Benign breast disease

DR. ASHOK PRADHAN
DU, TU

1. Benign Breast D isease DR. ASHOK PRADHAN 2 ND YR SURGERY JR

2. Breast Anatomy Modified sweat gland derived from the ectoderm Lies B/W subdermal layer of adipose tissue and superficial pectoral fascia Breast parenchyma composed of lobes, comprised multiple lobules Suspensory ligament of cooper – provides structural support to the breast B/W breast and pectoralis major muscle lies retromammary space, contain lymphatics and vessels

3. Cont. Breast extends from 2 – 6th rib Sternum to mid axillary line Axillary tail of Spence - upper outer portion of the breast passes deep to the deep fascia through the foramen of Langer, where it is in direct contact with anterior axillary lymph node.

4. Microscopic Anatomy Glandular epithelium – Composed of branching system of ducts, each major duct has lactiferous sinus Each major duct has progressive generation of branching and ultimately ends in the terminal ductules or acini Acini are the milk forming glands of lactating breast, which consist of lobular unit/ lobule Lined by myoepithelial cells

5. Cont. Fibrous stroma and supporting structure In adolescent, predominant tissue are epithelium and stroma Adipose tissue- In postmenopausal women, the glandular structures involute and replaced by adipose tissue Ligament of cooper provide shape of whole breast

6. Lympahtic Drinage Pectoralis minor muscle enclosed within clavipectoral fascia, extends laterally to fuse with axillary fascia, which contain loose aerolar fat of axilla, containing axillary lymph node Axillary lymph nodes are described in relation with pectoralis minor muscle Level I, level II, level III

7. Aberrations of Normal Development and Involution of the Breast (ANDI) ANDI –benign breast disorder, occurring at different periods of reproductive life in female Early reproductive phase (Lobular development): 15 – 25 yrs Matured reproductive phase (Cyclical hormonal modification): 25 – 40 yrs Involution phase ( Resorption of glandular structures): 40 – 55 yrs

8. Fibroadenoma Solid tumor composed of stromal and epithelial elements Hyperplasia of single lobule of the breast(ANDI) 2 nd most common tumor in breast after carcinoma and most common tumor in women younger than 30 years Late teen and early reproductive years,rare after 40 or 45 years

9. Cont. Small fibroadenoma <1cm, normal; larger<3cm, disorder and >3cm or giant fibroadenoma , disease Multiple fibroadenoma,.5 in number consider disease Shows hormonal dependence - normal breast lobules in that they lactate during pregnancy and involute during menopause 20% bilateral, 20% multiple

10. Clinical examination Firm mass, easily movable, may increase in size over a period of several months Remain static for long period, regress spontaneously over year Lobulate or smooth

11. Cont. Encapsulated Slide easily under the examine finger( breast mouse),non tender swelling Axillary lymph node- not enlarged

12. Cont. T wo type of fibroadenoma G iant fibroadenoma :more than 5 cm in diameter Juvenile fibroadenoma: large fibroadenoma that occurs in adolescent and young adult H istologically more cellular than usual fibroadenoma

13. Pathological type Pericanalicular type( hard fibroadenoma ): proliferation of fibrous tissue is more than the glandular element, feel firm, mobile within breast tissue Intracanlicular type( soft fibroadenoma ): proliferation of glandular tissue is more than fibrous tissue, soft feel

14. Investigation USG of breast Typical round/oval sharp contour. Doesn’t distinguish b/w cancer and fibroadenoma FNAC abundance of epithelial cells and stroma Mammography If age is greater than 35 years

15. Popcorn calcification

16. Cancer In Fibroadenoma Though benign tumor, neoplasia may developed in epithelial elements 50% of neoplasia are Lobular Carcinoma Insitu 35% infiltrating carcinoma 15% intraductal carcinoma

17. Treatment If <2 cm reassurance should should be done, regress spontaneously, F/U after 6months interval with USG Breast. Surgical treatment More 3cm in size, multiple, Giant variety Tumor size increasing in follow up, recurrance For cosmetic purpose( if patient is bother by mass) Cryoablation under USG guidance can be done

18. Incisional approach Incision made over the capsule Enucleation of tumor should be done Webster incision Gaillard Thomas

19. Fibrocystic disease of breast / Fibrocystadenosis / Mammary D ysplasia / Cyclical mastalgia with nodularity Estrogen dependent condition, e xaggerated response to breast stroma and epithelium Painful nodularity persist for >1 week of menstrual cycle -disorder Bluedome cyst of bloodgood Schimmelbuch’s disease Most common breast disease, upper outer quadrant Rare in nulliparous, ovulating and OCP taking women

20. Stages Stromal proliferation Adenosis Cyst formation.

21. Microscopic Features Stromal fibrosis Microcyst formation Glandular proliferation Hyperplasia ( epitheliosis ) Papillomatosis

22. Clinical features Bilateral , painful, diffuse, granular, swelling, better palpated with the fingers than palm. Pain and tenderness >> just prior to menstruation( thus cyclical mastalgia ) Discharge from nipple, 20% axillary lymph node enlargement

23. Investigation FNAC ( epitheliosis ) USG Breast Mammography

24. Treatment : Conservative management Oil of evening primrose – Gamolenic acid Danazol 200mg/day T amoxifen -10mg bd Vit E and B6 NSAIDs surgery Cyst excision Sub cutaneous mastectomy Indication Intractable pain Florid epitheliosis on FNAC Bloodgood cyst Persistant bloody discharge

25. Sclerosing A denosis Refers to the increased number of small terminal ductules or acini Associated with the proliferation of the stromal tissue, often with ca ++ deposition 30- 50 years, multiple small firm nodule ē fibrous tissue and cysts Cyclical mastalgia and tender breast mass Grossly and histologically mimic CA breast

