Benign Breast disease

Dr SA Al-Hourani MBBS CCBST MRCS

Congenital Anomalies of the Breast

Athelia: absence of nipples. Amastia: absence of breast tissue. may occur bilaterally or unilaterally. Athelia or amastia is sometimes associated with Poland syndrome.

Poland syndrome.
The classic ipsilateral features of Poland syndrome include the following: Absence of sternal head of the pectoralis major muscle Hypoplasia and/or aplasia of breast or nipple (athelia) Deficiency of subcutaneous fat and axillary hair Abnormalities of rib cage Upper extremity anomalies; short upper arm, forearm, or fingers (brachysymphalangism)

Amastia

Congenital Anomalies of the Breast

Polymastia: extra breast. Polythelia: extra nipple. approximately 1% of the population. Supernumerary nipples are slightly more common in males than in females. Extra breasts or nipples most commonly occur along the milk line, usually just underneath the normally located breasts or nipples. These accessory tissues have also been reported to undergo malignant transformation and should be removed.

Benign premature thelarche

Isolated breast development in females aged 6 months to 9 years. Physical examination for this entity should carefully seek out other signs of puberty, such as development of pubic hair, thickening of the vaginal mucosa, or accelerated bone growth. If no other signs of puberty are present, reassure the patient and family that this is a benign finding. Examine the child every 6-12 months.

Breast asymmetry
In this condition, one breast may develop before or more rapidly than the other . The physical examination findings usually include homogenous enlargement of one breast with no discrete masses or discharge. The patient and parents can be reassured that the asymmetry will become less noticeable with age.

Background
Breast masses can be broadly classified as benign or malignant. Common causes of a benign breast mass include fibrocystic disease, fibroadenoma, intraductal papilloma, and abscess. The main concern of many women presenting with a breast mass is the likelihood of cancer; however, most breast masses are benign.

Classification Based On Histologic Types

Non Proliferative Lesion
Simple Cyst
Complex cyst

Proliferative Lesions Without Atypia

Ductal hyperplasia

Fibroadenoma
Intraductal papilloma Sclerosing Adenoma Radial Scars

Atypical Hyperplasia
Atypical ductal hyperplasia Atypical lobular hyperplasia

Classification Based On Clinical Features

Mastalgia
Cyclic Non Cyclic

Tumors and Masses

Nodularity or glandular Cysts Galactoceles Fibroadenoma Sclerosing Adenosis Lipoma Harmatoma

Cystosarcoma Phylloides

Classification Based On Clinical Features )Contd)

Nipple discharge
Galactorrhea Abnormal nipple discharge

Breast infections and Inflammation

Intrinsic mastitis Postpartum engorgement Lactation mastitis Lactation breast abscess Chronic recurrent subareolar abscess Acute mastitis associated with macrocystic breasts

Extrinsic infections
Mondors Disease Hidradenitis suppurativa

Breast Infections
Breast infection most commonly affects women aged 18-50 years; in this age group, it can be divided into lactational and nonlactational infections. The process can affect the skin overlying the breast, where it can be a primary event, or it may occur secondary to a lesion such as a sebaceous cyst as hidrasenitis suppurativa.

Pathophysiology
The mammary glands arise along the milk lines that extend along the anterior surface of the body from the axilla to the groin. During puberty, pituitary and ovarian hormonal influences stimulate female breast enlargement, primarily due to accumulation of adipocytes. Each breast contains approximately 15-25 glandular units know as breast lobules, which are demarcated by Cooper ligaments.

Pathophysiology
Each lobule is composed of a tubuloalveolar gland and adipose tissue. Each lobule drains into the lactiferous duct, which subsequently empties onto the surface of the nipple. Multiple lactiferous ducts converge to form one ampulla, which traverses the nipple to open at the apex.

