Download THE BREAST DURING PUBERTY, PREGNANCY AND LACTATION

THE BREAST DURING
PUBERTY, PREGNANCY AND
LACTATION
Dr. Varda Stahl-Kent
DEPARTMENT OF RADIOLOGY AND THE
M. FANNY BREAST CARE INSTITUTE
ASSAF HAROFE MEDICAL CENTER
EMBRIOLOGY OF THE BREAST
At about the sixth week of embrionic life, breast
precursor develops from ectodermal origin.
The “milk line” extends from the axillary area to
the groin region.
Portions of the milk line atrophy except in the
region of the fourth intercostal space, from which
mammary tissue develops.
When portions of the milk line do not regress,
there is accessory breast tissue or accessory
nipple.
CHANGES IN THE BREAST DURING
CHILDHOOD
Branching of main ducts –terminal buds –
TDLU’s
Proliferation and enlargement of adipose
cells
Increasing of stroma and blood vessels
ULTRASOUND APPEARANCE OF THE
BREAST DURING CHILDHOOD
BREAST DEVELOPMENT DURING
PUBERTY
Estrogen responsible for ductal development.
Progesterone responsible for lobulo-alveolar
development.
Breast bud appearance – telarche – mean age
9.8 years.
Premature breast development – before age 8.
Delayed breast development – after 13.
Asymmetric breast development not uncommon,
not to be mistaken for a mass.
TANNER PHASES OF PUBERTAL
BREAST DEVELOPEMENT
1 – nipple elevation
2 – nipple and breast projection from chest
wall, palpable tissue in subareolar region
3 - increased glandular tissue and areolar
size
4 - development of nipple-areolar complex
5 - final adolescent development with
smooth breast contour
THE BREAST IN ADOLESCENCE
ASYMMETRICAL DEVELOPMENT IN A 13YEAR-OLD GIRL
DEVELOPMENTAL ANOMALIES
Polymastia
– aberrant breast – ectopic breast tissue with
no nipple or areola, usually close to the
normal breast (axilla, infraclavicular region
etc). Cancer and fibroadenoma may occur.
– Supernumerary breasts – have nipple, areola
or both, with or without breast tissue.
Anywhere from the axilla to the groin, but may
occur in many other areas.
ACCESSORY BREAST TISSUE
SEPARATED FROM THE MAIN BUD
ASYMMETRICAL DEVELOPMENT
Poland’s syndrome –
– Agenesis of pectoralis muscle and breast
tissue on one side.
Asymmetrical development of breast
tissue only.
POLAND’S SYNDROME
MASSES IN THE PEDIATRIC AND
ADOLESCENT PATIENT
Mostly benign etiology:
–
–
–
–
–
–
–
–
–
Gynecomastia
Cyst
Fibroadenoma
Phyllodes tumor (rare – only up to 10% under 20y)
Lymph node
Galactocele
Duct ectasia
Juvenile Papillomatosis
Infection
Only 0.2% of primary breast cancers occur in
this age group.
GYNECOMASTIA
Neonatal period.
Adolescence (peak at 13-14 years). Common,
frequently resolves within 2 years.
Elderly men.
Pathologic processes: renal or liver diseases, testicular
or adrenal tumors, hyperthyroidism
Medications: estrogen, psychoactive drugs,
cardiovascular drugs, diuretics, chemotherapy, drugs of
abuse
Ultrasound demonstrates hypoechogenic breast tissue in
subareolar region.
GYNECOMASTIA OF PUBERTY
Common etiology: transient imbalance between
estrogen and androgen.
– By the end of puberty, estrogen increases X3 and
testosterone X30
– the ratio estrogen : testosterone may be greater than
normal for a certain period
Breast tissue of affected individuals may be
more sensitive to estrogen.
Kleinfelter synd. (47 xxy)
Significant association with varicocele in the
ages 12-14
BILATERAL, ASYMMETRICAL
GYNECOMASTIA
ASSYMETRICAL GYNECOMASTIA
CYST
Most common in the ages 30-50, but may occur
in any age group.
Cysts are common - about 20% of the masses
in the young age group
Caused by dilation of the lobular acini – either
from obstruction of ducts or from imbalance of
production and absorption.
On ultrasound: anechoic, smooth wall, through
transmission (backwall enhancement).
FIBROADENOMA
The most common mass excised in the pediatric and
adolescent age group (50-75%)
Sometimes very large ( “giant fibroadenoma” if larger
than 8 cm).
Contains normal epithelial (mostly ductal ) and stromal
elements
Stimulated by hormonal changes
Commonly regresses around the age of 40
Does not have a malignant potential
On ultrasound: homogeneous, surrounded by a thin
pseudocapsule, few large lobulations or none, may have
backwall enhancement, usually a single vessel.
