Benign breast disorders

BENIGN BREAST DISORDERSDR. MINHAJUDDIN KHURRAM

OUTLINE

Anatomy (in brief)

Investigations

Anamolies

Injury to breast

Infections

Benign breast disease

Benign Neoplasms

Breast cysts

Nipple

ANATOMY

ANATOMY

ANATOMY

ANATOMY

ANATOMY

INVESTIGATIONS

Mammography

Ultrasound

MRI

Needle biopsy/ cytology

Large-needle with vacuum system

Triple assessment

INVESTIGATIONS

Mammography Direct radiograph

Exposure to low-voltage, high amperage Xrays

Exposure of 0.1 cGy (very low)

Sensitivity increases with age

Normal mammograph does not exclude carcinoma

INVESTIGATIONS

Ultrasound: USG more useful in young women : as breast is more dense

Mammographs are difficult to interpret

Distinguish cysts from solid lesions

Locate impalpable lumps

Diagnosis of axillary pathology

USG guided aspiration and biopsy

INVESTIGATIONS

MRI Distinguish scar from recurrence for women with previous surgeries

Becoming the standard when lobular ca is diagnosed To assess the multicentricity and multifocality

Best imaging modality for women with implants

Less useful in axilla pathology

Biopsy possible but difficult than USG guided

INVESTIGATIONS

Needle biopsy / cytology To obtain histology under local ansthesia

Spring loaded core needle biosy using 21G or 23G 10 ml syringe

Multiple passes with negative suction

Fixed or dried to view under microscope

Least invasive technique of obtaining a cell diagnosis

Receptor staining is possible

False negetives: cannot differentiate invasive carcinoma from in situ

Large-needle biopsy Less sampling error

Using 8G or 11G

More helping in calcifications

INVESTIGATIONS

Triple Assessment Clinical diagnosis

Imaging

Tissue diagnosis

Accuracy of 99.99%

ANAMOLIES

Amazia:

Athelia

Polymazia

Polythelia

Micro-mastia

Diffuse Hypertrophy

Gynacomastia

ANAMOLIES

Amazia: Congenital absence of breast (unilateral/ bilateral)

More common in males

Poland’s syndrome*

Athelia Congenital absence of nipple

ANAMOLIES

Polymazia Accessory breast tissue

Along the “MILK LINE”

Axilla is the commonest site

Other sites: groin, thigh and buttocks*

They function during lactation

Treatment is excision

Polythelia Multiple nipples along the “MILK LINE”

ANAMOLIES

Micromastia: due to hypo-functioning ovary (congenital defect); breasts are smaller

Diffuse Hypertrophy (Benign virginal hypertrophy) Occurs sporadically in otherwise normal female

At puberty or first pregnancy

Enormous size (may reach upto knees when sitting)

Rarely unilateral

Pathophysiology unknown

Some response to anti-oestrogen drugs*

Plastic surgical repair is the only definitive treatment

ANAMOLIES

Gynacomastia Breast-like swelling in males*

The breast is enlarged, not the nipple and areola

Unilateral/ bilateral

Mostly Physiological Oestradiol excess

Testosterone deficiency

ANAMOLIES

Gynacomastia Pathophysiology

Oestrogen excess: may result from an increase of oestradiol from

Testicular tumors

Leydig cell / Sartoli cell tumour

Choriocarcinoma

Embryonal carcinoma

Non testicular tumors

Adrenal cortical neoplasm

Lung carcinoma

Hepatocellular carcinoma

Endocrine disorders

Hyperthyroidism

Hypothyroidism

Liver cirhosis

ANAMOLIES


Androgen deficiency states

Aging

Kline-felter syndrome

Congenital anorchia

Heriditary defect in androgen biosynthesis

ACTH deficiency

Renal Failure

Secondary Testicular fauilure

Trauma

Orchitis

Crytochordism

Irridiation

Varicocoele

ANAMOLIES


Drugs

Oestrogen realted activity activity (Digitalis, Anabolic steroids)

Anti-testosterone ( cemitidine, phenytoin, spironolactone, diazepam)

Enhancing oestrogen activity (reserpine, theophylline, frusemide)

Pathology Breast show fibro-fatty proliferation rather than acinar growth!!

