Benign breast disease refers to abnormalities found in the breast that are not cancerous. It includes a range of findings from non-proliferative changes with no increased cancer risk to atypical hyperplasia which is associated with a higher risk. Management depends on the specific diagnosis and may involve imaging follow-up or surgical excision, especially if there is a higher cancer risk or discordance between imaging and pathology results. Breast pain is a common complaint that requires evaluation to determine if it is caused by a benign condition or something more concerning like cancer.

1. BENIGN BREAST DISEASE
Dr.Girish Saini
Resident 3rd year

2. WHAT IS BENIGN BREAST DISEASE
• When a radiologic or palpable abnormal area in the breast is subject to
biopsy and the pathology is benign.
Two scenarios:
1. A screening breast imaging test shows an abnormality that
leads to a benign breast biopsy
2. A patient may present with a palpable finding in the breast (with or
without suspicious imaging findings) and a biopsy shows benign results.
• The risk of cancer associated with various BBD lesions is important and
influenced by factors such as family history/genetics, hormonal exposures,
mammographic density, and lifestyle factors.

3. WHAT IS BENIGN BREAST DISEASE
• Core Biopsy Is the Standard of Care for Diagnostic Approach according to
National Comprehensive Cancer Network (NCCN) guidelines
• Generally, this is an image-guided biopsy performed under ultrasound,
stereotactic, or magnetic resonance imaging guidance.
• If cancer is diagnosed by core needle biopsy, there is a far greater chance of
successful treatment with only one operation compared to cases where
cancer is diagnosed with surgical excision

4. WHAT IS BENIGN BREAST DISEASE
• All percutaneous needle biopsies and their pathology findings must be
plausible to explain the imaging features of the lesion in that individual
case.
• When the imaging suggests a “suspicious finding” classified as Breast
Imaging Reporting and Data System (BI-RADS) 4 or 5 but the pathology is
benign, concern exists that the targeted lesion may have been missed at
biopsy.
• Surgical excision of the lesion is the recommended for such breast lesions
and for benign lesions that have an increased risk of cancer.

5. WHAT IS BREAST TISSUE
• Breast tissue consists of a branching series of ductal structures designed to
channel the flow of milk from the milk producing units of the breast, called
the terminal duct lobular units referred as lobules.
• This ductal and glandular structure is supported within a stroma of fibrous
tissue like cluster of grapes each lobule contains microscopic sacs called
acini (acinus)
• Acinus are lined with epithelium surrounding a central lumen. The
epithelium produces milk that flows into the central lumen and via the
ductal system out the lactiferous ducts of the nipple.

6. WHAT IS BENIGN BREAST DISEASE
• BBD includes abnormalities of both epithelial and stromal elements
• BBD is classified according to the degree of the epithelial abnormality which
correlates with long-term breast cancer risk.
• Non proliferative disease (NPD) (RR, 1.3)
• Proliferative disease without atypia (PDWA) (RR, 1.9)
• Atypical hyperplasia (AH) (RR, 4.2)

7. WHAT IS BENIGN BREAST DISEASE

8. Fibroadenoma
• Fibroadenomas are commonest breast tumors and presents as a palpable
mobile, well-defined breast mass or they may be incidentally detected as a
mass on mammography.
• On USG are round to oval circumscribed masses with homogenous
echotexture without posterior shadowing.
• Fibroadenomas are predominantly stromal lesions, composed of
collagenous stroma containing compressed epithelium that is not
proliferative.
• Fibroadenomas are either simple or complex. latter being based on the
finding of calcifications, or papillary hyperplasia within the fibro-adenoma

9. Fibroadenoma
Management:
• One diagnosed presumptively based on benign appearing imaging features
in a young woman who may elect to follow the lesion rather than undergo
diagnostic needle biopsy.
• One diagnosed by core needle biopsy do not need to be surgically excised
unless there is discordance with imaging.
• Fibroadenomas diagnosed presumptively (without core biopsy) need to be
followed clinically every 6 to 12 months and excised in the event of rapid
growth defined as a doubling in size over 6 to 12 months.
• Fibroadenomas that are proven on core needle breast biopsy do not require
any further evaluation or treatment.
• However surgical excision is recommended for a fibroadenoma that is
symptomatic or enlarging or measures over 2 cm.

10. Pseudo-angiomatousStromalHyperplasia
• PASH is a benign breast entity that presents as breast mass or on
imaging as an asymmetric density or breast mass.
• PASH is a stromal abnormality without epithelial proliferation, seen
as a diffuse dense fibrosis between lobular units where the
proliferation of fibroblasts results in slit-like spaces resembling blood
vessels
• Not a/w an increase in breast cancer risk.
Management
• If PASH is diagnosed with imaging or biopsy no further intervention is
needed.
• if further clinical growth of the breast mass occurs or a possible sampling
error; the lesion should be surgically excised.

