This document provides information on benign breast disease: - Benign breast disease is a heterogeneous group of lesions including developmental abnormalities, inflammatory lesions, and epithelial/stromal proliferations. - A study of 234 patients found the most common benign breast diseases were breast pain/nodularity (70.1%), fibroadenoma (17.5%), phyllodes tumor (4.3%), duct ectasia (3%), and duct papilloma (1.7%). - Benign breast diseases are very common, accounting for 9 out of 10 breast problems. They are often misunderstood and poorly treated. The incidence rises in the second decade and peaks in the 4th-5th decades.

1. Benign Breast Disease
Prof. Ajay K. Khanna
MS, FRCS, FAMS, FACS, FICS, FACRSI , FMAS, FCLS ,FRSTMH ,
FAIS, FUICC, FFIM, FUWAI, MNAMS, D.Sc, MBA, PDCR,
Ex Head of Department of Surgery
Institute of Medical Sciences
Banaras Hindu University

2. Benign Breast Disease
A heterogeneous group of lesions
• Development abnormalities
• Inflammatory lesions
• Epithelial and stromal proliferation
• Neoplasms

3. Diagnosis 234 Patients (Mastitis excluded)
Breast Pain and Nodularity 164(70.1%)
Fibroadenoma 41(17.5%)
Phyllodes Tumor 10(4.3%)
Duct Ectasia 7(3%)
Duct Papilloma 4 (1.7%)
Gynaecomastia 2 (0.9%)
Mondor’s Disease 2(0.9%)
Adolescent Hypertrophy 2(0.9%)
Tuberculosis / Cysticercosis 1 (04%) each

4. The Burden of Benign Breast
disease
• Very Common.
• 9 out 10 cases with breast problem
have benign disease
• Ill understood and poorly treated

5. Age and Breast Disease
• Majority lesions are not
malignant.
• Incidence of BBD
begins to rise in second
decade and peaks in 4th
and 5th decade (contrast
to malignancy)
• 4th and 5th Decade are
overlapping

6. Diagnosis
Diagnosis made without surgery by :
• Mammography
• Ultrasound
• MRI
• Needle Aspiration / Biopsy

7. Development abnormalities

8. Supernumerary and Ectopic
breast and nipple
Most common frequent site :
– Chest Wall along milk line, Axilla, Vulva

9. Supernumerary and Ectopic breast and nipple
RARE SITES
Sole, Knee, Thigh, buttock, face, ear, Neck

10. • Macromastia
• Hypoplasia (congenital / Acquired)
• Amastia (Absent nipple and breast
tissue)
• Amazia ( Absent breast tissue)
• Athelia ( Absence of NAC)

11. Macromastia
Virginial Hypertrophy Bi Giant Fibroadenoma

12. Tuberous Breast

13. Inflammatory

14. Acute Mastitis
• Usually during first 3 months
postpartum
(Puerperal / Lactational mastitis)
• Treatment
• Antibiotics (Amox/Linezolid)
• To stop milk nor not (Empty milk)
• To operate or aspirate or antibiotics

15. Breast abscess
Drainage Aspiration

16. Mastitis

17. Mastitis vs. Inflammatory CA

18. Granulomatous Mastitis
• Chronic Inflammatory Diseases of Breast
• Etiology : Not known
– Inflammatory Autoimmune Response to
epithelial damage and milk roteins
– Cornybacterium Kroppenstedtii (Lipophilic
Gram Positive rod) (Commensal for skin)
– Hyperprolactinaemia

19. Presentation
• Unilateral painful mass
with Erythema
• Abscesses/Sinuses
• Peau d’ Orange
• Nipple Retraction
• Axillary Nodes
• Erthyema Nodosum
• Arthritis

20. Imaging
• Mammo
– Focal area of asymmetry
single or multiple
– Skin Thickening
– Axillary Nodes
• Sonography
– Hetergenous Echogenic
Irregular Mass with no
distinct margins
• MRI
– Differentiate between
tumor and Inflammatory
process

21. BIOPSY
• FNAC Yield : 21-39%
• Core Needle : 94%
• Open Biopsy : Controversial
• Non Caseating Granuloma
with Chronic inflammatory
picture of lymphocytes and
Plasma Cells

22. D.Dx of
Granulomatous Mastitis
• Tubercular
• Sarcodosis
• Wegner’s Granulomatosis
• Histoplasmosis
• Actinomycosis
• Foreign Body Reaction
• Fat Necrosis
• Inflammatory Breast CA

23. Treatment of
Granulomatous Mastitis
• Majority patients get antibiotic initially but
they usually fail
• Corticosteroids Prednisone 60 mgm per
day with Gradual Taper
• Topical 0.1% Hydrocortisone cream
• Methotrexate 7.5 – 25 mgm weekly
• Azathioprine
• Wide Excision/ Mastectomy

