Aberration of normal development and involution (andi) of thebreast презентация

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

 Normal three phases of physiology of breast—
Lobular development;
Cyclical hormonal modifications;
Involution.

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.

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.

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.

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.

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.

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.

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.

Fibroadenoma Variants
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.

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.

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

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

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

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.

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

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%)

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

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

INVESTIGATIONS
ULTRASOUND
FNAC
CHEST XRAY

TREATMENT
Excision
Total Mastectomy If Malignant

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

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

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

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

FIBROCYSTADENOSIS

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

INVESTIGATIONS
FNAC- EPITHELIOSIS (PREMALIGNANT)
USG
MAMMOGRAPHY

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

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

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

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

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

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

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

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

MASTITIS
TYPES:
SUBAREOLAR MASTITIS- INFECTED GLAND OF MONTGOMERY
INTRAMAMMARY MASTITIS
-LACTATING ABSCESS
- NON LACTATING ABSCESS
RETROMAMMARY MASTITIS- TB OF INTERCOSTAL LYMPH NODES

MASTITIS

BREAST ABSCESS

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

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

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

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

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

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

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

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