 Introduction  General Approach to benign disease  Application to: › Breast examination › Breast cysts › Fibroadenomas  Mastalgia  Discharge  Self-detected breast / axillary lump   Nipple – discharge / itch / change  HRT – is it safe?  Family history – do I need to worry?

 Routine breast check  GP-detected lump

 Imaging report – cyst / solid lesion / calcification  Abnormalities during pregnancy / lactation  Breast infections  Gynaecomastia  Breast trauma – haematoma / fat necrosis

 Developmental anomalies › Polythelia (accessory ) › Polymastia (accessory ) › Hypoplasia (small breasts) / Amastia /

 Mondor’s disease – phlebitis of the thoracoepigastric vein Breast Anatomy and Histology

 Gives us framework to understand / classify benign

 Proliferative vs non-proliferative vs AH – all to do with the epithelium lining the ducts / lobules  Adeno – means diseased gland – again to do with the epithelium  Fibro- (implies connective tissue) therefore to do with the stroma  Some processes involve the major ducts (eg. papillomas) others the terminal duct-lobular units (eg. Cysts)

 Helps us understand the pathologist!! › PASH: pseudo-angiomatous stromal hyperplasia  growth of cells in the connective tissue that resembles vascular growths › Myoepithelial cells  Is the “lump” part of the normal glandular tissue being felt against the background fatty tissue?  Is it more of a thickening than a 3-D lump?  Is there similar lumpiness in the same position on the other side? (symmetry)  Do other parts of the same breast feel similar?  Is it prominent because of an underlying rib?  Is it in an area expected to have more glandular tissue? ie upper outer quadrant / inframammary ridge / sub-areolar region  You are not alone!! › One study found only 53% of masses felt by women <30 were true masses › Another study found that only 27% of masses detected by women <40 had an identifiable cause other than fibrocystic change › Among masses felt to be true abnormalities on examination by the surgeon, 28% were false-positive findings

Vargas et al. Outcomes of surgical and sonographic assessment of breast masses in women younger than 30. Am Surg 2005; 71: 716- 719

Morrow et al. The evaluation of breast masses in women younger than forty years of age. Surgery 1998; 124: 634-640  Think of the anatomy – UOQ / IM ridge / sub- areolar areas contain more glandular tissue  Compare to the other side  Compare to other areas in the same breast  Decide if the mass can be felt in 3-D  Feel away from chest wall as well as re- examining over a different area of the chest wall  Re-assess at a different time of the menstrual cycle in pre-menopausal women  Short term review (2-4 weeks)  Image (consider focused US – with marking)  Retrospective study over a 4-yr period ( all patients >28yrs of age as MMG was not done in younger age group)  374 patients with palpable abnormality and negative MMG and US  233 had 2 yr follow up  141 <2yr follow up but assumed cancer free  Six (2.6%) of the 233 had breast cancer in the area of palpable abnormality  All six were diagnosed in the 156 patients with dense breasts on MMG (ie 3.8% of the 156 patients with dense breasts)  The cancers were: IDC, 2 x DCIS, 2 x IDC + DCIS, ILC

Moy et al. Specificity of Mammography and US in the Evaluation of a Palpable Abnormality: Retrospective Review. Radiology 2002; 225: 176- 181  Devised in 1998 by American college of Radiologists

 Breast Imaging – Reporting and Data System

 Fluid-filled round or ovoid mass derived from the terminal duct lobular unit

 Begin as fluid accumulation in the TDLU because of distension and obstruction of the efferent ductule  Fluid constantly produced and reabsorbed in the milk ducts and acini  When a duct is blocked or fluid secretion exceedes absorption  fluid accumulates  cyst forms  Hormonally responsive: › Fluctuate during menstrual cycle › Tend to disappear after menopause › Can persist or appear de novo post- menopause on HRT  Very common – 7% of women present with a palpable cyst at some time in their life  More common to present as incidental lesions on imaging – 37% of women screened  Peak age 30-50  Smooth, soft to firm, mobile, sometimes tender  Cluster of cysts  tender area of nodularity  Classified on US as simple, complicated and complex  well-circumscribed  posterior acoustic enhancement  Without: › internal echoes (anechoic) › solid components › Doppler signal  Mgt: › Aspirate only if symptomatic › No need to aspirate for Diagnosis › Do not send cyst fluid unless blood stained macroscopically › No further imaging follow up required 1. Clustered microcysts are a cluster of simple anechoic cysts, each smaller than 2 to 3 mm, without discrete solid components.

