This is a detailed presentation of Benign breast diseases.A detailed presentation on "One Stop Breast clinic"

1. BENIGN DISEASES OF THE BREAST
ONE STOP BREAST CLINIC
EVALUATION OF BREAST LUMP
DR. ARTI ANAND
PGY3, UNTI S3
MODERATORS – DR. KUSUM MEENA
DR. ASHISH ARSIA

2. ANDI
• Aberrations of Normal Development and Involution
• Principles of classification –
1. Related to the normal processes of reproductive life and to
involution
2. Spectrum of conditions ranging from disorders to disease
3. Includes pathogenesis and degree of abnormality

4. EARLY REPRODUCTIVE YEARS
FIBROADENOMA
• Among ages 15 to 25 years
• Abundant stroma with histologically normal
cellular elements
• No genetic factors. However, family history +
• Larger fibroadenomas - </=3cm – DISORDER
• Giant fibroadenomas - >3cm
• Multiple fibroadenoma (>5 in one breast) –
DISEASE

5. • USG guided core needle biopsy – most accurate diagnosis
Conservative management is recommended
• <35 years age – follow- up every 6 months – no regression/ unchanged by age
35 years – surgical excision
• Women more than 35 years age – mammography
• Close follow-up every 6 months. Persistent after 12 months – excised
• Cryoablation, USG guided vacuum assisted biopsy  <3cm
• Larger  excision
• 1.3 to 2.1 times increased risk of breast cancer
• Risky characteristics – elements of sclerosing adenitis, epithelial calcifications,
papillary apocrine metaplasia – risk 3.1 times increased

6. NIPPLE INVERSION
• Disorder of development of the major ducts
• Congenital in 10% of the population
• Prevents normal protrusion of the nipple
• Cosmetically undesired and worrisome.
• Benign inverted nipple must be differentiated from
primary breast malignancy.
• 3 grades
MAMMARY DUCT FISTULA
• Nipple inversion  major duct obstruction
recurrent subareolar abscess  FISTULA
GIGANTOMASTIA
Occurs due to massive stromal hyperplasia

7. LATER REPRODUCTIVE YEARS
CYCLICAL MASTALGIA AND NODULARITY
• Associated with premenstrual enlargement of the breast
• Painful nodularity >1 week of the menstrual cycle – DISORDER
• Appropriately fitting garment
• Reassurance, evening primrose oil for 3 months
• Persistent/ severe – danazol, prolactin inhibitor (bromocriptine)
• Non-cyclical mastalgia – exclude extramammary causes like chest wall
pain, referred pain from shoulders, etc

8. DISORDERS OF INVOLUTION
• It is a two-step process that involves the
death of the secretory epithelium and its
replacement by adipo-cytes.
• During the first phase, remodelling is
inhibited and apoptotic cells can be seen
in the lumen of the alveoli. In the second
phase, there is remodelling of the
surrounding stroma and re-differentiation
of the adipocytes.
• If involution occurs too quickly – alveoli
remain – forms microcysts – precursors
of macrocysts.

9. SCLEROSING ADENITIS
• Disorder of both proliferative and involutional
phases
• No malignant potential
• Seen in childbearing and peri-menopausal age
groups
• Distorted breast lobules
• Rarely – palpable mass
• Management by observation

10. PERIDUCTAL MASTITIS
• Painful tender mass behind NAC
• Fluid aspirated and submitted for culture
• Antibiotics based on antibiogram
• Considerable pus – usg aspiration
PERIDUCTAL FIBROSIS
• Sequelae of periductal mastitis
• May result in nipple retraction

12. EPITHELIAL HYPERPLASIA
Seen in about 60% women above 70 years of age
Atypical proliferative disease
Approximately 10% of female breast biopsies will contain an atypical proliferative lesion
ATYPICAL DUCTAL HYPERPLASIA
• Similar to DCIS histologically
• Upto 3mm – ADH. >3mm – DCIS
• May require excisional biopsy for differentiation
• Increased risk of developing malignancy
ATYPICAL LOBULAR HYPERPLASIA
• Similar to LCIS
• <50% involvement of acini in TDLU
• Lack of E-cadherin expression seen like in LCIS (present in DCIS)

