Download 02. Benign Breast

Benign Breast Problems
Outline

Introduction

Anatomy

Structure of the breast

Classification

Initial approach to breast problems

Diagnostic workup

Conclusion

References
Introduction

Breast problems are a major reason why women visit the
primary care physician

Breast diseases in women constitute a spectrum of benign and
malignant disorders

The most common breast problems for which women consult a
physician are breast pain, nipple discharge and a palpable
mass.

Benign breast lesion is a non-cancerous lesion. According to
American Cancer society , when tissue biopsy is examined
under the microscope, nine out of every 10 women will have
some type of abnormality
AAFP journal , April 15, 2000. Volume 61/ No. 8
Anatomy

The breast is a modified sweat gland with a mass of glandular,
fatty and fibrous tissues on the pectoralis muscles in the chest
wall

It is attached to the chest wall by fibrous strands called coopers
ligaments

The glandular tissues of the breast consist of lobules, lobes and
ducts

Fatty and fibrous tissues surround the milk producing system (
lobules and ducts)
Anatomy
Major hormones responsible for breast development are estrogen,
progesterone and prolactin.
The blood supply is through the internal
mammary artery, axillary artery
intercostal artery
Venous drainage is through the
Internal mammary vein,
axillary vein and
intercostal veins
Anatomy



Lymphatic drainage
•
Majorly to the Axillary nodes
•
Inter mammary and the supra clavicular lymph nodes.
Three Lymph Node Levels
•
Level I – Lateral and inferior to Pectoralis Minor
•
Level II – Deep to Pectoralis Minor
•
Level III – Medial to Pectoralis Minor
•
Rotter’s – Between Pectoralis Minor & Major
Nerves
•
Long Thoracic Nerve:
 Serratus Anterior m.
 Winged Scapula
•
Thoracodorsal Nerve:
 Latissimus Dorsi
•
Intercostobrachial Nerve
Structure
Classification Based On Histologic Types



Non Proliferative Lesion

Simple Cyst

Complex cyst
Proliferative Lesions – Without Atypia

Ductal hyperplasia

Fibroadenoma

Intraductal papilloma

Sclerosing Adenoma

Radial Scars
Atypical Hyperplasia

Atypical ductal hyperplasia

Atypical lobular hyperplasia
Schnitt, SJ. Benign breast disease and breast cancer risk: morphology and beyond. Am J surg pathology 2003;27:836
Classification Based On Clinical Features

Mastalgia
 Cyclic
 Non Cyclic
 Tumors and Masses
 Nodularity or glandular
 Cysts
 Galactoceles
 Fibroadenoma
 Sclerosing Adenosis
 Lipoma
 Harmatoma
 Diabetic Mastopathy
 Cystosarcoma Phylloides
AAFP journal , April 15, 2000. Volume 61/ No. 8
Classification Based On Clinical Features
(Cont’d)


Nipple discharge

Galactorrhea

Abnormal nipple discharge
Breast infections and Inflammation

Intrinsic mastitis

Postpartum engorgement

Lactation mastitis

Lactation breast abscess

Chronic recurrent subareolar abscess

Acute mastitis associated with macrocystic breasts

Extrinsic infections

Mondor’s Disease

Hidradenitis suppurativa
J khosa, Benign breast disease including mastalgia ppt
Classification
 Lesions with Increased Risk of Ca
 Ductal hyperplasia
 Sclerosing adenosis
 Complex fibroadenomas
 Atypical hyperplasia
 Radial scars
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Classification
 Lesions with no Increased risk of Ca
 Fibrocystic disease
 Duct ectasia
 Solitary papillomas
 Simple fibroadenomas
 Mastitis or breast abscess
 Galactocele
 Fat necrosis
 Lipoma
Breast Pain (Mastalgia)
 Most common breast symptom for which women
consult the physician
 More common in premenopausal women than in
post menopausal women
 Can be cyclical (physiological) or non cyclical
Micheal S Sabel. Initial approach to the woman with breast problems. http://uptodateonline.com 2008, November 6
Breast Pain (Mastalgia)
Cyclic Pain ( Physiologic)

Usually Bilateral and poorly localized.

