Benign breast condition 2.pptx surgery ppt

Benign breast condition

1. BENIGN BREAST TUMOR RUQAYYA AHMED MOHAMED MD\10\055\TZ

2. Vasculature Arterial supply to the medial aspect of the breast is via the internal thoracic artery (also known as internal mammary artery) – a branch of the subclavian artery.   The lateral part of the breast receives blood from four vessels:   Lateral thoracic and thoracoacromial branches – originate from the axillary artery. Lateral mammary branches – originate from the posterior intercostal arteries (derived from the aorta). They supply the lateral aspect of the breast in the 2nd 3rd and 4th intercostal spaces. Mammary branch – originates from the anterior intercostal artery. The veins of the breast correspond with the arteries, draining into the axillary and internal thoracic veins.

3. Lymphatics The lymphatic drainage of the breast is of great clinical importance due to its role in the metastasis of breast cancer cells. There are three groups of lymph nodes that receive lymph from breast tissue axillary nodes (75%) parasternal nodes (20%) posterior intercostal nodes (5%). Skin – drains to the axillary, inferior deep cervical and infraclavicular nodes. Nipple and areola – drains to the subareolar lymphatic plexus.

4. Benign breast conditions are diverse group of non malignant disorders affecting the breast but do not exhibit invasive or metastatic potential. Benign breast conditions are classified based on ANDI, ploriferative as well as non proliferative disorders of the breast. The Aberrations of Normal Development and Involution (ANDI) classification is a structured system used to categorize benign breast disorders based on their deviation from normal physiology. =

5. It considers three key principles: 1. Benign breast disorders are related to the normal processes of development and involution. 2. They exist on a spectrum ranging from normal to disorder to disease. 3. The classification is influenced by the stage of reproductive life in which the condition develops.

6. Classification based on ANDI Early Reproductive Years (15-25 years) Gigantomastia Subareolar Abscess & Mammary Duct Fistula Fibroadenoma Later Reproductive Years (25-40 years)  Cyclical Mastalgia (Breast Pain) Nodularity bloody nipple discharge Involutional Years (35-55 years)  Duct Ectasia Nipple retraction Periductal Mastitis Atypical epithelial hyperplasia

7. Classification based on ANDI The classification recognizes that some conditions are mild deviations from normal (disorders), while others represent more severe abnormalities (diseases) that may require intervention. Understanding ANDI Classification by Reproductive Stages,The ANDI classification divides conditions based on the patient ’ s reproductive phase because different breast changes occur during puberty, adulthood, pregnancy, and menopause. 1. Early Reproductive Years (15-25 years) During this phase, the breast is undergoing active lobular and stromal development, making it susceptible to certain benign conditions.

8. Category Example Normal Lobular development, stromal development, nipple eversion Disorder Fibroadenoma, adenosis (increased glandular tissue), nipple inversion Disease Giant fibroadenoma (>3 cm), gigantomastia , subareolar abscess, mammary duct fistula

9. Gigantomastia : Pathophysiology: Uncontrolled hormonal stimulation leads to excessive proliferation of stromal and glandular tissue. Clinical Presentation: Massive bilateral breast enlargement with associated pain and skin ulceration. Management: Reduction mammoplasty or mastectomy if severe. Subareolar Abscess & Mammary Duct Fistula: Pathophysiology: Infection due to obstruction of lactiferous ducts. Clinical Presentation: Painful, erythematous swelling under the areola with purulent discharge.

10. Fibroadenoma: Most common benign breast tumor in young women. Pathophysiology: Composed of both glandular and stromal components. Growth is influenced by estrogen. Clinical Presentation: Well-defined, mobile, firm, rubbery mass. Spectrum: • Small fibroadenomas (<1 cm) are normal variants. • Larger ones (1-3 cm) are disorders. • Giant fibroadenomas (>3 cm) are disease, as they can cause cosmetic concerns and rapid growth.

