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