Benign Breast Diseases

Dr. Jyotshna Sapkota Intern Department of general surgery

Importance of benign breast diseases

Most of the pt who come with breast symptoms have benign diseases. Some benign diseases are risk factors for breast cancer. ANDI(Aberrations of development and involution). normal

Classification of benign breast diseases

What is ANDI
Aberration in normal development and involution. Most benign disorders are related to normal process of reproductive life. There is a spectrum that ranges from normal to aberration and occasionally to disease

Pathology of ANDI
1. Cyst formation 2. Fibrosis- fat and elastic tissue disappear and is replaced by dense white fibrous trabeculae 3. Hyperplasia of epithelium in the lining of the ducts and acini may occur 4. Papillomatosis

Stage

Main clinical presentation

Normal process Aberration Disease

Fibroademona Lobular development, Early reproductive (15-25yrs) Stromal development, Nipple eversion Adolescent hypertrophy, Nipple inversion

Giant fibroadenoma

Gigantomastasia, Subareolar abscess/mammary duct fistula

Stage

Main clinical presentation

Normal process Cyclical changes of mens, Aberration Disease

Cyclical mastalgia, Nodularity Bloody nipple

Incapacitating mastalgia

Mature reproductive (25-40yrs)

Epithelial hyperplasia of pregnancy

Stage

Main clinical presentation

Normal process Lobular involution, Aberration Disease

Involution (35-55yrs)

Duct involution, Dilatation, sclerosis, Epithelial turnover

Macrocysts sclerosing lesions, Duct ectasia Nipple retraction, Simple epith. Hyperplasia

Periductal mastitis

Non ANDI
These include conditions of well define etiology. Ex. fat necrosis, breast abscess.

Clinical presentation of BBD

Breast lumps Mastalgia- cyclical and non cyclical Nipple discharge Infection

Breast lumps
1. Normal breast nodularity or cyclical nodularity
Upper quad and axillary tail. Assessment is clinical, supplemented by USG cytology or core needle histology. Excisional biopsy if doubt persists.

Breast lump cont..

2. Fibroadenoma
15-25 yrs. Rubbery, firm, smooth or lobulated and extremely mobile. increase in size during pregnancy and involutes after parturition. >5cm is giant fibroadenoma. Phyllodes Tumour - D/D. T/t - If age<25 conservative. Excision is done if age>25, size increases, giant fibroadenoma and positive family h/o of carcinoma.

Fig: Fibroadenoma A: Cut surface - lobulated, solid, and gray-white B: Histologically the lesion consists of densely fibrotic stroma and compressed cleft-like ducts.

Breast lump cont..

3. Breast cysts
40-50 yrs. smooth and tense and easily palpable against the chest wall. USG and needle aspiration confirms. On aspiration cyst must disappear excisional biopsy is done if residual mass is present or blood stained fluid is present.

Breast lump cont..

4. Galactocele
Painless swelling appears in breast during or after cessation of lactation. Cyst filled with milky material and has same character as other cysts. Mainly found towards areola. Due to block in duct with some proteinacous materials. Repeated aspiration best mgt.

Fig: Galactocele left breast

Triple Assessment

Mastalgia
1. Cyclical
Related to menstrual cycle. Duration of >1 week per cycle is significant and called pronounced symptoms. Etiology
Hyperprolactenemia Increase level of estrogen after ovulation Abnormality of prostaglandin secondary to deficient essential fatty acid intake in diet.

Mastalgia cont
2. Non Cyclical Mastalgia
True non cyclical mastalgia Chest wall pain

Mastalgia cont..
T/T
Non Medical Measures Reassurance breast support dietary measures

 Medical Measures NSAIDS-topical application Evening primrose oil Danazol Bromocriptine Tamoxifen Nerve blocks

 Surgical measures subcutaneous mastectomy - the last resort

Planning of treatment
Cyclical evening primrose oil
danazol bromocriptine

Noncyclical danazol
bromocriptine and EPO

Nipple discharge
1. Discharge from single duct Blood stained
Intraductal carcinoma intraductal papilloma Duct ectasia fibrocystic disease duct ectasia carcinoma

Serous

Nipple discharge cont

2. Discharge from more than one duct
Blood Stained
Carcinoma Duct ectasia Duct ectasia Infection Duct ectasia Fibrocystic disease Carcinoma

Grumous

Purulent Serous

Duct Ectasia
Dilation of ducts associated with periductal inflammation. Presented as nipple discharge, sub areolar mass, abscess, mammary fistula and/or nipple retraction. t/t -rule out malignancy if lump or nipple retraction. -if suspicion remain excisional biopsy -excision of all major ducts.

Infections
Bacterial mastitis -cellulitic stage -abscess formn Tuberculosis Actinomycosis Syphilis

Benign vs malignant

Risk of malignancy after benign lesion

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

Slightly increased risk(1.52 times)

Hyperplasia,moderate or florid, solid or papilloma 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

Risk factors for breast cancer

Female gender Increasing age Early menarche Late menopause Nulliparity Older age at first live birth Family history of breast cancer Personal history of proliferative benign breast disease  History of radiation exposure  BRCA1, BRCA2, p53 or PTEN mutations  Current or prior estrogen or progesterone hormone replacement therapy        

Self breast examination

Step 1: Begin by looking at your breasts in the mirror with your shoulders straight and your arms on your hips.

 Step 2: Now, raise your arms and look for the same changes. Step 3: While you're at the mirror, gently squeeze each nipple between your finger and thumb and check for nipple discharge (this could be a milky or yellow fluid or blood).

 Step 4: Next, feel your breasts while lying down, using your right hand to feel your left breast and then your left hand to feel your right breast. Use a firm, smooth touch with the first few fingers of your hand, keeping the fingers flat and together.

 Step 5: Finally, feel your breasts while you are standing or sitting. Many women find that the easiest way to feel their breasts is when their skin is wet and slippery, so they like to do this step in the shower

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