breast mass (bening breast disease)

Breast Mass

Mustafa khaleel

Objective • ANATOMY• PHYSIOLOGY• BLOOD SUPPLY• LYMPHATIC DRAINAGE• BENIGN disease

Anatomy of breast

•  In females breast are hemispherical eminences in the front of chest, each extends from the second rib above to the sixth rib below, and from the side of the sternum to near the midaxillary line.

• Mature breast is cushioned between subcutaneous fat and superficial pectoral fascia. Between breast and superficial fascia there lies loose areolar tissue known as retro mammary space.

• Histologically breast consist of glandular tissue connected by fibrous tissue, the space in between is filled by fatty tissue.

• Total 15 to 20 lobes further divisible in several lobules.• Breast of young girl contain dense stroma and epithelium

while that of old age women contain more fat. Fat absorb less radiation thus mammography more useful in older women.

• Ductal system consist of acini that forms milk and open into lactiferous ducts that dilate before opening forming ampulla that act as resorvoir of milk. Ducts open on nipple in 10-15 orifices. At nipple cuboidal epithelium abruptly meets squamous epithelium.

• In stroma there are fibrous bands that run from superficial fascia to skin and give shape and support to breast known as cooper’s ligament

• Blood supply is derived from 1. Perforating branches of internal mammary artery.2. Lateral branches of posterior intercoastal arteries.3. Branches from axillary artery

Lymphatic drainage of breast• About 75% of lymphatics drain in axillary nodes while rest 25% drain

in parasternal nodes.• Axillary nodes are classified as:1. Lateral group along axillary vein2. Pectoral group or anterior group3. Scapular group or posterior group4. Central group5. Subclavicular group Rotter’s nodes described later.Surgically axillary nodes are assigned levels:Level I : Lateral to pectoralis minorLevel II: Deep to pectoralis minorLevel III: Medial to pectoralis minor

Anatomy of pectoral region

• Deep to pectoralis major muscle lies pectoralis minor enclosed in clavipectoral fascia.

• It further extends laterally to fuse with axillary fascia.• Breast is related posteriorly by pectoralis major, serratus

anterior and external oblique abdominis.• Interposed between pectoralis major and minor one to

four nodes know as rotter’s node. They receive lymphatics directly from breast and drain into central and supraclavicular nodes.

Devlopement and Physiology of Breast

• Breast development is influenced by several hormones like estrogen, progesterone and prolactin, oxytocin, thyroid hormone, cortisol and growth hormone.

• Estrogen initiates ductal development • Progesterone is responsible for differentiation of

epithelium and lobular development. Prolactin is primary hormonal stimulus for lactogenesis.

• After birth, in a female there is fall in steroidal hormone and breast remain under developed.

• In adolescence breast is mostly composed of mainly dense fibrous stroma and scattered duct lined by epithelium.

• After beginning of nocturnal pulsatile gonadotrophin release in puberty cause deposition of fat in stroma. Local homones like epidermal growth factors can replace estrogen thus have a proposed role of mediator of action.

• During menstrual cycle hormones have cyclical effects on breast. Dominant change is hypertrophy rather than hyperplasia.

• During late luteal (premenstrual) phase due to accumulation of fluid and interlobular edema that causes pain and heaviness in breast premenstrually.

• During anovulatory cycles engorgement, pain and nodularity get accentuated.

• During pregnancy fibrous stroma diminish to accommodate hypertrophied lobular tissues. This formation of new lobules or acini is termed as adenosis of pregnancy.

• Expulsion of milk occur by contraction of myoepithelial cells.• During menopause there is deposition of fats, atrophy of glandular

and connective tissue.

Benign breast diseasesBenign breast diseases

Fibroadenomas• Fibroadenomas are benign tumors composed of

stromal and epithelial elements. The tumors are commonly seen in young women.

• Fibroadenoma is a common well - circumscribed lesion of the breast & develop in the breast prior to menopause.

• Pericanalicular tumors usually being found below the age of 30 & intracanalicular tumors there after.

• Either breast may be affected and multiple & successive tumors may develop in the same or contra-Lateral breast.

FIBROADENOMA• The preicanalicular tumor forms a firm discrete

mass, which is freely mobile in the breast tissue, hence the name (BREAST MOUSE )

• The intracanalicular tumors tends to be softer & may grow to such size that there is necrosis of the overlying skin. To such a condition the terms serocystic disease of bordie OR cystisarcoma phylloides OR Giant fibroadenoma have been given. However despite the implication of malignancy in the later term, the tumor is benign.