11. GIGANTOMASTIA

12. 2. Later Reproductive Years (25-40 years)  Breast tissue becomes more responsive to cyclical hormonal changes, leading to variations in density and nodularity. Category Examples Normal Cyclical changes of menstruation, epithelial hyperplasia of pregnancy Disorder Cyclical mastalgia , nodularity, bloody nipple discharge Disease Incapacitating mastalgia

13. Cyclical Mastalgia (Breast Pain): Pathophysiology: Increased hormonal stimulation leads to fluid retention and glandular engorgement. Clinical Presentation: Breast pain worsens before menstruation, often bilateral. Spectrum: • Mild, short-duration pain is normal. • Persistent pain lasting >1 week of the cycle is a disorder. • Incapacitating mastalgia (severe pain limiting activities) is a disease.

14. Nodularity: Pathophysiology: Hormonal influence causes lobular hyperplasia and glandular engorgement. Clinical Presentation: Lumpiness in the breasts that fluctuates with the menstrual cycle. Differential Diagnosis: Fibrocystic changes vs. malignancy (requires imaging). Bloody Nipple Discharge: Causes: Often due to intraductal papilloma or duct ectasia.

15. 3. Involutional Years (35-55 years)  As menopause approaches, breast tissue undergoes involution, characterized by the shrinkage and degeneration of ducts and glandular tissue. Category Examples Normal Duct involution, dilatation, sclerosis, epithelial turnover Disorder Duct ectasia, nipple retraction, epithelial hyperplasia Disease Periductal mastitis, epithelial hyperplasia with atypia

16. Duct Ectasia: Pathophysiology: Aging leads to dilation of lactiferous ducts with accumulation of thick secretions. Clinical Presentation: Greenish nipple discharge, periductal inflammation, possible nipple retraction. Spectrum: • Mild cases are disorders. • If symptomatic with chronic inflammation, it is considered disease. Nipple Retraction: Causes: Can result from benign processes (ductal fibrosis) or malignancy.

17. Periductal Mastitis: Pathophysiology: Chronic inflammation around ducts leads to abscess formation. Clinical presentation: Pain, erythema, thickened ducts. Atypical Epithelial Hyperplasia: Pathophysiology: Proliferation of epithelial cells with cytologic atypia. Clinical Significance: 4-fold increased risk of breast cancer.

18. DUCT ECTASIA

19. Histological Classification Benign breast disorders can be classified based on their histological growth pattern and their potential to progress into malignancy . These classifications are crucial for determining the risk of breast cancer and guiding clinical management.  Non-proliferative Disorders of the Breast Proliferative Breast Disorders Proliferative Breast Disorders without Atypia Atypical Proliferative lesion Atypical Lobular Hyperplasia (ALH) Atypical Ductal Hyperplasia (ADH) 

20. 1. Non-proliferative Disorders of the Breast  Definition: These are benign breast changes that do not involve significant epithelial cell proliferation. They account for 70% of all benign breast conditions and carry no increased risk of breast cancer. 

21. Examples and Pathophysiology: Condition Pathophysiology Clinical Features Cysts and Apocrine Metaplasia Fluid-filled sac formed due to ductal obstruction and secretory activity of glandular epithelium Palpable, round, mobile, tender mass. May show “ blue dome ” appearance on aspiration. Duct Ectasia Dilation of lactiferous ducts with chronic inflammation and fibrosis Greenish nipple discharge, periductal inflammation, possible nipple retraction. . Mild Ductal Epithelial Hyperplasia Minimal proliferation of epithelial cells within breast ducts. No atypia Usually incidental finding on biopsy. No clinical symptoms Calcifications Deposition of calcium in ducts or cysts, often due to inflammation or fibrosis. Detected on mammography as benign microcalcifications.

22. 2. Proliferative Breast Disorders Proliferative Breast Disorders without Atypia Definition: These conditions involve increased proliferation of epithelial or stromal cells, but the proliferating cells appear normal (without cytologic atypia). These conditions slightly increase breast cancer risk (1.5 to 2-fold).