18 Y-O, FIBROADENOMA
TUBULAR ADENOMA
An uncommon benign mass with a
dominant uniform tubular element and
sparse stroma, hence “true” adenoma
Occurs mostly in young, non-pregnant
women. Unrelated to contraceptives.
On ultrasound – resembles fibroadenoma
In older patients – may contain
microcalcifications seen on mammography
and ultrasound.
14 Y-O,TUBULAR ADENOMA
JUVENILE PAPILLOMATOSIS
Approximately 50% by age 20
Solitary mass clinically resembling FA
Pathology: multiple cysts separated by
firm fibrous septae, may be filled with
secretions
Complete excision recommended – 1015% risk of Ca.
JUVENILE PAPILLOMATOSIS
INFECTION
Most common organisms –
staphylococcus and streptococcus.
Diabetic patients or patients under steroids
– more prone.
MALIGNANCY IN THE BREAST DURING
PUBERTY
Primary breast cancer exceedingly rare
– previous irradiation a predisposing factor
Metastases – from Rhabdomyosarcoma,
Non-Hodjkin lymphoma, leukemia,
malignant melanoma
Metastases may present as round, regular
masses.
NON-HODJKIN LYMPHOMA NODULES IN
THE BREAST
CHANGES OF THE BREAST DURING
PREGNANCY
Early in the first trimester:
– Proliferating glandular epithelium causes branching of
the ducts.
– Amount of fat and connective tissue decreases.
Second trimester:
– Alveolar epithelium differentiates into a secretory
epithelium.
– Arborization of the alveoli causes enlargement of the
breast.
– Colloid accumulates in the alveoli
CHANGES OF THE BREAST DURING
PREGNANCY
Third trimester:
– Differentiation of the of the milk-producing
cells and synthesis of milk.
– In the last days before delivery - increase of
blood flow in the breast and filling of the
alveoli and ducts with colostrum
THE BREAST IN THE LAST TRIMESTER
CHANGES OF THE BREAST DURING AND
AFTER LACTATION
Immediate post partum enlargement due to
colostrum accumulation
Milk secreted into alveoli 3 – 7 days post partum
Breastfeeding stimulates further release of
prolactin
Post lactational changes
– Periductal and perivascular stromal tissue increases
– Alveolar cells and ductal branches regress
THE BREAST DURING LACTATION IMAGING
Diffuse increase in density on
mammography - typical
May have little or no change in density
Mild increase in parenchymal echogenicity
on ultrasound.
Post lactational benign calcifications
reported.
LACTATING BREAST
NORMAL LACTATING BREAST
DUCT CONTAINING MILK
INDICATIONS FOR IMAGING OF THE
PREGNANT OR LACTATING PATIENT
Palpable lump
Persistence of inflammatory process
Suspected breast abscess
Persistent bloody nipple discharge
Pagetoid changes of the nipple
Axillary adenopathy
SCREENING OF THE ASYMPTOMATIC
PREGNANT PATIENT IS NOT INDICATED
INFLUENCE OF PREGNANCY AND
LACTATION ON BREAST EVALUATION
Clinical examination extremely difficult.
Breast masses may be masked or
believed to resolve as the breast enlarges.
Malignant masses may incorrectly be
attributed to benign processes.
PATHOLOGICAL CONDITIONS IN THE
BREAST DURING PREGNANCY AND
LACTATION
Infection
– Mastitis
– Abscess
Benign tumors – related to P & L
– Lactating adenoma
– Galactocele
Other benign tumors, not necessarily related to P&L
– Fibroadenoma
– Hamartoma
-Phyllodes tumor
-Lipoma
- Papilloma
Malignant tumors
– Primary
-
Secondary
BREAST IMAGING METHODS DURING
PREGNANCY AND LACTATION
Ultrasound examination directed at the region of
interest
If lesion still suspicious or malignancy is proven
– mammography , with limiting the number of
exposures. Dose to fetus 0.4 mrad (10 rad or
greater shown to cause malformations)
DENSITY OF THE BREAST INCREASES DURING
PREGNANCY AND EVEN MORE DURING LACTATION.
RETURN OF THE DENSITY TO THE PRE-PREGNANT
STATE OCCURS 1 – 5 MONTHS POST LACTATION.
INFECTIONS DURING PREGNANCY AND
LACTATION
More common during lactation.
Causative organisms are staphylococcus
aureus or streptococcus, from the infant’s
nose or throat.
Usually resolve with antibiotics – penicillin
An abscess should be drained, preferably
under US guidance.
MASTITIS
Erythema, pain and induration
Usually no need for imaging
– Imaging performed if there is no response to
antibiotics, or if an abscess is suspected
clinically.
Fluid and edema seen among tissue
planes, thickened skin.
