Benign Breast Disease

Mr Denis Evoy

Surgical Consult

• Majority of surgical consultation for Breast complaints ultimately prove to have a benign origin.

• Surgeon’s role in management of Benign Breast Disease includes:– Assessment of Breast Cancer Risk– Breast Cancer Screening– Providing Specific Diagnosis– Treatment/Management

ANATOMY

• Develops from Ectoderm Milk Streak

• Lobules and Ducts• The breast glandular tissue consists of 15 to 20 lobules (clusters of milk forming glands, or acini) that enter into branching and interconnected ducts. The ducts widen beneath the nipple as lactiferous sinuses and then empty via nipple openings.

ADH

ANATOMY

• Blood Supply – Branches of Internal Mammary Artery,

Intercostal arteries, Axillary Artery– Venous drainage via Internal Mammary,

Intercostal, Axillary Veins

• Lymphatic Drainage– 97% to Axillary Nodes– Internal Mammary and Supraclavicular

nodes

Anatomy

• Axillary lymph nodes defined by pectoralis minor muscle– Level 1 – lateral– Level 2 – posterior– Level 3 – medial

• Long Thoracic Nerve– Serratus anterior

• Thoracodorsal Nerve– Latissimus Dorsi

• Intercostalbrachial Nerve– Lateral cutaneous – Sensory to medial arm & axilla

BREAST MASS• Four Phases of Management

– CBE– Breast Imaging– Tissue Sampling– Treatment

• Palpable mass is most common presentation

• Mammogram/Sonogram/MRI• FNA/Core biopsy/Excisional biopsy

FNAC

• Fine Needle Aspiration Cytology involves attaching a 21g needle to a 10 or 20ml syringe to remove cells or fluid from a lesion. Applying suction by withdrawing the plunger from the

syringe, cells (or fluid) are extracted and expressed onto microscope slides for analysis.

• A report can be given in about 15 minutes. This can be useful if the initial sample is inadequate as repeat specimens can be taken at the first clinic visit. The major disadvantage is that it

requires the time of a dedicated technician with access to a cytologist. In many centres, this is

difficult to justify.

                                                                                             

• Fibrocystic disease

– Treatment: • Cyst aspiration• Analgesia • Firm Bra support• Vitamins (E, B6)• Avoidance of caffeine• Night time Primrose oil

• Danazole• Bromocryptine• Tamoxifen• Contraceptives• Reassurance

InflammatoryBreast disease

• Fibrocystic disease– Very common

– ? Hormonal origin

– Young patients (<40 years, < 2-3% cancer)

– Fibrous tissue, cysts, nodules

– Focal, general, uni/bilateral

– Round cell infiltration

– Pain (cyclical)

– Symptoms tend to improve /disappear with pregnancy

Cysts

• Cysts– Simple cyst may be observed or

aspirated– Bloody aspirate – send for cytology

• Fibrocystic Changes– Not considered “disease”– No increase risk of cancer– Common finding >50%

Fibroadenoma

• A fibroadenoma is a benign solid growth that usually presents as a palpable breast lump. On examination, it is usually a well circumscribed, firm, mobile discrete breast lump and can occasionally be multiple or bilateral. It is sometimes referred to as a breast mouse because of its mobility within the breast tissue.

• Fibroadenomas account for approximately 12% of all palpable symptomatic breast masses. They occur most commonly in women aged between 15

and 25 but still account for 15% of all discrete lesions in women aged 30 to 40 years. Thereafter,

they are less common.

                                                                              

                                                                                             

Evaluation and Treatment

• The diagnosis of a fibroadenoma can be strongly suspected on clinical grounds. This can be supported by cytological examination following fine

needle aspiration but the definitive diagnosis is only made on histology after excision of the lesion.

