This document discusses benign and malignant breast diseases. It begins by covering benign breast disorders and diseases, including their causes, classification, pathology, presentations, diagnoses, and management. Common benign conditions discussed include fibroadenomas, cysts, and mastalgia. The document then covers breast cancer, distinguishing between non-invasive (DCIS, LCIS) and invasive forms. Invasive breast cancer is further classified as early, locally advanced, inflammatory, or metastatic. Key points on epidemiology, screening, pathology, diagnoses, treatments, prognosis and the differences between familial and sporadic breast cancer are also summarized.

1. BENIGN AND MALIGNANT DISEASES OF TH
E BREAST
• Benign breast disorders and diseases
• Breast cancer
I Wayan Sudarsa
Department of Surgery Faculty of Medicine University of Udayana
Sanglah General Hospital Denpasar Bali

2. Benign breast disorders and disea
ses

5. Hormones affecting the breast
LHRH
(hypothalamus)
Pre/post-
menopausal
Premenopausal
Gonadotrophins
(FSH + LH)
Adrenocorticotrophic
hormone
(ACTH)
Adrenal
glands
Pituitary gland
Prolactin
Growth hormone
Oestrogens
Progesterone
Corticosteroids
Progesterone
Androgens Oestrogens
Peripheral conversion
Ovary

6. Lecture plan
 Incidence
Theories of aetiopathogenesis
 Classification : ANDI
 Pathology :histological risk factors
 Presentation & diagnosis (Triple assessment )
 Correlation of symptoms with possible diagnosis
 Clinical features & managment of common problems : lump, pain,
nipple discharge, nipple change, common cosmetic problems
 Conclusion : key points

7. Developed countries - malignant : benign breast disease ratio = 1:10
Developing countries - rising incidence
Gender : seldom affects men
Incidence
Compare with incidence of Carcinoma breast
M ore developed countries 579285 Cases 94.93 Crude rate
Less developed countries 471063 19.66
U. K 34815 116.27
USA 183494 129.9
- GLOBOCAN 2000, IARC Press, Lyon, 2001

8. Endocrine factors
1. Disturbances in the Hypothalamo Pituitary Gonadal steroid axis
2. Altered Prolactin profile – qualitative /quantitative change
Non endocrine factors
1. Methyl xanthines, Stress
Genetic predisposition to catecholamine supersensitivity  Intra cellular
C - AMP mediated events  cellular proliferation
2. Diet rich in saturated fat
Altered plasma essential fatty acid profile  receptor supersensitivity to norma
l levels of Oestrogen & Progesterone
3. Iodine deficiency
Receptor supersensitivity to normal levels of Oestrogen & Progesterone
Aetiopathogenesis – some theories

9. Normal Aberration ?? Disease
Reproductive phases
cysts, duct ectasia, mild epithelial hyperplasia
cyclical mastalgia & nodularity
fibroadenoma, juvenile hypertrophy
Involution
Cyclical & se
cretory
Development
Periductal mastitis
Epithelial hyperplasia with
atypia
Giant fibro adenoma
(> 5cms)
Multiple fibroadenoma
(> 5 per breast)
Spectrum of breast changes
ANDI classification ( Hughes et al, 1992 )

12. No risk
Fibroadenoma
Cysts
Duct ectasia
Mild hyperplasia
Slightly increased
risk
(1.5 – 2 times)
Moderately increased
risk
(5 times)
Insufficient data to
assign risk
Moderate / florid/
solid /papillary
hyperplasia
Atypical ductal /
lobular hyperplasia
Radial scar lesion
Pathology –relative risk of invasive breast cancer
- Gist of American College of Pathologists Consensus Statement

13.  Symptoms
Lump
Painful lump or lumpiness
Pain
Nipple discharge
Nipple change
Miscellaneous
 Triple Assessment
 Clinical examination
 Imaging ( Mammography/ US if < 35years)
 Pathology (FNAC/Core needle)
Presentation & Assessment
80%
99% accurate

14. Symptoms & possible diagnosis
1.Lump Fibroadenoma
Juvenile Fibroadenoma
Giant fibroadenoma
Phyllodes tumours
Cysts
Galactocele
2.Pain Mastalgia : Cyclical &
Non cyclical
3.Nipple
discharge
Physiological
Bloodstained in
pregnancy
Intraductal papillomas
and associated
conditions
Duct Ectasia
Galactorrhoea
Infections : Lactational & Non lactational
4.Nipple
change
Developmental inversion of nipple
Acquired nipple retraction : duct
ectasia, periductal mastitis etc
Eczema
Paget’s disease etc.
5.Cosmetic
& other
problems
Comon cosmetic problems : size,
shape & symmetry of breast mound
Uncommon cosmetic problems :
developmental & acquired
Trauma
Rare problems

