benign breast problems. introduction anatomy structure of the breast classification initial...

Benign Breast Problems

Introduction

Anatomy

Structure of the breast

Classification

Initial approach to breast problems

Diagnostic workup

Conclusion

References

Outline

Introduction

Breast problems are a major reason why women visit the

primary care physician

Breast diseases in women constitute a spectrum of benign and

malignant disorders

The most common breast problems for which women consult a

physician are breast pain, nipple discharge and a palpable

mass.

Benign breast lesion is a non-cancerous lesion. According to

American Cancer society , when tissue biopsy is examined

under the microscope, nine out of every 10 women will have

some type of abnormality

AAFP journal , April 15, 2000. Volume 61/ No. 8

Anatomy

The breast is a modified sweat gland with a mass of glandular, fatty

and fibrous tissues on the pectoralis muscles in the chest wall

It is attached to the chest wall by fibrous strands called coopers

ligaments

The glandular tissues of the breast consist of lobules, lobes and

ducts

Fatty and fibrous tissues surround the milk producing system

( lobules and ducts)

Anatomy

Major hormones responsible for breast development are estrogen,

progesterone and prolactin.

The blood supply is through the internal

mammary artery, axillary artery

intercostal artery

Venous drainage is through the

Internal mammary vein,

axillary vein and

intercostal veins

Anatomy

Lymphatic drainage• Majorly to the Axillary nodes• Inter mammary and the supra clavicular lymph nodes.

Three Lymph Node Levels• Level I – Lateral and inferior to Pectoralis Minor• Level II – Deep to Pectoralis Minor• Level III – Medial to Pectoralis Minor• Rotter’s – Between Pectoralis Minor & Major

Nerves• Long Thoracic Nerve:

Serratus Anterior m.

Winged Scapula• Thoracodorsal Nerve:

Latissimus Dorsi• Intercostobrachial Nerve

Structure

Classification Based On Histologic Types

Non Proliferative Lesion Simple Cyst Complex cyst

Proliferative Lesions – Without Atypia Ductal hyperplasia Fibroadenoma Intraductal papilloma Sclerosing Adenoma Radial Scars

Atypical Hyperplasia Atypical ductal hyperplasia Atypical lobular hyperplasia

Schnitt, SJ. Benign breast disease and breast cancer risk: morphology and beyond. Am J surg pathology 2003;27:836

Classification Based On Clinical Features

Mastalgia Cyclic Non Cyclic

Tumors and Masses Nodularity or glandular Cysts Galactoceles Fibroadenoma Sclerosing Adenosis Lipoma Harmatoma Diabetic Mastopathy Cystosarcoma Phylloides


Nipple discharge Galactorrhea Abnormal nipple discharge

Breast infections and Inflammation Intrinsic mastitis Postpartum engorgement Lactation mastitis Lactation breast abscess Chronic recurrent subareolar abscess Acute mastitis associated with macrocystic breasts Extrinsic infections Mondor’s Disease Hidradenitis suppurativa

Classification Based On Clinical Features (Cont’d)

J khosa, Benign breast disease including mastalgia ppt

Classification Lesions with Increased Risk of Ca

Ductal hyperplasia Sclerosing adenosis Complex fibroadenomas Atypical hyperplasia Radial scars

Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

Classification

Lesions with no Increased risk of Ca Fibrocystic disease Duct ectasia Solitary papillomas Simple fibroadenomas Mastitis or breast abscess Galactocele Fat necrosis Lipoma

Breast Pain (Mastalgia)

Most common breast symptom for which women

consult the physician

More common in premenopausal women than in

post menopausal women

Can be cyclical (physiological) or non cyclical

Micheal S Sabel. Initial approach to the woman with breast problems. http://uptodateonline.com 2008, November 6

http://uptodateonline.com/

Breast Pain (Mastalgia)

Cyclic Pain ( Physiologic) Usually Bilateral and poorly localized.

Occurs in about 60% of premenopausal women except

menopausal women on hormonal replacement therapy

Often described as heaviness , swelling or tenderness that

radiates to the arm and axilla

Associated with menstrual cycle , Most severe before

menstruation

Has variable Duration and Resolve spontaneously after menses

Attributed to fibrocystic breast changes

Etiology unknown, thought to be related to Gonadotrophic and

ovarian hormones

Mastalgia

Non-Cyclic Pain Most common in women 40 to 50 yrs of age

Often unilateral

Usually described as sharp, burning pain localized in the breast

Occasionally secondary to the presence of Fibroadenoma and

or cyst

Menstrual irregularity, emotional stress, trauma, , scars from

previous biopsies and medications have been associated


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Evaluation & Management of Breast Pain

Mastalgia should be treated when: It is severe enough to interfere with a woman’s life style It occurs more than a few days every month.