FIBROADENOMA• Pathophysiology:

– Fibroadenomas are benign tumors that represent a hyperplastic or proliferative process in a single terminal ductal unit; their development is considered to be an aberration of normal development. The cause is unknown. Approximately 10% of fibroadenomas disappear each year, and most stop growing after they are 2-3 cm in size.

– Fibroadenomas may involute in postmenopausal women, and coarse calcifications may develop. Conversely, the tumors may grow rapidly during pregnancy, during hormone replacement therapy, or during immunosuppression, in which case they can simulate malignancy.

– Fibroadenoma variants include juvenile fibroadenoma, which occurs in female adolescents.

FIBROADENOMA - Pathology

• This swelling has been variously regarded as a simple hyperplasia of epithelial and / or connective tissue elements or as a composite neoplasm of the breast in which the epithelial & mesnchymal components grow simultaneously

FIBROADENOMA• Clinical Features:

– On clinical examination, fibroadenomas may be nonpalpable or palpable, oval, freely mobile, rubbery masses. Their size varies from smaller than 1 cm in diameter to as large as 15 cm in diameter in the giant forms.

– Most commonly, the tumors are removed surgically when they are 2-4 cm in diameter. In young women, the tumors are usually palpable. In older women, the tumors typically appear as a mass on mammograms, and the tumor may be palpable or nonpalpable.

– The size of fibroadenomas also can vary during the menstrual cycle and during pregnancy.

– In the postmenopausal period, tumors regress and often develop calcifications

Fibroadenoma

• Types • Solitary • Few (< 5 / breast )• Multiple (> 5 / breast )• Giant (> 4 / 5 cms) & Juvenile Natural history

Majority remain small & static 50% involute spontaneously No future risk of malignancy

FIBROADENOMA

FIBROADENOMA - investigation

• Breast, fibroadenoma Sonogram. demonstrates a hypoechoic mass with smooth partially lobulated margins that are typical of a fibroadenoma.

FIBROADENOMA - investigation

• Breast, fibroadenoma. Craniocaudal mammograms obtained 1 year apart demonstrate a newly developing mass in the outer part of the breast.

FIBROADENOMA• Treatment • Reassurance of the patient• Excisional biopsy

Treatment• The natural history of these lesions has recently been

elucidated and has resulted in a change in management policy.

• Over a 2 year period approximately 20% slowly increase in size, 10% reduce in size, 20% completely resolve and 50% remain static.

• With knowledge of this natural history a conservative management policy can often be adopted. – In those <35 years and with a triple assessment

supporting the diagnosis then observation with regular review is acceptable.

– In those > 35 years and in younger patients requesting it, excision biopsy should be considered.

Management algorithm for Fibroadenomas

Discharge with advice on BSE

No change/ shrinkage / disappearence

Extra capsular Excision

Increase in size/At patient request

C linical observation for 2 years

All results concurrAge < 30 years

Excisionwith rim of normal tissue

Results do not concurrAge > 30 years

Excision of largestC linical observation of rest

Multiple fibroadenomas(Selective triple assessment)

Extracapsular Excision

Giant fibroadenoma/Juvenile fibroadenoma

Triple assessment

Fibroadenoma(clinical diagnosis)

Cystosarcoma phyllodes (CSP) • Cystosarcoma phyllodes (CSP) is a rare,

predominantly benign tumor that occurs almost exclusively in the female breast. Its name is derived from the Greek words sarcoma, meaning fleshy tumor, and phyllo, meaning leaf.

• Grossly, the tumor displays characteristics of a large, malignant sarcoma, takes on a leaflike appearance when sectioned, and displays epithelial cystlike spaces when viewed histologically (hence the name).

• Because most tumors are benign, the name may be misleading. Thus, the favored terminology is now phyllodes tumor.

Pathophysiology of CSP • Pathophysiology:

– Phyllodes tumor is the most commonly occurring nonepithelial neoplasm of the breast, and it occurs only in the female breast.

– It has a sharply demarcated, smooth texture and is typically freely movable. It is a relatively large tumor, and the average size is 5 cm. However, lesions more than 30 cm in size have been reported.

Cystosarcoma phyllodes

TREATMENT of CSP• Surgical Care:

– In most cases, perform wide local excision with a rim of normal tissue

– If the tumor/breast ratio is sufficiently high to preclude a satisfactory cosmetic result by segmental excision

– total mastectomy, with or without reconstruction, is an alternative.