23. Examples and Pathophysiology:. Condition Pathophysiology Clinical Features Sclerosing Adenosis Increased lobular glands with stromal fibrosis. Can mimic carcinoma histologically. Palpable mass or mammographic distortion. May cause breast pain. Radial and Complex Sclerosing Lesions Radial scars (<1 cm) and complex sclerosing lesions (>1 cm) are fibrotic lesions with central sclerosis and ductal branching. Usually asymptomatic but may present as a mass or mammographic abnormality. Ductal Epithelial Hyperplasia Increased number of epithelial cells within breast ducts but without atypia Incidental finding on biopsy, no distinct clinical symptoms. Intraductal Papillomas Benign papillary tumors growing inside breast ducts, leading to ductal obstruction. Bloody nipple discharge is the classic presentation

24. Atypical Ploriferative lesion Definition: These are proliferative breast disorders that show abnormal (atypical) cellular features but do not meet the full criteria for carcinoma in situ. They increase breast cancer risk by 4-fold and are considered precancerous lesions. There are two main types: Atypical Lobular Hyperplasia (ALH) Pathophysiology: Overgrowth of lobular epithelial cells with loss of normal cell cohesion due to E-cadherin loss (a key feature distinguishing it from ductal hyperplasia). Cells appear monomorphic, round, and evenly spaced.

25. Clinical Features: No distinct lump or symptoms. Often found incidentally on biopsy for other conditions. Cancer Risk: 4-fold increased risk of invasive lobular carcinoma in either breast.

26. Atypical Ductal Hyperplasia (ADH)  Pathophysiology: Proliferation of ductal epithelial cells that resemble low-grade ductal carcinoma in situ (DCIS) but are limited in extent. Cells have atypical nuclear features and architectural patterns but do not completely fill the ductal lumen. Clinical Features: No palpable mass; usually detected as microcalcifications on mammography. Cancer Risk: 4-fold increased risk of developing invasive ductal carcinoma, usually in the same breast.

27. Risk factors contribute to benign breast conditions 1.Hormonal Influences: Prolonged Estrogen Exposure, Early menarche and late menopause extend the duration of estrogen exposure. Estrogen stimulates the proliferation of breast epithelial and stromal cells, which over time can lead to benign hyperplastic changes. 2.Reproductive History: Nulliparity or Late First Pregnancy, Pregnancy induces differentiation of breast tissue, which is thought to protect against uncontrolled proliferation. Women who never become pregnant, or who have their first pregnancy later, miss out on this protective differentiation, leaving the tissue more susceptible to benign proliferative changes

28. 3.Genetic Predisposition: Family History: Inherited genetic factors can make breast tissue more sensitive to hormonal influences or predispose it to abnormal cellular proliferation. This means that if benign changes have occurred in a family, the underlying genetic background may contribute to similar processes. 4.Lifestyle Factors: Obesity: Adipose tissue is a site of aromatase activity, which converts androgens into estrogens. Increased adiposity leads to higher estrogen levels, further stimulating the breast tissue and potentially leading to benign conditions.

29. 5.Prior Breast Interventions or Conditions: History of Benign Breast Disease: A previous episode of benign breast change suggests that the tissue may already be predisposed to proliferative responses. Any additional hormonal or environmental stimulus can exacerbate this tendency.

30. Investigations Investigating benign breast conditions involves a comprehensive approach to accurately diagnose and differentiate non-cancerous abnormalities from malignant ones. The evaluation process typically includes a detailed clinical assessment, various imaging modalities, and, when necessary, laboratory analyses and biopsies.  1. Clinical Assessment: Patient History: Gathering information about the patient ’ s medical history, family history of breast conditions, hormonal factors, and any prior breast issues is essential. Physical Examination: A thorough breast examination is conducted to identify lumps, assess their size, shape, consistency, mobility, and check for skin or nipple changes.

31. 2. Imaging Studies: Mammography: This X-ray technique is fundamental in detecting and evaluating breast abnormalities. It can reveal masses, calcifications, and structural distortions indicative of benign conditions. Ultrasound: Often used alongside mammography, ultrasound helps distinguish between solid masses and fluid-filled cysts, providing detailed information about the internal characteristics of a lesion.  MRI (Magnetic Resonance Imaging): MRI offers detailed images and is employed in specific scenarios, such as assessing the extent of certain benign conditions or when other imaging results are inconclusive

32. 3. Laboratory Analyses: Nipple Discharge Examination: If nipple discharge is present, a microscopic evaluation can identify underlying causes. For non-milky discharge, a ductogram (galactogram) may be performed to visualize the milk ducts and detect abnormalities like intraductal papillomas . 

