Benign breast disorders and diseases

Benign breast disorders and diseases

Benign breast disorders and diseases

Benign Breast Disease  


 

Tutorial content :
1.Incidence
2.Aetio Pathogenesis
3.Classification
4.Pathological & Cytological features
5.Clinical Assessment
6.Management of individual problems  .


1.Incidence  

  • The ratio of malignant : benign breast diseases (BBD) is approximately 1:10 in the West. No comprehensive Indian statistics are available. But it is suspected that the position may be similar to that obtaining in the West.
  • There is a strong gender bias with males being affected by BBD only  rarely
  • There is a familial incidence of BBD, possibly related to a shared environment & lifestyle
  •  BBD is more common in the premenopausal age group. 

2.Aetio Pathogenesis          The factors involved are complex and poorly understood. 
They may be understood to form a multi looped Non-linear system controlled by negative feed back.

The possible aetiological factors are :  

Endocrine factors   

  • Disturbances in the Hypothalamo Pituitary Gonadal steroid axis
  • Altered PRL profile – a qualitative or a quantitative change

Non endocrine factors  

  • There is a presumed genetic predisposition leading to catecholamine super sensitivity. Methyl xanthenes & stress release catecholamines. In susceptible women, there is a cascade of  Intra cellular Cyclic AMP mediated events which leads to cellular proliferation.
  • Diets rich in saturated fat  alter the plasma essential fatty acid profile. This in turn leads to a receptor super sensitivity to Oestrogen & Progesterone
  • Iodine deficiency is also postulated to lead to a  receptor super sensitivity  to Oestrogen

3.Classification   The ANDI (Aberrations of Normal Development and Involution ) classification of  Hughes et al, was first proposed in 1987 and accepted by a multinational, multidisciplinary working party in 1992. The principles of the classification are :  

  • Benign disorders are related to the normal processes of reproductive life.
  • The spectrum ranges from normal to aberration to sometimes disease E.g. Ductal hyperplasia is presumed to progress to  Atypical Ductal hyperplasia.
  • The distinction between normal and abnormal is pragmatic.E.g. A small Fibro adenoma is presumed to grow into a Giant Fibro adenoma
  • The ANDI concept is a unifying concept – of symptoms, signs, histology and physiology
  • The classification is not comprehensive . It does not include :
    • Infective/ traumatic diseases E.G. Lactational Abscess,  Haematoma etc.
    • Male breast pathology is not explicit

 

ANDI CLASSIFICATION
Stage  Normal  >  Aberration >   ? Disease
Early  Duct development  
Lobule development
Stroma formation 
Nipple inversion
Fibroadenoma ( small /solitary )
Juvenile Hypertrophy
Fibroadenoma (giant / multiple) 
Mature Cyclic hormone activity on gland & stroma 
Epithelial activity
Mastalgia
Nodularity (Generalised/ Discrete) 
Papilloma 
Pregnancy
Lactation
Epithelial hyperplasia 
Lactation
Blood stained discharge
Galactocele
Involution Lobular involution
Ductal   involution
Epithelial  turnover
Cysts, Sclerosing lesions
Ectasia PeriductalMastitis
Ductal / Lobular hyperplasia
 Non Puerperal    Abscess 
? EH with atypia 

 

4.Pathological & Cytological features   

  • The histology of BBD is part of the spectrum of change that occurs in the lifetime of breast tissue
  • The cell kinetics of normal breast and BBD are similar
  • An Angiogenic switch is postulated to occur in presumptive progenitors of cancer.

ANGIOGENIC SWITCH

 

Relative risk of invasive breast cance

The American College of Pathologists Consensus Statement has assigned a relative risk assessment to the various histological categories as follows :  

No increased risk  

  • Adenosis

  • Mild Hyperplasia

  • Apocrine metaplasia

  • Cysts – micro or macro

  • Duct Ectasia

  • Periductal Mastitis

  • Fibro adenoma

Slight risk (1.5 – 2 times)  

  • Hyperplasia – moderate, florid, solid & papillary

  • Papilloma with fibro vascular core

Moderate risk (5 times)  

  • Atypical Ductal / Lobular Hyperplasia

Insufficient data to assign risk  

  • Solitary papilloma

  • Radial scar lesion


Clinical Assessment 
  

Symptoms ( same as Carcinoma  breast) 

 % of incidence

Lump
Painful lump or lumpiness 
Pain 

 80%

Nipple discharge

 5 

Nipple retraction

 3 

Miscellaneous 

 2

Accuracy of Triple Diagnosis = 99 %  

Triple Assessment 

 % Specificity for BBD

Clinical examination

 90 

Mammography ( Ultrasound in women under 35years)

85 

Fine needle aspiration cytology 

95 – 99%

Symptoms presentation &  Questions to be asked

 Symptom

Questions to ask 

Lump or thickening 

How long has it been present ? 
Has it  changed during that time particularly in relation to the menstrual  cycle 

Pain or tenderness

Does it have a cyclical or non-cyclical pattern ?
Does it involve both breasts ?
Is it localized to a specific point within the breast? 