13. MANAGEMENT OF ATYPICAL HYPERPLASIA
• Pre-malignant
• Excision recommended in high risk patients
• Low risk – no family h/o, no mutations – surveillance, medical therapy
with estrogen receptor modulators

14. HISTOLOGICAL DIFFERENTIATION

15. DUCT ECTASIA
• Dilated sub-areolar ducts
• Palpable , associated with a thick nipple discharge – green
or black
• Stagnation of secretions, epithelial ulceration, leakage of
ductal secretions into periductal tissues
• It is usually unilateral, emanating from a single duct, though
bilateral cases have been reported.
• If the discharge is bilateral, it is more likely to be due to
fibroadenocystic disease
• This produces local inflammation, periductal mastitis,
periductal fibrosis, nipple inversion, abscesses

16. • EVALUATION – triple assessment approach
• Imaging – recently introduced – duct endoscope – cannulation of the
discharging duct with 30G and injecting iodinated contrast and taking
CC view images – diagnosis if duct >3mm, smooth walled, without
filling defects
• USG – investigation of choice
• Mammo - microcalcifications, lobulated, partially smooth masses,
nipple retraction, retro-areolar duct dilatation, and rarely speculated
looking mass.
• Others – MRI
• Nipple discharge cytology – foamy macrophages in a proteinaceous
background with normal duct cells

18. TREATMENT
• Symptomatic treatment
• Local hygiene
• If associated with periductal mastitis – antibiotics
• If persistent abscess – I & D
• Recurrent symptoms and swelling – MICRODOCHECTOMY – excision of
the involved duct and surrounding inflammatory tissue

19. CALCIUM DEPOSITS
• Most are benign
• Caused by cellular secretions and debris
• Due to trauma / inflammation
• WORRISOME FEATURES – microcalcifications
(<0.5mm), fine and linear calcifications which
may show branching

20. BREAST HAMARTOMAS
• Discrete breast tumours
• 2 – 4 cms in size
• Most hamartomas have typical features on ultrasound and on
mammography, which are related to the presence of fibrous,
glandular, and adipose tissues
• Malignant transformation of a hamartoma is a very rare event, but it
can occur since the mass contains epithelial tissue

21. RADIAL SCARS
• Central sclerosis and various degrees of
epithelial proliferation
• Lesions upto 1 cm – radial scar
• Larger lesions – complex sclerosing lesions
• Maybe associated with papilloma
formation, apocrine metaplasia
• Imaging features may mimic CA – may
require Vacuum assisted biopsy or surgical
excision to exclude possibility of
malignancy

22. INTRADUCTAL PAPILLOMA
• Arise in major ducts
• Usually in premenopausal women
• Maybe as large as 5cm
• Nipple discharge – serous or bloody
• Usually attached to the duct wall by a stalk
• Does not increase malignancy risk, unless
associated with atypia
• Multiple intraductal papillomas in younger women
– malignant transformation

23. • Mammography – round or oval, well-circumscribed,
micorcalcificatiions
• USG – mass near the nipple
• Galactography – intraluminal filling defect with duct dilatation and
abrupt duct cut-off
• Diagnosis confirmation – core needle / vacuum assisted / open tisse
biopsy
• TREATMENT – surgical excision – complete removal of the papilloma

24. BREAST CYSTS
• Cysts seem to form as a result of fibrosis in
breast tissue development and subsequent
failure in the continuous process of the lobule
and terminal ductule formation.
• Palpable breast mass
• Needle biopsy with a 21 gauge needle
• disappear after aspiration
• For a simple cyst, repeat imaging should be
done 4 to 6 weeks after aspiration
• Complex cyst may be a result of underlying
malignancy
• Cyst wall - assessed by pneumocystogram

26. INFECTIOUS AND INFLAMMATORY DISORDERS
BACTERIAL INFECTIONS
• M/C – staphylococcus aureus and
streptococcus
• First few weeks of breast feeding
• Progression – subcutaneous, subareolar,
periductal, retromammary abscesses
• Antibiotics and repeated aspiration
• Failure – operative – I & D
• Epidemic puerperal mastitis - MRSA – high
morbidity
• Zuskas disease – recurrent periductal
mastitis – smoking as risk factor

