BENIGN BREAST DISEASE

Workup and Surgical Management

Surgical Consult
Majority of surgical consultation for Breast complaints ultimately prove to have a benign origin. Surgeon s role in management of Benign Breast Disease includes:
Assessment of Breast Cancer Risk Breast Cancer Screening Providing Specific Diagnosis Treatment/Management

ANATOMY
Develops from Ectoderm Milk Streak Lobules and Ducts
The breast glandular tissue consists of 15 to 20 lobules (clusters of milk forming glands, or acini) that enter into branching and interconnected ducts. The ducts widen beneath the nipple as lactiferous sinuses and then empty via nipple openings.

ANATOMY
Blood Supply
Branches of Internal Mammary Artery, Intercostal arteries, Axillary Artery Venous drainage via Internal Mammary, Intercostal, Axillary Veins

Lymphatic Drainage
97% to Axillary Nodes Internal Mammary and Supraclavicular nodes

ANATOMY
Three Lymph Node Levels: Level I Lateral 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

ANATOMY

Benign Breast Disease

Work up of Breast Mass Breast Pain Glandular Breast Parenchyma Nipple-Areolar Complex Breast Skin

BREAST MASS
Four Phases of Management
CBE Breast Imaging Tissue Sampling Treatment

Palpable mass is most common presentation Mammogram/Sonogram/MRI FNA/Core biopsy/Excisional biopsy

Breast Pain (Mastodynia)

More common during reproductive years (premenopausal) Association with cancer is uncommon Cyclic pain associated with Fibrocystic changes Noncyclic pain associated with infection or cancer if associated with mass or bloody nipple discharge. Tx: NSAIDs, Eve primrose oil, OCP, avoid caffeine

Parenchymal
Cysts
Simple cyst may be observed or aspirated Bloody aspirate send for cytology

Fibrocystic Changes
Not considered disease No increase risk of cancer Common finding >50%

Parenchymal
Fibroadenoma
Most common mass in <30 y/o Smooth, firm, rounded, mobile Definitive dx by core or excisional bx. Change size with menses, pregnancy Excise if growing or >30 y/o Long-term risk = 2.17 for cancer (IDC)

Parenchymal
Cystosarcoma Phyllodes
10% malignant Resembles Fibroadenoma Tx is WLE

Gynecomastia
Associated with THC, spironolactone Liver Failure Idiopathic

Nipple/Areolar Complex
Nipple D/C
Nonspontaneous, B/L, multiple ducts, greenish, milky is likely benign. Spontaneous, unilateral, bloody, serous is worrisome. Meds TCAs, Reglan, Verapamil, Reserpine Galactorrhea r/o Prolactinoma Intraductal Papilloma not premalignant
Most common cause of bloody nipple d/c Diffuse papillomatosis has increased risk of cancer

Mammo/sono/ Ductogram Ductal excision

Breast Skin
Mastitis/Abscess
S. Aureus Inflammatory Breast Cancer

Mondor s Dz.
Painful, cordlike superficial thrombophlebitis

Benign Breast Disease

NONPROLIFERATIVE
FIBROCYSTIC CHANGES NO INCREASED RISK

PROLIFERATIVE
PAPILLOMATOSIS 1-2X INCREASED RISK OF CANCER

ATYPICAL PROLIFERATION
ATYPICAL HYPERPLASIA 4-5X INCREASED RISK OF CANCER

Atypical Hyperplasia
Marked proliferation and atypia of the epithelium, either ductal or lobular. Found in 3% of benign breast biopsies Associated with a 13% subsequent development of breast cancer (4x risk factor) Some may be an under-diagnosed ductal carcinoma in situ. Excisional Biopsy do not need clear margins

Atypical Ductal Hyperplasia

ADH

NONINVASIVE CANCER
Ductal Carcinoma In Situ (DCIS)
Malignant cells of Ductal Epithelium without
invasion of basement membrane. 50-60% increased risk in ipsilateral breast. Lumpectomy and XRT. Need clear margins.

DCIS

IDC

NONINVASIVE CANCER
Lobular Carcinoma In Situ (LCIS)
Usually an incidental finding on biopsy Risk of Breast Cancer increases 1% per year b/l
breasts. Usually Ductal CA. Do not need clear margins Mgmt: Close clinical follow up or prophylactic B/L mastectomy.