Benign Breast Disease

Breast Anatomy
• Modified sweat gland derived from the ectoderm
• Lies B/W subdermal layer of adipose tissue and
superficial pectoral fascia
• Breast parenchyma composed of lobes,
comprised multiple lobules
• Suspensory ligament of cooper – provides
structural support to the breast
• B/W breast and pectoralis major muscle lies
retromammary space, contain lymphatics and
vessels
 Cont.
• Breast extends from 2 – 6th rib
• Sternum to mid axillary line
• Axillary tail of Spence - upper outer portion of
the breast passes deep to the deep fascia
through the foramen of Langer, where it is in
direct contact with anterior axillary lymph
node.
 Microscopic Anatomy
Glandular epithelium –
• Composed of branching system of ducts, each
major duct has lactiferous sinus
• Each major duct has progressive generation of
branching and ultimately ends in the terminal
ductules or acini
• Acini are the milk forming glands of lactating
breast, which consist of lobular unit/ lobule
• Lined by myoepithelial cells
 Cont.
Fibrous stroma and supporting structure
• In adolescent, predominant tissue are
epithelium and stroma
Adipose tissue-
• In postmenopausal women, the glandular
structures involute and replaced by adipose
tissue
Ligament of cooper provide shape of whole
breast
 Lympahtic Drinage
• Pectoralis minor muscle enclosed within
clavipectoral fascia, extends laterally to fuse with
axillary fascia, which contain loose aerolar fat of
axilla, containing axillary lymph node

• Axillary lymph nodes are described in relation

with pectoralis minor muscle

• Level I, level II, level III

 Aberrations of Normal Development and
Involution of the Breast (ANDI)
ANDI –benign breast disorder, occurring at
different periods of reproductive life in female
• Early reproductive phase (Lobular
development): 15 – 25 yrs
• Matured reproductive phase (Cyclical
hormonal modification): 25 – 40 yrs
• Involution phase (Resorption of glandular
structures): 40 – 55 yrs
 Fibroadenoma
• Solid tumor composed of stromal and epithelial
elements
• Hyperplasia of single lobule of the breast(ANDI)
• 2nd most common tumor in breast after
carcinoma and most common tumor in women
younger than 30 years
• Late teen and early reproductive years,rare
after 40 or 45 years
 Cont.
• Small fibroadenoma<1cm, normal; larger<3cm,
disorder and >3cm or giant fibroadenoma, disease

• Multiple fibroadenoma,.5 in number consider

disease

• Shows hormonal dependence - normal breast lobules

in that they lactate during pregnancy and involute
during menopause

• 20% bilateral, 20% multiple

 Clinical examination
• Firm mass, easily movable, may increase in
size over a period of several months

• Remain static for long period, regress

spontaneously over year

• Lobulate or smooth
 Cont.
• Encapsulated

• Slide easily under the examine finger( breast

mouse),non tender swelling

• Axillary lymph node- not enlarged

 Cont.
Two type of fibroadenoma
Giant fibroadenoma:more than 5 cm in
diameter
Juvenile fibroadenoma:
• large fibroadenoma that occurs in adolescent
and young adult
• Histologically more cellular than usual
fibroadenoma
 Pathological type
• Pericanalicular type( hard fibroadenoma):
proliferation of fibrous tissue is more than the
glandular element, feel firm, mobile within
breast tissue

• Intracanlicular type( soft fibroadenoma):

proliferation of glandular tissue is more than
fibrous tissue, soft feel
 Investigation
USG of breast
• Typical round/oval sharp contour.
• Doesn’t distinguish b/w cancer and
fibroadenoma
FNAC
•abundance of epithelial cells and stroma
Mammography
• If age is greater than 35 years
Popcorn calcification
 Cancer In Fibroadenoma
• Though benign tumor, neoplasia may
developed in epithelial elements

• 50% of neoplasia are Lobular

Carcinoma Insitu

• 35% infiltrating carcinoma

• 15% intraductal carcinoma

 Treatmen
t
If <2 cm reassurance should should be done,
regress spontaneously, F/U after 6months interval
with USG Breast.
Surgical treatment
 More 3cm in size, multiple, Giant variety
 Tumor size increasing in follow up, recurrance
 For cosmetic purpose( if patient is bother by
mass)
Cryoablation under USG guidance can be done
 Incisional approach

