1. BENIGN BREAST DISEASES
PROF. R. G. SANTHASEELAN
DEPT. OF GENERAL SURGERY
MMC AND RGGGH

2. Embryology-CONGENITAL LESIONS, Anatomy & Physiology of breast

3. Development of Breast
- Skin appendages arising from mammary ridge (Milk line) .. Ectoderm

5. CONGENITAL LESIONS OF BREAST

6. Gul
© Prof. Reda Mostafa

7. Accessory nipple
© Prof. Reda Mostafa

8. Accessory intra-mammary nipple
© Prof. Reda Mostafa

9. failure of nipple to evert during development. May be unilateral.
Congenital Nipple Inversion
failure of nipple to evert during development. May be unilateral.
Spontaneously corrected during growth of pregnancy or by simple traction.

10. Anatomy
Modified sweat gland between the superficial and deep layers of the chest wall

11. BLOOD SUPPLY THORACOACROMIAL ARTERY THORACODORSAL ARTERY
INTERNAL MAMMARY ARERY

12. LYMPHATICS ANTERIOR POSTERIOR LATERAL CENTRAL APICAL INTERNAL MAMMARY
INTER PECTORAL

13. CLASSIFICATION - ETIOLOGICAL
Congenital disorders
Traumatic
Inflammatory &
Infectious
Neoplastic
ANDI

14. The ANDI (Aberrations of Normal Development and Involution )
Breast –physiologically dynamic structure
unifying concept of symptoms, signs, histology and physiology
Benign disorders are related to the normal processes of reproductive life.
spectrum ranges from normal to aberration to sometimes disease.
classification is not comprehensive

15. ETIOLOGY
Endocrine
Disturbance of hypothalamic pituitary gonadal steroid axis
Altered prolactin profile
Non endocrine
Methylxanthines
Stress catecholamines
High saturated fat diet
Iodine deficiency

16. Normal
Benign disorder
Benign disease
Early reproductive
years
Nipple eversion
Nipple inversion
Subareoalar abscess,
duct fistula
Lobular development
Fibroadenoma Giant fibroadenoma
Stromal development
Adolescent Gigantomastia
Hypertrophy
Later reproductive years
Cyclical Hormonal changes
nodularity
Mastalgia, incapaciating mastalgia
Pregnancy
Lactation
Epithelial hyperplasia pregnancy
Bloody nipple discharge
Galactocele
Involution
Duct involution dialation
Duct ectasia
Periductal mastitis
Sclerosis
Lobular involution
Nipple retraction
Macrocysts,sclerosing lesions
Epithelial turnover
Epithelial hyperplasia
epi hyperplasia atypia

17. PATHOLOGICAL CLASSIFICATION
NONPROLIFERATIVE LESIONS
Cysts and apocrine metaplasia
Duct ectasia
Mild ductal epithelial hyperplasia
Calcifications
Fibroadenoma
II. PROLIFERATIVE BREAST DISORDERS WITHOUT ATYPIA
Sclerosing adenosis
Radial and complexing sclerosing lesions
Moderate and florid ductal epithelial hyperplasia
Intraductal papilloma
III. ATYPICAL PROLIFERATIVE LESIONS
Atypical lobular hyperplasia(ALH)
Atypical ductal hyperplasia(ADH)

18. INVESTIGATIONS IN BREAST DISEASE

19. Triple assessment

20. BREAST SONOGRAPHY Indications If Mammography is uncertain
To differentiate solid from cystic lesion
If asymmetric density
Visualise lesions near chest wall.
Interventional procedures.
Evaluate site of lumpectomy.
Lesion at periphery of breast.
Evaluating after surgical augmentation.

