Fwd: Benign Breast Disease Mr. Evoy


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Date: 2009/2/25
Subject: Benign Breast Disease Mr. Evoy
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Fwd: Benign Breast Disease Mr. Evoy

  1. 1. Benign Breast Disease Mr Denis Evoy
  2. 2. Surgical Consult <ul><li>Majority of surgical consultation for Breast complaints ultimately prove to have a benign origin. </li></ul><ul><li>Surgeon’s role in management of Benign Breast Disease includes: </li></ul><ul><ul><li>Assessment of Breast Cancer Risk </li></ul></ul><ul><ul><li>Breast Cancer Screening </li></ul></ul><ul><ul><li>Providing Specific Diagnosis </li></ul></ul><ul><ul><li>Treatment/Management </li></ul></ul>
  3. 3. ANATOMY <ul><li>Develops from Ectoderm Milk Streak </li></ul><ul><li>Lobules and Ducts </li></ul><ul><ul><li>The breast glandular tissue consists of 15 to 20 lobules (clusters of milk forming glands, or acini) that enter into branching and interconnected ducts. The ducts widen beneath the nipple as lactiferous sinuses and then empty via nipple openings. </li></ul></ul>
  4. 4. ADH
  5. 5. ANATOMY <ul><li>Blood Supply </li></ul><ul><ul><li>Branches of Internal Mammary Artery, Intercostal arteries, Axillary Artery </li></ul></ul><ul><ul><li>Venous drainage via Internal Mammary, Intercostal, Axillary Veins </li></ul></ul><ul><li>Lymphatic Drainage </li></ul><ul><ul><li>97% to Axillary Nodes </li></ul></ul><ul><ul><li>Internal Mammary and Supraclavicular nodes </li></ul></ul>
  6. 6. Anatomy <ul><li>Axillary lymph nodes defined by pectoralis minor muscle </li></ul><ul><ul><li>Level 1 – lateral </li></ul></ul><ul><ul><li>Level 2 – posterior </li></ul></ul><ul><ul><li>Level 3 – medial </li></ul></ul><ul><li>Long Thoracic Nerve </li></ul><ul><ul><li>Serratus anterior </li></ul></ul><ul><li>Thoracodorsal Nerve </li></ul><ul><ul><li>Latissimus Dorsi </li></ul></ul><ul><li>Intercostalbrachial Nerve </li></ul><ul><ul><li>Lateral cutaneous </li></ul></ul><ul><ul><li>Sensory to medial arm & axilla </li></ul></ul>
  7. 7. BREAST MASS <ul><li>Four Phases of Management </li></ul><ul><ul><li>CBE </li></ul></ul><ul><ul><li>Breast Imaging </li></ul></ul><ul><ul><li>Tissue Sampling </li></ul></ul><ul><ul><li>Treatment </li></ul></ul><ul><li>Palpable mass is most common presentation </li></ul><ul><li>Mammogram/Sonogram/MRI </li></ul><ul><li>FNA/Core biopsy/Excisional biopsy </li></ul>
  8. 8. FNAC <ul><li>Fine Needle Aspiration Cytology involves attaching a 21g needle to a 10 or 20ml syringe to remove cells or fluid from a lesion. Applying suction by withdrawing the plunger from the syringe, cells (or fluid) are extracted and expressed onto microscope slides for analysis. </li></ul><ul><li>A report can be given in about 15 minutes. This can be useful if the initial sample is inadequate as repeat specimens can be taken at the first clinic visit. The major disadvantage is that it requires the time of a dedicated technician with access to a cytologist. In many centres, this is difficult to justify. </li></ul>
  9. 9.                                                                                               
  10. 11. <ul><li>Fibrocystic disease </li></ul><ul><ul><li>Treatment: </li></ul></ul><ul><ul><ul><li>Cyst aspiration </li></ul></ul></ul><ul><ul><ul><li>Analgesia </li></ul></ul></ul><ul><ul><ul><li>Firm Bra support </li></ul></ul></ul><ul><ul><ul><li>Vitamins (E, B6) </li></ul></ul></ul><ul><ul><ul><li>Avoidance of caffeine </li></ul></ul></ul><ul><ul><ul><li>Night time Primrose oil </li></ul></ul></ul><ul><ul><ul><li>Danazole </li></ul></ul></ul><ul><ul><ul><li>Bromocryptine </li></ul></ul></ul><ul><ul><ul><li>Tamoxifen </li></ul></ul></ul><ul><ul><ul><li>Contraceptives </li></ul></ul></ul><ul><ul><ul><li>Reassurance </li></ul></ul></ul>
