approach to BENIGN BREAST DISEASES.pptx

description of benign diseases of the breast

1. BENIGN BREAST DISEASES

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4. BREAST ANATOMY Breast is a modified sweat gland derived from ectoderm. Vertically— it extends from the second to the sixth rib in the midclavicular line and lies over pectoralis major, serratus anterior and external oblique muscles. Horizontally— from the side of sternum to the mid-axillary line 4

5. Nipple is located at the level of 4th intercostal space just below the centre of the breast. It contains circular and longitudinal muscles to make nipple stiff or flat. Areola is circular pigmented area around the nipple. It is rich in modified sebaceous glands which enlarge during pregnancy and lactation as Montgomery tubercles . Breast parenchyma contains 15–20 lobes. Each lobe contains alveoli, lactiferous sinus and lactiferous duct .

6. Axillary Tail of Spence This is a prolongation from the outer part of the gland which passes up to the level of the 3rd rib in the axilla through a defect in the deepfascia ( Foramen of Langer ) where it is in direct contact with the main lymph node of the breasts (anterior axillary nodes). A Ligament of Cooper The breast is anchored to the overlying skin and to the underlying pectoral fascia by bands of connective tissue called ligament of Cooper. 1. In cancer, the malignant cells may invade these ligaments and consequent contraction of these strands may cause dimpling of the skin or attachment of the growth to the skin, which in turn cannot be pinched off from the lump. 2. If the cancer grows along the ligament of Cooper binding the breast to the pectoral fascia, the breast gets fixed to the pectoralis major , it then cannot be moved along the long axis of the muscle . 6

7. Blood Supply to the Breast The lateral thoracic artery, from the 2nd part of the axillary artery—30%. The perforating cutaneous branches of internal mammary artery to the 2nd, 3rd and 4th intercostal spaces—60%. The lateral branch of the 2nd, 3rd and 4th intercostal arteries. Pectoral branches of acromiothoracic artery, Superior thoracic artery. Venous Drainage x The superficial veins from the breast characterized by their proximity to the skin drain to the axillary, internal mammary, and intercostal vessels. x Phlebitis of one of these superficial veins feel like a cord immediately beneath the skin— ‘ Mondor’s disease’. x Through posterior intercostal veins, venous drainage communicates with paravertebral venous plexus ( Batson’s venous plexus ). So secondaries in vertebrae, is common in carcinoma of breast.

8. Lymphatic Drainage of the Breast Commonly into the axillary lymph nodes (25–35 nodes)—75%. 1. Anterior group (pectoral, external mammary)—along lateral thoracic vessels. Main drainage node. 2. Central group—next common node. It is the node most easily properly clinically palpable in axilla. 3. Posterior group (subscapular)—rare to involve in carcinoma. 4. Lateral group—along axillary vein; rare to involve in carcinoma. 5. Interpectoral node (Rotter’s node) —signifies the retrograde spread of tumour . It lies between pectoralis major and minor. 6. Apical. They are 4–6 nodes, also called as subclavicular or Halsted nodes . It lies most superior and deep to pectoralis minor medial to axillary vessels. 8

9. ABERRATION OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI) OF THE BREAST ANDI includes variety of benign breast disorders occurring at different periods of reproductive periods in females It is based on change in normal three phases of physiology of breast—(1) Lobular development; (2) Cyclical hormonal modifications; (3) Involution. In early reproductive age group (15–25 years) : x Normal lobule formation may cause aberration as fibroadenoma . If it is more than 5 cm it is called as giant fibroadenoma as a diseased status . It is AND of a lobule. x Normal stroma may develop juvenile hypertrophy as aberration and multiple fibroadenoma as diseased status . In mature reproductive age group (25–40 years) : x Normal cyclical hormonal effects on glands and stroma get exaggerated by aberration causing generalised enlargement. Its diseased status is cyclical mastalgia with nodularity also called as fibrocystadenosis . Involution age group (40–55 years) : x Lobular involution with microcysts, fibrosis, adenosis, apocrine metaplasia and eventual aberrations as macrocysts and cystic disease of breast. Macrocyst is an aberration of normal involution (ANI). Sclerosing adenosis is also a type of aberration. x Ductal involution may cause ductal dilatation and nipple discharge as aberration. Later disease status develops with periductal mastitis, bacterial infection, nonlactational breast abscess and mammary duct fistula. x Epithelial changes leads into epithelial hyperplasia and atypia. 9

