Tara PowerPoint Benign Breast Disease

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Benign Breast Conditions

Tara Sorg, M.H.A. R.T(R) (M) (BD)

[email protected]

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• Define and identify benign breast conditions• Identify the symptoms of benign breast conditions• Identify the correlation of benign breast

conditions and the risk of breast cancer• Demonstrate the diagnosis of benign breast

conditions

Objectives

Benign Breast Conditions

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Benign Breast Conditions

Definition of Benign Breast Disease

Benign breast conditions (also known as benign breast diseases) are non-cancerous disorders or changes in the breast. There are a variety of benign breast conditions.

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Benign Breast Conditions

Benign Breast Diseases• Cysts• Fibroadenomas• Hyperplasia (Typical and Atypical)• Intraductal Papillomas• Sclerosing Adenosis• Radial Scars• Galactocele• Lipoma• LCIS• Phyllodes Tumor

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Benign Breast Conditions

Symptoms

• Benign breast conditions are not life-threatening, but can cause bothersome symptoms such as a lump or nipple discharge.

• Certain benign conditions are linked with a higher risk of developing breast cancer in the future.

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Benign Breast Conditions

Cysts• Small fluid-filled sacs found in the breast• Most commonly found in premenopausal women • Do not increase the risk of developing breast cancer• May be felt by patient if large enough, otherwise seen

using mammography and breast ultrasound• Cause of cysts are unknown• No necessary follow-up unless causing discomfort to

the patient• Cyst aspiration is a treatment option

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Benign Breast Conditions

Case Study• 39 y/o presents with right breast lump in the UOQ• Tenderness at site of lump x 1 month• No discharge or inversion of nipple• 3D mammogram demonstrates a 1.7 cm oval-shaped nodule• There is also a possible 1.2 cm oval-shaped nodule present in

the subareolar region demonstrated on the MLO view• No obvious spiculation• >75% density

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Benign Breast Conditions

C-View Images

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Benign Breast Conditions

Ultrasound

Ultrasound demonstrates a simple cyst in the 10-11:00 position, 6 cmfn. It measures 2.7 x 1.5 x 2.5 cm. Several smaller cysts are seen within its immediate vicinity

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Benign Breast Conditions

Fibroadenomas• Fibroadenomas are benign tumors • They are most common in younger women (between the

ages of 15 and 35) • Most fibroadenomas do not increase the risk of breast

cancer• If a fibroadenoma causes discomfort, it may be excised• Blood flow may be present• Often followed using ultrasound every six months (up to 1

to 2 years) to track any change in size

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Benign Breast Conditions

Case Study

• 23 y.o. female• Right palpable mobile lump• Measures 2.3 x 1.2 x 1.6 cm• Lobulated homogeneous solid mass• Blood flow present• Followed over a sixth month period with no

significant change in size

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Benign Breast Conditions

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Benign Breast Conditions

Case Study

• 40 y.o. female• 0.7 x 1 x 1.3 cm hypoechoic mass• Right breast; 7:00 position• Moderate suspicion for malignancy• U/S of right breast demonstrates a well-circumscribed

macrolobulated hypoechoic lesion• No shadowing present• Given the solid appearance, biopsy recommended

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Benign Breast Conditions

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Benign Breast Conditions

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Benign Breast Conditions

Biopsy Results

• Patient underwent ultrasound-guided core biopsy• Pathology findings confirm a benign fibroadenoma• Six month follow-up ultrasound recommended to

look for any post-procedure changes

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Benign Breast Conditions

Hyperplasia

• High rate of mitosis or overgrowth (proliferation) of cells

• Most often occurs on the inside of the lobules (milk ducts) in the breast

• Two types of hyperplasia• Typical (Usual)• Atypical

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Benign Breast Conditions

• 50 y.o. female • Presents with 5 day history of spontaneous

bloody discharge; left breast• No breast lump or skin changes• Mild diffused breast pain• Physical exam demonstrated blood coming from a