  11. 12. Inflammatory Breast disease <ul><li>Fibrocystic disease </li></ul><ul><ul><li>Very common </li></ul></ul><ul><ul><li>? Hormonal origin </li></ul></ul><ul><ul><li>Young patients (<40 years, < 2-3% cancer) </li></ul></ul><ul><ul><li>Fibrous tissue, cysts, nodules </li></ul></ul><ul><ul><li>Focal, general, uni/bilateral </li></ul></ul><ul><ul><li>Round cell infiltration </li></ul></ul><ul><ul><li>Pain (cyclical) </li></ul></ul><ul><ul><li>Symptoms tend to improve /disappear with pregnancy </li></ul></ul>
  12. 13. Cysts <ul><li>Cysts </li></ul><ul><ul><li>Simple cyst may be observed or aspirated </li></ul></ul><ul><ul><li>Bloody aspirate – send for cytology </li></ul></ul><ul><li>Fibrocystic Changes </li></ul><ul><ul><li>Not considered “disease” </li></ul></ul><ul><ul><li>No increase risk of cancer </li></ul></ul><ul><ul><li>Common finding >50% </li></ul></ul><ul><ul><li> </li></ul></ul>
  13. 14. Fibroadenoma <ul><li>A fibroadenoma is a benign solid growth that usually presents as a palpable breast lump. On examination, it is usually a well circumscribed , firm , mobile discrete breast lump and can occasionally be multiple or bilateral. It is sometimes referred to as a breast mouse because of its mobility within the breast tissue. </li></ul><ul><li>Fibroadenomas account for approximately 12% of all palpable symptomatic breast masses . They occur most commonly in women aged between 15 and 25 but still account for 15% of all discrete lesions in women aged 30 to 40 years. Thereafter, they are less common. </li></ul>
  14. 15.                                                                                
  15. 16.                                                                                               
  16. 17. Evaluation and Treatment <ul><li>The diagnosis of a fibroadenoma can be strongly suspected on clinical grounds. This can be supported by cytological examination following fine needle aspiration but the definitive diagnosis is only made on histology after excision of the lesion. </li></ul><ul><li>4 types of fibroadenoma : </li></ul><ul><ul><li>common fibroadenoma </li></ul></ul><ul><ul><li>giant fibroadenoma </li></ul></ul><ul><ul><li>juvenile fibroadenoma </li></ul></ul><ul><ul><li>phylloides tumour </li></ul></ul><ul><li>There is no universally accepted definition of a giant fibroadenoma but most consider that a fibroadenoma must measure over 5 cm in size to qualify for this definition. </li></ul><ul><li>Most juvenile fibroadenomas undergo rapid growth and tend to be more cellular than ordinary fibroadenomas. </li></ul><ul><li>Phylloides tumours are a distinct pathological entity and, although they cannot always be differentiated from fibroadenomas clinically, their histology and behaviour are such that they should be classified separately . </li></ul>
  17. 18. Fibroadenoma <ul><li>It is routine practice to excise fibroadenomas that are over 3 or 4 cm in size. Fibroadenomas are benign and few increase in size. Once a definitive diagnosis is established by a combination of clinical examination and FNAC, the patient can be given the option of observation or surgical removal . Some believe that observation is only appropriate in women under the age of 40 because of the possibility of missing a breast cancer in older women. </li></ul><ul><li>If access to good quality cytology is not available, it is wise to excise all fibroadenomas to be certain that no malignant lesions are missed. </li></ul><ul><li>Phylloides Tumours </li></ul><ul><li>Phylloides tumours exhibit a spectrum of behaviour ranging from benign to malignant with a close correlation between the histological appearance and the subsequent behaviour. Only rarely do they metastasise and the main problem is local recurrence. </li></ul><ul><li>Treatment is by wide excision that in some instances means a mastectomy . </li></ul>
