Benign Breast Disease Alireza Mohammadzadeh, MD Thoracic Surgeon.

Benign Breast DiseaseBenign Breast Disease

Alireza Mohammadzadeh, MDAlireza Mohammadzadeh, MD

Thoracic SurgeonThoracic Surgeon

Benign breast disorders & diseases Benign breast disorders & diseases encompass a wide range of clinical and encompass a wide range of clinical and

pathologic entitiespathologic entities

Understanding of these for Understanding of these for ::

clear explanation to affected womenclear explanation to affected women

appropriate treatment institutedappropriate treatment instituted

unnecessary follow upunnecessary follow up

FibroadenomaFibroadenoma

Predominantly in younger women aged 15 to Predominantly in younger women aged 15 to 25 years25 years

Usually grow to 1 or 2 cm and then are stableUsually grow to 1 or 2 cm and then are stable

Small f. (Small f. (<1cm<1cm) are considered ) are considered normalnormal

Larger f.(Larger f.(<3cm<3cm) are ) are disordersdisorders

Giant f. (Giant f. (>3cm>3cm) are ) are diseasedisease

Multiple f. (more than 5 in one breast) are Multiple f. (more than 5 in one breast) are diseasedisease

UltrasoundUltrasound

BenignBenign– Pure and intensely Pure and intensely

hyperechoichyperechoic– Elliptical shape (wider Elliptical shape (wider

than tall)than tall)– LobulatedLobulated– Complete tine capsuleComplete tine capsule

MalignantMalignant– Hypoechoic, Hypoechoic,

spiculatedspiculated– Taller than wideTaller than wide– Duct extensionDuct extension– microlobulationmicrolobulation

FibroadenomaFibroadenoma

Core-needle biopsyCore-needle biopsy

Treatment Treatment

Surgical removalSurgical removal

Cryoablation Cryoablation

observationobservation

Sclerosing adenosisSclerosing adenosis

Prevalent during childbearing & Prevalent during childbearing & perimenopausal yearsperimenopausal years

No malignant potentialNo malignant potential

Occasionally presents as a palpable massOccasionally presents as a palpable mass

Benign calcificationBenign calcification

Lesions up to 1 cm are called Lesions up to 1 cm are called radial scarradial scar

Larger lesions are called Larger lesions are called complex complex sclerosing sclerosing

Sclerosing adenosisSclerosing adenosis

Mimic of cancerMimic of cancer

On physical examination, by On physical examination, by mammography, at gross pathologymammography, at gross pathology

Wire localized excisionl biopsyWire localized excisionl biopsy

Benign Breast DiseasesBenign Breast Diseases

Glandular breast parenchymaGlandular breast parenchyma– MassMass– Asymmetric nodularityAsymmetric nodularity– PainPain

Nipple-Areolar ComplexNipple-Areolar Complex– DischargeDischarge– RashRash– RetractionRetraction

Surrounding breast skinSurrounding breast skin– DimplingDimpling

ManagementManagement

HistoryHistory

Clinical Breast ExamClinical Breast Exam

Breast imagingBreast imaging

Tissue samplingTissue sampling

TherapyTherapy

HistoryHistory

AgeAge– MenarcheMenarche– PregnancyPregnancy

Breast feedingBreast feeding

– MenopauseMenopause

Family HistoryFamily History

Prior biopsiesPrior biopsies

Hormone therapyHormone therapy

Clinical ExamClinical Exam

InspectionInspection– SkinSkin– SymmetrySymmetry– MassesMasses

PalpablePalpable– GlandGland– Axilla, Supraclavicular Axilla, Supraclavicular

spacesspaces– Nipple-areola complexNipple-areola complex

Breast MassBreast Mass

Breast CystsBreast Cysts– Fluid-filled Fluid-filled – 1 out of every 14 women1 out of every 14 women

50% multiple and recurrent50% multiple and recurrent

– Hormonally influencedHormonally influenced– Needle aspiratedNeedle aspirated

Breast CystBreast Cyst

Breast MassBreast Mass

Phyllodes TumorPhyllodes Tumor– Proliferation of connective tissue with ductal Proliferation of connective tissue with ductal

elementselementsWhorled and cellular stromaWhorled and cellular stroma

– Firm, lobulatedFirm, lobulated– 2 to 40 cm in size2 to 40 cm in size– 10% malignant10% malignant– TreatmentTreatment

Wide excisionWide excision

Fibrocystic DiseaseFibrocystic Disease

Clinical, mammographic and histologic Clinical, mammographic and histologic findingsfindings

Exaggerated response from hormones Exaggerated response from hormones and growth factorsand growth factors– Cyclical painCyclical pain– Nodularity – upper outer quadrantsNodularity – upper outer quadrants

Fibrocystic DiseaseFibrocystic Disease

HistologyHistology– AdenosisAdenosis– Apocrine metaplasiaApocrine metaplasia– FibrosisFibrosis– Duct ectasiaDuct ectasia– Mild ductal hyperplasiaMild ductal hyperplasia