27. MYCOTIC INFECTIONS
• Rare – may involve blastomycosis or
sporotrichosis
• Antifungals. Occasionally drainage in case of
persistent infection
• Candida – inframammary folds – topical nystatin
application
HIDRADENITIS SUPPURATIVA
• Chronic inflammatory condition
• Originates from axillary sebaceous glands /
accessory areolar glands of Montgomery
• Antibiotics, I & D, excision of involved areas

28. MONDOR’S DISEASE
• Superficial thrombophlebitis of veins of anterior
chest wall
• Tender cord-like veins
• Lateral thoracic/ thoracoepigastric/ superficial
epigastric
• Self-limiting
• Anti-inflammatory agents, warm compresses
• Failure – excision of involved vein segment

29. CONGENITAL ABNORMALITIES
AMAZIA
• Congenital absence of the breast on one or
both sides
• May sometimes be seen as a part of Poland
syndrome
POLYMAZIA
• Accessory breasts
• May function during lactation

30. DIFFUSE HYPERTROPHY
• Occurs sporadically
• Occurs at puberty or during first pregnancy
• Alteration in normal sensitivity of breast to
oestrogenic hormones
• Treatment – reduction mammoplasty
TRAUMATIC FAT NECROSIS
• Painless lump
• May even mimic malignancy with skin tethering
and nipple retraction
• May follow a blow or due to indirect violence

31. BREAST TUBERCULOSIS
• Tuberculosis of the breast is a rare disease, mostly because organs or tissues like the
breast, skeletal muscle and spleen are more resistant to infection
• The routes of spreading to the breast are hematogenic, lymphatic, by direct extension
from the thoracic wall or the axillary lymph nodes, or by inoculation through
traumatized skin or ducts.
• The commonest clinical presentation is that of a lump
• Recurrent inflammation and abscess of the breast that do not respond to surgical
drainage and standard antibiotic therapy
• The gold standard for the diagnosis of breast tuberculosis is detection of M.
tuberculosis by Ziehl Neelsen staining or by culture

32. ONE STOP BREAST CLINIC
• Mammographic breast cancer screening programmes allow a 20%
reduction in breast cancer-specific mortality overall.
• Rapid diagnosis after a positive screening - allows rapid care or
reassurance depending on the final diagnosis. Offers same day
diagnosis and treatment
• One stop clinics must be provided by consultants because women are
seen only once and consultant radiologists and pathologists who must
be available for the whole clinic

34. DIAGNOSIS AND SCREENING OF A BREAST LUMP
• Determine patient’s age and reproductive history- age at menarche,
menopause
• Previous history of breast biopsies, family history
• History of a mass, breast pain, nipple discharge, skin changes
• Constitutional symptoms of metastasis
• Physical examination of breast and regional lymph nodes
• FNAC
• Core needle (method of choice)
• Excision biopsy

35. RISK ASSESSMENT
GAIL MODEL
• Assesses population risk using non-genetic factors
• Age, race, age at menarche, age at first live birth, number of breast
biopsies, presence of proliferative disease with atypia, presence of first
degree female relative with breast cancer
• 5 year calculated risk of >/= 1.67% is high risk
• Others - Claus model, BRCApro model, etc
• High risk – close surveillance with clinical breast examination,
mammography and breast MRI, chemoprevention, prophylactic surgeries

36. CLOSE SURVEILLANCE
• Surveillance guidelines established by NCCN
• Recommends – monthly self breast examination beginning at 18 years age,
semi-annual clinical examination from 25 years, annual mammography since 25
years or 10 years before the earliest age at onset in a family member – for
women in a family with breast and ovarian cancer syndrome
• Genetic counselling offered in these high risk groups
CHEMOPREVENTION
• Tamoxifen and Raloxifen
• Most effective in preventing ER positive cancers
• Metaanalysis – risk reduction by 38%
• Aromatase inhibitors – prevents contralateral breast cancer in post-menopausal
women

37. PROPHYLACTIC MASTECTOMY
• Reduces the chances of breast cancer in high risk women by 90%
• Risk reducing salpingooopherectomy – significant reduction in breast
cancer-specific mortality
BRCA TESTING
• Involves DNA sequencing
• Price varies between 20k – 30k in India
• Samples – blood/ saliva
• Can help in planning risk-reducing mastectomy and BSO

39. THANK YOU