Benign Breast Diseases Dr Richa Jain Associate Professor & Unit Head S.M.S. Medical college Jaipur

The breasts are large, modified sebaceous glands to which our culture attaches great significance. An individual woman may react to the tremendous anxiety of suspected breast disease with behaviour that varies from frequent visits to the physician for breast pain to denial of the presence of an obvious mass.

The term “benign breast diseases” encompasses a heterogeneous group of lesions that may present a wide range of symptoms or may be detected as incidental microscopic findings.

Developmental Abnormalities

Ectopic breast Both Supranummery and aberrant included in this term Supernumerary breast tissue is seen mostly along the milk line; the most frequent sites are the chest wall, vulva, and axilla. Aberrant breast tissue is usually located near the breast, most commonly in the axilla.

Ectopic breast tissue is more prone to malignant change and that ectopic breast cancer occurs at an earlier age

Hypoplasia of breast Usually associated with different syndromes such as ulnarmammary syn, poland syn, Turner syn. Poland’s syndrome has been reported to be associated with breast cancer most often.

Inflammatory Lesions

A variety of inflammatory and reactive changes can be seen in the breast. While some of these changes are a result of infectious agents, others do not have a well-understood etiology and may represent local reaction to a systemic disease, or a localized antigen-antibody reaction, and are classified as idiopathic.

Acute Mastitis Also known as puerperal or lactation mastitis Usually occurs during the first 3 months postpartum. a cellulitis of the interlobular connective tissue within the mammary gland, can result in abscess.

Etiology Improper nursing technique, leading to milk stasis and cracks or fissures of the nipple, facilitate entrance of microorganisms; and stress and sleep deprivation, which both lower the mother’s immune status and inhibit milk flow, thus causing engorgement.

Rx Breast emptying with frequent nursing or manual pumping and beginning empiric antibiotherapy . Incision and drainage, if abscess

Granulomatous Mastitis Granulomatous reactions resulting from an infectious etiology, foreign material, or systemic autoimmune diseases such as sarcoidosis and Wegener’s granulomatosis. Diagnosis requires microbiologic and immunologic testing in addition to histopathologic evaluation.

Contd… Idiopathic granulomatous mastitis - granulomatous lesions without an identifiable cause. Diagnosis made by excluding other possible causes of granulomatous lesions. Treatment is complete surgical excision whenever possible plus steroid therapy.

Foreign Body Reactions Foreign materials, such as silicone and paraffin, used for breast reconstruction may cause a granulomatous reaction in the breast. Silicone granulomas (“siliconomas”) occur after direct injection of silicone into the breast or after extracapsular rupture of an implant . Fibrosis and contractions may lead to clinically apparent firm nodules that may be tender.

Recurring Subareolar Abscess Zuska’s disease Triad of draining cutaneous fistula from the subareolar tissue; a chronic thick, pasty discharge from the nipple; and a history of multiple, recurrent mammary abscesses Caused by squamous metaplasia of one or more lactiferous ducts in their passage through the nipple, probably induced by smoking

Contd… Abscess drainage to allow for resolution of the acute inflammation and then complete excision of the affected duct and sinus tract.

Fat Necrosis Rare, often confused with carcinoma. Presents with a firm, tender, indurated, ill-defined mass. Sometimes fat necrosis liquefies and becomes cystic. Mammography demonstrates fine, stippled calcification and stellate contractions. Occasionally there is skin retraction. Treatment of fat necrosis is excisional biopsy. No relationship in fat necrosis & breast carcinoma.

Fat necrosis as seen on mammography

Duct Ectasia/Peri-ductal Mastitis Complex

Also been referred to as varicocele tumor, comedomastitis, periductal mastitis, stale milk mastitis, chemical mastitis, granulomatous mastitis, or mastitis obliterans.

Patey identified squamous metaplasia of the offending lactiferous ducts that lead to inflammation, dialatation and abscess. Meguid coined the term MAMMARY DUCT – ASSOCIATED INFLAMMATORY DISEASE SEQUENCE to encompass disease progression from nipple discharge & retraction to subareolar duct dialatation and further sequence.

Dixon`s Theory Periductal mastitis and ductal ectasia are separate entities. Acute inflammation occurs in young women with smoking history. Ductal ectasia occurs in older women, more commonly in non smokers.

Clinical PDM Abscesses are usually subareolar or juxtareolar, single small(1-2 cm) and unilocular. Abscess may be sterile or polymicrobial In younger women, often associated with congenital inverted nipple while in older women it is associated with multiple ectatic ducts.

Nipple discharge of off-white, creamy, brown grey, green colour may occur. Some cases may develop chronic indurated mass. Nipple retraction will develop ultimately due to fibrosis.

Breast Masses associated with PDM Evanescent Mass – Small, tender in subareolar region, disappear in 7-10 days. Recurrent Mass – Mass recur at same siteat intervals of a few months to 10 years or more. Persistent mass – mass persistes for few weeks Chronic Mass – Hard, oedematous mass fixed to skin, with nipple retraction, sometimes with axillary nodes, mimics cancer

Classic view of pathology Process Clinical Manifestation Duct Ectasia (a Hormonal effect) Stagnation of secretions, Nipple discharge Epithelial ulceration Bloddy nipple discharge Leakage of secretion into periductal tissue Evanescent painful mass Granulomatous reaction + secondary bacterial infection Abscess/fistula Periductal fibrosis Nipple retraction

Mammography

Sonography

Comparison with Fibrocystic disease

Comparison with Carcinoma

Indications for surgery Non – bloody discharge – though not an indication for sx, if it is profuse ; total duct excision can be done Bloody discharge Nipple inversion Subareolar abscess Retroareolar abscess with fistula

Fibrocystic diseases

Breast histology The life cycle of the breast consists of three main periods: development, mature reproductive life, and involution. After the breast has developed, it undergoes regular changes in relation to the menstrual cycle that results in an increased rate of cell proliferation during the luteal phase leading to an increase in breast size1.

