This document discusses the treatment of various benign breast diseases including fibroadenoma, fibrocystadenosis, sclerosing adenosis, mastitis, phylloides tumor, traumatic fat necrosis, galactocele, duct ectasia, antibioma, Mondor's disease, tuberculosis of the breast, gynecomastia, and duct papilloma. Conservative treatments include drugs like danazol, tamoxifen, bromocriptine, and vitamins. Surgical treatments include excision, drainage, aspiration, and mastectomy depending on the specific condition. Antibiotics are used to treat infections like mastitis.

1. Treatment of
benign diseases
of breast.
DR INDUMATHI B

2. BENIGN DISORDERS OF BREAST
-FIBROADENOMA
-FIBROCYSTADENOSIS
-SCLEROSING ADENOSIS
-MASTITIS
-PHYLLOIDES TUMOR
-TRAUMATIC FAT NECROSIS
-GALACTOCELE
-DUCT ECTASIA
-ANTIBIOMA
-MANDOR’S DISEASE
-TUBERCULOSIS OF BREAST
-GYNECOMASTIA
-DUCT PAPPILOMA

3. FIBROADENOMA
 TREATMENT:
 Excision through a
circumareolar incision
( Webster's) or
submammary incision
(Gaillard Thomas
incision) is done.
 Fibroadenoma which
is small ( <3
cm)/single/age <30
years )can be left
alone with regular
follow-up with USG at
6 monthly interval.

4. FIBROADENOMA
 Indications for surgery
 Size >3 cm.
 Recurrence.
 Multiple.
 Cosmesis.
 Giant type.
 Complex type.

6. FIBROADENOMA

7. FIBROCYSTADENOS
IS
 Conservative management:
 1.Reassurance,avoid caffeine,chocolate,salt
 2. Drugs:
 To stop progression.
 To relieve pain.
 To reverse changes.
 To soften breast tissue.

8. FIBROCYSTADENOSIS
 Oil of evening primrose used in
moderate pain-drug of choice.
 It contains gamolenic acid which
reverses saturated to unsaturated fatty
acids. 1000-3000 mg/day for 4-6
months.
 It also contains 7% of linolenic acid
and 72% of linoleic acid.

9. FIBROCYSTADENOSIS
 Gamolenic acid- 120 mg/day.
 Danazol-most effective drug; but
second drug of choice-severe cases;
200 mg/day; 3-6 months.
 very effective but causes acne,
hirsutism, weight gain and
amenorrhoea.
 It is teratogenic and so cannot be
used if patient is planning for
pregnancy.

10. FIBROCYSTADENOSIS
 Bromocriptine-lowers prolactin-2.5 mg/
day for 3 months.
 Tamoxifen-10 mg Bd is an
antiestrogenic drug.
 GHRH agonist (Goserelin) is reserved
for refractory cases.
 It shows 96-99% success. But it
causes reversible postmenopausal
symptoms.

11. FIBROCYSTADENOSIS
 Vitamin E and B6 are tried.
 NSAIDs-oral and topical.
 INDICATIONS FOR SURGERY:
 Intractable pain
 Florid epitheliosis on FNAC
 Persistent bloody discharge
 Psychological reason.

12. SURGICAL MANAGEMENT
 Excision of the cyst or localized excision
of the diseased tissue.
 Subcutaneous mastectomy with
prosthesis placement-severe &
persistent.
 Its removal of entire breast with retaining
skin over the breast,nipple&areola.
 Submammary gillard thomas incision.
 Adequate skin flap containing
subcutaneous fat is raised which
maintains the blood supply of the flap

13. SCLEROSING ADENOSIS
 The clinical significance of sclerosing
adenosis lies in its imitation of cancer.
 On physical examination, it may be confused
with cancer, by mammography, and at gross
pathologic examination.
 Excisional biopsy and histologic examination
are frequently necessary to exclude the
diagnosis of cancer.

15. Phylloides tumor

16. CONTINUED.
TREATMENT:
 Wide excision with
1cm margin or
subcutaneous
mastectomy(avoid
recurrence)
 Malignant-total
mastectomy with
adjuvant
chemotheraphy.

17. Phylloides tumor
 WIDE LOCAL EXCISION:
 Synonym terms include-
lumpectomy,tumourectomy and
tylectomy.
 Simple removal of tumour with
margins of normal tissue sufficient to
obtain macroscopic clearance.
 Quadrantectomy is the most certain
means of obtaining microscopically
clear margins.

