benign breast disease

MS Org Chart:

BENIGN BREAST DISEASES

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EMBROYOLOGY ANATOMY CLINICAL EXAMINATION INVESTIGATIONS BENIGN BREAST DISEASES FIBROCYSTIC DIDEASE FIBROADENOMA PHYLLODES BREAST CYST MASTALGIA NIPPLE DISCHARGE MASTITIS DUCT ECTASIA DUCT PAPILLOMA GALACTOCELE GYNAECOMASTIA APPROACH

APPROACH:

EMBROYOLOGY Skin appendages arising from mammary ridge (Milk line) .. Ectoderm Humans develop milk lines as early as week six of fetal life By week nine of fetal life, most milk lines fade away, except for those in the chest area EMBROYOLOGY

PowerPoint Presentation:

WITCHES MILK SYMMASTIA POLAND $ FLEISCHER’S $ EMBROYOLOGY EMBROYOLOGY

EMBROYOLOGY:

EMBROYOLOGY EMBROYOLOGY

EMBROYOLOGY:

EMBROYOLOGY Congenital nipple inversion failure of nipple to evert during development. May be unilateral. Spontaneously corrected during growth of pregnancy or by simple traction. EMBROYOLOGY

EMBROYOLOGY:

DOGS & CATS : 4 pairs PRIMATES: 2 pairs ELEPHANTS: 2 pairs RATS : 9 pairs GOATS : 2 pairs (inguinal) CATTLE :4 pairs(inguinal) INTERESTING FACTS EMBROYOLOGY

INTERESTING FACTS:

ANATOMY

ANATOMY:

ANATOMY Modified sweat gland between the superficial and deep layers of the chest wall ANATOMY

ANATOMY:

15-20 LOBES EACH LOBE : LACTIFEROUS DUCT EACH LACTIFEROUS DUCT : ends in an AMPULLA ACINI + EFFERNT DUCTULES : LOBULAR UNITS/ LOBULES MICROSCOPIC ANATOMY

MICROSCOPIC :

BLOOD SUPPLY ANATOMY

BLOOD SUPPLY:

CIRCULUS VENOSUS: subscribing the nipple BATSONS PLEXUS : vertebral plexus of veins Post intercostal veins drain to batsons plexus VENOUS DRAINAGE ANATOMY

VENOUS DRAINAGE:

LYMPHATICS ANATOMY

LYMPHATICS:

AXILLARY VEIN GROUP /LATERAL ( 4-6) EXT MAMMARY /ANT / PECTORAL (4-5) SCAPULAR / POSTERIOR/ SUBSCAPULAR ( 6-7) CENTRAL (3-4) SUBCLAVICULAR/ APICAL (6-12 ) INTERPECTORAL / ROTTERS (1-4) Described by Grossman & Rotters LYMPHATIC DRAINAGE ANATOMY

LYMPHATIC DRAINAGE:

W. SAMPSON HANDLEY : recognised spread to internal mammary LN DONALD MORTON: Sentinel LN biopsy HALSTEADS RADICAL MASTECTOMY : ~50 LN SAPPEYS PLEXUS : specialised lymphatic channel under nipple and areola 75 % drainage : Axillary LN INTERESTING FACTS ANATOMY

INTERESTING FACTS:

2-6 LAT AND ANT CUTANEOUS BRANCHES ANT OR MEDIAL BRANCH OF SUPRACLAVICULAR INTERCOSTAL BRACHIAL NERVE ( sensory branch from Lat branch of 2 nd intercostal joins medial cutaneous Nerve of arm ) NERVE SUPPLY ANATOMY

NERVE SUPPLY :

Triple assessment

Triple assessment:

CLINICAL EXAMINATION CLINICAL EXAMINATION

CLINICAL EXAMINATION:

Inspection CLINICAL EXAMINATION

Inspection:

Palpation CLINICAL EXAMINATION

Palpation:

Sitting posture Pulp of the fingers Axillary group of LNs Pectoral group Brachial group Subscapular group Central group Apical group Supraclavicular nodes PALPATION OF LN CLINICAL EXAMINATION

PALPATION OF LN:

SYSTEMIC EXAMINATION CLINICAL EXAMINATION

SYSTEMIC EXAMINATION:

