Download Benign Breast Diseases

Benign Breast Diseases
Dr Richa Jain
Associate Professor & Unit Head
S.M.S. Medical college
Jaipur
• The breasts are large, modified sebaceous
glands to which our culture attaches great
significance. An individual woman may react to the
tremendous anxiety of suspected breast disease with
behaviour that varies from frequent visits to the
physician for breast pain to denial of the presence of
an obvious mass.
• The
term
“benign
breast
diseases”
encompasses a heterogeneous group of
lesions that may present a wide range of
symptoms or may be detected as incidental
microscopic findings.
DEVELOPMENTAL ABNORMALITIES
Ectopic breast
• Both Supranummery and aberrant included in
this term
• Supernumerary breast tissue is seen mostly along
the milk line; the most frequent sites are the
chest wall, vulva, and axilla.
• Aberrant breast tissue is usually located near the
breast, most commonly in the axilla.
• Ectopic breast tissue is more prone to
malignant change and that ectopic breast
cancer occurs at an earlier age
Hypoplasia of breast
• Usually associated with different syndromes
such as ulnarmammary syn, poland syn,
Turner syn.
• Poland’s syndrome has been reported to be
associated with breast cancer most often.
Inflammatory Lesions
• A variety of inflammatory and reactive changes
can be seen in the breast. While some of these
changes are a result of infectious agents, others
do not have a well-understood etiology and may
represent local reaction to a systemic disease, or
a localized antigen-antibody reaction, and are
classified as idiopathic.
Acute Mastitis
• Also known as puerperal or lactation mastitis
• Usually occurs during the first 3 months
postpartum.
• a cellulitis of the interlobular connective tissue
within the mammary gland, can result in
abscess.
Etiology
• Improper nursing technique, leading to milk
stasis and cracks or fissures of the nipple,
facilitate entrance of microorganisms; and
stress and sleep deprivation, which both lower
the mother’s immune status and inhibit milk
flow, thus causing engorgement.
Rx
• Breast emptying with frequent nursing or
manual pumping and beginning empiric
antibiotherapy .
• Incision and drainage, if abscess
Granulomatous Mastitis
• Granulomatous reactions resulting from an infectious
etiology, foreign material, or systemic autoimmune
diseases
such
as
sarcoidosis
and
Wegener’s
granulomatosis.
• Diagnosis requires microbiologic and immunologic
testing in addition to histopathologic evaluation.
Contd…
• Idiopathic granulomatous mastitis granulomatous lesions without an identifiable
cause.
• Diagnosis made by excluding other possible
causes of granulomatous lesions.
• Treatment is complete surgical excision
whenever possible plus steroid therapy.
Foreign Body Reactions
• Foreign materials, such as silicone and paraffin,
used for breast reconstruction may cause a
granulomatous reaction in the breast.
• Silicone granulomas (“siliconomas”) occur after
direct injection of silicone into the breast or after
extracapsular rupture of an implant .
• Fibrosis and contractions may lead to clinically
apparent firm nodules that may be tender.
Recurring Subareolar Abscess
• Zuska’s disease
• Triad of draining cutaneous fistula from the
subareolar tissue; a chronic thick, pasty discharge
from the nipple; and a history of multiple, recurrent
mammary abscesses
• Caused by squamous metaplasia of one or more
lactiferous ducts in their passage through the nipple,
probably induced by smoking
Contd…
• Abscess drainage to allow for resolution of the
acute inflammation
and
then
complete
excision of the affected duct and sinus tract.
Fat Necrosis
• Rare, often confused with carcinoma.
• Presents with a firm, tender, indurated, ill-defined mass.
• Sometimes fat necrosis liquefies and becomes cystic.
• Mammography demonstrates fine, stippled calcification and stellate
contractions. Occasionally there is skin retraction.
• Treatment of fat necrosis is excisional biopsy.
• No relationship in fat necrosis & breast carcinoma.
• Fat necrosis as
seen on
mammography
Duct Ectasia/Peri-ductal
Mastitis Complex
• Also been referred to as varicocele tumor,
comedomastitis, periductal mastitis, stale milk
mastitis, chemical mastitis, granulomatous
mastitis, or mastitis obliterans.