10. Aberration in Normal Development and Involution (ANDI) ANDI includes variety of benign breast disorders occurring at different periods of reproductive periods in females It is based on change in normal three phases of physiology of breast—(1) Lobular development; (2) Cyclical hormonal modifications; (3) Involution.

11. 11 FIBROCYSTADENOSIS/ FIBROCYSTIC DISEASE

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14. 14 It is a benign encapsulated tumour occurring commonly in young females of 15–25 years age group . it is the most common benign tumour of the breast below 30 years of age in females. It is bilateral in 20% of cases. 20% are multiple. Juvenile fibroadenoma occurs in adolescent girls, rarely (variant). Even though it shows rapid growth with stromal and epithelial hyperplasia, it does not show any alteration in stromal epithelial balance or cellular atypia or periductal cellular concentration. Complex fibroadenoma is a condition (variant) having typical fibroadenoma with fibrocystic changes like apocrine metaplasia, cyst formation, sclerosing adenosis . Core biopsy is needed to confirm the condition. 30% of fibroadenomas may disappear or reduce in size in 2–4 years. 10–15% will increase in size progressively. It does not occur after menopause . FIBROADENOMA

15. Types Gross: 1. Soft—common after 30 years; more cellular; often bilateral. 2. Hard—common below 30 years; more fibrous. 3. Giant (> 5 cm in size)—common in A frica. Microscopy: 1. Intracanalicular—large and soft—mainly cellular stroma w ith distorted duct. 2. Pericanalicular —small and hard—mainly fibrous stroma w ith normal duct. Clinical Features It presents as a painless swelling in one of the quadrants, which is smooth, firm, nontender, well- localised and moves freely within the breast tissue (mouse in the breast). Axillary lymph nodes are not enlarged Investigations Mammography (well- localised smooth regular shadow). It may show popcorn calcification on mammography. FNAC Ultrasound (to confirm solid nature). 15

16. Treatment Excision through a circumareolar incision ( webster’s ) or submammary incision ( gaillard thomas incision ) is done under general anaesthesia. Fibroadenoma which is small (<3 cm)/single/age <30 years-Can be left alone with regular follow-up with USG at 6 monthly interval Indications for surgery are: Size >3 cm. Multiple. Giant type Recurrence Cosmesis Complex type 16

17. FIBROCYSTADENOSIS (FIBROCYSTIC DISEASE OF THE BREAST/MAMMARY DYSPLASIA/CYCLICAL MASTALGIA WITH NODULARITY) It is presently called as cyclical mastalgia with nodularity. It is an estrogen dependent condition. One of the cysts may get enlarged to become a clinically palpable, well-localized. it is fluctuant, transilluminant , nontender, often tensely cystic swelling ( macrocyst ) with thin bluish capsule. It should be aspirated initially. Surgical excision is done if it persists or recurs even after two aspirations; if it is blood stained; if there is residual lump after aspiration. Clinical Features Presentation is during menstruating age group as a bilateral,painful , diffuse, granular, tender, swelling which is better felt with palpating fingers (poorly felt with palm). Common in upper outer quadrant. Pain and tenderness are more just prior to menstruation (cyclical mastalgia ). It subsides during pregnancy, lactation and after menopause. Discharge from the nipple when present will be serous or occasionally greenish. Occasionally shotty enlargement of axillary lymph nodes can occur (20%). Not fixed to skin, muscle or chest wall. 17