11. Columnar Cell Change
• Columnar cell change (called columnar cell alteration): an abnormality of
the breast epithelium in which the cells exhibit a columnar shape.
• The acini within lobules may enlarge in size with larger lumens.
• No epithelial proliferation.
Management
• Columnar cell change identified on core biopsy does not require surgical
excision.
• Columnar cell change without hyperplasia and without atypia does not
increase in risk of breast cancer

12. Mild Ductal Hyperplasia
• Mild ductal hyperplasia refers to an increase in the number of
epithelial cells above the basement membrane within the lobular
acini with the epithelial cells having a normal appearance.
• There are three to four layers the cells do not completely fill or cross
the lumen of acinus.
Management
• Mild ductal hyperplasia found on core biopsy does not require surgical
excision
• This change is NPD and associated with no increase in breast cancer risk.

13. Proliferative Disease
• Two fold increased long term risk (RR, 1.9) of breast cancer
• Moderate/Florid ductal hyperplasia
• Radial scar
• Complex sclerosing lesion
• Sclerosing adenosis
• Papillary lesions, columnar cell hyperplasia
• Flat Epetheleal Atypia

14. Moderate/Florid Ductal Hyperplasia
• Moderate or florid hyperplasia is overgrowth of normal appearing epithelial
cells that completely fill the lumen of the ductal structure and portray a
streaming pattern
microscopically.
• The cells have a normal cytologic appearance
Management
• Moderate ductal hyperplasia found on core biopsy does not require surgical
excision; here is concern of discordance
• This is associated with an approximate two fold increase in breast cancer
risk

15. RadialScar/ComplexSclerosingLesion
• Radial scar and complex sclerosing lesions are the same histologically
• Distinguished only by their size, with lesions >1 cm termed complex
sclerosing lesions.
• Present as a palpable mass or on breast imaging and radiologically mimics
breast cancer due to its spiculated appearance, prompting diagnostic core
needle biopsy.
• Composed of a dense collagenous core with epithelial components trapped
in this core, mostly benign epithelium, but there may be atypical epithelium
within the radial scar.

16. RadialScar/ComplexSclerosingLesion
Management
• Radial scar can be an incidental finding seen with benign proliferative breast
changes on core needle biopsy.
• Surgical excision is not warranted. But
• If atypia is present within a radial scar, these lesions should be excised due
to an approximate 30% risk of cancer.
• If the lesion is >1 cm in size, if there is discordance, surgical excision should
also be performed.
If radial scar was biopsied with a larger gauge (11-gauge) vacuum biopsy
technique with 12 or more cores obtained at biopsy, and no atypia is present,
the upgrade rate is likely 5% or less and short-term follow-up mammogram in
6 months is reasonable to assure stability.

17. Sclerosing Adenosis
• Sclerosing adenosis is characterized by an increase in the number of lobular
acini and myoepithelial cells.
• This lesion presents as mammographically detected mass or architectural
distortion with calcifications leading to a core needle biopsy.
Management
• If the imaging is discordant, surgical excision would be advised to rule out
malignancy.
• If concordant with imaging, no further work-up is be needed, and routine
breast screening recommended
• Proliferative breast lesion, the long-term risk of breast cancer is increased

18. Papillary Lesions
• Papillomas are a heterogeneous group of lesions that include
a. Benign solitary intraductal papillomas
b. Atypical papillomas
c. Papillary cancer.
• An epithelium-lined, branching, fibro-vascular stalk present clinically with
nipple discharge or a breast mass that
may be noted radiologically demonstrate an intraductal mass

19. PapillaryLesions: benignductalpapiloma
Management
• Papillary lesions can be challenging to diagnose with percutaneous core
needle biopsy.
• If atypia is present, then surgical excision is required due to 25% to 30% risk
of upgrade to carcinoma.
• Papillary lesions that present as a mass over 1.0 cm in size, or if there is
imaging and pathology discordance, are also managed with surgical excision
• If observation is planned, clinical and radiologic follow-up in the short term
is recommended to assess stability of the finding.
• Papillary lesions without atypia are a form of proliferative breast disease
and are a/w an approx. twofold increase in breast cancer risk.
• Four fold increased risk of breast cancer in papillary lesions containing AH