18. Phylloides tumor

19. Phylloides tumor
 SURGICAL TECHNIQUE
 skin incision is made
 The skin and subcutaneous fat are
dissected off the breast tissue.
 When elevating skin- subcutaneous
fat should not be disrupted as thin skin
flaps give a poor cosmetic result.
 The skin flaps should be elevated 1 to
2 cm beyond the edge of the cancer.

20.  The fingers of the
nondominant hand are
then placed over the
palpable tumour & the
breast tissue divided
beyond the fingertips.
 The line of incision
should be 1cm beyond
the limit of the palpable
mass
 Breast tissue is divided
beyond the edge and,
the deep aspect of the
tumor can be palpated .

21.  Dissection through the breast tissue is
continued down to the pectoral fascia.
 The breast tissue containing the
tumour is lifted off the pectoral fascia.
 Having lifted the tumor and
surrounding breast tissue off the chest
wall muscles, the tumour are grasped
between the finger and the thumb of
the nondominant hand and excision is
completed at the other margins .

23.  After excision of the tumour
mobilization of the breast tissue
should be done.
 Suturing the defect in the breast
without mobilization of the breast
tissue - distortion of the breast
contour.
 skin wound should be closed in layers
with absorbable sutures,.

24.  COMPLICATIONS:
 Bleeding with hematoma formation,
 Infection & Incomplete excision-Poor cosmetic
results.

25. Phylloides tumor
 Doxorubicin plus Ifosfamide is the
most common regimen used.
 Liposomal doxorubicin in combination
with bevacizumab has been tried in
one case.
 In an Indian report, epirubicin with
ifosfamide was administered to four
patients.
 When disease progression happens,
trabectedin and pazopanib is used.

26. Phylloides tumor
 Olaratumab is an IgG1 monoclonal
antibody targeting platelet-derived
growth factor receptor alpha
(PDGFRα) thus blocking PDGF-AA,
PDGF-BB and PDGF-CC binding and
receptor activation.
 combination of doxorubicin with
olaratumab is tried recently.

27. CYCLICAL
MASTALGIA
 Treatment:
 Diclofenac gel-is very useful as local application.
 Evening primrose oil 325 mg BD.
 Gamolenic acid 120 mg BD.
 Danazol (100-200 mg BD)-antigonadotrophin
agent.
 Bromocriptine (2.5 mg BD)-prolactin inhibitor.
 Tamoxifen (20 mg daily).
 GnRH analogue 3.6 mg injection depot-monthly.
 Vitamin B6, B12.
 Analgesics.

28. NONCYCLICAL MASTALGIA
 Treatment:
 Cause has to be identified.
 Malignancy has to be ruled out.
 Avoid coffee and stress.
 Proper support to breasts.

29. TRAUMATIC FAT NECROSIS
 Capillary ooze
 Trigycerides in fat to dissociate
 calcium from blood
 Saponification inflammatory reaction
 swelling of the breast

30. TRAUMATIC FAT NECROSIS
 Painless
 Nonprogressive
 Nonregressive
 FNAC-chalky fluid
with fat globules
 Treatment is
excision.

31. GALACTOCELE
 Cessation of lactation
 Blockage of lactiferous duct -
dilation of lactiferous sinus.
 Retention cyst in subareolar
region.
 Lower quadrant,nontender.
 FNAC-
thick,creamy,greenish/brown
fluid.

32. GALACTOCELE
 TREATMENT:
 Resolve spontaneously after hormonal
change associated with pregnancy
and lactation is ceased.
 Aspiration of the content.
 Excision
 Abscess when formed should be
drained under cover of antibiotics.

33. MASTITIS
 3 TYPES
 SUBAREOLAR
 INTRMAMMARY
 RETROMAMMARY

34. SUBAREOLAR MASTITIS
 Treatment –under antibiotic coverage
pus is drained by subareolar incision..
 Fluid obtained is submitted for culture
for the detection of anaerobic
organisms.
 Antibiotics are then continued based
on sensitivity tests.
 When considerable purulent material
is present, repeated ultrasound guided
aspiration is performed.

