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
 Aetiopathogenesis – some theories
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
 CLASSIFICATION
Physiological Normal Aberration Benign disease
stage of the
breast
Development Duct devt. Nipple
inversion
Lobular devt. Fibroadenoma Giant
Stromal devt. Adolescent fibroadenoma
hypertrophy
Cyclical Hormonal Mastalgia &
change activity on nodularity
gland &
stroma Benign
Epithelial papilloma
activity
Pregnancy & Epithelial Blood stained
lactation hyperplasia discharge

lactation galactocele

Involution Ductal Duct ectasia Periductal

involution Nipple mastitis with
retraction suppuration
Lobular Cysts,
involution Sclerosing
adenosis
Involutional Hyperplasia & Lobular or
epithelial micro ductal
hyperplasia papillomatosis hyperplasia
with atypia
Pathology –relative risk of invasive breast cancer

No risk Slightly Moderately Insufficient data

increased risk increased risk to assign risk
(1.5 – 2 times) (5 times)
Fibroadenoma
Moderate / florid/ Atypical ductal / Radial scar lesion
Cysts
solid /papillary lobular hyperplasia
Duct ectasia hyperplasia
Mild hyperplasia

- Gist of American College of Pathologists Consensus Statement

 Developmental anomalies

Athelia-absence of nipple
Amazia-absence of breast tissue.asso with
poland syndrome
POLYMASTIA-common
Commonly in axilla
Supernumerary nipples-male
predominance 1.7:1
Assn. 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
 1. Lump

Discrete lump
 Fibroadenoma
 Giant fibroadenoma
Juvenile fibroadenoma
 Phyllodes tumours
 Cysts : macrocysts

Nodularity
 Generalised
 Localised

Age incidence of lumps in the breast

 Fibroadenoma
Types Natural history
Solitary
Few (< 5 / breast ) Majority remain small & static
Multiple (> 5 / breast ) 50% involute spontaneously
Giant (> 4 / 5 cms) & Juvenile 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
 Treatment of Phyllodes tumours

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
 Cysts
Common in the West ( 70 % of women )

 50% are solitary cysts

 30% 2 - 5 cysts &
 rest have > 5 cysts

Types

 Apocrine cysts
Lined 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

C ys t
(C linic a l d ia g no s is )

F ine ne e d le a s p ira tio n

N o n b lo o d s ta ine d a s p ira te B lo o d s ta ine d a s p ira te

N o re s id ua l m a s s R e s id ua l m a s s F N A C /S urg ic a l b io p s y
N o c ys t re c urre nc e C ys t re c urre nc e (X 3 )

N o ro utine fo llo w up S urg ic a l b io p s y

 2. Pain

Mastalgia
• Cyclical mastalgia
• Non cyclical mastalgia
•True (breast related)
• Musculoskeletal : costochondral or lateral chest wall
Infections
True breast pain
• 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

True breast pain
Lateral chest Costo
wall pain Chondral pain
mild

Musculo skeletal pain

 Management protocol for true mastalgia

• 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
 Drugs of established value in mastalgia
D ru g Dose C lin ic a l re s p o n s e S id e C o m m e n ts

e ffe c ts

E v e n in g 3 g / d ay C yc lic al m as talg ia 4 4 % L ow ( 2 % ) E ffic ac y as m ed ic in e

p rim ro s e o il N on c yc lic al m as talg ia q u es tion ed . M arketin g

27% au th ority w ith d raw n .

Danazol 2 0 0 m g / d ay red u c ed to C yc lic al m as talg ia 7 0 % H ig h (2 2 % ) M ore effec tive in C yc lic al

1 0 0 m g on altern ate N on c yc lic al m as talg ia m as talg ia.

d ays (low d os e reg im e) 30% S om e s id e effec ts m ay b e

p erm an en t.

B ro m o c rip tin e 2 .5 m g tw ic e / d ay C yc lic al m as talg ia 4 7 % H ig h (4 5 % ) N ot rec om m en d ed d u e to

(in c rem en tal d os e N on c yc lic al m as talg ia s eriou s s id e effec ts

reg im e) 20%

T a m o x ife n 1 0 m g / d ay C yc lic al m as talg ia 9 4 % H ig h (2 1 % ) N ot lic en s ed for u s e in

N on c yc lic al m as talg ia M as talg ia.