4 types of fibroadenoma: • common fibroadenoma • giant fibroadenoma • juvenile fibroadenoma • phylloides tumour

• There is no universally accepted definition of a giant fibroadenoma but most consider that a fibroadenoma must measure over 5 cm in size to qualify for

this definition. • Most juvenile fibroadenomas undergo rapid growth and tend to be more

cellular than ordinary fibroadenomas. • Phylloides tumours are a distinct pathological entity and, although

they cannot always be differentiated from fibroadenomas clinically, their histology and behaviour are such that they should be classified separately.

Fibroadenoma • It is routine practice to excise fibroadenomas that are over 3 or 4

cm in size. Fibroadenomas are benign and few increase in size. Once a definitive diagnosis is established by a combination of

clinical examination and FNAC, the patient can be given the option of observation or surgical removal. Some believe that

observation is only appropriate in women under the age of 40 because of the possibility of missing a breast cancer in older

women. • If access to good quality cytology is not available, it is wise to

excise all fibroadenomas to be certain that no malignant lesions are missed.

Phylloides Tumours • Phylloides tumours exhibit a spectrum of behaviour ranging from

benign to malignant with a close correlation between the histological appearance and the subsequent behaviour. Only rarely

do they metastasise and the main problem is local recurrence.• Treatment is by wide excision that in some instances means a

mastectomy.

Cysts

• Cysts are a common type of benign breast lump present in patients at breast clinics. Cysts can be painful; they occur most frequently in women between the ages of 38 and 53.

• Evaluation and Treatment• If a breast lump is suspected to be a cyst, it should be

aspirated directly or under ultrasonographic guidance. The cyst fluid has a variable colour from a pale yellow to brown or dark green. Routine cytological examination of

cyst fluid is not rewarding and can be potentially misleading.

• It is mandatory to confirm that the cyst has disappeared after aspiration and that the fluid is not blood-stained. If ultrasonography shows a solid component to the cyst, this should be investigated with FNAC or wide-bore needle

biopsy.

Duct Ectasia/Peri-ductal Mastalgia

• Peri-ductal mastalgia is characterised by mastalgia of a non-cyclical nature, nipple discharge and periareolar

inflammation that may be associated with nipple retraction. The formation of mammary fistulae and non-

lactating breast abscesses is frequently seen. • In this condition, the ducts are not dilated but are

surrounded by an inflammatory response. The aetiology of the inflammation is unknown. Duct ectasia typically occurs in the peri-menopausal or late pre-menopausal groups. The role

of bacterial infection in the pathogenesis is controversial.

Evaluation and Treatment• Treatment of duct ectasia and peri-ductal mastalgia includes

antibiotic therapy for the acute inflammatory episode. Ongoing symptoms are best resolved through total major

duct excision.

Duct Papilloma

• Benign papillomas of the ducts are very common and should be regarded

as aberrations of cyclical change rather than true benign tumours. These

lesions are either single or multiple. • The most frequent symptom is nipple

discharge that may be blood-stained. Treatment consists of

microdochectomy, which involves excising the duct.

                                                                                             

Nipple Discharge

• A small amount of fluid can be expressed in two-thirds of all non-lactating women by application of suction to the nipple. This is

regarded as physiological. It varies in colour from a clear off white fluid through yellow to dark green and should never be blood-

stained. • A discharge is significant when it occurs spontaneously and is a

dominant symptom. A blood-stained nipple discharge can range from serosanguinous to heavily blood-stained. This discharge is

often due to epithelial hyperplasia in the form of a duct papilloma. The condition is most often benign but the risk of

malignancy increases with age. Duct ectasia may lead to blood-stained nipple-discharge withulceration within the ducts.

• A discharge associated with breast cancer is usually blood-stained and associated with a palpable lump. In a minority of patients, no cause of a discharge is established even after an operation such

as major duct excision.

Nipple discharge

• Serous discharge– Common

– Usually benign (> age 60 D/D carcinoma)

– Complete breast evaluation!