ANAMOLIES

Gynacomastia Clinical features

No complaints other than enlargement of breast

May be associated with slight pain

Breast tissue can be moved over the underlying muscle

Serious psychological consequences

Can be associated with various pathologies

ANAMOLIES

Gynacomastia Treatment

Idiopathic gynacomastia resolves by itself so “wait and waitch”

Androgen deficiency: administer testosterone

Danazol, tamoxifene

No cause elicited: surgical excision by sub-areolar mastectomy

In case of suspected pathology: HPR should be sent for

INJURY TO BREAST

Haematoma: Resolving haematoma gives impression of a lump

In the absence of an overlying bruise, diagnosis is difficult unless biopsied

Traumatic Fat Necrosis: May be acute or chronic

Some sort of injury: Direct or Indirect

Diagnosis is confused with ca.

Prsents as a painless lump, firm and irregular

Some skin tethering

No retraction of nipple may be present)

No axillary lymph nodes

History of trauma*

INJURY TO BREAST

Traumatic Fat Necrosis: Pathophysiology

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

Chronic cases mimic new lumps

Treatment: Whenever in doubt excisional biopsy should be done

INFECTIONS

Acute Inflammatory Mastitis

Chronic Inflammatory Mastitis

Sub-areolar abscess

Duct ectesia / periductal mastitis

Mastitis of infants

Retromammary abscess

Tuberculosis

Syphilis

Mondor’s Disease

INFECTIONS

Acute Inflammatory Mastitis Aetiology

Acute bacterial mastitis is very common: associated with lactation

Develepment of cracks and bruises in the nipple: ascending infection

Staph aureus infection, penicillin resistant if nosocomial*

Streptococcus cuases more toxic symptoms

Blockage of one or more of the lactiferous ducts with epithelial debris*

Retracted nipple*

INFECTIONS

Acute Inflammatory Mastitis Clinical features

Acute mastitis

Redness, oedema, induration

Cellulitis Abscess

Redness, oedema and induration are somewhat localized

Fluctuation is very difficult to elicit

INFECTIONS

Acute Inflammatory Mastitis Treatment:

Cellulitis stage: breast support + local heat + analgesia + antibiotics

Feeding from the affected site can be continued if patient can manage

Absces stage: whenever pus has formed, it has to be let out

Antibiotics at this stage will lead to the formation of Antibioma*

Incision and drainage to be done*

Latest view: Repeated aspirations have the same result

Can be accomplished with USG guidance

No scar and patient can breast feed

INFECTIONS

Acute Inflammatory Mastitis Treatment:

Incision and drainage: needed only if there is marked skin thinning

Radial incision in the most prominent part

Counter-incision if it is not the dependent part

Break all loculi

Pack loosely with gauze, drain may be kept

Give firm support.

INFECTIONS

Chronic Inflammatory Mastitis Continuous antibiotic treatment

Improper drainage of the abscess

Too tight packing of the abscess cavity

Has thick fibrous cavity

May have sterile pus

May mimic carcinoma

Incision of the cavity wall and curettage of the walls

INFECTIONS

Sub-areolar abscess Not a true mastitis

Results from an infected sebaceous gland of Montogomery of areola

Or follow a furuncle near the areola

Incision and drainage of pus OR excision of the sebaceous cyst

INFECTIONS

Sub-areolar abscess/ Periductal mastitis/ Duct ectesia/ Plasma cell mastitis More common in smokers

Develops behind the nipple pointing towards the areola; avoiding the tough fibromuscular tissue of the areola

Dilatation of the larger peri-areolar ducts

Usually 6-8 ducts are involved, rest are normal

May be bilateral

Condition may mimic carcinoma with an indurated mass beneath the areola

INFECTIONS

Sub-areolar abscess/ Periductal mastitis/ Duct ectesia/ Plasma cell mastitis

INFECTIONS

Sub-areolar abscess/ Periductal mastitis/ Duct ectesia/ Plasma cell mastitis Duct dilatation theories:

Hormonally induced muscular relaxation of duct wall

Inadequate absorption of secretions

Obstruction of duct with squamous debris (but how bilateral?)