26. Cont. Important component of fibrocystic disease No significant malignant potential Mammography: microcalcification indistinguishable from intraductal carcinoma Needle direct biopsy of microcalcification - most common pathologic diagnosis Conservative management with regular F/U

27. Phyllodes Tumors Tumors of mixed connective tissue and epithelium, biphasic proliferation of stroma and mammary epithelium With increasing cellularity, invasive margin, pleomorphism and mitotic activities with sarcomatous apperance  malignant phyllodes tumor

28. Cont. Benign phyllodes tumors – firm lobulated masses range in size, average of aprrox . 5cm Histologically similar to fibroadenoma , but whorled stroma forms larger cleft lined by epithelium that resembel clusters of leaflike structure Size increases rapidly and attained the size of breast,soft , lobulated surface,free from skin and underlying pectoral muscle Premenopausal women

29. investgation Mammography -Round density with smooth borders USG- Discrete structure with cystic spaces Cytology – cannot differentiate with fibroadenoma Core biopsy- difficult to differentiate B/W benign and malignant form Final diagnosis – excisional biopsy with careful histopathological report

30. Treatment Local excision of benign phyllods Boderline phyllodes tumor – excision with the margin of @ least 1cm of normal tissue Malignant phyllodes tumor – complete surgical excision of entire tumor with the margin of normal tissue If tumor involved whole breast- total masectomy

31. Mastalgia 45 % of women present with mastalgia , 21% severe Unknown etiology Predisposing conditions:HRT , Caffeine, tobacco, large pendulous breast Types : Cyclical (65%) Non cyclical (30 %) Chest wall pain (5%)

32. Cyclical : Related to Menstrual cycle B /l diffuse pain with heavy feeling Similar to ANDI like fibrocystoadenosis T reatment similar to ANDI Evening primrose, danazol Tamoxifen , vit B6, B12, Analgesics

33. Non cyclical R/O other causes of breast pain- Periductal mastitis, cervical root pain, Teitz syndrome U /l chronic , burning or dragging Occurs in both pre and post menopausal age group Treatment of underlying causes Avoid coffee and stress

34. Traumatic fat necrosis Palpable mass Episode of trauma to breast, any surgical procedure or radiation treatment Important characteristics- calcification Histologically lipid laden macrophages, chronic inflammatory cells No malignant potential PATHOGENESIS: Capillary ooze - triglyceride in fat to dissociate into fatty acid –Combines with Ca – Saponification - Inflammatory reaction - Swelling

35. Cont. Investigation Mammography- calcification FNAC-lipid laden macrophages Treatment Excision

36. Galactocele Accumulation of milk  cyst, round, well circumscribed and easily movable within breast After cessation of lactation or when feeding frequency has curtailed significantly Pathogenesis is unknown but inspissated milk within duct is responsible Located in central portion of breast/ under nipple

37. Cont.. Needle aspiration- thick creamy material, dark green or brown, though appears purulent, fluid is sterile Treatment: Needle aspiration of thick milky secretion Surgery If unable to aspirated Infected galatocele

38. Mastitis Types Sub areolar Intra mammary, a ) Lactational abscess b ) Non- lactational abscess Retro mammary

39. Sub areolar Infection developing d/t cracks in the nipple, infected Montgomery glands or a furuncle Can be caused by duct ectasia Common in nonlactating women CLINICAL FINDINGS: Red, inflamed areola, tender, nipple retraction may be present . Treatment – subaerolar incision and driange

40. Intra mammary mastitis Lactational abscess Seen in lactating maother , usually up to 6 months of feeding Predisposing factors: Cracked nipple Retracted nipple Improper cleaning Inadequate suckling by the baby or stasis Infection from the mouth of the baby Most common organism  Staph. Aureus

41. CLINICAL FEATURES: Fever with chills and rigors Throbbing pain, severe tenderness Redness , local rise in temperature, induration Purulent discharge from the nipple. Entire breast may be involved and may end up having fluctuation + ve . Investigation USG BLOOD TC/DC Treatment –I/D with antibiotics coverage

42. inflammation Blocked duct

43. Retro mammary abscess D /t Tuberculosis of the internal mammary nodes and ribs beneath Breast tissue -normal . Investigations: FNAC USG breast and chest wall Treatment: R etromammary incision

44. Duct Ectasia It is dilatation of lactiferous ducts d/t relaxation of the myoepithelial cells of the duct wall with p eriductal mastitis Duct ectasia led to stagnation of secretion, epithelial ulceration, and leakage of duct secretion( fatty acid as irritating substance) into periductal tissue PERIDUCTAL FIBROSIS AND NIPPLE RETRACTION

45. Cont. Another theory, perductal mastitis, leads to weaking of ducts and secondary dilataion Both process together and explain the wide spectrum of problems, such as nipple discharge, nipple retraction, inflammatory masses and abscess

46. CLINICAL FEATURES: Investigation Ductography Mammgraphy T reatment Stop smoking Cone excision of the major duct- ADAIR HADFIELD OPERATION Antibiotics Melhem Novel modified breast ductal system excision

47. Duct Papilloma Intraductal papillomas arise in the major ducts , usually in premenopausal women. < 0.5 cm in diameter but may be as large as 5 cm. A Common presenting symptom is nipple discharge, which may be serous or bloody. Grossly , intraductal papillomas are pinkish tan, friable

48. Cont. Attached to the wall of the involved duct by a stalk They rarely undergo malignant transformation , and their presence does not increase a woman’s risk of developing breast cancer Intraductal papillomas , which occur in younger women and are less frequently associated with nipple discharge

49. Cont. Investigation FNAC Ductogram Mammography Treatment M icrodochectomy