  18. 19. Cysts <ul><li>Cysts are a common type of benign breast lump present in patients at breast clinics. Cysts can be painful; they occur most frequently in women between the ages of 38 and 53. </li></ul><ul><li>Evaluation and Treatment </li></ul><ul><li>If a breast lump is suspected to be a cyst, it should be aspirated directly or under ultrasonographic guidance. The cyst fluid has a variable colour from a pale yellow to brown or dark green. Routine cytological examination of cyst fluid is not rewarding and can be potentially misleading. </li></ul><ul><li>It is mandatory to confirm that the cyst has disappeared after aspiration and that the fluid is not blood-stained . If ultrasonography shows a solid component to the cyst, this should be investigated with FNAC or wide-bore needle biopsy . </li></ul>
  19. 20. Duct Ectasia/Peri-ductal Mastalgia <ul><li>Peri-ductal mastalgia is characterised by mastalgia of a non-cyclical nature, nipple discharge and periareolar inflammation that may be associated with nipple retraction . The formation of mammary fistulae and non-lactating breast abscesses is frequently seen. </li></ul><ul><li>In this condition, the ducts are not dilated but are surrounded by an inflammatory response. The aetiology of the inflammation is unknown. Duct ectasia typically occurs in the peri-menopausal or late pre-menopausal groups. The role of bacterial infection in the pathogenesis is controversial. </li></ul><ul><li>Evaluation and Treatment </li></ul><ul><li>Treatment of duct ectasia and peri-ductal mastalgia includes antibiotic therapy for the acute inflammatory episode. Ongoing symptoms are best resolved through total major duct excision . </li></ul>
  20. 21. Duct Papilloma <ul><li>Benign papillomas of the ducts are very common and should be regarded as aberrations of cyclical change rather than true benign tumours. These lesions are either single or multiple. </li></ul><ul><li>The most frequent symptom is nipple discharge that may be blood-stained. Treatment consists of microdochectomy, which involves excising the duct . </li></ul>
  21. 22.                                                                                               
  22. 23. Nipple Discharge <ul><li>A small amount of fluid can be expressed in two-thirds of all non-lactating women by application of suction to the nipple. This is regarded as physiological. It varies in colour from a clear off white fluid through yellow to dark green and should never be blood-stained. </li></ul><ul><li>A discharge is significant when it occurs spontaneously and is a dominant symptom . A blood-stained nipple discharge can range from serosanguinous to heavily blood-stained. This discharge is often due to epithelial hyperplasia in the form of a duct papilloma. The condition is most often benign but the risk of malignancy increases with age. Duct ectasia may lead to blood-stained nipple-discharge with </li></ul><ul><li>ulceration within the ducts. </li></ul><ul><li>A discharge associated with breast cancer is usually blood-stained and associated with a palpable lump. In a minority of patients, no cause of a discharge is established even after an operation such as major duct excision. </li></ul>