15. Discrete lump
 Fibroadenoma
 Giant fibroadenoma
Juvenile fibroadenoma
 Phyllodes tumours
 Cysts : macrocysts
Nodularity
 Generalised
 Localised
1. Lump
Age incidence of lumps in the breast

16. Fibroadenoma
Types
Solitary
Few (< 5 / breast )
Multiple (> 5 / breast )
Giant (> 4 / 5 cms) & Juvenile
Natural history
Majority remain small & static
50% involute spontaneously
No future risk of malignancy

17. DischargewithadviceonBSE
Nochange/shrinkage/disappearence
ExtracapsularExcision
Increaseinsize/
Atpatientrequest
Clinicalobservationfor2years
Allresultsconcurr
Age<30years
Excision
withrimofnormaltissue
Resultsdonotconcurr
Age>30years
Excisionoflargest
Clinicalobservationofrest
Multiplefibroadenomas
(Selectivetripleassessment)
ExtracapsularExcision
Giantfibroadenoma/
Juvenilefibroadenoma
Tripleassessment
Fibroadenoma
(clinicaldiagnosis)
Management algorithm for Fibroadenomas
Chances of malignancy masquerading as Fibroadenoma
Age 20 – 25 yrs 1: 3000 possibility
Age 25 – 30 yrs 1: 300 possibility

18. Phyllodes tumours
 Comprise less than 1% of all breast neoplasms
 May occur at any age but usually in 5th decade of life
 No clinical or histological features to predict recurrence
 16 - 30% may be malignant
 Common sites of metastasis : lungs, skeleton, heart, and liver

19. 1. Primary treatment
Local excision with
a rim of normal tissue
2. Recurrence
 Re excision
or
Mastectomy with or witho
ut reconstruction
 Response to chemother
apy and radiotherapy for r
ecurrences and metastas
es poor
Treatment of Phyllodes tumours

20. Cysts
Common in the West ( 70 % of women )
 50% are solitary cysts
 30% 2 - 5 cysts &
 rest have > 5 cysts
Types
 Apocrine cysts
Lined by secretory epithelium
Cyst fluid has a Na : K ratio < 3
Likely to have multiple cysts
Likely to develop further cysts
 Non apocrine cysts
Cyst fluid has a Na : K ratio >3
Resembles plasma
 Mixture of both

21. Management algorithm for cysts
No routine followup
Noresidual mass
Nocyst recurrence
Surgical biopsy
Residual mass
Cyst recurrence(X3)
Nonbloodstainedaspirate
FNAC/Surgical biopsy
Bloodstainedaspirate
Fine needle aspiration
Cyst
(Clinical diagnosis)

22. 2. Pain
True breast pain
Mastalgia
• Cyclical mastalgia
• Non cyclical mastalgia
•True (breast related)
• Musculoskeletal : costochondral or lateral chest wall
Infections
• Lactational infections
• Nonlactational infections
• Central : Periductal mastitis (inflammation, mass, abscess, mammary duct fistula)
• Peripheral : associated with diabetes, rhuematoid arthritis, steroid usage, trauma etc.
• Rare : Tuberculosis, Granulomatous mastitis, Diabetic (lymphocytic) mastitis, etc.
• Skin associated : intertrigo, infected sebaceous cyst, hidradenitis suppurativa etc.

23. Mastalgia
Definition : Pain severe enough to interfere with daily life or lasting o
ver 2weeks of menstrual cycle
True breast pain
Costo
Chondral pain
Lateral chest
wall pain
mild
True breast pain
Musculo skeletal pain

24. • Assess type of pain
• Assess severity of pain ( Pain diary + Visual analogue scale )
• Evaluation with Triple assessment
• Treatment :
 Reassurance is the key to management
 Use of supportive undergarments
 Low fat, Methyl xanthine restricted diet
 Stop Oral contraceptives / HRT etc
 Review patient. Sucessful in the majority ( 80 – 85 % ) of patients
 Start drugs in those not responding to nonpharmacological treatment
 Review and assess response
Management protocol for true mastalgia

25. Drugs of established value in mastalgia
Drug Dose Clinicalresponse Side
effects
Comments
Evening
primroseoil
3g/day Cyclical mastalgia44%
Noncyclical mastalgia
27%
Low(2%) Efficacyasmedicine
questioned.Marketing
authoritywithdrawn.
Danazol 200mg/dayreducedto
100mgonalternate
days(lowdoseregime)
Cyclical mastalgia70%
Noncyclical mastalgia
30%
High(22%) MoreeffectiveinCyclical
mastalgia.
Somesideeffectsmaybe
permanent.
Bromocriptine 2.5mgtwice/day
(incremental dose
regime)
Cyclical mastalgia47%
Noncyclical mastalgia
20%
High(45%) Notrecommendeddueto
serioussideeffects
Tamoxifen 10mg/day Cyclical mastalgia94%
Noncyclical mastalgia
56%
High(21%) Notlicensedforusein
Mastalgia.
UsedinRefractory
mastalgia&relapse
Goserelin 3.75mg/month
intramusculardepot
injection
Cyclical mastalgia91%
Noncyclical mastalgia
67%
High Majorlossof trabecular
bonelimitsuseinRefractory
mastalgia&relapse

