Pathogenesis:ANDI ( Aberration of Normal Development and Involution)Involutional cystic hyperplasia, Mammary dysplasia,Fibroadenosis, cysic disease of the breast"The commonest disease of the female breast"
Due to fluctuation of oestrogen level during reproductive period or menopause. The breast gland may undergo abnormal development or involution which give:
(1) Glandular hyperplasia: Increase number of acini with increase cells inside which form papillary projections inside the acini. ( adenosis, epitheliosis and papillomatosis). The acini appears as solid masses of cells.
(2) Connective tissue hyperplasia: fibrous tissues will replace many epithelial elements (Fibrosis).
(3) Cyst formation:
(A) Large cysts: due to obstruction by fibrosis with accumulation of secretions.
(B) Small cysts: due to abnormal involution of the ducts.
ÄSometimes; one or many large cysts are formed at the pre-menopausal period with atrophy of the lobules of the breast with accumulation of fluid inside it and referred as "Blue-domed cysts of Blood good".
(4) Lymphocytic infiltration: occurs early in the disease. Hence the old name chronic interstitial mastitis.
Relation of the disease with CA. breast:
Due to high incidence of CA. breast with the disease
- Some say that it is precancerous "on top of its hyperplasia".
- Others say that it is only coincidental lesion.
Ä Incidence:- Common in apprehensive & tense females.
1- 20 : 40 years of age.
2- Spinsters, nullipara & those who did not suckle her infants
1- Painful lump or lumps in the breast which normally bilateral.
- The pain becomes more just before menstruation.
2- Discharge per nipple
(1) The mass difficulty felt by flat of the hand but clearly felt by tip of the fingers.
(2) Brownish or black discharge "D.D. of bloody discharge of the nipple".
(3) Axillary lymph nodes may be enlarged, firm and tender.
Differential Diagnosis: From other causes of hard lump in the breast:
1- CA breast. 2- Ch. breast abscess.
3- Plasma cell mastitis. 4- Traumatic fat necrosis.
The differences from cancer are:
1- Usually bilateral and diffuse, but rarely localized (sector type).FibroadenosisCarcinoma
Usually unilateral and localized.
2- Difficult to feel it by flat of the hands.
Felt easily by both flat of the hand and tips of the fingers.
3- The masses are not attached to skin or pectoral fascia.
May be attached to both causing dimpling or puckering of the skin.
4- Nipple retraction, if present it is usually old not recent retraction.
It may cause recent nipple retraction
5- Axillary Lymph nodes if enlarged never to be hard.
Lymph nodes if enlarged are hard and may be fixed
I) Conservative treatment:
1- Reassurance : tell the patient that it's not pre-malignant .
2- Support of the breast by firm brassiere.
3-Analgesics to relieve pain.
4- Very rarely an antioestrogen is necessary to deprive the breast epithelium from oestrogenic drive.
5- Antiprolactin (parlodel) is given in cases with discharge per nipple in a dose of 2.5 mg twice daily for 3 months. Starting with small doses incrasing gradually can prevent nausea, headache, irritability and hypotension which may occur with parlodel therapy.
II) Surgical treatment:
1- Localized mass ® do Excision biopsy .
2- Multiple cysts involving most of the breast ® do subcutaneous mastectomy and replacement of breast tissue by synthetic prosthesis ® "Augmentation mammoplasty"
F N.B. Types of Mammoplasty:SOURCE: Prof. AYMAN SALEM'S BOOK
1- Excision mammoplasty as in gynaecomastia.
2- Reduction mammoplasty as in diffuse hypertrophy.
3- Augmentation mammoplasty as in "Fibroadenosis".
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