Lecture notes for UG MBBS

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6. Good for self study also.
7. See notes for bibliography.

2. ANDI
Aberrations in the Normal
Differentiation and Involution of
the breast
• AKA fibrocystic disease, fibroadenosis, chronic
mastitis and mastopathy

3. Learning Objectives
1.

4. Learning Objectives
1. Introduction & History
2. Relevant Anatomy, Physiology
3. Aetiology
4. Pathophysiology
5. Pathology
6. Classification
7. Clinical Features
8. Investigations
9. Management
10. Prevention
11. Guidelines
12. Take home messages

5. Relevant Physiology
•

6. Physiology
The female breast passes through 5phases
during lifetime
1. Prepubertal
2. Post pubertal
3. Pregnancy
4. Lactational
5. Menopausal
• Superimposed on this is changes during
menstrual cycle.

7. Physiology
• The resting (non-lactating) breast, consists
mostly of fibrous & fatty tissue
• During phases of the menstrual cycle the
breast epithelium and lobular stroma
undergo cyclic stimulation.
• Dominant process is hypertrophy and
alteration of morphology rather than
hyperplasia.

8. Physiology
• With pregnancy, there is diminution of the
fibrous stroma to accommodate the
hyperplasia of the lobular units.
• Growth is influenced by high circulating
levels of estrogen and progesterone and
prolactin .

9. Physiology
• After childbirth, there is a sudden loss of the
placental hormones.
• A continued high level of prolactin is the
principal trigger for lactation.
• The actual expulsion of milk is under
hormonal control and is caused by the
contraction of the myoepithelial cells by
hormone Oxytocin.
• Stimulation of the nipple is the physiologic
signal for both the continued pituitary
secretion of prolactin and for the acute
release of oxytocin.

10. Physiology
• When breast-feeding ceases, there is a fall
in prolactin and no stimulus for release of
oxytocin. The breast then returns to a
resting state and to the cyclic changes
induced when menstruation begins again.

11. Physiology
• After menopause progressive atrophy of
lobes & ducts takes place – Involution-
• Increased fat deposition
• Diminished connective tissue
• Disappearance of lobular units.

12. Classification

13. ANDI Classification of Benign Breast
Disorders
Normal Disorder Disease
Early reproductive
years (age 15–25)
Lobular development Fibroadenoma Giant fibroadenoma
Stromal development Adolescent hypertrophy Phyllodes tumor
Nipple eversion Nipple inversion Subareolar abscess
Mammary duct fistula
Later reproductive
years (age 25–40)
Cyclical changes of
menstruation
Cyclical mastalgia Incapacitating mastalgia
Nodularity
Epithelial hyperplasia of
pregnancy
Bloody nipple discharge
Involution (age 35–55) Lobular involution Macrocysts
Sclerosing lesions
Duct involution
–Dilatation Duct ectasia Periductal mastitis
–Sclerosis Nipple retraction
Epithelial turnover Epithelial hyperplasia Epithelial hyperplasia with atypia

14. Aetiology
• Idiopathic
• Congenital/ Genetic
• Nutritional Deficiency/excess
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative / lifestyle
• Iatrogenic
• Psychosomatic
• Poisoning/ Toxins/ Drug induced

15. Idiopathic
• Mondor’s disease
• Duct ectasia/periductal mastitis
• ANDI
• Breast cysts
• Galactocele
• Fibroadenoma
• Phyllodes tumour

16. Congenital
Nipple
• Nipple retraction
• Cracked nipple
• Papilloma of the nipple
• Retention cyst of a gland of Montgomery
• Eczema
• Discharges from the nipple

17. Congenital
Breast
• Amazia
• Polymazia
• Mastitis of infants
• Diffuse hypertrophy

18. Traumatic
• Haematoma
• Traumatic fat necrosis

19. Infections
• Bacterial mastitis and Abscess.
• Chronic intramammary abscess
• Tuberculosis of the breast
• Actinomycosis