21. Breast Imaging Reporting And Data System [BI-RADS]
Categories are:
0: Incomplete – needs additional imaging
1: Negative - routine mammogram yearly
2: Benign finding(s) -yearly mammogram
3: Probably benign- short term follow up
4: Suspicious abnormality - biopsy should be considered
5: Highly suggestive of malignancy
6: Known biopsy-proven malignancy to r/o ca in opposite breast

22. BREAST MRI To distinguish scar from recurrence
Gold standard for imaging breast with implants
Detection of vertebral body metastasis & musculoskeletal pathology
Visualisation of axilla

23. BREAST MRI Indications
Radiologically dense breasts when mammography fails.
If Axillary node +ve and breast normal after mammo and sonography.
To rule out multifocality multicentricity before BCS.
To assess induction chemotherapy.
Followup after BCS.
Contrast enhanced more sensitive

24. FINE NEEDLE ASPIRATION CYTOLOGY
Uses 21 gauge needle & 10 ml syringe
Multiple passes through lump without releasing negative pressure
Aspirate is smeared onto slide & fixed
Differentiates solid & cystic lesions

25. CORE NEEDLE BIOPSY If fnac is inconclusive Advantages
significant core of tissue obtained
can distinguish invasive from intra ductal carcinoma
Grading of tumor
To know ER/PR and Her 2 status
Disadvantage
seeding of malignant cells along needle tract

26. When core needle biopsy is inconclusive
Removal of small portion of tumour
> 4cm in size
INCISION BIOPSY
EXCISION BIOPSY
Whole tumour is removed preferably
if <4 cm in size

27. OPEN BIOPSY(EXCISIONAL BIOPSY)
Most accurate and the Best Diagnostic Procedure for a Suspicious Breast Lesion.
Complete excision with a rim of normal tissue
Plan the incision in such a way that subsequent radical surgery can easily include the scar.
Follow Langer’s line

28. Case scenario 1
25 year old female patient presented with a lump in the breast. She gives a history of slow growing lump not associated with any pain or discharge from nipple & is very much anxious.

29. Differential diagnoses
Fibro adenoma
Phyllodes tumour
Breast cyst
Traumatic fat necrosis
Carcinoma

30. Fibroadenomas Second most common tumor of breast ANDI
Represent a hyperplastic or proliferative process in a single lobule
Etiology is unknown, thought to be due to hormonal influence
Risk of malignant transformation is rare
Resulting carcinoma is often a lobular carcinoma
Mimic malignancy in pregnancy,HRT

31. Types Simple/solitary/small(2-3 cm) Multiple(>5)
Juvenile-in young women between the ages of
Giant(>5cm)-rapidly growing,more common in
afro-caribbean population
Complex -contain other histological changes such as sclerosing adenosis, duct epithelial Hyperplasia, epithelial calcification.
Associated with slightly increased risk of cancer

32. Clinical features
Between the ages of years & size of 2-3cm
Painless lump- capsulated,smooth, firm, well defined, nontender, BREAST MOUSE
Confused with phyllodes
Microscope-
intracanalicular pericanalicular

33. diagnosis Clinical examination
Ultrasound scan –circumscribed lobulated mass
FNAC/Core needle biopsy

34. Treatment-conservative
Surgery
Very large/increasing in size
Suspicious cytology
Surgery is desirable
Extracapsular excision with a 1cm rim of normal tissue
Newer techniques-laser ablation &cryoablation

35. PHYLLOIDES TUMOUR Histopathology
Proliferation of intralobular stroma
Fusiform fibroblast
3 types:-
benign
borderline
malignant
(cellularity,atypia,mitoses &invasion by edges)

36. Phylloides vs Fibroadenoma
Phyllodes
Fibroadenoma
Age
Older(40-50y)
Younger
Duration
Rapid growth
Slower progression
Recurrence
Common
Less common
Size
Large ,bosselated
Smaller
Mammogram
Round density with smooth borders
Same
Ultrasound
Cystic spaces +/-
Cytology
More cellular, malignant type
Same as low grade phyllodes

37. CLINICAL APPEARANCE HISTOPATHOLOGY

38. Management
Wide local excision Benign Borderline - Follow up Malignant -SIMPLE MASTECTOMY

39. Traumatic Fat Necrosis
Clinical features - Pain & lump in the breast
Lump is hard - extensive fibrosis caused by tissue reaction
D.D : Carcinoma breast
Mammography findings - density lesion; can have calcifications; may mimic carcinoma breast
Treatment - excision of the lump

40. BREAST CYSTS Introduction
Definition – non integrated involution of breast tissue
Age group – 30-50
Multiple and bilateral
Can mimic malignancy
Confirmed by USG and
aspiration

41. Routine followup

42. Case scenario2
28 year old lady presenting with complaints of pain in both her breast for the past 6 years & increases just prior to menstruation, no pain during her pregnancy and lactation.

