Discussion:
The histogenesis of lactating adenoma is somewhat controversial. In some studies, the lactating adenoma is considered to be a pure lesion that is morphologically distinguishable from tubular and fibroadenoma and is associated with either pregnancy or lactation. The tumors may not exhibit lactational secretions [7,8]. However, they do exhibit secretory changes that mimic the physiological changes manifested in pregnancy; that is why they proposed to name them “tumors of pregnancy”. Scholars such as Hertel et al. [9] believed that lactating adenomas have precursors, including fibroadenoma and tubular adenomas. These lesions then undergo secretory changes associated with physiological states of pregnancy. These give rise to controversies that may belong to different nature of the growth which is influenced by the effect of hormones on the breast both during pregnancy and lactation period. However, World Health Organization recognizes both views in their latest book on breast tumors [10]. About 3% of breast cancers are diagnosed during pregnancy [11]. And due to the physiological changes that occur in the breast during pregnancy, the possibility of the presence of or the coexistence of malignant lesions should not be neglected [12].
Many cases of lactating adenoma that have been mentioned in the literature were of atypical presentation. Some of them are even with an aggressive presentation. Though lactating adenomas are rendered to benign behavior, the literature has mentioned the coexistence of benign and malignant tumors in the same patient [12,9,13], others in the same anatomical site [14]. Hence, caution must be taken while dealing with lactating adenoma when the patient comes with atypical presentation or with signs and symptoms suspicious of carcinoma as in this case, where she was presented with features that mimic inflammatory breast carcinoma.
The relation between the effect of females’ hormones and breast tumors is not well understood and many studies have subjugated this complex relation to intense investigations. Gill S et, al. concluded in their study that a high prolactin concentration has a positive correlation to female breast tumors [5]. However, the exact mechanism remains very sophisticated [5,15]. In the case of our patient, the complicated growth picture, enlarged LN, and the presence of ulceration may be attributed to the hormonal changes during pregnancy and lactation, especially the growth picture in this case seems against the classical histology of lactating adenosis that appears as well-circumscribed, lobulated, solitary or multiple, gray with areas of necrosis; microscopically, they are seen as cuboidal cells with actively secreting, closely packed glands [16]. There has been a strong recommendation for using triple assessment in such cases in order to differentiate between adenoma and carcinoma of the breast [16,17], but even though with such complex growth the distinguishable point from cancer clinically remains very difficult and only histology can give clear differentiation. The detection of positive P63 in the histopathology has been linked to underlying ductal carcinoma in situ and some cases of invasive ductal carcinoma, and this add sounds of doubts for future behavior of this benign tumor [17], a simple mastectomy is the safest option for huge ulcerated lactating adenoma which is resistant to conservative management.
Conclusion: Menstruation and pregnancy in young females can be followed by an aggressive type of lactating adenosis with a complex macro-histological picture that mimics cancer growth. Moreover, under the influences of puerperal hormones, bilateral breast involvement can be inevitable. The complex growth of giant lactating adenosis can be missed as cancer even with usual triple assessment, and the immunohistochemistry is the mainstay of differentiation, and with the suspicion of underlying DCIS, the safest option of treatment of such cases with complex growth is simple mastectomy which can give much promising prognosis. Eventually, this case sheds light on the complex growth of benign breast tumors and the effect of hormonal changes during both pregnancy and lactation, and it is the effect on the pathogenesis of tumors and bilateral complex growth.
Lactating adenomas are benign tumors of the breast and are most commonly found during pregnancy and lactation. This is a very complex case of benign lactating adenosis reported in Sudan. However, Fibroadenoma is one of the commonest benign breast tumors in young females in Sudan, but little is known about lactating adenosis and other benign breast tumors.