Benign Breast disease

1. BENIGN BREAST
DISEASES
Dr. Muhammad Zoha Farooq

2. Agenda
• Fibroadenoma and related tumors
• Nipple discharge
• Breast Abscess

3. FibroAdenoma

4. Fibroadenoma
• Most common benign tumor of breast
• Part of Aberration of Normal Development and involution
(ANDI)
• WHO Definition- Discrete benign tumor showing evidence
of connective tissue and epithelial proliferation.
• Histological Variants- Hyper cellularity or Atypia
• Stromal element is the key to classification
• Stroma with low cellularity and low cytology
• Clinical Variants- Large size or Rapid Growth

5. Types of Fibroadenoma
• Fibroadenoma Simplex
• Giant Fibroadenoma
• Microfibroadenoma
• Myoxid Fibroadenoma
• Juvenile Fibroadenoma

6. Fibroadenoma Simplex
• Young women
• Rubbery firm, smooth, very mobile mass
• Mostly a clinical diagnosis
• Early years after Menarche 16-25 years
• Overall incidence is highest in 30s and 40s
• Lobular in origin / Mostly remain static
• 1-3cm in size increase over 1-5 years
• Most common in left breast and upper outer quadrants.

7. Giant Fibroadenoma
• 30 % of all Fibroadenoma
• Greater than 6 cm
• Differential diagnosis with Phyllodes Tumor
• Confirmed via histology
• 4% are reported in pregnancy and lactating adenomas.
• Potential of LCIS- Benign
• Steroid receptors for Estrogen and Progesterone.
• Women on HRT has increased incidence.
• Combined pill has a protective role- Progesterone
element
• BCL-2 Gene. Delay apoptosis

8. Histology
• Macroscopic- sharply demarcated ,rounded, white
glistening surface.
• Microscopic- Pale stroma, duct like structures lined by
regular epithelium
1. Pericanalicular – Abundant epithelila structures
2. Intra Canalicular- Epithelilal clefts surround islands of
stroma
• Fibroadenomatoid Hyperplasia- Microfibroadenomas
• Apocrine and Squamous Metaplasia- Related to future
cancer risk.

9. Pericanalicular/Intracnalicular

10. Rare Fibroadenomas
• Myoxid Fibroadenoma
Carney Syndrome ( Myxomas of skin and heart)
• Juvenile Fibroadenoma
Floridly glandular and more cellular stroma.

11. Clinical Features
• Common Features
 Different in young girls, middle aged and post
menopausal
 Smooth ,round and mobile- Breast Mouse
 Exception- Behind the nipple, mobility decreased by
surrounding ducts
 Older Woman- Involutional fibrotic changes, present as
dominant mass.
 Older Women- Diagnoses on Biopsy

12. Clinical Features
• Less Common Presentation
 Small Superficial Nodules 3-4 mm-young women
 As Discrete masses in later years of reproductive life
 Pregnancy-Increase in size

13. Investigations
• Triple assesment
• Mammography
Age above 35
Typical solitary lesion,
Stippled calcification
( Popcorn Appearance)

14. Investigations
• Sonography
 Younger Women below 35
 Typical round/oval sharp contour.
 Doesn’t distinguish btw cancer and fibroadenoma
 Color Doppler differentiate from cancer.

15. Investigations
• Cytology
FNAC shows,
abundance of epithelia
cells and stroma.
Replaced by core
needle Biopsy as a
standrd investigation.

16. Managment
• Overall Conservative.
• Reassurance
• Once tissue diagnosis has been obtained patient can be
observed
• Offer exicision
• if >3cm / rapid increase
• Symptomatic
• Patients choice, patients satisfaction.
• Surgical- If within 3cm of nipple, periareolar incision.
• Alternative- Laser Ablation, Cryosurgery
• Hormonal- Tamoxifen. Not favored due to unwanted side
effects.

18. Cancer and Fibroadenoma
• Three Clinical Aspects
1. Association of cancer with fibroadenoma
2. Incidence of Breast Ca in patients with fibroadenoma
3. Progression of fibroadenoma to Phyllodes tumor

19. Cancer In Fibroadenoma
• 95% LCIS
• 5% DCIS
• LCIS is usually within the fibroadenoma
• In DCIS either there is direct infiltration from adjacent
cancer or tumor growing along the duct in the epithelial
clefts.
• In case LCIS is diagnosed post excision, further exicision
is required.
• In any case ignore fibroadenoma and treat according to
cancer policy.

20. Fibroadenoma and Subsequent Cancer
risk
• Population at Risk.
• Family Hx of malignancy
• Genetic Changes
• COX expression
• NM23-H1 messenger RNA
• P53
• BCL-2 gene

21. Phyllodes Tumor and Phyllodes Sarcoma
• Phyllodes Tumor Benign vs Giant Breast Tumors
• Phyllodes Sarcoma –Malignant
• Histology- Both epithelial and fibrous elements, stroma
shows hyerpcellularity,hperchromatisim,irregularity and
mitosis.

22. Treatment
• Under age of 20 – Mass Exicision
• Peri and Post Menopausal
• Clear margin of 1 cm necessary
.

23. NIPPLE DISCHARGE

24. Nipple Discharge
• Spontaneous eflux of fluid from the nipple apart from
physiological function of perpureum and lactation.
• Losses significance if occurs in presence of a lump.
• Incidence vary
• Important- if age above 50, bloodstained in young women
and persistent single duct discharge.