History and Physical

Diagnostic work up Mammogram


Management of Breast Pain

Treatment Goals Alleviate pain

Reduce or relieve irregularity

Rule out cancer of the breast


Diet and Lifestyle Modification Elimination of Methylxanthines, Caffeine and

Chocolates Reassurance Supportive Bra Low fat and high complex carbohydrate Vitamin E supplementation Evening Primrose oil



Pharmacological Treatment NSAIDs OCPs Danazol 100- 400mg per day 75% of women with non cyclic pain will be symptom free SE: Weight gain , menstrual irregularity , acne , hirsutism Tamoxifen 10mg Bromocriptine – prolactin antagonist Surgery has no role in management of breast pain


Evaluation & Management of Breast Pain


Breast Masses

Normal glandular tissue of the breast is nodular

This is a general pattern or consistency of the breast which include persistent lumpiness or nodularity which is generally not abnormal when it is related to the menstrual cycle.

Dominant masses are characterized by persistence throughout the menstrual cycle

Cystic Breast Mass Common cause of dominant breast mass

May occur at any age, but uncommon in post menopausal

women

Fluctuates with menstrual cycle

Well demarcated from the surrounding tissue

Characteristically firm and mobile

May be tender

Difficult to differentiate from solid mass

Breast Masses: Cysts


Fibrocystic Breast Disease Most common of all benign breast disease Most common between ages 20- 50 50% of women with Fibrocystic changes have clinical

symptoms 53% have histologic changes Believed to be associated the Imbalance of progesterone

and estrogen. May present with bilateral cyclic pain, breast swelling,

palpable mass and heaviness

Breast Masses: Cysts

Fibrocystic Breast Disease

Physical Examination Tenderness Increased engorgement and more dense breast Increased lumpiness / glandular Occasional spontaneous nipple discharge

Micheal Sabel .Overview of benign breast disease. Uptodate 2008, November 14

Breast Cysts: Diagnostics

Mammogram Cystic outline No calcification No increased density

Ultra Sonogram Cyst

Fine Needle Aspiration

Outpatient procedure Non bloody fluid Cyst disappears If bloody fluid, surgical

biopsy of cyst is required Reexamination 4-6 weeks

after aspiration

Management of Breast Cysts


Breast Masses

Breast Mass: Fibroadenomas

Simple: Second most common benign breast lesion Benign solid tumors containing glandular as well as fibrous tissue . Usually

present as well defined, mobile mass

Commonly found in women between the ages of 15 and 35 years

Cause is unknown, thought to be due to hormonal influence

May increase in size during pregnancy or with estrogen therapy

Giant: Fibroadenomas over 10cm in size Excision is recommended

Juvenile Variant of fibroadenomas

Found in young women between the ages of 10 -18.

Vary in size from 5 - 20cm in diameter. Usually painless, solitary, unilateral

masses

Excision is recommended

Breast Mass: Fibroadenomas (Cont’d)

Complex Complex fibroadenomas contain other proliferative changes

such as sclerosing adenosis, duct epithelial Hyperplasia,

epithelial calcification.

Associated with slightly increased risk of cancer

Dupont, WD page, DL, parl, FF, et al. Long term risk cancer in women with fIbroadenoma. NEJM 1994;331:10Carty, NJ, Carter, c, Rubin, C et al management of fibroadenoma of the breast. Annals of royal college of surgeon England 1995:77:127Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

Phylloides Tumors: Rapidly growing One in four malignant One in Ten Metastasize Create bulky tumors that distort the breast May ulcerate through the skin due to pressure necrosis Treatment consists of wide excision unless metastasis has occurred

Fat Necrosis: Rare Secondary to trauma- often not remembered Tender, ill defined mass Occasionally skin retraction Treat with excisional biopsy

Breast Mass

Breast Mass Galactocele

Milk filled cyst from over distension of a lactiferous duct.

Presents as a firm non tender mass in the breast,

Commonly in upper quadrants beyond areola.

Diagnostic aspiration is often curative.

Duct ectasia:

Generally found in older women.

Dilatation of the subareolar ducts can occur.

A palpable retroareolar mass, nipple discharge,

or retraction can be present.

Tx involves excision of area

Breast Mass

Gynecomastia: Benign growth of the glandular tissue of the male breast. Due to an imbalance in the estrogen to androgen activity. May be unilateral or bilateral Common in infancy, adolescence and adult life Pseudogynecomastia may be seen obese individuals Causes include; drugs, chronic dxs, metabolic, pubertal, Hormonal, tumors, idiopathic, hypogonadism.

Braunstein, GD. Gynecomastia. NEJM 1993;328:490

Nipple Discharge

Majority of causes are benign Most common cause is lactational Overstimulation also common Prolactin secreting tumors Hypothyroidism Drugs Intraductal and other carcinomas Unilateral, spontaneous, bloody discharge is

suspicious

Nipple Discharge

Intraductal Papilloma Benign growth within ductal system Presents as bloody nipple discharge Excision is the only way to differentiate from

carcinoma

Galactorrhea Bilateral milky discharge Obtain prolactin level, TSH level

Nipple Discharge

Good history

Prolactin & TSH levels

Mammogram

Decrease stimulation

Breast Inflammation & Infections

Mastitis Most common in lactating female Dry, cracked fissured areola/nipple complex provides portal

for infection Usually caused by Staph/Strep organisms Rule out malignancy Treat with heat, continued breast feeding, Antibiotics for 10-14 days to cover staph and strept infections


