Benign breast disorders

dr. Milvan Hadi, SpOG

 THE BREAST

SURGICALLY RELEVANT ANATOMY

Basic Structure

Composed of glandular, fibrous, and adipose tissue

Lies within layers of superficial pectoral fascia
Each mammary gland consistsof approximately 15 to 20 lobules, each of
which has a lactiferousduct that opens on the areola
Has ligaments that extend from the deep pectoral fascia to the superficial
dermal fascia that provide structural support referred to as Cooper ligaments
Frequently extends into axilla as the axillary tail of Spence
Is partitioned into 4 quadrants by vertical and horizontal lines across the nipple :
Upper inner quadrant (UIQ), lower inner quadrant (LIQ), upper outer quadrant
(UOQ), and lower outer quadrant (LOQ)
INITIAL EVALUATION OF PATIENTS WITH POSSIBLE
BREAST DISEASE

Complete medical history, including risk factors for breast cancer . Be sure to
inquire about any history of nipple discharge or any changes in the size, shape,
symmetry, orcountour of thebreasts.

Physical examination :
Inspection : Note color, symmetry, size, shape, andcountour, and check for dimpling,
erythema, edema,or thickening of skin with a porous appearance (peadorange).
Palpation : Palpate all four quadrants, the axillary lymph nodes, and the nipple-
areolarcomplex for anydischarge.
EVALUATION OF A PALPABLE BREAST MASS
Approach
If age < 30, serial physical examination with observation for 2 to 4 weeks or until next
menstrual period is an option
Age > 30

Ultrasound or
needle aspiration

No fluid aspirated or mass Aspirate non-bloody and

Persists after aspiration The mass resolves

Get mammogram and obtain tissue for Serial physical examinations and screening
Pathologic diagnosis via FNA, needle biopsy, etc Mammograms according to previously estabilished
(other options as previously discussed) recommendations

Diagnosis obtained Nondiagnostic

Definitive treatment
Obtain more tissue
Tailored to specific
For diagnosis by
Diagnosis with
Excisional biopsy
Appropriate follow-up

Definitive treatment
Tailored to specific
Diagnosis with
Appropriate follow-up
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Type Cause Frequency

Normal nodularity Common

Prominent fat lobule Less Common
Normal Prominent rib Less Common
Struktur Intra mammary Lymph node Rare
Edge of Biopsy wound Less Common
Assessory breast Rare
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Type Cause Frequency

Fibroadenoma Common
Cyclical nodularity Common
ANDI Cyst Common
Galactocele Rare
Sclerosing adenosis Less Common
Stromal fibrosis Rare
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Chronic infective abscess Rare

Fat necrosis Rare
Inflamatory Foreign body granuloma Rare
Mondors disease Rare

Duct papiloma Less common

Benign Giant fibroadenoma Rare
tumours Lipoma Rare
Granular cell myoblastoma Rare
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Intermediat Phyllodes tumor Rare

tumours Carsinoma in situ Less
common

Malignant Primary tomuors Common

Secondary tumour Rare
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Squamous papiloma Less common

Lession of the Leiomyoma Rare
Nipple and Retention cyst Rare
Areola Papilary adenoma Rare

Sebaceous cyst Less common

Lession of the Hidradenitis Rare
Skin Benign and malignat Rare
skin tumours
EVALUATION OF A PALPABLE BREAST MASS

Differential Diagnosis

Infectious/inflammatory : Mastitis, fat necrosis,

Mondors disease
Benign lesions : Fibroadenoma, fibrocystic changes,
mammary duct ectasia, cystosarcoma phyllodes
(occasionally malignant), intraductal papiloma,
gynecomastia
Premalignant disease : Ductal carcinomain situ (DCIS),
lobular carcinoma in situ (LCIS)
Malignant tumors : Infiltrating ductal, infiltrating
lobular, and inflammatory carcinoma ; Pagets
Disease ; and other less common histologic types of
breast cancer
INFECTIOUS / INFLAMMATORY
Mastitis

Usual etiologic agent : Staphylococcus aureus or

Streptococcus spp.
Most commonly occurs during early weeks of breast-
feeding
Physical exam : Focal tenderness with erythema and
warmth of overly ing skin, fluctuant mass Occasionally
palpable.
Diagnosis : Ultrasound can be used to localize an
abscess ; if abscess present, aspirate fluid for Gram
stain and culture.
Treatment : Continue breast feeding and recommend
use of breast pump as an alternative
Cellulitis : Wound care and IV antibiotics
Abscess : Incision and drainage followed by IV
INFECTIOUS / INFLAMMATORY

