Reassure
Minor symptoms
Multi ductal
Reassure
Minor symptoms/No suspicion of malignancy
Microdochectomy
Distressing symptoms/No suspicion of malignancy
Surgery
Distressing symptoms/Suspicion of malignancy
Uniductal
Normal
Surgery
Abnormal
Triple assessment
Spontaneous nipple dischare
Management of spontaneous nipple discharge
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)
Causes of galactorrhoea
Physiological causes Drugs Pathological causes
Extremes of age
Stress
Mechanical stimulation
Oestrogen therapy
Anaesthesia
Dopamine receptor blocking agents
Dopamine re-uptake blocker s
Dopamine depleting agents
Inhibitors of Dopamine turnover
Stimulation of serotoninergic system
Histamine H2-receptor antagonists
Hypothalamic lesions
Pituitary tumors
Reflex causes : Chest wall injury, Herpes
zoster neuritis, Upper abdominal surgery
Hypothyroidism
Renal failure
Ectopic production : Bronchogenic and
renal carcinoma
4. Nipple changes
Causes :
1. Developmental inversion
2. 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
Reassure / surgery at patient request
Normal
Further evaluation
Abnormal
Triple assessment
N ipple retraction
Management of nipple retraction