Webster incision

Gaillard Thomas

Incision made over the capsule

Enucleation of tumor should be done
 Fibrocystic disease of
breast/ Fibrocystadenosis/ Mammary
Dysplasia/ Cyclical mastalgia with nodularity
• Estrogen dependent condition,exaggerated
response to breast stroma and epithelium
• Painful nodularity persist for >1 week of
menstrual cycle -disorder
• Bluedome cyst of bloodgood
• Schimmelbuch’s disease
• Most common breast disease, upper outer
quadrant
• Rare in nulliparous, ovulating and OCP taking
women
Stages
• Stromal proliferation

• Adenosis

• Cyst formation.
 Microscopic Features
• Stromal fibrosis

• Microcyst formation

• Glandular proliferation

• Hyperplasia (epitheliosis)

• Papillomatosis
 Clinical features
• Bilateral, painful, diffuse, granular, swelling,
better palpated with the fingers than palm.

• Pain and tenderness >> just prior to

menstruation( thus cyclical mastalgia)

• Discharge from nipple, 20% axillary lymph

node enlargement
 Investigation
• FNAC (epitheliosis)

• USG Breast

• Mammograph
y
 Treatment
:
Conservative management surgery
• Oil of evening primrose • Cyst excision
– Gamolenic acid • Sub cutaneous mastectomy
• Danazol 200mg/day Indication
• Intractable pain
• Tamoxifen -10mg bd
• Florid epitheliosis on FNAC
• Vit E and B6
• Bloodgood cyst
• NSAIDs • Persistant bloody discharge
 Sclerosing Adenosis
• Refers to the increased number of small
terminal ductules or acini
• Associated with the proliferation of the
stromal tissue, often with ca++ deposition
• 30- 50 years, multiple small firm nodule ē
fibrous tissue and cysts
• Cyclical mastalgia and tender breast mass
• Grossly and histologically mimic CA
breast
 Cont.
• Important component of fibrocystic disease
• No significant malignant potential
• Mammography: microcalcification
indistinguishable from intraductal carcinoma
• Needle direct biopsy of microcalcification-
most common pathologic diagnosis
• Conservative management with regular
F/U
 Phyllodes Tumors
• Tumors of mixed connective tissue and
epithelium, biphasic proliferation of stroma
and mammary epithelium

