BENIGN

BREAST

DISEASES

Dr. Saba Khan

Intern

General Surgery

Unit 3

Outline Introduction

Anatomy

Structure of the breast

Classification

Initial approach to breast problems

Diagnostic workup

Conclusion

Introduction Breast problems are a major reason why women visit

the primary care physician

Breast diseases in women constitute a spectrum of

benign and malignant disorders

The most common breast problems for which women

consult a physician are breast pain, nipple discharge

and a palpable mass.

Anatomy The breast is a specialized accessory gland with

a mass of glandular, fatty and fibrous tissues on

the pectoralis muscles in the chest wall

It is attached to the chest wall by fibrous strands

called coopers ligaments

The base of breast extends from 2nd - 6th rib and

from the lateral margin of sternum to the mid-

axillary line

The glandular tissues of the breast consist of

lobules, lobes and ducts

Fatty and fibrous tissues surround the milk

producing system (lobules and ducts)

Each breast consists of 15 - 20 lobes, which

radiate out from the nipple

AnatomyMajor hormones responsible for

breast development are estrogen, progesterone and prolactin.

The blood supply is through the internal mammary artery, axillary artery, and intercostal artery

Venous drainage is through the

Internal mammary vein, axillary vein and intercostal veins

Anatomy Lymphatic drainage

• Majorly to the Axillary nodes• Inter mammary and the supraclavicular lymph

nodes (parasternal and medial)

Three Lymph Node Levels

Axillary lymph nodes defined by pectoralis minor muscle• Level I – Lateral and inferior to Pectoralis Minor• Level II – Deep to Pectoralis Minor• Level III – Medial to Pectoralis Minor

Rotter’s Nodes – Between Pectoralis Minor & Major

Nerves• Long Thoracic Nerve:

Serratus Anterior m.• Thoracodorsal Nerve:

Latissimus Dorsi• Intercostobrachial Nerve

Sensory to medial arm & axilla

Structure

Classification Based On Pathology Non Proliferative Lesion

Simple Cyst Complex cyst

Proliferative Lesions – Without Atypia Ductal hyperplasia Fibroadenoma Intraductal papilloma Sclerosing Adenoma Radial Scars

Atypical Hyperplasia Atypical ductal hyperplasia Atypical lobular hyperplasia

Classification Based On Clinical Features Mastalgia

Cyclic Non Cyclic

Tumors and Masses Nodularity or glandular Cysts Galactoceles Fibroadenoma Sclerosing Adenosis Lipoma Harmatoma Diabetic Mastopathy Cystosarcoma Phylloides

Classification Based On Clinical Features (Cont’d)

Nipple discharge Duct ectasia Fibrocystic disease Duct papilloma Galactorrhea

Breast infections and Inflammation Postpartum engorgement Intrinsic mastitis Lactation mastitis Lactation breast abscess Chronic recurrent subareolar abscess Acute mastitis associated with macrocystic breasts Extrinsic infections Mondor’s Disease Hidradenitis suppurativa

Relative risk of invasive breast carcinoma based on pathological examination of benign breast tissue:

No increased risk Adenosis, sclerosing or fibroid Cysts, macro &/or micro Duct ectasia Fibroadenoma Fibrosis Hyperplasia Mastitis (inflammation) Periductal mastitis Squamous metaplasia

Slightly increased risk (1.5-2 times Hyperplasia, moderate or florid,

solid or papillary Pappiloma with a fibrovascular core

Moderately increased risk (5 times) Atypical hyperplasia, ductal or

lobular

Insufficient data to assign a risk solitary papilloma of lactiferous

sinus Radical scar lesion

Breast Pain (Mastalgia)More common in premenopausal women than in post menopausal women