  23. 24. Nipple discharge <ul><li>Serous discharge </li></ul><ul><ul><li>Common </li></ul></ul><ul><ul><li>Usually benign (> age 60 D/D carcinoma) </li></ul></ul><ul><ul><li>Complete breast evaluation! </li></ul></ul><ul><ul><li>Tx: Observation </li></ul></ul><ul><ul><ul><li>Abstain from repeated breast manipulation </li></ul></ul></ul><ul><ul><ul><li>Treatment of underlying problem </li></ul></ul></ul>
  24. 25. Nipple discharge <ul><li>Bloody discharge </li></ul><ul><ul><li>Fibrocystic disease </li></ul></ul><ul><ul><li>Ductal papilloma </li></ul></ul><ul><ul><li>Ductal carcinoma </li></ul></ul><ul><ul><li>Management: </li></ul></ul><ul><ul><ul><li>With lump -> treat the lump </li></ul></ul></ul><ul><ul><ul><li>W/O lump -> complete breast evaluation Ductogram Duct endoscopy Lacrimal probe to localize duct Duct excision NO FROZEN SECTION! </li></ul></ul></ul>Age< 40 Age> 40
  25. 26. Evaluation and Treatment <ul><li>Investigation of a bloody nipple discharge should include: </li></ul><ul><ul><li>haemostix testing to confirm the presence of blood </li></ul></ul><ul><ul><li>cytological examination </li></ul></ul><ul><ul><li>assessment of the breast with examination and mammography </li></ul></ul><ul><li>Surgical excision of the involved duct through microdochectomy , is preferred for a single discharging duct. As the risk of malignancy is higher for a patient with multiple duct discharge and in patients over the age of 50 with a single duct discharge, total duct excision is the favoured approach . </li></ul>
  26. 27. Mammary Fistula <ul><li>A mammary fistula is a rare recurrent condition characterised by draining abscesses above the nipple in one or both breasts. Because little is known about the disease, it is often misdiagnosed and inappropriately treated.  </li></ul><ul><li>Evaluation and Treatment </li></ul><ul><li>The clinical and pathological findings are similar to duct ectasia or peri-ductal mastalgia and usually consist of a swelling or mass at the areola, draining fistula from the subareolar tissue, a chronic thick, discharge from the nipple and pain. Core excision of the fistula and all the retroareolar fibroglandular tissue and the ductal tissue within the nipple is the usual definitive therapy </li></ul>
  27. 28. Gynaecomastia <ul><li>Gynaecomastia- abnormal enlargement of the male mammary gland - is the most common condition affecting the male breast. The condition is entirely benign and usually reversible. It may be physiological as in neonatal or pubertal. It may also be related to drugs, in particular cimetidine and tricyclic antidepressants. Gynaecomastia also occurs in chronic liver disease due to failure of the liver to metabolise circulating oestrogens. </li></ul>
  28. 29.                                                                  
  29. 30. Evaluation and Treatment <ul><li>The majority of cases will be idiopathic in apparently healthy men. It is, however, important to verify that the testes are normal and to exclude cirrhosis. Because gynaecomastia results from a hormonal imbalance or as a side effect of certain drugs, firm reassurance that this is a benign condition will suffice. </li></ul><ul><li>Malignancy should be suspected in patients without a cause for gynaecomastia, especially if there is an eccentric hard lump or ulcerating lesion . </li></ul><ul><li>Medical therapy is seldom of value except when a specific cause has been established. Discontinuation of causative drugs often leads to breast regression. Surgical removal of the breast tissue is indicated where medical treatment fails or where the degree of breast enlargement is a cosmetic or psychological problem. Subcutaneous mastectomy is performed through a periareolar or infra mammary incision, depending on the extent of the tissue to be excised. </li></ul>