INVESTIGATIONS IN BREAST DISEASE INVESTIGATIONS

INVESTIGATIONS IN BREAST DISEASE:

MAMMOGRAPHY INVESTIGATIONS

MAMMOGRAPHY:

Mammography evaluation BENIGN MALIGNANT Mass lesion Well Circumscribed Spiculated Density Low High Asymmetry Asymmetric involution, Trauma Intraductal CA Calcification Duct ectasia - needlelike Arterial -parallel line Fibroadenoma –popcorn Microcystic disease-teacup Fat necrosis- oilcyst calcification Fine, numerous, only sign in early noninvasive CA

Mammography evaluation:

Categories are: 0: Incomplete – needs additional imaging 1: Negative - routine mammogram yearly 2: Benign finding(s) -yearly mammogram 3: Probably benign- short term follow up 4: Suspicious abnormality - biopsy should be considered 5: Highly suggestive of malignancy 6: Known biopsy-proven malignancy B reast I maging R eporting A nd D ata S ystem [BI-RADS] INVESTIGATIONS

Breast Imaging Reporting And Data System [BI-RADS]:

INDICATIONS: If Mammography is uncertain To differentiate solid from cystic lesion If asymmetric density Interventional procedures. Evaluating after surgical augmentation . BREAST SONOGRAPHY INVESTIGATIONS

BREAST SONOGRAPHY:

Features of malignant lesion on Sonomammography STAVROS CRITERIA Spiculation 87-90% Thick Hyperechoic Halo 74% Hypoechoic nodule 70% Irregular margins 70% Posterior shadowing 50% Depth >width Shape: Microlobulation 1-2mm Branching pattern Punctate calcification INVESTIGATIONS

Features of malignant lesion on Sonomammography :

BREAST MRI To distinguish scar from recurrence Gold standard for imaging breast with implants dense breasts If Axillary node + ve and breast normal after mammo and sonography . INVESTIGATIONS

BREAST MRI:

Metabolic activity & vascular circulation always higher in pre cancerous tissue Neo-angiogenesis Suggest a pre cancerous state viz impalpable THERMAL IMAGING ( Digital infrared) INVESTIGATIONS

THERMAL IMAGING (Digital infrared):

TH1 : normal uniform non vascular TH2 :normal uniform , vascular TH3 : equivocal TH4 : Abnormal TH5: Severely abnormal Grading - Thermography

Grading - Thermography:

Uses 21gauge needle & 10 ml syringe Multiple passes through lump without releasing negative pressure Aspirate is smeared onto slide & fixed Differentiates solid & cystic lesions FINE NEEDLE ASPIRATION CYTOLOGY INVESTIGATIONS

FINE NEEDLE ASPIRATION CYTOLOGY:

If fnac is inconclusive Advantages significant core of tissue obtained can distinguish invasive from intra ductal carcinoma Grading of tumor To know ER/PR and Her 2 status Disadvantage seeding of malignant cells along needle tract CORE NEEDLE BIOPSY INVESTIGATIONS

CORE NEEDLE BIOPSY:

Core needle biopsy under ultrasound guidance INVESTIGATIONS

Core needle biopsy under ultrasound guidance:

> 4cm in size When core needle biopsy is inconclusive if <4 cm in size INCISION BIOPSY EXCISION BIOPSY INVESTIGATIONS

When core needle biopsy is inconclusive:

Most accurate and the Best Diagnostic Procedure for a Suspicious Breast Lesion. Complete excision with a rim of normal tissue Plan the incision in such a way that subsequent radical surgery can easily include the scar. Follow Langer’s line EXCISION BIOPSY INVESTIGATIONS

EXCISION BIOPSY:

MAMMOTOME Used for taking stereotactic biopsy from mammographically detected breast lesions that are not clinically palpable . INVESTIGATIONS

MAMMOTOME:

DUCTOSCOPE  A fiber optic scope less than a millimeter thick is inserted into the milk duct at the nipple and threaded deep into the breast through the duct. An imaging system displays the output of the scope on a computer monitor. Samples of epithelial cells can be collected onto microscope slides for further analysis. INVESTIGATIONS

DUCTOSCOPE:

DUCTOSCPOY INDICATIONS Patients with pathologic nipple discharge Patients who are at high-risk for developing cancer but have normal breast on examination and imaging studies. INVESTIGATIONS