First Stage The first stage occurs in women in their 20s and is termed mazoplasia (mastoplasia). Breast pain is noted primarily in the upper, outer quadrants of the breast. The indurated axillary tail is in the most tender area of the breast. During this phase there is intense proliferation of the stroma.

Second Stage The second clinical stage of adenosis occurs generally in women in their 30s. The breast pain and tenderness are premenstrual but less severe. Multiple small breast nodules vary from 2 to 10 mm in diameter. The histologic picture of adenosis demonstrates marked proliferation and hyperplasia of ducts, ductules, and alveolar cells.

Third Stage The last stage is termed the cystic phase and usually occurs in women in their 40s. There is no severe breast pain unless a cyst increases rapidly in size. In this situation a woman experiences a sudden pain with point tenderness and discovers a lump. Cysts are tender to palpation and vary from microscopic to 5 cm in diameter.

Contd… This leads to a spectrum ranging from normal histologic features to features that mainly exhibit patterns of fibrous change and cyst formation. Since this histologic pattern may be evident in up to 60 % of women without breast disease, it led Love et al to suggest that fibrocystic “disease” does not exist. The currently accepted term for this condition is ′Fibrocystic change‘,

Eponyms  Bloodgood‘s disease, Cooper's disease (after Sir Astley Paston Cooper), Phocas’ disease, Reclus’ disease (after Paul Reclus), Reclus-Schimmelbusch disease, Schimmelbusch disease and Tillaux-Phocas disease.

Basic bidirectional framework of the ANDI classification Horizontal – Spectrum of severity Vertical – Pathogenesis based on reproductive period Development 15 – 25 years Cyclical activity 25 – 45 years Involution 35 – 55 years

Principles underlying the ANDI Concept Most benign disorders are related to normal processes of reproductive life There is a spectrum that ranges from normal to aberration, and occasionally to disease. The definition of normal and abnormal is pragmatic The ANDI concept embraces all aspects : symptoms, signs, histology and physiology

Classification They can be subdivided into non-porliferative and proliferative patterns.

Non-proliferative fibrocystic change Cysts and fibrosis Characterized by an increase in fibrous stroma associated with dilation of ducts and formation of cysts of various sizes.

Radiology

Fibrocystic changes of breast

Proliferative fibrocystic change Epithelial hyperplasia It is proliferative lesion within the ductules, the terminal ducts and sometimes the lobules of the breast. Sclerosing adenosis This variant is less common, but it is significant because its clinical features are similar to those of carcinoma.

Epithelial hyperplasia Sclerosing adenosis

FIBROCYSTIC DISEASES OF BREAST NON-PROLIFERATIVE FIBROCYSTIC DISEASE PROLIFERATIVE FIBROCYSTIC DISEASE CYSTS FORMATION AND FIBROSIS EPITHELIAL DUCT HYPERPLASIA SCLEROSING ADENOSIS

Treatment

Nonpharmacological Interventions Psychological Associations and Relaxation Training - In 1829, Sir Astley Cooper wrote that women seeking advice for breast pain usually had “a nervous and irritable temperament.”

Stop Smoking Lower dietary fat intake Methylxanthine (Caffeine) Restriction

Nutritional Supplements and Herbal Agents Vitamin E (α-tocopherol) Soy is a rich source of the isoflavones genistein and daidzen, which exert their effect by binding to estrogen receptors Evening Primrose Oil

Pharmacological Interventions Simple Analgesics Oral Contraceptives (OCs), Estrogen, and Progesterone Danazol Bromocriptine Tamoxifen

Radial Scar and Complex Sclerosing Lesion Radial scars are benign pseudoinfiltrative lesions of uncertain significance. They are characterized by a fibroelastotic core with entrapped ducts, surrounded by radiating ducts and lobules. Some authors have suggested using the term “radial scar” for lesions measuring <1 cm, whereas the term “complex sclerosing lesion” was reserved for lesions measuring 1 cm or larger

Contd… The radiographic features of radial scars are nonspecific and may mimic carcinoma The role of FNA cytology in diagnosis is limited. A spiculated lesion suggestive of radial scar or complex sclerosing lesion at mammography may be excised on the basis of its size and amount of sampling performed by core biopsy

Contd…

Intraductal papilloma It is a discrete benign tumor of the epithelium of mammary ducts. It can arise at any point in the ductal system and shows a predilection for the extreme ends of the ductal system: the lactiferous sinuses and the terminal ductules The central papillomas tend to be solitary, whereas the peripheral ones are usually multiple. Serous or serosanguinous nipple discharge is the presenting symptom in most women.

Clinical Symptoms The classical symptom of an intraductal papilloma is spontaneous bloody discharge from one nipple. This symptom usually appears in a woman in the perimenopausal age group. The discharge from the nipple is spontaneous and intermittent

Contd… During examination of the breast, it is important to circumferentially put radial pressure on different areas of the areola. This technique helps to identify whether the discharge emanates from a single duct or multiple openings

Papillomatosis (multiple papillomas) is defined as a minimum of five clearly separate papillomas within a localized segment of breast tissue, usually in a peripheral or subareolar location. Juvenile papillomatosis of the breast is defined as severe ductal papillomatosis occurring in young women of <30 years old