Ddx

1. Fibroadema

Fibroadenoma is the second most common tumor in the breast (after carcinoma) and is the most
common tumor in women younger than 30 years. They most often arise during the late teens and early
reproductive years and are rarely seen as new masses in women after age 40 or 45 years. They arise
from hyperplasia of a single lobule and usually grow up to 2–3 cm in size and manifest as firm masses
that are easily movable and may increase in size over several months. They slide easily under the
examining fingers and may be lobulated or smooth. Mammography is of little help in discriminating
between cysts and fibroadenomas; however, ultrasonography can readily distinguish between them
because each has specific characteristics. It does not require excision unless associated with suspicious
cytology, it becomes very large or the patient expressly desires the lump to be removed.

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2. Breast cyst

Cysts within the breast parenchyma are fluid-filled, epithelial lined cavities that vary in size from
microscopic to large palpable masses containing 20 to 30 mL of fluid. A palpable cyst develops in at least
1 in every 14 women, and 50% of cysts are multiple or recurrent. The pathogenesis of cyst formation is
not well understood. Cysts are influenced by ovarian hormones so they vary with the menstrual cycle.
Most cysts occur in women older than 35 years; the incidence steadily increases until menopause and
sharply declines thereafter. New cyst formation in older women is generally associated with exogenous
HRT. A palpable mass can be confirmed to be a cyst by direct aspiration or ultrasonography. Surgical
removal is usually not indicated but may be required.

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3. Hamartomas

Breast hamartoma is an uncommon benign, slow-growing proliferations of variable amounts of

epithelium and stromal supporting tissue found in all age groups after puberty. It is a discrete nodule
that contains closely packed lobules and prominent, ectatic extralobular ducts.
They most commonly are asymptomatic or present as a painless soft breast lump. They may also present
as unilateral breast enlargement without a palpable localized mass. On physical examination,
mammography, and gross inspection, a hamartoma is indistinguishable from a fibroadenoma. During
pregnancy and lactation, adenomas may increase in size, and histologic examination shows secretory
differentiation. Biopsy is required to establish the diagnosis.

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4. Phyllodes tumor

Benign phyllodes tumors are firm lobulated masses that can range in size, with an average size of
approximately 5 cm. histologically, they are similar to fibroadenomas and are indistinguishable from
fibroadenomas on mamography. The diagnosis is suggested by the larger size, history of rapid growth,
and occurrence in older patients. The final diagnosis is best made by excisional biopsy followed by
careful pathologic review. Local excision is curative. Affected patients are at some risk for local
recurrence, most often within the first 2 years after excision. Close follow-up with examination and
imaging allows early detection of recurrence.

Malignant phyllodes tumors are characterized by features such as stromal overgrowth, cellular atypia,
and high number of mitoses. These tumors are treated similarly to soft tissue sarcomas that occur on
the trunk or extremities. Complete surgical excision of the entire tumor with a margin of normal tissue is
advised. When the tumor is large with respect to the size of the breast, total mastectomy may be
required. Metastases from malignant phyllodes tumors occur via hematogenous spread. The optimal
palliative treatment of patients with metastatic phyllodes tumors has not been determined.

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5. Fat necrosis

Fat necrosis may follow an episode of trauma to the breast or be related to a prior surgical procedure or
radiation therapy. Following a blow, or even indirect violence (e.g. contraction of the pectoralis major), a
lump, often painless, appears. This may mimic a carcinoma, even displaying skin tethering and nipple
retraction, and biopsy is required for diagnosis. A history of trauma is not diagnostic as this may merely
have drawn the patient’s attention to a preexisting lump. It can mimic cancer on mammography by
producing a palpable mass or density that may contain calcifications. This lesion has no malignant
potential.

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6. Breast Ca

Breast cancer is the most commonly diagnosed & the leading cause of cancer death in women globally.
Incidence rates vary greatly worldwide from 19.3 per 100,000 women in Eastern Africa to 89.7 per
100,000 women in Western Europe. Risk factors are: geographical, increasing age, female sex, women
with a family history of breast cancer, diets low in phyto-oestrogens, high intake of alcohol, nulliparity,
not breast feeding, first child after 35 years of age, early menarche and late menopause, obesity, OCP
and HRT use, history of radiation to the chest

Breast cancer may arise from the epithelium of the duct system anywhere from the nipple end of the
major lactiferous ducts to the terminal duct unit, which is in the breast lobule. The disease may be
entirely in situ, an increasingly common finding with the advent of breast cancer screening, or may be
invasive cancer. The degree of differentiation of the tumour is usually described using three grades: well
differentiated, moderately differentiated or poorly differentiated.

Breast cancer can spread: locally via invasion of other portions of the breast, skin, pectoral muscles and
chest wall, lymphatic metastasis via axillary and the internal mammary lymph nodes and hematogenous
spread to bone, liver, lungs, brain, adrenal glands and ovaries.

Breast cancer is found most frequently in the upper outer quadrant. Most breast cancers will present as
a hard lump, which may be associated with indrawing of the nipple. As the disease advances locally
there may be skin involvement with peau d’orange or frank ulceration and fixation to the chest wall
described as cancer-en-cuirasse. Other presentations include change in color or appearance of areola,
nipple discharge or bleeding, ulceration and axillary mass. Advanced stage can present with symptoms
of metastatic disease.

Classical staging of breast cancer by means of the TNM (tumour–node–metastasis) or UICC (Union
Internationale Contre le Cancer) criteria is used less often as we gain more knowledge of the biological
variables that affect prognosis.

The best indicators of likely prognosis in breast cancer remain tumour size, grade and lymph node
status; however, the prognosis of a cancer depends not on its chronological age but on its invasive and
metastatic potential.

The two basic principles of treatment are to reduce the chance of local recurrence and the risk of
metastatic spread.

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