BREAST DISEASES

1. Benign breast disease
DR MUHAMMED MUNEER M
MS GENERAL SURGERY
SGMC & RF
TRIVANDRUM KERALA

2.  Benign breast diseases are often under diagnosed.
 Malignancy is not commonly associated with benign
disease
 Management of BBD depends on accurate diagnosis
 Most benign disease can be managed without
surgery.

3.  Congenital disorder
 Inverted nipple
 Supernumerary breast / nipples
 Non- breast disorders
 Tietze’s disease (Costochondritis)
 Sebaceous cyst & other skin conditions
 ANDI
 Cyclical nodularity and mastalgia
 Cysts
 Fibroadenoma, Duct Ectasia / Periductal mastitis
 Non-ANDI - Inflammation
 -Infection- Acute & Chronic ( specific & nonspecific)
 Injury - Traumatic fat necrosis, Cracks of nipple ,Hematoma, Traumatic
mastitis, Milk fistula
 Pregnancy related
 Galactocele
 Puerperal abscess

4.  Nonproliferative : no increase in risk
 Cysts :micro & macro
 Ductal ectasia
 Mastitis
 Fibrosis
 Metaplasia :Squamous or apocrine
 Mild hyperplasia.
 Proliferative :RR 1.5-2.0
 Complex fibroadenoma
 Papilloma
 Sclerosing adenosis
 Hyperplasia :moderate or severe
 Proliferative with Atypia: RR 4.5- 5.0
 Atypical ductal hyperplasia
 Atypical lobular hyperplasia
(RR- relative risk)

5.  Proliferative disease and absolute risk of
breast cancer development is 20% in 15 years
among patients with family history of first
degree relative, and 8% in those group which
do not have family history.

6.  Developed by LE Hughes at Cardiff breast
clinic 1987
 Replaces fibrocystic disease, fibroadenosis,
chronic mastitis, mastopathy etc.
 Most benign breast diseases arise from normal
physiological process & range from normality to
mild abnormality (aberration) to severe abnormality
(disease).

7.  Cyst formation
 Retention cysts
 Blue –domed cyst of Bloodgood (macrocysts)
 Brodie’s tumor (microcysts)
 Fibrosis
 Epithelial proliferation
 Adenosis (increase in no. of acinar units per lobule)
 Epithelial Hyperplasia ( of cells) + Papilloma formation
 papillamatosis

9. Age ( years) normal process aberration
<25 Breast development
Stromal Juvenile hypertrophy
Lobular Fibroadenoma
25-40 yr Cyclical activity
Cyclical mastalgia
Cyclical nodularity
(diffuse or focal)
35- 55 yr Involution
Lobular Macrocyst
Stromal Sclerosing adenosis,
Radial scar, Complex
Sclerosing lesion
Ductal Duct ectasia

11.  Mastalgia
 Cyclical
 Non-Cyclical
 Lump - many causes
 Periareolar Disorder
 Nipple Discharge
 Nipple Retraction

12.  90 % of condition that cause breast pain are benign.
 Cyclical  2 weeks before menses and diminish with
onset of menses
 Noncyclical  more common in peri-menopausal than
in post menopausal lady .
 It may be assoc with ANDI or referred pain from chest
wall.
 Drugs - Antideprssants, Digoxin, Thiazide, Methyldopa
can cause it
 About 5% of breast cancer exhibit pain at presentation.

13. MANAGEMENT OF ANDI
Exclude cancer
Reassure
Use pain chart If cyclical or non cyclical .
Also allows time for reassurance to become active
Adequate support Firm bra during the day and softer bra at night
Exclude caffeine
Vitamin E & B6 and Diuretics
Work for some although not very efficacious .
Reduction in symptoms in some cotrolled clinical
trials
Evening primrose oil (gammalinoleic acid)–
adequate dose (80mg tid )given over 3 months
Better effect in women over 40 yr old than in
younger women (will help >50% of these women)
For those with intractable pain
Antigonadotropin -Danazol ,100 -400mg tds
Prolactin inhibitor- Bromocriptine 2.5mg BD
Start at 100mg per day & increase (seldom used
theses days)
Antiestrogen- tamoxifen 10 – 20 mg/day
Luteinising hormone releasing hormone agonist
(LHRH)-(ovarian suppression) for refractory cases .
No role for ablative surgery.
Psychiatrist consultation +/-
Not licensed for this indication but
occasionally very helpful.
To deprive the breast epithelium of estrogenic
drive.

14.  Exclude extra mammary causes such as chest wall
pain, musculoskeletal pain,(eg-Bornholm
mayalgia),costocondritis(2nd rib/cartilage joint –
Tietze’s syndromes)
 Mondor’s disease , abdominal and pleural disease.
 Common in post menapausal women who are not on
HRT ,& the neck and shoulder are common sights of
referred pain.
 Rx may be NSAID or by injection with local
anaesthetic on a trigger spot.