18. Treatment Conservative line of management is preferred. Reassurance, avoid caffeine, chocolate, salt. Drugs Oil of evening primrose used in moderate pain Danazol Bromocriptine—lowers prolactin—2.5 mg/day for 3 months. Tamoxifen—10 mg BD is an antiestrogenic drug. Vitamin E and B6 . NSAIDs—oral and topical. Surgery : Subcutaneous mastectomy with prosthesis placement— Only in severe, persistent disease. Excision of the cyst or localised excision of the diseased tissue. 18

19. SCLEROSING ADENOSIS It is a benign proliferative condition of terminal duct lobular units with increased number of acini. It occurs in 30–50 years of age group. Multiple, small, firm, nodules with fibrous tissue and tiny cysts are common pathology. Recurring pain alike cyclical mastalgia and often breast mass (20% cases) is the presentation. Tender breast often with palpable tender firm mass may be felt with granular surface. It contains proliferative terminal ductules and acini with proliferation of stroma often with deposition of calcium. Number of acini per terminal duct is increased more than double the number of normal lobule. There is lobular enlargement, fibrous stromal proliferation and distortion. Mammography may show distortion, asymmetrical density, amorphous calcifications mimicking carcinoma breast. MRI is better investigation with guided tru cut or vacuum assisted biopsy. It is considered as an independent risk factor for developing breast cancer with 1.5–2 higher risk. But it is not a precancerous condition. Treatment: Regular follow is needed. 19

20. PHYLLOIDES TUMOUR (CYSTOSARCOMA PHYLLOIDES/SEROCYSTIC DISEASE OF BRODIE) They can be benign, borderline or malignant. Gross: large capsulated area with cystic spaces and cut surface shows soft, brownish, cystic areas. Microscopy: It contains cystic spaces with leaf like projections, hence the name cells show hypercellularity and pleomorphism. Clinical features They occur in premenopausal women (30–50 years). It is usually unilateral, grows rapidly to attain a large size with bosselated surface. Swelling is smooth, nontender, soft, fluctuant with necrosis of skin over the summit due to pressure. 20

21. Skin over the breast is stretched, red and with dilated veins over it. Tumour is warmer, not fixed to skin or deeper muscles or chest wall. Nipple retraction is absent. Lymph nodes are usually not involved. These are the differentiating features from carcinoma. Grows rapidly; undergoes necrosis at various places; causes cystic areas. Investigations Ultrasound. FNAC, core biopsy Mammography Treatment Excision or subcutaneous mastectomy is done. If malignant (sarcoma), total mastectomy is indicated. 21

22. MASTALGIA (“Pain in the Breast”) Types Cyclical—65%. , Noncyclical—30%. , Chest wall pain—5%. Cyclical pain related to menstrual cycles. usually seen in ANDI like fibrocystadenosis . pain is more during menstruation. it is bilateral, diffuse with “heavy feeling”. Noncyclical other causes of breast pain are periductal mastitis, malignancy, Cervical root pain, musculoskeletal pain, previous surgery, tietze’s s yndrome , idiopathic, mondor’s syndrome. it is unilateral, chronic, burning or dragging in nature, occurs both In pre- and postmenopausal age group. 5% of breast cancers present as pain during first presentation. 22

23. 23 Treatment: x Cause has to be identified. x Malignancy has to be ruled out. x Avoid coffee and stress. x Proper support to breasts. Tietze’s syndrome: Costochondritis of second costal cartilage, commonly seen in females, mimics mastalgia .