26. Reassuare
Paracetamol
Mild
Review
OralNSAID
Moderate
Review
&
repeatifnecessary
1%lignocaine
+
40mgmethylprednisolone
aslocalinjection
Severe
withtriggerpoints
Noncyclicalmastalgia
Musculoskeletaltype
Management protocol for musculo skeletal pain

27. Infections
1. Lactational infections
 Diminishing incidence
 Usually caused by S.aureus
 Clinical features : pain, redness, swel
ling, tenderness &systemic symptom
s
Treatment :
 Antibiotics (E.G. Flucloxacillin, Co a
moxyclav etc) before pus formation
 Abscess : Repeated aspiration / mini
incision with topical anaesthetic crea
m ( I& D under GA occasionally)
 May continue to breast feed

28. Infections
2. NonLactational infections : Central
 Usually due to Periductal mastitis
 Affects younger women. Often smokers in
the West
 May present as : inflammation +/- mass, a
bscess, mammary duct fistula
 Aerobic + anaerobic organisms may be in
volved
Treatment :
 Antibiotics (E.G. Co amoxyclav etc) before
pus formation
 Abscess : Repeated aspiration / mini incisi
on with topical anaesthetic cream ( I& D u
nder GA occasionally)
 MDF : Excision fistula + Total duct excisio
n

29. Nipple discharge
Causes of nipple discharge
Benign (common) Malignant (less common)
Physiological causes
Intraductal pailloma and associated
conditions
Blood stained nipple discharge of
pregnancy
Galactorrhoea
Periductal Mastitis
Duct Ectasia
In situ carcinoma (DCIS)
Invasive carcinoma

30. Charecterestics of nipple discharges
Nonsignificantnippledischarge Significantnippledischarge
Elicited Spontaneous
Age<40years Age>60years(newsymtom)
Bilateral Unilateral
Intermittent Persistent
Thick Watery
Nontroublesome Troublesome
Multiductal Uniductal
Negativetest for blood(reagent sticktest for
blood)
Positivetestforblood

31. Totalductexcision
Distressingsymptoms
Reassure
Minorsymptoms
Multiductal
Reassure
Minorsymptoms/
Nosuspicionofmalignancy
Microdochectomy
Distressingsymptoms/
Nosuspicionofmalignancy
Surgery
Distressingsymptoms/
Suspicionofmalignancy
Uniductal
Normal
Surgery
Abnormal
Tripleassessment
Spontaneousnippledischare
Managment of spontaneous nipple discharge

32. Galactorrhoea
Management :
 Estimate PRL levels. If very high, evaluate for pituitary lesion
 Physiological - Reassurance, cessation of stimulation
 Drug induced - Stop or change drug if possible
 Pathological - Cabergoline / Bromocriptine, treat cause if possible ( E.G. Pituit
ary surgery)
Causesofgalactorrhoea
Physiologicalcauses Drugs Pathologicalcauses
Extremesofage
Stress
Mechanicalstimulation
Oestrogentherapy
Anaesthesia
Dopaminereceptorblockingagents
Dopaminere-uptakeblockers
Dopaminedepletingagents
InhibitorsofDopamineturnover
Stimulationofserotoninergicsystem
HistamineH2-receptorantagonists
Hypothalamiclesions
Pituitarytumors
Reflexcauses:Chestwallinjury,Herpes
zosterneuritis,Upperabdominalsurgery
Hypothyroidism
Renalfailure
Ectopicproduction:Bronchogenicand
renalcarcinoma

33. 4. Nipple changes
Causes :
1. Developmental inversion
2. Acquired inversion
 Periductal mastitis
 Duct ectasia (classical slit retraction)
 Juxta areolar carcinoma with recent & fixed nipple retraction
 Paget’s disease
 dry & scaly variety
 moist & eczematoid
 erosion of nipple
 thickening / macroscopically normal nipple
3. Rare problems : adenoma, papilloma etc

34. Reassure/surgeryatpatientrequest
Normal
Furtherevaluation
Abnormal
Tripleassessment
Nippleretraction
Management of nipple retraction

35. 1. Common cosmetic problems
 Small /large volume breasts
 Ptosis
 Asymmetry of breast size, shape.
Treatment :
Augmentation / Reduction mammoplasty
2. Uncommon cosmetic problems
 Congenital &
 Acquired disturbances of breast devel
opment & growth
5.Cosmetic problems

