benign breast diseases
TRANSCRIPT
S5,Medical College,
Trivandrum
presents
BENIGN BREAST DISEASES
the ‘team’• Syamamol P.S• Syam G.• Thomas Mathai.• Thushara U.B• Varkey S.Kulangara• Varsha Vijayan.• Vidyakrishna• Vidya S.• Tobin Dominic
“ The breast from their prominence, the colour of their skin, and the red colour of the nipples, by which they are surmounted, add great beauty to the female form”
APPROACH
• Embryology-congenital lesions , anatomy & physiology of breast
• Classification• Investigations• Case scenario1-lump• Case scenario 2-mastalgia• Case scenario 3-nipple discharge• Case scenario 4-BBD in pregnancy & lactation• Case scenario 5-BBD in males
Embryology-CONGENITAL LESIONS, Anatomy & Physiology of breast
Syamamol.P.S
Development of Breast- Skin appendages arising from mammary ridge (Milk line) .. Ectoderm
CONGENITAL LESIONS OF BREAST
© Prof. Reda Mostafa 9
Gul
© Prof. Reda Mostafa 10
Accessory nipple
© Prof. Reda Mostafa 11
Accessory intra-mammary nipple
• Congenital Nipple Inversion • failure of nipple to evert during development. May
be unilateral. • Spontaneously corrected during growth of pregnancy
or by simple traction.
Anatomy
• Modified sweat gland between the superficial and deep layers of the chest wall
BLOOD SUPPLY
LYMPHATICS
BBD CLASSIFICATION
Tobin Dominic
• Congenital disorders• Traumatic• Inflammatory & • Infectious• Neoplastic• ANDI
The ANDI (Aberrations of Normal Development and Involution )
• Breast –physiologically dynamic structure• unifying concept of symptoms, signs, histology and
physiology • Benign disorders are related to the normal processes
of reproductive life. • spectrum ranges from normal to aberration to
sometimes disease.• classification is not comprehensive
ETIOLOGY• Endocrine• Disturbance of hypothalamic pituitary gonadal steroid
axis• Altered prolactin profile• Non endocrine• Methylxanthines• Stress catecholamines• High saturated fat diet• Iodine deficiency
Normal Benign disorder Benign disease
Early reproductiveyears
Nipple eversion Nipple inversion Subareoalar abscess, duct fistula
Lobular development Fibroadenoma Giiant fibroadenoma
Stromal development Adolescent GigantomastiaHypertrophy
Later reproductive years
Cyclical Hormonal changesnodularity
Mastalgia, incapaciating . mastalgia
Pregnancy
Lactation
Epithelial hyperplasia pregnancy
Bloody nipple discharge
Galactocele
Involution Duct involution dialation Duct ectasia Periductal mastitis
SclerosisLobular involution
Nipple retractionMacrocysts,sclerosing lesions
Epithelial turnover Epithelial hyperplasia epi hyperplasia atypia
PATHOLOGICAL CLASSIFICATIONI. NONPROLIFERATIVE LESIONS
Cysts and apocrine metaplasia Duct ectasia Mild ductal epithelial hyperplasia Calcifications Fibroadenoma
II. PROLIFERATIVE BREAST DISORDERS WITHOUT ATYPIA
Sclerosing adenosis Radial and complexing sclerosing lesions Moderate and florid ductal epithelial hyperplasia Intraductal papilloma
III. ATYPICAL PROLIFERATIVE LESIONS
Atypical lobular hyperplasia(ALH) Atypical ductal hyperplasia(ADH)
INVESTIGATIONS IN BREAST DISEASE
Syam G & Thomas mathai
Triple assessment
Confident diagnosis in 99.9%
Inspection
Palpation
Examination of LNS
Sitting posturePulp of the fingersAxillary group of LNs
Pectoral groupBrachial groupSubscapular groupCentral groupApical group
Supraclavicular nodes
system examination
BREAST SONOGRAPHYIndications
If Mammography is uncertainTo differentiate solid from cystic lesionIf asymmetric densityVisualise lesions near chest wall.Interventional procedures.Evaluate site of lumpectomy.Lesion at periphery of breast.Evaluating after surgical augmentation.