35. SUBAREOLAR MASTITIS
 Subareolar abscess is usually
unilocular & associated with a single
duct system.
 Ultrasound will accurately delineate
its extent.
 In a woman of childbearing age,
simple drainage is preferred.
 But if there is an anaerobic infection,
recurrent infection frequently
develops.

36. SUBAREOLAR MASTITIS
 Recurrent abscess with fistula may
occur.
 Treatment of periductal fistula was
initially recommended to be opening
up of the fistulous track and allowing it
to granulate.
 The preferred initial surgical treatment
is by fistulectomy and primary closure
with antibiotic coverage.

37. SUBAREOLAR MASTITIS
Radial incision for subareolar abscess with
fistula. A. Excise island of skin around fistula
and involved central nipple dermis, with
connecting radial incision through areola.
B. Completely excise abscess cavity and
fistula tract.

38. SUBAREOLAR MASTITIS
Simple radial closure, leaving gauze wick
at lateral aspect to allow packing into
subareolar space.

39. A.Infra-areolar incision for
chronic subareolar abscess with
fistula. B. Appearance after
resection
of fistula tract and central nipple
ducts via small ellipse of nipple

40.  C. Gauze wick is exteriorized for packing. D.
Postoperative result.

41. SUBAREOLAR MASTITIS

42. LACTATIONAL ABSCESS OF
THE BREAST
 TREATMENT:
 Antibiotics-
cephalosporins,flucl
oxacillin &
amoxycillin.
 Feeding from the
affected side may
continue.
 Support of the
breast, local heat
and analgesia will
help to relieve pain.

44. LACTATIONAL ABSCESS OF
THE BREAST
 Use of antibiotic in the presence of
undrained pus ‘antibioma’
 This is a large, sterile, brawny
oedematous swelling that takes many
weeks to resolve.
 Incision and drainage- if the infection
did not resolve within 48 hours.
 Repeated aspirationsunder antibiotic
cover (if necessary using ultrasound
for localisation) be performed.

45. LACTATIONAL ABSCESS OF
THE BREAST
 Operative drainage of a breast
abscess:
 Incision of a lactational abscess -
marked skin thinning & usually done
under local anaesthesia.
 Incision is sited in a radial direction
over the affected segment.
 The incision passes through the skin
and the superficial fascia.

46. LACTATIONAL ABSCESS OF
THE BREAST
 A long artery forceps is then inserted
into the abscess cavity.
 Every part of the abscess is palpated
against the point of the artery forceps
and its jaws are opened.
 All loculi that can be felt are entered.

47. LACTATIONAL ABSCESS OF
THE BREAST
 Finally, the artery forceps are
withdrawn & a finger is introduced to
disrupt remaining septa.
 The wound may then be lightly packed
with ribbon gauze or a drain inserted
to allow dependent drainage.

48. Nonlactational breast abscess
 Duct ectasia and periareolar infection
 Organisms-Bacteriodes,Anerobic
streptococci
 Diabetic
 Recurrent swelling with tenderness under
areola.
 TREATMENT:
 Antibiotics
 Repeated aspirations
 Drainage and later cone excision of the duct
is done.

49. DUCT ECTASIA
 Treatment:
 stop smoking.
 Antibiotic therapy - co-amoxiclav or
flucloxacillin and metronidazole.
 Cone excision of involved major ducts
(Adair-Hadfield operation).
 It is important to shave the back of the
nipple to ensure that all terminal ducts
are removed.
 Melhem Novel modified breast ductal
system excision.

50. DUCT ECTASIA
 Infra-areolar incision in made that
should not exceed 1/3rd of the
circumference of the areola.
 Dilated ducts containing secretions
are identified and all ductal tissue is
excised.

51. MONDOR’S DISEASE
 Self-limiting.
 The only treatment
required is restricted
arm movements.
 subsides within a few
months without
recurrence,
complications or
deformity.
 Anti inflammatory
drugs may be needed.
 Refractory cases-
excision of involved
segment of vein.

52. TB BREAST
 The treatment of
breast tuberculosis
consists of anti-
tubercular
chemotherapy and
surgery by specific
indications.
 Anti-tubercular
therapy with four
drugs is the primary
line of treatment.

53. TB BREAST
 The six-month regimen
comprises of a two-
month intensive phase.
 Ethambutol 800 mg/day
 Pyrazinamide1500
mg/day,
 Rifampicin 450 mg/day
 Isoniazid 300 mg/day
 Followed by a
continuation phase of
four months with two
drugs Isoniazid and
Rifampicin.