56% U s ed in R efrac tory

m as talg ia & relap s e

G o s e re lin 3 .7 5 m g / m on th C yc lic al m as talg ia 9 1 % H ig h M ajor los s of trab ec u lar

in tram u s c u lar d ep ot N on c yc lic al m as talg ia b on e lim its u s e in R efrac tory

in jec tion 67% m as talg ia & relap s e

Management protocol for musculo skeletal pain
N o n c y c lic a l m a s ta lg ia
M u s c u lo s k e le ta l ty p e

M ild M o d e ra te S e v e re
w ith trig g e r p o in ts

R e a s s u a re O ra l N S A ID 1 % lig n o c a in e
P a ra c e ta m o l +
4 0 m g m e th y l p re d n is o lo n e
a s lo c a l in je c tio n

R e v ie w R e v ie w
&
re p e a t if n e c e s s a ry
 Nipple discharge
Causes of nipple discharge
Benign (common) Malignant (less common)

Physiological causes In situ carcinoma (DCIS)

Intraductal pailloma and associated Invasive carcinoma
conditions
Blood stained nipple discharge of
pregnancy
Galactorrhoea
Periductal Mastitis
Duct Ectasia
 Characterestics of nipple discharges
N o n s ig n ific a n t n ip p le d is c h a rg e S ig n ific a n t n ip p le d is c h a rg e

E lic ite d S p o n ta n e o u s

A g e < 4 0 y e a rs A g e > 6 0 y e a rs (n e w s y m to m )

B ila te ra l U n ila te ra l

In te rm itte n t P e rs is te n t

T h ic k W a te ry

N o n tro u b le s o m e T ro u b le s o m e

M u ltid u c ta l U n id u c ta l

N e g a tiv e te s t fo r b lo o d (re a g e n t s tic k te s t fo r P o s itiv e te s t fo r b lo o d

b lo o d )
 Management of spontaneous nipple discharge
S p o n ta n e o u s n ip p le d is c h a re

T rip le a s s e s s m e n t

N o rm a l Ab n o rm a l

M u lti d u c ta l U n id u c ta l S u rg e ry

D is tre s s in g s y m p to m s M in o r s y m p to m s M in o r s y m p to m s / D is tre s s in g s y m p to m s / D is tre s s in g s y m p to m s /

N o s u s p ic io n o f m a lig n a n c y N o s u s p ic io n o f m a lig n a n c y S u s p ic io n o f m a lig n a n c y

R e a s s u re R e a s s u re M ic ro d o c h e c to m y S u rg e ry
T o ta l d u c t e x c is io n
 Galactorrhoea
C a u s e s o f g a la c to rrh o e a

Ph y s io lo g ic a l c a u s e s D ru g s Pa th o lo g ic a l c a u s e s

E x tre m e s o f a g e O e s tro g e n th e ra p y H y p o th a la m ic le s io n s

Stre s s A n a e s th e s ia P itu ita ry tu m o rs

M e c h a n ic a l s tim u la tio n D o p a m in e re c e p to r b lo c k in g a g e n ts R e fle x c a u s e s : C h e s t w a ll in ju ry , H e rp e s

D o p a m in e re -u p ta k e b lo c k e r s z o s te r n e u ritis , U p p e r a b d o m in a l s u rg e ry

D o p a m in e d e p le tin g a g e n ts H y p o th y ro id is m

In h ib ito rs o f D o p a m in e tu rn o v e r R e n a l fa ilu re

Stim u la tio n o f s e ro to n in e rg ic s y s te m E c to p ic p ro d u c tio n : B ro n c h o g e n ic a n d

H is ta m in e H 2 -re c e p to r a n ta g o n is ts re n a l c a rc in o m a

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)
 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
 Management of nipple retraction

N ip p le re tra c tio n

T rip le a s s e s s m e n t

N o rm a l A b n o rm a l

R e a s s u re / s u rg e ry a t p a tie n t re q u e s t F u rth e r e v a lu a tio n