1. Juhi Asad, DO Sharon Rosenbaum Smith, MD Dept. of Breast Surgery
Benign Breast Disease
Juhi Asad, DO
Sharon Rosenbaum Smith, MD
Dept. of Breast Surgery

2. Outline
Anatomy
Benign disease
Management
Genetics

3. Anatomy
Modified sweat gland between the superficial and deep layers of the chest wall
Cooper’s Ligament
Fibrous band of tissue

4. Anatomy
Ducts
Terminal ductules
Milking forming glands
Lobule

5. Question
Axillary lymph nodes are classified accordingly to the relationship with the
Axillary vein
Pec.major
Pec.minor
Latissimus dorsi
Serratus anterior

6. Anatomy Axillary lymph nodes defined by pectoralis minor muscle
Level 1 – lateral
Level 2 – posterior
Level 3 – medial
Long Thoracic Nerve
Serratus anterior
Thoracodorsal Nerve
Latissimus Dorsi
Intercostalbrachial Nerve
Lateral cutaneous
Sensory to medial arm & axilla

7. Anatomy Hormonal Effects Estrogen Progesterone Prolactin
Development of the breast and lactiferous ducts
Progesterone
Secretory acinar tissue – lobules
Prolactin
Synergizes the effect of estrogen and progesterone

8. Benign Breast Diseases
Glandular breast parenchyma
Mass
Asymmetric nodularity
Pain
Nipple-Areolar Complex
Discharge
Rash
Retraction
Surrounding breast skin
Dimpling

9. Management History Clinical Breast Exam Breast imaging Tissue sampling
Therapy

10. History Age Family History Prior biopsies Hormone therapy Menarche
Pregnancy
Breast feeding
Menopause
Family History
Prior biopsies
Hormone therapy

11. Question What are the risk factors that are part of the Gail Model?
Race
Age
Age of 1st menses
Age at 1st pregnancy
# of 1st degree relatives
# of biopsies

12. Clinical Exam Inspection Palpable Skin Symmetry Masses Gland
Axilla, Supraclavicular spaces
Nipple-areola complex

13. Question
22 yo female presents with a new right breast mass. Complains of mild tenderness. No other complaints. On physical exam, there is a 1 cm nodule at the 2:00 position. Your diagnostic test of choice is….
Mammogram
Ultrasound
Excisional biopsy
Incisional biopsy

14. Breast Mass Breast Cysts Fluid-filled 1 out of every 14 women
50% multiple and recurrent
Hormonally influenced
Needle aspirated

15. Breast Cyst
Anechoic, well marginated, well defined posterior shadowing

16. Breast Mass Fibroadenoma Stromal and epithelial elements
Most common in women <30yo
Firm, solitary tumors
Multiple
Increase in size
Management
Biopsy
Excisional biopsy

17. Fibroadenoma
Hypoechoic, no acoutic transmission

18. Breast Mass Phyllodes Tumor
Proliferation of connective tissue with ductal elements
Whorled and cellular stroma
Firm, lobulated
2 to 40 cm in size
10% malignant
Treatment
Wide excision

20. Fibrocystic Disease Clinical, mammographic and histologic findings
Exaggerated response from hormones and growth factors
Cyclical pain
Nodularity – upper outer quadrants

21. Fibrocystic Disease Histology Adenosis Apocrine metaplasia Fibrosis
Duct ectasia
Mild ductal hyperplasia

22. Fibrocystic Disease Risk Factors Dense breast Sclerosing adenosis
Atypical ductal, papillary, or lobular hyperplasia

23. Question
34 yo female referred to you for evaluation of breast pain. The pain is burning and sharp in nature. Always present. On physical exam, dense glandular tissue bilaterally. Your working diagnosis is….
Cyclical breast pain
Noncyclical breast pain
cancer

24. Breast Pain Cyclical pain – hormonal Non-cyclical pain
Dull, diffuse and bilateral
Luteal phase
Treatment
Reassurance
NSAIDS
Evening primrose oil
Non-cyclical pain
Non-breast vs breast
Imaging

25. Breast Infections Mastitis Generalized cellulitis of the breast
Ascending infection subareolar ducts
commonly occurs during lactation
Staph. aureus
Erythema, pain, tenderness

26. Mastitis
Treatment
Abx
Continue to breast feed
Close follow-up

27. Breast Abscess Abscess Breast tissue Treatment Abx Needle aspiration
Incision and drainage

28. Question
What is the difference between spontaneous vs non-spontaneous nipple discharge?

29. Nipple Discharge Physiologic Bilateral Involves multiple ducts
Heme (-)
Non-spontaneous
Discharge – green, milky – galactorhea prolactin level.

