Benign breast disease and its management

benign breast disease

1. Benign breast disease and its management Dr shambhavi sharma MS general surgery

2. ANDI CLASSIFICATION OF BENIGN BREAST DISORDERS Normal Disorder disease Early reproductive years (15-25 years) Lobular development Fibroadenoma Giant fibroadenoma Stromal development Adolescent hypertrophy gigantomastia Nipple eversion Nipple inversion Subareolar abscess Mammary duct fistula

3. Late reproductive years (25-40 years ) Normal Disorder disease Cyclical changes of menstruation Cyclical mastalgia Incapacitating mastalgia nodularity Epithelial hyperplasia of pregnancy Bloody nipple dischage

4. Involution (35-55 years) Normal Disorder disease Lobular involution Macrocysts sclerosing lesion Duct involution Dilatation Duct ectasia Periductal mastitis sclerosis Nipple retraction Epithelial turnover Epithelial hyperplasia Epithelial hyperplasia with atypia

5. Classification Non proliferative disorder of the breast Cyst and apocrine metaplasia Duct ectasia Mild ductal epithelial hyperplasia Calcifications Fibroadeoma and related lesions Proliferative breast disorder with atypia Sclerosing adenosis Radial and complex sclerosing lesion Ductal epithelial hperplasia Intraductal papillomas Atypical proliferative lesion Atypical lobular hyperplasia Atypical ductal hyperplasia

6. Risk for malignancy No increased risk in fibroadenoma,intraductal papilloma , sclerosing adenosis 1.5-2 fold rise in epithelial hyperplasia 4 fold rise in atypia with hyperplasia

7. Fibroadenoma Benign solid tumors comprising of stromal and epithelial components 15% of all palpble breast lumps Mostly in females younger than 3o years of age ANDI involving a lobule

8. Clinical features Most growth arrested by 2-3cm; may reach >10cm highly mobile, firm , non-tender, and often palpable breast mass.  Multiple in 15%- 20 % Bilateral in 20% Axillary lymph nodes not palpable Types: Juvenile (rapid epithelial and stromal growth) Complex (with fibrocystic changes)

9. 10-15% will increase in size progressively Spontaneous infarction – pregnancy/lactation Reports of regression 20-25% Risk of carcinoma: rare (in complex fibroadenoma and atypia in microscopy) 50%LCIS, 35% invasive carcinoma, 15% intraductal carcinoma

10. Investigations well-circumscribed , firm mass, solid mass the cut surface appears lobulated and bulging Investigations Ultrasonography Mammography FNAC

11. investigations

12. findings management Triple assesment Results concur Age <30 years Clinical observation for 2 years If disappears/regresses : counselling No change/ increase in size /patient request : excision/ cryotherapy /vacuum assisted biopsy Resuts donot concur Age > 30 years excision Multiple lesions Excision of the largest Observation for the rest Giant fibroadenoma Juvenile fibroadenoma Complex type Extracapsular excision cryotherapy

13. AKA MAMMARY DYSPLASIA /CYCLICAL MASTALGIA WITH NODULARITY SCHIMMELBUSCHS DISEASE: diffuse small multiple cysts.

14. b. Surgical management Subcutaneous mastectomy with prosthesis placement Excision of cyst or localised excision of diseased tissues Indication : Intractable pain Florid epithliosis in FNAC Bloodgood cyst Persistant bloody discharge Psychological reason

15. MAMMOGRAM

16. treatment

17. ANDI Terminal ductules and acini with proliferation of stroma often with deposition of calcium Number of normal duct is increased than number of normal lobule Types: complex type Radial scar No risk of malignancy Investigation : stereotactic /core needle biopsy Treatment: conservative

18. ANTIBIOMA

19. ( Submammary ) and biopsy

20. Fat necrosis benign nonsuppurative inflammatory process of adipose tissue. occur secondary to accidental or surgical trauma, may be associated with carcinoma any lesion that provokes suppurative necrotic degeneration, such as mammary duct ectasia and, to a lesser extent, fibrocystic disease with large cyst formation

