Benign breast diseases

S5,Medical College,

Trivandrum

presents

BENIGN BREAST DISEASES

the ‘team’• Syamamol P.S• Syam G.• Thomas Mathai.• Thushara U.B• Varkey S.Kulangara• Varsha Vijayan.• Vidyakrishna• Vidya S.• Tobin Dominic

“ The breast from their prominence, the colour of their skin, and the red colour of the nipples, by which they are surmounted, add great beauty to the female form”

APPROACH

• Embryology-congenital lesions , anatomy & physiology of breast

• Classification• Investigations• Case scenario1-lump• Case scenario 2-mastalgia• Case scenario 3-nipple discharge• Case scenario 4-BBD in pregnancy & lactation• Case scenario 5-BBD in males

Embryology-CONGENITAL LESIONS, Anatomy & Physiology of breast

Syamamol.P.S

Development of Breast- Skin appendages arising from mammary ridge (Milk line) .. Ectoderm

CONGENITAL LESIONS OF BREAST

© Prof. Reda Mostafa 9

Gul

© Prof. Reda Mostafa 10

Accessory nipple

© Prof. Reda Mostafa 11

Accessory intra-mammary nipple

• Congenital Nipple Inversion • failure of nipple to evert during development. May

be unilateral. • Spontaneously corrected during growth of pregnancy

or by simple traction.

Anatomy

• Modified sweat gland between the superficial and deep layers of the chest wall

BLOOD SUPPLY

LYMPHATICS

BBD CLASSIFICATION

Tobin Dominic

• Congenital disorders• Traumatic• Inflammatory & • Infectious• Neoplastic• ANDI

The ANDI (Aberrations of Normal Development and Involution )

• Breast –physiologically dynamic structure• unifying concept of symptoms, signs, histology and

physiology • Benign disorders are related to the normal processes

of reproductive life. • spectrum ranges from normal to aberration to

sometimes disease.• classification is not comprehensive

ETIOLOGY• Endocrine• Disturbance of hypothalamic pituitary gonadal steroid

axis• Altered prolactin profile• Non endocrine• Methylxanthines• Stress catecholamines• High saturated fat diet• Iodine deficiency

Normal Benign disorder Benign disease

Early reproductiveyears

Nipple eversion Nipple inversion Subareoalar abscess, duct fistula

Lobular development Fibroadenoma Giiant fibroadenoma

Stromal development Adolescent GigantomastiaHypertrophy

Later reproductive years

Cyclical Hormonal changesnodularity

Mastalgia, incapaciating . mastalgia

Pregnancy

Lactation

Epithelial hyperplasia pregnancy

Bloody nipple discharge

Galactocele

Involution Duct involution dialation Duct ectasia Periductal mastitis

SclerosisLobular involution

Nipple retractionMacrocysts,sclerosing lesions

Epithelial turnover Epithelial hyperplasia epi hyperplasia atypia

PATHOLOGICAL CLASSIFICATIONI. NONPROLIFERATIVE LESIONS

Cysts and apocrine metaplasia Duct ectasia Mild ductal epithelial hyperplasia Calcifications Fibroadenoma

II. PROLIFERATIVE BREAST DISORDERS WITHOUT ATYPIA

Sclerosing adenosis Radial and complexing sclerosing lesions Moderate and florid ductal epithelial hyperplasia Intraductal papilloma

III. ATYPICAL PROLIFERATIVE LESIONS

Atypical lobular hyperplasia(ALH) Atypical ductal hyperplasia(ADH)

INVESTIGATIONS IN BREAST DISEASE

Syam G & Thomas mathai

Triple assessment

Confident diagnosis in 99.9%

Inspection

Palpation

Examination of LNS

Sitting posturePulp of the fingersAxillary group of LNs

Pectoral groupBrachial groupSubscapular groupCentral groupApical group

Supraclavicular nodes

system examination

BREAST SONOGRAPHYIndications

If Mammography is uncertainTo differentiate solid from cystic lesionIf asymmetric densityVisualise lesions near chest wall.Interventional procedures.Evaluate site of lumpectomy.Lesion at periphery of breast.Evaluating after surgical augmentation.

