BENIGN BREAST DISEASES
PROFFESOR.S.FLORET
NORMAL STRUCTURE DEVELOPMENTAL/CONGENITAL
• Polythelia • Polymastia • Athelia • Amastia ‐ poland syndrome • Nipple inversion • Nipple retraction
• NON‐BREAST DISORDERS • Tietze disease • Sebaceous cyst & other skin disorders. • Monder’s disease BENIGN DISEASE OF BREAST
• Fibroadenoma • Fibroadenosis‐ ANDI • Duct ectasia • Periductal papilloma • Infective conditions‐ Mastitis ‐ Breast abscess ‐ Antibioma ‐ Retromammary abscess Trauma –fat necrosis. NIPPLE INVERSION
• Congenital abnormality • 20% of women • Bilateral • Creates problem during breast feeding • Cosmetic surgery does not yield normal protuberant nipple. NIPPLE INVERSION NIPPLE RETRACTION
• Nipple retraction is a secondary phenomenon due to • Duct ectasia‐ bilateral nipple retarction. • Past surgery • Carcinoma‐ short history,unilateral,palpable mass. NIPPLE RETRACTION ABERRATIONS OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI)
• Breast : Physiological dynamic structure. ‐ changes seen throught the life. • They are ‐ developmental & involutional ‐ cyclical & associated with pregnancy and lactation. • The above changes are described under ANDI. PATHOLOGY
• The five basic pathological features are: • Cyst formation • Adenosis:increase in glandular issue • Fibrosis • Epitheliosis:proliferation of epithelium lining the ducts & acini. • Papillomatosis:formation of papillomas due to extensive epithelial hyperplasia. ANDI & CARCINOMA
• NO RISK: • Mild hyperplasia • Duct ectasia. • SLIGHT INCREASED RISK(1.5‐2TIMES): • Moderate hyperplasia • Papilloma with fibrovascular core. • MODERATE RISK(4‐5times): • Atypical ductal hyperplasia • Atypical lobular hyperplasia Progression to Breast Cancer CLINICAL FEATURES
• ANDI presents in various forms including: • Discrete breast lump • Lumpy breast • Nipple discharge • Breast pain(cyclical,noncyclical) • Mastalgia affects upto 70% of women at some point in their life. • Two‐third of patients affected have cyclical mastalgia & one‐third have non‐cyclical mastalgia. INVESTIGATIONS
• FNAC • Biopsy • Mammography • ultrasound TREATMENT
• Reassurance itself may suffice for those with lumpy breasts. • CYCLICAL MASTALGIA : due to hyperestrogenism. abnormal prolactin secretion also been implicated. • Initial treatment: assurance. evening primrose oil(gammalinolenic acid). • Treatment of choice:Danazol Bromocriptine Tamoxifen(promising drug of choice) • NON‐CYCLICAL MASTALGIA: difficult to treat. • Search should be made for musculoskeletal cause of pain. • Excising a painful trigger spot in breast causes occasional relief. FIBROADENOMA
• Benign tumor of breast lobule. • Composed of stromal & epithelial elements. • AETIOLOGY: • Occurs in developmental stage of breast. • Due to oestrogen sensitivity. FIBROADENOMA PATHOLOGY
• Gross examination: tumor is, ‐ 2 to 3cm in size. ‐ sharp boundaries ‐ cut surface is glistening white. • Microscopically,there are two types: • Intracanalicular type: stroma compresses the ducts into slit‐like structures. • Pericanalicular type: stroma just surrounds the ducts without compressing them. FIBROADENOMA FIBROADENOMA‐ cut‐ section
bulging,
whirled like
cut‐cabbage. • Fibroadenoma is not a premalignant condition. • Co‐existentence in cancer pts is most often a lobular carcinoma in situ. • fibroadenoma – bimodal age of occurrence. • Younger pts – juvenile fibroadenoma. • fibroadenoma>5cm –Giant fibroadenoma – no malignant potential. GIANT FIBROADENOMA‐>5cm CLINICAL FEATURES
• Common in 2nd & 3rd decade. • Firm. • Extremely mobile –” breast mouse”. • Lobulated tumor • 2 to 3cm in size. • Painless. • 10% cases – multiple. • Increasing age –less mobile – due to involution. TYPES
• HARD FIBROADENOMA: • Younger age. • No malignant potential
• SOFT FIBROADENOMA: • Older age • Has malignant potential. • DIAGNOSIS: FNAC • TREATMENT: • Women <25yrs – not removed. • Older women – Excisional biopsy. • Local recurrence is rare. • Giant fibroadenoma – enucleation of complete tumor by cosmetic incision. PHYLLODES TUMOR
