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.