aberrations of normal development and involution and benign breast disorders - presentation for MBBS students

1. Dr. Dileep Ramesh Hoysal

2. ANDI
ABERRATION OF NORMAL DEVELOPMENT
AND INVOLUTION (ANDI) OF THE BREAST

3.  Normal three phases of physiology of breast—
(1) Lobular development;
(2) Cyclical hormonal modifications;
(3) Involution.

4.  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 females—early, matured and involution phase of
reproductive age group.

5. 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.

6. 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.

7. 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.

8. Ductal involution
 Aberration - ductal dilatation and nipple discharge.
 Later Disease status develops with
 Periductal mastitis,
 Nonlactational breast abscess and
 Mammary duct fistula.
 Periductal fibrosis - partial nipple retraction.
 Epithelial changes leads into epithelial hyperplasia
and atypia.

9. FIBROADENOMA
 Hyperplasia 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.

10. 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.

11. Fibroadenoma Variants
1. Juvenile 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.

12. 2. Complex fibroadenoma
 It 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.

13. Pathological Types
1. Intracanalicular: large and soft—mainly cellular.
Stroma with distorted duct.
2. Pericanalicular : small and hard—mainly fibrous.
Stroma with normal duct

14. Clinical Features
 Painless swelling
 Smooth, firm, nontender, well-localised and
 Moves freely within the breast tissue (mouse in the
breast).

15. Investigations
 Mammography (well-localised smooth regular
shadow).
 FNAC.
 Ultrasound (to confirm solid nature).

16. Treatment
 Fibroadenoma 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.

18. Early Reproductive Period(15-25yrs)
NORMAL
PROCESS
• LOBULE
FORMATION
• STROMA
FORMATION
ABERRATION
• FIBROADENOMA
• JUVENILE
HYPERTROPHY
DISEASE STATE
• GIANT
FIBROADENOMA
• MULTIPLE
FIBROADENOMA

20. PHYLLOIDES TUMOR
 Aka 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%)

22.  Gross : Large, Capsulated, Cystic Changes
 Cut Curface: Soft, Cystic Spaces
 Microscopy: Cystic Spaces With Leaf Like Projections
Hence Called “Phylloides”

25. CLINICAL FEATURES
 30-50yrs
 Unilateral
 Grows rapidly to attain large size
 Bosselated surface with necrosis of skin
 Swelling is warm, not fixed to skin or chest wall

27. INVESTIGATIONS
 ULTRASOUND
 FNAC
 CHEST XRAY

28. TREATMENT
 Excision
 Total Mastectomy If Malignant

29. Mature Reproductive Period (25-40yrs)
NORMAL
• CYCLICAL
HORMONE
EFFECTS ON
GLANDULAR
TISSUE AND
STROMA
ABERRATION
• EXAGGERATED
CYCLICAL
EFFECTS
DISEASED STATE
• CYCLICAL
MASTALGIA
AND
NODULARITY

30. Cyclical Mastalgia With Nodularity
 Aka Fibrocystadenosis / Fibrocystic Disease Of Breast/
Mammary Dysplasia
 Estrogen Dependant

32. BLUEDOME CYST OF BLOODGOOD
 One Of The Cyst May Get Enlarged And Become
Clinically Palpable
 Non Tender, Fluctuant, Transilluminant With Thin
Bluish Capsule

33.  Initially Aspirated
 Surgical Excision Done If Recurs/ Persists/ Blood
Stained/ Residual Lump Remains
 Multiple Small Cysts – Schimmelbusch’s Disease

34. FIBROCYSTADENOSIS

35. CLINICAL FEATURES
 B/L, Diffuse, Painful, Granular Swelling Better Felt
With Palpating Fingers
 Pain And Tenderness More Just Prior To
Menstruatuion
 Subsides During Pregnancy/ Lactation/ After
Menopause

36. INVESTIGATIONS
 FNAC- EPITHELIOSIS (PREMALIGNANT)
 USG
 MAMMOGRAPHY

38. TREATMENT
(A) CONSERVATIVE
 Reassurance
 Oil Of Evening Primrose: Gamolenic Acid
 NSAIDS
 Vit E And B6
 Bromocriptine- Prolactin Inhibitor
 Tamoxifen- Estrogen Antagonist
 Danozol- Antigonadotrohin Agent

