ABERRATION IN NORMALDEVELOPMENT ANDINVOLUTION
 Developed and described by Cardiff  breast clinic in Wales Wide spectrum of clinicopathological  features ranging from ...
Aetiopathogenesis – some theoriesEndocrine factors     1.   Disturbances in the Hypothalamo Pituitary Gonadal steroid axis...
CLASSIFICATIONPhysiological   Normal          Aberration   Benign diseasestage of thebreastDevelopment     Duct devt.     ...
Pregnancy &   Epithelial     Blood stainedlactation     hyperplasia    discharge              lactation      galactoceleIn...
Pathology –relative risk of invasive breast cancer No risk            Slightly             Moderately            Insuffici...
Developmental anomaliesAthelia-absence of nippleAmazia-absence of breast tissue.asso with  poland syndrome  POLYMASTIA-com...
DIFFUSE HYPERTROPHYOccurs in otherwise  healthy girls  at puberty Alteration in the  normal sensitivity  of the breast to...
1. LumpDiscrete lump Fibroadenoma      Giant fibroadenoma     Juvenile fibroadenoma Phyllodes tumours Cysts : macrocy...
FibroadenomaTypes                                Natural historySolitaryFew (< 5 / breast )                  Majority rema...
Phyllodes tumours Comprise less than 1% of all breast neoplasms May occur at any age but usually in 5th decade of life ...
Treatment of Phyllodes tumours1. Primary treatmentLocal excision witha rim of normal tissue2. Recurrence Re excision     ...
CystsCommon in the West ( 70 % of women )       50% are solitary cysts       30% 2 - 5 cysts &       rest have > 5 cyst...
Management algorithm for cysts                                                          C ys t                            ...
2. PainMastalgia• Cyclical mastalgia• Non cyclical mastalgia    •True (breast related)    • Musculoskeletal : costochondra...
MastalgiaDefinition : Pain severe enough to interfere with daily life or lasting   over 2weeks of menstrual cycle         ...
Management protocol for true mastalgia•   Assess type of pain•   Assess severity of pain ( Pain diary + Visual analogue sc...
Drugs of established value in mastalgiaD ru g                 Dose                             C lin ic a l re s p o n s e...
Management protocol for musculo skeletal pain                         N o n c y c lic a l m a s ta lg ia                  ...
Nipple discharge                    Causes of nipple discharge      Benign (common)                  Malignant (less commo...
Characterestics of nipple dischargesN 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...
Management of spontaneous nipple discharge                                                                                ...
Galactorrhoea                                                            C a u s e s o f g a la c to rrh o e aPh y s io lo...
4. Nipple changesCauses :1.   Developmental inversion2.   Acquired inversion    Periductal mastitis    Duct ectasia (cla...
Management of nipple retraction                                                N ip p le re tra c tio n                   ...
 ABERRATION IN NORMAL DEVELOPMENT AND INVOLUTION
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ABERRATION IN NORMAL DEVELOPMENT AND INVOLUTION

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ABERRATION IN NORMAL DEVELOPMENT AND INVOLUTION

  1. 1. ABERRATION IN NORMALDEVELOPMENT ANDINVOLUTION
  2. 2.  Developed and described by Cardiff breast clinic in Wales Wide spectrum of clinicopathological features ranging from near normality to severe disease
  3. 3. Aetiopathogenesis – some theoriesEndocrine factors 1. Disturbances in the Hypothalamo Pituitary Gonadal steroid axis 2. Altered Prolactin profile – qualitative /quantitative changeNon endocrine factors1. Methyl xanthines, StressGenetic predisposition to catecholamine supersensitivity  Intra cellular C - AMP mediated events  cellular proliferation2. Diet rich in saturated fatAltered plasma essential fatty acid profile  receptor supersensitivity to normal levels of Oestrogen & Progesterone3. Iodine deficiencyReceptor supersensitivity to normal levels of Oestrogen & Progesterone
  4. 4. CLASSIFICATIONPhysiological Normal Aberration Benign diseasestage of thebreastDevelopment Duct devt. Nipple inversion Lobular devt. Fibroadenoma Giant Stromal devt. Adolescent fibroadenoma hypertrophyCyclical Hormonal Mastalgia &change activity on nodularity gland & stroma Benign Epithelial papilloma activity
  5. 5. Pregnancy & Epithelial Blood stainedlactation hyperplasia discharge lactation galactoceleInvolution 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
  6. 6. 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
  7. 7. Developmental anomaliesAthelia-absence of nippleAmazia-absence of breast tissue.asso with poland syndrome POLYMASTIA-commonCommonly in axillaSupernumerary nipples-male predominance 1.7:1Assn. With other syndrome- turner,fanconi,ectodermal dysplasia
  8. 8. DIFFUSE HYPERTROPHYOccurs in otherwise healthy girls at puberty Alteration in the normal sensitivity of the breast to estrogen Reduction mammoplasty
  9. 9. 1. LumpDiscrete lump Fibroadenoma  Giant fibroadenoma Juvenile fibroadenoma Phyllodes tumours Cysts : macrocystsNodularity Generalised Localised Age incidence of lumps in the breast
  10. 10. FibroadenomaTypes Natural historySolitaryFew (< 5 / breast ) Majority remain small & staticMultiple (> 5 / breast ) 50% involute spontaneouslyGiant (> 4 / 5 cms) & Juvenile No future risk of malignancy
  11. 11. 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
  12. 12. Treatment of Phyllodes tumours1. Primary treatmentLocal excision witha rim of normal tissue2. Recurrence Re excision orMastectomy with orwithout reconstruction Response tochemotherapy andradiotherapy forrecurrences andmetastases poor
  13. 13. CystsCommon in the West ( 70 % of women )  50% are solitary cysts  30% 2 - 5 cysts &  rest have > 5 cystsTypes 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
  14. 14. 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 teN 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 yN 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
  15. 15. 2. PainMastalgia• Cyclical mastalgia• Non cyclical mastalgia •True (breast related) • Musculoskeletal : costochondral or lateral chest wallInfections 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.
  16. 16. MastalgiaDefinition : Pain severe enough to interfere with daily life or lasting over 2weeks of menstrual cycle True breast pain breast pain True Lateral chest Costo wall pain Chondral pain mild Musculo skeletal pain
  17. 17. 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
  18. 18. Drugs of established value in mastalgiaD 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 tsE 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 ep 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 eG 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
  19. 19. 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
  20. 20. Nipple discharge Causes of nipple discharge Benign (common) Malignant (less common)Physiological causes In situ carcinoma (DCIS)Intraductal pailloma and associated Invasive carcinomaconditionsBlood stained nipple discharge ofpregnancyGalactorrhoeaPeriductal MastitisDuct Ectasia
  21. 21. Characterestics of nipple dischargesN 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 eE lic ite d S p o n ta n e o u sA 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 lIn te rm itte n t P e rs is te n tT h ic k W a te ryN o n tro u b le s o m e T ro u b le s o m eM u ltid u c ta l U n id u c ta lN 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 db lo o d )
  22. 22. 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 ryD 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
  23. 23. Galactorrhoea C a u s e s o f g a la c to rrh o e aPh 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 sE 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 sStre s s A n a e s th e s ia P itu ita ry tu m o rsM 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 aManagement : 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)
  24. 24. 4. Nipple changesCauses :1. Developmental inversion2. 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 nipple3. Rare problems : adenoma, papilloma etc
  25. 25. 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 lR 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

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