Benign Breast Diseases

Benign Breast Diseases - COO Breast Development  Arise from the epidermis forming ducts capped by alveolar buds  Puberty = breast   Differentiation  Ducts communicate and lobules develop  Final full breast   Differentiation = Term Pregnancy 

Menstrual and Ovarian Cycle  Epithelial cells proliferate during luteal phase  Programmed cell death after the luteal phase  Associated with edema of the extracellular space Menopause  Lobules involute  Collagenous stroma is replaced by fat   Estrogen receptor increases History  Focus on:  Nipple Discharge  Character of discharge  Breast Mass  Association of symptoms with the menstrual cycle  Change in breast shape, size, or texture  Previous breast biopsies Detection  The patient should be questioned about the following risk factors for breast cancer  Family History of Breast CA  High Fat Diet, Obesity and Alcohol Intake  Nulligravid  Increasing age  Age of menarche < 12 years  Nulliparity or first pregnancy >30 years of age  Late menopause (older than 55 years of age)  Family history of breast cancer (especially premenopausal or bilateral disease)  Number of first-degree relatives with breast  cancer and their ages when diagnosed  Family history of male breast cancer  Inherited conditions associated with a high risk  for breast cancer:  BRCA1 and BRCA2 genes  Li-Fraumeni syndrome  Cowden's disease  ataxia telangiectasia syndrome  Peutz-Jeghers syndrome Evaluation of Breast Lump Triple Test   Clinical examination  Imaging  Pathology / Biopsy Clinical Examination  Inspection  Symmetry  Contour  Skin Appearance and skin changes  Dimpling  Nipple discharge

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Palpation  Location of the mass is reported based on clock position  Measure distance from the nipple  Breast temperature  Texture  Thickness of the skin  Generalized or focal tenderness  Nodularity  Density  Dominant masses  Nipple Discharge

Diagnostic imaging  Mammography Breast Biopsy  Needle biopsy  Fine needle biopsy  Core needle biopsy Breast Cancer Detection  Self-detection 48%  Breast Imaging 41%  Physician PE 11%  Recommendation:  Premenopausal: Monthly 7 – 10 days after the onset of menses  Menopausal: Select a specific calendar date and perform monthly Breast self-examination Breast Imaging Mammography   Detects slow growing breast cancer before it  reaches a size detectable by palpation  Indications:  Screening for women at risk for breast CA  Evaluate a questionable/ ill-defined breast  mass or other suspicious change in the breast  detected by breast examination  Baseline breast mammogram and reevaluate patients at yearly intervals to diagnose a potentially curable breast cancer before it has been diagnosed clinically  Search for occult breast CA in those with metastatic disease in axillary nodes or elsewhere from the primary origin  Screen for unsuspected CA before cosmetic operations or biopsy of a mass  Monitor breast CA pts. Treated with breastconserving surgery and radiation Screening  American Cancer Society  Women with average risk for breast CA begin mammography by 40 years old  Women 20s to 30s clinical breast exam every 3 years or annually  Women >40 years old annual breast exam plus mammography  American Geriatric Society  Annual/ biennial mammography up to 75 years old  For high risk women initiation of screening must be earlier and more frequent 

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Benign Breast Diseases - COO Mammographic Abnormalities  Morphologic Categories of Mammographic Abnormalities:  Calcification distribution  Number of calcifications  Description of calcifications  Mass margin  Shape of mass  Density of mass  Associated findings  Special cases Mammographic Reports  Six Categories:  Incomplete, needs further imaging  Negative  Benign finding  Probably benign, short-interval follow-up recommended  Suspicious finding and biopsy should be considered  Highly suggestive of malignancy and appropriate action should be undertaken  Known malignancy Correlation of Findings  Biopsy is done on a dominant/suspicious mass despite absent mammographic findings Ultrasonography   Used for focused scanning of a questionable finding/ evaluation of a mammographic finding  Preferred method to distinguish between solid and cystic masses  Not recommended for routine screening

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Indications:  Characterization: Palpable abnormality 

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Ambiguous mammographic findings Silicone leak  Mass in woman 99% accurate  If benign – follow-up PE every 6 months.  If malignant, refer to surgery  If non-concordant, excision of breast mass.

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Benign Breast Diseases - COO Algorithm for Management of Breast Masses in Premenopausal women

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Benign Breast Diseases - COO Algorithm for Management of Breast masses in Postmenopausal women

Benign Breast Disorders Fibrocystic Change  Most common lesions of the breast   Histologically refers to:  Fibrosis in the breast   Cyst formation in the breast   Epithelial hyperplasia in the breast   33-55 years old  Associated with benign breast epithelium Clinical Findings:  Asymptomatic mass  Smooth and mobile  Nipple discharge  May be accompanied by pain or tenderness during the premenstrual phase  Cyclic breast pain is the most common associated symptom Differential Diagnosis  Breast CA  Cysts  Papillomatosis  Adenosis  Fibrosis  Ductal epithelial hyperplasia Diagnostic Tests  Mammography: no diagnostic signs  Ultrasound  Mass with thin walls

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Smooth round shape Absence of internal echoes  Posterior acoustic enhancement  Fine Needle Biopsy Tissue Biopsy  No cyst fluid is obtained  Bloody fluid  Fluid is thick   Complex cyst   There is an intracystic mass  Mass persist after aspiration  Persistent mass noted at any time during follow up 

