BENIGN BREAST

DISEASESDr. Muhammad Zoha Farooq

Agenda

• Fibroadenoma and related tumors

• Nipple discharge

• Breast Abscess

FibroAdenoma

Fibroadenoma

• Most common benign tumor of breast

• Part of Aberration of Normal Development and involution

(ANDI)

• WHO Definition- Discrete benign tumor showing evidence

of connective tissue and epithelial proliferation.

• Histological Variants- Hyper cellularity or Atypia

• Stromal element is the key to classification

• Stroma with low cellularity and low cytology

• Clinical Variants- Large size or Rapid Growth

Types of Fibroadenoma

• Fibroadenoma Simplex

• Giant Fibroadenoma

• Microfibroadenoma

• Myoxid Fibroadenoma

• Juvenile Fibroadenoma

Fibroadenoma Simplex

• Young women

• Rubbery firm, smooth, very mobile mass

• Mostly a clinical diagnosis

• Early years after Menarche 16-25 years

• Overall incidence is highest in 30s and 40s

• Lobular in origin / Mostly remain static

• 1-3cm in size increase over 1-5 years

• Most common in left breast and upper outer quadrants.

Giant Fibroadenoma

• 30 % of all Fibroadenoma

• Greater than 6 cm

• Differential diagnosis with Phyllodes Tumor

• Confirmed via histology

• 4% are reported in pregnancy and lactating adenomas.

• Potential of LCIS- Benign

• Steroid receptors for Estrogen and Progesterone.

• Women on HRT has increased incidence.

• Combined pill has a protective role- Progesterone

element

• BCL-2 Gene. Delay apoptosis

Histology

• Macroscopic- sharply demarcated ,rounded, white

glistening surface.

• Microscopic- Pale stroma, duct like structures lined by

regular epithelium

1. Pericanalicular – Abundant epithelila structures

2. Intra Canalicular- Epithelilal clefts surround islands of

stroma

• Fibroadenomatoid Hyperplasia- Microfibroadenomas

• Apocrine and Squamous Metaplasia- Related to future

cancer risk.

Pericanalicular/Intracnalicular

Rare Fibroadenomas

• Myoxid Fibroadenoma

Carney Syndrome ( Myxomas of skin and heart)

• Juvenile Fibroadenoma

Floridly glandular and more cellular stroma.

Clinical Features

• Common Features

Different in young girls, middle aged and post

menopausal

Smooth ,round and mobile- Breast Mouse

Exception- Behind the nipple, mobility decreased by

surrounding ducts

Older Woman- Involutional fibrotic changes, present as

dominant mass.

Older Women- Diagnoses on Biopsy

Clinical Features

• Less Common Presentation

Small Superficial Nodules 3-4 mm-young women

As Discrete masses in later years of reproductive life

Pregnancy-Increase in size

Investigations

• Triple assesment

• Mammography

Age above 35

Typical solitary lesion,

Stippled calcification

( Popcorn Appearance)

Investigations

• Sonography

Younger Women below 35

Typical round/oval sharp contour.

Doesn’t distinguish btw cancer and fibroadenoma

Color Doppler differentiate from cancer.

Investigations

• Cytology

FNAC shows,

abundance of epithelia

cells and stroma.

Replaced by core

needle Biopsy as a

standrd investigation.

Managment

• Overall Conservative.

• Reassurance

• Once tissue diagnosis has been obtained patient can be observed

• Offer exicision• if >3cm / rapid increase

• Symptomatic

• Patients choice, patients satisfaction.

• Surgical- If within 3cm of nipple, periareolar incision.

• Alternative- Laser Ablation, Cryosurgery

• Hormonal- Tamoxifen. Not favored due to unwanted side effects.

Cancer and Fibroadenoma

• Three Clinical Aspects

1. Association of cancer with fibroadenoma

2. Incidence of Breast Ca in patients with fibroadenoma

3. Progression of fibroadenoma to Phyllodes tumor

Cancer In Fibroadenoma

• 95% LCIS

• 5% DCIS

• LCIS is usually within the fibroadenoma

• In DCIS either there is direct infiltration from adjacent

cancer or tumor growing along the duct in the epithelial

clefts.

• In case LCIS is diagnosed post excision, further exicision

is required.

• In any case ignore fibroadenoma and treat according to

cancer policy.

Fibroadenoma and Subsequent Cancer

risk• Population at Risk.

• Family Hx of malignancy

• Genetic Changes

• COX expression

• NM23-H1 messenger RNA

• P53

• BCL-2 gene

Phyllodes Tumor and Phyllodes Sarcoma

• Phyllodes Tumor Benign vs Giant Breast Tumors

• Phyllodes Sarcoma –Malignant

• Histology- Both epithelial and fibrous elements, stroma

shows hyerpcellularity,hperchromatisim,irregularity and

mitosis.