16.  Duct normally contain 2 layer of epithelial cell.
when number of layers increases we call it as
ductal hyperplasia (mild if 3 or 4)
 Can be with or without atypia
 Atypical hyperplasia may be dutal or lobular

17. Immediate
risk
Subareoalar papilloma
5-10%
Distal papilloma
>10%
Papillomatosis
10%
Radial Scar
10-25%
ALH
13%
LCIS
17%
ADH
26%

19.  Common fibroadenoma
 Giant fibroadenoma
 Juvenile fibroadenoma

20.  Painless, freely mobile,
rubbery hard swelling in the
breast smooth , bosselated
surface.
 Age group -15- 25 years
 It is hyperplasia of a single
lobule. (neoplasm from
single cell)

21.  1/3rd gets smaller or disappear over two years
 Less than 5% increase in size
 No need for excision below 30 years
INDICATIONS FOR SURGERY
 a lump more than 3-4 cm size
 Above 30 years
 Suspicious cytology
 Patient desire
 Multiple fibroadenoma associated with Maffucci
syndrome, cowden syndrom, carney complex
should be excised.

22.  Image guided core biopsy
 VAB/VAM – Vacuum assisted biopsy – Vacuum assisted
mammotomy system.( 7-8 G needle)
 Local anaesthesia and small incision.
 Large core radiofrequency biopsy system( BLES –
Breast lesion excision system). – 6-8 mm skin insicion.
10 – 20 mm lesion can be removed.
 Radiological excision of fibroadenoma. Lesions up to
2.5 to 3 cm size can be removed. ( 7-8 G needle).

23.  Can do under local anaethesia
 USG guidance for 3D probe placement within
center of lesion . Once the probe is in place, the
fibroadenoma is frozen.usually two freeze/thaw
cycles are performed .cryo ablation continues until a
frozen ball encompasses all of the tumor area

24.  Fibroadenoma > 5cm in
size

25.  Most common benign tumor of breast and typically
occur in women younger than 30 yr
 Arises from the breast lobules (not from single cell)–
comprised of stromal and epithelial cells.
 Firm rubbery masses with a well circumscribed border
 Usually single tumor
 15% multiple tumor
 10% B/L tumor
 >5 cm tumor called as giant fibroadenoma
 Fibroadenoma had no risk for breast cancer

26.  Stromal element define their classification and
behaviour
 Simple fibroadenoma- stroma of low cellularity and
regular cytology
 Phyllodes – stroma with marked cellularity and
atypia. May or maynot from fibroadenoma

27.  Tubular adenoma- fibroadenoma with
fibroconnective stroma containing glandular tissue
 When entire lesion consist of gland with very little
stroma intervening this is termed as tubular
adenoma
 Lactating adenoma- same but in pregnant lady

28.  Criteria for excision-
 Size >2-3 cm
 Symptomatic tumor
 Diagnosis doubt- vascularity, irregular border , on
USG
 Increase in size documented by USG
 No need of additional surrounding breast tissue as
non infiltrative lesion
 Tripple test negative  go for cryoablation
percutaneously

29.  Observation
 Excision
 Non invasive removal / excision OR percutaneous
excision with newer devices
 Newer ablative therapies-
 Insitu Cryoablation
 Radio-frequency ablation
 Laser ablation
 Microwave ablation

30.  Factor that dictate the choice of management are
 Size (most important),should be <4cm.
 Patients preferrence
 Proximity of lesion to skin
 Shape of lesion
 Should sonographically visible

31.  The lesion must be sonographically visible
 Diagnosis of fibroadenoma must be confirmed
histologically
 Lesion should be less than 4cm in largest diameter
 Cotraindication-
 Core Bx diagnosis of suggestive of Cystosarcoma
phyllodes or other malignancy
 Poor visualisation of lesion by Ultrasound
 Core Bx diagnosis to be discordant with findings on
imaging or physical examination.

32.  It is the most frequent female breast disease
 1/3rd of women aged 30-50 yr have cysts in their breast
 Most common in 3rd decade and sharp diminishes after
menopause
 Due to non-integrated involution of stroma and epithelium ,
often multiple and bilateral and can mimic malignancy.
 Cystic disease caused by dilation of duct & acini to form cyst
,proliferation & metaplasia of ducts &acini (adenosis)
resulting in obstruction of the terminal ductal lobular unit
 Diagnosis confirm by aspiration &/or USG.
 Cyst >3mm can be visualized by USG & are potentially
palpable on breast examination.

33. SIMPLE CYST-
 Round or oval shape
 Anechoic with posterior enchancement
 Relative mobility in the surrounding tissue
 Cyst with above finding includes in BIRAD-2
 USG has 98% accuracy for diagnosis simple cyst

34. Benign breast cysts,
in cross-section,
previously filled with fluid
Ultrasound, breast cyst

35.  often with septation with in the cyst ,homogeneous low
level internal echoes & brightly echogenic foci.
 Thick walls ,thick internal septations, mixture of cystic
& solid components are at high risk of malignancy, &
should undergo biopsy
 Cysts are often asymptomatic
 Symptomatic cyst with pain ,or larger cyst USG guided
aspiration to be done
 Aspirated fluid  clear yellow, green can be
discarded. If bloody or floating debris  sent for
cytology

36.  Complex cyst with negative cytology can be
managed with 6 months follow up imaging studies
if asymptomatic.
 Cyst not completely collapsed after aspiration or
with asymmetric wall thickening should undergo an
image guided biopsy of cyst wall or local excision
for histological diagnosis to exclude
cystadenocarcinoma. (0.1%)
 Any lesion with atypical cellularity noted in the
aspirate should also excised..