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Risk for Breast CA  Not associate with increased risk of breast CA  Unless with histological evidence of:  proliferative epithelium w/ or w/o atypia  Atypical ductal/ lobular hyperplasia= 5X  CA in-situ=8 – 10 x  Family history PLUS atypia = 11x  Cyst plus family history = 3x Management   No specific treatment required  Discontinue coffee, tea and chocolate  Vitamin E and B6 may be helpful  Self-Breast Exam every month just after menses

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Benign Breast Diseases - COO Mastalgia  Types of Mastalgia  Cyclic Mastalgia Related to exaggerated premenstrual  cycle Breast engorgement, pain, heaviness and  bilateral tenderness Common in the 3rd and 4th decade of life  Accounts for 2/3 of all breast pain  symptoms  Noncyclic Mastalgia Independent of the menstrual cycle  Achy, burning soreness  Intermittent/ constant   Unilateral  Common in the 4th and 5th decade   Extramammary Pain Perceived to be breast in origin but   extramammary in nature May be:  Chest wall muscular pain Coastal cartilage symptoms Costochondritis Herpes zoster Rib fracture     

Management of Mastalgia  Reassurance  Medications:  Anesthetics  Diuretics  Bromocriptine  Tamoxifen  Vitamins  Primrose oil  Mechanical support   Discontinuation of hormone therapy Fibroepithelial Lesions Fibroadenoma  Most Common Benign Tumor  Common in women < 25 years old  Rare after menopause  May be single or multiple lesions  Most are detected at 2 – 3 cm mass  Physical Examination:  Firm  Smooth  Rubbery  Mobile  Bilobed  On Imaging:  Well defined  Smooth  Solid mass with clear defined margins and borders  Risk to Breast CA  Not associated with increased risk to Breast  CA  Management:  Conservative Complete Excision

Phyllodes Tumor  Rare fibroepithelial tumors  Maybe:  Benign 70%  Borderline 7%  Malignant 23%  Rarely bilateral  Difficult to distinguish clinically w/ fibroadenoma  Management:  Wide local excision w/ 1-2 cm margin  Mastectomy for women with small breast   Axillary node dissection not indicated Breast Conditions Requiring Evaluation Nipple Discharge  Spontaneous 48%  Provoked 52% = no pathologic significance  Spontaneous discharge + Breast CA : 4 – 10% Non neoplastic causes:  Galactorrhea: most common  Physiologic conditions due to mechanical manipulation  Parous condition  Periductal mastitis  Subareolar abscess  Fibrocystic changes  Mammary duct ectasia Neoplastic causes in non-lactating women:  Solitary intraductal papilloma  Carcinoma  Papillomatosis  Squamous Metaplasia  Adenosis Extramammary causes:  Hormones and drugs Important Characteristics of the Discharge  Nature of Discharge  Association with a mass  Unilateral or bilateral  Single or multiple ducts  Spontaneous/ expressed  Relations to menses  Premenopausal/ postmenopausal  Hormonal medication  Nipple discharge cytology is rarely performed  Surgical excision of trigger point   Lacrimal probe is done  Breast resection for 3 to 5 cm  Patient is warned against:  Possible loss of: Skin  Nipple  Nipple sensation deformity  Inability to breast feed 

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Benign Breast Diseases - COO Erosive Adenomatosis of the Nipple  Rare benign condition that mimics Paget’s disease  Present with pruritus, burning and pain  Physical Examination:  Nipple maybe ulcerated, crusting, scaling, indurated and erythematous  Nipple is enlarged and prominent during menses  Differential Diagnosis: Squamous Cell CA, Psoriasis, Contact Dermatitis, Seborrheic Keratosis, AdenoCA of the skin and unusual primary tumor of the nipple  Local Excision is curative Fat Necrosis  With a history of trauma in 50%  Seen in active women  Ecchymosis may be seen near the tumor  Tenderness may be (+)/ (-)  May spontaneously disappear Breast Abscess Lactational Abscess  Common in first time breast feeders, this is true if  baby is not properly latched.  Lactational mastitis is due to transmission of  bacteria during nursing and poor hygien e  Staphylococcus aureus most common cause  Management:  Early stages: continue breast feeding plus dicloxacillin 250mg QID or oxacillin 500 mg QID for 7 – 10 days  If with a local mass and with signs of systemic infection  drainage and discontinue breastfeeding NonLactational Abscess  Develop in young/ middle age women  Due to trauma, or even hair.  Abscess is evaluated with ultrasound  Antibiotics and drainage is indicated if the fluid collection is > 3 ml  Otherwise aspiration of the pus is enough Subareolar Abscess and Lactiferous Duct Fistula  Due to obstruction of the distal ducts with inspissated debris  Most common organism Staphylococcus aureus  Definitive Management   Excision and drainage of lactiferous duct sinus Disorders of Breast Augmentation  Contraction of breast implants  Scarring around the implants  Causing firmness and breast distortion  Implant rupture  Bleeding of gel through the capsule  US and MRI for diagnose if there’s a l eaking of  breast implant:  Management:  Surgical removal if implants rupture

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