single duct at the 3:00 position

Case Study

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Benign Breast Conditions

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Benign Breast Conditions

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Benign Breast Conditions

Ultrasound-Guided Biopsy

• Subareolar ultrasound demonstrates slightly prominent ducts with no debris

• Fairly well circumscribed hypoechoic lesion is seen measuring 9x4 mm

• No shadowing, but of solid nature

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Benign Breast Conditions

Ultrasound and Ultrasound-Guided Biopsy

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Benign Breast Conditions

Pathology

• Ultrasound-guided biopsy was performed and sent to pathology

• Indication: Hypoechoic lesion• Pathologic diagnosis: Atypical ductal

hyperplasia• Recommended follow-up: Excision of area

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Benign Breast Conditions

ADH• Classification between TDH and ADH is dependent on

histological features• High reproducibility is important classification• Typical cells appear heterogeneous and atypical are

homogeneous in cell type• ADH is more related to DCIS than typical• ADH is rare and seen in approx. 4% of symptomatic benign

biopsies• ADH is more commonly linked to sreen-detected benign calcs

(31%) and is more commonly an incidental finding• Patients are at a 4-5x higher risk of developing BrCA with a h/o

ADH• Risk is even higher if patient has a first degree relative with BrCA

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Benign Breast Conditions

ADH

Three components to the diagnosis of ADH:1. Pattern2. Cytology3. Disease Extent

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Benign Breast Conditions

Intraductal Papillomas• Small growths that occur in the lobules• Can cause nipple discharge• Sometimes presents as a lump• Most commonly seen in women 35-55 years old• May be removed by a breast surgeon• No follow-up necessary• Does not increase a woman’s risk of developing

breast cancer

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Benign Breast Conditions

Case Study• 51 y.o. female• Perimenopasual • Presents with bloody discharge from the right

nipple• Physical examination revealed no evidence of

lumps, asymmetry or dimpling of the skin • Small amount of bloody fluid appeared when

pressure was exerted on the nipple

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Benign Breast Conditions

Ultrasound demonstrates a solid mass measuring 2.45 mm within a dilated duct

Ultrasound

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Benign Breast Conditions

Recommendation• After reviewing the negative mammogram from six

months prior, immediate surgical consultation was recommended

• Mass was excised • Histological examination revealed it was benign

(intraductal papilloma, central)• Following excision, all of the patient's symptoms

disappeared• No follow-up required

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Benign Breast Conditions

Sclerosing Adenosis• A group of small breast lumps caused by enlarged lobules• A lump may be felt and may be painful• Can be found mammographically• May be mistaken for breast cancer due to its shape and feel• A biopsy is often necessary to rule out breast cancer• Sclerosing adenosis does not need medical treatment• This can be found alongside an existing or developing cancer

and/or atypical hyperplasia

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Benign Breast Conditions

Case Study

• 40 y.o. female• Presents with right breast lump at 6:00• Imaging also shows amorphous calcifications• U/S guided biopsy recommended

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Benign Breast Conditions

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Benign Breast Conditions

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Benign Breast Conditions

Biopsy Results

• Right stereo core biopsy preformed at 6:00• Results show proliferative fibrocystic disease with cellular

change and focal sclerosing adenosis• Calcifications look to be benign; repeat magnification

views in six months• Microscopic descriptions in addition to above

demonstrates typical ductal hyperplasia and intraductal cells and cysts

• 6 month f/u recommended

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Benign Breast Conditions

Case Study

• 50 y.o. female• Cluster of pleomorphic calcifications seen on the

CC and MLO views• Left UOQ of breast• Due to irregular borders, biopsy recommended• Stereo-core biopsy

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Benign Breast Conditions

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Benign Breast Conditions

Biopsy Results

• Pathology demonstrates non-proliferative fibrocystic disease

• Rare benign focus suggesting early sclerosing adenosis

• Calcifications present in benign ducts• Findings are concordant with imaging features

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Benign Breast Conditions

Radial Scars (Also known as complex sclerosing lesions)

• Made up of connective tissue fibers from which milk ducts and lobules grow from

• Present similar to breast cancer on a mammogram, but they are not cancer

• Because of their appearance on imaging, they are often biopsied and excised

• After they are removed, no further treatment is necessary

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Benign Breast Conditions

Case Study• 40 y.o. female presented to the breast clinic with a

history of irregular nodularity in the right breast • Serous nipple discharge x 5 months• Physical examination demonstrates a firm nodularity

in right breast• Mammographically, the nodule measures 0.7 cm• Radiating spicules noted• No calcifications or architectural distortion was

appreciated

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Benign Breast Conditions

Biopsy and Diagnosis

• Patient underwent an ultrasound-guided fine needle aspiration

• Sample of the material was insufficient for a definitive diagnosis

• A lumpectomy was performed on the patient as the mammography was suggestive of a radial scar