43. MASTALGIA CYCLICAL MASTALGIA
Menstruating age group
Hormone related-ANDI
Dull diffuse bilateral
Upper outer quadrant

44. ETIOLOGY Relative hyperoestrogenism Hyperprolactinaemia Psychological
Caffeine
Abnormal lipid metabolism

45. UNOPPOSED ACTION OF PROLACTIN
RECENT THEORY
LOW PGE1
LOW EFA
UNOPPOSED ACTION OF PROLACTIN

46. MANAGEMENT
1.Pain diary 2.Reassurance 3.Exclude caffeine 4.Low fat diet 5.Stop OCPs/HRT 6.stop smoking 7.drugs

47. PRIM ROSE OIL
GOOD RESPONSE
NO RESPONSE IN 4 MONTHS
TREAT 6 MONTHS
DANAZOL
GOSERELIN
BROMOCRIPTINE

48. NON CYCLICAL MASTALGIA
CAUSES
1.musculoskeletal pain
2.teitz syndrome
3.malignancy

49. FEATURES Unilateral Chronic burning or dragging
Pre and post menopausal

50. MANAGEMENT
EXCLUDE MALIGNANCY
TREAT THE CAUSE

51. FIBROCYSTIC BREAST DISEASES synonyms
Fibrocystic changes
Cystic Mastopathy
Chronic cystic disease
Mazoplasia
Cooper’s disease
Fibroadenomatosis
Reclus’s disease

52. What is fibroadenosis? ANDI Age group :30-50 years
Aberration in normal cyclical hormonal effects
Cyclcial mastalgia with nodularity

53. Pathomorphology Fibrosis Cyst formation Adenosis Epitheliosis
Papillomatosis
Apocrine metaplasia

54. Clinical features
lump
Cyclical mastalgia
Nipple discharge

55. Diagnosis
TRIPLE ASSESSMENT Rule out malignancy manage as cyclcial mastalgia
Treatment

56. Surgical Treatment Indications intractable pain
florid epitheliosis on fnac
Blood good cyst

57. surgery
1. Excision of the cyst or localized excision of the diseased tissue
2. Subcutaneous mastectomy with prosthesis placement

58. CASE SCENARIO 3
30 year old female came to OP with complaints of lump in both the breasts.Also complains of discharge from both the breasts.

59. DIFFERENTIAL DIAGNOSIS
MALIGNANCY??
Duct papilloma
Duct ectasia
Fibrocystic disease

60. Causes NIPPLE DISCHARGE Surface Eczema Psoriasis Chancre
Dischage from a single duct
Blood stained Serous
intraduct papilloma fibrocystic disease
duct ectasia duct ectasia

61. Discharge from more than one duct
blood stained : duct ectasia
black/green : duct ectasia
purulent : infection
Serous : fibrocystic disease
duct ectasia
Milk : lactation
hypothyroidism
pituitary tumours
drugs

62. Approach to a patient Clinical examination Nature of discharge
Mass present or not
Unilateral or bilateral
Single or multiple duct
Spontaneous/expressed
Relation to menstruation
Pre/post menopausal
Taking ocp/estrogen

63. Investigations
discharge analysis for malignant cells and occult blood

64. Treatment
REASSURANCE
MICRODOCHECTOMY
HADFIELD’S SURGERY

65. DUCTAL ECTASIA
Dilatation of the breast ducts associated with chronic inflammatory response in the periductal tissue

66. Clinical features Older age group Smokers
Nipple discharge: bilateral multifocal ,thick,opalascent,variable colour

67. DUCTOGRAPHY
MICRODOCHECTOMY
DIAGNOSIS TREATMENT

68. Proliferative breast disease without atypia
polyps of epithelium lined duct

69. Clinical features
Nipple discharge :unilateral,blood stained,from a single duct
Palpable mass/density lesion in mammography