36. Conclusion - Key points
 Benign breast disorders & diseases are common
 The aetiopathogenesis is complex and not fully understood
The ANDI classification is a unifying concept
 Histological risk factors for future malignancy are relative and not abs
olute risk factors
 Lump and pain are the most common complaints
 Evaluation is done by Triple assessment
 Treatment is based on the natural history of clinical problems
 Management algorithms are general guidelines
 Treatment must be tailored to individual needs

37. BREAST CANCER
NONINVASIVE BREAST CANCER:
DCIS (DUCTAL CARCINOMA IN SITU)
LCIS (LOBULAR CARCINOMA IN SITU)
INVASIVE BREAST CANCER:
EARLY BREAST CANCER (EBC)
LOCALLY ADVANCED BREAST CANCER(LABC)
INFLAMMATORY BREAST CANCER (IBC)
METASTATIC BREAST CANCER (MBC)

38. Lecture plan
• EPIDEMILOGY
• SCREENING
• FAMILIAL BREAST CANCER SPORADIC BR
EAST CANCER
• EARLY DETECTION
• PATHOLOGY
• DIAGNOSIS
• TREATMENTS
• ADJUVANT/NEOADJUVANT TH/
• PROGNOSIS

39. EPIDEMIOLOGY
• The most common cancer in women in the western world.
• The incidence is increasing in developing countries
• Second in common after cervical cancers in indonesia
• The changing of lifestyle, food pattern, more animal product/fat
s
• 70-80% came in late stages
• 70% Ductal carcinomas, 15-20% lobular ca
the rest are miscellaneous
• Risk factors

48. SCREENING
• The objectives is to reduce the incidence (if posible) and mortality
• The result of screening is quite strong in older women, it reduce the mortali
ty up to 50%
• The result of screening is controversial among younger women
• The relations between benign epithelial breast lesion and malignancy is not
clear yet
• The techniques of (individual/mass) screening are “SADARI”, mammograph
y, mammosonography
• SADARI is not a early detection, but it is more likely to down stage the canc
ers

50. EARLY DETECTION
• Secondary prevention (WHO priorities)
• Decrease incidence and increase survival
• Non palpable breast cancer
• Stereotactic biopsy (sono/mammography)
• Conservative surgery (BCT)

51. Familial BC vs Sporadic BC
• 90-95% is sporadic breast cancers
• 5-10% is familial breast cancer
• Familial BC are related to the mutation of specific tumor suprresor g
enes BRCA-1 and BRCA-2
• Phenotype and clinical behaviour of familial BC are different. (more
aggrresive histotype, highly proliferative, high percentage of s-phase
fractions, poor survival etc)
• Pedigree, genetic diagnosis, and counseling
• More intensive screening, chemoprevention, or prophylactic surgerie
s

52. PATHOLOGY
• Majority (70-80%) of breast cancer are from ductal e
pithelium (DCIS or IDC)
• 15% are LCIS or ILC
• Subtype (NOS, comedo, micropapiler, cribriform, solid
, tubuler, papiler, mucinous, medullary)
• Unusual BC pathology (apocrine ca, metaplastic ca,
adenoid cystic ca, malignant phylloides tumor)
• Malignancies from other tissues (sarcomas, Lymphom
a, metastatic cancer)

53. DIAGNOSIS
• Triple diagnosis is the golden standard:
clinical (Ax and risk factors, physical exam)
Imaging (mammography, mamosonography
Pathologic examination (cytology, histopatol
FNAB or open biopsy
• Stage according to TNM system (UICC/AJCC)
• Sentinel lymph node mapping/biopsy (?)

57. TREATMENT
• Surgery (loco-regional control):
Radical Mastectomy (RM): Halsted.
Modified RM (MRM): Patey/Madden/Auchinclos
Breast Conserving Therapy (BCT/BCS)
• Radiation theraphy (loco-regional control)
• Chemotherapy (systemic control): CMF, CAF/CEF, Taxans
• Hormonal therapy (systemic control): Tamoxifen, aromat
ase inhibitor
• Immunotherapy and gene therapy (?)

64. Neoadjuvant and adjuvant th/
• Neoadjuvant therapy (Ctx or Rtx) is given before su
rgery in order to kill micrometastasis and down stag
e the cancer. Rationally it sould have some impact o
n DFS or OS.
The usual technique is by giving chemotherapy (CA
F/CEF) for 3 cycles and followed by surgery.
Preoperative radiation therapy is 40-50 Gy and follo
wed by surgery.
• Adjuvant therapy (Ctx or Rtx) is given after surgery.

65. PROGNOSIS
• AGE
• Clinical stage (tumor size, Lnn status, meta)
• Tumor grade and histotype
• ER and PgR
• HER-2 neu
• Biologic marker (Oncogene/tumor supressor gene expres
sion, growth factors/receptors, proliferative markers, adh
esions molecules).