Fibrocystic DiseaseFibrocystic Disease

Risk FactorsRisk Factors– Dense breastDense breast– Sclerosing adenosisSclerosing adenosis– Atypical ductal, papillary, or lobular Atypical ductal, papillary, or lobular

hyperplasiahyperplasia

Breast PainBreast Pain

Cyclical pain – hormonalCyclical pain – hormonal– Dull, diffuse and bilateralDull, diffuse and bilateral– Luteal phaseLuteal phase– TreatmentTreatment

ReassuranceReassuranceNSAIDSNSAIDSEvening primrose oilEvening primrose oil

Non-cyclical painNon-cyclical pain– Non-breast vs breastNon-breast vs breast– ImagingImaging– TreatmentTreatment

ReassuranceReassuranceNSAIDSNSAIDSEvening primrose oilEvening primrose oil

Breast InfectionsBreast Infections

MastitisMastitis– Generalized cellulitis of the breastGeneralized cellulitis of the breast– Ascending infection Ascending infection subareolar ductssubareolar ducts

commonly occurs during lactationcommonly occurs during lactation– Staph. aureusStaph. aureus

– Erythema, pain, tendernessErythema, pain, tenderness

MastitisMastitis

TreatmentTreatment– AbxAbx– Continue to breast Continue to breast

feedfeed– Close follow-upClose follow-up

Breast AbscessBreast Abscess

AbscessAbscess– Breast tissueBreast tissue– TreatmentTreatment

AbxAbx

Needle aspirationNeedle aspiration

Incision and drainageIncision and drainage

Nipple DischargeNipple Discharge

PhysiologicPhysiologic– BilateralBilateral– Involves multiple ducts Involves multiple ducts – Heme (-)Heme (-)– Non-spontaneousNon-spontaneous

Nipple DischargeNipple Discharge

PathologicPathologic– UnilateralUnilateral– SpontaneousSpontaneous– Heme (+)Heme (+)

Most common cause intraductal papillomaMost common cause intraductal papilloma

Bloody Nipple DischargeBloody Nipple Discharge

Intraductal PapillomaIntraductal Papilloma

Single ductSingle duct

BenignBenign

4% of intraductal ca4% of intraductal ca

ImagingImaging

MammographyMammography

UltrasoundUltrasound

MRIMRI

MammographyMammography

Screening toolScreening tool– Age of 40Age of 40

Estimated reduction Estimated reduction in mortality 15-25%in mortality 15-25%

10% false positive 10% false positive raterate

Densities & Densities & calcificationscalcifications

CalcificationCalcification

MacrocalcificationsMacrocalcifications– Large white dotsLarge white dots– Almost always noncancerous and require no Almost always noncancerous and require no

further follow-up. further follow-up.

MicrocalcificationsMicrocalcifications– Very fine white specks Very fine white specks – Usually noncancerous but can sometimes be Usually noncancerous but can sometimes be

a sign of cancer.a sign of cancer.– Size, shape and patternSize, shape and pattern

BI-RADSBI-RADS

BI-RADS BI-RADS ClassificationClassification

FeaturesFeatures

00 Need additional imagingNeed additional imaging

11 Negative – routine in 1 yrNegative – routine in 1 yr

22 Benign finding – routine in 1 yrBenign finding – routine in 1 yr

33 Probably benign, 6mo follow-upProbably benign, 6mo follow-up

44 Suspicious abnormality, biopsy Suspicious abnormality, biopsy recommendedrecommended

55 Highly suggestive of malignancy; Highly suggestive of malignancy; appropriate action should be takenappropriate action should be taken

UltrasoundUltrasound

Not a screening toolNot a screening tool

Palpable vs cysticPalpable vs cystic

Mammographic detected lesionMammographic detected lesion

UltrasoundUltrasound

Malignant or Benign

Malignant vs Benign

MRIMRI

High risk patientsHigh risk patients– Personal history of breast caPersonal history of breast ca– LCIS, atypiaLCIS, atypia– 11stst degree relative with breast cancer degree relative with breast cancer– Very dense breastVery dense breast

High sensitivity (95-100%)High sensitivity (95-100%)– 10-20% will have a biopsy10-20% will have a biopsy

MRIMRI

Pre Gad Post Gad Color Overlay

DiagnosisDiagnosis

Fine needle aspiration Fine needle aspiration – CytologyCytology

Core biopsyCore biopsy– Image guidedImage guided– StereotacticStereotactic

Excisional biopsyExcisional biopsy– Needle localizationNeedle localization

FNAFNA

Fast, inexpensiveFast, inexpensive

96% accuracy96% accuracy

Institution dependentInstitution dependent

Unable to differentiate Unable to differentiate b/w in situ vs CAb/w in situ vs CA

Core Needle BiopsyCore Needle Biopsy

14-18 gauge spring loaded needle14-18 gauge spring loaded needle

TissueTissue

Multiple Multiple

Large Core BiopsyLarge Core Biopsy

6-14 gauge core6-14 gauge core

Large samplesLarge samples

Single insertionSingle insertion

Core biopsy Vacuum Assisted

Excisional BiopsyExcisional Biopsy

Atypical lesionsAtypical lesions

LCISLCIS

Radial scarRadial scar

Atypical papillary lesionsAtypical papillary lesions

Radiologic-pathologic discordanceRadiologic-pathologic discordance

PhyllodesPhyllodes

Inadequate tissue harvestingInadequate tissue harvesting