70. Investigations
Ductography :filing defect

71. treatment Surgery less than 30 yrs:microdochectomy
more than 45 yrs:major duct excision(Hadfield)

72. CASE SCENARIO 4
24 year old lactating female presented in OP with throbbing pain in the left breast and fever…

73. BBD IN PREGNANCY AND LACTATION

74. BACTERIAL MASTITIS Types Subareolar abscess Intramammary abscess
Retromammary abscess

75. AETIOLOGY Staph aureus – penicillin resistant if hospital acquired
Streptococus
Ascending infection from a sore and cracked nipple

76. CLINICAL FEATURES PAIN SWELLING REDNESS FEVER ALTERED NIPPLE SENSATION
DISCHARGE
ITCHING
TENDERNESS
?LUMP

77. TREATMENT Flucloxacillin or co-amoxiclav
Support of the breast,local heat,& analgesics
Incision & drainage
Now recommended is repeated aspiration under antibiotics
continue breast feeding
close follow up
Antibioma if I&D not done
DD-inflammatory carcinoma of breast

78. BREAST ABCESS
Tender subareolar mass
Mammary duct fistula

79. slit like retraction of nipple

80. Investigations
If mass or nipple retraction is present rule out malignancy
Mammography
Cytology,histopathology

81. Treatment
Antibiotic
flucloxacillin and metronidazole

82. OPERATIVE DRAINAGE OF A BREAST ABSCESS
Local anaesthesia
Radial or circumareolar incision
drainage
Septa is disrupted & wound is packed

83. MONDOR’S DISEASE
Thromboplebitis of superficial veins of the breast & chest wall
Aetiology not known
C/F – thrombosed subcutaneous cord
DD – breast cancer
Treatment – antiinflamatory medication
warm compresses & support
restriction of movement
symptoms persist - excision

84. Thrombosed subcutaneous cord

85. GALACTOCOELE Definition Pathogenesis-inspissated milk c/f-pain & lump
Diagnosis-needle aspiratation

86. Management
Aspiration
Antibiotics

87. OTHER BBD IN PREGNANCY AND LACTATION
Nipple discharge
Simple cysts
Breast infarcts
Breast pain

88. OTHER INFECTIOUS CONDITIONS
Tuberculosis of breast
Syphilis of the breast
Actinomycosis

89. TUBERCULOSIS OF BREAST
Multiple c/c abscess & sinuses
Bluish attenuated apearance of surrounding skin
Diagnosis
Treatment

90. SYPHILIS OF THE BREAST Primary chancre of nipple
Secondary lesions – diffuse mastitis

91. CASE SCENARIO 5
15 year old male presented with enlarged breast on right side.

92. Male breast
Contains only ducts
No alveoli

93. BENIGN BREAST LUMPS IN MALES
Gynaecomastia
Fibroadenoma
Phyllodes tumour
Epidermal inclusion cysts
Sub cutaneous leiomyoma
Sub areolar abscess
Intra mammary lymph node

94. GYNAECOMASTIA
Hypertrophy of breast tissue in males.

95. PATHOPHYSIOLOGY Estrogen excess states Androgen deficiency states
Drug related
Systemic diseases with idiopathic mechanisms

96. CLINICAL CLASSIFICATION
Grade I -Mild breast enlargement without skin redundancy
Grade IIa- Moderate breast enlargement without skin redundancy
Grade IIb-Moderate breast enlargement with skin redundancy
Grade III-Marked breast enlargement with skin redundancy and ptosis, which simulates a female breast

97. MANAGEMENT

98. TREATMENT Depends on the cause -androgen deficiency -medications
-endocrine defects
medicines
-surgery

99. THANK YOU