Nipple discharge

Is it spontaneous or elicited ?
Is it from a single duct or multiple ducts ?
What is it’s appearance?
Has it ever been  blood stained? 

Change or nipple inversion

How long has it been present ?

 
6.Management of individual problems  

#Lump 
Lumps in the breast may be discrete, but often turn out to be  lumpiness. 
Solitary lumps are differentiated from multiple lumps by Clinical examination and / or Imaging.
Lumps may be solid or cystic and may be painless or painful. 
Solid lumps are differentiated from cystic lumps by Ultrasound.   

(a)Discrete lump  

  • Fibro adenoma  is the most common discrete lump seen in young women

  • Cyst is more common in peri or post menopausal women

(b) Nodularity  

  • Generalised

  • Localised   E.G.Localised Nodularity, Cysts etc.

Fibroadenoma
Types  

  • Solitary / Few  (less than  5 per breast ) / small (less than 5 cms in size)

  • Multiple / Giant

  

Fibroadenoma

Calcified Fibroadenoama

   

Solitary / Few Fibroadenoma (s)

Solitary small or a few Fibroadenomas are the most common discrete masses found  in younger women.
 
It is diagnosed by Triple assessment.
Fully assessed Fibroadenomas may be treated conservatively.
Some Surgeons insist on two independant FNACs prior to  conservative management.
 
Fibroadenomas may remain small and static, 50% involute spontaneously. 

There is no future risk of malignancy.  

Treatment  : 

  • Conservative treatment with follow up (monthly Self Breast Examination and annual Clinical Breast Examination ) in fully assessed Fibroadenomas.

  • Extra capsular excision ( with a 1cm rim of normal tissue around the Fibroadenoma) in older women  or those patients in whom surgery is desirable.

Giant  Fibro adenoma
These are defined as Fibroadenomas  greater than 4 / 5cms in diameter.
They are uncommon in West and more common in the East.
Whether they grow from small Fibroadenomas to  giant Fibroadenomas is a matter of contention.
It is postulated by some to arise de novo.

Giant Fibroadenoma Left breast
(in a  teenager from Assam, India) 
 


Multiple Fibroadenomata   
They  are defined as more than 5  per breast
They are uncommon 
Occur more often in Post renal transplant patients  as a possible function of immunosupression and or a drug side effect, possibly to Cyclosporin. 
They are a difficult problem  to manage.  

Localised / Generalised Nodularity
This is a common problem which usually requires only reassurance. 
Causative agents if any may be addressed. For instance the Oral Contraceptive Pill or Hormone Replacement Therapy, if responsible may be withdrawn or altered.

Cysts  

  • Are extremely common affecting 7% of women in the West

  • 50% of these are solitary,  30% have 2-5 cysts and the  rest more than 5 cysts

Types of breast cysts :
Apocrine  

  • Are lined by secretory epithelium (Na : K <3 )

  • Likely to have more than 5 cysts 

  • 5 times  likely to develop further cysts

Flattened  

  • Lined by  less active epithelium. (Na : K ratio = greater than 3 )

  • Fluid resembles plasma

Mixture of apocrine and flattened cysts

2 Cysts in Ultrasound 

Cyst with intramural nodule  ? Carcinoma


Management :  

  • Needle aspiration is diagnostic and curative

  • Routine cytological assessment of clear fluid unnecessary

  • Drug treatment not useful 

  • Routine follow up is not needed

Beware of carcinoma  if :  

  • The aspirate is blood stained

  • There is a residual mass

  • There is a persistent density in the Mammogram after cyst aspiration

  • The cyst recurs on 3 occasions after aspiration

  • The carcinoma is likely to be a composite of solid and cystic areas

  • Intracystic carcinomas are rare (0.1%)

Mastalgia

Classification   

  • Cyclical

  • Non Cyclical

    • True Non cyclical pain

    • Chest wall pain

      • Costochondral

      • Lateral Chest Wall         

Management Protocol for Mastalgia  

  • Determine the type of pain (Cyclical or Non Cyclical)  + Assess of severity (with a Breast pain chart)

  • Reassurance is the key to management in all patients

  • Supportive undergarments

  • Diet low in saturated fat & Methyl xanthenes

  • Stop Oral contraceptive pill  / Hormone Replacement Treatment where possible

  • Stop Tobacco

  • Commence treatment with 1st line drug (Gamma Linoleic Acid for 3 months)

  • Review ( with Breast pain score )  :

Excellent  response             > Treat for 6 /12  > Review
Substantial                          > Treat for 6 /12  > Review
Poor, but no side effects     > Treat for 2 /12  > Review
No response                       > 2nd line drug Danazol  > Review
Relapse                              >  Repeat 1st line drug for 8 /52   > Review
Refractory                          >  3rd line drugs (Tamoxifen Cabergoline Goserlin)  

  • Always obtain written consent from the patient prior to Danazol use.

