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

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