Pathophysiology
Below the nipple surface, lactiferous ducts form large dilations called the lactiferous sinuses, which act as milk reservoirs during lactation. When the lactiferous duct lining undergoes epidermalization, keratin production may cause plugging of the duct, resulting in abscess formation.[

Postpartum mastitis
Postpartum mastitis is a localized cellulitis caused by bacterial invasion through an irritated or fissured nipple. It typically occurs after the second postpartum week and may be precipitated by milk stasis. There is usually a history of a cracked nipple or skin abrasion.

Postpartum mastitis
Staphylococcus aureus is the most common organism responsible, but Staphylococcus epidermidis and streptococci are occasionally isolated. Drainage of milk from the affected segment should be encouraged and is best achieved by the use of a breast pump.

Nonlactating infections
Nonlactating infections may be divided into central (periareolar) and peripheral breast lesions. Periareolar infections consist of active inflammation around nondilated subareolar breast ductsa condition termed periductal mastitis. Peripheral nonlactating breast abscesses are less common than periareolar abscesses and are often associated with an underlying condition such as diabetes, rheumatoid arthritis, steroid treatment, granulomatous lobular mastitis, and trauma.

Primary skin infections

Primary skin infections of the breast (cellulitis or abscess) most commonly affect the skin of the lower half of the breast and often recur in women who are overweight, have large breasts, or have poor personal hygiene.

Neonatal mastitis
Neonatal mastitis usually occurs in term or near-term infants, is twice as common in females, and progresses to development of a breast abscess in approximately 50% of cases. Treatment includes antibiotics. If an abscess occurs, needle aspiration should be performed. Try to avoid I&D.

Breast Mass
Breast masses can involve any of the tissues that make up the breast, including overlying skin, ducts, lobules, and connective tissues. Fibrocystic disease, the most common breast mass in women, is found in 60-90% of breasts during routine autopsy.

Breast Mass
Fibroadenoma, the most common benign tumor, typically affects women younger than 30 years. Infiltrating ductal carcinoma is the most common malignant tumor; however, inflammatory carcinoma is the most aggressive and carries the worst prognosis.

Frequency
Breast cancer is the most commonly diagnosed cancer in women, after skin cancer, accounting for approximately almost 1 in 3 cancers diagnosed in Jordanian women. Infectious complications occur in as many as 10% of lactating women. Lactational mastitis is seen in approximately 23% of lactating women,and breast abscess may develop in 5-11% of women with mastitis.

Breast Masses
Breast masses in adolescent girls are usually benign. The most common discrete breast mass is a fibroadenoma (70%). Upon examination, these masses are smooth, mobile, and round. They may occasionally become larger just before the patient's menstrual period. Masses with the characteristics of fibroadenoma may be serially monitored (every 1-3 mo) with a careful physical examination. As many as 15% of patients may have multiple fibroadenomas.

giant, fibroadenomas
giant, fibroadenomas are unusually large (>5 cm). They usually display rapid growth but are usually benign. Management consists of surgery.

Cystosarcoma phyllodes tumors

Manifest as a painless breast mass. Patients may have a history of sudden enlargement of a previously stable mass. Ultrasonography cannot usually be used to distinguish between a fibroadenoma and a phyllodes tumor. The differentiation between a fibroadenoma and cystosarcoma phyllodes lies in histologic examination.

Cystosarcoma phyllodes tumors

Phyllodes tumors have a more cellular stroma with nuclear atypia and mitotic figures. As many as 25% of phyllodes tumors are considered malignant. The management for a benign or malignant phyllodes tumor is wide excision with a margin of normal breast tissue. Malignant phyllodes tumors rarely metastasize to the axilla. Axillary dissections are indicated for patients with palpable lymph nodes.

Breast hamartomas
Are rare in the adolescent population but have been described. breast hamartomas are densely packed enlarged lobules in a fibrous stroma. Clinically, they present as discrete painless masses similar to a fibroadenoma. They are treated with complete surgical excision and can recur if not completely removed.

Fat necrosis
Trauma to the breast, iatrogenic or blunt, may result in a palpable mass. The trauma causes fat necrosis, or breakdown of the adipose tissue. complicate the diagnosis, women may or may not recall the inciting event. Upon physical examination, the mass is sometimes indistinguishable from a cancer.

