A Problem oriented approach

BENIGN BREAST DISEASE

Dr.B.SELVARAJ MS;Mch;FICS;

�PEDIATRIC SURGEON

�ASSOCIATE PROFESSOR

�MELAKA MANIPAL MEDICAL COLLEGE

�MALAYSIA

Benign breast disease - Symptoms

Benign Breast Disease -- Anatomy

• TDLU

Classification of Benign Breast

disease

Common causes of breast

symptoms

INTRODUCTION

�Breast is host to a spectrum of benign and

malignant diseases.

�Benign breast conditions are practically a

universal phenomena among women.

� It accounts for 80% of clinical presentation

related to the breast.

CONGENITAL & DEVELOPMENTAL

ABNORMALITIES

� Although the normal location of the breast is the anterior thorax, breast tissue with or without a nipple or just nipple and areola alone can occur any where along the milk line

� The milk line is an ectodermal thickening appearing at 6 weeks of gestation running from axilla to the midportion of inguinal ligament

The milk line

(ectoderm) extends

from the axilla to groin.

Along this line

accessory breast or

nipples may be found

Development of the

breast

CONGENITAL & DEVELOPMENTAL

ABNORMALITIES

� total lack of breast tissue ( amastia) or of nipple (athlelia) is unusual

� supernumerary nipples polythelia & breast polymasita are quite common.

� when polymastia is present in women, the additional breast tissue can secret milk when nipple is present.

Amastia

� Amastia: A rare condition wherein the normal growth of the breast or nipple does not occur.

� Unilateral amastia (just on one side) is often associated with absence of the pectoral muscles�Poland’s syndrome

� Bilateral amastia (with absence of both breasts) is associated in 40% of cases with multiple congenital anomalies involving other parts of the body as well.

� Amastia is distinguished from amazia wherein the breast tissue is absent, but the nipple is present. Amazia typically is a result of radiation or surgery.

Amastia

Mastalgia

� Mastalgia is breast pain and is generally

classified as either cyclical (associated with

menstrual periods) or noncyclical

� Breast pain of any type is a rare symptom of

breast cancer , only 7% of breast cancer have

mastalgia as the only symptom.

� Most mastalgia is of minor to moderate severity

and accepted as part of the normal changes that

occur in relation to menstrual cycle.

Mastalgia

�Cyclical mastalgia: begin since average

30 yrs, relieved by menopause, physical

activity can increase the pain, e.g. by

weight lifting and prolonged use of arm.

�Non-cyclical mastalgia: affects older

women (mean age 43), arises from chest

wall� eg: Teitz’s disease, Breast itself or

outside the breast.

Cyclical Mastalgia - treatment

�Danazol: 200-300 mg daily, slowly reduced

to 100 mg daily or on alternative day, given

on days 14-28 of menstrual cycle.

�Gamma-lineolic acid(evening primerose

oil)

320mgm/day for 3to4 months

�Responses are usually seen within 3

months

�Weight gain, acne and hirsutism

Non Cyclical Mastalgia -

treatment

�More resistant to treatment than cyclical breast

pain

�Hormonal manipulation ineffective

� Symptomatic- analgesics and anti-inflammatory

drugs

� Firm supportive bra

FIBROCYSTIC DISEASE

FIBROCYSTIC DISEASE

FAT NECROSIS

� This is traumatic in nature & is met with women with large fatty breast

� Results from injury to breast fat by Trauma, surgery, biopsy4.

� Causes to focal fibrosis and cicatrix formation.

� Early: edema of the fat lobules,increased echogenicity.

� Post surgical scar, hematoma, seroma

FAT NECROSIS

Clinically: The patient develop sever bruising after moderately sever

trauma, When the bruise settles the woman notice swelling which is clinically Impossible to distinguish from carcinoma of the breast because the Irregular mass is often attached to the skin.

Microscopically a central area of necrotic fat cells are surrounded by a granulomatous reaction consisting of macrophage cells.

FAT NECROSIS

Treatment:

By surgical excision, the excised mass is an infiltrative yellowish white mass.

Duct Ectasia

This condition has several stages of involvement & vanity of names include (plasma- cell mastitis, comedo mastitis, & chronic abscess simulating carcinoma).

It is benign lesion may be virtually impossible to differentiate from carcinoma by it is gross appearance

Duct Ectasia

is a widening of the ducts of the breast, a

condition that occurs most frequently in women in

their 40s and 50s. A thick and sticky discharge,

usually gray to green in color, is the most

common symptom.

Tenderness and redness of the nipple and

surrounding breast tissue may also be present.

Sometimes, scar tissue forms around the

abnormal duct, leading to a lump that may be

initially mistaken for cancer.

