Porth's Essentials of Pathophysiology, 4e

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Disorders of the Female Genitourinary System

C h a p t e r 4 0

advisable for the mother to continue breast-feeding dur- ing antibiotic therapy to prevent this. Mastitis is not confined to the postpartum period; it can occur as a result of hormonal fluctuations, tumors, trauma, or skin infection. Cyclic inflammation of the breast occurs most frequently in adolescents, who com- monly have fluctuating hormone levels. Tumors may cause mastitis secondary to skin involvement or lymphatic obstruction. Local trauma or infection may develop into mastitis because of ductal blockage of trapped blood, cel- lular debris, or the extension of superficial inflammation. The treatment for mastitis symptoms may include applica- tion of heat or cold, excision, aspiration, mild analgesics, antibiotics, and a supportive brassiere or breast binder. Mammary Duct Ectasia. Mammary duct ectasia refers to the presence of dilated breast ducts containing a thick pasty material, with accompanying periductal inflam- mation and fibrosis. 57 The dilated ducts may rupture, resulting in grayish-green nipple discharge. Palpation of the breast increases the discharge. The disorder is usually unilateral, occurring after menopause, most often in elderly multiparous women. Women typically present with a poorly defined perialveolar mass that is often associated with thick, white nipple secretions and sometimes with nipple retraction. Pain and erythema are uncommon. Duct ectasia may be difficult to distinguish clinically from carcinoma and may require biopsy. Fat Necrosis. Fat necrosis is a distinct clinical and histo- logic entity, resulting in either a localized or diffuse mass lesion of the breast. The majority of women have a his- tory of trauma, surgery, or radiation therapy. 57,58 Initially the lesion consists of necrotic adipocytes and hemor- rhage, after which the inflammatory cells phagocytize the lipid debris. Macrophages may produce a granulo- matous inflammatory response. Fibroblast proliferation and collagen deposition during healing may lead to scar tissue (fibrosis). As a result, an irregular fixed hard mass may form that clinically resembles breast cancer. Unlike a malignant mass, however, fat necrosis is typically very tender and has a specific mammographic appearance. Benign Epithelial Disorders A wide variety of benign alterations in ducts and lob- ules are observed in the breast. Most are detected by mammography or as incidental findings on surgical specimens. These lesions have been divided into three groups according to the subsequent risk of developing carcinoma: nonproliferative (fibrocystic) changes, pro- liferative breast disease without atypia, and proliferative breast disease with atypia. 57 Nonproliferative (Fibrocystic) Breast Changes. Formerly called fibrocystic disease , fibrocystic changes are the most frequent lesions of the breast. They encom- pass a wide variety of lesions and breast changes. Microscopically, fibrocystic changes refer to a constel- lation of morphologic changes manifested by (1) cystic dilation of terminal ducts, (2) relative increase in fibrous tissue, and (3) variable proliferation of terminal duct

epithelial elements. 57 They are most common in women 30 to 50 years of age and are rare in postmenopausal women not receiving hormone therapy. 56,57 Fibrocystic changes usually present as nodular (i.e., “shotty”), granular breast masses that are more promi- nent and painful during the luteal or progesterone-dom- inant portion of the menstrual cycle. Discomfort ranges from heaviness to exquisite tenderness, depending on the degree of vascular engorgement and cystic distention. Although fibrocystic changes have been thought to increase the risk of breast cancer, only certain variants in which proliferation of the epithelial components is demonstrated represent a true risk. Fibrocystic changes with giant cysts and proliferative epithelial lesions with atypia are more common in women who are at increased risk for development of breast cancer. The nonproliferative form of fibrocystic changes that does not carry an increased risk for development of cancer is more common. Diagnosis of fibrocystic changes is made by physi- cal examination, mammography, ultrasonography, and biopsy (i.e., aspiration or tissue sample). Mammography may be helpful in establishing the diagnosis, but increased breast tissue density in women with fibrocystic changes may make an abnormal or cancerous mass difficult to discern among the other structures. Ultrasonography is useful in differentiating a cystic from a solid mass. Because a mass caused by fibrocystic changes may be indistinguishable from carcinoma on the basis of clini- cal findings, suspect lesions should undergo biopsy. Any discrete mass or lump on the breast should be viewed as possible carcinoma, and cancer should be excluded before instituting the conservative measures used to treat fibrocystic changes. Treatment for fibrocystic changes is usually symp- tomatic. Mild analgesics (e.g., aspirin, acetaminophen, or NSAIDs), vitamin E, and local application of heat or cold may be used for pain relief. Prominent or persistent cysts may be aspirated and any fluid obtained sent to the laboratory for cytologic analysis. Women should be encouraged to wear a good supporting brassiere, and are advised to avoid foods that contain xanthines (e.g., coffee, cola, chocolate, and tea) in their daily diets, par- ticularly premenstrually. Proliferative Lesions without Atypia. Proliferative lesions without atypia, which are commonly detected as mammographic densities or calcifications, include epi- thelial hyperplasia, sclerosing adenosis, and intraductal papillomas. 57 These lesions are characterized by prolif- eration of ductile or lobular epithelial cells and/or are stromal without the cytologic or structural changes sug- gestive of carcinoma in situ. If there is increased fibro- sis within the lobule with distortion and compression of the epithelium, the lesion is termed sclerosing adenosis . Papillomas are intraductal growths composed of multiple fibrovascular cores, each having a connective tissue axis lined with epithelial cells. 57 Solitary intraductal papillo- mas are found in the major lactiferous ducts of women, typically between the ages of 30 and 50 years. The papil- lomas, which can range in size from 2 mm to 5 cm, often present with serous or serosanguineous drainage.