Occurs in about 60% of premenopausal women except
menopausal women on hormonal replacement therapy

Often described as heaviness , swelling or tenderness that
radiates to the arm and axilla

Associated with menstrual cycle , Most severe before
menstruation

Has variable Duration and Resolve spontaneously after menses

Attributed to fibrocystic breast changes

Etiology unknown, thought to be related to Gonadotrophic and
ovarian hormones
Mastalgia
Non-Cyclic Pain

Most common in women 40 to 50 yrs of age

Often unilateral

Usually described as sharp, burning pain localized in the breast

Occasionally secondary to the presence of Fibroadenoma and
or cyst

Menstrual irregularity, emotional stress, trauma, , scars from
previous biopsies and medications have been associated
Micheal S Sabel. Initial approach to the woman with breast problems. http://uptodateonline.com 2008, November 6
Evaluation & Management of Breast Pain
 Mastalgia should be treated when:

It is severe enough to interfere with a woman’s life style

It occurs more than a few days every month.
 History and Physical
 Diagnostic work up

Mammogram
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Management of Breast Pain
Treatment Goals
 Alleviate pain
 Reduce or relieve irregularity
 Rule out cancer of the breast
Management of Breast Pain
 Diet and Lifestyle Modification

Elimination of Methylxanthines, Caffeine and
Chocolates

Reassurance

Supportive Bra

Low fat and high complex carbohydrate

Vitamin E supplementation

Evening Primrose oil
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Management of Breast Pain
 Pharmacological Treatment

NSAIDs

OCPs

Danazol 100- 400mg per day

75% of women with non cyclic pain will be symptom free

SE: Weight gain , menstrual irregularity , acne , hirsutism

Tamoxifen 10mg
Bromocriptine – prolactin antagonist
Surgery has no role in management of breast pain


Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Evaluation & Management of Breast Pain
AAFP journal , April 15, 2000. Volume 61/ No. 8
Breast Masses
 Normal glandular tissue of the breast is nodular
 This is a general pattern or consistency of the breast
which include persistent lumpiness or nodularity
which is generally not abnormal when it is related to
the menstrual cycle.
 Dominant masses are characterized by persistence
throughout the menstrual cycle
Breast Masses: Cysts
Cystic Breast Mass

Common cause of dominant breast mass

May occur at any age, but uncommon in post menopausal
women

Fluctuates with menstrual cycle

Well demarcated from the surrounding tissue

Characteristically firm and mobile

May be tender

Difficult to differentiate from solid mass
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Breast Masses: Cysts
 Fibrocystic Breast Disease

Most common of all benign breast disease

Most common between ages 20- 50

50% of women with Fibrocystic changes have clinical
symptoms

53% have histologic changes

Believed to be associated the Imbalance of progesterone
and estrogen.

May present with bilateral cyclic pain, breast swelling,
palpable mass and heaviness
Fibrocystic Breast Disease
 Physical Examination

Tenderness

Increased engorgement and more dense breast

Increased lumpiness / glandular

Occasional spontaneous nipple discharge
Micheal Sabel .Overview of benign breast disease. Uptodate 2008, November 14
Breast Cysts: Diagnostics
 Mammogram
 Fine Needle Aspiration

Cystic outline

Outpatient procedure

No calcification

Non bloody fluid

No increased density

Cyst disappears

If bloody fluid, surgical
biopsy of cyst is required

Reexamination 4-6 weeks
after aspiration
 Ultra Sonogram

Cyst
Management of Breast Cysts
AAFP journal , April 15, 2000. Volume 61/ No. 8
Breast Masses
Breast Mass: Fibroadenomas


Simple: Second most common benign breast lesion

Benign solid tumors containing glandular as well as fibrous tissue . Usually
present as well defined, mobile mass

Commonly found in women between the ages of 15 and 35 years

Cause is unknown, thought to be due to hormonal influence

May increase in size during pregnancy or with estrogen therapy
Giant: Fibroadenomas over 10cm in size


Excision is recommended
Juvenile

Variant of fibroadenomas

Found in young women between the ages of 10 -18.

Vary in size from 5 - 20cm in diameter. Usually painless, solitary, unilateral
masses

Excision is recommended
Breast Mass: Fibroadenomas
(Cont’d)
 Complex

Complex fibroadenomas contain other proliferative changes
such as sclerosing adenosis, duct epithelial Hyperplasia,
epithelial calcification.

