Benign Breast Diseases 2013

Benign Breast Complaints

Osama Hussein, MD, PhD Associate Professor Surgical Oncology

23 Dec., 2013

OBJECTIVES

To appreciate the epidemiological disease pattern of benign vs. Malignant breast conditions

To be able to diagnose and provide management for frankly benign conditions

To be able to pick up and refer suspicious lesions for proper specialized health carte

Breast Complaint

Breast is a unique body site

Differential diagnosis of breast complaint can be depicted as:

cancer or not cancer !

General practitioner should be familiar with these Benign conditions

Fibrocystic diseases Periductal mastitis / Duct ectasia Lactational mastitis / Breast abscess Fibroadenoma / Phylloids tumor Radial scar / Sclerosing adenosis Fat necrosis Breast cysts Papilloma Galactorrhea Granulomatous conditions (TB, Diabetic, others)

Diagnosis of Breast Complaints

Age

Course, duration of illness

Physical examination

Radiology

Biopsy

AGE IN YEARS

RA

TE O

F B

REA

ST C

AN

CER

AGE DISTRIBUTION OF BREAST CANCER

Arbitrary graph

AGE

Before puberty: almost no risk

Below 35 years: low risk of cancer

Premenopausal: high risk, high morbidity

Postmenopausal: higher risk, lower morbidity

COURSE / DURATION

Since when: Days vs. Weeks vs. Years

Complaint passed one period or not yet

Fluctuating course

PHYSICAL EXAMINATION

Cystic vs. Solid

Skin manifestations = advanced cancer

Cancer hard or firm, benign soft or rubbery but

EXCEPTIONS EXIST !!

Benign lesions that might mimic cancer

Radial scar

Traumatic fat necrosis

Diabetic fibrous mastopathy

Granulomatous mastitis

Malignant lesions that might mimic benign

Lobular carcinoma in situ

Medullary carcinoma

Tubular carcinoma

Phylloid tumor

Breast Complaint

Lump (mass)

Pain (Mastalgia)

Nipple discharge

Workup of breast mass

35 years or younger:

According to clinical suspicion; may include assurance, ultrasonography, FNAC &/or excision

Over 35 years old:

Triple assessment with clinical mammographic and microscopic examination is required

Mastalgia

Cyclic Mastalgia

Non-cyclic Mastalgia

Cyclic Mastalgia

At first visit, ask the patient to document the symptoms in a calendar to verify the cyclic pattern

Cyclic Mastalgia

Related to menstrual cycle (isolated or a part of PMTS)

Young age

Worse at luteal phase, better with onset of menses

Diffuse, bilateral, heaviness or soreness

Non cyclic Mastalgia

Middle age

Localised

Sharp, burning

Underlying cause

Cyclic Mastalgia

Reassurance

Breast support

Primrose oil

Tamoxifen

Danazol

Morrow M. Am Fam Physician. 2000 Apr 15;61(8):2371-8, 2385.

Nipple Discharge

I. Galactorrhia (milk, systemic disease)

II. True nipple discharge (watery, coloured, serous or bloody, local cause):

a. Physiological

b. Pathological

Physiological Discharge

No palpable masses

Multiductal

Upon squeezing

Serous, white, yellow or green

Pathological Discharge

May be associated with a mass

May be uniductal

May be spontaneous

May be WATERY or bloody

Diagnostic Workup of Nipple Discharge

If a mass, deal with the mass

If older than 35 years, obtain mammography

If unilateral or bloody, refer to surgical consultation

Cytology is often not helpful

Fibrocyctic Changes (FCC)

Hormone dependent changes (i.e. Do not diagnose FCC in menopausal women !)

Variable combination of adenosis, hyperplasia, fibrosis, sclerosing adenosis, cyst formation and atypia

Presents with mastalgia, masses, discharge or a combination of these symptoms

Sclerosing adenosis.

Guray M , Sahin A A The Oncologist 2006;11:435-449

2006 by AlphaMed Press

Ductal epithelial hyperplasias.



Radial scar.



Fibrocyctic Changes (FCC)

Risk of malignancy is related to the degree of hyperplasia

Adenosis, cysts, fibrosis etc are not risky

Florid (marked) hyperplasia is associated with moderate risk

Hyperplasia with atypia is associated with high risk

Atypical Hyperplasia

Adenosis and florid epithelial hyperplasia associated with cellular atypical changes i.e. monotonous cells with increased N/C ratio

Carcinoma in Situ

Extensive form of atypical hyperplasia i.e. The same morphology at wider extent

NORMAL

DUCT PAPILLOMA

PERIDUCTAL MASTITIS

DUCT ECTASIA

COMMON PATHOLOGY OF THE BREAST MAJOR DUCTS

Osama Hussein

PERIDUCTAL MASTITIS / DUCT ECTASIA

Chronic inflammation of the major terminal ducts of the breast (retroareolar) with or without dilation (ectasia).

Younger age (mastitis), middle age (ectasia)

Often due to mixed aerobic and anaerobic microorganisms

Presents with multicoloured discharge, recurrent inflammation or abscesses

PAPILLOMA

Affects the major terminal ducts leading to obstruction and dilation which may be palpable.

Leads to unilateral, unifocal bloody nipple discharge

TRAUMATIC FAT NECROSIS

An area of dense fibrosis that presents as a localised, firm to hard, irregular swelling

Differentiation from cancer is by biopsy

History of trauma is not helpful in diagnosis

Common after autologous breast reconstruction

BREAST ABSCESS

Non-lactational abscess is usually due to periductal mastitis / duct ectasia

Lactational abscess is more common and is usually due to colonisation of babys mouth with staphylococcus aureus.

Treatment is early drainage and parentral antibiotics

BREAST ABSCESS

BEWARE OF INFLAMMATORY BREAST CARCINOMA AS A DIFFERENTIAL DIAGNOSIS

OF BREAST INFLAMMATION !

Breast Cyst

Fluid filled structure

Arise from terminal duct structure, tend to be peripheral

Aspirate, cytological examination of clear fluid is not indicated

Bloody aspirate or solid component may be associated with cancer

K/Na > 1.5 might be associated with risk of cancer

Management of Breast Cysts

Aspiration

Surgical biopsy if:

o Bloody aspirate

o Residual solid area after aspiration

o Recollection twice or more

RESOURCES www.pubmed.gov

1: Vaidyanathan L, Barnard K, Elnicki DM. Benign breast disease: when to treat, when to reassure, when to refer. Cleve Clin J Med. 2002 May;69(5):425-32.

PMID: 12022387

2: Guray M, Sahin AA. Benign breast diseases: classification, diagnosis, and management. Oncologist. 2006 May;11(5):435-49.

PMID: 16720843

3: Morrow M. The evaluation of common breast problems. Am Fam Physician. 2000 Apr 15;61(8):2371-8, 2385. Review.

PMID: 10794579

Questions

Tel. : +2 (010) 9981 5110

[email protected]

[email protected]

Thanks

Benign Breast Diseases 2013

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