BENIGN BREAST

DISEASES

 In females breast are hemispherical eminences in the front of chest, each extends from the second rib above to the sixth rib below, and from the side of the sternum to near the midaxillary line.

Mature breast is cushioned between subcutaneous fat and superficial pectoral fascia. Between breast and superficial fascia there lies loose areolar tissue known as retro mammary space.

Anatomy of breast

Histologically breast consist of glandular tissue connected by fibrous tissue, the space in between is filled by fatty tissue.

Total 15 to 20 lobes further divisible in several lobules.

Breast of young girl contain dense stroma and epithelium while that of old age women contain more fat. Fat absorb less radiation thus mammography more useful in older women.

Ductal system consist of acini that forms milk and open into lactiferous ducts that dilate before opening forming ampulla that act as resorvoir of milk. Ducts open on nipple in 10-15 orifices. At nipple cuboidal epithelium abruptly meets squamous epithelium.

In stroma there are fibrous bands that run from superficial fascia to skin and give shape and support to breast known as cooper’s ligament

Blood supply is derived from 1. Perforating branches of internal

mammary artery.2. Lateral branches of posterior intercoastal

arteries.3. Branches from axillary artery

About 75% of lymphatics drain in axillary nodes while rest 25% drain in parasternal nodes.

Axillary nodes are classified as:1. Lateral group along axillary vein2. Pectoral group or anterior group3. Scapular group or posterior group4. Central group5. Subclavicular group

Rotter’s nodes described later.Surgically axillary nodes are assigned levels:Level I : Lateral to pectoralis minorLevel II: Deep to pectoralis minorLevel III: Medial to pectoralis minor

Lymphatic drainage of breast

Deep to pectoralis major muscle lies pectoralis minor enclosed in clavipectoral fascia.

It further extends laterally to fuse with axillary fascia.

Breast is related posteriorly by pectoralis major, serratus anterior and external oblique abdominis.

Interposed between pectoralis major and minor one to four nodes know as rotter’s node. They receive lymphatics directly from breast and drain into central and supraclavicular nodes.

Anatomy of pectoral region

Breast development is influenced by several hormones like estrogen, progesterone and prolactin, oxytocin, thyroid hormone, cortisol and growth hormone.

Estrogen initiates ductal development Progesterone is responsible for

differentiation of epithelium and lobular development. Prolactin is primary hormonal stimulus for lactogenesis.

Devlopement and Physiology of Breast

After birth, in a female there is fall in steroidal hormone and breast remain under developed.

In adolescence breast is mostly composed of mainly dense fibrous stroma and scattered duct lined by epithelium.

After beginning of nocturnal pulsatile gonadotrophin release in puberty cause deposition of fat in stroma. Local homones like epidermal growth factors can replace estrogen thus have a proposed role of mediator of action.

During menstrual cycle hormones have cyclical effects on breast. Dominant change is hypertrophy rather than hyperplasia.

During late luteal (premenstrual) phase due to accumulation of fluid and interlobular edema that causes pain and heaviness in breast premenstrually.

During anovulatory cycles engorgement, pain and nodularity get accentuated.

During pregnancy fibrous stroma diminish to accommodate hypertrophied lobular tissues. This formation of new lobules or acini is termed as adenosis of pregnancy.

Expulsion of milk occur by contraction of myoepithelial cells.

During menopause there is deposition of fats, atrophy of glandular and connective tissue.

Tanner’s Stage

1. Absent (Amastia) or accessory breast tissue (Polymastia) amastia is rare , during adolsence hypertrophy of one breast compared to other is common. There could be supernumerary nipples anywhere along milk line but true polythelia reffers to more than one nipple serving single breast. Accessory breast tissue that enlarge during preganancy. Surgery indicated only for cosmetic reasons

Abnormal devlopment and physiology

2. Gynecomastia hypertrophy of breast in men. Physiological in neonatal, pubertal and senescent age group. Phases when circulating testosterone is less than estrogen. Pathological in liver, renal disease, certain cancers and drugs.

In non obese person a breast tissue of 2 cm in diameter should be there for diagnosis. Usually gynecomastia doesn’t predispose to breast cancer except for those having klinefelter’s syndrome(XXY).

Drugs causing gynecomastia are ketoconazole, estrogen, cimetidine, spironolactone, digitalis.

Grades Clinical classification of gynecomastia

Grade I Mild breast enlargement without skin redundancy

Grade IIa Moderate breast enlargement without skin redundancy

Grade IIb Moderate breast enlargement with skin redundancy

Grade III Marked breast enlargement with skin redundancy and ptosis, which simulates a female breast

Gynecomastia

Gynecomastia could present with tenderness or discomfort and breast tissue is symmetrical around areola. Carcinoma is non tender and asymmetric tissue around areola, firm, irregular and at times fixed to dermis or fascia.

and senescent age group require only reassurance only indication for surgery is cosmetic

3. Galactocele Is a milk filled cyst, round well circumscribed and easily

movable. Usually following cessation of lactation.Treatment is needle aspiration. On aspiration thick

creamy material with dark green tinge.Surgery indicated only if cyst cannot be aspirated or get

infected.

