Benign Breast Disorders

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Pathophysiology

Summary

Benign breast disorders are diverse conditions that can be understood by appreciating the anatomy of the breast, which is mainly composed of epithelial and stromal aspects. The epithelial components includes the breast lobules, responsible for milk production, and lactiferous ducts, which channel milk to the nipple. The stromal component comprises fatty & fibrous connective tissue, making up most of the breast's volume when not lactating.

Mastitis is an inflammatory disorder affecting the breast ducts and is commonly associated with breastfeeding. It manifests as erythema and breast pain, most often initiated by nipple trauma during breastfeeding. A possible complication is the formation of a galactocele, a milk-filled cyst that can become infected, commonly by Staphylococcus aureus. Continued breastfeeding is recommended to alleviate ductal obstruction.

Mammary duct ectasia results from blocked lactiferous ducts laden with cellular debris. Clinical signs include breast pain and dilated ducts, along with a characteristic thick, greenish nipple discharge. Radiographic findings may show radio-opacities due to calcified secretions within the ducts.

Fat necrosis is typically caused by breast trauma, and presents as an irregular mass and breast pain. Like mammary duct ectasia, fat necrosis can also exhibit radiological opacities, often making it a differential diagnosis for breast cancer.

The most prevalent benign breast disorder in premenopausal women is fibrocystic change, which can be nonproliferative or proliferative.

Nonproliferative lesions include breast cysts, characterized by small, fluid-filled sacs scattered throughout the breast. Breast cysts are the most prevalent nonproliferative lesion, often manifesting as a lumpy breast texture due to fibrous stromal proliferation. Radiographically, these cysts may display regions of calcification, and manifest as ‘blue dome cysts’ on gross pathology.

Papillary apocrine change manifests as ductal epithelial cells that resemble apocrine glands. These cells are granular and can be associated with cyclic mastalgia in premenopausal women, particularly within the scope of non-proliferative fibrocystic change.

Proliferative lesions include epithelial hyperplasia, which features an increase in organized epithelial cells, leading to occlusion of the mammary ducts or lobules. When these cells undergo atypical changes—marked by disorganized architecture and dark purple nuclei—the condition escalates to atypical epithelial hyperplasia, which increases the risk of breast cancer.

Sclerosing adenosis is another proliferative lesion characterized by an overgrowth of glandular tissue in the lobules and accompanying fibrous tissue, or ‘sclerosis.’ Sclerosing adenosis also increases the risk of developing breast cancer.

Benign breast tumors include fibroadenomas, which are estrogen-responsive tumors that worsen in high estrogen states (pregnancy, lactation, pre-ovulation) and predominantly appear in young women. Fibroadenomas present as palpable masses that are well-defined, rubbery, and mobile. Histology shows proliferation in both the fibrous stroma and adenomatous ducts. In contrast, phyllodes tumors typically arise in women in their 40s and may display malignant behavior despite their benign classification.

Intraductal papillomas occur within lactiferous ducts, and are the leading cause of bloody nipple discharge. These growths can sometimes harbor cellular atypia or ductal carcinoma in situ, thereby heightening the risk for malignancy.

Lastly, Galactorrhea presents as bilateral milky nipple discharge unrelated to breastfeeding. It may arise either through mechanical factors or be precipitated by specific conditions like prolactinomas. Medications that inhibit dopamine receptors, particularly D2 dopamine receptor antagonists such as certain antipsychotics, can also cause galactorrhea.

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FAQs

What are the common symptoms of mastitis and how is it related to breastfeeding?

Mastitis is an inflammatory condition affecting the breast ducts, commonly presenting with erythema and breast pain. Some cases may feature purulent nipple discharge. It is most frequently associated with breastfeeding, specifically due to nipple trauma caused by the baby's latch. This trauma can lead to poor milk drainage and duct obstruction, resulting in lactational mastitis. Continuing to breastfeed is an essential part of treating lactational mastitis as it helps relieve the breast obstruction.

What are the clinical features and etiologies of mammary duct ectasia and fat necrosis?

Mammary duct ectasia is characterized by blocked lactiferous ducts filled with debris, leading to inflammation. Symptoms include breast pain and a thick, green nipple discharge. On mammograms, it may show radio-opacities due to calcified secretions. Fat necrosis, in contrast, is a benign condition involving the necrosis of breast adipose tissue, most commonly triggered by breast trauma. It manifests as breast pain and an irregular breast mass, and may also display radio-opacities on a mammogram due to calcification of the necrotic fat.

What are the characteristics of fibrocystic change?

Fibrocystic change is the most prevalent breast abnormality among premenopausal women. It can be either nonproliferative, featuring breast cysts and fibrous stromal proliferation that result in dense, lumpy breasts, or proliferative, involving conditions like atypical epithelial hyperplasia or sclerosing adenosis. These changes often cause cyclic mastalgia, or breast pain, in premenopausal women. On gross pathology, breast cysts may appear blue and can show radio-opacities on mammograms due to fluid calcification.

What are the similarities and differences between fibroadenomas and phyllodes tumors?

Fibroadenomas and phyllodes tumors are both benign fibroepithelial tumors of the breast. Fibroadenomas are more common in young women aged 15-35 and present as well-defined, rubbery, mobile, and painless masses. They are estrogen-responsive and result from the proliferation of both fibrous stroma and ducts. Phyllodes tumors, however, typically occur in women in their 40s and can grow quite large. While generally benign, they have the potential for malignant behavior. Both types of tumors are well-defined, painless, and mobile, but they differ in age distribution and malignant potential.

What is galactorrhea and what are its causes?

Galactorrhea is characterized by bilateral milky nipple discharge that is not related to breastfeeding. It can be triggered by various factors such as mechanical nipple stimulation, prolactinomas, or D2 dopamine receptor antagonists that inhibit dopamine’s inhibitory effect on the release of prolactin from the anterior pituitary, resulting in galactorrhea.