– Tx: Observation• Abstain from repeated breast manipulation

• Treatment of underlying problem

Nipple discharge

• Bloody discharge– Fibrocystic disease

– Ductal papilloma

– Ductal carcinoma

– Management:• With lump -> treat the lump

• W/O lump -> complete breast evaluation Ductogram Duct endoscopy Lacrimal probe to localize duct

Duct excision NO FROZEN SECTION!

Age< 40

Age> 40

Evaluation and Treatment

Investigation of a bloody nipple discharge should include: • haemostix testing to confirm the presence of blood • cytological examination • assessment of the breast with examination and

mammography

• Surgical excision of the involved duct through microdochectomy, is preferred for a single discharging duct. As the risk of malignancy is higher for a patient with multiple duct discharge and in patients over the age of 50 with a single duct discharge, total duct excision is the

favoured approach.

Mammary Fistula

• A mammary fistula is a rare recurrent condition characterised by draining abscesses above the nipple in one or both breasts. Because little is known about the

disease, it is often misdiagnosed and inappropriately treated. 

Evaluation and Treatment • The clinical and pathological findings are similar to duct

ectasia or peri-ductal mastalgia and usually consist of a swelling or mass at the areola, draining fistula from the subareolar tissue, a chronic thick, discharge from the

nipple and pain. Core excision of the fistula and all the retroareolar fibroglandular tissue and the ductal tissue

within the nipple is the usual definitive therapy

Gynaecomastia

• Gynaecomastia-abnormal enlargement of the male mammary gland - is the most common condition affecting the male breast. The condition is entirely benign and usually reversible. It may be physiological as in neonatal or pubertal. It may also be related to drugs, in particular cimetidine and tricyclic antidepressants. Gynaecomastia also occurs in chronic liver disease due to failure of the liver to metabolise circulating oestrogens.

                                                                

Evaluation and Treatment

• The majority of cases will be idiopathic in apparently healthy men. It is, however, important to verify that the testes are normal and to exclude cirrhosis. Because gynaecomastia results from a hormonal

imbalance or as a side effect of certain drugs, firm reassurance that this is a benign condition will suffice.

• Malignancy should be suspected in patients without a cause for gynaecomastia, especially if there is an eccentric hard lump or

ulcerating lesion. • Medical therapy is seldom of value except when a specific cause

has been established. Discontinuation of causative drugs often leads to breast regression. Surgical removal of the breast tissue is indicated where medical treatment fails or where the degree of

breast enlargement is a cosmetic or psychological problem. Subcutaneous mastectomy is performed through a periareolar

or infra mammary incision, depending on the extent of the tissue to be excised.

Breast Skin

• Mastitis/Abscess– S. Aureus– Inflammatory Breast Cancer

• Mondor’s Dz.– Painful, cordlike superficial

thrombophlebitis

Benign Breast Disease

• NONPROLIFERATIVE– FIBROCYSTIC CHANGES– NO INCREASED RISK

• PROLIFERATIVE– PAPILLOMATOSIS– 1-2X INCREASED RISK OF CANCER

• ATYPICAL PROLIFERATION– ATYPICAL HYPERPLASIA– 4-5X INCREASED RISK OF CANCER

Relationship between benign and malignant breast disease

No increased riskSclerosing adenosis, Apocrine change Duct ectasia Mild hyperplasia Apocrine metaplasia Fibroadenoma, hamartoma, Cysts

Slight increased risk (1.5 to 2 times)Moderate or florid hyperplasia Papilloma with fibro vascular core Moderate increased risk (4 to 5 times)Atypical ductal hyperplasia Atypical lobular hyperplasia Radial scar

Mastalgia

• Mastalgia — a general term for breast pain — is one of the most common symptoms and affects

up to 70% of women at some time in their lives. It accounts for approximately 50% of

referrals to a specialised breast clinic and is the most frequent reason for breast-related

consultation in general practice. • At present the aetiology of mastalgia remains

obscure. Although the cyclical nature of the condition would suggest that hormones are

involved, there are several studies which show no difference in oestrogen levels between these

patients and controls

Evaluation and Treatment

• The most important aspects in the evaluation and treatment of breast pain consist of a thorough history, physical and radiological

evaluation. These can be used to reassure the patient that she does not have breast cancer.