37.  More than 35 yrs do mammogram prior to needle aspiration.
 Aspirate the cyst to dryness with 21 gauge needle.
 No need for fluid cytology unless blood stained.
 After aspiration examine the patient for residual mass.
 If there is a residual lump do FNAC from that.
 30 % of cysts will recur and require reaspiration.
 Review patient 3 to 6 weeks after aspiration to check for
refilling.

38.  If the cysts refil more than twice
 If the fluid is blood stained
 If there is residual lump.
 Did not disappear completely after aspiration
 Recures in 6 weeks

39.  ANDI
 Lymph cysts
 Hydatid cyst
 Galactocele
 Intracystic papilliferous ca
 Colloid degeneration of ca.
 Papillary cystadenoma
 Hematoma
 Chronic abscess.

40. Cysts of the
breast
Ductal system Neoplastic
ANID
Macro
cysts
Micro
cysts
Stroma
Duct
papilloma
Papillary
cystadenoma
Benign
Degeneration
of carcinoma
Degeneration
of sarcoma
Intracystic
carcinoma
Serous
Lymphatic
Blood
Inflammatory
TB cold abscess
Chronic abscess
Hyadatid
Galactocele
Skin cysts
Malignant
Sebaceous
Dermoid

42.  A galactocele is a milk-filled cyst that is round ,well circumscribed, &
easily movable within the breast.
 Occurs after the cessation of lactation.
 Can occur up to 6-10 months after breastfeeding has ceased
 Pathogenesis is unknown, but is thought that inspissated milk within duct
is responsible
 Solitary subareolar cyst
 Dates from lactation
 Contains milk
 Needle Aspiration produce sterile thick creamy material that may tinged
dark green or brown
 Can calcify
 Can greatly increase in size
 Treatment is needle aspiration, and surgery reserved for those cyst that
cannot be aspirated and become infected.

43.  Most nipple contain 5-9 ductal orifices
 Affect the duct in retroareolar region
 Defined as nonspecific dilatation of one or more
duct typically >2mm in diameter
 Dut ectasia may be palpable and may assoc with
nipple discharge
 Exact reason unknown- often assoc with periductal
inflammation

45. Normal Duct
Intraductal
Hyperplasia
Atypical
Ductal
Hyperplasia
Ductal
Carcinoma
In Situ
Invasive
Ductal
Carcinoma
Predict and
Prevent
Detect
and Treat

46.  Histology
 Same features as LCIS
 Not suffieciently developed
 Qualitative and quantitative
factors distinguish from
LCIS (< 50 to 75% of one
lobule)

47. Identified
 Coincidentally in biopsy for proliferative lesion causing
mass or mammographic abnormality
 On needle biopsy of calcifications of associated sclerosing
adenosis or benign calcs (rarely forms calcifications)
 It is not mammographically detectable
 Associated Risk
ALH is considered a pre-malignant lesion
It is associated with an increased risk of BILATERAL
breast cancer 4.5-5 X more than average risk

48.  Histology
Fills some but not all
criteria of DCIS
About 2 mm
Distinct cell borders,
increased nuc/cyto ratio,
nuclear enlargement,
irregular chromatin or
nucleoli
Changes associated with
proliferation.

49. Identified
 Incidentally on biopsy for benign lesion
 On stereotactic biopsy of mammographic abnormality (usually
indeterminant calcs)
Associated Risk
ADH is considered a pre-malignant lesion
It is associated with an increased risk of BILATERAL breast
cancer 4.5-5 X more than average risk
EX: Dupont and Page: 3303 patients 2.2% NP dev Ca
4.3% with PDWA and 12.9% with atypia in 17 years
American J Epidemiol 1987; 1225: 769-779

50. The percentage of women with a 10-year Gail risk > 4
developing breast cancer within 3 years:
Without atypical cells: 4%
With atypical cells: 15%
The increase in breast cancer risk from atypical cells is
independent of the Gail risk.
Fabian CJ, Kimler BF, et al. J Natl Cancer Inst. 2000;92:1217-27

52.  Acute
 Mastitis neonatorum
 Pubertal mastitis
 Traumatic mastitis
 Metastatic mastits
 Mammary duct
ectasia
 Lactational mastits
 Acute suppurative
mastitis
 Chronic
 Chronic non specific
 chronic breast abscess
 Hidradenitis
 Pilonidal Disease
 Postoperative Wound
Infections
 specific
 Tuberculosis
 Syphillis
 Actinomycosis