24. TRAUMATIC FAT NECROSIS It may be due to either direct or indirect trauma (trauma may not be Noticed many times). Pathogenesis Capillary ooze causes triglyceride in the fat to dissociate into fatty acids. It combines with calcium from the blood resulting in saponification which causes inflammatory reaction and later presents as a non progressive swelling in the breast. Features Painless swelling in the breast which is smooth, hard, nontender And adherent to breast tissue. It is nonprogressive, nonregressive . Investigations: FNAC shows chalky fluid with fat globules. Mammography to rule out malignancy. Treatment: excision 24

25. GALACTOCELE seen in lactating women. occurs during cessation of lactation. Often up to 10 months after lactation. it is due to the blockage of lactiferous duct resulting in enormous dilatation of lactiferous sinus. it contains milk and epithelial debris within.. Clinical Features lump in the lower quadrant of the breast which is usually unilateral, large, soft, fluctuant, with smooth surface. it is usually nontender. it may get precipitated, inspissated or get calcified . When it is calcified it mimics carcinoma breast. If it gets infected it will form an abscess. Investigations Ultrasound. FNAC. Aspiration shows thick, creamy, greenish/brown fluid. Treatment Aspiration of the content. Excision ( submammary incision). Abscess when formed should be drained under general anaesthesia under cover of antibiotics. 25

26. MASTITIS Types 1. Subareolar. 2. Intramammary. 3. Retromammary ( submammary ). Subareolar Mastitis It is the infection under the areola due to cracks in the nipple or areola. It results from an infected gland of montgomery or a furuncle of the areola. There is blockage of the ducts of these glands. often it is associated with duct ectasia—causing formation of Abscess, sinus and fistula. it is common in nonlactating women. risk factors are – diabetes, smoking, nipple cracks . 26

27. a. Lactational abscess of the breast : Commonly seen in lactating women. Usually up to 6 months of lactation period. It occurs in 3% of breastfeeding mothers. Precipitating factors Cracked nipple Retracted nipple Improper cleaning of the nipple Inadequate milk sucking by baby or milk expression causing stasis Infection from the mouth of the baby Haematoma getting infected Mode of infection: Bacteria ( staph. Aureus —most common) enters the breast during sucking through the cracked nipple. Occasionally, it can be from haematogenous spread BY staphylococcus epidermidis , . Clinical features : Continuous throbbing pain in the breast and high grade fever. Diffuse redness, tenderness, warmness and brawny induration in the breast. Purulent discharge from the nipple. Entire breast may get involved eventually. Occasionally tender , fluctuant swelling (10%) may be felt; Ulceration and discharge can occur at a later period. Tender Axillary lymph nodes may be palpable. 27

28. USG breast to identify an abscess, its location, size, loculi. USG guided aspiration can be done; pus should be sent for Culture and sensitivity. Treatment: Antibiotics—cephalosporins, flucloxacillin and amoxicillin. USG guided aspiration Drainage under general anaesthesia Retromammary mastitis it is due to tuberculosis of the intercostal lymph nodes or ribs beneath or suppuration of the intercostal lymph nodes. Investigations: chest x-ray, FNAC, ESR, peripheral smear. USG of breast and chest wall. CT scan chest may be needed. Treatment: cause has to be treated. drainage through submammary /retromammary incision. 28

29. ANTIBIOMA If intramammary mastitis is not drained but only treated by antibiotics, pus localises and becomes sterile with a thick fibrous tissue cover and it is called as antibioma . Features previous history of mastitis treated with antibiotics. swelling which is painless, smooth, nontender, hard, fixed to breast tissue without involving the pectorals and chest wall. Investigations : FNAC; mammography; USG breast. Treatment : excision ( submammary incision). Later antibiotics 29

30. DUCT ECTASIA AND PERIDUCTAL MASTITIS It is dilatation of lactiferous ducts due to myoepithelial relaxation of duct wall with periductal mastitis . Features Greenish discharge or creamy / paste like from the nipple. indurated mass under the areola which is often tender . retraction of nipple which occurs at later stage of the disease. Slit like retraction of nipple due to fibrosis occurs. eventually it forms an abscess and fistula . often they are bilateral and multifocal. more common in smokers—in relation to arterial pathology. common in multiple pregnancies, perimenopausal age , hyperprolactin status. may present as mastalgia . axillary nodes may be palpable as nonspecific. secondary bacterial infection (anaerobic) is common. Investigations : Discharge study, FNAC. Mammography. 30