21. Clinically, fat necrosis may mimic breast cancer if appears as an ill-defined or spiculated dense mass, associated with skin retraction, ecchymosis , erythema , and skin thickness . Mammographic, sonographic , and magnetic resonance imaging findings : may not always distinguish fat necrosis from a malignant lesion. Histologically : characterized by anuclear fat cells often surrounded by histiocytic giant cells and foamy phagocytichistiocytes Treatment : Excisional biopsy is required if carcinoma cannot be excluded preoperatively

22. NIPPLE DISCHARGE

23. NIPPLE DISCHARGE

24. Blood and Serosangious Discharge Due to epithelial hyperplasia , duct papilloma , malignancy. Rare due to duct ectasia >55years age increase risk of malignancy Incidence of cancer is 3% below 40yrs,10% between 40-60 and 32% over 60yrs Blood discharge in pregnancy- Bilateral, 2nd to 3rd trimester

25. Intraductal Papilloma rare,occurs in middle-age. ANDI of lactiferous ducts Variant of epithelial hyperplasia (fibrocystic disease) Presents as blood-stained or serous nipple discharge. Usually solitary lump <1cm with a small lump in the areola papiliferous projections near nipple origin ,vascular stalk usually present

26. investigations Discharge study ( FNAC Ductogram mammography

27. TREATMENT MICRODOCHECTOMY Via tennis racket incision

28. Unilateral discharge in pregnancy must be investigated. Post surgery – usually due to communication btw operative site and ducts. Watery discharge-rare, same significance as bloody.

29. Risk for carcinoma: Management MELHEM NOVEL MODIFIED BREAST DUCTAL SYSTEM EXCISION

30. mastitis Types: Subareolar : Common in non lactating women Infection of montgomery tubercles or furuncle of areola Due to cracked nipples Red inflamed edematous areola with a tender swelling .may have nipple retraction Treatment: incision and drainage by subareolar incision Retromammary : due to tb /suppuration of intercoastal lymph nodes/ribs

31. Breast abscess ( Intramammary ) Classification : Breast abscesses can be classified into : Lactational Non- lactational Non- lactating breast abscesses can be further divided into Central ( periareolar ) infection Peripheral Infection

32. Lactating Infection • usually develops within the first 6 weeks of breastfeeding or occasionally, during weaning. 3% of lactating mothers Causative organism: Staphylococcus aureus occasionally staph epidermidis and streptococci

33. Drainage of milk from the affected segment often reduced, causing stagnant milk to become infected. risk factors: Cracked nipples Retracted nipple Infection from mouth of baby Improper cleaning of nipples Hematoma getting infected

34. Presenting features :continuous throbbing pain, swelling, tenderness and a cracked nipple or skin abrasion, brawny induration ,purulent nipple discharge, fluctuant swelling

35. Non-Lactating Infection Central or periareolar infections This is most commonly seen in young women (mean age 32 years) cause : periductal mastitis Risk factor : smoking

36. Peripheral Non-lactating abscess These are less common than peri-areolar abscesses sometimes associated with an underlying condition, such as diabetes, rheumatoid arthritis, steroid treatment, or trauma.

37. Clinical features : breast pain Erythema peri-areolar swelling and tenderness and/or nipple retraction in relation to the affected duct

38. investigations Ultrasonography breast Treatment 1.Antibiotics 2.Repeated aspirations 3.Incision and drainage

39. MASTALGIA Breast pain that interferes with daily activities of the patients

40. Galactocele

41. Serum chemistry LFT Thyroid function test Renal function test Total or free testosterone level , serum prolactin , LH , oestradiol , dehydroepiandrostenone sulphate levels to evaluate a patient with possible feminization syndrome Urinary 17 ketosteroid Beta HCG Imaging Studies : USG breast Mammography Testicular USG MRI for pituitary gland CT scan for adrenal

42. treatment Reassurance (if psysiological ) Treatment of cause (stop drugs) Medical therapy ( danazol,clomiphene citrate,tamoxifen ) Surgical therapy

43. Surgery is indicated in patients in whom the gynaecomastia causes distress and psychological trauma , when there is no underlying treatable condition and when hormonal treatment is failed • Open subcutaneous mastectomy • Endoscopic assisted subcutaneous mastectomy • Liposuction assisted mastectomy • Ultra sound assisted liposuction

44. References Swartz Sabiston Bailey and love text book of surgery