• Patey identified squamous metaplasia of the offending
lactiferous ducts that lead to inflammation, dialatation
and abscess.
• Meguid coined the term MAMMARY DUCT –
ASSOCIATED INFLAMMATORY DISEASE SEQUENCE to
encompass disease progression from nipple discharge
& retraction to subareolar duct dialatation and further
sequence.
Dixon`s Theory
• Periductal mastitis and ductal ectasia are
separate entities.
• Acute inflammation occurs in young women
with smoking history.
• Ductal ectasia occurs in older women, more
commonly in non smokers.
Clinical PDM
• Abscesses are usually subareolar or juxtareolar,
single small(1-2 cm) and unilocular.
• Abscess may be sterile or polymicrobial
• In younger women, often associated with
congenital inverted nipple while in older women
it is associated with multiple ectatic ducts.
• Nipple discharge of off-white, creamy, brown
grey, green colour may occur.
• Some cases may develop chronic indurated
mass.
• Nipple retraction will develop ultimately due
to fibrosis.
Breast Masses associated with PDM
• Evanescent Mass – Small, tender in subareolar
region, disappear in 7-10 days.
• Recurrent Mass – Mass recur at same siteat
intervals of a few months to 10 years or more.
• Persistent mass – mass persistes for few weeks
• Chronic Mass – Hard, oedematous mass fixed
to skin, with nipple retraction, sometimes with
axillary nodes, mimics cancer
Classic view of pathology
Process
Clinical Manifestation
Duct Ectasia (a Hormonal
effect)
Epithelial ulceration
Stagnation of secretions,
Nipple discharge
Bloddy nipple discharge
Leakage of secretion into
periductal tissue
Granulomatous reaction +
secondary bacterial infection
Evanescent painful mass
Periductal fibrosis
Nipple retraction
Abscess/fistula
Mammography
Sonography
Comparison with Fibrocystic disease
Comparison with Carcinoma
Indications for surgery
• Non – bloody discharge – though not an
indication for sx, if it is profuse ; total duct
excision can be done
• Bloody discharge
• Nipple inversion
• Subareolar abscess
• Retroareolar abscess with fistula
Fibrocystic diseases
Breast histology
• The life cycle of the breast consists of three main
periods: development, mature reproductive life, and
involution.
• After the breast has developed, it undergoes regular
changes in relation to the menstrual cycle that results
in an increased rate of cell proliferation during the
luteal phase leading to an increase in breast size1.
First Stage
• The first stage occurs in women in their 20s and is
termed mazoplasia (mastoplasia). Breast pain is
noted primarily in the upper, outer quadrants of
the breast. The indurated axillary tail is in the
most tender area of the breast. During this phase
there is intense proliferation of the stroma.
Second Stage
• The second clinical stage of adenosis occurs
generally in women in their 30s. The breast pain
and tenderness are premenstrual but less severe.
Multiple small breast nodules vary from 2 to 10
mm in diameter. The histologic picture of
adenosis demonstrates marked proliferation and
hyperplasia of ducts, ductules, and alveolar cells.
Third Stage
• The last stage is termed the cystic phase and
usually occurs in women in their 40s. There is no
severe breast pain unless a cyst increases rapidly
in size. In this situation a woman experiences a
sudden pain with point tenderness and discovers
a lump. Cysts are tender to palpation and vary
from microscopic to 5 cm in diameter.
Contd…
• This leads to a spectrum ranging from normal
histologic features to features that mainly exhibit
patterns of fibrous change and cyst formation.
• Since this histologic pattern may be evident in up to 60
% of women without breast disease, it led Love et al to
suggest that fibrocystic “disease” does not exist.
• The currently accepted term for this condition is
′Fibrocystic change‘,
Eponyms
• Bloodgood‘s disease, Cooper's disease (after
Sir Astley Paston Cooper), Phocas’ disease,
Reclus’ disease (after Paul Reclus), ReclusSchimmelbusch
disease,
Schimmelbusch
disease and Tillaux-Phocas disease.