Smoking arteriopathy periductal inflammation damage to the duct wall duct dilatation stasis infection or healing by fibrosis*.

Cessation of smoking prolongs the long term survival.

INFECTIONS

Sub-areolar abscess/ Periductal mastitis/ Duct ectesia/ Plasma cell mastitis Clinical features

Mostly seen after menopause

Diffuse lump in the sub-areolar region

Differentiate with ca.

Nipple retraction (slit like)

Nipple discharge

Clasically it is thick and creamy / but may be greenish

Bloody discharge at times

Chronic milk fistula (on and off with abscess)

No adenopathy

INFECTIONS

Sub-areolar abscess/ Periductal mastitis/ Duct ectesia/ Plasma cell mastitis Treatment:

Exclude malignancy by mammography

If unsure: excision of the mass

Antibiotics

Fistula; fistulectomy with excision of the involved duct

Recurrent plasma cell mastitis : Hadfield’s operation

Remove all the terminal ducts*

INFECTIONS

Mastitis of infants Drop of colourless fluid can be expressed on the third day of life

Witch’s milk

Seen only in full-term infants

Cause: Stimulation by prolactin from the mother’s milk

INFECTIONS

Retromammary abscess: This conditionis nothing to do with breasts

Infection arises from Infected haematoma

Tuberculosis of the ribs

Osteomyletis of the ribs

Incision and drainage by Guillard Thomas incision breast lifted and chest wall drained corrugated rubber drain kept dressing done.

Appropriate antibiotics

INFECTIONS

Tuberculosis of Breast Usually secondary to:

Pulmonary tuberculosis

Chest wall tuberculosis

Cervical lymph node tuberculosis

Mediastenal tuberculous lymphadenitis

Blood borne

Clinical features: Parous women mostly

Primary focus somewhere else in the body

Multiple chronic abscesses with bluish hue

INFECTIONS

Tuberculosis of Breast Clinical features:

Cold abscess: no or very little signs of inflammation

Discharging sinuses, may be multiple

Anti-tubercular therapy

Mastectomy only with persistent residual infection

INFECTIONS

Syphilis: All three stages can be seen in breast

Primary: Primary chancre seen on the nipple

Secondary: Mucous patches in the sub-mammary folds; with diffuse mastitis

Diffuse Syphilitic Mastitis)

Tertiary: Gumma (very rare)

INFECTIONS

Mondor’s disease Superficial thrombophlebitis of the superficial veins

No known cause

Not encountered in arm

Clinical feature: Thrombosed sub-cutaneous chord, usually attached to the skin

May be painful and tender

When arm is raised; a groove alongside the vein is seen

Treatment: Rest to the arm and firm support to the breast*

D/D: lymphatic permeation of occult malignancy to be ruled out

BENIGN BREAST DISEASE (ANDI)

Concept: Breast in in dynamic change throughout reproductive life

Super-imposed by menstrual cycles and pregnancies

Concept of ANDI was first given by L.E. Hughes et.al of Cardiff University (1987)

This concept recognizes conditions as being within a spectrum from normal to mild abnormalities to disease process.



Pathology: The disease consists centrally of four features:

Cyst formation

Fibrosis

Hyperplasia

Papillomatosis


Pathology: Cyst formation: Two types of cysts are found

Simple cysts: Formed due to passive diffusion of plasma through simple membrane to cause cyst

Aspirate from simple cysts are similar to plasma in Na:K ratio

These are single and do not recur with no risk of malignancy

Complex cysts: Lined by apocrine epithelium cahractereised by large columnar cells like those in sweat glands

These cysts arise from a single lobule.*

The solitary draining duct is blocked and cysts become very large

Multiple cysts: but all may not be palpable


Pathology: Complex cysts:

Complex cysts tend to recur

May be associated with malignancy

Classic diffuse cystic disease :Schimmelbusch’s Disease

One large cyst becomes tense and blue domed: “Blue-domed cyst of Bloodgood”

Cysts usually contain greyish green desquamated cells

Cysts may contain blood due to haemorrhage


Pathology: Fibrosis: Fat and elastic tissue is replaced by white fibrous tissue

Interstitium is infiltrated with chronic inflammatore cells

This fibrous tissue compresses the ducts and distorts the acinar patterns.