Features of malignant lesion on Sonomammography
STAVROS CRITERIA • Spiculation• Hypoechoic• Irregular margins• Posterior shadowing• Depth :width ratio <1• Microlobulation
MAMMOGRAPHY
Mammography views
Mediolateral oblique Craniocaudal
Mammography evaluationMass lesion
DensityAsymmetry
Malignant CalcificationBenign calcification
Well circumcribed –benignSpiculated-malignant 95%Low density benign ,high-malignantAsymmetric involution in bbd.HRTTrauma ,Intraductal CAFine ,numerous CA,only sign in early noninvasive CAScattered ,round circumscribedDuctectasia- needlelikeArterial -parallel lineFibroadenoma –popcornMicrocystic disease-teacupFat necrosis-oilcyst calcification
Breast Imaging Reporting And Data System [BI-RADS]
Categories are:0: Incomplete – needs additional imaging1: Negative - routine mammogram yearly2: Benign finding(s) -yearly mammogram3: Probably benign- short term follow up4: Suspicious abnormality - biopsy should be
considered5: Highly suggestive of malignancy6: Known biopsy-proven malignancy to r/o ca in
opposite breast
BREAST MRI To distinguish scar from
recurrence Gold standard for
imaging breast with implants
Detection of vertebral body metastasis & musculoskeletal pathology
Visualisation of axilla
BREAST MRIIndications
Radiologically dense breasts when mammography fails.If Axillary node +ve and breast normal after mammo and sonography.To rule out multifocality multicentricity before BCS.To assess induction chemotherapy.Followup after BCS.•Contrast enhanced more sensitive
THERMAL IMAGING(Digital infrared)
Thermal imaging is an advanced technology that creates a visual image of the heat pattern of breast.
FINE NEEDLE ASPIRATION CYTOLOGY
Uses 21gauge needle & 10 ml syringe
Multiple passes through lump without releasing negative pressure
Aspirate is smeared onto slide & fixed
Differentiates solid & cystic lesions
If fnac is inconclusiveAdvantagessignificant core of tissue obtainedcan distinguish invasive from intra ductal carcinomaGrading of tumorTo know ER/PR and Her 2 statusDisadvantage
seeding of malignant cells along needle tract
CORE NEEDLE BIOPSY
Core needle biopsy under ultrasound guidance
When core needle biopsy is inconclusive
Removal of small portion of tumour
> 4cm in size
•Whole tumour is removed preferably if <4 cm in size
INCISION BIOPSY
EXCISION BIOPSY
Most accurate and the Best Diagnostic Procedure for a Suspicious Breast Lesion.
Complete excision with a rim of normal tissuePlan the incision in such a way that
subsequent radical surgery can easily include the scar.
Follow Langer’s line
OPEN BIOPSY(EXCISIONAL BIOPSY)
MAMMOTOME
Used for taking stereotactic biopsy from mammographically detected breast lesions that are not clinically palpable.
Mammotome
DUCTOSCOPE• A fiber optic scope less
than a millimeter thick is inserted into the milk duct at the nipple and threaded deep into the breast through the duct.
• An imaging system displays the output of the scope on a computer monitor.
• Samples of epithelial cells can be collected onto microscope slides for further analysis.
DUCTOSCPOY
INDICATIONS Patients with pathologic nipple
dischargePatients who are at high-risk for
developing cancer but have normal breast on examination and imaging studies.
After application of a numbing cream, a small clear cap with a syringe attached is placed over thenipple. This device (the nipple aspirator) is similar to a small breast pump and is used to see if fluid will come out of the nipple.
•To encourage fluid production,women are instructed in breast massage and heat packs may be used on the breasts.
•If fluid is not produced, the lavage is not performed.
DUCTAL FLUID COLLECTION
If fluid is obtained with the nipple aspirator,then the lavage procedure is started.
One or two small dilators to help open the duct.
Then the ductal lavage catheter is inserted and a small amount of lidocaine, as anesthetic may be injected through the catheter for comfort.
DUCTAL LAVAGE
• Saline, is injected through the catheter into the duct and the breast massaged to bring ductal cells into the chamber of the catheter.
• An empty syringe attached to the catheter is used to collect the cells from the catheter chamber.
• The cells are then placed in a preservative and sent to the cyto - pathologist where they are processed and read much like a Pap smear.