Duct Ectasia

Microscopically

-The periductal elastic

tissue is destroyed &

the surrounding

tissue are infiltrated

with lymphocytes &

plamsa cell

Duct Ectasia

Clinically:- this condition present as solitary or multiple tender swelling in the sub or Peri-areolar region of the breast.

- Nipple retraction, skin adherence, edema & axillary

adenopathy may accompany a hard, diffuse mass within the

breast

- palpation reveals a number of cord like swelling which radiate from the areola.

- the ducts are dilated & contain an inspissated yellow cheesy material that can be expressed like toothpaste from the cut end of a duct.

- occasionally, the inflammatory response are so acute that

skin changes occur & the condition may be mistaken for

a breast abscess.

Duct Ectasia

Treatment : Small volume discharge is managed conservatively

Socially embarrassing discharge is treated by Major duct excision

Galactocele

Cystically dilated terminal ductules that are filled with milk and lined by double layer of breast epithelium and myoepithelium.

Classically appears as a painless lump weeks – months after cessation of breast feeding.

GALACTOCELE

It is probably formed by obstruction to a duct

in the puerperium . the milk retained proximal

to the obstruction eventually becomes

cheese-like.

The common complication of this type of

swelling is infection.

The treatment is by surgical excision.

INTRA-DUCTAL PAPILLOMA

This benign lesions of the lactiferous duct wall occur centrally beneath the areola In 75% of cases.

They most commonly produce a bloody nipple discharge, some times associated with Pain

They are solitary proliferation of ductal epithelium

Intraductal papillomas should be treated by excision of a duct as a wedge resection.

Cystosarcoma phyllodes (CSP)

Cystosarcoma phyllodes (CSP) is a rare, predominantly benign tumor that occurs almost exclusively in the female breast. Its name is derived from the Greek words sarcoma, meaning fleshy tumor, and phyllo, meaning leaf.

Grossly, the tumor displays characteristics of a large, malignant sarcoma, takes on a leaflike appearance when sectioned, and displays epithelial cystlike spaces when viewed histologically (hence the name).

Because most tumors are benign, the name may be misleading. Thus, the favored terminology is now phyllodes tumor.

Cystosarcoma phyllodes (CSP)

Pathophysiology of CSP

Pathophysiology:

Phyllodes tumor is the most commonly

occurring nonepithelial neoplasm of the

breast, and it occurs only in the female

breast.

It has a sharply demarcated, smooth texture

and is typically freely movable. It is a

relatively large tumor, and the average size

is 5 cm. However, lesions more than 30 cm

in size have been reported.

Cystosarcoma phyllodes (CSP)

Cystosarcoma phyllodes (CSP)

TREATMENT of CSP

Surgical Care: In most cases, perform wide local excision with a rim of normal tissue

If the tumor/breast ratio is sufficiently high to preclude a satisfactory cosmetic result by segmental excision

total mastectomy, with or without reconstruction, is an alternative.

More radical procedures generally are not warranted

Perform axillary lymph node dissection only for clinically suspicious nodes. However, virtually all of these nodes are reactive and do not contain malignant cells.

MASTITIS

MASTITIS

Breast mastitis is an infection that commonly affects women who are breast-feeding (especially during the first two months after childbirth) but can occur in all women at any time.

Mastitis is a benign condition that can usually be treated successfully with antibiotics.

Inflammation can be caused by many types of injury including : infectious agents and their toxins,

physical trauma

or chemical irritants

SIGNS AND SYMPTOMS OF MASTITIS

Part or all of the breast is intensely: painful,

hot, tender, red, and swollen.

Some patients can pinpoint a definite area of inflammation, while at other times the entire breast is tender. - feel tired, run down, achy, have chills .feel like flu .

A breastfeeding mother who thinks she has the flu probably has mastitis.

SIGNS AND SYMPTOMS OF

MASTITIS

chills or feel feverish, or temperature 38c or higher. These symptoms suggest an infection.

Feeling progressively worse, the breasts are growing more tender, and the fever is becoming more pronounced.

Other signs of mastitis: cracked or bleeding nipples,

stress or getting run down,

missed feedings or longer intervals between feedings.

SIGNS AND SYMPTOMS OF

MASTITIS

TREATMENT OF MASTITIS

Mastitis usually requires treatment.Treatment for mastitis may require the following:

Antibiotics are usually prescribed by a physician to help clear up the infection.

Use warm water on the infected area of the breast before breast-feeding to help stimulate let-down (the milk ejection reflex).

Breast-feed or pump frequently, using both breasts. Lactation consultants recommend first breast-feeding from the unaffected breast until let-down (milk ejection reflex) occurs and then switch to the breast with mastitis.

Breast-feed only until the breast is soft.

Apply icy compresses to the breasts after breast-feeding to relieve pain and swelling.