Hyperplasia: Hyperplasia of epithelium of ducts and acini Hyperplasia of both glandular and connective tissue

Ductal lumen may get full of cells

Can be a pre-malignant condition if epitheliosis is more

Papillomatosis: Hyperplasia may be extensive enough to cause papillomatous growth within the ducts


Clinical feature: A benign discrete lump in the breast is commonly a cyst or fibroadenoma

Lumpiness : described by patient as heaviness in the upper outer quadrant

Mastalgia: Cyclical mastalgia with nodularity (fibrocystic disease)

Non-cyclical mastalgia


Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Aetiology: It is an Aberration in normal involution (ANI) of breast

Hyper-oestrogenism

Increased estrogen OR

Decreased progesterone

Exessive caffeine

Inadequate essential fatty acids

Pathology: Cyst formation

Fibrosis

Hyperplasia

Papillomatosis


Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Clinical feature:

Cyclical mastalgia: breast pain has a definitive relation to the menstrual cycle

40% of the patients present with cyclical mastalgia in breast clinic

Discomfort lasts for a varying period of time (for months) then disappears, to relapse again after years

Pain is mostly located in the upper-outer quadrant

May radiate to axilla, chest wall or side of the arms

No mammographic findings


Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Clinical feature:

Lumps or lumpiness: The next mode of presentation

Upper-outer quadrant

Just before menstruation both lump and pain increase with tenderness

On examination: Nodular lesion with lumps, lumps are inseparable

Best palpated between thumb and fingers

Easily movable lumps, not adherent

No axillary lymph nodes enlarged

No retraction of nipple


Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Management of cyclical mastalgia

Breast pain monthly diary

Re-assurance

Breast support

Evening primrose oil

Danazol

Bromocriptine

Tamoxifene

MedroxyProgesterone

Oral contraceptives

Avoid conception for three months when using bromocriptine and danazol


Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Management of lumpy breast

In case of no discrete lump (supported by mammography)

Reassurance

Ask the patient to come in different phase of cycle*

In case of lumps

Mammography and USG to exclude other conditions

Biopsy from a single or multiple lumps


Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Management of lumpy breast

Surgical management:

Indications:

Intolerable pain

Lump inspite of best conservative management

Presence of concomitant malignancy cannot be excluded

Older patients causing anxiety

Excision biopsy by circumareolar incision

If not possible then sub-mammary of Gaillard Thomas

In case of failure then radial or curved incision over Langer’s line


Sclerosing adenosis: It is an AND of normal breast

Characterised by terminal duct and myo-epithelial proliferation

Distorted glandular proliferation: loss of normal lobular architecture

May be multifocal

May calcify: mimics carcinoma

Causes mastalgia :perineural invasion causing “trigger spot zones”

Causes mastalgia rather than lump

Lump: smooth relative mobile mass

Treatment: Reassurance and management of mastalgia

NON-CYCLICAL MASTALGIA

Cyclical nodularity: Mass rather than pain, being the chief complaint

Teenagers mostly affected /premenopausal women may sometimes be affected

A large and uncomfortable swelling develops in the upper outer quadrant

Vague discomfort may be associated

Examination: Diffuse nodular swelling with tenderness

Management: Reassurance: may resolve by next cycle

Mammography

Aspiration cytology in older women


No co-relation with the menstrual history

More commonly seen in peri-menopausal women

Less understood

Mostly felt in the medial quadrant of breasts

Described as “burning” or “dragging”

Sometimes well localized at “trigger spot zones”

May be associated with Periductal mastitis

50% doesn’t arise from breast.