DUCTOGRAPHY/GALACTOGRAPHYA ductogram is a mammographic procedure that is performed to help identify the breast duct that may be the source of nipple discharge.
Ductal ectasia.- Craniocaudal ductogram shows a dilated ductal system.
Carcinoma. -craniocaudal ductogram shows an outlined intraductal abnormality (arrow). Note the pleomorphic calcifications (arrowheads)
BREAST IMAGING EMERGING TECHNOLOGIES
Digital mammographyUse of FDG-PETBreast scintimammography (nuclear medicine breast imaging- Miraluma
Tc-99m sestamibi compound)Computerised thermal imaging(CTI)Computerised tomographic
lasermammography (CTLM)
Breast imaging -emerging technology
Digital tomosynthesis or three dimensional mammography
ElastographyDigital subtraction mammography
TUMOR MARKERS IN BBD
Expression of P53 in immunohistochemical staining identifies the sub group with maligant potential
Overexpresson of HER-2 in benign proliferative lesion predicts increased risk
Saint Agatha of Sicily
Case scenario 1
• 25 year old female patient presented with a lump in the breast.She gives a history of slow growing lump not associated with any pain or discharge from nipple & is very much anxious.
Possibilities????
• Fibro adenoma• Phyllodes tumour• Breast cyst• Traumatic fat necrosis• carcinoma
FIBROADENOMA
Fibroadenomas• Second most common tumor of breast
• ANDI
• Represent a hyperplastic or proliferative process in a
single lobule
• Etiology is unknown, thought to be due to hormonal influence
• Risk of malignant transformation is rare• Resulting carcinoma is often a lobular carcinoma • Mimic malignancy in pregnancy,HRT
types• Simple/solitary/small(2-3 cm) • Multiple(>5)• Juvenile-in young women between the ages of 10 -
18.• Giant(>5cm)-rapidly growing,more common in afro-caribbean population
• Complex -contain other histological changes such as sclerosing adenosis, duct epithelial Hyperplasia, epithelial calcification.
Associated with slightly increased risk of cancer
Clinical features
• Between the ages of 15-25 years & size of 2-3cm• Painless lump- capsulated,smooth, firm, well defined,
nontender, BREAST MOUSE• Confused with phyllodes• Microscope- intracanalicular pericanalicular
diagnosis
• Clinical examination• Ultrasound scan –circumscribed lobulated
mass• FNAC/Core needle biopsy
• Treatment-conservative• Surgery • Very large/increasing in size• Suspicious cytology• Surgery is desirable• Extracapsular excision with a 1cm rim of
normal tissue • Newer techniques-laser ablation &cryoablation
PHYLLODES TUMOUR
VARSHA VIJAYAN
Gk word phyllon
Histopathology
• Proliferation of intralobular stroma• Fusiform fibroblast• 3 types:- benign borderline malignant (cellularity,atypia,mitoses &invasion by edges)
Phylloides vs FibroadenomaPhyllodes Fibroadenoma
Age Older(40-50y) Younger
Duration Rapid growth Slower progression
Recurrence Common Less commonSize Large ,bosselated Smaller Mammogram Round density with
smooth bordersSame
Ultrasound Cystic spaces +/- SameCytology More cellular,
malignant typeSame as low grade phyllodes
Excisional biopsy Histopathology
Management
Wide local excision Benign Borderline - Follow up Malignant -SIMPLE MASTECTOMY
SIMPLE MASTECTOMY
Breast Trauma
Traumatic Fat Necrosis
• Clinical features - Pain & lump in the breast• Lump is hard - extensive fibrosis caused by
tissue reaction• D.D : Carcinoma breast• Mammography findings - density lesion; can
have calcifications; may mimic carcinoma breast
• Treatment - excision of the lump
Breast cystvarkey s kulangara
Introduction
• Definition – non integrated involution of breast tissue• Age group – 30-50• Multiple and bilateral• Can mimic malignancy• Confirmed by USG and aspiration
No routine followup
No residual massNo cyst recurrence
Surgical biopsy
Residual massCyst recurrence (X3)
Non blood stained aspirate
FNAC/Surgical biopsy
Blood stained aspirate
Fine needle aspiration
Cyst(C linical diagnosis)
Routine followup
Pop-Quiz
Which is bigger??