Bacterial infections most commonly Staph. aureus and Streptococccus are involved. Staph typically causes breast abcess which present with point tenderness, erythema and hyperthermia. Abcess are related with lactation and occur with in first few weeks of breastfeeding. Location could be subcutaneous, subareolar, interlobular and retromammary. Preoperative sonography can guide the extent of surgery. Circum areolar or along langer’s line incision to be taken. Staphylococcus causes more localized deep seated abscess formation requiring surgery while streptococcus in diffuse superficial involvement managed by local wound care and IV antibiotics.

Infectious and inflammatory diseases of breast

Epidemic puerperal mastitis is caused by MRSA spread due to baby’s mouth and require stopping of breast feeding as site of infection is intra ductal while non epidemic purperal mastitis has inter lobular involvement and breast feeding can be continued. Patient usually have milk stasis and breast emptying with suction pumps reduces symptoms and duration of disease. Zuska’s disease refer to recurrent periductal masititis characterized by recurrent retroareolar infection and abcess. Symptomatic management with IV antibiotics and incision drainage is done but for long term prevention chronically inflammed tissue should be debridded. Smoking has been implicated as an important risk factor

• Myocotic infectionsRare entity. Usually blastomycosis or sporotrichosis. Get

incoculated from mouth of suckling infant. Treatment: Incision drainage and antifungals. Chronic infection debridement of infected tissue.

Skin of breast if infected with Candida albican(intertrigo) managed with topical antifungals

• Hiradenitis suppurativaChronic inflammatory disease of nipple areolar glands of

Montgomery or axillary sebaceous glands. Common in women having acne. When in nipple areolar complex mimic Paget’s disease or invasive carcinoma. Managed by antibiotics and incision drainage. If recurrent debridement required.

• Mondor’s diseaseIt is a variant of thrombo phlebitis that involve

superficial veins of anterior chest wall and breast. Described by Mondor in 1939 as “string phlebitis” . Commonly involved veins are lateral thoracic vein and thoracoepigastric vein.

C/F: acute pain in lateral part of breast. A hard cord like structure palpable.

Treatment: anti inflammatory drugs. Resolves on its own in 3-4 weeks. If not excision of involved segment of vein done.

Mondor’s disease

There are three basic principles underlying ANDI :

1. Benign breast diseases and disorders are related to the normal processes of reproductive life and involution.

2. There are spectrum of breast condition that ranges from normal to disorder.

3. The ANDI encompasses all aspects of breast diseases including pathogenesis and degree of abnormality.

Abberations of Normal Devlopment and Involution(ANDI)

Normal Disorder Disease

Early reproductive years (age 15-25 yrs)

Lobular development

Fibroadenoma Giant fibroadenoma

Stromal development

Adolescent hypertrophy

Gigantomastia

Nipple eversion Nipple inversion Subareolar abcessMammary duct fistula

Later reproductive years (age 25- 40 yrs)

Cyclical changes of menstruation

Cyclical mastalgiaNodularity

Incapaiating mastalgia

Epithelial hyperplasia of pregnancy

Bloody nipple discharge

Involution (age 35-55yrs)

Lobular involution MacrocystsSclerosing lesion

Ductal involution

Dilatation Duct ectasia Periductal mastitis

Sclerosis Nipple retraction

Epithelial turnover

Epithelial hyperplasia

Epithelial hyperpalasia with atypia

ANDI classification of benign breast disorders

Fluid filled cavity lined by epithelium.Influenced by hormones.Diagnosed by ultrasonography or needle

aspiration.Formed by destruction and dilatation of terminal

lobules and ductules.Histololgically flattened epithelium having features

of apocrine metaplasia or pappillary epithelium.During surgery sometimes seen as dark cyst

known as blue dome cyst.Treatment is aspiration. Send for cytology if bloody.

If recur more than twice excision is justified.

Cysts

Most common of all benign breast disease Most common between ages 20- 50

Incidence-varying, related to age Early fibrocystic manifestations may occur between the age of 20 and 25 years,

but most patients (70% to 75%) are in their mid 30s and 40s. Predominantly afflicted are

women with menstrual abnormalities nulliparous women patients with a history of spontaneous abortions nonusers of oral contraceptives and women with early menarche and late menopause.

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

Simple: Second most common benign breast lesion Benign solid tumors containing glandular as well as fibrous tissue . Usually

present as well defined, mobile mass. slips between palpating fingers

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

Histologically presents with variable proportion of epithelial and stromal proliferation. Stroma is either cellular or replaced with acellular swirls of collagen.