– More radical procedures generally are not warranted– Perform axillary lymph node dissection only for

clinically suspicious nodes. However, virtually all of these nodes are reactive and do not contain malignant cells.

FIBROCYSTIC DISEASE• This is the most common lesion of the female breast.• Cystic lobular hyperplasia & fibrocystic disease of

the breast are the two common acceptable description.

• Cystic hyperplasia is a variant of normal cyclic changes in the breast that occur with menstruation.

• This hyperplasia usually presents bilaterally in the upper outer quadrant of the breast & is most painful in the premenstrual period

Fibrocystic Breast Disease• Most benign breast condition• Incidence-varying, related to age

– Menstruating years-20%– 30-50% in premenopausal years

• Synonyms-– Mammary dysplasia, – Cystic disease, – Cyclic Mastopathy, – Cystic Hyperplasia

Pathophysiology of fibrocystic disease

• The exact cause of fibrocystic disease is unkwon• Hormonal basis

– Oestrogen & Progesterone– Prolactin– Thyroid

• Methylexanthiones• Trauma- NOT A CAUSE

Pathophysiology of fibrocystic disease(cont)

• Oestrogen & Progesterone– Oestrogen predominance over progesterone is

considered causative– Serum levels of Oestrogen high – Luteal phase is shortened

– Progesterone level decreased to 1/3 normal, and women with progesterone deficiency carry a five fold risk of premenopausal breast cancer

– Corp. Lut. Deficiency / Anovulation in 70% – Patients with Pre Menstrual Tension syndrome more

likely to develop FDB

Pathophysiology of fibrocystic disease(cont)

• Prolactin- – levels are increased in 1/3 of women with FDB– Probably due to Oestrogen dominance on

pituitary• Thyroid –

– Suboptimal levels sensitize mammary epithelium to Prolactin stimulation

• Methylexanthiones-– Increased intake of coffee, tea, cold drinks

chocolate is associated with development of FDB

Pathomorphology• Oestrogens stimulate proliferation of connective and

epithelial tissues.• The polymorphism of fibrocystic disease is

documented by :• fibrosis, • cyst formation, • epithelial proliferation, • and lobular-alveolar atrophy

Clinical Course of fibrocystic disease

• FDB represents a clinical problem in approximately 30% of patients.

• Predominantly afflicted are – women with menstrual abnormalities– nulliparous women – patients with a history of spontaneous abortions– nonusers of oral contraceptives and – women with early menarche and late menopause.

• Early fibrocystic manifestations may occur between the age of 20 and 25 years, but most patients (70% to 75%) are in their mid 30s and 40s.

Clinical Course of fibrocystic disease

Incidence of FBD

10%20%

50%

0%

10%

20%

30%

40%

50%

60%

Under 21 Years Menstrual years Pre-menopausal

Clinical Course of fibrocystic disease

• Clinically, three phases of fibrocystic disease can be recognized-– Phase I - Moderate stromal fibrosis, beginning

hardness of breast tissue and premenstrual breast tenderness

– Phase II - Progressive fibrosis leading to increased hardening and tenderness, cyst formation, moderate modularity

– Phase III - Pronounced fibrosis and tenderness, macrocyst formation

Diagnosis of fibrocystic diseasetriple assessment

Symptoms and Signs -– Fibrocystic disease has a history of many months

to several years.– Fibrocystic disease is rare in ovulating women,

multiparous women, and patients using oral contraceptives.

– Breast pain (mastodynia) and/or tenderness is observed in the majority of patients.

• In 40% to 60% of patients these are associated with irregular menses, dysmenorrhea, menometrorrhagia, or ovarian cysts.

Diagnosis of fibrocystic disease

• Nipple secretion- – In one third of patients with FDB, discharge is

spontaneous or secretion can be expelled from the nipple. The cytological features may include amorphous material (fat, proteins), ductal cells, erythrocytes, and / or foam cells. the fluid is straw yellow, greenish, or bluish. In 2-3% carcinoma is diagnosed

• Bloody Nipple secretion- when present– 50-60% due to intra ductal proliferation (Papilloma)– 30-40% due to carcinoma ( 64% after age 50).

Diagnosis of fibrocystic disease

Patients with early fibrocystic change show small areas of increased density on the mammographic film.These are irregular and scattered, with varying degrees of density. As disease progresses, dark areas may occur along with the whitish grey areas, and microcalcifications may also become prominent. These calcifications can be single or multiple small flecks located in intraductal or periductal stroma or in entire lobules.