Features of malignant lesion on Sonomammography

STAVROS CRITERIA • Spiculation• Hypoechoic• Irregular margins• Posterior shadowing• Depth :width ratio <1• Microlobulation

MAMMOGRAPHY

Mammography views

Mediolateral oblique Craniocaudal

Mammography evaluationMass lesion

DensityAsymmetry

Malignant CalcificationBenign calcification

Well circumcribed –benignSpiculated-malignant 95%Low density benign ,high-malignantAsymmetric involution in bbd.HRTTrauma ,Intraductal CAFine ,numerous CA,only sign in early noninvasive CAScattered ,round circumscribedDuctectasia- needlelikeArterial -parallel lineFibroadenoma –popcornMicrocystic disease-teacupFat necrosis-oilcyst calcification

Breast Imaging Reporting And Data System [BI-RADS]

Categories are:0: Incomplete – needs additional imaging1: Negative - routine mammogram yearly2: Benign finding(s) -yearly mammogram3: Probably benign- short term follow up4: Suspicious abnormality - biopsy should be

considered5: Highly suggestive of malignancy6: Known biopsy-proven malignancy to r/o ca in

opposite breast

BREAST MRI To distinguish scar from

recurrence Gold standard for

imaging breast with implants

Detection of vertebral body metastasis & musculoskeletal pathology

Visualisation of axilla

BREAST MRIIndications

Radiologically dense breasts when mammography fails.If Axillary node +ve and breast normal after mammo and sonography.To rule out multifocality multicentricity before BCS.To assess induction chemotherapy.Followup after BCS.•Contrast enhanced more sensitive

THERMAL IMAGING(Digital infrared)

Thermal imaging is an advanced technology that creates a visual image of the heat pattern of breast.

FINE NEEDLE ASPIRATION CYTOLOGY

Uses 21gauge needle & 10 ml syringe

Multiple passes through lump without releasing negative pressure

Aspirate is smeared onto slide & fixed

Differentiates solid & cystic lesions

If fnac is inconclusiveAdvantagessignificant core of tissue obtainedcan distinguish invasive from intra ductal carcinomaGrading of tumorTo know ER/PR and Her 2 statusDisadvantage

seeding of malignant cells along needle tract

CORE NEEDLE BIOPSY

Core needle biopsy under ultrasound guidance

When core needle biopsy is inconclusive

Removal of small portion of tumour

> 4cm in size

•Whole tumour is removed preferably if <4 cm in size

INCISION BIOPSY

EXCISION BIOPSY

Most accurate and the Best Diagnostic Procedure for a Suspicious Breast Lesion.

Complete excision with a rim of normal tissuePlan the incision in such a way that

subsequent radical surgery can easily include the scar.

Follow Langer’s line

OPEN BIOPSY(EXCISIONAL BIOPSY)

MAMMOTOME

Used for taking stereotactic biopsy from mammographically detected breast lesions that are not clinically palpable.

Mammotome

DUCTOSCOPE• A fiber optic scope less

than a millimeter thick is inserted into the milk duct at the nipple and threaded deep into the breast through the duct.

• An imaging system displays the output of the scope on a computer monitor.

• Samples of epithelial cells can be collected onto microscope slides for further analysis.

DUCTOSCPOY

INDICATIONS Patients with pathologic nipple

dischargePatients who are at high-risk for

developing cancer but have normal breast on examination and imaging studies.

After application of a numbing cream, a small clear cap with a syringe attached is placed over thenipple. This device (the nipple aspirator) is similar to a small breast pump and is used to see if fluid will come out of the nipple.

•To encourage fluid production,women are instructed in breast massage and heat packs may be used on the breasts.

•If fluid is not produced, the lavage is not performed.

DUCTAL FLUID COLLECTION

If fluid is obtained with the nipple aspirator,then the lavage procedure is started.

One or two small dilators to help open the duct.

Then the ductal lavage catheter is inserted and a small amount of lidocaine, as anesthetic may be injected through the catheter for comfort.

DUCTAL LAVAGE

• Saline, is injected through the catheter into the duct and the breast massaged to bring ductal cells into the chamber of the catheter.

• An empty syringe attached to the catheter is used to collect the cells from the catheter chamber.

• The cells are then placed in a preservative and sent to the cyto - pathologist where they are processed and read much like a Pap smear.

DUCTOGRAPHY/GALACTOGRAPHYA ductogram is a mammographic procedure that is performed to help identify the breast duct that may be the source of nipple discharge.