Case scenario2
• 28 year old lady presenting with complaints of pain in both her breast for the past 6 years & increases just prior to menstruation, no pain during her pregnancy and lactation.
MASTALGIA
VARKEY S KULANGARA
• Definition• types
CYCLICAL MASTALGIA
• Menstruating age group• Hormone related-ANDI• Dull diffuse bilateral• Upper outer quadrant
ETIOLOGY
1. Relative hyperoestrogenism2. Hyperprolactinaemia3. Psychological4. Caffeine5. Abnormal lipid metabolism
RECENT THEORY
LOW EFA LOW PGE1
UNOPPOSED ACTION OF PROLACTIN
MANAGEMENT
1.Pain diary 2.Reassurance 3.Exclude caffeine 4.Low fat diet 5.Stop OCPs/HRT 6.stop smoking 7.drugs
PRIM ROSE OIL
BROMOCRIPTINE
GOOD RESPONSE
DANAZOL
TREAT 6 MONTHS
NO RESPONSE IN 4 MONTHS
GOSERELIN
NON CYCLICAL MASTALGIA
• CAUSES 1.musculoskeletal pain 2.teitz syndrome 3.malignancy
FEATURES
• Unilateral • Chronic• burning or dragging• Pre and post menopausal
MANAGEMENT
• EXCLUDE MALIGNANCY• TREAT THE CAUSE
FIBROCYSTIC BREAST DISEASE
Varkey S Kulangara
synonyms
Fibrocystic changes Cystic Mastopathy Chronic cystic disease Mazoplasia Cooper’s disease Fibroadenomatosis Reclus’s disease
What is fibroadenosis?
ANDIAge group :30-50 yearsAberration in normal cyclical hormonal effectsCyclcial mastalgia with nodularity
• bloodgood’s bluedomed cyst• Schimmelbusch’s disease
Pathomorphology
• Fibrosis• Cyst formation• Adenosis• Epitheliosis• Papillomatosis• Apocrine metaplasia
Clinical features
• lump • Cyclical mastalgia• Nipple discharge
Diagnosistriple assessment
CLINICAL
Treatment
Rule out malignancy manage as cyclcial mastalgia
Surgical Treatment
• Indicationsa) intractable painb) florid epitheliosis on fnacc) Blood good cyst
surgery
1. Excision of the cyst or localized excision of the diseased tissue
2. Subcutaneous mastectomy with prosthesis placement
F
CASE SCENARIO 3
• 30 year old female came to OP with complaints of lump in both the breasts.Also complains of discharge from both the breasts.
Possibilities???
• MALIGNANCY??• Duct papilloma• Duct ectasia• Fibrocystic disease
NIPPLE DISCHARGE vidya s
Causes Surface Eczema Psoriasis Chancre
Dischage from a single duct
Blood stained Serous intraduct papilloma fibrocystic disease duct ectasia duct ectasia
Discharge from more than one duct blood stained : duct ectasia black/green : duct ectasia purulent : infection Serous : fibrocystic disease duct ectasia Milk : lactation hypothyroidism pituitary tumours drugs
Approach to a patient
CLINICAL EXAMINATION Nature of discharge Mass present or not Unilateral or bilateral Single or multiple duct Spontaneous/expressed Relation to menstruation Pre/post menopausal Taking ocp/estrogen
Investigations discharge analysis for malignant cells and occult
blood
Mammography
FNAC BIOPSY
Treatment
REASSURANCE
MICRODOCHECTOMY
HADFIELD
DUCT ECTASIA
• Dilatation of the breast ducts associated with chronic inflammatory response in the periductal tissue
Pathogenesis
Duct dilatati
on
Discharge to
periductal tissues Periductal
mastitis
fistula
fibrosis
abcess
Microscopy
foam cells
inflammatory cells
Clinical features
• Older age group• Smokers
Nipple discharge: bilateral multifocal ,thick,opalascent,variable colour
• Breast abcess Tender subareolar mass
• Mammary duct fistula
• slit like retraction of nipple
Investigations
• If mass or nipple retraction is present rule out malignancy
Mammography Cytology,histopathology
Cytology of discharge: foam cells Ductography: ectatic ducts
Treatment
Antibiotic flucloxacillin and metronidazole
Surgery Hadfield’s operation
inci