Management: Exclude extra mammary causes like chest pain*

Non- steroidal analgesics

Injection with local ansthetics in the trigger spots

Surgical excision of trigger spot zone (NOT WIDELY ACCEPTED)

BENIGN NEOPLASMS

Fibroadenoma

Phyllodes tumour

Duct papilloma

Papillary cystadenoma

BENIGN NEOPLASMS

Fibroadenoma The most common tumour female breast

It is composed of both glandular and fibrous tissue

Aetiology: It is AND May be seen along with Fibroadenosis (ANI)

Pathology Increased sensitivity to oestrogen

More common in blacks

Mostly spherical; may be multinodular

They typically stop growing after 2 to 3 cm size

May harbor lobular carcinoma in situ

BENIGN NEOPLASMS

Fibroadenoma Types:

The Pericanalicular (hard fibroadenoma): it is firmer, smaller and moves well within the breast tissue “BREAST MOUSE”

The Intracanalicular (Soft fibroadenoma): is relatively less firm, grows larger with profuse connective tissue “INTRADUCTAL MYXOMA”

Both variants can co-exist

BENIGN NEOPLASMS

Fibroadenoma Clinical features

The pericanalicular occurs in younger females (15 to 30 yrs)

The intracanalicular affects older age group (30 to 50 yrs)

Painless, slow growing solitary lump (pain when associated fibroadenosis)

Mostly seen in the lower part of the breast

Multiple may be present; 10% cases

Intracanalicular can grow large causing pain due to stretching skin

No discharge per nipple

BENIGN NEOPLASMS

BENIGN NEOPLASMS

Fibroadenoma On examination:

No visible swelling ( large intracanaliclar may be visible)

Freely mobile; more in young girls*

Firm consistency

No axillary lymph nodes

Treatment: Present trend: women under 25 yrs of age, routine excision is avoided

The fibroadenoma grows upto 3 cm in 5 yrs

Thereafter gradually become smaller

BENIGN NEOPLASMS

Fibroadenoma Treatment:

In case of suspected pathology: excision biopsy is the treatment of choice

Enucleation of the pericanacular variety

Excision of the intracanalicular variety

Peri-areolar or Sub mammary incision (Gaillard Thomas’s incision)

If not possible then radial or curved incision over Langer’s lines

BENIGN NEOPLASMS

Giant fibro-adenoma Grows more than 5 cm in size

Bimodal age of presentation (at puberty and peri-menopause)

More common in blacks

Epithelial hyperplasia and atypia

Characterised by rapid growth

Differentiate from phyllodes tumour, Benign virginal hypertrophy

On examination: Enlarged breast

Displaced nipples

Stretched and shiny skin

Dilated veins

Skin necrosis may occur

Treatment: Enucleation

BENIGN NEOPLASMS

Phyllodes Tumour Also called Cystosarcoma Phyllodes, Serocystic Disease Of Brodie or Benign

Cystosarcoma

Mostly seen in premenopausal women (40yrs age)

Show a wide range of histology From an almost benign condition resembling fibroadenoma

To the ones with high mitotic index

Tumour has irregular projections: cause for recurrences

Clinical features: Presents as massive tumour

Unevenly bosselated surface

BENIGN NEOPLASMS

Phyllodes Tumour Clinical features:

Pressure necrosis of overlying skin

Or warm, red, shiny skin with dilated veins

Normal nipple

Firm consistency

Smooth margins

Not fixed: the stretched skin can be picked up

No axillary lymph node involvement

Known for local recurrence

BENIGN NEOPLASMS

BENIGN NEOPLASMS

Phyllodes Tumour Treatment:

Younger women (Benign end of spectrum): Simple enucleation

Older patients (Malignant end of the spectrum) :Wide excision with 1 cm margin or more

Recurrences: mastectomy with recostruction

BENIGN NEOPLASMS

Duct Papilloma Benign tumour, usually small

Arising from ther lining epithelium of lactiferous duct

It may too small for clinical palpation, but may obstruct a duct for cyst formation

Not a pre-cancerous condition*

Usually single and unilateral

Papillonama has a stalk

Papilloma vs papillomatosis (epithelial hyperplasia without a stalk)

BENIGN NEOPLASMS

Duct Papilloma Clinical features

Age 30 to 50 yrs

Bloody discharge: commonest presentation

Small and soft lump palpable beneath the areola or nipple; often difficult

Discharge from the affected duct on pressing the lump

May present with a cystic swelling; due to impalpable lump blocking the duct

No lymph nodes are affected

BENIGN NEOPLASMS

Duct Papilloma Treatment:

Complete excision of the affected duct Microdochectomy

Wedge resecteion

If not palpable then gently probe the affected duct

Carry on the resection with 1mm distance from the probe

Papilloma is mostly situated 4-5 cm away from the nipple

BENIGN NEOPLASMS

Papillary cystadenoma: Swellings or lumps are composed of cysts

Into these cysts papillomatous processes extend

Cysts are almost filled with these papillomatous processes

Swelling feels soft: not cystic

Management Excision and biopsy

Benign condition

BREAST CYSTS

Type I Classification

A FROM THE DUCTS: Fibroadenosis

Blue domed cyst of Bloodgood

Galactocoele

Serocystic disease of Brodie

Papillary cystadenoma

Intradeuctal papillary carcinoma

BREAST CYSTS

Type I Classification

B FROM THE STROMA Blood Cyst (encapsulation of haematoma)

Lymphatic cyst

Hydatid cyst

Colloid Degeneration of carcinoma

BREAST CYSTS

Type II Classification

A FROM MAMMARY DYSPLASIA Fibroadenosis

Cyclical nodularity

Bluedomed cyst of Bloodgood

Sclerosing adenosis

B RETENTION CYSTS Galactocoele

BREAST CYSTS

Type II Classification

C FROM TUMOURS

Benign Papillary cystadenoma

Serocystic disease of Brodie

Malignant Intracystic papillary carcinoma

Colloid or mucinous carcinoma

Medullary carcinoma

D MISC Lymphatic cyst

Hydatid cyst

Blood cyst

BREAST CYSTS

Clinical presentation Mostly seen in the last decade of reproductive life*

Usually single in presentation, or just single cyst is palpable

Relation to menstruation

Sudden appearance (subclinical state)

Mammography

Aspiration of cyst (for confirmation of diagnosis)

Treatment: Aspirate when in doubt

Blood, mass after aspiration or recurrence: malignancy

No blood; no mass after aspiration : Benign nature (Mostly Fibroadenosis)

Follow up after 2 months

BREAST CYSTS

Treatment: Diagnosis in Doubt / multiple cyst: excision and biopsy

Theoritically: Patients with breast cysts are at increased risk of malignancy

BREAST CYSTS

Galactocoele: Accumulation of milk and amorphous epithelial debris

Blockage of main duct

Presents as sub-areolar cyst

Presents in patients who have just cased breast feeding

Management: Excision of the affected duct

NIPPLE

Nipple retraction

Discharge per nipple

Cracked nipple

NIPPLE

Nipple retraction Causes:

Benign horizontal inversion

Duct ectesia

Carcinoma

Post surgical

Types: Slit-like: Duct ectesia

Circumferential: Carcinoma /Post surgical

May cause retention of secretions

NIPPLE

Nipple retraction Treatment:

Spontaneous resolution during pregnancy or lactation

Mechanical suction device

Simple cosmetic surgery

Ducts will have to be divided

NIPPLE

Discahrge per Nipple:

A. Discharge from the surface Paget’s disease

Skin diseases (eczema, psoriasis)

Rare cuases (chancre)

B. Discharge from a single duct

Blood stained Intraduct papilloma

Intraduct carcinoma

Duct ectesia

Serous (any-colour) Fibrocystic disease

Duct ectesia

Carcinoma

NIPPLE

Discahrge per Nipple:

C. Discharge from more than one duct

Blood- satined Carcinoma

Ectesia

Fibrocystic disease

Black or green Duct ectesia

Purulent Infection

Serous Fibrocystic disease

Duct ectesia

NIPPLE

Discahrge per Nipple: Management: Mammography in those more than 35 yrs of age

Microdochectomy: Probe and remove a single duct upto 5cm

Hadfield operation: Cone excision of the major ducts* Patient will not be able to breastfeed

Underlying pathology to be dealt with

NIPPLE

Other conditions: Cracked nipple: fore-runner of acute mastitis

Breast feeding should be rested for 48 hrs

Milk to be evacuated with a breast pump

Resume feeding as soon as possible

Papilloma of nipple: Same features as cutaneous papilloma

Excision with tiny disc of skin

Eczema: Usually associated with eczema elsewhere in the body

0.5% hydrocortisone

THANK YOU

Benign breast disorders

Health & Medicine