• Previously termed as cystosarcoma phyllodes. • PATHOLOGY: The tumor is • Circumscribed • Irregular surface with projections(leaf‐like) hence called as phyllodes. • Soft in consistency • Cut surface –brown color,with areas of hemorrhage,necrosis,cystic change. • Histologically: epithelial & fibrous elements present. • 3 GRADINGS: • BENIGN. • INTERMEDIATE. • MALIGNANT. • Malignant lesions have evidence of sarcoma which is usually liposarcoma or rhabdomyosarcoma. PHYLLODES TUMOR • CLINICAL FEATURES: • Women between 30 – 50yrs. • Tumor –grows‐ large size –usually mobile. • Skin –not infiltrated but stretched out,reddened with ulceration due to pressure necrosis. • TREATMENT: • Excision. • Large tumors –simple mastectomy. • Local recurrence‐ upto 25% ‐ wide local excision. BREAST CYST
• Formed due to cystic lobular involution with formation of lobular microcysts which coalesce to form macrocyst. • Predisposing factor – obstruction to lobular outflow. • It is a type of ANDI and associated with hyperestrogenism. BREAST CYST CYST ‐ 2 TYPES
• SIMPLE CYST: simple cuboidal epithelium • Single • Do not recur. • No association with cancer. • APOCRINE CYST: apocrine epithelium • Tendency to recur. • Association with cancer. • CLINICAL FEATURES:age group of 40‐50 yrs. • Pain – occasionally present. • Solitary & large at time of presentation. • Examination: cysts – smooth surfaced & dark in color – blue domed cysts. • DIAGNOSIS:Aspiration of cyst fluid‐ pale yellow to black color. • Mammography & ultrasound to exclude malignancy. • TREATMENT: • Aspiration of cyst till it is impalpable. • Residual mass after aspiration is an indication for FNAC or biopsy. • Indications for surgical excision are: • Blood stained aspirate‐ indicator of intracystic carcinoma. • Cyst recurrence after repeated aspiration. GALACTOCOELE
• Milk filled cyst –either occurs at time of cessation of lactation or frequency of lactation is less. • Occurs due to obstruction of major lactiferous duct by inspissated milk. • TREATMENT: • Needle aspiration • Surgery –when cyst cannot be aspirated or gets infected. GALACTOCOELE DUCT PAPILLOMA
• Papilloma are true polyps‐ arise from epithelium lined ducts in the breast. • Solitary papilloma located in subareolar region. • Multiple papilloma – peripherally located –increased tendency to develop carcinoma. • Histologically – core of fibrovascular tissue covered by epithelium –areas of necrosis & infarction. • Epithelial hyperplasia – responsible for malignant change. • Presents with nipple discharge or lump. • Commonest cause of bloody discharge and should be differentiated from ca breast. INTRADUCTAL PAPILLOMA INTRADUCTAL PAPILLOMA
Single.
Sub‐areolar.
Less malignant potential. • INVESTIGATION: • FNAC done for lump. • Cytology of bloody discharge • Mammagraphy • Ductography identifies offending duct‐insensitive. • TREATMENT: • Surgical excision. • Offending duct probed‐ circumareolar incision made‐ probe identified‐ duct excision‐ sent for histopathology. DUCT ECTASIA
• Type of ANDI occurs due to ductal involution. • Perimenopausal age group. • Dilation of large periareolar ducts. • PATHOLOGY: • Ducts filled with periductal infiltration of thick green or creamy secretion with periductal infiltration of chronic inflammatory cells. • Discharge: bilateral‐ multifocal‐ thick –varying colors. • Intraductal ulceration‐ bloody,unifocal discharge from nipple. • Periductal ulceration‐ mass below nipple. DUCT ECTASIA • The exact mechanism of ductal dilatation is not known but possibly due to: • Primary periareolar inflammation leading to ductal dilation. • Obstruction of the ducts with dilation. • Management:Reassurance & antibiotics for suppuration. • Needle aspiration • Incision & drainage • Repeated episode of infection –total duct excision under antibiotic cover. TRAUMATIC FAT NECROSIS
• Not a premalignant condition. • Preceded by history of trauma to the breast. • Histology :granular histiocytes surrounding cyst containing free lipid. • Importance lies in differentiating it from ca breast. MONDOR’S DISEASE
• Is characterized by thrombophlebitis of the superficial veins adjacent to the breast. • Precipitated by surgical procedures,infection, repetitive movements of upper extremity. • Lateral thoracic vein & thoracoepigastric veins are most commonly affected. • Benign • Painful • Examination: tender firm cords in the direction of veins. • DIAGNOSIS: • Biopsy –if there is mass adjacent to affected veins. • TREATMENT:Analgesic & local hot compresses. • Resolution within 2‐6weeks • Refractory cases – ligature above & below the site of involvement. MONDOR’S DISEASE BREAST ABSCESS