Fat necrosis
Ultrasonography, mammography, and even MRI of the breast may not be able to discern the difference, leading to biopsies in concerning masses. Although pathognomonic for fat necrosis, key featuresincluding peripheral calcifications, fibrotic scar, and echogenic internal bands may also be consistent with breast cancer. Findings of lipid cysts or ultrasonographic evidence of fat necrosis may assist in the decision to monitor a palpable abnormality or perform a biopsy.

Fibrocystic changes
Fibrocystic changes of the breast are very common in the adolescent population. Physical examination findings may reveal discrete breast cysts or diffuse small lumps throughout. Breast tenderness and heaviness may be experienced by the patient, especially before her menstrual period.

Fibrocystic changes
A single dominant lump that is present for several months likely requires excisional biopsy. Single dominant cysts may be aspirated in an outpatient setting. Cytopathologic examination should be conducted if the fluid is bloody. Fibrocystic changes are histologically classified into 3 categories: nonproliferative changes, proliferative changes without atypia, and proliferative changes with atypia. Patients with proliferative changes and/or atypia have a higher risk for future malignancies.

Fibrocystic changes
Although no specific data are available in adolescents, the risks in adults are well-described. Proliferative fibrocystic disease (described histologically as moderate or florid hyperplasia, sclerosing adenosis, or papilloma with a fibrovascular core) has been associated with a 1.5- to 2-fold increased risk of developing breast cancer. The most substantial increase in risk of breast cancer is observed in patients with atypical or lobular hyperplasia; this is associated with a 4.4-fold increase in cancer risk, which increases to 9-fold with a positive family history.

Mammary duct ectasia

Is a benign lesion of the breast that consists of dilation of the mammary ducts, periductal fibrosis, and inflammation. This entity has been described in infants, prepubertal boys and girls, and adult men and women. The patient presents with nipple discharge, which may be bloody.

Mammary duct ectasia

In children and adolescents, the lesion is usually unilateral. Infectious and inflammatory causes have been implicated in the etiology of this finding. Ultrasonography findings are usually suggestive, revealing dilated mammary ducts radially located around the nipple. The process is usually self-limited; therefore, surgery is not recommended if the diagnosis is certain.

Periductal mastitis
Mean age 32 yrs Active inflammation around non-dilated ducts Plasma cell rich NOT duct ectasia Smoking virtually ubiquitous May present with inflammation or abscess Antibiotics +/- standard treatment for abscess Often recurrent

Non-lactating infection: Periareolar/ periductal mastitis

Mammary duct fistula

Major complication of periductal mastitis Median age 35 > 90% smokers Usually preceding episodes of abscess Usually single involved duct May have several openings

Mammary duct fistula

Mammary duct fistula

Lay open and heal secondary intention Complete excision and primary closure

Gynecomastia
condition that results in excessive development of breast tissue in males. Physical examination findings vary from discrete, 1- to 3-cm, round, mobile, and usually tender masses located just underneath the areola to diffusely enlarged breasts. If the mass is large or fixed or if a discharge is present, further workup is necessary.

Gynecomastia
The differential diagnosis for gynecomastia includes Klinefelter syndrome, testicular feminization, hormone-secreting tumors, hyperthyroidism, hypothyroidism, cirrhosis, drug use (eg, cimetidine, marijuana), familial predisposition, and obesity. Young men with gynecomastia may often be monitored in the clinic and may be reassured that the condition is self-limited.

Gynecomastia
If the breast enlargement is such that it causes pain, discomfort, or psychological trauma, subcutaneous mastectomies may be performed.

Mondor Disease
Sclerosing thrombophlebitis of the subcutaneous veins of the anterior chest wall. The sudden appearance of a subcutaneous cord, which is initially red and tender and subsequently becomes a painless, tough, fibrous band that is accompanied by tension and skin retraction, is characteristic. The condition, though benign and self-limited, has been associated with breast cancer. It requires only symptomatic therapy.