DUCTOSCPOY:

INVESTIGATIONS

PowerPoint Presentation:

DUCTOGRAPHY A ductogram is a mammographic procedure that is performed to help identify the breast duct that may be the source of nipple discharge. INVESTIGATIONS

DUCTOGRAPHY:

DUCTAL ECTASIA .- Craniocaudal ductogram shows a dilated ductal system . INVESTIGATIONS

DUCTAL ECTASIA:

CARCINOMA - craniocaudal ductogram shows an outlined intraductal abnormality (arrow). Note the pleomorphic calcifications (arrowheads) INVESTIGATIONS

CARCINOMA:

Use of FDG-PET Breast scintimammography (nuclear medicine breast imaging- Miraluma Tc-99m sestamibi compound ) Computerised thermal imaging(CTI) Computerised tomographic lasermammography (CTLM) Digital tomosynthesis or three dimensional mammography Elastography Digital subtraction mammography BREAST IMAGING FUTURE INVESTIGATIONS

BREAST IMAGING FUTURE:

BBD CLASSIFICATION Tobin Dominic

BBD CLASSIFICATION:

ANDI Congenital disorders Traumatic Inflammatory Infectious Neoplastic CLASSIFICATION

CLASSIFICATION:

Breast –physiologically dynamic structure Benign disorders are related to the normal processes of reproductive life. spectrum ranges from normal to aberration to sometimes disease. ANDI

ANDI:

Endocrine Disturbance of hypothalamic pituitary gonadal steroid axis Altered prolactin profile Non endocrine Methylxanthines Stress : catecholamines High saturated fat diet Iodine deficiency ETIOLOGY

ETIOLOGY:

Normal Benign disorder Benign disease Early reproductive Years (15-25) Nipple eversion Nipple inversion Subareoalar abscess, duct fistula Lobular development Fibroadenoma Giant fibroadenoma Stromal development Adolescent Gigantomastia Gigantomastia Hypertrophy Later reproductive years(25-40 ) Cyclical Hormonal changes nodularity Mastalgia , incapaciating . mastalgia Pregnancy Lactation Epithelial hyperplasia pregnancy Bloody nipple discharge Galactocele Involution (35-55) Duct involution: dil alation Sclerosis Duct ectasia Periductal mastitis Lobular involution Nipple retraction Macrocysts,sclerosing lesions Epithelial turnover Epithelial hyperplasia epi hyperplasia atypia

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NONPROLIFERATIVE LESIONS ( RISK : 1.0) PROLIFERATIVE ( RISK : 1.3-1.9) ATYPICAL PROLIFERATIVE (RISK: 3.7-4.2) Cysts Sclerosing adenosis Atypical lobular hyperplasia(ALH) apocrine metaplasia Radial and complexing sclerosing lesions Atypical ductal hyperplasia(ADH Duct ectasia Intraductal papilloma Mild ductal epithelial hyperplasia Moderate and florid ductal epithelial hyperplasia Calcifications Fibroadenoma PATHOLOGICAL CLASSIFICATION

PATHOLOGICAL CLASSIFICATION:

FIBROCYSTIC BREAST DISEASE

FIBROCYSTIC BREAST DISEASE:

Cystic Mastopathy Chronic cystic disease Mazoplasia Cooper’s disease Fibroadenomatosis Reclus’s disease Schimmelbusch’s disease SYNONYMS

SYNONYMS:

Age group :30-50 years Aberration in normal cyclical hormonal effects Cyclcial mastalgia with nodularity Blue-domed cyst of Bloodgood : Large cysts often contain brown fluid, which gives a blue color to the intact cyst, the blue-domed cyst of Bloodgood What is fibroadenosis ?