• Lumpectomy specimen revealed a firm stellate area of about 0.6 cm

• Microscopically, the lesion had a central fibroelastotic core with radiating tubules characteristic of a radial scar

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Benign Breast Conditions

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Benign Breast Conditions

Ultrasound of radial scar

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Benign Breast Conditions

Galactocele

• Most common benign breast lesion• Typically occurs in young lactating women• Is also referred to as a lactocele• Presents with a painless breast lump occurring over weeks to

months • Can present as a single or multiple nodule(s) • Unilateral or bilateral• Diagnosis can be done with an aspiration • Most likely located near the sub-areolar region

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Benign Breast Conditions

Case Study• Presents with lump x 2 weeks• Patient currently breast feeding• No pain• No skin changes• Physical exam of lump demonstrates a firm and mobile lesion• Ultrasound demonstrates a well-circumscribed hyperechoic

lesion• Mild shadowing• Mild doppler flow• Ultrasound-guided biopsy recommended

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Benign Breast Conditions

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Benign Breast Conditions

• Ultrasound appearances can be widely variable

• Sonographic characteristics according to one study is as follows:• cystic / multicystic: ~ 50% • mixed (cystic + solid): ~ 37%• solid: ~ 13%

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Benign Breast Conditions

Biopsy Results

Benign breast tissue with lactational change and features consistent with galactocle

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Benign Breast Conditions

Lipoma• Slow growing, fatty lump • Are mobile and “squishy” to the touch • Are not usually tender• Most commonly found in middle age • Some people have more than one at a time• Lipomas are most often harmless and go untreated• If the lipoma is bothersome, painful or growing, patient

may have it removed

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Benign Breast Conditions

Case Study

• 40 y.o. female• Density seen on baseline mammogram• Right UOQ• Persists with spot compression views• Ultrasound recommended

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Benign Breast Conditions

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Benign Breast Conditions

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Benign Breast Conditions

Ultrasound and Ultrasound-guided biopsy

• Ultrasound demonstrates a circumscribed almost completely isoechoic lesion

• Lesion measures 2.2 x 1.3 cm • Biopsy recommended• Ultrasound- guided biopsy performed• Biopsy results demonstrate a fatty benign lesion; lipoma• Six month follow-up recommended• Patient did not undergo surgery or treatment

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Benign Breast Conditions

Lobular Carcinoma (LCIS)

• An area or areas of abnormal cellular growth • Increases a person’s risk of developing invasive breast cancer later

on in life• Lobular means that the abnormal cells start growing in the lobules,

the milk-producing glands at the end of breast ducts• Carcinoma refers to any cancer that begins in the skin or other

tissues that cover internal organs — such as breast tissue• In situ or “in its original place” means that the abnormal growth

remains inside the lobule and does not spread to surrounding tissues

• Diagnosis of LCIS tends to have more than one lobule affected

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Benign Breast Conditions

LCIS

Despite the fact that its name includes the term “carcinoma,” LCIS is not a true breast cancer.

LCIS is an indication that a person is at higher-than-average risk for getting breast cancer at some point in the future.

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Benign Breast Conditions

Case Study

• 48 y/o • Mammographic findings demonstrate a

small group of calcifications in the upper outer posterior right breast

• Magnification views recommended

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Benign Breast Conditions

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Benign Breast Conditions

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Benign Breast Conditions

Mammographic Findings

• Calcifications appear to be new compared to prior studies• Indeterminate• BIRADS 4: Suspicious findings• Stereotactic scout attempted• Breast tissue measures too thin for stereotactic biopsy• Patent was referred for a surgical specimen• Needle localization recommended and undertaken• Specimen reveals LCIS and area is excised

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Benign Breast Conditions

Phyllodes Tumor• Rare breast tumors that, like fibroadenomas, contain 2 types of breast

tissue: stromal (connective) tissue and glandular (lobule and duct) tissue

• Most commonly found in women in their 30s and 40s, but they may be found in women of any age