  30. 31. Breast Skin <ul><li>Mastitis/Abscess </li></ul><ul><ul><li>S. Aureus </li></ul></ul><ul><ul><li>Inflammatory Breast Cancer </li></ul></ul><ul><li>Mondor’s Dz. </li></ul><ul><ul><li>Painful, cordlike superficial thrombophlebitis </li></ul></ul>
  31. 32. Benign Breast Disease <ul><li>NONPROLIFERATIVE </li></ul><ul><ul><li>FIBROCYSTIC CHANGES </li></ul></ul><ul><ul><li>NO INCREASED RISK </li></ul></ul><ul><li>PROLIFERATIVE </li></ul><ul><ul><li>PAPILLOMATOSIS </li></ul></ul><ul><ul><li>1-2X INCREASED RISK OF CANCER </li></ul></ul><ul><li>ATYPICAL PROLIFERATION </li></ul><ul><ul><li>ATYPICAL HYPERPLASIA </li></ul></ul><ul><ul><li>4-5X INCREASED RISK OF CANCER </li></ul></ul>
  32. 33. Relationship between benign and malignant breast disease No increased risk Sclerosing adenosis, Apocrine change Duct ectasia Mild hyperplasia Apocrine metaplasia Fibroadenoma, hamartoma, Cysts Slight increased risk (1.5 to 2 times) Moderate or florid hyperplasia Papilloma with fibro vascular core Moderate increased risk (4 to 5 times) Atypical ductal hyperplasia Atypical lobular hyperplasia Radial scar
  33. 34. Mastalgia <ul><li>Mastalgia — a general term for breast pain — is one of the most common symptoms and affects up to 70% of women at some time in their lives. It accounts for approximately 50% of referrals to a specialised breast clinic and is the most frequent reason for breast-related consultation in general practice. </li></ul><ul><li>At present the aetiology of mastalgia remains obscure. Although the cyclical nature of the condition would suggest that hormones are involved, there are several studies which show no difference in oestrogen levels between these patients and controls </li></ul>
  34. 36. Evaluation and Treatment <ul><li>The most important aspects in the evaluation and treatment of breast pain consist of a thorough history , physical and radiological evaluation . These can be used to reassure the patient that she does not have breast cancer. </li></ul><ul><li>The best way to assess whether the pain is cyclical is to ask the patient to complete a breast pain chart , a blank calendar where the patient notes the occurrence and severity of pain daily, as well as keeping track of the dates of her menstrual cycle. </li></ul><ul><li>After exclusion of breast cancer, 85% of patients can be discharged from the clinic without specific treatment . Therapy may consist of a well-fitting bra , a decrease in dietary fat intake, manipulation to reduce saturated fat or supplemental essential fatty acid intake and a discontinuance of oral contraceptives or hormone replacement therapy . </li></ul><ul><li>Women resistant to these simple measures may experience relief from using gammalinolenic Acid as first line therapy. Danazol or Bromocriptine are usually used as second line agents. Both are effective treatments but have a much higher incidence of side effects such as weight gain , nausea or oily skin . </li></ul><ul><li>Patients with severe recurrent or refractory mastalgia may require treatment with Tamoxifen, Goserelin or Testosterone, treatments generally prescribed by a breast cancer specialist. </li></ul>
  35. 37. Atypical Hyperplasia <ul><li>Marked proliferation and atypia of the epithelium, either ductal or lobular. </li></ul><ul><li>Found in 3% of benign breast biopsies </li></ul><ul><li>Associated with a 13% subsequent development of breast cancer (4x risk factor) </li></ul><ul><li>Some may be an under-diagnosed ductal carcinoma in situ. </li></ul><ul><li>Excisional Biopsy – do not need clear margins </li></ul>
  36. 38. Atypical Ductal Hyperplasia
  37. 39. ADH