54. TB BREAST
 Excisional biopsy
is necessary
mainly for
diagnostic
purposes.
 Excision of
residual sinus
tracts or lumps
after poor
response to
antituberculosis

55. BREAST CYSTS
 A solitary cyst or
small collection of
cysts can be
aspirated.
 Surgical excision is
done -
 if cyst recurs after
two aspirations
 if there is bloody
discharge
 residual mass if felt
after aspiration.

56. BREAST CYSTS
 After aspiration one should examine
for the residual lump.
 FNAC of this residual lump should be
done.
 Cyst when recurs (30%) reaspiration
should be done.
 Patient should be examined for
refilling of the cyst in 6 weeks.

57. GYNECOMASTIA
 TREATMENT:
 Treat the cause
 MEDICAL TREATMENT:
 3 classes of medical tretment:
 ANDROGENS
 ANTI-ESTROGENS
 AROMATASE INHIBITORS

58. GYNECOMASTIA
 ANDROGENS:
 Testosterone is used to treat
hypogonadism,its use to specifically
counteract gynecomastia is limited.
 Dihydrotestosterone ,is used in
patients with prolonged pubertal
gynecomastia.
 Danazol ,a weak androgen that
inhibits gondotropin secretion ,200mg
BD.

59. GYNECOMASTIA
 ANTI ESTROGENS:
 Clomiphene citrate-100mg/day
 Tamoxifen –low side effect & high
efficacy
 10mg BD or 20mg OD daily for 3-6
months.
 Patients usually improve within one
month.
 Raloxifene has also been used in the
treatment of pubertal gynecomastia.

60. GYNECOMASTIA
 AROMATASE
INHIBITORS:
 Newer aromatase
inhibitors such as
Anastrozole and
letrozole is used.
 Testolactone is
under trial.

61. GYNECOMASTIA
 Indications for surgical treatment:
 Ineffective medical therapy
 Long standing gynecomastia
 psychological or cosmetic problem.
 When gynecomastia interferes with
the patients activities of daily living
 Suspicion of malignancy of breast

62. GYNECOMASTIA
 Treatment :surgical excision.
 Removal of glandular tissue coupled
with liposuction.
 Gaillard thomas submammary incision
 Reduction mammoplasty
 Causative drugs should be stopped.

63. GYNECOMASTIA
 REDUCTION MAMMOPLASTY:
 HISTORY-
 Theodore Galliard –Thomas
suggested a sub-mammary incision to
rescue a part of the glandular disc.
 Vincenz Czerny transplanted the
nipple following a simple mastectomy
to preserve the natural breast.

64. REDUCTION MAMMOPLASTY:
 Axhausen pioneered his three step
technique:
 Extensive subcutaneous undermining
of the breast to reduce the glandular
portion of the breast.
 Nipple transposition
 Fashioning of a skin brassiere.

65. REDUCTION MAMMOPLASTY:
 Biesenberger combined three
elements:
 Separation of skin from gland.
 Resection of lateral half of the gland.
 Transposition of nipple on the retained
gland

66. REDUCTION MAMMOPLASTY:
 Wise ,modified Biesenberger
operation but his contribution was
more in the form of excision patterns
and mechanical aids to produce a
safer reduction.
 McKissock described the popular
vertical bipedicle dermal pedicle
technique where the vascularity of the
nipple areola depended on the intact
dermal parenchymal pedicle

67. REDUCTION MAMMOPLASTY:
 Requirements of an ideal breast
reduction:
 two breasts should be symmetrical
 The nipple and areola should be
translocated to an appropriate location.
 The blood supply to nipple and areola
should not be jeopardized.
 The function of the breast should be
preserved.
 The scars should not be prominent.

68. PEDICLES
 Inferior pedicle-4th and 5th intercostal
arteries are responsible for the
viability of the inferior pedicle.

69. PEDICLES
 Superior pedicle

70. PEDICLES
 Central pedicle- perforating branches
of the intercostal arteries

71. PEDICLES
 Lateral pedicle- based on the lateral
thoracic artery perforators.

72. SKIN RESECTION
PATTERNS

74.  skin
resection
pattern is
marked
 The pedicle
is then
marked so
that the base
is 6 to 8 cms
wide and
centered on
the breast it
extends for
about 2 cms
above the
nipple areola
complex .