33. 4. Biopsy Procedures:  When imaging studies reveal suspicious or unclear findings, a biopsy is conducted to obtain tissue samples for histological examination: Fine-Needle Aspiration (FNA): Utilizes a thin needle to extract cells or fluid from a breast lump, aiding in distinguishing between cystic and solid masses. Core Needle Biopsy: Involves a larger needle to remove a core of tissue, providing more information about the lesion ’ s architecture and cellular composition. Surgical (Excisional) Biopsy: In cases where needle biopsies are inconclusive or when the lesion is large, a surgical procedure may be performed to remove part or all of the suspicious area for examination

34. Management Surgical management of benign breast conditions follows a structured approach to ensure patient safety, complete lesion removal, and optimal recovery. The treatment plan varies depending on the condition but generally includes preoperative preparation, intraoperative procedures, and postoperative care. 1. Preoperative Treatment (Preparation Phase)  The goal of preoperative preparation is to assess the patient, confirm the diagnosis, and optimize conditions for safe surgery.  A. Clinical Evaluation & Diagnosis History & Physical Examination: • Assess for pain, lump characteristics (size, mobility, tenderness), nipple discharge, and skin changes. • Evaluate risk factors, family history of breast disease, and previous breast conditions.

35. B. Preoperative Counseling & Consent • Explain the benign nature of the condition and the rationale for surgery. • Discuss possible complications (infection, hematoma, recurrence, scarring). • Inform about postoperative expectations, including wound healing and possible temporary breast shape changes. C. Preoperative Medical Optimization • Antibiotic Prophylaxis: Not routinely required, except for infected lesions (e.g., abscesses). • Pain Management: Mild analgesics (NSAIDs) may be given preoperatively for symptomatic relief.

36. 2. Intraoperative Treatment (Surgical Management Phase)  The choice of surgery depends on the type and size of the benign lesion.  Common Surgical Procedures for Benign Breast Conditions are, 1.Excision of Fibroadenoma • Performed under local or general anesthesia, depending on size and depth. • Enucleation (removal of the fibroadenoma only) is performed for smaller lesions. • Wide local excision is preferred for rapidly growing or large fibroadenomas (>3 cm).

37. 2.Cyst Excision or Aspiration • Simple cysts can be aspirated under ultrasound guidance. • If the cyst is recurrent, complex, or contains solid components, surgical excision is recommended. 3.Duct Excision for Nipple Discharge (Intraductal Papilloma or Duct Ectasia) • Microdochectomy (removal of affected duct) for single-duct involvement. • Total duct excision (Hadfield ’ s procedure) if multiple ducts are involved.

38. 4.Excision of Phyllodes Tumors • Requires wide local excision with a ≥ 1 cm margin to prevent recurrence. • Mastectomy may be needed for large, rapidly growing, or recurrent tumors. 5.Incision & Drainage (I&D) for Breast Abscess • For acute breast abscesses, a small incision is made, pus is drained, and wound care is initiated. • Chronic or recurrent abscesses may require total duct excision.

39. Key Intraoperative Considerations • Hemostasis: Proper bleeding control to prevent postoperative hematoma. • Cosmetic Consideration: Minimal scarring techniques like inframammary or periareolar incisions.

40. 3. Postoperative Treatment (Recovery & Follow-up Phase)  The goal of postoperative care is to ensure proper wound healing, pain control, and early detection of complications. A. Immediate Postoperative Care Vital Sign Monitoring Assess for bleeding, infection, or allergic reactions to anesthesia. Pain Management: NSAIDs (e.g., ibuprofen, diclofenac) or acetaminophen. Opioids (only for severe pain). Antibiotics (if needed): For infected lesions or surgical site infections (e.g., cephalexin or clindamycin). Wound Care: Keep the incision clean and dry

41. B. Monitoring for Complications Hematoma Infection • Treatment: Oral or IV antibiotics, depending on severity. Scarring & Cosmetic Issues: Silicone gel or pressure dressing can help reduce scarring.

42. C. Long-Term Follow-up • First Follow-up (1 – 2 weeks post-op): Wound assessment, pain management, and histopathology review. • Subsequent Follow-ups (3 – 6 months): Monitor for recurrence of fibroadenomas, cysts, or papillomas . Routine breast self-examination (BSE) and periodic imaging if indicated. • Lifestyle Modifications: Avoidance of excessive caffeine (may reduce fibrocystic breast changes). Supportive bras for comfort

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