Cyclic Pain ( Physiologic) Usually Bilateral and poorly localized. Occurs in about 60% of premenopausal women except

menopausal women on hormonal replacement therapy Often described as heaviness , swelling or tenderness that

radiates to the arm and axilla Associated with menstrual cycle , Most severe before

menstruation Has variable Duration and Resolve spontaneously after menses Attributed to fibrocystic breast changes Etiology unknown, thought to be related to Gonadotrophic and

ovarian hormones

Breast Pain (Mastalgia)Non-Cyclic Pain Most common in women 40 to 50 yrs of age

Often unilateral

Usually described as sharp, burning pain localized in the

breast

Occasionally secondary to the presence of

Fibroadenoma and or cyst

Menstrual irregularity, emotional stress, trauma, MSK,

scars from previous biopsies and medications have

been associated

Management of Breast Pain Pharmacological Treatment

NSAIDs OCPs Danazol 100- 400mg per day 75% of women with non cyclic pain will be symptom

free SE: Weight gain , menstrual irregularity , acne ,

hirsutism Tamoxifen 10mg Bromocriptine – prolactin antagonistSurgery has no role in management of breast pain

Evaluation & Management of Breast Pain

Breast Masses: Cysts

Cystic Breast Mass Common cause of dominant breast mass

May occur at any age, but uncommon in post

menopausal women

Fluctuates with menstrual cycle

Well demarcated from the surrounding tissue

Characteristically firm and mobile

May be tender

Difficult to differentiate from solid mass

Breast Masses: CystsFibrocystic Breast Disease

Most common of all benign breast disease Most common between ages 20- 50 50% of women with Fibrocystic changes have clinical

symptoms 53% have histologic changes Believed to be associated the Imbalance of

progesterone and estrogen. May present with bilateral cyclic pain, breast

swelling, palpable mass and heaviness

Fibrocystic Breast Disease Physical Examination

Tenderness Increased engorgement and more

dense breast Increased lumpiness / glandular Occasional spontaneous nipple

discharge

Breast Cysts: Diagnostics Mammogram

Cystic outline No calcification No increased density

Ultra Sonogram Cyst

Fine Needle Aspiration Outpatient procedure Non bloody fluid Cyst disappears If bloody fluid, surgical

biopsy of cyst is required

Reexamination 4-6 weeks after aspiration

Management of Breast Cysts

Breast Masses

Breast Mass: Fibroadenomas Simple: Second most common benign breast lesion

Benign solid tumors containing glandular as well as fibrous tissue . Usually present as well defined, mobile mass

Commonly found in women between the ages of 15 and 35 years Cause is unknown, thought to be due to hormonal influence May increase in size during pregnancy or with estrogen therapy

Giant: Fibroadenomas over 10cm in size Excision is recommended

Juvenile Variant of fibroadenomas Found in young women between the ages of 10 -18. Vary in size from 5 - 20cm in diameter. Usually painless, solitary,

unilateral masses Excision is recommended

Breast Mass: Fibroadenomas (Cont’d)

Complex Complex fibroadenomas contain other proliferative

changes such as sclerosing adenosis, duct epithelial Hyperplasia, epithelial calcification.

Associated with slightly increased risk of cancer

Breast Mass Phylloides Tumors:

Rapidly growing One in four malignant One in Ten Metastasize Create bulky tumors that distort the breast May ulcerate through the skin due to pressure necrosis Treatment consists of wide excision unless metastasis has occurred

Fat Necrosis: Rare Secondary to trauma- often not remembered Tender, ill defined mass Occasionally skin retraction Treat with excisional biopsy

Breast Mass Galactocele

Milk filled cyst from over distension of a lactiferous duct.

Presents as a firm non tender mass in the breast, Commonly in upper quadrants beyond areola. Diagnostic aspiration is often curative.

Duct ectasia: Generally found in older women. Dilatation of the subareolar ducts can occur. A palpable retroareolar mass, nipple discharge,

or retraction can be present. Tx involves excision of area

Breast Mass Gynecomastia:

Benign growth of the glandular tissue of the male breast.

Due to an imbalance in the estrogen to androgen activity.

May be unilateral or bilateral Common in infancy, adolescence and

adult life Pseudogynecomastia may be seen

obese individuals Causes include; drugs, chronic dxs,

metabolic, pubertal, Hormonal, tumors, idiopathic,

hypogonadism.