Mammography

Diagnosis of fibrocystic disease

• Ultrasonography - – Particularly useful in delineating solid from cystic breast

masses. – Ultrasound of cystic masses characteristically defines a

mass with a uniform outer margin demonstrating no asymmetry or unusual thickness of the wall. The central part of the mass shows no echoes, and there is posterior wall enhancement.

Diagnosis of fibrocystic disease

• Needle aspiration biopsy –– Indicated in patients with breast mass, a lump like

structure,, a hard dense area or any abnormal tissue areas, as defined by clinical examination, mammography or USG.

– In patients at high risk of breast cancer, needle aspiration should be performed when the slightest suspicion arises.

– In women with fibrocystic disease, ductal epithelium consists of cohesive cells with a scant rim of cytoplasm and round or oval small, slightly hyper chromatic nuclei. Connective (fibrous) tissue is usually predominant.

Treatment of fibrocystic disease

Goal-Goal- To stop progressionTo stop progression To relieve painTo relieve pain To reverse changesTo reverse changes Soften breast tissueSoften breast tissue

Indicated when-Indicated when- FDB not increasing in FDB not increasing in

sizesize No nipple dischargeNo nipple discharge No psychological effectNo psychological effect

Medical- Surgical-

Intervention indicated Intervention indicated when-when- FBD is increasing in FBD is increasing in

sizesize Serous / Serous /

Serosanguineous / Serosanguineous / bloody discharge bloody discharge occursoccurs

Patients are Patients are pshychologicaly pshychologicaly disturbeddisturbed

Treatment of fibrocystic disease

OC pills- Users are protected from FBD Progestogen potency should

be high Progestogens -

To be given in the luteal phase for 9-12 months

About 80% get relief but 40% require restart of therapy of therapy

Medical-

Hormones

Danazol Remains the most

effective therapy Basis- ovarian

supression Dose-200-600mg/day

Treatment of fibrocystic disease

Efficacy of Danazol

47%

75%81.40%

90%

0%10%20%30%40%50%60%70%80%90%

100%

200mg 400mg 100-800mg 200-400mg

Treatment of fibrocystic disease

• Surgical treatment • surgical removal of lumps, in most severe

cases of benign fibrocystic breast disease

Duct Ectasia• This condition has several stages of involvement &

vanity of names include (plasma- cell mastitis, comedo mastitis, & chronic abscess simulating carcinoma).

• It is benign lesion may be virtually impossible to differentiate from carcinoma by it is gross appearance

• is a widening of the ducts of the breast, a condition that occurs most frequently in women in their 40s and 50s. A thick and sticky discharge, usually gray to green in color, is the most common symptom.

• Tenderness and redness of the nipple and surrounding breast tissue may also be present. Sometimes, scar tissue forms around the abnormal duct, leading to a lump that may be initially mistaken for cancer.

Duct EctasiaMicroscopically-The periductal elastic

tissue is destroyed & the surrounding tissue are infiltrated with lymphocytes & plamsa cell

Duct EctasiaClinically:- this condition present as solitary or multiple tender swelling in the

sub or Peri-areolar region of the breast. - Nipple retraction, skin adherence, edema & axillary adenopathy may accompany a hard, diffuse mass within the breast - palpation reveals a number of cord like swelling which radiate

from the areola. - the ducts are dilated & contain an inspissated yellow cheesy

material that can be expressed like toothpaste from the cut end of a duct.

- occasionally, the inflammatory response are so acute that skin changes occur & the condition may be mistaken for a breast abscess.

Duct Ectasia• Treatment :

– Small volume discharge is managed conservatively

– Socially embarrassing discharge is treated by Major duct excision

Galactocele• Cystically dilated terminal ductules that are filled with

milk and lined by double layer of breast epithelium and myoepithelium.

• Classically appears as a painless lump weeks – months after cessation of breast feeding.

GALACTOCELE• It is probably formed by obstruction to a duct in the

puerperium . the milk retained proximal to the obstruction eventually becomes cheese-like.

• The common complication of this type of swelling is infection.

• The treatment is by surgical excision.

INTRA-DUCTAL PAPILLOMA • This benign lesions of the lactiferous duct wall occur

centrally beneath the areola In 75% of cases.• They most commonly produce a bloody nipple

discharge, some times associated with Pain • They are solitary proliferation of ductal epithelium• Intraductal papillomas should be treated by excision

of a duct as a wedge resection.