• The best way to assess whether the pain is cyclical is to ask the patient to complete a breast pain chart, a blank calendar where the

patient notes the occurrence and severity of pain daily, as well as keeping track of the dates of her menstrual cycle.

• After exclusion of breast cancer, 85% of patients can be discharged from the clinic without specific treatment . Therapy may consist of a well-fitting bra, a decrease in dietary fat intake, manipulation to

reduce saturated fat or supplemental essential fatty acid intake and a discontinuance of oral contraceptives or hormone replacement

therapy.• Women resistant to these simple measures may experience relief

from using gammalinolenic Acid as first line therapy. Danazol or Bromocriptine are usually used as second line agents. Both are

effective treatments but have a much higher incidence of side effects such as weight gain, nausea or oily skin.

• Patients with severe recurrent or refractory mastalgia may require treatment with Tamoxifen, Goserelin or Testosterone, treatments

generally prescribed by a breast cancer specialist.

Atypical Hyperplasia• Marked proliferation and atypia of the epithelium,

either ductal or lobular.

• Found in 3% of benign breast biopsies

• Associated with a 13% subsequent development of breast cancer (4x risk factor)

• Some may be an under-diagnosed ductal carcinoma in situ.

• Excisional Biopsy – do not need clear margins

Atypical Ductal Hyperplasia

ADH

NONINVASIVE CANCER

• Ductal Carcinoma In Situ (DCIS)– Malignant cells of Ductal Epithelium without

invasion of basement membrane.– 50-60% increased risk in ipsilateral breast.– Lumpectomy and XRT. Need clear margins.

DCIS

IDC

NONINVASIVE CANCER

• Lobular Carcinoma In Situ (LCIS)– Usually an incidental finding on biopsy– Risk of Breast Cancer increases 1% per year b/l

breasts. Usually Ductal CA.– Do not need clear margins– Mgmt: Close clinical follow up or prophylactic

B/L mastectomy.

CongenitalBreast disease

Amazia

Supernumerary Nipple

Acessory Breast(s)

TraumaticBreast disease

• Fat necrosis

• Hematoma

• Post Surgery

• D/D: Carcinoma

InflammatoryBreast disease

• Mastitis neonatorum– Occurs within few weeks

of birth

– Response to mothers hormone exposure (prolactin, estrogen)

– Resolves spontaneously

– Occasionally becomes infected

Other inflammatorycauses of breast pain

• Mondor’s disease– Thrombophlebitis lateral

thoracic vein

• Tietze’s disease– Osteochondritis, usually 2nd

& 3rd chostochondral junction

– Treatment for both: NSAID analgetics

Tumorsof the breast

• Cystosarcoma Phylloides– Rare– Age +/- 40– Rarely malignant

– Large– Mobile– Bosselated– Ulceration of skin

• Gynecomastia– Neonates

• Mother’s hormones

– Puberty• Hormonal imbalance

– Seniors• Androgen deficiency

– General Etiology:• Idiopathic• Endocrine

Testicular atrophy

Testicular tumors

Adrenal tumors

Hyperthyroidism

Pituitary tumors

• Genetic

XO, XXY, …• Liver disease• Bronchial carcinoma• Kidney failure• HIV• Medications

Digitalis, Spironolactone, Anabolic steroids, Marihuana, …

Tumorsof the breast

• Gynecomastia

– Thorough history and physical!

– Endocrine workup as indicated

– Biopsy & Mammogram when:• clinical suspicion

• persistence w/o clear cause

• age > 60

– Tx: • Observation

• Danazole / Tamoxifen

• Excision

Benign disease of the Breast

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