  38. 40. NONINVASIVE CANCER <ul><li>Ductal Carcinoma In Situ (DCIS) </li></ul><ul><ul><li>Malignant cells of Ductal Epithelium without invasion of basement membrane. </li></ul></ul><ul><ul><li>50-60% increased risk in ipsilateral breast. </li></ul></ul><ul><ul><li>Lumpectomy and XRT. Need clear margins. </li></ul></ul>
  39. 41. DCIS
  40. 42. IDC
  41. 43. NONINVASIVE CANCER <ul><li>Lobular Carcinoma In Situ (LCIS) </li></ul><ul><ul><li>Usually an incidental finding on biopsy </li></ul></ul><ul><ul><li>Risk of Breast Cancer increases 1% per year b/l breasts. Usually Ductal CA. </li></ul></ul><ul><ul><li>Do not need clear margins </li></ul></ul><ul><ul><li>Mgmt: Close clinical follow up or prophylactic B/L mastectomy. </li></ul></ul>
  42. 44. Congenital Breast disease Amazia Supernumerary Nipple Acessory Breast(s)
  43. 45. Traumatic Breast disease <ul><li>Fat necrosis </li></ul><ul><li>Hematoma </li></ul><ul><li>Post Surgery </li></ul><ul><li>D/D: Carcinoma </li></ul>
  44. 46. Inflammatory Breast disease <ul><li>Mastitis neonatorum </li></ul><ul><ul><li>Occurs within few weeks of birth </li></ul></ul><ul><ul><li>Response to mothers hormone exposure (prolactin, estrogen) </li></ul></ul><ul><ul><li>Resolves spontaneously </li></ul></ul><ul><ul><li>Occasionally becomes infected </li></ul></ul>
  45. 47. Other inflammatory causes of breast pain <ul><li>Mondor’s disease </li></ul><ul><ul><li>Thrombophlebitis lateral thoracic vein </li></ul></ul><ul><li>Tietze’s disease </li></ul><ul><ul><li>Osteochondritis, usually 2 nd & 3 rd chostochondral junction </li></ul></ul><ul><ul><li>Treatment for both: NSAID analgetics </li></ul></ul>
  46. 48. Tumors of the breast <ul><li>Cystosarcoma Phylloides </li></ul><ul><ul><li>Rare </li></ul></ul><ul><ul><li>Age +/- 40 </li></ul></ul><ul><ul><li>Rarely malignant </li></ul></ul><ul><ul><li>Large </li></ul></ul><ul><ul><li>Mobile </li></ul></ul><ul><ul><li>Bosselated </li></ul></ul><ul><ul><li>Ulceration of skin </li></ul></ul>
  47. 49. <ul><li>Gynecomastia </li></ul><ul><ul><li>Neonates </li></ul></ul><ul><ul><ul><li>Mother’s hormones </li></ul></ul></ul><ul><ul><li>Puberty </li></ul></ul><ul><ul><ul><li>Hormonal imbalance </li></ul></ul></ul><ul><ul><li>Seniors </li></ul></ul><ul><ul><ul><li>Androgen deficiency </li></ul></ul></ul><ul><ul><li>General Etiology: </li></ul></ul><ul><ul><ul><li>Idiopathic </li></ul></ul></ul><ul><ul><ul><li>Endocrine </li></ul></ul></ul><ul><ul><ul><ul><li>Testicular atrophy </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Testicular tumors </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Adrenal tumors </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Hyperthyroidism </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Pituitary tumors </li></ul></ul></ul></ul><ul><ul><ul><li>Genetic </li></ul></ul></ul><ul><ul><ul><li>XO, XXY, … </li></ul></ul></ul><ul><ul><ul><li>Liver disease </li></ul></ul></ul><ul><ul><ul><li>Bronchial carcinoma </li></ul></ul></ul><ul><ul><ul><li>Kidney failure </li></ul></ul></ul><ul><ul><ul><li>HIV </li></ul></ul></ul><ul><ul><ul><li>Medications </li></ul></ul></ul><ul><ul><ul><ul><li>Digitalis, Spironolactone, Anabolic steroids, Marihuana, … </li></ul></ul></ul></ul>
  48. 50. Tumors of the breast <ul><li>Gynecomastia </li></ul><ul><ul><li>Thorough history and physical! </li></ul></ul><ul><ul><li>Endocrine workup as indicated </li></ul></ul><ul><ul><li>Biopsy & Mammogram when: </li></ul></ul><ul><ul><ul><li>clinical suspicion </li></ul></ul></ul><ul><ul><ul><li>persistence w/o clear cause </li></ul></ul></ul><ul><ul><ul><li>age > 60 </li></ul></ul></ul><ul><ul><li>Tx: </li></ul></ul><ul><ul><ul><li>Observation </li></ul></ul></ul><ul><ul><ul><li>Danazole / Tamoxifen </li></ul></ul></ul><ul><ul><ul><li>Excision </li></ul></ul></ul>
  49. 51. Benign disease of the Breast ?