Basic bidirectional framework of the
ANDI classification
Horizontal – Spectrum of severity
Vertical – Pathogenesis based
on reproductive period
Development
15 – 25 years
Cyclical activity
25 – 45 years
Involution
35 – 55 years
Principles underlying the ANDI Concept
• Most benign disorders are related to normal processes
of reproductive life
• There is a spectrum that ranges from normal to
aberration, and occasionally to disease.
• The definition of normal and abnormal is pragmatic
• The ANDI concept embraces all aspects : symptoms,
signs, histology and physiology
Classification
• They can be subdivided into non-porliferative
and proliferative patterns.
Non-proliferative fibrocystic
change
• Cysts and fibrosis
– Characterized by an increase in fibrous stroma
associated with dilation of ducts and formation of
cysts of various sizes.
Radiology
Fibrocystic changes of breast
Proliferative fibrocystic change
• Epithelial hyperplasia
– It is proliferative lesion within the ductules, the terminal
ducts and sometimes the lobules of the breast.
• Sclerosing adenosis
– This variant is less common, but it is significant because its
clinical features are similar to those of carcinoma.
Epithelial hyperplasia
Sclerosing adenosis
FIBROCYSTIC DISEASES
OF BREAST
NON-PROLIFERATIVE
FIBROCYSTIC DISEASE
CYSTS FORMATION
AND
FIBROSIS
PROLIFERATIVE
FIBROCYSTIC DISEASE
1. EPITHELIAL DUCT HYPERPLASIA
2. SCLEROSING ADENOSIS
Treatment
Nonpharmacological Interventions
• Psychological Associations and Relaxation
Training - In 1829, Sir Astley Cooper wrote
that women seeking advice for breast pain
usually
had
temperament.”
“a
nervous
and
irritable
• Stop Smoking
• Lower dietary fat intake
• Methylxanthine (Caffeine) Restriction
Nutritional Supplements and Herbal
Agents
• Vitamin E (α-tocopherol)
• Soy is a rich source of the isoflavones
genistein and daidzen, which exert their effect
by binding to estrogen receptors
• Evening Primrose Oil
Pharmacological Interventions
• Simple Analgesics
• Oral Contraceptives (OCs), Estrogen, and
Progesterone
• Danazol
• Bromocriptine
• Tamoxifen
Radial Scar and Complex Sclerosing Lesion
• Radial scars are benign pseudoinfiltrative lesions of
uncertain significance.
• They are characterized by a fibroelastotic core with
entrapped ducts, surrounded by radiating ducts and
lobules.
• Some authors have suggested using the term “radial scar”
for lesions measuring <1 cm, whereas the term “complex
sclerosing lesion” was reserved for lesions measuring 1 cm
or larger
Contd…
• The radiographic features of radial scars are
nonspecific and may mimic carcinoma
• The role of FNA cytology in diagnosis is limited.
• A spiculated lesion suggestive of radial scar or
complex sclerosing lesion at mammography may
be excised on the basis of its size and amount of
sampling performed by core biopsy
Contd…
Intraductal papilloma
• It is a discrete benign tumor of the epithelium of mammary ducts.
• It can arise at any point in the ductal system and shows a
predilection for the extreme ends of the ductal system: the
lactiferous sinuses and the terminal ductules
•
The central papillomas tend to be solitary, whereas the peripheral
ones are usually multiple. Serous or serosanguinous nipple
discharge is the presenting symptom in most women.
Clinical Symptoms
• The classical symptom of an intraductal
papilloma is spontaneous bloody discharge
from one nipple. This symptom usually
appears in a woman in the perimenopausal
age group. The discharge from the nipple is
spontaneous and intermittent
Contd…
• During examination of the breast, it is
important to circumferentially put radial
pressure on different areas of the areola. This
technique helps to identify whether the
discharge emanates from a single duct or
multiple openings
• Papillomatosis (multiple papillomas) is defined as
a minimum of five clearly separate papillomas
within a localized segment of breast tissue,
usually in a peripheral or subareolar location.
• Juvenile papillomatosis of the breast is defined
as severe ductal papillomatosis occurring in
young women of <30 years old