Drink fluids and get enough rest.

Analgesia to control the pain.

BREAST ABSCESS

BREAST ABSCESS

This condition is usually found during lactation . as role the infecting organism is : staphylococcus aureus, and less commonly streptococcus pyogenes .

the usual mode of infection is via the nipple, the infection being carried by suckling infant in the nasopharynx.

The infection is at first limited to the segment drained by the lactiferous duct but it may subsequently spread to involve other areas of the breast.

BREAST ABSCESS

CAUSES :

Staphylococcus aureus and streptococcal

species are the most common organisms

isolated in puerperal breast abscesses.

Nonpuerperal abscesses typically contain

mixed flora (S aureus, streptococcal

species) and anaerobes.

BREAST ABSCESS

CLINICAL FEATURES

SYMPTOM

Localized breast area edematous,

erythematous, warm, and painful

History of previous breast abscess

Associated symptoms of fever, vomiting,

and spontaneous drainage from the mass or

nipple

May be lactating

BREAST ABSCESS

CLINICAL FEATURES

SIGNS

Localized breast area erythematous, hot, edematous, and extremely painful

Most commonly found in the areolar or periareolar area

Fluctuance of the mass

May have associated fever or axillary lymphadenopathy

Discharge with palpation from nipple or mass

Nipple inversion

Investigations

1-Ultrasound: used to localize the abscess

2. FNAC: used to exclude underlying carcinoma

especially in chronic Breast abscess where the

abscess become encapsulated with a thick

fibrous capsule & the condition can’t be

distinguished from a carcinoma without a biopsy.

3. Needle Aspiration: to confirm presence of pus.

4. Mammogram: to exclude underlying carcinoma.

BREAST ABSCESS MANAGEMENT

1- If the patient present in the cellulitis stage the patient should be treated with an appropriate Antibiotic.

2- Breast rested with feeding on the opposite side only.

3- The milk should be expressed from the healthy segments of the affected breast.

4- Support of the breast

5- Local heat & analgesia to relive the pain.

6- If the infection doesn’t resolve within 48 h, the breast should be incised & drained.

N.B. if antibiotics used in the presence of undrained pus, an Antibioma form. This is a large sterile brawny edematous swelling which takes many weeks to resolve.

BREAST ABSCESS

MANAGEMENT 7.If pus is present at the time of presentation, which can

be confirmed by Needle aspiration, Incision &

Drainage is done which can be achieved by : � Simple Needle Aspiration: using a wide pore needle under local anesthesia.

� Guided drainage: under image control with radiological or ultrasound techniques a tube drain can be inserted & left until the cavity has collapse.

� Surgical drainage: it is the most certain method, not only can all loculi be reached, but also dead tissue can be removed. The cavity is then dressed regularly & left open to heal by 2ry intention.

� Excision of all of the major ducts in case of Periductal Mastitis.

BREAST ABSCESS � Prevention

� Taking care of Breasts during pregnancy & Lactation

� Stop lactating from cracked nipple.

� Treating Mastitis in its early stages with appropriate medication & duration.

�Drainage of Post-traumatic Hematoma.

� Excision of Sebaceous Cyst.

� Self Examination for any masses or tenderness.

�Control of concomitant disease that increase the tendency to get infections such as DM

MANAGEMENT

Lactational breast abscess

Usually due to Staph. aureus

Usually peripherally situated

Surgery may be pre-empted by early diagnosis

Attempt aspiration

If no pus - antibiotics

If pus present consider repeated aspiration or incision and drainage

Consider biopsy of cavity wall

Continue breast feeding from opposite breast

No need to suppress lactation

Non-lactational breast abscess

Occur in periareolar tissue

Culture yield - Bacteroides, anaerobic strep, enterococci

Usually manifestation of duct ectasia / periductal mastitis

Occur 30- 60 years , More common in smokers

Often give history of recurrent breast sepsis

Repeated aspiration is the treatment of choice

Metronidazole and flucloxacillin

Drain through small incision if non-resolving

Definitive treatment when quiescent with antibiotic prophylaxis

Usually a major duct excision = Adair's operation

Spontaneous discharge or surgical excision can result in mammary fistula

BREAST ABSCESS

Mondor’s Disease

Superficial

thrombophelebitis of vein

over breast & chest–

thoracoepigastric artery

Thrombosed subcutaneous

cord attached to skin

Self limiting condition

Treatment is restricted arm

movement

Benign breast disease

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CONCLUSION

Benign breast disorders & diseases are common

The aetiopathogenesis is complex and not fully understood

Lump and pain are the most common complaints

Evaluation is done by Triple assessment

Histological risk factors for future malignancy are relative and not absolute risk factors

Treatment is based on the natural history of clinical problems

Treatment must be tailored to individual needs

EMQ