Treatment

• Under age of 20 – Mass Exicision

• Peri and Post Menopausal

• Clear margin of 1 cm necessary

.

NIPPLE DISCHARGE

Nipple Discharge

• Spontaneous eflux of fluid from the nipple apart from

physiological function of perpureum and lactation.

• Losses significance if occurs in presence of a lump.

• Incidence vary

• Important- if age above 50, bloodstained in young women

and persistent single duct discharge.

Types of Nipple Discharge

• Four groups

1. Physiological Galactorrhea

2. Secondary Galactorrhea

3. Coloured Opalescent or Grumous

4. Serosangious and Watery

Diagnosis of Nipple Discharge

Type of discharge Main Cause Less Common cause

Bloody Hyperplastic lesions Duct Ectasia

Watery Hyperplastic lesions Duct Ectasia

Coloured Opalescent Duct Ectasia Cyst

Milk Physiological Galactorrhea/ Endocrine

origin

Hyperplastic lesions include hyperplasia, papilloma, carcinoma in

situ and IDC.

Physiological Galactorrhea

• Milk secretion unrelated to breast feeding

• Causes

A. Mechanical stimulation

B. Extremes of reproductive life ( puberty/ menopause)

C. Postlactational

D. Stress

• Treatment-Reassurance and explanation that its self

limiting.

Secondary Milk Discharge

• Drugs

A. Dopamine receptor Blocking: Chlorpromazine,

Haloperidol, Metoclopramide,Domperidone

B. Dopamine Depleting Agents: Reserpine, Methyldopa

C. Estrogen ( OCP)

D. Opiates

• Pathological

A. Hypothalamic / Pituitary stalk lesions

B. Pituitary Adenoma/ Microadenoma

C. Ectopic Prolactin ( Bronchogenic Carcinoma)

Coloured Opalescent Discharge

• Apart from serosangious and milk discharge

• Wide range of color and consistency

• Creamy, purulent, yellow, brown, green and black.

• No increased cancer risk

• Common in late reproductive life

• Most common pathology Duct Ectasia

• Sometimes due to underling cyst

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% btw40-60 and

32% over 60yrs

• Blood discharge in pregnancy- Bilateral, 2nd to 3rd

trimester.

• 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.

Investigations

• Mammography

• Glactography

• Ultrasound

• Ductal Lavage

• Fiberoptic ductography

• Exfoliative cytology

Managment

• In case of lump- treat according to lump, disregard

discharge

• No lump present- treat the underlying cause.

Benign Duct Papilloma

1. Discrete Duct papilloma- common

2. Multiple duct papillomas-rare

3. Juvenile papilloma-very rare

Discrete Papilloma 2-3mm diameter, grows along the length of duct, no pre malignant potential. Either observe or excise.

Multiple Papilloma Involve peripheral ductules, premalignant potential, complete excision with healthy margins.

Juvenile Papilloma histological diagnosis. Excision with clear margins

Duct Ectasia

• Dilatation of the ducts

• Leads to stagnation and accumulation of discharge

• May cause ulceration

• If Blood discharge- Duct exicision

Duct Exicision

BREAST ABSCESS

Breast Abscess

• This condition is usually found during lactation . as role the infecting organism is :

• staphylococcus aureus, and less commonly streptococcus pyogenes .

• the usual mode of infection is via the nipple, the infection being carried from the nasopharynx of the suckling infant

• The infection is at first limited to the segment drained by the lactiferous duct but it may subsequently spread to involve other areas of the breast.

Clinical Presentation

• Localized breast area edematous, erythematous, warm, and painful

• History of previous breast abscess

• Associated symptoms of fever, vomiting, and spontaneous

drainage from the mass or nipple

• May be lactating

Investigations

• Ultrasound- to localize abscess

• Needle aspiration- confirm presence of pus

• Mammogram- to exclude Ca

Lactational breast abscess

• Usually due to Staph. aureus• Usually peripherally situated • Attempt aspiration • If no pus - antibiotics • If pus present consider

repeated aspiration or incision and drainage

• Consider biopsy of cavity wall • Continue breast feeding from

opposite breast / evacuation of ipsilateral side

• No need to suppress lactation

Non-lactational breast abscess

• Occur in periareolar tissue • Culture yield - Bacteroides,

anaerobic strep, enterococci • Usually manifestation of duct

ectasia / periductal mastitis • Occur 30- 60 years , More

common in smokers • Often give history of recurrent

breast sepsis • Repeated aspiration is the

treatment of choice • Metronidazole and flucloxacillin• Drain through small incision if non-

resolving

Managment

Complication Of I AND D

• Mammary Duct Fistula

After incision and Drainage of lactational breast abscess

Typical hx and appearance

Surgical scar with inverted nipple

Milk / Pus discharge

Two groups-superficial and deep

Superficial Involves areolar glands, conservative

management

Deep Involves duct, will need excision of involved duct

and fistula.

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