75.  The procedure
begins by
stretching the
areola and its
then incised to
the dermis.
 The inferior
pedicle is de-
epithelialised

76.  With the breast centralized and
supported on the chest, medial and
lateral triangular excisions are carried
out

77.  The superior flaps are thinned to
achieve coning of the breast .

78.  After thorough haemostasis, the
medial and lateral flaps are
approximated and closed along the
inframammary crease

79.  An adequate opening for the nipple
areola complex is created by excision
of skin and the suturing is done

80. DUCT PAPILLOMA
 Mammary ductoscopy (MD)
 New endoscopic technique
 Sub-millimetre fiberoptic micro-
endoscopes measure between 0.7
and 1.2 mm in external diameter.
 Allow direct visualization of the
mammary ductal epithelium.

81. DUCT PAPILLOMA
 Scopes also provide working channels
for insufflation,irrigation, ductal lavage,
and possible therapeutic intervention.
 ADVANTAGES:
 Accurate localisation of pathology
 Ductal lavage under direct
visualization.
 Intra-operative guidance especially for
lesions deep within the ductal system

82. DUCT PAPILLOMA
 Cytological analysis of endoscopically
retrieved ductal lavage has been
recently reported to be more accurate
than simple discharge cytology.

83. DUCT PAPILLOMA
 Discharge – localized to a single duct,
microdochectomy gives satisfactory
results in younger patients with a
minimal interference with the breast.
 In older patients where breast-feeding
is not required-major duct excision.
 When a specific duct cannot be
identified then blind excision of the
retro-areolar ductal system is usually
performed.

84. DUCT PAPILLOMA
 MD can detect
multiple lesions
within the same
duct.
 Reduce the
number of duct
excision
procedures &
minimise the
extent of surgical
resection.

85. DUCT PAPILLOMA

86. DUCT PAPILLOMA

87. DUCT PAPILLOMA

88. DUCT PAPILLOMA
 Microdochectomy:
 It is important not to express the blood
before the operation.
 A lacrimal probe or length of stiff nylon
suture is inserted into the duct from
which the discharge is emerging.
 A tennis racquet incision can be made
to encompass the entire duct.

89. DUCT PAPILLOMA
 Nipple flap dissected to reach the
duct.
 The duct is then excised.
 A papilloma is nearly always situated
within 4–5 cm of the nipple orifice.

90. DUCT PAPILLOMA
 Cone excision of the major ducts
(after Hadfield)(subareolar resection)
 A periareolar incision is made and a
cone of tissue is removed with its
apex.
 Just deep to the surface of the nipple
and its base on the pectoral fascia.

91. DUCT PAPILLOMA
 The resulting defect may be
obliterated by a series of purse-string
sutures.
 A temporary suction drain will reduce
the chance of long-term deformity.

92. DUCT PAPILLOMA

94. DUCT PAPILLOMA

96. references
 Bailey and love 27th edition
 Sabiston text book of surgery,20th
edition
 Schwartzs principle of surgery 10 th
edition
 Breast tuberculosis: Diagnosis,
management and treatment by
Spyridon Marinopoulosa,∗, Dionysia
Lourantoua, Thomas Gatzionisa,
Constantine Dimitrakakisa, Irini
Papaspyroub, Aris Antsaklisa

97. references
 Breast papillomas: current
management with a focus on a new
diagnostic and therapeutic modality by
W Al Sarakbi1, D Worku1, PF
Escobar2 and K Mokbel*
 Galactocele in the Axillary Accessory
Breast Mimicking Suspicious Solid
Mass on Ultrasound by Donya
Farrokh, Ali Alamdaran, Farhad
Yousefi, and Bita Abbasi

98. references
 Management of Mastitis in Breastfeeding
Women JEANNE P. SPENCER, MD,
Conemaugh Memorial Medical Center,
Johnstown, Pennsylvania.
 The response of phyllodes tumor of the
breast to anticancer therapy: An in vitro and
ex vivo study.
 Olaratumab administered in two cases of
phyllodes tumour of the breast: end of the
beginning?
 Current Trends in the Management of
Phyllodes Tumors of the Breast Taiwo
Adesoye

99. Thank you