25. Types of Nipple Discharge
• Four groups
1. Physiological Galactorrhea
2. Secondary Galactorrhea
3. Coloured Opalescent or Grumous
4. Serosangious and Watery

26. Diagnosis of Nipple Discharge
Type of discharge Main Cause Less Common cause
Bloody Hyperplastic lesions Duct Ectasia
Watery Hyperplastic lesions Duct Ectasia
Coloured Opalescent Duct Ectasia Cyst
Milk Physiological Galactorrhea/ Endocrine
origin
Hyperplastic lesions include hyperplasia, papilloma, carcinoma in
situ and IDC.

27. Physiological Galactorrhea
• Milk secretion unrelated to breast feeding
• Causes
A. Mechanical stimulation
B. Extremes of reproductive life ( puberty/ menopause)
C. Postlactational
D. Stress
• Treatment-Reassurance and explanation that its self
limiting.

28. Secondary Milk Discharge
• Drugs
A. Dopamine receptor Blocking: Chlorpromazine,
Haloperidol, Metoclopramide,Domperidone
B. Dopamine Depleting Agents: Reserpine, Methyldopa
C. Estrogen ( OCP)
D. Opiates
• Pathological
A. Hypothalamic / Pituitary stalk lesions
B. Pituitary Adenoma/ Microadenoma
C. Ectopic Prolactin ( Bronchogenic Carcinoma)

29. Coloured Opalescent Discharge
• Apart from serosangious and milk discharge
• Wide range of color and consistency
• Creamy, purulent, yellow, brown, green and black.
• No increased cancer risk
• Common in late reproductive life
• Most common pathology Duct Ectasia
• Sometimes due to underling cyst

30. Blood and Serosangious Discharge
• Due to epithelial hyperplasia , duct papilloma, malignancy.
• Rare due to duct ectasia
• >55years age increase risk of malignancy
• Incidence of cancer is 3% below 40yrs,10% btw40-60 and
32% over 60yrs
• Blood discharge in pregnancy- Bilateral, 2nd to 3rd
trimester.
• Unilateral discharge in pregnancy must be investigated.
• Post surgery – usually due to communication btw
operative site and ducts.
• Watery discharge-rare, same significance as bloody.

31. Investigations
• Mammography
• Glactography
• Ultrasound
• Ductal Lavage
• Fiberoptic ductography
• Exfoliative cytology

32. Managment
• In case of lump- treat according to lump, disregard
discharge
• No lump present- treat the underlying cause.

33. Benign Duct Papilloma
1. Discrete Duct papilloma- common
2. Multiple duct papillomas-rare
3. Juvenile papilloma-very rare
Discrete Papilloma 2-3mm diameter, grows along the
length of duct, no pre malignant potential. Either observe or
excise.
Multiple Papilloma Involve peripheral ductules,
premalignant potential, complete excision with healthy
margins.
Juvenile Papilloma histological diagnosis. Excision with
clear margins

34. Duct Ectasia
• Dilatation of the ducts
• Leads to stagnation and accumulation of discharge
• May cause ulceration
• If Blood discharge- Duct exicision

35. Duct Exicision

36. BREAST ABSCESS

37. Breast Abscess
• This condition is usually found during lactation . as role
the infecting organism is :
• staphylococcus aureus, and less commonly
streptococcus pyogenes .
• the usual mode of infection is via the nipple, the infection
being carried from the nasopharynx of the suckling infant
• The infection is at first limited to the segment drained by
the lactiferous duct but it may subsequently spread to
involve other areas of the breast.

38. Clinical Presentation
• Localized breast area edematous, erythematous, warm, and painful
• History of previous breast abscess
• Associated symptoms of fever, vomiting, and spontaneous
drainage from the mass or nipple
• May be lactating

39. Investigations
• Ultrasound- to localize abscess
• Needle aspiration- confirm presence of pus
• Mammogram- to exclude Ca

40. Lactational breast abscess
• Usually due to Staph. aureus
• Usually peripherally situated
• Attempt aspiration
• If no pus - antibiotics
• If pus present consider
repeated aspiration or incision
and drainage
• Consider biopsy of cavity wall
• Continue breast feeding from
opposite breast / evacuation of
ipsilateral side
• No need to suppress lactation
Non-lactational breast abscess
• Occur in periareolar tissue
• Culture yield - Bacteroides,
anaerobic strep, enterococci
• Usually manifestation of duct
ectasia / periductal mastitis
• Occur 30- 60 years , More
common in smokers
• Often give history of recurrent
breast sepsis
• Repeated aspiration is the
treatment of choice
• Metronidazole and flucloxacillin
• Drain through small incision if non-
resolving

41. Managment

42. Complication Of I AND D
• Mammary Duct Fistula
After incision and Drainage of lactational breast abscess
Typical hx and appearance
Surgical scar with inverted nipple
Milk / Pus discharge
Two groups-superficial and deep
Superficial Involves areolar glands, conservative
management
Deep Involves duct, will need excision of involved duct
and fistula.

43. THANK YOU