Ductal ectasia.- Craniocaudal ductogram shows a dilated ductal system.

Carcinoma. -craniocaudal ductogram shows an outlined intraductal abnormality (arrow). Note the pleomorphic calcifications (arrowheads)

BREAST IMAGING EMERGING TECHNOLOGIES

Digital mammographyUse of FDG-PETBreast scintimammography (nuclear medicine breast imaging- Miraluma

Tc-99m sestamibi compound)Computerised thermal imaging(CTI)Computerised tomographic

lasermammography (CTLM)

Breast imaging -emerging technology

Digital tomosynthesis or three dimensional mammography

ElastographyDigital subtraction mammography

TUMOR MARKERS IN BBD

Expression of P53 in immunohistochemical staining identifies the sub group with maligant potential

Overexpresson of HER-2 in benign proliferative lesion predicts increased risk

Saint Agatha of Sicily

Case scenario 1

• 25 year old female patient presented with a lump in the breast.She gives a history of slow growing lump not associated with any pain or discharge from nipple & is very much anxious.

Possibilities????

• Fibro adenoma• Phyllodes tumour• Breast cyst• Traumatic fat necrosis• carcinoma

FIBROADENOMA

Fibroadenomas• Second most common tumor of breast

• ANDI

• Represent a hyperplastic or proliferative process in a

single lobule

• Etiology is unknown, thought to be due to hormonal influence

• Risk of malignant transformation is rare• Resulting carcinoma is often a lobular carcinoma • Mimic malignancy in pregnancy,HRT

types• Simple/solitary/small(2-3 cm) • Multiple(>5)• Juvenile-in young women between the ages of 10 -

18.• Giant(>5cm)-rapidly growing,more common in afro-caribbean population

• Complex -contain other histological changes such as sclerosing adenosis, duct epithelial Hyperplasia, epithelial calcification.

Associated with slightly increased risk of cancer

Clinical features

• Between the ages of 15-25 years & size of 2-3cm• Painless lump- capsulated,smooth, firm, well defined,

nontender, BREAST MOUSE• Confused with phyllodes• Microscope- intracanalicular pericanalicular

diagnosis

• Clinical examination• Ultrasound scan –circumscribed lobulated

mass• FNAC/Core needle biopsy

• Treatment-conservative• Surgery • Very large/increasing in size• Suspicious cytology• Surgery is desirable• Extracapsular excision with a 1cm rim of

normal tissue • Newer techniques-laser ablation &cryoablation

PHYLLODES TUMOUR

VARSHA VIJAYAN

Gk word phyllon

Histopathology

• Proliferation of intralobular stroma• Fusiform fibroblast• 3 types:- benign borderline malignant (cellularity,atypia,mitoses &invasion by edges)

Phylloides vs FibroadenomaPhyllodes Fibroadenoma

Age Older(40-50y) Younger

Duration Rapid growth Slower progression

Recurrence Common Less commonSize Large ,bosselated Smaller Mammogram Round density with

smooth bordersSame

Ultrasound Cystic spaces +/- SameCytology More cellular,

malignant typeSame as low grade phyllodes

Excisional biopsy Histopathology

Management

Wide local excision Benign Borderline - Follow up Malignant -SIMPLE MASTECTOMY

SIMPLE MASTECTOMY

Breast Trauma

Traumatic Fat Necrosis

• Clinical features - Pain & lump in the breast• Lump is hard - extensive fibrosis caused by

tissue reaction• D.D : Carcinoma breast• Mammography findings - density lesion; can

have calcifications; may mimic carcinoma breast

• Treatment - excision of the lump

Breast cystvarkey s kulangara

Introduction

• Definition – non integrated involution of breast tissue• Age group – 30-50• Multiple and bilateral• Can mimic malignancy• Confirmed by USG and aspiration

No routine followup

No residual massNo cyst recurrence

Surgical biopsy

Residual massCyst recurrence (X3)

Non blood stained aspirate

FNAC/Surgical biopsy

Blood stained aspirate

Fine needle aspiration

Cyst(C linical diagnosis)

Routine followup

Pop-Quiz

Which is bigger??

Case scenario2

• 28 year old lady presenting with complaints of pain in both her breast for the past 6 years & increases just prior to menstruation, no pain during her pregnancy and lactation.