24. Clinical presentation of Tub
Mastitis (52)
• Breast Lump 12(23%)
• Breast Lump with sinus 20(39%)
• Sinus only 6 (12%)
• Tender nodularity 12 (23%)
• Axillary Sinus 2 (4%)
• Associated axillary nodes 21(41%)
• Previously drained abscess 4(8%)

25. Diagnosis of Tub Mastitis (52)
• Mauntoux test Positive in 46 (91%)
• ESR raised in 39 (77%)
• X-ray Chest : Tuberculosis in 7 (14%) of
which 4 had calcific lesion
• All Discharges negative for Ziehl
Neelson staining

26. Management of Tub Mastitis
(52)
• Only ATT : 28 responders
• Excision of lump: 12
• Repeated aspiration: 5
• Excision of sinus: 5
• Simple mastectomy: 2
ATT in all cases

28. Epithelial and
stromal
proliferation

29. Fibrocystic changes (FCCs)
Most frequent benign disorder
Syn.:
• Fibroadenosis
• Fibrocystic disease
• Cystic mastopathy
• Chronic cystic disease
• Mazoplasia
• Reclus’s disease
• Nodular Breast Disease

30. Fibrocystic changes (FCCs)
• Multifocal, Bilateral
• Breast Pain
• Tender nodularity
Cause :
Hormonal imbalance
* Estrogen predominance over progesteron
Pathology :
• Cysts (Macro and micro)
• Solid lesions
– Adenosis, epithelial hyperplasia, apocrine
metaplasia, radial scar, papilloma

31. Fibrocystic changes (FCCs)
Dupont and Page classification
• Non Proliferative (Cysts, Papillary apocrine changes,
epithelial related calcification, mild epithelial hyperplasia, ductal
ectasia, non sclerosing adenosis, periductal fibrosis)
• Proliferative without atypia (Moderate or
florid ductal hyperplasia, sclerosis, adenosis, radial scar,
intraductal papilloma , papillomatosis
• Proliferative with atypia (atypical
hyperplasia) (Atypical ductal or lobular
hyperplasia)
Upto 70% biopsies shows nonproliferative lesions
Dupont et al N Eng J Med 1985; 312:229-37

32. Cysts
• Fluid filled , round or ovoid
• Most are microcysts
• In 20-25% cases, they may be palpable
(gross) cyst
• Ultrasound and aspiration are
diagnostic
– Clear fluid
– Non hemorrhagic
– Disappearance of lump

33. Giant Cyst

34. The Aberration in
Normal
Development and
Involution
The ANDI Concept of Breast
Diseases

35. Stage Normal Process Aberration Disease
Early
Reproductive life
15-25 yrs
Lobular
Development
Fibroadenoma Giant
Fibroadenoma
15-25 yrs Stromal
Development
Adolesecent
Hypertrophy
Gigantomastia
15-25 yrs Nipple Eversion Nipple Inversion Subareolar
abscess/Mamm
ary duct fistula
25-45 yrs Cyclic changes of
menstruation
Cyclical
mastalgia/Nodularity
Incapacitationg
Mastalgia
25-45 yrs Epithelial
Hyperplasia of
pregnancy
Bloody Nipple
Discharge
Involution 35-55
yrs
Lobular Involution Macrocyst/Sclerosin
g adenosis
35-55 Yrs Duct Involution Ductal Ectasia Periductal
Mastitis/Absces
s

36. Proliferative Breast Disease
CANCER RISK
Hyperplasia 1.9
Atypical Hyperplasia(AH) 4.5
AH + Family History 11
Cysts 1.5
Cysts + Family History 3.0

38. Breast Pain
• Mastalgia / Mastodynia
• Commonest symptom in a Breast Clinic
• Universal – all women have it
• Pathological-
– more than 7 days in a cycle
– Pain score > 3 on a VLA of 0-10
– Pain interfering routine life

39. Breast Pain
• Cyclical
• Non Cyclical
• Extra mammary causes (Tietze disease,
Mondor disease)

40. Characteristics of Breast Pain
by Type

41. Extramammary causes
Tietze’s syndrome
Trauma (post biopsy)
Cancer
Musculo-skeletal
Mondor’s disease

42. Management of Mastalgia
• EXCLUDE Cancer
• Reassure- 85% will be relieved
• Reassure/Reassure/Reassure
• Pain Chart for 1-2 menstrual cycles
• Life style modification-
– Tight bra, Avoid caffeine, coca, chocolates
– Vitamin E, Flex Seeds, Evening Primrose oil

43. • Drug Therapy
• Anti-inflammatory gel
• Local Anaesthetic with Steroid
Injection for trigger point pain
• Excision of painful nodule
Management of Mastalgia

