benign breast disease

1. Benign breast disease and its
management
Dr shambhavi sharma
MS general surgery

3. ANDI CLASSIFICATION OF BENIGN
BREAST DISORDERS
Normal Disorder disease
Early reproductive
years (15-25 years)
Lobular development Fibroadenoma Giant fibroadenoma
Stromal
development
Adolescent
hypertrophy
gigantomastia
Nipple eversion Nipple inversion Subareolar abscess
Mammary duct
fistula

4. Late reproductive
years
(25-40 years )
Normal Disorder disease
Cyclical changes of
menstruation
Cyclical mastalgia Incapacitating
mastalgia
nodularity
Epithelial
hyperplasia of
pregnancy
Bloody nipple
dischage

5. Involution
(35-55 years)
Normal Disorder disease
Lobular involution Macrocysts
sclerosing lesion
Duct involution
Dilatation Duct ectasia Periductal mastitis
sclerosis Nipple retraction
Epithelial turnover Epithelial
hyperplasia
Epithelial
hyperplasia with
atypia

6. Classification
Non proliferative disorder of the breast
Cyst and apocrine metaplasia
Duct ectasia
Mild ductal epithelial hyperplasia
Calcifications
Fibroadeoma and related lesions
Proliferative breast disorder with atypia
Sclerosing adenosis
Radial and complex sclerosing lesion
Ductal epithelial hperplasia
Intraductal papillomas
Atypical proliferative lesion
Atypical lobular hyperplasia
Atypical ductal hyperplasia

7. • Risk for malignancy
• No increased risk in fibroadenoma,intraductal
papilloma, sclerosing adenosis
• 1.5-2 fold rise in epithelial hyperplasia
• 4 fold rise in atypia with hyperplasia

8. Fibroadenoma
• Benign solid tumors comprising of stromal and
epithelial components
• 15% of all palpble breast lumps
• Mostly in females younger than 3o years of
age
• ANDI involving a lobule

9. Clinical features
• Most growth arrested by 2-3cm; may reach
>10cm
• highly mobile, firm , non-tender, and often
palpable breast mass.
• Multiple in 15%- 20 %
• Bilateral in 20%
• Axillary lymph nodes not palpable
Types:
• Juvenile (rapid epithelial and stromal growth)
• Complex (with fibrocystic changes)

10. • 10-15% will increase in size progressively
• Spontaneous infarction – pregnancy/lactation
• Reports of regression 20-25%
• Risk of carcinoma: rare (in complex
fibroadenoma and atypia in microscopy)
• 50%LCIS, 35% invasive carcinoma, 15%
intraductal carcinoma

11. Investigations
well-circumscribed
, firm mass, solid mass
the cut surface
appears lobulated
and bulging
Investigations
Ultrasonography
Mammography
FNAC

12. investigations

13. findings management
Triple assesment Results concur
Age <30 years
Clinical
observation for 2
years
If
disappears/regresse
s : counselling
No change/ increase
in size /patient
request :
excision/cryotherap
y/vacuum assisted
biopsy
Resuts donot concur
Age > 30 years
excision
Multiple lesions Excision of the
largest
Observation for the
rest
Giant fibroadenoma Extracapsular

14. AKA MAMMARY DYSPLASIA /CYCLICAL MASTALGIA WITH
NODULARITY
SCHIMMELBUSCHS DISEASE: diffuse small multiple cysts.

19. b. Surgical management
• Subcutaneous mastectomy with prosthesis
placement
• Excision of cyst or localised excision of diseased
tissues
Indication:
• Intractable pain
• Florid epithliosis in FNAC
• Bloodgood cyst
• Persistant bloody discharge
• Psychological reason

22. MAMMOGRAM

24. • treatment

26. • ANDI Terminal ductules and acini with proliferation of
stroma often with deposition of calcium
• Number of normal duct is increased than number of
normal lobule
• Types: complex type
• Radial scar
• No risk of malignancy
• Investigation : stereotactic /core needle biopsy
• Treatment: conservative

27. ANTIBIOMA

28. (Submammary ) and biopsy

29. Fat necrosis
• benign nonsuppurative inflammatory process of
adipose tissue.
• occur secondary to accidental or surgical
trauma,
• may be associated with carcinoma
• any lesion that provokes suppurative
• necrotic degeneration, such as mammary duct
ectasia and, to a lesser extent, fibrocystic disease
with large cyst formation

