1. Alireza Mohammadzadeh, MD Thoracic Surgeon
Benign Breast Disease
Alireza Mohammadzadeh, MD
Thoracic Surgeon

2. Benign breast disorders & diseases encompass a wide range of clinical and pathologic entities

3. Understanding of these for :
clear explanation to affected women
appropriate treatment instituted
unnecessary follow up

4. Fibroadenoma Predominantly in younger women aged 15 to 25 years
Usually grow to 1 or 2 cm and then are stable
Small f. (<1cm) are considered normal
Larger f.(<3cm) are disorders
Giant f. (>3cm) are disease
Multiple f. (more than 5 in one breast) are disease

5. 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

6. Fibroadenoma
Hypoechoic, no acoutic transmission

7. Core-needle biopsy

8. Treatment
Surgical removal
Cryoablation
observation

9. Sclerosing adenosis
Prevalent during childbearing & perimenopausal years
No malignant potential
Occasionally presents as a palpable mass
Benign calcification
Lesions up to 1 cm are called radial scar
Larger lesions are called complex sclerosing

10. Sclerosing adenosis Mimic of cancer
On physical examination, by mammography, at gross pathology
Wire localized excisionl biopsy

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

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

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

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

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

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

17. 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

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

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

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

22. 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

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

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

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

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

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

28. Bloody Nipple Discharge

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

30. Imaging
Mammography
Ultrasound
MRI

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

34. 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

38. 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

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

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

41. Ultrasound

42. Malignant or Benign

43. Malignant vs Benign

44. 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

45. MRI
Pre Gad Post Gad Color Overlay

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

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

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

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

51. Core biopsy Vacuum Assisted

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