44. Breast Pain Chart

45. Drug Therapy of Mastalgia
– Danazol- Only US FDA approved
Dose 100 – 300 mg
Response 70% good control
Side effects – 25% wt. gain, hair growth,
– Bromocriptine:
2.5-10 mgm
Side effect: Nausea, vomiting
- Evening Primrose oil
Response 2/3rd good control
Side effects minimal- 4%
No benefit over placebo

46. Drug Therapy for Mastalgia
• Tamoxifen- 10 mg daily for 3
months
–Response- 98% for cyclical, 56%
noncyclical
–Well Tolerated
–Side effects 50% - hot flushes,
vaginal discharge

47. Problems with Available Options
Drug Usual dose Side effects
Tamoxifen 10mg od
Hot flushes, menstrual irregularity
(nausea, dryness, rarely DVT, pulmonary
embolus)
Danazol 100 mg bid
Amenorrhea, menstrual irregularity,
Weight gain (hirsutism, deepening voice,
hot flashes)
Bromocriptine
2.5mg bid after
gradual increase
Nausea, dizziness, headache, postural
hypotension (rarely seizures, stroke or
hypertension)
Evening Primrose Oil 3gm Soft stools, headaches
J Obstet and Gynecol Canada. 2006; 28(1):49-57

48. Centchroman (Ormeloxifene)
• Synthesized at the Central Drug Research
Institute, Lucknow
• Marketed in India since 1992 (SAHELI)
• Included in the National Family Welfare
Programme in 1995 as an OCP

49. Ormeloxifene (Centochroman)
• 3rd generation selective estrogen receptor
modulator (SERM)
• Only non-steroidal oral contraceptive in
clinical use in the world today
• Developed by the CDRI in 1970 as a
contraceptive
• Licensed for marketing in 1990
Kavita YD et al. Int Gyn & Women’s Health. 2018;1(1): 1-4

50. Clinical Uses Of Ormeloxifene
• Oral contraceptive
• Control of Abnormal Uterine Bleeding
(approved by DCGI, 1995)
• Breast disorders – Mastalgia &
fibroadenoma
Kamboj VP et al.Front Biosci (Elite Ed). 2018 Jan 1;10:1-14.

51. ORMELOXIFENE IN REGRESSION OF MASTALGIA
AND FIBROADENOMA
Dhar A and Srivastava A. 2007
World J Surg (2007) 31:1178–1184
 N= 60 women with benign breast disease patients 17 to 35 yrs.
 Intervention:
 30 mg oral tablet on alternate days for a period of 3 months and were followed up
for 6 months
Outcomes
• A safe nonsteroidal drug for the treatment of mastalgia and fibroadenoma
Condition At baseline At 1 week At 2 weeks At 12 weeks
Breast nodularity
in cases with
mastalgia
(N=35)
No nodularity 5 (14%)
-
100%
Regress partially 16 (46%) 0
No change 14 (40%) 0
Fibroadenoma in
cases with lump
and mastalgia
(N=18)
Complete
disappearance
-
1(6%)
7(41%)
Reduced 5(29%) 4(24%)
No change 11 (65%) 6(35%)
During follow-up of
6 months none of the
fibroadenomas
that disappeared
recurred

53. Why all mastalgia do not
respond to Danazol

54. BREAST MASSES

55. Breast Masses
• Fibroadenoma
• Macrocysts
• Galactoceles
• Lipoma
• Abscess
• Rare causes- sclerosing adenosis,
cystosarcoma phyllodes
• Malignancy

56. The Lady with a Lump
• DISCRETE LUMP
– Fibroadenoma
– Phyllodes tumour
– Nipple Adenoma and Papilloma
– Breast cyst and Galactocele
• ILL DEFINED LUMP
Cyclical Nodularity
Fat necrosis
• NORMAL STRUCTURES
Prominent Rib
Intramammary lymph node
Prominent fat lobule
Edge of Breast or Biopsy scar

58. Triple Assessment
Careful history – hormones, relation with
menstrual cycle, pregnancy or lactation
1.Clinical Breast Examination
2.Imaging- Ultrasound all ages /
Mammography above 35 years
3.Fine needle aspiration cytology/ or
Core Biopsy
Diagnostic accuracy for a lump = 100%

59. USG
Malignant
Benign
Ovoid smooth solid mass
Narrow in AP diameter the transverse
diameter
Even low level internal echoes

60. MASS
Benign
Malignant

61. Calcifications
Benign Malignant

62. Core Biopsy
Non guided Guided

63. Fibroadenoma
• Rubbery, firm, smooth or lobulated and
extremely mobile
• Fibroadenoma show enlargement
during pregnancy and lactation and
involution after parturition.
• Giant fibroadenoma > 5 cm

64. Treatment of Fibroadenoma
• Only observation
• Lumpectomy
• Laser ablation
• Cryoablation
• Radiofrequency ablation
• Mammotome (Suction with ultrasound)
• Drugs : Centchroman

66. Treatment of Fibroadenoma
• Conservative policy is reasonably safe
if less than 25 years of age, after the
triple assessment is negative and size <
3cm.
– 10% - 30% regress
• Removal in case of increase in size
– For older age group (>25 years) excision,
especially if a +ve family H/O cancer and
doubt in diagnosis.

