Benign Disease of the Breast

1. Benign Disease of the Breast • Dr. Bader Ashkanani • Dr. Ibtisam Al-Bader

2. Objectives • Anatomy of the female breast • Development and Physiology of the female breast • Diagnostic approach • Common Benign disease of the breast

3. Anatomy • Modified sweat glands • Lie in superficial fascia of ant. chest wall • Ant. To pectorals major with retromammary in between • Clinically devided into 4 quadrants • Nipple-areola complex • Axillary tail = Tail of Hence

4. Anatomy

5. Anatomy • Composed of 2 types of tissue: • - glandular : lobules ( produces milk) & ducts (carry milk to nipple) • - stromal: connective tissue supports the breast ( ligaments of Cooper)

6. Blood supply • Perforating branches: • - internal thoracic artery • - intercostal arteries • - lateral thoracic artery • - thoracoacromial artery • Veins correspond to art.

7. Lymph Nodes • Clinical: medial, lateral, anterior, posterior, apical • Anatomical: lateral, anterior (pectoral), posterior (subscapular), central, subclavicular, interpectoral (Rotter's) • Relation to pectoralis minor Msl. • - Level I : below and lateral • - Level II : deep to Msl. • - Level III : above and medial

8. Applied Anatomy • Long thoracic nerve: • - supply serratus ant. • - injury -> winged scapula • Thoracodorsal nerve: • - post. cord of brachial pl. • - supply latissmus dorsi • - injury -> medial rotation, adduction and extension of shoulder joint • Medial and lat. Pectoral nerves • - supply pact. major • - injury --> adduction and flexion of shoulder

9. Objectives • Anatomy of the female breast • Development and Physiology of the female breast • Diagnostic approach • Common Benign disease of the breast

10. Fetal and Neonatal • Linear thickening of ectoderm at 6th week known as the milk ridge • Ridge extends from axilla to inguinal region • Disappear giving rise to breast parenchyma • Localized depression in the line --> nipple • Areola recognized at 5 months

11. Fetal and Neonatal • Witch's milk: • Milk expressed from the breasts of both sexes in majority of newborns due to abrupt withdrawal of maternal hormones • May also be associated wit breast hypertrophy ( physiological gynecomastia )

12. Childhood • Minimal branching of the ducts • No alveolar formation • End of it --> Puberty

13. Puberty • GnRH --> FSH & LH --> estrogen & progesterone • Estrogen: ductal growth and branching • Progesterone : development of lobular units • Increase in periductal connective tissue

14. Menstrual Cycle

15. Pregnancy • Intense stimulation of breast • Hormonal drive : sex steroids, HCG, HPL, prolactin and growth hormone • Two major phases: developmental & differentiation

16. Phase I - Developmantal • Increase in numbers of alveoli • Marked ductal elongation • Engorged, heavy breasts • Darkening of nipple and areola

17. Phase II - Differentiation • Under progesterone influence • Differentiation of lobules into secretory units • Massive increase in blood supply • Breast size and weight increase

18. Menopause • Cessation of ovarian function • Age of 50's • Reduction in numbers of ducts and lobules • Breast tissue replaced by fat deposition

19. Objectives • Anatomy of the female breast • Development and Physiology of the female breast • Diagnostic approach • Common Benign disease of the breast

20. Diagnostic approach • History & Physical Examination • Biopsy • Imaging

21. History • History of the mass • Constitutional symptoms if Ca suspected • Age at menarche/menopause • Pregnancies & lactation • HCT & OCP • Oopherectomy • Past & family history

22. Physical Examination • Upright sitting • Inspection • Palpation • Lymph nodes

23. Imaging • Detect small, non palpable breast abnormality • Evaluate clinical findings & guide diagnostic procedures • Mammogram - MRI - Ultra sound (U/S)

24. Mammogram • Best for screening • Best in women above 35 yrs • Standard vs. Digital mammo. • BI-RADS scoring

25. Breast Imaging Reporting and Data System (BI-RADS) • - CATEGORY DEFINITION: • 0 Incomplete assessment—need additional imaging evaluation or prior mammograms for comparison • 1 Negative—nothing to comment on; usually recommend annual screening • 2 Benign finding—usually recommend annual screening • 3 Probably benign finding (<2% malignant)—initial short-interval follow-up suggested • 4 Suspicious abnormality (2%-95% malignant)—biopsy should be considered • 5 Highly suggestive of malignancy (>95% malignant)—appropriate action should be taken • 6 Known biopsy—proven malignancy

26. MRI • Evaluate primary tumor + extension • For young women • Pre-op for breast conservation • Not useful in screening • Sensitive for invasive Ca, not DCIS

27. Ultrasound • Cystic vs solid • Tense breast • Operator dependent • False positives ( Berg WA, 2008 ) • Not effective in screening