Has no malignant potential. Chances of malignancy in a women having fibroadenoma is only modestly more than that in other women.

In young women should be biopsied by a core needle biopsy and if excision needed cosmetic circumareolar incsion with modest tunneling to be used.

Fibroadenomas

Giant: Fibroadenomas over 5cm 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

Histologically more cellular than normal fibroadenomas

Excision is treatment of choice

Cystosarcoma Phyllodes 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 Histologically its an fibroadenoma compressed by swirls of

fibroblastic growth, these whorls of stroma resembles clusters of leaf like structure that gives it the name.

Treatment consists of wide excision unless metastasis has occurred.

Cystosarcoma phylloides

Fat Necrosis: Rare Secondary to trauma- often not remembered Tender, ill defined mass Occasionally skin retraction Usually sampled since it presents as a mass clinically and on

mammography it present as a density lesion that calcify. On histology it shows lipid laden macrophages, scar tissue and

chronic inflammatory cells. Not an epithelial lesion and no malignant potential. Treat with excisional biopsy

Tubular adenoma: Cellular neoplasm of ductules packed closely together forming

sheets of tiny glands without supporting storma. Histologically shows secretory differentiation. Non malignant condition.

Polyps of epithelium lining breast duct. Present with bloody discharge, less

frequently palpable mass. Appear as density lesion on mammogram.

Treatment is excision via circumareolar incision.

Papilloma

Common Middle age Associated with smoking Pain and greenish discharge Sometimes a palpable retroareolar mass

or retraction can be present.

Episode of sepsis Tx : reassurance, stop smoking, antibiotic for sepsis, limited

excision ( microdochectomy ), partial mastectomy.

Duct ectasia

Marked proliferation and atypia of the epithelium, either ductal or lobular.

Found in 3% of benign breast biopsies

Associated with a 13% subsequent development of breast cancer (4x risk factor)

Some may be an under-diagnosed ductal carcinoma in situ.

Excisional Biopsy – do not need clear margins

Atypical Hyperplasia

Symptom pain lump discharge asymmetry Skin change Nipple change Menestrual status menarch Obst. Hx pregnancy lactation

Approach to Breast disorders

• More common during reproductive years (premenopausal)

• Association with cancer is uncommon• Cyclic pain associated with Fibrocystic

changes• Noncyclic pain associated with infection or

cancer if associated with mass or bloody nipple discharge.

• Tx: NSAIDs, primrose oil, OCP, avoid caffeine .

Mastalgia

Nonspontaneous: B/L, multiple ducts, greenish, milky is likely benign.

Spontaneous: unilateral, bloody, serous is worrisome.

◦ Meds – TCAs, Verapamil, Reserpine◦ Galactorrhea – r/o Prolactinoma◦ Intraductal Papilloma – not premalignant

Most common cause of bloody nipple d/c Diffuse papillomatosis has increased risk of cancer

◦ Mammo/sono/ Ductogram◦ Ductal excision ( microdochectomy)

Nipple discharge

Inspection Symmetry Skin / Nipple Change Bulges / Retractions

Palpation Breast

Axilla

Supraclavicular 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

Examination of breast

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

Mammogram Ultrasonography Ductography FNAC Fine needle biopsy

Investigations

uses low dose radiation 0.1cGy.

Includes magnification and compression imagings.

Features of malinancy are::1. Density2. Abnormalities(mass,

architerctural distortions or asymmetry)

3. microcalcification

Mammogram

BI-RAD

BI-RADS CLASSIFICATION

• 0• 1• 2• 3

• 4

• 5

FEATURE

• Need additional imaging• Negative- routine in 1 yr• Benign finding – routine

in 1 yr• Probable benign, 6 m

follow-up• Suspicious abnormality,

biopsy recommended• Highly suggestive of

malignancy; appropriate action should be takin

Uses sound energy to produce images.

Based on echo generated at interfaces of tissues of different density.

Best to differentiate a cyst from solid mass.

Ulatra sonography

Involved ductule is identified in nipple and cannulated with a flexible small cannula with the help of microscope.

Contrast is injected and adequacy of contrast is checked with sonography.

Image is taken at various angles to ensure cannula doesn’t obstruct the view.

Ductography

FNA Fast, inexpensive 96% accuracy Institution dependent Unable to differentiate b/w in situ vs CA

CORE NEEDLE BIOPSY 14-18 gauge spring loaded needle Tissue Multiple

Approach to benign breast lump

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 Last but not the least benign breast disorders are more

difficult for a surgeon to manage than malignant breast

conditions.

Micheal S Sabel. Initial approach to the woman with breast problems. http://uptodateonline.com 2008, November 6

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