BENIGN BREAST DISEASE

Workup and Surgical Management

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.

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• Three Lymph Node Levels:

• Level I – Lateral to Pectoralis Minor• Level II – Deep to Pectoralis Minor• Level III – Medial to Pectoralis Minor• Rotter’s – Between Pectoralis Minor & Major

• Nerves• Long Thoracic Nerve

• Serratus Anterior m.• Winged Scapula

• Thoracodorsal Nerve• Latissimus Dorsi

• Intercostobrachial Nerve

ANATOMY

Benign Breast Disease

• Work up of Breast Mass • Breast Pain• Glandular Breast Parenchyma• Nipple-Areolar Complex• Breast Skin

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

Breast Pain (Mastodynia)

• More common during reproductive years (premenopausal)

• Association with cancer is uncommon• Cyclic pain associated with Fibrocystic changes• Noncyclic pain associated with infection or cancer

if associated with mass or bloody nipple discharge.• Tx: NSAIDs, Eve primrose oil, OCP, avoid caffeine

Parenchymal

• 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%

Parenchymal

• Fibroadenoma•Most common mass in <30 y/o•Smooth, firm, rounded, mobile•Definitive dx by core or excisional bx.•Change size with menses, pregnancy•Excise if growing or >30 y/o•Long-term risk = 2.17 for cancer (IDC)

Parenchymal

• Cystosarcoma Phyllodes•10% malignant•Resembles Fibroadenoma•Tx is WLE

• Gynecomastia•Associated with THC, spironolactone•Liver Failure• Idiopathic

Nipple/Areolar Complex• Nipple D/C

• Nonspontaneous, B/L, multiple ducts, greenish, milky is likely benign.

• Spontaneous, unilateral, bloody, serous is worrisome.

• Meds – TCAs, Reglan, Verapamil, Reserpine• Galactorrhea – r/o Prolactinoma• Intraductal Papilloma – not premalignant

• Most common cause of bloody nipple d/c• Diffuse papillomatosis has increased risk of

cancer

• Mammo/sono/ Ductogram• Ductal excision

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

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.