What is fibroadenosis?:

Fibrosis Cyst formation Adenosis Epitheliosis Papillomatosis Apocrine metaplasia PATHOMORPHOLOGY

PATHOMORPHOLOGY:

lump Cyclical mastalgia Nipple discharge CLINICAL FEATURES

CLINICAL FEATURES:

CLINICAL DIAGNOSIS ( triple assessment)

DIAGNOSIS (triple assessment):

Most women with fibrocystic changes and no symptoms do not need treatment, but closer follow-up  Rule out malignancy manage as cyclical mastalgia TREATMENT

TREATMENT:

Indications intractable pain florid epitheliosis on FNAC Blood good cyst SURGERY

SURGERY:

FIBROADENOMA

FIBROADENOMA:

“Benign solid tumors composed of stromal and epithelial elements “ Represent a hyperplastic or proliferative process in a single lobule Etiology is unknown, thought to be due to hormonal influence Risk of malignant transformation is rare Resulting carcinoma : 50% LCIS , 35% IDC, 15% DCIS FIBROADENOMA

FIBROADENOMA:

Simple/solitary/small (<1 cm ) Multiple (>5) Juvenile -in young women between the ages of 10 - 18. Large ( 1-3 cm) Giant (> 5cm)-rapidly growing, Complex -contain other histological changes such as sclerosing adenosis , duct epithelial Hyperplasia, epithelial calcification. Associated with slightly increased risk of cancer TYPES

TYPES:

Between the ages of 15-25 years Painless lump- BREAST MOUSE Confused with phylloides Microscope- intracanalicular ( stromal proliferation predominates, compresses the ducts ) & pericanalicular (  fibrous stroma proliferates around the ductal spaces) CLINICAL FEATURES

CLINICAL FEATURES:

Clinical examination Ultrasound scan –circumscribed lobulated mass FNAC/Core needle biopsy DIAGNOSIS

DIAGNOSIS:

Conservative : Reassurance Surgery Very large/increasing in size Suspicious cytology Surgery is desirable Extracapsular excision with a 1cm rim of normal tissue Newer techniques -laser ablation & cryo -ablation (<2cm) TREATMENT

TREATMENT:

PHYLLODES TUMOUR PHYLLODES TUMOUR ( serocystic disease of Brodie .) GIANT FIBROADENOMA

PHYLLODES TUMOUR:

Phyllodes Fibroadenoma Age Older(40-50y) Younger Duration Rapid growth Slower progression Recurrence Common Less common Size Large , bosselated Smaller Mammogram Round density with smooth borders Same Ultrasound Cystic spaces +/- Same Cytology More cellular, malignant type Same as low grade phyllodes Phylloides vs Fibroadenoma

Phylloides vs Fibroadenoma:

classified as a  fibroepithelial tumor Proliferation of intralobular stroma considered   benign , borderline, or  malignant  depending on histologic features ( cellularity,atypia,mitoses &invasion by edges) HISTOPATHOLOGY

HISTOPATHOLOGY:

CLINICAL very fast growing  between the ages of 40 and 50, prior to  menopause  60-70% of examined tumors are benign Gelatinous, cystic and solid areas Molecular biology : monoclonar ( derived from a single progenitor cell )

CLINICAL:

Small/Benign :Wide local excision Suspicious/Borderline - Wide local excision ( 1 cm margin ) +Follow up Large/Malignant -SIMPLE MASTECTOMY chemotherapy and radiation therapy are not effective ALND : not recommended TREATMENT

TREATMENT:

Breast cyst

Breast cyst :

Definition – non integrated involution of breast tissue Age group – 30-50 Confirmed by USG and aspiration BREAST CYST

BREAST CYST:

Routine followup

PowerPoint Presentation:

Clear aspirate : discarded Blood stained : cytological analyis Pneumocystogram : In complex cysts, inject air into the cyst and then mammogram

PowerPoint Presentation:

MASTALGIA

MASTALGIA :

CYCLICAL NON CYCLICAL MASTALGIA

MASTALGIA:

Menstruating age group Hormone related-  pain around the time of ovulation Dull diffuse bilateral Upper outer quadrant CYCLICAL MASTALGIA

CYCLICAL MASTALGIA:

Relative hyperoestrogenism Hyper prolactinaemia Psychological Caffeine Abnormal lipid metabolism ETIOLOGY

ETIOLOGY:

RECENT THEORY LOW EFA LOW PGE1 ( PROSTAGLANDIN ) UNOPPOSED ACTION OF PROLACTIN

RECENT THEORY:

1.Pain diary 2.Reassurance 3.Exclude caffeine 4.Low fat diet 5.Stop OCPs/HRT 6.stop smoking 7.drugs MANAGEMENT

MANAGEMENT:

PRIM ROSE OIL BROMOCRIPTINE ( blocks prolactin) GOOD RESPONSE DANAZOL TREAT 6 MONTHS NO RESPONSE IN 4 MONTHS TAMOXIFENE GOSERELIN