Abscess May present with breast swelling, tenderness and fever On PE, breast is tender , warm and fluctuant, may also have

purulent discharge Treated by surgical drainage


Mondor’s Disease Phlebitis of the thoracoepigastric and lateral thoracic vein Palpable, visible, skin retraction over tender extending to

chest wall Spontaneous or related to trauma Ultrasound may be helpful in confirming this diagnosis. Treatment self-limited, can use NSAIDs Mammogram if over 35yo to r/o malignancy


Chronic Subareolar Abscess Occurs at base of lactiferous duct, and squamous

metaplasia of duct may occur. Sinus tract to areola develops Treatment requires complete excision of sinus tract Recurrence is common

Mastitis Neonatorum Occurs within few weeks of birth Response to mothers hormone exposure

(prolactin, estrogen)

Resolves spontaneously Occasionally becomes infected

About 1-5 % of the population have

accessory nipples, and less

commonly accessory breast

Usually develop along the milk line

Most common site for accessory

nipple is below the breast

Most common site for accessory

breast is in the axilla

Rarely require treatment except for

cosmetic reasons

Subject to the same diseases as the

normal breast.

J Micheal Dixon .ABC of breast diseases. 3 rd edition BMJ 2005

Gershon Efron. Benign breast disease ppt , google health search

Congenital Breast Disease

Approach to Breast Problems

History Age Family history (Cancer) Onset Duration Discharge Frequency Lump , Nodules Trauma Menstruation (menarche, menopause, contraceptives) Pain

Inspection Symmetry Skin / Nipple Change Bulges / Retractions

Palpation Breast

Axilla

Supraclavicular

Approach to Breast Problems

Breast Examination The breast examination starts with inspection of both breast

Sitting up with arms in relaxed position,

Both arms raised over the head

Hands on the hips

Complete regional lymph node examination while patient is in the sitting

position.

Bimanual may be done while patient is still in the sitting position, useful in

patient with large pendulous breast

Complete with the patient in a supine position, with the arms raised above

the head, breast exam can be accomplished with either concentric circles,

radial approach, or vertical strip approach

Areas examined should extend from the clavicle superiorly to the rib cage

inferiorly and from the sternum medially to the mid axillary line laterally


Breast Examination

Diagnostic Work Up

Ultrasound

Mammography

FNA vs. Core Biopsy

Incisional biopsy

Excisional biopsy

Cyst aspiration

MRI

Ultrasonography: First diagnostic test of choice to differentiate a

cystic mass from a solid mass

Mammogram: Not routinely done in women younger than 35yo,

however not inappropriate in a suspicious mass in younger women

Digital mammography is superior to conventional

A normal mammogram at any age does not eliminate the

need for further evaluation of a suspicious mass.

MRI: Not indicated for the work up of undiagnosed mass. Reserved

for diagnostic dilemmas and should be used with discretion due to

false positive results

FNA: Useful for cystic lesions. If lesion is completely drained and

fluid not bloody or cloudy, no further evaluation needed

Diagnostic Work Up


Diagnostic Work Up

Core Needle Biopsy: This provides a best diagnostic

information for solid palpable mass which can be visualized on

the USS or mammogram

Excisional Biopsy: Useful in cases where core needle biopsy

is non diagnostic, non concordant with imaging results or yield

any high risk changes

Incisional Biopsy: useful when core needle biopsy is not

helpful in confirming diagnosis


BI-RADS Classification

BI-RADS Classification – features

0 - Need additional imaging

1 - Negative – routine in 1 yr

2 - Benign finding – routine in 1 yr

3 - Probably benign, 6mo follow-up

4 - Suspicious abnormality, biopsy recommended

5 - Highly suggestive of malignancy; appropriate action

should be taken

Conclusion

Benign breast problems account for the majority of

breast problems seen in women

Breast complaints need careful assessment with

thorough history and physical as well as diagnostic

work up if indicated

Women with breast problems can present with a

mass, pain, nipple discharge or skin changes. They

can also be asymptomatic

It is important to rule out breast cancer


References

1. AAFP journal , April 15, 2000. Volume 61/ No. 82 Schnitt, SJ. Benign breast disease and breast cancer risk:

morphology and beyond. Am J surg pathology 2003;27:836

3.J khosa, Benign breast disease including mastalgia ppt4. Dupont, WD page, DL, parl, FF, et al. Long term risk cancer in

women with fIbroadenoma. NEJM 1994;331:105. Carty, NJ, Carter, c, Rubin, C et al management of fibroadenoma

of the breast. Annals of royal college of surgeon England 1995:77:127

6. Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

7. J Micheal Dixon .ABC of breast diseases. 3 rd edition BMJ 20058.Gershon Efron. Benign breast disease ppt , google health search9. Micheal S Sabel. Initial approach to the woman with breast

problems. http://uptodateonline.com 2008, November 610. Braunstein, GD. Gynecomastia. NEJM 1993;328:490

benign breast problems. introduction anatomy structure of the breast classification initial...

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