This document describes aberrations in normal breast development and involution. It discusses various benign and malignant conditions that can occur, including lumps, pain, nipple discharge, galactorrhea, and nipple changes. Potential causes are endocrine disturbances, genetic factors, environmental exposures, and developmental anomalies. Conditions range from near-normal to severe disease. Management depends on the condition but may include reassurance, lifestyle changes, medications, or surgery. Differentiating benign from malignant conditions requires evaluation using a triple assessment approach.

1. ABERRATION IN NORMAL
DEVELOPMENT AND
INVOLUTION

2.  Developed and described by Cardiff
breast clinic in Wales
 Wide spectrum of clinicopathological
features ranging from near normality to
severe disease

3. 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

4. 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

5. 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

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. 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

8. DIFFUSE HYPERTROPHY
Occurs in otherwise
healthy girls
at puberty
 Alteration in the
normal sensitivity
of the breast to
estrogen
 Reduction
mammoplasty

9. 1. Lump
Discrete lump
 Fibroadenoma
 Giant fibroadenoma
Juvenile fibroadenoma
 Phyllodes tumours
 Cysts : macrocysts
Nodularity
 Generalised
 Localised
Age incidence of lumps in the breast

10. 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

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. 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

13. 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

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 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

15. 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.

16. Mastalgia
Definition : 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. 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. 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

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. 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

21. 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 )

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 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

23. 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)

24. 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

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 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