• With increasing cellularity, invasive margin,

pleomorphism and mitotic activities with
sarcomatous apperance  malignant
phyllodes tumor
 Cont.
• Benign phyllodes tumors – firm lobulated masses
range in size, average of aprrox. 5cm
• Histologically similar to fibroadenoma, but
whorled stroma forms larger cleft lined by
epithelium that resembel clusters of leaflike
structure
• Size increases rapidly and attained the size of
breast,soft, lobulated surface,free from skin and
underlying pectoral muscle
• Premenopausal women
 investgation
• Mammography -Round density with smooth
borders
• USG- Discrete structure with cystic spaces
• Cytology – cannot differentiate with
fibroadenoma
• Core biopsy- difficult to differentiate B/W
benign and malignant form
• Final diagnosis – excisional biopsy with careful
histopathological report
 Treatmen
t
• Local excision of benign phyllods
• Boderline phyllodes tumor – excision with the
margin of @ least 1cm of normal tissue
• Malignant phyllodes tumor – complete
surgical excision of entire tumor with the
margin of normal tissue
• If tumor involved whole breast- total
masectomy
 Mastalgia
• 45% of women present with mastalgia, 21%
severe
• Unknown etiology
• Predisposing conditions:HRT, Caffeine, tobacco,
large pendulous breast
Types:
• Cyclical (65%)
• Non cyclical (30 %)
• Chest wall pain (5%)
 Cyclical:
• Related to Menstrual cycle
• B/l diffuse pain with heavy feeling
•Similar to ANDI like fibrocystoadenosis
Treatment similar to ANDI
• Evening primrose, danazol
• Tamoxifen , vit B6, B12, Analgesics
 Non cyclical
• R/O other causes of breast pain-Periductal
mastitis, cervical root pain, Teitz
syndrome
• U/l chronic, burning or dragging
• Occurs in both pre and post menopausal age
group
• Treatment of underlying causes
• Avoid coffee and stress
 Traumatic fat necrosis
• Palpable mass
• Episode of trauma to breast, any surgical procedure or
radiation treatment
• Important characteristics- calcification
• Histologically lipid laden macrophages, chronic
inflammatory cells
•No malignant potential
PATHOGENESIS:
• Capillary ooze -triglyceride in fat to dissociate into fatty
acid –Combines with Ca – Saponification-Inflammatory
reaction -Swelling
 Cont.
Investigation
• Mammography- calcification
•FNAC-lipid laden macrophages
Treatment
• Excision
 Galactocele
• Accumulation of milk  cyst, round, well
circumscribed and easily movable within
breast
• After cessation of lactation or when feeding
frequency has curtailed significantly
• Pathogenesis is unknown but inspissated milk
within duct is responsible
• Located in central portion of breast/ under
nipple
 Cont..
• Needle aspiration- thick creamy material, dark
green or brown, though appears purulent,
fluid is sterile
Treatment:
•Needle aspiration of thick milky secretion
Surgery
• If unable to aspirated
• Infected galatocele
 Mastitis
Types
Sub areolar
Intra mammary,
• a) Lactational
abscess
•b) Non-lactational abscess
Retro mammary
 Sub areolar
• Infection developing d/t cracks in the nipple,
infected Montgomery glands or a furuncle
• Can be caused by duct ectasia
• Common in nonlactating women
• CLINICAL FINDINGS: Red, inflamed areola,
tender, nipple retraction may be present.
• Treatment –subaerolar incision and
driange
 Intra mammary mastitis
Lactational abscess
• Seen in lactating maother, usually up to 6 months
of feeding
Predisposing factors:
• Cracked nipple
• Retracted nipple
• Improper cleaning
• Inadequate suckling by the baby or stasis
• Infection from the mouth of the baby
• Most common organism  Staph. Aureus
 CLINICAL FEATURES:
• Fever with chills and rigors
• Throbbing pain, severe tenderness
• Redness, local rise in temperature, induration
• Purulent discharge from the nipple.
• Entire breast may be involved and may end up
having fluctuation +ve.
Investigation
• USG
• BLOOD TC/DC
Treatment –I/D with antibiotics coverage
inflammation

Blocked duct
 Retro mammary abscess
• D/t Tuberculosis of the internal mammary
nodes and ribs beneath
• Breast tissue -normal.
• Investigations:
• FNAC
• USG breast and chest wall
• Treatment: Retromammary incision
 Duct Ectasia
• It is dilatation of lactiferous ducts d/t
relaxation of the myoepithelial cells of the
duct wall with periductal mastitis
• Duct ectasia led to stagnation of secretion,
epithelial ulceration, and leakage of duct
secretion( fatty acid as irritating substance)
into periductal tissue PERIDUCTAL FIBROSIS
AND NIPPLE RETRACTION
 Cont.
• Another theory, perductal mastitis, leads to
weaking of ducts and secondary dilataion

• Both process together and explain the wide

spectrum of problems, such as nipple
discharge, nipple retraction, inflammatory
masses and abscess
 CLINICAL FEATURES:
Investigation
– Ductography
– Mammgraphy
Treatment
• Stop smoking
• Cone excision of the major duct- ADAIR HADFIELD
OPERATION
• Antibiotics
• Melhem Novel modified breast ductal system
excision
 Duct Papilloma
• Intraductal papillomas arise in the major
ducts, usually in premenopausal women.
• <0.5 cm in diameter but may be as large as 5
cm. A
• Common presenting symptom is nipple
discharge, which may be serous or bloody.
• Grossly, intraductal papillomas are pinkish tan,
friable
 Cont.
• Attached to the wall of the involved duct by a
stalk
• They rarely undergo malignant
transformation, and their presence does not
increase a woman’s risk of developing breast
cancer
• Intraductal papillomas, which occur in
younger women and are less frequently
associated with nipple discharge
 Cont.
Investigatio
n FNAC
Ductogram
Mammography
Treatment
Microdochectom
y