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Benign Diseases Of Breast

Most benign lesions of breast are aberrations of normal processes.
  1. Functional disorders:
    1. Galactorrhea.
    2. Mastodiniya. Breast pain (mastalgia):
      Cyclical (2/3rd) or Non cyclical - can be of of Chest wall etiology such as arthritis and muscle overuse.
      Mastalgia is treated by Caffeine abstinence, vitamin E, Oil of evening primrose and Danazol.
      Tietze’s disease is costochondritis of 2nd costochondral junction.
  2. Regressive changes:
    1. Dystrophy (transformation of breast tissue to fat, mucine or calcified formation)
    2. Fat necrosis (focal necrosis of fat tissues in the breast)        
      It is associated with trauma or surgical intervention.
      Fat necrosis may mimic carcinoma with a mass or skin retraction.
      Histologically fat necrosis is characterized by irregular empty spaces, which are lined by foamy histiocytes.
  3. Inflammatory changes:
    1. Intertrigo (eczema of the submammal sulkus).
    2. Mastitis
  1. Dysplasia : Fibrocystic disease of the breast Q.
    This is the most common breast alteration characterized by fibrosis or epithelial hyperplasia and the formation of cysts mainly due to hormonal effects (estrogen, progesterone, prolactin).
    1. Here, histologic pattern in each case is different like cystic lesions, focal fibrosis or ductal and lobular epithelial hyperplasia.
    2. The epithelial cells proliferate in the ducts (ductal hyperplasia) and lobules (adenosis) with increased estrogenic stimulation and with decreased estrogen levels, the epithelium involutes, the ducts become cystic, and the lobules(sclerosing adenosis) and stroma increase fibrous tissue (stromal fibrosis)
    3. Fibrocystic change can cause
    4. Ducts: ductal hyperplasia and cyst formation
    5. Lobules: adenosis (lobular hyperplasia) and sclerosing adenosis
    6. Stroma: fibrosis
    7. Cysts are fluid-filled spaces from the terminal ductal lobular unit or from an obstructed duct.
    8. Gross cyst in fibrocystic breast disease in women in 40's overlaps carcinoma age incidence therefore needle aspiration or ultrasound should be done for diagnosis. In FNAC if the lump disappears/ fluid obtained is non bloody/ Re-examination 6 weeks later shows no mass it is considered a successful cyst aspiration. If these criteria are not met then excisional biopsy should be done.
    9. Micro cysts in fibrocystic disease in young women, are usually diffuse and disappears after menopause.  
  2. Epithelial Hyperplasia With and Without Atypia Q
    1. In ductal hyperplasia, both epithelial and myoepithelial cells undergo hyperplasia
    2. The morphologic features of ductal hyperplasia are increased cellularity and altered architectures, most commonly with papillary formation, cribriform or solid form.
    3. In the presence of architectural and nuclear atypicality, the ductal hyperplasia is designated as atypical ductal or lobular hyperplasia.
    4. Atypical hyperplasia is charecterizec by marked proliferation and atypia of the epithelium (monoclonal neoplastic proliferation), either ductal or lobular (3% of all biopsy). Associated with 4 fold risk of cancer
    5. Radial sclerosing lesion, Q also known as radial scar is a benign stellate lesion having a central fibrous core with contracted ducts and mimicking cancer.
    6. “Dupont and Page” classification of epithelial proliferations; with and without atypia.
 Proliferative Lesions and their Relative Risks for Developing Invasive Breast Cancer*
Nonproliferative changes: 70%  of cases
Relative Risk = 1.0
Cysts and apocrine change
Ductal ectasia
Mild epithelial hyperplasia of usual type
Proliferative disease without atypia: 26% of cases
Relative Risk = 1.5-2.0
Hyperplasia of usual type, moderate or florid
Sclerosing adenosis
Proliferative disease with atypia: 4% of cases
Relative Risk = 4-5
Atypical ductal hyperplasia
Atypical lobular hyperplasia
  1. Mammary duct ectasia (periductal mastitis)
    1. Duct ectasia is a dilatation of the major subareolar ducts and rarely smaller ducts not associated with fibrocystic change.
    2. It can present with pain in nonlactational breast and periareolar abscess formation usually involving one duct system. In chronic form it presents with nipple discharge.
    3. Microscopically, the dilated ducts contain foamy macrophages mixed with lipid material, cholesterol   clefts and eosinophilic debris. Q
    4. Infiltration of lymphocytes, plasma cells, and histiocytes occurs in the periductal tissue showing fibrosis with chronicity (Thus called plasma cell mastitis, obliterative mastitis and comedomastitis). Histologically, there is hyperplasia of duct epithelium surrounded by plasma cell infiltrate.
    5. The most common benign disorder is fibrocystic change (affecting 40–50% women).
  2. Gynecomastia
    1. Gynecomastia refers to an enlarged breast in the male.
    2. Physiologic gynecomastia usually occurs during three phases of life: the neonatal period, adolescence, and senescence.
    3. Common to each of these phases is an excess of circulating estrogens in relation to circulating testosterone.
    4. In gynecomastia, the ductal structures of the male breast enlarge, elongate, and branch with a concomitant increase in epithelium.
Pathophysiologic Mechanisms of Gynecomastia
  1. Estrogen excess states
    1. Gonadal origin
      1. True hermaphroditism
      2. Gonadal stromal (nongerminal) neoplasms of the testis
        • Leydig cell (interstitial)    
        • Sertoli cell       
        • Granulosa-theca cell
      3. Germ cell tumors
        • Choriocarcinoma      
        • Seminoma, teratoma               
        • Embryonal carcinoma
    2. Nontesticular tumors
      1. Adrenal cortical neoplasms
      2. Lung carcinoma
      3. Hepatocellular carcinoma
    3. Endocrine disorders
    4. Diseases of the liver—nonalcoholic and alcoholic cirrhosis
    5. Nutrition alteration states
  2. Androgen deficiency states
    1. Senescence
    2. Hypoandrogenic states (hypogonadism)
      1. Primary testicular failure
        • Klinefelter's syndrome (XXY)
        • Reifenstein's   
        • syndrome
        • Rosewater-Gwinup-Hamwi familial gynecomastia
        • Kallmann syndrome
        • Kennedy's disease with associated gynecomastia
        • Eunuchoidal state (congenital anorchia)
        • Hereditary defects of androgen biosynthesis
        • Adrenocorticotropic hormone deficiency
      2. Secondary testicular failure
        • Trauma   
        • Orchitis    
        • Cryptorchidism
        • Irradiation
    3. Renal failure
  3. Drug effects
  4. Systemic diseases with idiopathic mechanisms

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