20. ColumnarCell Hyperplasiaand Flat Epithelial
Atypia
• An abnormality of the breast epithelium in which the cells exhibit a
columnar shape and appearance with hyperplasia defined as more than two
cell layers thick.
• When this is also accompanied by cytologic atypia in the epithelial cells
termed FEA.
• FEA is an uncommon entity that is seen in about 5% of percutaneous breast
biopsies
Management
• Columnar cell hyperplasia found on core needle biopsy does not require
surgical excision
• As a proliferative lesion carries a twofold increase in risk of breast cancer.
• The management of FEA is more controversial.
• Upgrade rates for FEA diagnosed on core needle biopsy show at surgical
excision approx. 8% to 10%

21. ColumnarCell Hyperplasiaand Flat Epithelial
Atypia
• Due to the risk of finding cancer surgical excision is recommended for FEA
diagnosed on core needle biopsy.
• As always, surgical excision should be performed in any case of discordant
findings
• A recent study of 282 women in the Mayo Clinic Benign Breast Disease
cohort showed that FEA has a risk similar to other proliferative lesions
without atypia.
• At this time, the recommendation is that if surgical excision shows no
evidence of AH or malignancy, the patient can resume yearly breast
screening with mammography.

22. AtypicalHyperplasia (AtypicalDuctalHyperplasiaand
AtypicalLobularHyperplasia)
• Lesions characterized by an epithelial proliferation with atypical cytologic
changes in the lobules
• In ADH, there is a monomorphic epithelial proliferation that fills the acinar
lumens
• Often with cribriform architecture and secondary “punched out” lumens
• The cytologic atypia and architectural changes of ADH are similar to ductal
carcinoma in situ (DCIS), but unlike ductal carcinoma in situ, ADH involves
only 1 to 2 ducts and measures less than 2 mm
• As a result Core needle biopsy can result in underdiagnosis of cancer
(especially DCIS) in 10% to 30% of cases.
• In ALH, the atypical epithelial cells have a monomorphic and discohesive
appearance and distend and enlarge the lobules.

23. Atypical Hyperplasia (AtypicalDuctalHyperplasiaand
AtypicalLobularHyperplasia)
Management
• Surgical excision is the standard of care.
• Current NCCN guidelines recommend surgical excision of ADH and ALH
lesions diagnosed by core needle biopsy
• In cases of ALH where the ALH is an incidental finding and there is
radiologic-pathologic concordance, and no other high-risk lesion is seen
microscopically, In that event, an observation approach is reasonable with
imaging follow-up at 6 and 12 months.
• For ADH on core needle biopsy, criteria for avoiding excision are still in
evolution but will likely include a lesion size less than 1 cm, near complete
removal of the lesion mammographically, and only 1 or 2 foci of ADH
microscopically.

24. Atypical Hyperplasia (AtypicalDuctalHyperplasiaand
AtypicalLobularHyperplasia)
• Women with AH have an absolute risk 1% to 2% per year for breast cancer
• Research suggests that long term risk in these women is stratified by the
number of separate foci of AH found at the time of biopsy, with risk
increasing in stepwise fashion for 1, 2, and 3 or more foci of AH.
• In these women, closer screening is warranted, with annual mammography
starting at age 40 (possibly earlier depending on other risk factors for breast
cancer such as family history and mammographic density).
• Similarly, supplemental screening can be considered with breast magnetic
resonance imaging if overall lifetime risk is estimated to be at least 25%.
• Women with ADH or ALH should be counseled about lifestyle changes to
reduce risk and the use of prevention medications, which reduce breast
cancer risk

25. Lobular Carcinoma In Situ
• LCIS presents as an incidental finding seen on breast biopsy.
• Histologically it is similar to ALH with expanded acini in the TDLUs and a
monomorphic discohesive cytologic appearance.
• LCIS differs from ALH in that the TDLUs is completely involved (LCIS) instead
of partially involved (ALH), and the degree of expansion of the acini and the
TDLUs itself is much greater with LCIS.
• LCIS is often multifocal in nature and can be present in both breasts.

26. Lobular Carcinoma In Situ
Management
• The need for surgical excision is controversial for LCIS observed on core
needle breast biopsy.
• Published studies show wide variation in upgrade rates to cancer, but
• Recent studies support an approach for imaging surveillance rather than
surgical excision with a <5% risk of missed cancer with the following criteria:
• LCIS is an incidental finding radiologic-pathologic concordance is confirmed

27. Lobular Carcinoma In Situ
• There are no other high-risk lesions that would indicate surgical excision
• Long-term risk estimated as an eightfold increase in RR
• In terms of absolute risk estimation, recent data show ∼2% per year long-
term risk
• Long-term management of women with LCIS should include more intensive
imaging surveillance, as well as thorough discussion of risk reduction
options, including prevention medications as well as surgical risk reduction
with bilateral mastectomy.