PowerPoint Presentation:

CAUSES 1.musculoskeletal pain 2.teitz syndrome 3.malignancy NON CYCLICAL MASTALGIA

NON CYCLICAL MASTALGIA:

Unilateral Chronic burning or dragging Pre and post menopausal FEATURES

FEATURES:

EXCLUDE MALIGNANCY TREAT THE CAUSE MANAGEMENT

MANAGEMENT:

NIPPLE DISCHARGE

NIPPLE DISCHARGE :

Surface Eczema Psoriasis Chancre Dischage from a single duct Blood stained Serous intraduct papilloma fibrocystic disease duct ectasia duct ectasia Causes

Causes:

Discharge from more than one duct blood stained : duct ectasia black/green : duct ectasia purulent : infection Serous : fibrocystic disease duct ectasia Milk : lactation hypothyroidism pituitary tumours drugs

PowerPoint Presentation:

Clinical examination Nature of discharge Mass present or not Unilateral or bilateral Single or multiple duct Spontaneous/expressed Relation to menstruation Pre/post menopausal Taking ocp /estrogen Approach to a patient

Approach to a patient:

discharge analysis for malignant cells and occult blood Investigations

Investigations :

Mammography

Mammography:

FNAC & BIOPSY

FNAC & BIOPSY :

Treatment REASSURANCE MICRODOCHECTOMY HADFIELD

Treatment:

BACTERIAL MASTITIS

BACTERIAL MASTITIS :

Lactational Periductal mastitis / duct ectasia Types Subareolar abscess Intramammary abscess Retromammary abscess

Types:

Staph aureus – penicillin resistant if hospital acquired Streptococus Ascending infection from a sore and cracked nipple AETIOLOGY

AETIOLOGY:

CLINICAL FEATURE

CLINICAL FEATURE:

Antibiotics : metro + dicloacillin Support of the breast , local heat,& analgesics Incision & drainage Now recommended : is repeated aspiration under antibiotics coverage close follow up Antibioma if I&D not done DD- inflammatory carcinoma of breast TREATMENT

TREATMENT :

Local anaesthesia Radial or circumareolar incision drainage Septa is disrupted & wound is packed OPERATIVE DRAINAGE OF A BREAST ABSCESS

OPERATIVE DRAINAGE OF A BREAST ABSCESS:

DUCT ECTASIA

DUCT ECTASIA:

Dilatation of the breast ducts associated with chronic inflammatory response in the periductal tissue Definition

Definition :

Pathogenesis Duct dilatation Discharge to periductal tissues Periductal mastitis fistula fibrosis abcess

Pathogenesis:

Microscopy

Microscopy:

Older age group Smokers Nipple discharge: bilateral multifocal,thick,opalascent,variable colour  nipple retraction, inversion, pain Clinical features

Clinical features:

Breast abcess Tender subareolar mass Mammary duct fistula Complications

Complications :

slit like retraction of nipple Complications

Complications :

If mass or nipple retraction is present rule out malignancy Mammography Cytology, histopathology Cytology of discharge: foam cells Ductography : ectatic ducts Investigations

Investigations:

Antibiotic flucloxacillin and metronidazole Treatment

Treatment:

Hadfield’s operation Surgery

Surgery:

INTRA DUCTAL PAPILLOMA

INTRA DUCTAL PAPILLOMA:

Proliferative breast disease without atypia polyps of epithelium lined duct Differentiate from pappilomatosis : epithelial hyperplasia in association with fibroicystic changes. Not true polyp

PowerPoint Presentation:

Size: usually less than 0.5 cm, may be as large as 5cm Site: central type :near the nipple. solitary and nearing menopause. peripheral type: multiple papillomas arising at the peripheral breasts, in younger women. higher risk of malignancy Gross: Pinkish tan friable ,attached to the wall by a stalk Pathology

Pathology:

Microscopy

Microscopy:

Nipple discharge : unilateral,blood stained,from a single duct Palpable mass/density lesion in mammography Clinical features

Clinical features:

Ductography :filing defect Investigations

Investigations:

Surgery less than 30 yrs:microdochectomy more than 45 yrs:major duct excision(Hadfield ) treatment

treatment:

Thromboplebitis of superficial veins of the breast & chest wall Aetiology not known C/F – thrombosed subcutaneous cord DD – breast cancer In axilla, this condition is known as axillary web syndrome . MONDOR’S DISEASE

MONDOR’S DISEASE:

Treatment – anti- inflamatory medication warm compresses & support restriction of movement symptoms persist - excision It is named after  Henri Mondor  (1885-1962), a surgeon in  Paris, France  who first described the disease in 1939

PowerPoint Presentation:

GALACTOCELE

GALACTOCELE:

essentially a retention cyst resulting from lactiferous duct occlusion C/F: painless breast lump  Diagnosis- needle aspiration Mammograms in the MLO obtained with the patient erect may show the characteristic finding of nodules containing  fat fluid levels.

PowerPoint Presentation:

Tuberculosis of breast Syphilis of the breast Actinomycosis OTHER INFECTIOUS CONDITIONS

OTHER INFECTIOUS CONDITIONS:

Breast tuberculosis is a rare form of tuberculosis often overlooked and misdiagnosed as carcinoma or pyogenic abscess Breast tissue is remarkably resistant to tuberculosis considered invariably secondary to a lesion elsewhere in the body Peau d’ orange is often seen Multiple c/c abscess & sinuses Bluish attenuated appearance of surrounding skin Diagnosis: FNAC an important diagnostic tool TUBERCULOSIS OF BREAST

TUBERCULOSIS OF BREAST :

AFB on FNAC is not mandatory AFB negative breast abscess that fail to heal despite adequate drainage and antibiotic therapy, and those with persistent discharging sinuses should raise suspicion of underlying tuberculosis Biopsy of the abscess wall Rx : Small lesions are eminently treatable by an excision biopsy followed by a full course of ATT extensive disease : Simple mastectomy

PowerPoint Presentation:

Primary chancre of nipple Secondary lesions – diffuse mastitis SYPHILIS OF THE BREAST

SYPHILIS OF THE BREAST:

Breast Trauma

Breast Trauma:

Clinical features - Pain & lump in the breast Lump is hard - extensive fibrosis caused by tissue reaction it can gradually change into scar tissue or may collect as liquid within an  oil cyst . D.D : Carcinoma breast Mammography findings - density lesion; can have calcifications; may mimic carcinoma breast Treatment - excision TRAUMATIC FAT NECROSIS

TRAUMATIC FAT NECROSIS:

Benign Breast Disease in Males

Benign Breast Disease in Males:

Contains only ducts No alveoli Male breast

Male breast:

Gynaecomastia Fibroadenoma Phyllodes tumour Epidermal inclusion cysts Sub cutaneous leiomyoma Sub areolar abscess Intra mammary lymph node BENIGN BREAST LUMPS IN MALES

BENIGN BREAST LUMPS IN MALES:

“  benign enlargement of breast tissue in males” Physiological: Neonate Adolescence (U/L) Senescense (B/L) GYNAECOMASTIA

GYNAECOMASTIA:

Estrogen excess states : Gonadal Stromal Neoplasms: Leydig / Sertoli Germ cell tumors: Choriocarcinoma / Seminoma/ Embryonal Non Gonadal tumors: Adrenal/Lung/HCC Endo ( hyper and hypothyroidism ) Hepatic (non alc or alc cirrhosis) Protein and Fat deprivation Androgen deficiency states Sensesccense Hypogonadism Primary testicular failure : Klienfelters / Kallmann /ACTH defi Secondary testicular failure: trauma/ orchitis Renal failure Refeeding gynecomastia : Resumption of pituitary gonadotropin secretion after pituitary shutdown. Drug related : Reserpine/Theophylline/Verapamil Systemic diseases PATHOPHYSIOLOGY

PATHOPHYSIOLOGY:

Grade I: Minor enlargement, no skin excess Grade II: Moderate enlargement, no skin excess Grade III: Moderate enlargement, skin excess Grade IV: Marked enlargement , skin excess , Ptosis simulates a female breast CLINICAL CLASSIFICATION

CLINICAL CLASSIFICATION:

MANAGEMENT If androgen defi : Testosterone administration If progressive and does not respond : Surgery subcutaneous mastectomy, liposuction-assisted mastectomy, laser-assisted liposuction, laser-lipolysis without liposuction Danazol : Androgenic side effects