• Two types: • Lactational breast abscess • Non‐Lactational breast abscess LACTATIONAL BREAST ABSCESS
• Occurs either at commencement of feeding orduring the period of weaning,when breast is engorged due to residual breast milk. • Cracked nipple –entry of infective organism‐ usually staphylococcus aureus. • Presents –breast discomfort followed by pain & fever. • Signs of acute inflammation –if untreated –abscess formation. • On aspiration‐ pus not found‐ systemic antibiotics(flucloxacillin,cloxacillin) for 10 days needed. • Tetracycline,chloramphenicol & ciprofloxacin‐ contraindicated. • If pus is aspirated‐ incision & drainage done. • Suppression of lactation required – bromocriptine 2.5mg/d for 14days. PREDISPOSING FACTOR‐ Cracked nipple. BREAST ABSCESS BREAST ABSCESS BREAST ABSCESS INCISION & DRAINAGE
• Done when pt does not respond to 2 to 3days of antibiotics. • Incision made at site of maximum tenderness – radial or transverse. • Counterdrainage advised when abscess is deep. NON‐LACTATIONAL BREAST ABSCESS
• Complication of duct ectasia‐ tends to recur. • Seen in periareolar region. • Bacteroides, anerobic streptococci & enterococci. Administration of cloxacillin &metronidazole. • Incision & drainage –avoided if possible. NIPPLE DISCHARGE
• Suspicion of breast carcinoma which is rarely associated. • May or may not be associated with lump. • CAUSES OF BREAST DISCHARGE: • PHYSIOLOGICAL:‐ during pregnancy‐ reassured. • DUCT ECTASIA:‐ discharge‐ multifocal‐bilateral‐ varying colors. • DUCT PAPILLOMA:‐serous,serosanguinous or frankly blood‐stained. • GALACTORRHOEA:‐milky discharge‐ hyperprolactinaemia,menarche,menopause,drugs(haloperidol,met oclopramide,methyldopa). • CARCINOMA:‐usually from single duct‐ serous or blood‐stained. • CYSTS • IDIOPATHIC:‐10% cases TYPES OF NIPPLE DISCHARGE
• SEROUS DISCHARGE: • Duct papilloma • Mammary dysplasia • BLACK/GREEN DISCHARGE(altered blood): • Duct ectasia • BLOOD STAINED DISCHARGE: • Duct papilloma • Duct carcinoma • Duct ectasia • MILKY DISCHARGE: • Galactorrhoea • Endocrine disorders(pituitary adenoma,cushing’s syndrome,TCA’s,verapamil). INVESTIGATIONS
• Mammography • Ductography • Cytology of discharge TREATMENT OF NIPPLE DISCHARGE
• 1.Nipple discharge with lump: remove the lump. • 2. Nipple discharge without lump: • Discharge from one duct only‐ perform microdochectomy(remove affected duct by passing a probe into it). • Discharge from more than one duct‐ check the discharge for haemoglobin ‐ if positive in women over 40 yrs‐ cone excision of major ducts. ‐ if negative or positive in pts less than 40yrs‐ policy is to observe. GYNAECOMASTIA
• Presence of female type of mammary gland in the male.
‐Not a disease. ‐Enlargement of male breast is common. GYNAECOMASTIA • PHYSIOLOGIC GYNAECOMASTIA: during three phases of life.
NEONATAL PERIOD – action of placental estrogen on neonatal breast parenchyma. ADOLESCENCE PERIOD‐ Excess of estrogen with relation to testosterone. SENESENCE PERIOD‐ increase of estrogen relation to testosterone. PATHOPHYSIOLOGY
• 1.Estrogen excess state • 2.Androgen deficient state • 3.Drug related • 4.Systemic disease with idiopathic mechanism. PATHOLOGY
• There is combined increase in glandular & stromal element. • There is regular distribution of each element throught enlarged breast. • The ductal structure of the male breast enlarge,elongate & branch out with ensheathing connective tissue. • ADOLESCENCE GYNAECOMASTIA: • Often unilateral. • Typically between age of 12 to 15yrs. • SENESCENT GYNAECOMASTIA: • Usually bilateral. • Gynaecomastia do not predispose to cancer. • By contrast, • Hypoandrogenic state of ‐ primary testicular failure. ‐ klinfelter’s syndrome Is associated with high risk of breast cancer. CLINICAL FEATURES
• Dominant non‐tender mass. • Local area of firmness • Irregularity • Asymmetric CLINICAL CLASSIFICATION
I. Mild engorgement withOUT skin reduntancy II. Moderate engorgement withOUT skin reduntancy III. Moderate engorgement with skin reduntancy IV. Marked engorgement with skin reduntancy & ptosis similar to female breast. INVESTIGATION
• USG • Mammography • To differentiate‐ indistinguishable or ill‐defined fatty tissue from male breast lesion& soft tissue structure.
• TREATMENT: Treat the cause. • Due to drugs‐ stop the drugs. • Syndromes‐ treat the primary cause. • Idiopathic‐ physiological‐ assurance below the age of 18. • Bigger size‐ surgery‐ websters