BENIGN BREAST DISEASES. Dr. B.Naresh Post graduate - S4

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1 BENIGN BREAST DISEASES ` Dr. B.Naresh Post graduate - S4

2 BREAST DEVELOPMENT AND FUNCTION Initiated by a variety of hormonal stimuli Estrogen Progesterone Prolactin Oxytocin Thyroid hormone Cortisol Growth hormone

3 HORMONAL REGULATION HYPOTHALAMUS +/- GnRH ANTERIOR PITUITARY` basophilic cells FSH LH OVARIES Estrogen Progesterone INACTIVE Breast ACTIVE Breast

4 HORMONAL EFFECTS ON BREAST TISSUE Estrogen Ductal development Progesterone Epithelial differentiation Lobular development Prolactin Lactogenesis

5 @ 10 YEARS OF AGE BREAST BUD (or) MOUND Mammary tissue grow beneath the areola, producing the characteristic protuberence on the chest wall.

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7 @ 12 YEARS OF AGE TRUE NIPPLES develop By further areolar growth and formation of bulk of breast tissue. may be asymmetrical

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9 @ 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

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11 DURING PREGNANCY ADENOSIS Lobular Alveolar growth new Secretory units develop Capillary growth Venous engorgment Myoepithelial cell proliferate Colostrum formation Doubling of breast weight From 200g to 400g

12 Areola darkens Montgomery glands - prominent Increased conc. Of Luteal hormones Placental sex hormones Placental Lactogens HCG

13 DURING LACTATION

14 DURING LACTATION TRUE MILK - after 2 days of parturition Alveoli - source of milk production. Milk let down reflex NEURAL REFLXES Nipple Areolar complex Production of PROLACTIN OXYTOCIN

15 DURING WEANING POST LACTATIONAL INVOLUTION Prolactin & oxytocin decreases Dormant milk - increase pressure within ducts Atrophy of alveoli epithelium Lymphocytic infiltration & Hyalinization - lobules

16 DURING MENOPAUSE Estrogen & Progesterone secretion decreases Involution of ducts & alveoli Breast tissue replaced Adipose tissue. Fibrous connective tissue increase in density

17 MALE BREAST GYNAECOMASTIA Enlargement of ductal and stromal tissue of male breast. Physiological (or) Pathological increased Estrogen : Androgen ratio

18 PHYSIOLOGICAL (PRIMARY) GYNAECOMASTIA Neo natal Placental estrogen Adolescence Estradiol > Testosterone Senescence Circulating testosterone - falls

19 PATHOLOGICAL (SECONDARY) GYNAECOMASTIA Estrogen excess state Androgen deficiency states Drug related Systemic diseases with idiopathic mechanism

20 PATHOLOGICAL (SECONDARY) GYNAECOMASTIA Estrogen excess state Gonadal origin True hermaphroditism Testicular tumour Non germinal neoplasm Germ cell tumour Non Testicular tumour Adrenal cortical neoplasm Lung carcinoma Hepatocellular carcinoma Endocrine disorder Liver disease Nutrition alteration

21 PATHOLOGICAL (SECONDARY) GYNAECOMASTIA Androgen deficiency states Hypogonadism Primary testicular failure Klinefelter s syndrome Kallmann s syndrome Reifenstein s syndrome Kennedy s disease Eunuchoidal males ACTH deficiency Secondary testicular failure Trauma Orchitis Irradiation Renal failure

22 PATHOLOGICAL (SECONDARY) GYNAECOMASTIA Drug related with Estrogenic activity Digitalis, Estrogens, Steroids, Marijuana enhance Estrogen synthesis Human chorionic gonadotropin inhibit Testosterone synthesis Cimetidine, ketoconazole, phenytoin, frusemide, antineoplastic agents, spironolactone, diazepams.

23 GYNAECOMASTIA CLINICAL FEATURES Unilateral / Bilateral Painless, sometimes little pain On Palpation nontender, & movable Psychological problem may accompany Associated various breast pathologies.

24 GYNAECOMASTIA - CLASSIFICATION GRADE I IIa IIb III Mild breast enlargement (-) Skin redundancy Moderate enlargement (-) Skin redudancy Moderate enlargement (+) Skin redudancy Marked enlargement (+) Skin redudancy & Ptosis, simulates a female breast

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26 BENIGN BREAST DISEASES Breast 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 % of woman suffer from this condition.

27 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.