30. Nipple Discharge Pathologic Unilateral Spontaneous Heme (+)
Most common cause intraductal papilloma

31. Bloody Nipple Discharge

32. Intraductal Papilloma
Single duct
Benign
4% of intraductal ca

33. Imaging
Mammography
Ultrasound
MRI

34. Mammography Screening tool Estimated reduction in mortality 15-25%
Age of 40
Estimated reduction in mortality 15-25%
10% false positive rate
Densities & calcifications

37. Calcification Macrocalcifications Microcalcifications Large white dots
Almost always noncancerous and require no further follow-up.
Microcalcifications
Very fine white specks
Usually noncancerous but can sometimes be a sign of cancer.
Size, shape and pattern

41. BI-RADS Features Need additional imaging 1 Negative – routine in 1 yr
BI-RADS Classification
Features
Need additional imaging 1
Negative – routine in 1 yr 2
Benign finding – routine in 1 yr 3
Probably benign, 6mo follow-up 4
Suspicious abnormality, biopsy recommended 5
Highly suggestive of malignancy; appropriate action should be taken

42. Ultrasound Not a screening tool Palpable vs cystic
Mammographic detected lesion

43. Central anecho, well circumscribed margins, enhanced thru transmission

44. Ultrasound Benign Malignant Pure and intensely hyperechoic
Elliptical shape (wider than tall)
Lobulated
Complete tine capsule
Malignant
Hypoechoic, spiculated
Taller than wide
Duct extension
microlobulation

45. Ultrasound

46. Malignant or Benign

47. Malignant vs Benign

48. MRI High risk patients High sensitivity (95-100%)
Personal history of breast ca
LCIS, atypia
1st degree relative with breast cancer
Very dense breast
High sensitivity (95-100%)
10-20% will have a biopsy

49. MRI
Pre Gad Post Gad Color Overlay

50. Diagnosis Fine needle aspiration Core biopsy Excisional biopsy
Cytology
Core biopsy
Image guided
Stereotactic
Excisional biopsy
Needle localization

51. FNA Fast, inexpensive 96% accuracy Institution dependent
Unable to differentiate b/w in situ vs CA

52. Core Needle Biopsy
14-18 gauge spring loaded needle
Tissue
Multiple

54. Large Core Biopsy
6-14 gauge core
Large samples
Single insertion

55. Core biopsy Vacuum Assisted

56. Stereotactic Biopsy Suspicious mammographic abnormalities
Patients lay prone

58. Stereo View

62. Excisional Biopsy Atypical lesions LCIS Radial scar
Atypical papillary lesions
Radiologic-pathologic discordance
Phyllodes
Inadequate tissue harvesting

63. High-Risk Prior breast cancer Family history of breast cancer
Ovarian cancer
BRCA-1 or BRC-2 gene
Prior mantle radiation
Biopsy proven of atypia or LCIS

64. Screening Prior breast cancer or atypia Family Hx BRCA
Annual mammography
6 mo CBE
Family Hx
10 yrs younger than relative’s diagnosis
BRCA
25 yo – annual mammography

65. Genetics Early age of onset
2 breast primaries or breast and ovarian CA
Clustering of breast CA with:
Male breast CA,
Thyroid CA,
Sarcoma,
Adrenocortical CA,
Pancreatic CA
leukemia/lymphoma on same side of family
Family member with BRCA gene
Male breast CA
Ovarian CA

66. Genetics Hereditary Breast/Ovarian Syndrome Li-Fraumeni Syndrome
BRCA 1 – chromosome 17
BRCA 2 – chromosome 13
Li-Fraumeni Syndrome
P53 mutation – chromosome 17
Cowden Syndrome
PTEN mutation – chromosome 10
Autosomal dominant pattern

67. BRCA Account to 25% of early-onset breast cancers
36%-85% lifetime risk of breast CA
16-60% lifetime risk of ovarian CA

68. BRCA BRCA 1 gene BRCA 2 gene Ovarian CA Male breast CA Prostate CA
Pancreatic CA

69. BRCA Management Monthly BSE -- 18yo 6 mo CBE & annual mammo -- 25yo
Discuss risk reducing options
Prophylactic mastectomies
Salpingo-oophorectomy – upon completion of child bearing
6 mo transvaginal US & CA125 – 35 yo

70. Li-Fraumeni Syndrome Mutation of p53 gene Premenopausal breast CA
Tumor suppressor
Premenopausal breast CA
Childhood sarcoma
Brain tumors
Leukemia
Adrenocortical CA
Accounts for 1% of breast CA

71. Cowden Syndrome Major criteria Minor criteria Thyroid CA (follicular)
Marcocephaly
Cerebellar tumors
Endometrial CA
Breast CA – 25%-50% risk
Skin and mucosal lesions
Minor criteria
Thyroid lesions
GU tumors
GI hamartomas
Fibrocystic breast
Mental retardation
PTEN gene mutation on chromosome 10q23