Link to cancer risk• Not usually cancerous, but in rare cases they may be related• One third of these tumors are classified as malignant based on how

they look under the microscope, less than 5% of phyllodes tumors overall are clearly true cancers

• Can reappear; close follow-up with frequent breast exams and imaging is usually recommended after treatment

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Benign Breast Conditions

Diagnosis• Tumors are usually felt as a painless lump, but may be painful• Capable of growing quickly and can stretch the skin• Difficult to differentiate from fibroadenomas on imaging tests and by

biopsy• Often the tumor needs to be removed to prove it is a phyllodes tumor• Microscopically the main difference between phyllodes tumors and

fibroadenomas is the overgrowth of connective tissue• Cells that make up the connective tissue part can look abnormal under

the microscope• Histology classifies tumors dependent on the cellular makeup;

phyllodes tumors may be classified as benign (non-cancerous), malignant (cancerous), or borderline (looking more abnormal than benign tumors, but not quite malignant)

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Benign Breast Conditions

Mammographic Example (not case-study related)

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Benign Breast conditions

Case Study• 48 y/o female• Presents with large lump in the medial aspect of the left

breast• Ultrasound images of the breast demonstrate large

heterogenous mass of 5.6 x 3.4 cm• Contains multiple lobulations and cystic spaces • The appearance of the tumor is “leaf-like” in its internal

architecture• There is also posterior acoustic enhancement

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Benign Breast Conditions

Ultrasound

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Benign Breast Conditions

Ultrasound Images

• The images show minimal internal vascularity on color Doppler ultrasound

• Internal lobulation with typical leaf like pattern on sonography

• Age of the patient, large size of tumor and typical ultrasound features are highly suggestive of this being a Phyllodes tumor of the left breast

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Benign Breast Conditions

Treatment• Phyllodes tumors (even benign ones) can re-grow in the same place if

they are removed without taking enough of the normal tissue around them

• Treated by removing the tumor and at least a 1 cm (a little less than ½ inch) area of normal breast tissue around the tumor

• Malignant phyllodes tumors are treated by removing them along with a wider margin of normal tissue, or by mastectomy if necessary

• Malignant phyllodes tumors are different from the more common types of BrCA

• They do not respond to hormone therapy and are less likely than most breast cancers to respond to RT or chemo

• Phyllodes tumors that have spread to distant areas are often treated more like sarcomas (soft-tissue cancers) than breast cancers

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Benign Breast Conditions

ReferencesAmerican Cancer Society (2014). Non-cancerous breast conditions. Retrieved December 19, 2014 from http://www.cancer.org/healthy/findcancerearly/womenshealth/non-cancerousbreastconditions/non-cancerous-breast-conditions-intro

Bortolotto, C., & Canepari, E., & Tarallo, V. (2012). Intraductal papilloma of the breast: A case report. Retrieved March 3, 2015 from http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3558092/

Breastcancer.org (2015). LCIS-Lobular carcinoma in situ. Retrieved February 3, 2015 from http://www.breastcancer.org/symptoms/types/lcis

Department of Radiation Oncology, Tata Memorial Hospital (2009). Secretory carcinoma arising in radial scars of the breast: A case report and review of literature. Retrieved March 2, 2015 from http://www.ijpmonline.org/article.asp?issn=0377-4929;year=2009;volume=52;issue=1;spage=83;epage=85;aulast=Menon

Mayo Clinic (2014). Atypical Hyperplasia of the breast. Retrieved December 19, 2014 from http://www.mayoclinic.org/diseases-conditions/atypical-hyperplasia/basics/definition/CON-20032601

Pinder, S. E., & Ellis, I. O. (2003). The diagnosis and management of pre-invasive breast disease DCIS and ADH- current definitions and classification. University of Nottingham. Retrieved April 1, 2015.

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ReferencesRadiopaedia.org (2015). Galactocele. Retrieved January 29, 2015 from http://radiopaedia.org/articles/galactocele

Susan G. Komen (2014). Benign breast conditions. Retrieved December, 19, 2014 from http://ww5.komen.org/BreastCancer/BenignConditions.html