39. SURGERY
 Excision Of Cyst/ Diseased Tissue
 D/D: Tietze’s Disease Costochondritis Of Second
Costal Cartilage

40. Involution (35-55 yrs)
NORMAL
• LOBULAR
INVOLUTION
• DUCTAL
INVOLUTION
• EPITHELIAL
TURNOVER
ABERRATION
• MACROCYST,
SCLEROSING
ADENOSIS
• DUCT
DILATATION,
PERIDUCTAL
FIBROSIS
• MILD
EPITHELIAL
HYPERPLASIA
DISEASED STATE
• CYSTIC DIAEASE
• PERIDUCTAL
MASTITIS, NON
LACTATIONAL
BREAST ABSCESS
• EPITHELIAL
HYPERPLASIA
WITH ATYPIA

41. SCLEROSING ADENOSIS
 30-50yrs
 Present With Breast Lump Or Mastalgia
 Smooth, Relatively Mobile Mass
 Mimic Carcinoma Clinically, Radiologically And
Histologically

42. DUCT ECTASIA
 Dilatation Of Lactiferous Duct Due To Muscular
Relaxation Of Duct Wall With Periductal Matitis
 Aka Plasma Cell Mastitis
 Many Ducts Involved

43. CLINICAL FEATURES
 GREENISH NIPPLE DISCHARGE
 TENDER INDURATED MASS UNDER THE AREOLAR
 EVENTUALLY FORMS ABSCESS AND FISTULA
 LATER STAGE- RETRACTION OF NIPPLE

44.  COMMON IN SMOKERS- IN RELATION TO
ARTERIAL PATHOLOGY
 B/L AND MULTIFOCAL
 D/D –CARCINOMA BREAST

47. TREATMENT
 STOP SMOKING
 CONE EXCISION OF INVOLVED MAJOR DUCTS-
HADFIELD OPERATION
 ANTIBIOTICS

48. MASTITIS
 TYPES:
(1) SUBAREOLAR MASTITIS- INFECTED GLAND OF
MONTGOMERY
(2) INTRAMAMMARY MASTITIS
-LACTATING ABSCESS
- NON LACTATING ABSCESS
(3) RETROMAMMARY MASTITIS- TB OF
INTERCOSTAL LYMPH NODES

49. MASTITIS

50. BREAST ABSCESS

51. ANTIBIOMA
IF INTRAMAMMARY ABSCESS NOT
DRAINED BUT ONLY TREATED
WITH ANTIBIOTICS
PUS LOCALIZES AND BECOMES
STERILE
THICK FIBROUS CAPSULE AROUND
IT

52.  PREVIOUS HISTORY OF MASTITIS
 D/D- CARCINOMA AS IF HARD AND FIXED TO
BREAST TISSUE
 EXCISION

53. OTHER BENIGN BREAST
CONDITIONS
 GALACTOCOELE
-SEEN IN LACTATING WOMEN
-RETENSION CYST IN SUBAREOLAR REGION
-BLOCK OF LACTIFEROUS DUCT
-MASSIVE ENLARGEMENT OF LACTIFEROUS
SINUS

54.  PRESENT AS LARGE, SMOOTH, SOFT, FLUCTUANT
LUMP
 CAN GET INFECTED
 EXCISION

56. TRAUMATIC FAT NECROSIS
 DIRECT OR INDIRECT TRAUMA
 SMOOTH, HARD, NON TENDER, NOT ADHERENT
 EXCISION

57. CAPILLARY OOZE
TG IN FAT TO
DISSOCIATE TO FA
FA+CA
(SAPONIFICATION)

60. DUCT PAPILLOMA
 COMMONEST CAUSE OF BLOODY NIPPLE
DISCHARGE
 USUALLY SINGLE FROM A SINGLE LACTIFEROUS
DUCT
 IF MUTIPLE – CAN BE PREMALIGNANT

62.  INVESTIGATION- INJECT CONTRAST INTO DUCT
(DUCTOGRAM)
 MICRODOCHECTOMY: PROBED LACTIFEROUS
DUCT IS OPENED AND THE PAPILLOMA EXCISED
USING TENNIS RAQUET INCISION

64. GYNECOMASTIA
 HYPERTROPHY OF MALE BREAST DUE TO
INCREASE IN DUCTAL AND CONNECTIVE TISSUE
ELEMENT OFTEN ATTAINING FEATURES OF
FEMALE BREAST
 U/L OR B/L

65. CAUSES
(1) IDIOPATHIC
(2) DRUGS: SPIRONOLACTONE. INH,
PHENOTHIAZIDES, DIGITALIS
(3) LIVER FAILURE AND LIVER DISEASE
(4) LEPROSY
(5) TEROTOMA TESTIS
(6) ADRENAL AND PITUITARY DISEASE
(7) ECTOPIC HORMONE PRODUCTION
(8) KLINEFELTERS

66.  SMALL , WELL LOCALIZED, FIRM SWELLING
BELOW THE ARELOAR WHICH IS PAINFUL
 WHEN SYMPTOMATIC- EXCISED

70. THANK YOU