Fat Necrosis
Presentation : Firm, irregular mass of varying
tenderness
History of local trauma elicited in 50% of patient
Predisposing factors : Chest wall or breast
trauma
Physical exam : Irregular mass without discrete
borders that may or may not be tender ; later,
collagenous scars predominate
Often indistinguishable from carcinoma by
clinical exam or mammography
Diagnosis and treatment : Excisional biopsy with
pathologic evaluation for carcinoma
BENIGN DISEASE
Fibroadenoma

Definition : Fibrous stroma surrounds duct-like epithelium and forms

a benign tumor that is grossly smooth, white, and well circumscribed.
Risk factors : More common in black women than in white women.
Incidence : Typically occurs in late teens to early 30s; estrogen-
sensitive (increased tenderness during pregnancy).
Signs and symptoms : Smooth, discrete, circular, mobile mass.
Diagnosis : FNA
Treatment :
If FNA is diagnostic for fibroadenoma and patient is under 30, may
observe depending on severity of symptoms and size (<3cm).
If FNA is nondiagnostic, patient is over 30, or is symptomatic, must
excise mass. The mass is well encapsulated and can be shelled out
easily at surgery.
BENIGN DISEASE

Mondors Disease

Definition : Superficial thrombophlebitis of lateral thoracic or

thoracoepigastric vein.
Predisposing factors : Local trauma, surgery,. Infection,
repetitive movements of upper extremity.
Presentation : Acute pain in axilla or superior aspect of lateral
breast.
Physical exam : Tender cord palpated.
Diagnosis : Confirm with ultrasound.
Treatment :
Clear diagnosis by ultrasound : Salicylates, warm compresses,
limit motion of affected upper extremity. Usually resolves
within 2 to 6 weeks.
If persistens, surgery to divide the vein above and below the
site of thrombosis or resectthe affected segment.
Ultrasound nondiagnostic or an associated mass present :
Excisional biopsy.
BENIGN DISEASE

Fibrocystic Changes

Usually diagnosed in 20s to 40s.

Presentation : Breast swelling (often bilateral),
tenderness, and/or pain.
Physical exam : Discrete areas of nodularity within
fibrous breast tissue.
Evaluation : Serial physical examination with
documentation of the fluctuating nature of the
symtoms is usually sufficient unless a persistent
discrete mass is identified ; definitive diagnostic
requires aspiration or biopsy with pathologic evaluation.
 Fibrocystic Changes

Symtoms thought to be of hormonal etiology and tend

to fluctuate with the menstrual cycle.
Associated with a group of characteristic histologic
findings, each of which has a variable relative risk
for the development of cancer.
Not associated with an increased risk for breast
cancer unless biopsy reveals lobular or ductal
hyperplasia with atypia.
Treatment :
For cases with a classic history or absence of a
persistent mass : Conservative management ; options
include nonsteroidal anti-inflammatory drugs
(NSAIDs), oral contraceptive pills (OCPs),danazol, or
tamoxifen, tobacco, cola drinks).
If single dominant cyst, aspirate fluid ; may discard
if green or cloudy but must send to cytology and
excise cyst if bloody.
BENIGN DISEASE

Cystosarcoma Phyllodes

A variant of fibroadenoma.
Majority are benign.
Patients tend to present later than those with fibroadenoma
(>30 years).
Characteristics : Indistinguishable from fibroadenoma by
ultrasound or mammogram.
The distinction between the two entities can be made on the
basis of their histologic features (phylloides tumors have more
mitotic activity). Most are benign and have a good prognosis.
Exam : Large, freely movable mass with overlying skin changes.
Diagnosis : Definitive diagnosis requires biopsy with pathologic
evaluation
Treatment :
Smaller tumors : Wide local excision with at least a 1-cm
margin
Larger tumors : Simple mastectomy
BENIGN DISEASE

Intraductal Papilloma

Definition : A benign local proliferation of ductal

epithelial cells.
Characteristics : Unilateral serosanguinous or bloody
nipple discharge.
Presentation : Subareolar mass and / or spontaneous
nipple discharge.
Evaluation : Radially compress breast to determine which
lactiferous duct expresses fluid ; mammography.
Diagnosis : Definitive diagnosis by pathologic evaluation
of resected specimen
Treatment : Excise affected duct.
Galaktokel
Fitzwilliams 1845, kista berisi susu
sering pada masa laktasi
bersamaan dengan duct ectasia dan
recurrent sub areola abses
klinis timbul massa tanpa nyeri setelah
beberapa minggu/ bulan menyapih
dapat hilang sendiri a setelah aspirasi
lokasi tersering sub areola
TERIMAKASIH