28. Biopsies • Fine Needle Aspiration Biopsy ( FNA ) • Core Needle Biopsy

29. FNA • 22 gauge needle, syringe, 95% alcohol prep./ Normosol • Differ. cystic/solid, but used in new masses • Diagnostic ( cytology ) & therapeutic ( aspiration ) • May require further core biopsy according to FNA result

30. Core Needle Biopsy • Done under U/S, mammo., MRI guidance • Patient in prone position • Multiple samples through small incision usin 11 gauge needle with vacuum assistance • Clip is placed to localize the lesion • Provide grading and receptor status

31. The diagnosis of breast lesions using a minimally invasive procedure, such as core needle biopsy, is the preferred approach. The use of excisional breast biopsy as a diagnostic procedure increases costs and results in delays to definitive surgery for patients with cancer. • Nelson H, Tyne K, Naik A, et al: Screening for breast cancer: Systematic evidence review update for the U.S. Preventive Services Task Force. Ann Intern Med  2009

32. Non-palpable abnormalities • Detected by mammography • Further investigation according to BI-RADS • Image guided core biopsy in 75 - 80 % of cases • Wire-Localized surgical excision

33. Wire-Localized excision • Diagnosis not yet obtained / ADH --> DCIS • Wire through introduced needl • Under mammography guidance • Nearby lesion

34. Objectives • Anatomy of the female breast • Development and Physiology of the female breast • Diagnostic approach • Common Benign disease of the breast

35. Fibroadenoma • Commonest tumor < 30 yrs • Firm, mobile, smooth / lobulated, may increase in size • Related to high estrogen level • Benign Tumor, rarely neoplastic • Simple vs complex

36. Fibroadenoma • Dx : • - Ultrasound • - FNAC --> stromal & epithelial elements • Tx : • - Reassurance • - Surgical excision • - Cryoabillation

37. Papillomas • Solitary intraductal papilloma • Often close to areola, but can occur peripherally • < 1 cm, can increase up to 4 cm • Causes bloody nipple discharge • No high risk of Ca • Tx : surgical excision

38. Breast cysts • Very common ( age 30 - 40 ) • Smooth, firm, mobile, +\- tenderness, anywhere in breast • Rarely malignant - disappear at menopause • Associated with OCP

39. Radial scars • Complex sclerosing lesions • Contain microcysts, epithelial hyperplasia, adenosis and central sclerosis • Architectural distortion on mammogram • Associated with increased risk of Ca • Tx is surgical excision to r/o Ca

40. Sclerosing adenosis • Proliferation of stromal tissue • Microcalcification on mammogram • Component of fibrocystic disease • No malignant potential

41. Phyllodes Tumor • Large, fast growing masses • < 1% of breast neoplasia • Arise from periductal stroma • Can be benign, borderline, malignant • Occur in adult women (40-50) • Composed of both epithelial & stromal element

42. Phyllodes Tumor • Tx: surgical excision + safety margin • Chemotherapy , radiotherapy , hormonal therapy doesn't work much • Regular imaging and f/u necessary

43. Breast infections and abscess • Lactational infections • Chronic subareolar infections ( duct ectasia )

44. Lactational infections • Fever, leukocytosis, erythema, tenderness • Most common --> Staph. Aureus • Mastitis --> Tx: antibiotics + frequent emptying of the breast • Abscess --> Tx: surgical drainage + antibiotics

45. Chronic subareolar infections • Non lactating --> subareolar ducts infected • Periductal mastitis / Duct ectasia • Mixed: aerobic + anaerobic skin flora • Associated with smoking and diabetes

46. Chronic subareolar infections • Series of infections • - Inflammatory changes and scarring • - Retraction / inversion of nipple • - Chronic fistulas from subareolar ducts to periareolar skin • - Subareolar masses ( on palpation & mammo. )

47. Chronic subareolar infections • Tx: • - Early --> antibiotic + warm soaks • - Abscess --> drainage + antibiotics • - Recurrent --> excision of entire subareolar duct complex after infection resolves + I.V. Antibiotic • - Rarely, excision of nipple and areola

48. Gynecomastia • Hypertrophy of breast • Most common benign disease of male breast • Increase in both stromal and ductal elements • Unilateral / Bilateral • Physiological vs. Pathological

49. Gynecomastia • Pathological • - Drugs: digoxin , diuretics , marijuana , heroin , TCA , anabolic steroids • - Disease: liver disease , bronchioectasis , T.B. , COPD, testicular tumors • Tissue biopsy to exclude malignancy • Tx: surgical excision

50. Galactocele • Milk-filled cyst • Occur after cessation of breast feeding • Center of breast or below nipple • Pathogenesis unknown • Aspiration --> thick creamy fluid • Surgery in infected / difficult to aspirate cysts