ABERRATIONS OF NORMAL DEVELOPMENT AND INVOLUTION(ANDI)

PRESENTED BY :DR.RAJANI DEVIUNDER THE GUIDENCE

:DR.NARASIMHAM,M.SDR.VENKAT REDDY,M.S;DR.SAILAJA RANI,M.S

• MOST BENIGN BREAST CONDITIONS ARISE FROM NORMAL PHYSIOLOGICAL PROCESS OF REPRODUCTIVE LIFE

• NORMAL –ABERRATION-DISEASE• CHIEF SYMPTOMS ARE CYCLICAL PAIN AND

NODULARITY

EMBRYOLOGY

• 7 th week- Ectodermal mammary ridge invades epidermis

• 9 th week-Formed vascular envelope around each of major ducts specialised fat cells also invade the matrices between blood vessels and fibrous septae.Nipple is flattened and rudimentary sebacious glands and Montgomery tubercles are present

• 10 th week-tenth week to birth ingrowth of connective tissue partitions

• 12 th week –progressing to the budding stage• 13-20 th week –mammary ridge is shortened

and migrating dorso ventrallyand form elevated nipple primordium on ventral wall of thorax

• Epithelial bud then branches and canalizes to form 15 to 20 major ducts found in adult breast.

• Ducts have small vesicles and no lobules• At birth – transient secretory changes occur in

new born gives witches milk or neonatal mastitis

• Prepubertal breat is identical in both sexes

CHANGES AT PUBERTY

• At about 10 years-Breast bud or mound –growth of mammary tissue beneath areola

• At 12 years –nipple begins to grow outwards• 14-15 years-increasing sub areolar growth

leads to elevation of areo;a above breast gives secondary mound-nipple projecting

• FSH and LH-Responsible for initiation of puberty.

• Causes activation of primordial ovarian follicles and secretion of oestrogen,which is responsible for 1 st stage of breast development

• Oestrogen(1 st year of anovulation)-duct sprouting and branching.

• Connective tissue and vascular growth.• Fat deposition

• Progesterone-Differentiation of terminal ductular buds to form adult lobes.

• Lobulo alveolar development.• Insulin ,GH, Cortico steroids ,Prolactin-are also

required for breast development but to a minor role

CYCLICAL CHANGES

• Ovarian activity is under the controle of pitutary gonadotrophins-FSH & LH.

• LH is under the controle ofGnRH.• Modulated by the negative feed back effect of

oestradiol and progestrone.• Mid cycle LH surge --> ovulation.• Breast during menstrual cycle-1 st half-

mitosis,2 nd half-apoptosis

• Estrogen causes mitosis in ductular and alveolar cells.• During follicular phase- moderate increase in mitosis in

ductular cells.• Progesterone- biphasic effect.• -First stimulating mitosis then slows down.• -Induce cytoplasmic changes conducive to lactation with

accumulation of fluid ,protein,and electrolytes

• i

• -Responsible for premenstrual fullness and tenderness.

• -Both mitosis and apoptosis reach a peak towards end of cycle and during mensruation.

• 2 peaks –day 25 for mitosis,-day 28 for apoptosis,} mirror images of the changes in endometrium.

• These changes did not vary with parity ,use of O.C pills or presence of fibroadenoma.

• With increasing age- decrease in mitosis,more significant decrease in apoptosis.

• This is responsible for some of involtional changes in ANDI

CHANGES DURING PREGNANCY AND LACTATION

• Increased luteal and placental sex steroids,placental lactogen,chorionic gonadotrophins-lobulo alveolar growth.

• Histologically dilated alveoli.• Prolactin-milk production

• 0 weeks: resting brest approx 200 grms.• 1-4 weeks:Ductular sprouting/lobular

formation.• 5-8 weeks:Breast enlarges/vascular

engorgement/alveolar pigmentation/predominant lobular formation.

• >12 weeks:large alveoli with single epithelial cell layer,beginning of colostrum formation

• >20 weeks:Alveolar dilatation/colostrum formation/new capillary formation/myoepithelial cell hypertrophy.

• Term:80% increase in mammary blood flow,weight approxmately 400 grams,fat droplets accumilate in alveolar cells

POST MENOPAUSAL CHANGES

• FSH levels increase from 30 years to menopause.

• But levels of oestradiol and LH remain constant.

• Oestradiol levels are very high in some women at the time of menopause(responsible for breast tenderness).