INTRA DUCTAL PAPILLOMA
• Proliferative breast disease without atypia• polyps of epithelium lined duct
Pathology
• Size: usually less than 0.5 cm, may be as large as 5cm
• Site: lactiferous duct within 4 to 5 cm from nipple orifice
• Gross: Pinkish tan friable ,attached to the wall by a stalk
Microscopy
Fibrovascular core Papilloma Duct
Clinical features
• Nipple discharge :unilateral,blood stained,from a single duct
• Palpable mass/density lesion in mammography
Investigations
• Ductography :filing defect
treatment
Surgery• less than 30 yrs:microdochectomy
• more than 45 yrs:major duct excision(Hadfield)
Milky Way
CASE SCENARIO 4
• 24 year old lactating female presented in OP with throbbing pain in the left breast and fever…
BBD IN PREGNANCY AND LACTATION Vidyakrishna & Thushara
BACTERIAL MASTITIS
Thushara u b
BACTERIAL MASTITIS
Types1. Subareolar abscess2. Intramammary abscess3. Retromammary abscess
AETIOLOGY
• Staph aureus – penicillin resistant if hospital acquired• Streptococus Ascending infection from a sore and cracked nipple
CLINICAL FEATURE
TREATMENT
• Flucloxacillin or co-amoxiclav• Support of the breast,local heat,& analgesics• Incision & drainage• Now recommended is repeated aspiration under antibiotics• continue breast feeding• close follow up• Antibioma if I&D not done• DD-inflammatory carcinoma of breast
OPERATIVE DRAINAGE OF A BREAST ABSCESS
• Local anaesthesia• Radial or circumareolar incision• drainage• Septa is disrupted & wound is packed
MONDOR’S DISEASE
• Thromboplebitis of superficial veins of the breast & chest wall• Aetiology not known• C/F – thrombosed subcutaneous cord• DD – breast cancer• Treatment – antiinflamatory medication warm compresses & support restriction of movement symptoms persist - excision
Thrombosed subcutaneous cord
GALACTOCELE
• Definition• Pathogenesis-inspissated milk• c/f-pain & lump• Diagnosis-needle aspiratation
Management
OTHER BBD IN PREGNANCY AND LACTATION
• Nipple discharge• Simple cysts• Breast infarcts• Breast pain
Pregnancy and investigations???
OTHER INFECTIOUS CONDITIONS
Tuberculosis of breast Syphilis of the breast Actinomycosis
TUBERCULOSIS OF BREAST
• Multiple c/c abscess & sinuses
• Bluish attenuated apearance of surrounding skin
• Diagnosis• Treatment
SYPHILIS OF THE BREAST
• Primary chancre of nipple• Secondary lesions – diffuse mastitis
CASE SCENARIO 5
• 15 year old male presented with enlarged breast on right side.
Benign Breast Disease in MalesVidya Krishna
Male breast
• Contains only ducts• No alveoli
BENIGN BREAST LUMPS IN MALES
• Gynaecomastia• Fibroadenoma• Phyllodes tumour• Epidermal inclusion cysts• Sub cutaneous leiomyoma• Sub areolar abscess• Intra mammary lymph node
GYNAECOMASTIA
GYNAECOMASTIA
• Hypertrophy of breast tissue in males.
PATHOPHYSIOLOGY
• Estrogen excess states• Androgen deficiency states• Drug related• Systemic diseases with
idiopathic mechanisms
CLINICAL CLASSIFICATION
• 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
MANAGEMENT
TREATMENT
• Depends on the cause-androgen deficiency-medications-endocrine defectsmedicines-surgery
Were you attentive??
• ANDI• Gold standard for imaging breast with implants• Giant fibroadenoma?• Carcinoma simulating mastitis• Difference between male & female breast• Commonest benign breast disease • Popcorn calcification in mammogram?
Thank you …
Guided by
Dr. Viswanathan
Special thanks to
Dr. John S Kurien
Moderator
Tobin Dominic
Presenters
SyamamolSyam g
Thomas Thushara
Presenters
VarkeyVarshaVidya S
Vidyakrishna
© 2011S5,Medical College,
Trivandrum