MASTALGIA

VARKEY S KULANGARA

• Definition• types

CYCLICAL MASTALGIA

• Menstruating age group• Hormone related-ANDI• Dull diffuse bilateral• Upper outer quadrant

ETIOLOGY

1. Relative hyperoestrogenism2. Hyperprolactinaemia3. Psychological4. Caffeine5. Abnormal lipid metabolism

RECENT THEORY

LOW EFA LOW PGE1

UNOPPOSED ACTION OF PROLACTIN

MANAGEMENT

1.Pain diary 2.Reassurance 3.Exclude caffeine 4.Low fat diet 5.Stop OCPs/HRT 6.stop smoking 7.drugs

PRIM ROSE OIL

BROMOCRIPTINE

GOOD RESPONSE

DANAZOL

TREAT 6 MONTHS

NO RESPONSE IN 4 MONTHS

GOSERELIN

NON CYCLICAL MASTALGIA

• CAUSES 1.musculoskeletal pain 2.teitz syndrome 3.malignancy

FEATURES

• Unilateral • Chronic• burning or dragging• Pre and post menopausal

MANAGEMENT

• EXCLUDE MALIGNANCY• TREAT THE CAUSE

FIBROCYSTIC BREAST DISEASE

Varkey S Kulangara

synonyms

Fibrocystic changes Cystic Mastopathy Chronic cystic disease Mazoplasia Cooper’s disease Fibroadenomatosis Reclus’s disease

What is fibroadenosis?

ANDIAge group :30-50 yearsAberration in normal cyclical hormonal effectsCyclcial mastalgia with nodularity

• bloodgood’s bluedomed cyst• Schimmelbusch’s disease

Pathomorphology

• Fibrosis• Cyst formation• Adenosis• Epitheliosis• Papillomatosis• Apocrine metaplasia

Clinical features

• lump • Cyclical mastalgia• Nipple discharge

Diagnosistriple assessment

CLINICAL

Treatment

Rule out malignancy manage as cyclcial mastalgia

Surgical Treatment

• Indicationsa) intractable painb) florid epitheliosis on fnacc) Blood good cyst

surgery

1. Excision of the cyst or localized excision of the diseased tissue

2. Subcutaneous mastectomy with prosthesis placement

F

CASE SCENARIO 3

• 30 year old female came to OP with complaints of lump in both the breasts.Also complains of discharge from both the breasts.

Possibilities???

• MALIGNANCY??• Duct papilloma• Duct ectasia• Fibrocystic disease

NIPPLE DISCHARGE vidya s

Causes Surface Eczema Psoriasis Chancre

Dischage from a single duct

Blood stained Serous intraduct papilloma fibrocystic disease duct ectasia duct ectasia

Discharge from more than one duct blood stained : duct ectasia black/green : duct ectasia purulent : infection Serous : fibrocystic disease duct ectasia Milk : lactation hypothyroidism pituitary tumours drugs

Approach to a patient

CLINICAL EXAMINATION Nature of discharge Mass present or not Unilateral or bilateral Single or multiple duct Spontaneous/expressed Relation to menstruation Pre/post menopausal Taking ocp/estrogen

Investigations discharge analysis for malignant cells and occult

blood

Mammography

FNAC BIOPSY

Treatment

REASSURANCE

MICRODOCHECTOMY

HADFIELD

DUCT ECTASIA

• Dilatation of the breast ducts associated with chronic inflammatory response in the periductal tissue

Pathogenesis

Duct dilatati

on

Discharge to

periductal tissues Periductal

mastitis

fistula

fibrosis

abcess

Microscopy

foam cells

inflammatory cells

Clinical features

• Older age group• Smokers

Nipple discharge: bilateral multifocal ,thick,opalascent,variable colour

• Breast abcess Tender subareolar mass

• Mammary duct fistula

• slit like retraction of nipple

Investigations

• If mass or nipple retraction is present rule out malignancy

Mammography Cytology,histopathology

Cytology of discharge: foam cells Ductography: ectatic ducts

Treatment

Antibiotic flucloxacillin and metronidazole

Surgery Hadfield’s operation

inci

INTRA DUCTAL PAPILLOMA

• Proliferative breast disease without atypia• polyps of epithelium lined duct

Pathology

• Size: usually less than 0.5 cm, may be as large as 5cm

• Site: lactiferous duct within 4 to 5 cm from nipple orifice

• Gross: Pinkish tan friable ,attached to the wall by a stalk

Microscopy

Fibrovascular core Papilloma Duct

Clinical features

• Nipple discharge :unilateral,blood stained,from a single duct

• Palpable mass/density lesion in mammography

Investigations

• Ductography :filing defect

treatment

Surgery• less than 30 yrs:microdochectomy

• more than 45 yrs:major duct excision(Hadfield)