2. Cysts with thin septa that are less than 0.5 mm in thickness are defined as simple cysts.

 Mgt: › As per simple cysts  Masses with homogenous low-level internal echoes due to echogenic debris  Without: › solid components › thick walls › thick septa › vascular flow  Mgt: › Aspirate and send for cytology › Core biopsy if residual solid component  masses with thick walls  septa greater than 0.5 mm  presence of cystic and solid components  absence of posterior wall enhancement  Mgt: › All should be aspirated  cytology › Solid component  core biopsied  Simple cysts › No need for biopsy unless symptomatic › No need for further follow up imaging › If aspirated, no need to send fluid unless blood-stained macroscopically

 Complicated / Complex cysts › FNA biopsy +/- core biopsy

 Benign fibro-epithelial lesion  Classified as proliferative lesions without atypia  Incidence of 7-13% from adolescence to mid 20s who present to speciality clinics  Incidence in the general population for this age group is 2.2% and decreases with age  Fibro – implies stromal element › Cellularity of this component is increased in the young › If there is mitotic activity within this component, it is a phylloides tumour › In older patients, stroma may become calcified or even ossified (ancient fibroadenoma)  Adenoma – implies glandular / epithelial element › This is the basis of classifying FA as a proliferative lesion › Range of epithelial changes – some which may be associated with increased risk of breast cancer › Basis of Simple vs Complex fibroadenoma  Risk of malignant transformation is 0.0125 to 0.03%  Risk of malignant transformation in complex fibroadenomas has not been reported.  Malignant transformation within the epithelial elements is assumed to be the same as the rest of the breast  hence treated in the same way  Phylloides is rare (incidence 2.1 per million)  Peak age 45-49  Rapidly growing lump  Difficult to differentiate from FA on imaging

 Classified as benign / borderline / malignant depending on mitotic count in the stroma  Core biopsy: › More helpful in differentiating malignant phylloides › Difficult to differentiate benign from FA  Monoclonal vs polyclonal: › Molecular pathology not helpful but some studies show FA to be polyclonal (hence hyperplastic) and Phylloides monoclonal (hence neoplastic)  Conclusion: Take out FA if enlarging or suspicious of Phylloides on core biopsy  Most FA do not grow over 3cm  Rapid growth should raise concern  excision  Giant FA › same histology as simple FA but grow to very large size  excision  Juvenile FA › in adolescents and younger women › Stroma more cellular than simple FA › Excision  Some authors recommend excision of any FA > 3- 4cm › ? Because most <3cm › ? Difficulty differentiating from Phylloides › ? Excision of larger lesions more cosmetically challenging  <5% of FA occur in women >50  Some authors recommend excision of FA if age >35 › ?will remove potentially malignant lesions arising from FA – Kuijper et al 2001 (Radical view?)  Others recommend excision of any palpable FA if age >40 – Westmead Group - NSW › ?as likelihood of cancer increases with age › ? Radical view again?  No significant increased risk of carcinoma › Within lesion Or › To the rest of the breast  Complex FA managed as Simple FA  Management of lesion based on BIRADS (biopsy BIRADS-3 and above)  Excise giant / juvenile FA  Excise painful / tender FA  Otherwise excision based on triple test  US 6/12 post biopsy to ensure lesion stable in size – if significant growth may indicate Phylloides  US 6/12-ly for 2 yrs if no biopsy – to ensure stability