67. Centchroman in
Fibroadenoma
• 18 women
• Centchroman 30mg alternate day for 3
months and followed for 6 months.
• Complete regression on ultrasound in
40%, partial regression in 20% and no
response in 40%.
Dhar and Srivastava World J Surg 2007

68. Cancer Risk in Fibroadenoma
• No increased risk of cancer for simple
fibroadenoma without family history of
breast cancer. (Dupont et al 1985)
• Complex fibroadenoma with cysts,
sclerosing adenosis, epithelial
calcification or papillary apocrine
change with atypia and a family history
of breast cancer has a relative risk of 3-
4 times

69. Phylloides tumour
Cystosarcoma Phyllodes
• Greek words sarcoma, meaning fleshy , and
phyllo, meaning leaf.
• Thus, the favored terminology is now
Phyllodes tumor

70. Phyllodes Tumor
Huge Lump
Dilated Veins
Probe Test
Nodes -ve

71. Phyllodes Tumor Bilateral

72. Treatment of Phyllodes Tumor
• Wide excision
with a cm margin
for small lumps
• Mastectomy for
large tumours

73. Rec Cystosarcoma

74. 38 patients in a period of 20 years
• Age : 38.4 Yrs (24 – 68 years)
• Sex : 36 females, 2 males
• Duration : 28 + 8 months (6-180 months)
• Tumor diameter : 12.8 cm (4-30 cm)
• 2 women had bilateral PT
• Palpable axillary node in 6 cases –
+ve nodes in 1

75. Type of Surgery
• Local excision
(Margin <1 cm) : 6
• Wide Local Excision
(Margin >1 cm) : 26
• Mastectomy : 6

76. Histopathology
Benign - 20
Borderline - 10
Malignant - 8

77. Recurrence
Simple Excision (6) - 3
(1 benign, 1 borderline, 1 malignant)
Wide Excision (26) - 2
(1 malignant, 1 borderline)
Mastectomy (6) - 1
(1 borderline)
>50% Lost to FU

78. Pyllodes Tumor in males

79. NIPPLE DISCHARGE

80. Causes of Nipple Discharge
• Physiological : Pregnancy, Lactational
• Breast lesions- intraductal papilloma, ductal ectasia,
fibrocystic changes, breast abscess
• Drug induced- phenothiazines, reserpine,
methyldopa, imipramine, amphetamine, OCPs
• CNS lesions- pituitary adenoma, hypothalamic tumor
• Medical conditions- Cushings, hypothyroid, chronic
renal failure
• Carcinoma
• Idiopathic

81. Types of Nipple Discharge
Bloody Ductal hyperplasia and
papilloma, duct ectasia,
pregnancy, cancer
Serous or Watery Ductal hyperplasia, duct
ectasia, FCC
Coloured Duct ectasia, Cyst
Milk Physiological,
Galactorrhoea with
Prolactin secreting lesions

82. Nipple Discharge
Physiologic
Bilateral, Multiple ducts
Pathologic
Unilateral, single duct,
associated with mass,
Bloody
No further evaluation
No treatment
Reassurance Physical Exam/
Mammo/
Cytology/
Galactography/
Occult blood testing

83. Worrysmome Nipple discharge
• Spontaneous Single duct & Bloody
discharge
• Positive cytology
• Positive mammography/USG
• Age >50 yrs old
• Associated with mass

85. Duct Papilloma

86. Duct Ectasia
• Process of involution
• Age related (42-65 yrs)
• Nipple retraction, cheesy toothpaste like nipple
discharge.
• Culture usually sterile.
• Characteristic coarse calcification along duct
on mammogram.
• Tt.: Radical Duct Excision (Hadfield Operation)

87. Eczema vs Paget’s

88. HYDATID CYST

89. Gangrene of Breast

90. Hidradenitis Suppurativa
Papilloma of Nipple

91. Benign Diseases of
male breast
Gynecomazia, Benign Tumors, Inflammatory

92. Conclusions
• Majority of breast lesions are benign.
• Breast pain, lump and nipple discharge
common
• Cancer must be excluded .
• Mostly need reassurance and medical
treatment
• Surgery for few cases.

93. Breast Examination