Milky Way

CASE SCENARIO 4

• 24 year old lactating female presented in OP with throbbing pain in the left breast and fever…

BBD IN PREGNANCY AND LACTATION Vidyakrishna & Thushara

BACTERIAL MASTITIS

Thushara u b

BACTERIAL MASTITIS

Types1. Subareolar abscess2. Intramammary abscess3. Retromammary abscess

AETIOLOGY

• Staph aureus – penicillin resistant if hospital acquired• Streptococus Ascending infection from a sore and cracked nipple

CLINICAL FEATURE

TREATMENT

• Flucloxacillin or co-amoxiclav• Support of the breast,local heat,& analgesics• Incision & drainage• Now recommended is repeated aspiration under antibiotics• continue breast feeding• close follow up• Antibioma if I&D not done• DD-inflammatory carcinoma of breast

OPERATIVE DRAINAGE OF A BREAST ABSCESS

• Local anaesthesia• Radial or circumareolar incision• drainage• Septa is disrupted & wound is packed

MONDOR’S DISEASE

• Thromboplebitis of superficial veins of the breast & chest wall• Aetiology not known• C/F – thrombosed subcutaneous cord• DD – breast cancer• Treatment – antiinflamatory medication warm compresses & support restriction of movement symptoms persist - excision

Thrombosed subcutaneous cord

GALACTOCELE

• Definition• Pathogenesis-inspissated milk• c/f-pain & lump• Diagnosis-needle aspiratation

Management

OTHER BBD IN PREGNANCY AND LACTATION

• Nipple discharge• Simple cysts• Breast infarcts• Breast pain

Pregnancy and investigations???

OTHER INFECTIOUS CONDITIONS

Tuberculosis of breast Syphilis of the breast Actinomycosis

TUBERCULOSIS OF BREAST

• Multiple c/c abscess & sinuses

• Bluish attenuated apearance of surrounding skin

• Diagnosis• Treatment

SYPHILIS OF THE BREAST

• Primary chancre of nipple• Secondary lesions – diffuse mastitis

CASE SCENARIO 5

• 15 year old male presented with enlarged breast on right side.

Benign Breast Disease in MalesVidya Krishna

Male breast

• Contains only ducts• No alveoli

BENIGN BREAST LUMPS IN MALES

• Gynaecomastia• Fibroadenoma• Phyllodes tumour• Epidermal inclusion cysts• Sub cutaneous leiomyoma• Sub areolar abscess• Intra mammary lymph node

GYNAECOMASTIA

GYNAECOMASTIA

• Hypertrophy of breast tissue in males.

PATHOPHYSIOLOGY

• Estrogen excess states• Androgen deficiency states• Drug related• Systemic diseases with

idiopathic mechanisms

CLINICAL CLASSIFICATION

• Grade I -Mild breast enlargement without skin redundancy

• Grade IIa- Moderate breast enlargement without skin redundancy

• Grade IIb-Moderate breast enlargement with skin redundancy

• Grade III-Marked breast enlargement with skin redundancy and ptosis, which simulates a female breast

MANAGEMENT

TREATMENT

• Depends on the cause-androgen deficiency-medications-endocrine defectsmedicines-surgery

Were you attentive??

• ANDI• Gold standard for imaging breast with implants• Giant fibroadenoma?• Carcinoma simulating mastitis• Difference between male & female breast• Commonest benign breast disease • Popcorn calcification in mammogram?

Thank you …

Guided by

Dr. Viswanathan

Special thanks to

Dr. John S Kurien

Moderator

Tobin Dominic

Presenters

SyamamolSyam g

Thomas Thushara

Presenters

VarkeyVarshaVidya S

Vidyakrishna

© 2011S5,Medical College,

Trivandrum