  • Potential side effects include permanent lowered voice pitch.

  • The use of Bromocriptine for the treatment of Mastalgia is not advisable.

  • Note : In the U.S.A, there is no FDA approval for treatment of Mastalgia by Bromocriptine because, potential side effects include : seizures, strokes, MI and Death.

Dosages of commonly used drugs :
EPO 3gm /day
Danazol 200 mg/day for month,
100 mg /day for 1 month, 100 mg /day on alternate days
Tamoxifen 10mg/day
Goserlin 3.75 mg im monthly depot injection
Cabergoline Incremental starting with 0.25 mg twice /week 

Nipple discharge  
Relatively uncommon complaint (3 – 5% of referrals)  

Types  

  • Spontaneous 

  • Elicited

  • 75% of Premenopausal women show elicited nipple discharge with suction cups.

  • Nipple discharges are usually due to benign causes if they are non bloody, bilateral and from multiple ducts

  • If the discharge is bloody and from a single duct, it is often due to Solitary Intraduct Pailloma

  • Elicited discharges are usually but not invariably investigated

Common causes of nipple discharge are :  

  • Galactorrhoea

  • Duct Ectasia 

  • Solitary Intraduct Papilloma

Clinical assessment : 
1.Physical examination : 

  • Is the discharge Unilateral or bilateral ? 

  • From a Single duct or from multiple ducts ? 

  • Is it small volume or profuse ? 

  • What is the colour – blood related or other ? 

2. Mammogram if the patient is over 35 years of age
3. Haem stick testing of red, brown / serous discharges are  done. 
4. Smear Cytology of Nipple discharge is very unreliable  

Galactorrhoea  

Definition : Milky discharge unrelated to lactation  

Causes  

  • Physiological 

    • Mechanical stimulation, 

    • Extremes of reproductive life 

    • Post lactational 

  • Drug induced

    • Dopaminergic receptor blocking agents

    • Phenothiazines 

    • Dopamine depleting agents 

    • Oestrogens 

    • Opiates   

  • Pathological

    • Hypothalamic & Pituitary stalk lesions 

    • Pituitary tumours (adenomas & micro adenomas) 

    • Other (ectopic PRL secretion, hypothyroidism, CRF) 

Treatment  :
1.Physiological   –   Reassurance, cessation of stimulation
2.Drug induced    –   Stop or change drug if possible
3.Pathological     –    Bromocriptine, Surgery

Duct Ectasia, Periductal Mastitis, Solitary Duct Papilloma  

Duct Ectasia  

  • Occurs in older age groups ( Ectasia is an involutional process)

  • Presents with nipple discharge or retraction

  • The nipple discharge tends to be bilateral, from multiple ducts and multi coloured

  • The nipple retraction tends to be a slit retraction 

  • Socially embarrassing discharge is treated by Major duct excision. Small volume discharge is managed conservatively

 Periductal mastitis  

  • Incidence is higher in tobacco smokers

  • Presents as a Subareolar abcess

    • Minor abcesses are treated by aspiration 

    • Larger abscesses require incision & drainage

    • Antibiotics are used  for covering both aerobes & anaerobes

    • Non Steroidal Anti Inflammatory Drugs are useful adjuncts

    • Cessation of smoking

  • Non Peurperal sepsis can be a  difficult problem to treat

Non lactational abcess (sub areolar) which burst spontaneously, in a patient from Tamil Nadu, India Age : 53 years (Non smoker) 

Non lactational abcess( peripheral) which was incised, in a patient from West Bengal, India Age : 25 years (Non smoker) 

Solitary Duct Papilloma  

  • Usually presents with a bloody discharge 

  • A subareolar mass is found in 50% of patients 

  • In women less than 30years of age, Microdochectomy is the treatment of choice. In  women over 45years of age, a Major Duct Excision is done. In the intermediate group,  treatment is individualised.

 

Bloody discharge from nipple 

Slit retraction of nipple 

Paget’s disease nipple – moist 

Paget’s disease nipple – dry 

Nipple change 

  •  Nipple Retraction 

A slit retraction is often due to Duct Ectasia 
Rapidly progressive retraction may be due to malignancy 

  • Nipple change 

Causes : 

  • Eczema of nipple

  • Erosive adenomatosis

  • Factitious lesions

Differential diagnosis : Paget’s disease 


Dr.Uma Krishnaswamy MS,FRCSEd,FAIS,MA.
Consultant General Surgeon
Email: [email protected]  

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