28 CLASSIFICATION -- SYMPTOMS Breast Pain (Mastalgia) Breast Lumps Disorders of Nipple & Periareolar region Breast Infection

29 BREAST PAIN (MASTALGIA) Cyclical Non Cyclical Musculo skeletal Cervical root pain Sclerosing adenosis Post - operative

30 Cyclical Non - cyclical Median age 35 years of age 45 years of age Features Wax and Wane not always bilateral Chronic unilateral Localized Poorly Trigger spot zones Located Upper, outer quadrants Medial quadrant Peri areolar regions Type of pain Heaviness of breast Burning Dragging Aetiology Hormonal (estrogen ; prolactin) Excessive caffeine Inadequate EFA Psychoneurosis Unclear Ductal ectasia Lumps Post operative Surrounding structures

31 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)

32 NON CYCLICAL MASTALGIA Musculo skeletal (Tiet z syndrome) Usually unilateral the Lateral wall of chest Costo chondral junction Reffered cervical root pain Usually in elderly people

33 BREAST LUMPS Fibroadenoma Giant Fibroadenoma Phyllodes tumour Cyclical nodularity Cysts Galactocele Sclerosing adenosis Fat necrosis Lipoma Chronic abscess Duct papilloma Haematoma

34 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

35 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

36 FIBROADENOMA

37 FIBROADENOMA Peri Canalicular variety (Hard Fibroadenoma) years of age Firmer, smaller, movable -- Breast Mouse Intra Canalicular variety (Soft Fibroadenoma) years of age Less Firmer, Grows rapidly and larger Compresses the glandular and ductal system due to proliferation hence Intraductal myxoma Both patterns can co-exist within the same tumour

38 GIANT FIBROADENOMA Bimodal age presentation yrs of age ---- Juvenile Fibroadenoma yrs of age Rapid growth. Size > 5 cms in diameter Painful Blacks have greater propensity

39 GIANT FIBROADENOMA

40 GIANT FIBROADENOMA Histologically, typical hypocellular stroma epithelial components showing mild degree of hyperplasia and atypia, with mitoses. Clinically Breast enlarged, Nipple displacement, Shiny skin with dilated veins Skin necrosis may occur

41 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

42 PHYLLODES TUMOUR Clinically, Unevenly bosselated surface with projections Skin warm, red, shiny with dilated veins Pressure necrosis skin ulceration Cut section, Soft brown in color Exhibit cysts, necrosis or haemorrhage Leaf like appearance Histologically, Hypercellular, much atypia, numerous mitoses.

43 DISORDERS OF NIPPLE & PERIAREOLAR Nipple Inversion Nipple Retraction Nipple Discharge Mammary fistula Duct ectasia / Periductal mastitis Skin - eczema

44 NIPPLE INVERSION

45 NIPPLE RETRACTION Not congenital Due to Duct ectasia Carcinoma Post surgical retraction

46 NIPPLE RETRACTION

47 NIPPLE DISCHARGE

48 ECZEMA --- SKIN

49 BREAST INFECTION Intramammary mastitis (acute / chronic) Subareolar mastitis (acute / chronic) Retromammary abscess Tuberculosis Syphillis Actinomycosis / Blastomycosis Hidradenitis suppurativa Mondor s disease

50 INTRA MAMMARY ABSCESS Lactating breast --- Nursing Mother Aetiology Development of cracks and bruises in the nipple Blockade of one or more lactiferous ductules Retracted nipple Infectious organism Staphylococcus aeurus streptococcus

51 INTRA MAMMARY ABSCESS Cellulitic stage Redness Oedema Tenderness Brawny induration Extremely painful Abscess formation Chronic abscess Antibioma

52 SUBAREOLAR ABSCESS

53 RETROMAMMARY ABSCESS Arises from the tissue deep to breast Infected haematoma Emphyema TB of rib and spine Osteomyelitis of rib

54 TUBERCULOSIS -- BREAST

55 SYPHILIS -- BREAST

56 MONDOR S DISEASE

57 ABERRATION OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI) Early Reproductive yrs (age 15-25) Late Reproductive yrs (age 25-40) Involution (age 35-55) NORMAL DISORDER DISEASE Lobular development Stromal development Nipple Eversion Cyclical changes of menstruation Epithelial hyperplasia of pregnancy Lobular involution Ductal involution (dilatation / sclerosis) Epithelial turnover Fibroadenoma Adol. Hypertrophy Nipple inversion Cyclical mastalgia Nodularity Bloody nipple dischrge Macrocysts Sclerosing leisons Duct ectasia Nipple retraction Epithelial hyperplasia Giant fibroadenoma Gigantomastia Sub areolar abscess Mammary. duct. fistula In-capactitating. mastalgia Peri ductal mastitis Atypical Epithelial... hyperplasia

58 CLASSIFICATION HISTOLOGICAL DIFFERENTIATION Non Proliferative disorders of breast Cysts and apocrine metaplasia Duct ectasia Calcifications Fibroadenoma and related leisons Proliferative breast disorders without atypia Sclerosing adenosis Radial and complex sclerosing leisons Ductal epithelial hyperplasia Intraductal papillomas Atypical proliferative leisons Atypical lobular hyperplasia (ALH) Atypical ductal hyperplasia (ADH)

59 Thank you