28. BREAST PAIN
• Breast pain (or mastalgia) is a common concern for women and may
necessitate a clinical visit for evaluation.
• Breast pain is the indication for 47% of breast-related clinical visits.
Etiology/Pathophysiology
• Breast pain may often be physiologically related to hormone effects on
breast tissue.
• Evaluation is needed to determine cause is due to a benign condition or
malignancy.
• Mastalgia can be classified as cyclic or noncyclic based on its relationship
with the menstrual cycle.

29. BREAST PAIN
• Cyclic mastalgia occurs in premenopausal women, who experience mastalgia most
prominently in the second half of the menstrual cycle and that resolves with the
onset of menstruation
• Noncyclic mastalgia is unrelated to the menstrual cycle and may be related to
conditions such as breast infection or mastitis, breast lumps such as fibroadenomas,
or hematoma from breast trauma, thrombophlebitis of the breast (Mondor disease)
• Other non-breast related include chest wall pain from costochondritis,
radiculopathy, cardiac etiology, or gastro-esophageal reflux disease (GERD).
• Breast cancer is in the differential diagnosis for breast pain, although most of the
breast pains are benign

30. BREAST PAIN
Clinical Presentation
• A detailed history and examination are important components of the
evaluation.
• The patient history should include location of pain, duration, intensity,
timing related to the menstrual cycle, radiation of pain to or from another
site, aggravating or relieving factors, recent trauma, and medication
changes especially related to hormone use; these can all provide clues to
the etiology of pain
• On examination, it is important to pinpoint the location of the pain,
especially focal pain such as in a specific breast location, or parasternal pain
as with costochondritis, or pectoral muscle pain.

31. Benign Breast Pain

32. BREAST PAIN
Evaluation
• Breast imaging with mammography and targeted ultrasound is reasonable
for patients aged 30 or older with a palpable abnormality or focal breast
pain to rule out an underlying cyst or mass contributing to the symptom.
• For women younger than 30 years, targeted ultrasound alone is reasonable.
• Persistent breast pain despite treatment also warrants reassessment

33. BREAST PAIN
Management
• Women with mastalgia and no abnormality on examination or imaging can
be reassured of the absence of malignancy and no further intervention is
needed.
• In addition, conservative management approaches can be discussed.
• Use of a fitted bra has been offered for patients with breast pain as
breast tissue can pull on the chest wall if the tissue is unsupported or
inadequately supported.
• Using a well-fitting bra for physical activity such as running is also
recommended.

34. BREAST PAIN
• Methylxanthines including caffeine found in coffee, tea, chocolates, and
some respiratory medications have been thought to cause breast pain.
• However, research in this area does not provide strong evidence of an
association.
• Although controversial, many patients report benefits with discontinuation
of caffeine, it is reasonable for the patient to try to see if it helps symptoms.

35. Breast Pain
• A low fat diet has also been reported to help symptoms.
• Gentle massages, stretching exercises for upper body, and use of
nonsteroidal antiinflammatory medications also helpful
• Women on postmenopausal estrogen therapy, stopping the medication can
result in pain relief.
• Another approach to reduce estrogen stimulation on the breast tissue is to
use tamoxifen, a selective estrogen receptor modulator, which has been
shown to provide relief of breast pain
• It should be used only for short periods such as 3 to 6 months for symptom
relief

36. Breast Pain
• Side effects include hot flashes, vaginal symptoms, and more serious but
infrequent concerns of deep vein thrombosis, pulmonary embolism, stroke
risk, and uterine cancer risk.
• The only medication that has been Food and Drug Administration (FDA)
approved for breast pain is danazol.
• However, the significant androgenic side effects of the medication make it a
less attractive option for symptom management unless the patient is
refractory to all other nonsurgical options
• The dopamine agonist, bromocriptine has also been studied for breast pain
management
• Although therapeutically effective, the medication is rarely used due to the
significant side effects of nausea and vomiting, and headache.

37. Breast Pain
• Evening oil of primrose and vitamin E have been reported to relieve breast
pain symptoms but a randomized, double blind, placebo-controlled study
failed to report benefit of either of these agents when compared with
placebo.
• In a meta-analysis report on agents used for treatment of mastalgia,
bromocriptine, danazol, and tamoxifen were shown to result in significant
pain relief while evening primrose oil had no benefit.
• Surgical procedures, such as excisional biopsy of a tender area or
mastectomy for mastalgia, should only be done as a last option and if
requested by the patient, ensuring that the patient is well informed and
understands that the surgery may not relieve the pain symptom.

38. In summary, a detailed history and examination, targeted
imaging as needed, and if no abnormality, conservative
management with plan for reassessment for persistent or
worsening pain is recommended.

39. Thank You For Your Patience