Introduction
Lactating adenoma is a rare tumour and
arises during, rather than after, pregnancy.2 They are uncommon and any association with fibroadenoma or fibrocystic disease seems coincidental.4 The microscopic changes are similar to those seen in normal pregnant breast but vary in degree and are out of phase with it. Immunocytochemistry can demonstrate clear differences between lactating adenomas and other breast lesions. There is no convincing association between the development of lactating adenomas and the use of oral contraceptives (OC), and there is no evidence that lactating adenomas are associated with an increased risk of carcinoma.1,6 They are usually less than 3 cm in size but can present as a rapidly enlarging large mass and so can be mistaken for a malignant tumour.5
A case of Giant Lactating Adenoma is hereby reported which was treated with Breast Conservative Surgery.
Case Report
A 23 year old, Hindu woman who was 1 week post-partum presented with the chief complain of sudden enlargement of rt. breast with heaviness and spontaneous milky discharge from the nipple since 7 days.
Patient had history of multiple nodularities in her right breast since last 4 months but she ignored it because they were asymptomatic. The nodularities had remain stable in size and asymptomatic until she delivered, but post partum it rapidly grew in size and started causing heaviness in the breast. This was her first pregnancy. There was no history of OC pill ingestion. The left breast was normal.
On examination, left breast was normal. Right breast was grossly enlarged, the skin was tense and had dilated superficial veins on it. Nipple areola complex was markedly enlarged with hyperpigmentation of areola but there was no retraction / deviation or excoriation. Milky discharge was seen on the nipple. There was no local warmth over the swelling. Breast was tender to touch. There was a large breast lump measuring about 30 x 26 x 24 mm in size. The lump was multinodular and varied in consistency from firm to cystic in different areas. It was free from the chest wall and the overlying skin.
Axilla - left axilla was normal. Right axilla had single, firm, non-tender mobile palpable lymph node.
USG of the right breast showed multicystic mass with in between solid components suggestive of Fibrocystic Disease. FNAC from the lesion showed few acinar cells in small groups. Cells had abundant cytoplasm with small round to oval nucleus. It was suggestive of fibrocystic disease. Considering the size of the lump and discomfort with the mass, patient was planned for lumpectomy with axillary lymph node biopsy. Biopsy of the lump showed that the lesion was composed of secretory lobules separated by septa. Lobules were lined by cells having vacuolated cytoplasm. Overall morphology was suggestive of Lactating Adenoma.
Post operative outcome and recovery was excellent. She continued to breast fed the baby by left breast. There was no wound infection; however there was milky discharge from the wound for the first few post-operative days.
 |
 |
Fig. 1 : Pre-operative appearance.
|
Fig. 2 : Post-operative appearance. |
Discussion
Hertel et al3 proposed a classification of adenomas of the breast that has been widely accepted. These lesions were divided into true adenomas (tubular, lactating, and of sweat gland origin), nipple adenomas and fibroadenomas. These were then differentiated by histochemical studies.2,4
Histopathological features
Lactating Adenomas:
- Greatly enlarged secretory units - (acini and lobules).
- Stroma consists of oedematous connective tissue.
- Most cells show intracytoplasmic and supranuclear vacuolation.
Tubular Adenomas:
- Small tightly packed tubules in solid mass, no acinar formation
- Incomplete fibrous septa for stroma.
- Slight cytoplasmic vacuolation of tubular epithelium.
Immunocytochemisty
S100 Protein :
- Absent in ductal carcinomas.
- Weakly positive in normal pregnant breast.
- Stained strongly in lactating adenomas.
HMFG 1 and 2 (human milk fat globule antigen) :
- Intracytoplasmic staining in ductal carcinomas.
- Luminal staining in benign and lactating adenomas.
Clinically,5 lactating adenomas are discrete, palpable, freely movable breast masses in women who are either pregnant or lactating. The average age at presentation is 25 years. They do not tend to recur locally, and there is no proven malignant potential. Anatomically5 these are sharply demarcated from the surrounding normal breast tissue but do not have a true capsule. The cut surface is lobulated and tan-yellow. Microscopically,5 lactational changes dominate. There is an increase in lobular features and a network of large alveolar spaces separated by fine fibrovascular trabeculae. The trabeculae are lined with typical cuboidal cell containing prominent vacuoles that stain positively for fat.
Treatment with bromocriptine5 to shrink the mass, followed by surgical excision is reasonable therapeutic approach to minimize cosmetic sequelae. It is a dopamine agonist and reduces prolactin secretion by its affect on anterior pituitary. It may thus reduce the mass size or may at times cause it to disappear completely. It is indicated for pre operative size reduction to achieve good cosmetic results. The drug however suppresses lactation and so this needs to be discussed with the patient before starting the therapy. In our case surgery was used as a primary modality of treatment due to the large lump size causing discomfort to patient, and also patient did not give consent for bromocriptine treatment, since she wanted to breast feed the child.
References
- Anonymous. Lactating adenomas of the breast (editorial). Lancet 1989; i : 252.
- Choudhury M. Lactating Adenoma - Cytomorphologic study with review of literature. Indian J Pathol Microbiol 2001; 44 (4) :
445-8.
- Hertel B, Zaloudek C, Kempson RL. Breast adenomas. Cancer 1976; 37 : 2891-2905.
- James K. Breast tumour of pregnancy (Lactating adenoma). J Pathol 1988; 156 (1) : 37-44.
- Reeves ME. Lactating adenoma presenting as a giant breast mass. Surgery 2000; 127 (5) : 586-8.
- Saglam A, Can B. Coexistence of lactating adenoma and invasive ductal carcinoma of breast in pregnant woman. A J Clin Pathol 2005; 58 (1) : 87-9.
|
PRIMARY PREVENTION OF CHD SAVES MORE LIVES THAN SECONDARY
Between 1981 and 2000, primary prevention of coronary heart disease (CHD) may have saved about four times more lives than did secondary prevention in England and Wales.
Unal and colleagues found reductions in three major risk factors - smoking, high blood cholesterol concentration, and high blood pressure - saved about 45 370 lives, with 81% in people without CHD and 19% in patients with CHD. The authors argue that the government should shift the focus of its policy from secondary prevention to primary prevention.
BMJ, 2005; 331 : 614.
|
|