ANDISTAGE NORMAL PROCESS ABERRATION DISEASE

EARLY REPRODUCTION:15-25 YRS

-LOBULAR DEVELOPMENT

-FIBRO ADENOMA -GAINT FIBROADENOMA

15 -25 -STROMAL DEVELOPMENT

-ADOLSCENT HYPERTROPHY

-GIGANTOMASTIA

15 -25 -NIPPLE EVERSION -NIPPLE INVERSION -SUB AREOLAR ABSCESS/MAMARY DUCT FISTULA

MATURE REPRODUCTIVE AGE 25-45

-CYCLICAL CHANGEAS OF MENSTRUATION

-CYCLICAL MASTALGIA,NODULARITY

-INCAPACITATING MASTALGIA

25 -45 -EPITHELIAL HYPERPLASIA OF PREGNANCY

-BLOODY NIPPLE DISCHARGE

INVOLUTION 35-55 -LOBULAR INVOLUTION

-MACROCYSTS,SCLEROSING LESIONS

35 -55 -DUCT INVOLUTION,DILATATION,SCLEROSIS

-DUCT ECTASIA,NIPPLE RETRACTION

-PERIDUCTAL MASTITIS/ABSCESS

35 -55 -EPITHELIAL TURNOVER

-SIMPLE EPITHELIAL HYPERPLASIA

-WITH ATYPIA

VARIOUS BBD INCLUDED IN ANDI

• 1.DISORDERS OF DEVELOPMENT:• a)Fibroadenoma.• b)Giant fibroadenoma-Cystosarcoma phylloids• c)Adolscent hypertrophy• d)Cyclical mastalgia and

nodularity(Fibroadenosis)

• 2.DISORDERS OF INVOLUTION:• a)Cyst formation• b)Sclerosing adenitis• c)Duct ectasia and periductal mastitis• d)Epithelial hyperplasia• e)Galactocele• f)apocrine metaplasia

FIBROADENOMA• Breast mouse• 15 to 25 years• Arise from hyperplasia of single lobule• Grow upto 2 to 3 cms in diameter• Covered by a capsule• Rubbery,firm,smooth,or lobulated• Respond to normal harmonal stimuli as normal

breast tissue• <30 years do not require excision• If suspeced cytology-enucleation

GAINT FIBROADENOMA(CYSTOSARCOMA PHYLLOIDS)

• >5 cms in diameter• No skin involvement• Not adherent to chest wall• > 40 years of age

ADOLSCENT HYPERTROPHY

• Gross stromal hyperplasia at time of puberty• Enormous enlargement• Unknown etiology• Treatment:Danazole has some beneficial

effect• Very large –surgical excision

CYCLICAL MASTALGIA AND NODULARITY(FIBROADENOSIS)

• Premenstrual enlargement and postmenstrual involution is common with each cycle,

• If pain and nodularity persists for more than a week,

• Increased prolactin from pitutary,• Treatment is reassurence• Treatment for mastalgia is-avoid caffeine

drinks,

• Adequate support to the breast by wearing a firm bra

• Evening prime rose oil-6 capsules per day for 6 months

• Evening prime rose oil contains7%of Linolenic acid and72%of Linoleic acid-richest source of essential fatty acids

• Danazole-100 mg 3 times a day• Bromocriptine:1.25 mg/day

CYST FORMATION

• Due to aberration in the involution of stroma &epithelium

• If stroma dis appears early ,epithelial acini remain and form microcysts

• By obstruction of efferent ductules-macro cysts formation occur

• Require no active treatment• Simple aspiration is sufficient

SCLEROSING ADENOSIS

• Epithelial acini are rreplaced by fibrous tissue• Causing lump or pain• Requires no treatment

DUCTAL ECTASIA AND PERIDUCTAL MASTITIS

• Dialted ducts• Stagnation of secretions,epithelial

ulceration,leakage of duct secretions containing chemically irritant fatty acids into periductal tissues

• Give a chemical inflammatory process• Leads to periductal fibrosis

• Fibrous contraction and nipple retraction• Normal process in postmenopausal breast• Clinical symptoms:nipple discharge,nipple

retraction,periducal inflamation• Treatment:reassurance• If discharge is profuse-totalduct excision• EPITHELIAL HYPERPLASIA:without atypia

GALACTOCELE

• Preformed cyst filled with milky material after a period of lactation

• Leads to chronic sinuses• Painless swelling of breast after few weeks to

months after ceasing lactation• Swelling is smooth and mobile• Aspiration->milk• Treatment:simple aspiration

APOCRINE METAPLASIA

• Precursors to malignant transformation

• RISK OF MALIGNANT TRANSFORMATION IN ALL TYPES ANDI IS ALMOST ZERO

THANK YOU