C h a p t e r 4 0
Disorders of the Female Genitourinary System
1043
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.