Associated with slightly increased risk of cancer
Dupont, WD page, DL, parl, FF, et al. Long term risk cancer in women with fIbroadenoma. NEJM 1994;331:10
Carty, NJ, Carter, c, Rubin, C et al management of fibroadenoma of the breast. Annals of royal college of surgeon England 1995:77:127
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
Breast Mass


Phylloides Tumors:

Rapidly growing

One in four malignant

One in Ten Metastasize

Create bulky tumors that distort the breast

May ulcerate through the skin due to pressure necrosis

Treatment consists of wide excision unless metastasis has occurred
Fat Necrosis:

Rare

Secondary to trauma- often not remembered

Tender, ill defined mass

Occasionally skin retraction

Treat with excisional biopsy
Breast Mass


Galactocele

Milk filled cyst from over distension of a lactiferous duct.

Presents as a firm non tender mass in the breast,

Commonly in upper quadrants beyond areola.

Diagnostic aspiration is often curative.
Duct ectasia:

Generally found in older women.

Dilatation of the subareolar ducts can occur.

A palpable retroareolar mass, nipple discharge,
or retraction can be present.

Tx involves excision of area
Breast Mass
 Gynecomastia:







Benign growth of the glandular tissue of the male breast.
Due to an imbalance in the estrogen to androgen activity.
May be unilateral or bilateral
Common in infancy, adolescence and adult life
Pseudogynecomastia may be seen obese individuals
Causes include; drugs, chronic dxs, metabolic, pubertal,
Hormonal, tumors, idiopathic, hypogonadism.
Braunstein, GD. Gynecomastia. NEJM 1993;328:490
Nipple Discharge
 Majority of causes are benign
 Most common cause is lactational
 Overstimulation also common
 Prolactin secreting tumors
 Hypothyroidism
 Drugs
 Intraductal and other carcinomas
 Unilateral, spontaneous, bloody discharge is
suspicious
Nipple Discharge
 Intraductal Papilloma

Benign growth within ductal system

Presents as bloody nipple discharge

Excision is the only way to differentiate from
carcinoma
 Galactorrhea

Bilateral milky discharge

Obtain prolactin level, TSH level
Nipple Discharge
 Good history
 Prolactin & TSH levels
 Mammogram
 Decrease stimulation
Breast Inflammation & Infections
 Mastitis

Most common in lactating female

Dry, cracked fissured areola/nipple complex provides portal
for infection

Usually caused by Staph/Strep organisms

Rule out malignancy

Treat with heat, continued breast feeding,

Antibiotics for 10-14 days to cover staph and strept infections
Breast Inflammation & Infections
 Abscess

May present with breast swelling, tenderness and fever

On PE, breast is tender , warm and fluctuant, may also have
purulent discharge

Treated by surgical drainage
Breast Inflammation & Infections
Mondor’s Disease


Phlebitis of the thoracoepigastric and lateral thoracic vein

Palpable, visible, skin retraction over tender extending to
chest wall

Spontaneous or related to trauma

Ultrasound may be helpful in confirming this diagnosis.

Treatment self-limited, can use NSAIDs

Mammogram if over 35yo to r/o malignancy
Breast Inflammation & Infections

Chronic Subareolar Abscess

Occurs at base of lactiferous duct, and squamous
metaplasia of duct may occur.


Sinus tract to areola develops

Treatment requires complete excision of sinus tract

Recurrence is common
Mastitis Neonatorum

Occurs within few weeks of birth

Response to mothers hormone exposure
(prolactin, estrogen)

Resolves spontaneously

Occasionally becomes infected
Congenital Breast Disease

About 1-5 % of the population have
accessory nipples, and less
commonly accessory breast

Usually develop along the milk line

Most common site for accessory
nipple is below the breast

Most common site for accessory
breast is in the axilla

Rarely require treatment except for
cosmetic reasons

Subject to the same diseases as the
normal breast.
J Micheal Dixon .ABC of breast diseases. 3 rd edition BMJ 2005
Gershon Efron. Benign breast disease ppt , google health search
Approach to Breast Problems
 History

Age

Family history (Cancer)

Onset

Duration Discharge

Frequency

Lump , Nodules Trauma

Menstruation (menarche, menopause, contraceptives) Pain
 Inspection

Symmetry

Skin / Nipple Change

Bulges / Retractions
Approach to Breast Problems
 Palpation

Breast

Axilla

Supraclavicular
Breast Examination

The breast examination starts with inspection of both breast

Sitting up with arms in relaxed position,

Both arms raised over the head

Hands on the hips

Complete regional lymph node examination while patient is in the sitting
position.