20. Clinical Features
•

21. Clinical Features
• Pain
• Lump
• Nipple discharge

22. ANDI :Pathology
• Four features that may vary in extent and degree
in any one breast.
1. Cyst formation.
2. Fibrosis. Fat and elastic tissues disappear and are
replaced with dense white fibrous trabeculae. The
interstitial tissue is infiltrated with chronic
inflammatory cells.
3. Hyperplasia of epithelium in the lining of the
ducts and acini with or without atypia.
4. Papillomatosis. The epithelial hyperplasia may
be soextensive that it results in papillomatous
overgrowth within the ducts

23. Triple Assesment
• Clinical Assessment
• Imaging Studies
• FNAC/ True cut

24. Fibroadenoma
•

25. Fibroadenoma
• Second most common tumor of breast
• ANDI
• Represent a hyperplastic or proliferative process in a single
lobule
• Etiology is unknown, thought to be due to hormonal
influence
• Between the ages of 15-25 years & size of 2-3cm
• Painless lump- capsulated,smooth, firm, well defined,
nontender, BREAST MOUSE
• Microscope-
intracanalicular pericanalicular

26. Fibroadenoma
• Develops from single lobule.
• Well-encapsulated masses that may easily detach from the
surrounding breast tissue.
• Histologically, a variable proportion of epithelial and stromal
proliferation is present, and the stroma may be quite cellular
or replaced by acellular swirls of collagen.

27. Juvenile Fibroadenoma and Giant
Fibroadenoma
• Unusually large size, typically greater than 5 cm
• Juvenile fibroadenoma occasional large fibroadenoma that
occurs in adolescents and young adults and histologically is
more cellular than the usual fibroadenoma.
• The differential diagnosis for a cellular juvenile
fibroadenoma is benign phyllodes tumor

28. Fibroadenoma
• Treatment-conservative
• Surgery -
– Very large/increasing in size
– Suspicious cytology
– Surgery is desired.
– Enucleation

29. Fibroadenoma
• Alternatives to surgery -
1. Cryoablation
2. Heating with high-frequency ultrasound
(echotherapy)
3. Removal with a large core vacuum biopsy
system.

30. PHYLLODES TUMOUR
•

31. PHYLLODES TUMOUR
• Proliferation of intralobular stroma
• Fusiform fibroblast
• 3 types:-
benign
borderline
malignant
(cellularity,atypia,mitoses &invasion by
edges)

32. Management
Wide local excision
Benign
Borderline - Follow up
Malignant -SIMPLE MASTECTOMY

33. Traumatic Fat Necrosis
• Clinical features - Pain & lump in the breast
• Lump is hard - extensive fibrosis caused by
tissue reaction
• D.D : Carcinoma breast
• Mammography findings - density lesion;
can have calcifications; may mimic
carcinoma breast
• Treatment - excision of the lump

34. Breast cyst
 Age group – 30-50
• Multiple and bilateral
• Can mimic malignancy
• Confirmed by USG and
aspiration

35. Breast cyst
 Aspirate
 Excision biopsy if-
Bloody aspiration
Residual mass
Suspicious cytology
Recurs

36. MASTALGIA
•

37. MASTALGIA
• Menstruating age group
• Hormone related-ANDI
• Dull diffuse bilateral
• Upper outer quadrant

38. Mastalgia: Introduction
• Breast pain is common and a symptom that
brings a woman to her physician. Usually it
is of functional origin and uncommonly is it
a symptom of breast cancer.
• Most patients with pain do not have breast
cancer.

39. Types
• Cyclical mastalgia.
• Noncyclical mastalgia.

40. Cyclical mastalgia
• Normal ovarian hormonal influences on breast
glandular elements frequently produce cyclical
mastalgia.
• It is most common in women in their mid-30s
• Pain is dull, diffuse
• Bilaterally symmetrical in the upper outer
quadrants.
• It is predominantly experienced in the luteal phase
of the menstrual cycle and abates
with menstruation.