Gynecomastia• Gynecomastia is the growth of glandular tissue in

male breasts. • The name comes from the Greek term (gyne +

mastos) meaning "female-like breasts." It is a benign condition that accounts for more than 65% of male breast abnormalities.

• it is usually unilateral & occur in young man. there is no hormonal dysfunction in unilateral Gynecomastia.

• Bilateral Gynecomastia is due to systemic causes.• Causes of Gynecomastia may be regarded as:

Primary Gynecomastia physiological causes

• Neonatal gynaecomastia– is due to the trans-placental passage of maternal

oestrogen and may be associated with a nipple discharge known as 'witch's milk'. It usually resolves during the first few weeks of life.

• Pubertal gynaecomastia – is the commonest male breast lesion. It can be either

unilateral or bilateral. Reassurance is often the only treatment that is required. The lesion will generally settle spontaneously but may persist for months or years.

• Senile gynaecomastia – can be difficult to differentiate from the pseudo-

gynaecomastia due to general adiposity increasingly seen in old age.

Secondary Gynecomastia – pathological causes

• Primary testicular failure – Anorchia– Klinefelter's syndrome – or bilateral cryptorchidism.

• Acquired testicular failure – Mumps– irradiation.

• Secondary testicular failure – hypopituitarism. – Isolated gonadotrophin deficiency.

• Endocrine tumours – Testicular– adrenal– pituitary.

Gynecomastia – pathological causes

• Non-endocrine tumours– bronchial carcinoma– Lymphoma– hypernephroma.

• Hepatic disease – alcoholic cirrhosis– haemochromotosis.

• Drugs – oestrogen agonists (spironolactone), – hyperprolactinaemia (phenothiazines), – Testosterone target cell inhibitors (cimetidine, cyproterone

acetate)

Pathophysiology of breast gynecomastia

• Pathophysiology of breast gynecomastia. Estradiol is the growth hormone of the breast, and an

excess of estradiol leads to the proliferation of breast tissue.

Under normal circumstances, most estradiol in men is derived from the peripheral conversion of testosterone and adrenal estrone.

The basic mechanisms of gynecomastia are a decrease in androgen production, an absolute increase in estrogen production, and an increased availability of estrogen

precursors for peripheral conversion to estradiol.

gynecomastia

Gynecomastia – clinical features

• The cause is often self evident from a full history and examination.

• The testes should always be examined. • Useful investigations may include

– a chest x-ray, – full blood count – and liver function test.– If there is suspicion of a testicular tumour then

ultrasound should be requested.– Hormonal assays may confirm endocrinopathies

Treatment• Treatment of gynecomastia• for physiological causes reassurance is all what is

needed• stop drugs causing gynecomastia• subcutaneous mastectomy in troublesome cases• Liposuction - assisted mastectomy

FAT NECROSIS This is traumatic in nature & is met with women with

large fatty breast Results from injury to breast fat by Trauma, surgery,

biopsy…. Causes to focal fibrosis and cicatrix formation.

Early: edema of the fat lobules,increased echogenicity.

Post surgical scar, hematoma, seroma

Pathophysiology

• Trauma Focal necrosis of fat Inflammatory reaction subsequent scarring to give rise to a focus of firmer consistency

• Chronic cases mimic new lumps

FAT NECROSISClinically: The patient develop sever bruising after moderately

sever trauma, When the bruise settles the woman notice swelling which is clinically Impossible to distinguish from carcinoma of the breast because the Irregular mass is often attached to the skin.

Microscopically a central area of necrotic fat cells are surrounded by a granulomatous reaction consisting of macrophage cells.

FAT NECROSIS

TreatmentTreatment:by surgical excision, the excised mass is an infiltrative

yellowish white mass.

Myths & Facts•Touching the breasts too often will lead to cancer

•Talking about cancer causes cancer

•Using illegal drugs causes cancer

•Herbs cure breast cancer(uña de gato/cat’s claw)

•A bruise on the breast will lead to breast cancer.

•If an incision is made during breast cancer surgery,the cancer will spread.

•Getting too many mammograms leads tobreast cancer.

•Mammograms are only used to evaluatebreast lumps.

Myths & Facts

• Breast cancer only affects older women• If you have a risk factor for breast

cancer, you're likely to get the disease• Using antiperspirants causes breast

cancer.• A breast cancer diagnosis is an

automatic death sentence.• Breast cancer is preventable

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