NORMAL RT. BREAST
MASTITIS LT.BREAST
BREAST ABSCESS
Round or oval mass , may be irregular
Through sound transmission
Thick walls
Fluid/debris level
Occasional air in cavity with bright reflections
Increased vascularity in the periphery of the
lesion
Management is by aspiration and antibiotics.
ABSCESS AFTER DELIVERY
AIR IN AN ABSCESS
GALACTOCELE - DEFINITIONS
A milk-containing cyst that results from occlusion
of a lactiferous duct and is lined by flattened
cuboidal epithelium
Retention of milk-like fluid (fatty material) in
areas of cystic duct dilatation appearing usually
during or shortly after lactation
– SOME GALACTOCELES HAVE BEEN REPORTED
WITH NO HISTORY OF LACTATION AND EVEN
PREGNANCY, PROBABLY DUE TO DUCTAL
OBSTRUCTION OF ANOTHER ETIOLOGY.
GALACTOCELE – CLINICAL
CONSIDERATIONS
Palpable, firm, mobile mass in pregnant,
lactating or early post lactational patient.
May be seen up to several years post lactation
May be seen in chronic galactorrhea, in patients
receiving prolactin stimulating agents or in
pituitary adenoma
May occur after breast augmentation
Rarely reported in postmenopausal women, in
males and in infants
GALACTOCELE – IMAGING FINDINGS
Well-circumscribed mass
Echogenicity depends on the amount of fat
and protein within the milk
Frequently subareolar but may be
anywhere in the breast
Solitary, multiple, unilateral or bilateral
Average size 2 cm, may exceed 5 cm.
GALACTOCELE -MAMMOGRAPHIC
FINDINGS
-Mammograhy performed only if
appearance on ultrasound is suspicious.
-Circumscribed mass of variable density.
-Fat-fluid level on lateral film, fluid-calcium
level, peripheral curvilinear calcifications.
-Often obscured by surrounding dense
tissue.
GALACTOCELE – CYSTIC, WITH SEPTATIONS
AND THICK FLUID CONTENTS
COMPLEX-CYST APPEARANCE
25 CC OF MILK WERE DRAINED
FAT FLUID LEVEL
FAT - FLUID LEVEL WITH SHADOWING
FAT-FLUID LEVEL WITH A CLOT OF MILK
MOVING OF THE FAT-FLUID LEVEL
GALACTOCELE CONTAINING FAT ONLY
(LIPOMA TYPE)
PSEUDOHAMARTOMA LIKE
GALACTOCELE
GALACTOCELE WITH PERIPHERAL
CALCIFICATIONS
INFECTED GALACTOCELEA COMPLEX CYSTIC MASS
RESOLUTION OF A GALACTOCELE
INCOMPLETE RESOLUTION OF A
GALACTOCELE
GALACTOCELE MIMICKING A TUMOR
GALACTOCELE – MANAGEMENT
Usually spontaneous resolution
No need for treatment unless suspicious
or unless symptomatic relief needed.
Aspiration under ultrasound guidance
After core biopsy fistulae may occur.
ASPIRATED GALACTOCELE CONTENTS
LACTATING ADENOMA – KEY FACTS
The most common breast mass in a young
pregnant patient.
Well-differentiated benign tumor .
Clinically soft , mobile, palpable mass.
Spontaneous regression after completion of
breastfeeding.
Presentation may be delayed – up to 10 months
after cessation of nursing.
5% undergo infarction and become painful
No malignant potential.
LACTATING ADENOMA – PROPOSED
ORIGINS
De novo in hormonally stimulated breast
Arises from pre-existing fibroadenoma,
tubular adenoma or lobular hyperplasia
Premature lactational changes, out of
phase with surrounding breast tissue.
LACTATING ADENOMA – IMAGING - 1
Oval or macrolobulated hypoechoic mass.
Parallel to skin.
Hyperechoic bands and pseudocapsule.
Posterior enhancement.
Most often in anterior portion of breast
Hypervascular on doppler exam.
20-30% compressibility
LACTATING ADENOMA – IMAGING - 2
Size – usually 2 – 4 cms, the largest
reported - 21 cms.
May be multiple.
Less common findings –
Posterior shadowing (occurs with
infarction)
Angulated or ill-defined margins.
Hyperechoic or isoechoic.
VASCULAR LACTATING ADENOMA
INFARCTED LACTATING ADENOMA
LACTATING ADENOMA –
D.D.(US)
– Fibroadenoma
– Galactocele
– Complicated cyst
– Tubular adenoma
– Well-circumscribed carcinoma.
LACTATING ADENOMA - MANAGEMENT
Spontaneous regression after completion of
lactation.
If suspicious – core biopsy needed (FNA not
diagnostic)
If very large and/or painful – Bromocriptine
has been reported to reduce size, through
suppression of Prolactin.