41. MASTALGIA
• Menstruating age group
• Hormone related-ANDI
• Dull diffuse bilateral
• Upper outer quadrant

42. Noncyclical mastalgia
1.Non breast etiology specific significant
breast condition
• Cervical radiculopathy,
• Costochondritis,
• Intercostal muscle strain.
• Gastroesophageal reflux disorder,
• symptomatic gallstones,
• Cardiovascular disease,
• Pulmonary pathology

43. Noncyclical mastalgia
2.Specific breast conditions:
• Breast cyst
• Breast cellulitis (mastitis) .
• Inflammatory breast cancer,
• Ca. Breast

44. Investigations
• Laboratory Studies
– Routine
– Special
• Imaging Studies
• Tissue diagnosis
– Cytology
• FNAC
– Histlogy

45. Diagnostic Studies
Imaging Studies
• X-Ray: Mammography
• USG
• CT
• Angiography
• MRI
• Endoscopy
• Nuclear scan

46. MASTALGIA:MANAGEMENT
• 1.Pain diary
• 2.Reassurance
• 3.Exclude caffeine
• 4.Low fat diet
• 5.Stop OCPs/HRT
• 6.stop smoking
• 7.drugs

47. MASTALGIA:Drugs
• Analgesics
• Evening prim rose oil
• Goserelin
• Prolactin inhibitor Bromocriptine,
• Antigonadotrophin Danazol
• Antioestrogen Tamoxifen

48. Duct Papilloma
•

49. Duct Papilloma
• Proliferative breast disease without atypia
• Polyps of epithelium lined duct
• Bloody discharge
• Microdochectomy

50. Duct ectasia
• Dilatation of the breast ducts associated
with chronic inflammatory response in the
periductal tissue
• Greenish discharge
• Duct excision

51. Breast Abscess /Mastitis
• Flucloxacillin or co-amoxiclav
• Support of the breast,local heat,&
analgesics
• Incision & drainage
• Now recommended is repeated aspiration
under antibiotics
• Continue breast feeding.

52. MONDOR’S DISEASE
• Thromboplebitis of superficial veins of the breast
& chest wall
• Aetiology not known
• C/F – thrombosed subcutaneous cord
• DD – breast cancer
• Treatment – anti-inflammatory medication
warm compresses & support
restriction of movement
symptoms persist - excision

53. Virginal Hypertrophy
• Huge enlargement.
• Reduction mastoplasty
• Mastectomy

54. Guidelines
• https://www.acog.org/clinical/clinical-
guidance/practice-
bulletin/articles/2016/06/diagnosis-and-
management-of-benign-breast-disorders

55. Bibliography
• https://www.ncbi.nlm.nih.gov/books/NBK2
78994/

56. MCQs
Which of the following is not a treatment
for Phyllodes tumor?—karnataka 2007
A. Quadrantectomy
B. Enucleation
C. Wide local excision
D. Simple mastectomy

57. MCQs
Which of the following is not a treatment
for Phyllodes tumor?—karnataka 2007
A. Quadrantectomy
B. Enucleation
C. Wide local excision
D. Simple mastectomy

58. MCQs
Acute mastitis commonly occurs during?
(DNB 2000)
(A) Pregnancy
(C) Lactation
(B) Puberty
(D) Infancy

59. MCQs
Acute mastitis commonly occurs during?
(DNB 2000)
(A) Pregnancy
(C) Lactation
(B) Puberty
(D) Infancy

60. MCQs
• Surgery for periductal mastitis - ,(MAHE
07)
A. Hadfield's operation
B. Patey's mastectomy
C. Modified radical mastectomy
D. None of the above

61. MCQs
• Surgery for periductal mastitis - ,(MAHE
07)
A. Hadfield's operation
B. Patey's mastectomy
C. Modified radical mastectomy
D. None of the above

62. MCQs
• Bacteria mastitis is most often caused by -
(a) Anaerobic bacteria
(b) Staphylococcus
(c) Streptococcus
(d) Pneumococcus

63. MCQs
• Bacteria mastitis is most often caused by -
(a) Anaerobic bacteria
(b) Staphylococcus
(c) Streptococcus
(d) Pneumococcus

64. MCQs
• Following are true of pubertal mastitis
except -
– (a) Suppurates frequently
– (b) Usually unilateral
– (c) Subsides spontaneously
– (d) Common in males

65. MCQs
• Following are true of pubertal mastitis
except -
– (a) Suppurates frequently
– (b) Usually unilateral
– (c) Subsides spontaneously
– (d) Common in males

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