BENIGN BREAST DISEASES

Yuvaraj Karthick

Anatomy•Modified sweat gland – derived from the ectoderm•Each breast consists of 15-20 lobules

•Breast extends from 2 – 6th rib •Sternum to mid axillary line•Lies in the superficial fascia, superficial to the pectoral fascia.•Axillary tail of Spence - upper outer portion of the breast passes deep to the deep fascia through the foramen of Langer.

Aberrations of Normal Development and Involution of the Breast (ANDI)•Breast in Females goes through various phases

• 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

•Presents as a spectrum of diseases at various stages of development

•Early reproductive age group:• Fibroadenoma

• Giant• Multiple

• Juvenile hypertrophy

•Mature reproductive age group:• Caused due to cyclical hormonal effects

• Generalized enlargement• Cyclical mastalgia with nodularity Fibroadenosis or fibrocystic disease

•Involution age group• Lobular involution: Microcysts, fibrosis, adenosis, apocrine metaplasia

Macrocysts, cystic disease of breast, sclerosing adenosis

Ductal involution: Nipple discharge, periductal mastitis, bacterial infection, nonlactational breast abscess, mammary duct fistula

Fibroadenoma•Benign, encapsulated tumor occurring in younger patients 15- 25 yrs

•Presently considered as hyperplasia of single lobule.•Most common lesion in patients < 30 yrs old•Shows similar hormonal activity as normal breast tissue.

•Juvenile fibroadenoma:• Adolescent girls with rapid growth (Epithelial & Stromal hyperplasia)

• May clinically mimic phyllodes tumor

•Giant Fibroadenoma:• Size > 5 cm

•Multiple fibroadenoma

•Clinical features:• Painless, smooth, nontender, well localized swelling• Moves freely within the breast tissue• No node enlargement

• Investigation: ???

•Treatment:

Fibrocystic disease of breast/Fibrocystadenosis/ Mammary dysplasia/ Cyclical mastalgia with nodularity•Estrogen dependent condition.•Most common breast condition•Exaggerated response of breast stroma and epithelium to Hormones and growth factors

•Stages• Stromal proliferation• Adenosis• Cyst formation.

•Clinical features:

• Bilateral, painful, diffuse, granular, swelling• Better palpated with the fingers than palm.

• Commonly in upper outer quadrant.

• Pain and tenderness >> just prior to menstruation

• Subsides during pregnancy, lactation and post menopause.• Occasionally serous discharge may be present

•Treatment:•Conservative management

• Oil of evening primrose – Linolenic acid + Linoleic acid• Danazol – Interferes with FSH and LH decreases Est and Pro• Bromocriptin – Lowers Prolactin• Tamoxifen – Antiestrogenic drug.• Vit E and B6• NSAIDs

•Severe cases not subsiding with Medical management Subcutaneous mastectomy or Cyst excision.

Sclerosing Adenosis•30 – 50 yrs of age•Patient presents with mastalgia & Lump•Palpation – Smooth, relatively mobile mass.•Patho – Proliferative terminal ductules & acini, with proliferation of stroma often with deposition of Ca.

•Treatment:??

Phyllodes Tumor:•Spectrum of disease.•Benign Malignant•Arises from the stromal element of the breast•Microscopy:

• Contains cystic spaces with leaf like projections hence the name.

• Cells chow hyper cellularity and pleomorphism.

•Clinical Features:• Premenopausal women,• Usually unilateral, Rapid growth• Smooth bossellated, overlying skin necrosis may be present• Skin may be stretched, shiny, dilated veins + over the lesion.• Recurrence is common.

• Investigation:???• Treatment:???

Mastalgia:•45% of women present with mastalgia•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• Patho Similar to ANDI• Hence treatment similar to ANDI

•Non cyclical:• Rule out other causes of breast pain• Periductal mastitis, cervical root pain, malignancy, Teitz syndrome

• U/l C/c, burning or dragging in nature.• Occurs in both pre and post menopausal age group

Traumatic fat necrosis:

•Caused d/t trauma•PATHOGENESIS:

• Capillary ooze triglyceride in fat to dissociate into fatty acid Combines with Ca Saponification Inflammatory reaction Swelling

•CLINICAL FEATURES:• Painless swelling• Hard, irregular and adherent to breasts tissue.

• INVESTIGATIONS:???•TREATMENT:???

Galactocele:• It is a retention cyst.•Occurs in Lactating women and up to 10 months after lactation.

•The lactiferous duct gets blocked and large amount of milk gets collected.

•Contents are milk and epithelial debris.

•CLINICAL FEATURES:• Large, soft, fluctuant swelling usually in the lower quadrant.• Untreated gets precipitated and calcified and mimics cancer.• Usually gets infected Abscess

• Investigation:???

•Treatment:???

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 Montgomerie glands or a furuncle

• Can be caused by duct ectasia• CLINICAL FINDINGS: Red, inflamed areola, tender, nipple retraction may be present.

• TREATMENT: ???

Intra mammary mastitis•Usually up to 6 months of feeding•Predisposing factors:

• Cracked nipple• Retracted nipple• Improper cleaning• Inadequate suckling by the baby 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.

•Treatment: ???

Retro mammary abscess:•D/t Tuberculosis of the internal mammary nodes, ribs, empyema necessitans, hematoma

•Breast tissue per say is normal.

• Investigations:???

Treatment:???

Antibioma:• If intra mammary mastitis Poorly treated with repeated with Abx and/or inadequate drainage.

•Collection persists Surrounding inflammation settles with thick fibrous septum formation Antibioma

•CLINICAL FEATURES: H/o Mastitis Rxed with Abx•Lump, hard, non tender, smooth, fixed to surrounding breast tissue.

• INCESTIGATIONS AND MAMAGEMENT:

Duct Ectasia:• It is dilatation of lactiferous ducts d/t relaxation of the myoepithelial cells of the duct wall + Periductal mastitis.

•Hormones Duct wall relaxation + Ineffective reabsorption of secretions Desquamation of epithelium in to the duct

•CLINICAL FEATURES:• Greenish discharge or creamy discharge• Indurated mass under the areola• Retraction of the nipple at a later stage ( ??? )• Eventually Abscess Fistula• May be bilateral and multifocal

• Investigation and treatment: ???

Galactorrhoea•Primary:

• Stress and other factors.• Physiological during puberty or menopause.

•Secondary:• Dopamine receptor blockers like haloperidol, methyl dopa, chlorpromazine, metoclopramide

• Prolactin secreting pituitary tumors.• Hypothyroidism • Ectopic prolactin secreting tumors (like Bronchogenic Ca)• CRF

• INVESTIGATION AND TREATMENT

Duct Papilloma•Epithelium lined papillae occurring in the lactiferous ducts.• It is the most common cause of bloody discharge from the nipple.

•Usually < 1cm in size, fell as a mound in the retroareolar region.

• INVESTIGATION AND MANAGEMENT:

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