FIBROADENOMA
Most common benign tumor in all women
under 35
Benign fibroepithelial tumor
May develop or markedly enlarge during
pregnancy
Variable appearance on ultrasound,
usually oval or macrolobulated,
homogeneously hypoechoic .
FIBROADENOMA WITH INCREASED
VASCULARITY
PHYLLODES TUMOR
Rare tumor, histologically similar to
fibroadenoma, but 16 – 28% recur locally
after excision.
Low incidence of metastases.
Solid, macrolobulated hypoechoic mass
sometimes not homogeneous, or with
cystic spaces.
May have posterior enhancement.
PHYLLODES TUMOR - MANAGEMENT
F.N.A and core biopsy not reliable in
differentiating Phyllodes tumor from
fibroadenoma.
Excisional biopsy recommended.
If proven Phyllodes tumor – excision with
clean margins indicated.
BLOODY NIPPLE DISCHARGE DURING
PREGNANCY
Usually appears during the third trimester.
The cause is increased vascularity, and a minor
trauma.
Usually ceases with the onset of nursing, but
may persist during lactation.
Cytological analysis may be false positive.
US should be performed.
If normal exams – follow-up every month.
If pathological cause suspected (mass, positive
cytology )- galactography and biopsy.
PREGNANCY-ASSOCIATED BREAST
CANCER
Definition: breast cancer that occurs during
pregnancy or within 12 months thereafter
Incidence – 1:3,000 – 1:10,000 pregnancies
(most common cancer and cause of cancer
death in pregnancy)
0.2 – 3.8% of all breast cancers
Approximately 7 – 14% of newly diagnosed
breast cancers in women under 40 are
associated with pregnancy.
PREGNANCY-ASSOCIATED BREAST
CANCER
Distribution of histologic types – same as in nonpregnant patients.
2 – 4% - inflammatory carcinomas.
No evidence that pregnancy itself is a risk factor
for the development of breast cancer.
Cancer is found frequently in an advanced
stage.
Prognosis similar to the non-pregnant patients
when matched for age and stage.
INFLAMMATORY CARCINOMA
Erythema, warmth and induration with or
without “peau d’orange”
Typically evolves over 3 months or less
The cause is embolization of dermal
lymphatics by tumor.
Frequently misdiagnosed as mastitis or
abscess
Biopsy should be performed when an
abscess is drained during pregnancy
CAUSES FOR DELAY IN DIAGNOSIS
DURING PREGNANCY AND LACTATION
Difficulty in physical examination.
Attribution of a mass to a benign process.
Hormones causing growth enhancement.
Higher percentage of ER negative tumors
which are more aggressive.
Rich blood supply probably enhances
growth of metastases.
EVALUATION OF A PALPABLE MASS IN
THE PREGNANT OR LACTATING PATIENT
Ultrasound
– Cystic or galactocele – follow up.
– Solid – biopsy.
If lesion is clinically suspicious – F.N.A or core
biopsy.
If malignancy proven– tailored mammography
to the lesion and contralateral MLO.
– Dose to fetus 0.5mGy (natural background radiation
during pregnancy 1.0 mGy)
MRI IN THE PREGNANT PATIENT
Safety not clear.
Gadolinium crosses
the placenta , causes
fetal malformations in
rats, and is to be used
only if benefits
outweigh the risk, and
only after the first
trimester.
BREAST BIOPSY DURING PREGNANCY
F.N.A may give false positive result.
Core or open biopsy preferred - but may
cause milk fistula or infection.
Excisional biopsy or incisional biopsy may
be performed under local anesthesia.
Bleeding more common than in nonpregnant patients.
STAGEING BREAST CANCER IN THE
PREGNANT PATIENT
Chest x-ray performed with abdominal shielding.
CT avoided because of inability to shield the
abdomen and because of the use of iodine
contrast material which may cause
hypothyroidism in the newborn.
Radionuclide bone scan is contraindicated (dose
is 20mCi)
Sentinel lymph node mapping – not
recommended.
TAKE-HOME MESSAGE - 1
Breast pathological conditions may be
found at all ages, but are uncommon in the
younger age group , under 30.
Ultrasound is the method of choice for
evaluating children, adolescents, pregnant
and lactating patients.
Need for biopsy determined by imaging
findings and/or clinical impression.
TAKE-HOME MESSAGE - 2
A DOMINANT MASS IN THE PREGNANT OR
LACTATING PATIENT SHOULD BE PROMPTLY
EVALUATED.
SCREENING MAMMOGRAPHY IN HIGH RISK
PATIENTS OVER 40 SHOULD NOT BE
POSTPONED. SHOULD BE PERFORMED
AFTER NURSING.