 Cyclical vs Non-cyclical vs Extra-mammary  Exclude extra mammary pain: (eg. Costochondritis can respond to non- steroidal topical gel)  Exclude a breast lump (nodularity is common but a discrete lump should have a triple assessment – examination, imaging +/- biopsy)  Consider a breast pain diary as treatment of breast pain depends on duration, severity and impact on the patient’s activities  Any woman >35 presenting with a new breast symptom should have a mammogram  In the absence of a discrete lump, ultrasound is unlikely to give useful information – especially in the setting of cyclical mastalgia  There is no increased breast cancer risk with cyclical mastalgia.  Only 5% of breast pain is due to breast cancer  When both imaging studies and breast examination are normal, it is unusual to detect an underlying breast cancer in women presenting with breast pain  Supportive brassiere (support without compression – eg sports bra)  Reduce caffeine intake  Reduce dietary fat intake  Regular exercise – eg. A brisk 30 minute walk daily  Avoid stress / anxiety  Evening primrose oil (EPO) › Avoid in patients with a history of epilepsy › Active ingredient: gamma-linolenic acid – a long-chain unsaturated fatty acid which is thought to act in a similar manner to reduction in dietary fat. › Dose: 3 x 1000mg tablets daily (in a single or divided doses). › Duration: 3 months – initial trial (continue if efficacious).  Vitamin B6: › Usually added to EPO but can be used as an alternative › 100mg daily for 3 months  Iodine: › Correct iodine deficiency (a morning spot urinary iodine is the test of choice for iodine deficiency) › Consider iodine replacement with 3-6mg/day of iodine › Tamoxifen – 10mg daily for 3 months then every alternate day for a further 3 months

› Danazol

› Bromocrpitine – 2.5mg bd

› significant side effects such as hot flashes, nausea, weight gain, hirsutism, depression › increased risk of DVTs and endometrial ca (with Tamoxifen)  Topical NSAIDs

 Referral for acupuncture

 Topical tamoxifen gel (Afimoxefene) – not available in Australia

 5% of referrals to breast clinics  95% have a benign cause  Features of a significant pathological process: spontaneous, single duct, persistent, troublesome and contains blood (micro or macro)  Spontaneous or induced  Single or multiple ducts  One or both breasts  Characteristics of the discharge: › Viscous / watery › Colour: clear / milky / green / blue-black  Frequency of the discharge › Persistent defined as more than twice a week › – defined as copious, arising from multiple ducts of both breasts  Age is an important predictor of malignancy:

<40 – 3%

40-60 – 10%

>60 – 30%  ?  Firm pressure around the to identify site of a dilated duct (pressure  discharge) – important for deciding incision site  Test the discharge for haemoglobin: › <10% of those with blood stained or positive haemoccult have a malignancy › Absence of blood does not exclude malignancy – (sensitivity of hemoccult only 50%)  MMG – most pts with discharge have negative MMG › Sensitivity of MMG for malignancy with pts with 60%

 US – pts with a visible lesion on US significantly more likely to have a malignancy

 MRI – large papillomas with enhancing rims c/w malignancy. But no role for MRI in investigating nipple discharge  Physiologic: › 2/3 of non-lactating women can have small amount of fluid expressed from the ducts with massage and gentle suction › Colour varies from white to yellow to green to brown to blue-black › These are apocrine secretions (the breast is a modified apocrine gland) › Emanates from multiple ducts and colour can vary from each duct › Noticed after warm bath or nipple manipulation › Not usually spontaneous or blood stained › Reassure. No specific treatment required  Intra-ductal papilloma  Multiple papillomas  Carcinoma  Bloody nipple discharge in pregnancy or lactation  Galactorrhea  Periductal and duct ectasia  Other causes of “nipple” discharge: › Long-standing nipple inversion with maceration › Paget’s › Eczema  If lump or lesion on imaging, manage accordingly.  Surgery is indicated for spontaneous single duct discharge AND 1 of: › Bloodstained or large amount of blood on testing › Persistent (>2 occasions per week) › Associated with a mass › New development >age 50 that is not thick or cheesy  Surgery only if distressing symptoms – or base on age:  <30, serosanguineous / watery  observe, review in 6/52, if persistent (>2/wk)  offer microdochectomy

 >45  TDE (more effective than microdochectomy at establishing diagnosis and not missing malignancy in women >40)

 30-45  Either of above approaches.