31. • Clinically, fat necrosis may mimic breast cancer
• if appears as an ill-defined or spiculated dense mass,
associated with skin retraction, ecchymosis, erythema,
and skin thickness .
• Mammographic, sonographic, and magnetic resonance
imaging findings : may not always distinguish fat
necrosis from a malignant lesion.
• Histologically: characterized by anuclear fat cells
often surrounded by histiocytic giant cells and foamy
phagocytichistiocytes
• Treatment : Excisional biopsy is required if carcinoma
cannot be excluded preoperatively

32. NIPPLE DISCHARGE

33. NIPPLE DISCHARGE

37. 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%
between 40-60 and 32% over 60yrs
• Blood discharge in pregnancy- Bilateral, 2nd to
3rd trimester

38. Intraductal Papilloma
• rare,occurs in middle-age.
• ANDI of lactiferous ducts
• Variant of epithelial hyperplasia (fibrocystic
disease)
• Presents as blood-stained or serous nipple
discharge.
• Usually solitary lump <1cm with a small lump in
the areola
• papiliferous projections near nipple origin
,vascular stalk usually present

39. investigations
Discharge study ( FNAC
Ductogram
mammography

40. TREATMENT
• MICRODOCHECTOMY
Via tennis racket incision

41. • 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.

45. Risk for carcinoma:
• Management
• MELHEM NOVEL MODIFIED BREAST DUCTAL SYSTEM EXCISION

46. mastitis
• Types:
Subareolar :
• Common in non lactating women
• Infection of montgomery tubercles or furuncle of
areola
• Due to cracked nipples
• Red inflamed edematous areola with a tender
swelling .may have nipple retraction
• Treatment: incision and drainage by subareolar
incision
Retromammary : due to tb/suppuration of
intercoastal lymph nodes/ribs

47. Breast abscess (Intramammary)
• Classification :
Breast abscesses can be classified into :
• Lactational
• Non- lactational
Non- lactating breast abscesses can be further
divided into
 Central (periareolar) infection
 Peripheral Infection

48. Lactating Infection
• • usually develops within the first 6 weeks of
breastfeeding or occasionally, during weaning.
• 3% of lactating mothers
• Causative organism: Staphylococcus aureus
occasionally staph epidermidis and
streptococci

49. • Drainage of milk from the affected segment
often reduced, causing stagnant milk to become
infected.
risk factors:
• Cracked nipples
• Retracted nipple
• Infection from mouth of baby
• Improper cleaning of nipples
• Hematoma getting infected

50. Presenting features :continuous throbbing pain,
swelling, tenderness and a cracked nipple or
skin abrasion, brawny induration ,purulent
nipple discharge, fluctuant swelling

51. Non-Lactating Infection
Central or periareolar infections
• This is most commonly seen in young women
(mean age 32 years)
• cause : periductal mastitis
• Risk factor : smoking

52. Peripheral Non-lactating abscess
• These are less common than peri-areolar
abscesses
• sometimes associated with an underlying
condition, such as diabetes, rheumatoid
arthritis, steroid treatment, or trauma.

53. Clinical features :
• breast pain
• Erythema
• peri-areolar swelling and tenderness
• and/or nipple retraction in relation to the
affected duct

54. investigations
• Ultrasonography breast
Treatment
1.Antibiotics
2.Repeated aspirations
3.Incision and drainage

55. • MASTALGIA
Breast pain that interferes with daily activities of
the patients

59. Galactocele

64. • Serum chemistry
• LFT
• Thyroid function test
• Renal function test
• Total or free testosterone level , serum prolactin , LH
, oestradiol , dehydroepiandrostenone sulphate
levels to evaluate a patient with possible
feminization syndrome
• Urinary 17 ketosteroid
• Beta HCG
• Imaging Studies : USG breast
• Mammography
• Testicular USG
• MRI for pituitary gland
• CT scan for adrenal

65. treatment
• Reassurance (if psysiological)
• Treatment of cause (stop drugs)
• Medical therapy (danazol,clomiphene
citrate,tamoxifen)
• Surgical therapy

66. Surgery
is indicated in patients in whom the gynaecomastia
causes distress and psychological trauma , when
there is no underlying treatable condition and
when hormonal treatment is failed
• Open subcutaneous mastectomy
• Endoscopic assisted subcutaneous mastectomy
• Liposuction assisted mastectomy
• Ultra sound assisted liposuction

67. References
• Swartz
• Sabiston
• Bailey and love text book of surgery