Bimanual may be done while patient is still in the sitting position, useful in
patient with large pendulous breast

Complete with the patient in a supine position, with the arms raised above
the head, breast exam can be accomplished with either concentric circles,
radial approach, or vertical strip approach

Areas examined should extend from the clavicle superiorly to the rib cage
inferiorly and from the sternum medially to the mid axillary line laterally
Micheal S Sabel. Initial approach to the woman with breast problems. http://uptodateonline.com 2008, November 6
Breast Examination
Diagnostic Work Up
 Ultrasound
 Mammography
 FNA vs. Core Biopsy
 Incisional biopsy
 Excisional biopsy
 Cyst aspiration
 MRI
Diagnostic Work Up

Ultrasonography: First diagnostic test of choice to differentiate a
cystic mass from a solid mass

Mammogram: Not routinely done in women younger than 35yo,
however not inappropriate in a suspicious mass in younger women

Digital mammography is superior to conventional

A normal mammogram at any age does not eliminate the
need for further evaluation of a suspicious mass.

MRI: Not indicated for the work up of undiagnosed mass. Reserved
for diagnostic dilemmas and should be used with discretion due to
false positive results

FNA: Useful for cystic lesions. If lesion is completely drained and
fluid not bloody or cloudy, no further evaluation needed
Micheal S Sabel. Initial approach to the woman with breast problems. http://uptodateonline.com 2008, November 6
Diagnostic Work Up

Core Needle Biopsy: This provides a best diagnostic
information for solid palpable mass which can be visualized on
the USS or mammogram

Excisional Biopsy: Useful in cases where core needle biopsy
is non diagnostic, non concordant with imaging results or yield
any high risk changes

Incisional Biopsy: useful when core needle biopsy is not
helpful in confirming diagnosis
Micheal S Sabel. Initial approach to the woman with breast problems. http://uptodateonline.com
2008, November 6
BI-RADS Classification
BI-RADS Classification – features
0 - Need additional imaging
1 - Negative – routine in 1 yr
2 - Benign finding – routine in 1 yr
3 - Probably benign, 6mo follow-up
4 - Suspicious abnormality, biopsy recommended
5 - Highly suggestive of malignancy; appropriate action
should be taken
Conclusion
 Benign breast problems account for the majority of
breast problems seen in women
 Breast complaints need careful assessment with
thorough history and physical as well as diagnostic
work up if indicated
 Women with breast problems can present with a
mass, pain, nipple discharge or skin changes. They
can also be asymptomatic
 It is important to rule out breast cancer
Micheal S Sabel. Initial approach to the woman with breast problems. http://uptodateonline.com 2008, November 6
References
1. AAFP journal , April 15, 2000. Volume 61/ No. 8
2 Schnitt, SJ. Benign breast disease and breast cancer risk:
morphology and beyond. Am J surg pathology 2003;27:836
3.J khosa, Benign breast disease including mastalgia ppt
4. Dupont, WD page, DL, parl, FF, et al. Long term risk cancer in
women with fIbroadenoma. NEJM 1994;331:10
5. Carty, NJ, Carter, c, Rubin, C et al management of fibroadenoma
of the breast. Annals of royal college of surgeon England
1995:77:127
6. Micheal S sabel .Overview of benign breast disease. Uptodate
2008, November 14
7. J Micheal Dixon .ABC of breast diseases. 3 rd edition BMJ 2005
8.Gershon Efron. Benign breast disease ppt , google health search
9. Micheal S Sabel. Initial approach to the woman with breast
problems. http://uptodateonline.com 2008, November 6
10. Braunstein, GD. Gynecomastia. NEJM 1993;328:490