Introduction General Approach to benign breast disease Application to: › Breast examination › Breast cysts › Fibroadenomas Mastalgia Nipple Discharge Self-detected breast / axillary lump Breast pain 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 nipples) › Polymastia (accessory breasts) › Hypoplasia (small breasts) / Amastia / Athelia Mondor’s disease – phlebitis of the thoracoepigastric vein Breast Anatomy and Histology Gives us framework to understand / classify benign breast disease 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