Nipple Discharge Physiological cause During pregnancy and lactation

Intraductal Papilloma Benign growth within ductal system Presents as bloody nipple discharge Excision is the only way to differentiate from carcinoma

Galactorrhea Secretion of milk not related to pregnancy or lactation. Stress & mechanical stimulation of breast Side-effect of drugs that enhances dopamine activity e.g. chlorpromazine,

metoclopromide & methyldopa. Hyperprolactinaemia due to prolactin-secreting tumor or from a secondary

source of bronchogenic carcinoma. Obtain prolactin level. If normal, simple reassurance Stop mechanical stress or ingestion of drugs Treatment of prolactin-secreting tumor or bronchogenic carcinoma

Breast Inflammation & Infections Mastitis

Most common in lactating female Dry, cracked fissured areola/nipple complex

provides portal

for infection Usually caused by Staph/Strep organisms Rule out malignancy Treat with heat, continued breast feeding, Antibiotics for 10-14 days to cover staph and

strept infections

Breast Inflammation & Infections Abscess

May present with breast swelling, tenderness and fever

On PE, breast is tender , warm and fluctuant, may also have

purulent discharge Treated by surgical drainage

Breast Inflammation & Infections Mondor’s Disease

Phlebitis of the thoracoepigastric and lateral thoracic vein

Palpable, visible, skin retraction over tender extending to chest wall

Spontaneous or related to trauma Ultrasound may be helpful in confirming this

diagnosis. Treatment self-limited, can use NSAIDs Mammogram if over 35yo to r/o malignancy

Breast Inflammation & Infections Chronic Subareolar Abscess

Occurs at base of lactiferous duct, and squamous

metaplasia of duct may occur. Sinus tract to areola develops Treatment requires complete excision of sinus tract Recurrence is common

Mastitis Neonatorum B/L or unilateral enlargement of breasts. In 50%, swelling is later

accompanied by secretion of creamy fluid similar to colostrum, which is called ‘Witch’s Milk’

Occurs on the 3rd or 4th day of birth Response to mothers hormone exposure (prolactin, estrogen) Resolves spontaneously after 2 weeks when the estrogen level

automatically falls Occasionally becomes infected

Congenital Breast Disease About 1-5 % of the

population have accessory nipples, and less commonly accessory breast (Polymazia)

Usually develop along the milk line

Most common site for accessory nipple is below the breast

Most common site for accessory breast is in the axilla

Rarely require treatment except for cosmetic reasons

Approach to Breast Problems History

Age Family history (Cancer) Onset Duration Discharge Frequency Lump , Nodules Trauma Menstruation (menarche, menopause, contraceptives)

Pain

Inspection Symmetry Skin / Nipple Change Bulges / Retractions

Approach to Breast Problems Palpation

Breast

Axilla

Supraclavicular

Breast Examination The breast examination starts with inspection of both breast

Sitting up with arms in relaxed position,

Both arms raised over the head

Hands on the hips

Complete regional lymph node examination while patient is in the

sitting position.

Bimanual may be done while patient is still in the sitting position,

useful in patient with large pendulous breast

Complete with the patient in a supine position, with the arms raised

above the head, breast exam can be accomplished with either

concentric circles, radial approach, or vertical strip approach

Areas examined should extend from the clavicle superiorly to the rib

cage inferiorly and from the sternum medially to the mid axillary line

laterally

Diagnostic Work Up Ultrasonography: First diagnostic test of choice to

differentiate a cystic mass from a solid mass

Mammogram: A normal mammogram at any age does not

eliminate the need for further evaluation of a suspicious

mass.

FNAC: Useful for cystic lesions. If lesion is completely drained

and the fluid is not bloody or cloudy, no further evaluation is

needed Core Needle Biopsy: This provides a best diagnostic information

for solid palpable mass which can be visualized on the USG or

mammogram

Excisional Biopsy

Incisional Biopsy MRI

Triple Assessment of Breast SymptomsIn any pt. who presents with a breast lump or other symptoms suspicious of carcinoma:

Conclusion Benign breast problems account for the majority

of breast problems seen in women

Breast complaints need careful assessment with

thorough history and physical as well as

diagnostic work up if indicated

Women with breast problems can present with a

mass, pain, nipple discharge or skin changes.

They can also be asymptomatic

It is important to rule out breast cancer

Thank You !