Benign Breast Diseases - COO

Breast Development Arise from the epidermis forming ducts capped by alveolar buds Puberty = breast Differentiation Ducts communicate and lobules develop Final full breast Differentiation = Term Pregnancy Menstrual and Ovarian Cycle Epithelial cells proliferate during luteal phase Programmed cell death after the luteal phase Associated with edema of the extracellular space Menopause Lobules involute Collagenous stroma is replaced by fat Estrogen receptor increases History Focus on: Nipple Discharge Character of discharge Breast Mass Association of symptoms with the menstrual cycle Change in breast shape, size, or texture Previous breast biopsies Detection The patient should be questioned about the following risk factors for breast cancer Family History of Breast CA High Fat Diet, Obesity and Alcohol Intake Nulligravid Increasing age Age of menarche < 12 years Nulliparity or first pregnancy >30 years of age Late menopause (older than 55 years of age) Family history of breast cancer (especially premenopausal or bilateral disease) Number of first-degree relatives with breast cancer and their ages when diagnosed Family history of male breast cancer Inherited conditions associated with a high risk for breast cancer: BRCA1 and BRCA2 genes Li-Fraumeni syndrome Cowden's disease ataxia telangiectasia syndrome Peutz-Jeghers syndrome Evaluation of Breast Lump Triple Test Clinical examination Imaging Pathology / Biopsy Clinical Examination Inspection Symmetry Contour Skin Appearance and skin changes Dimpling Nipple discharge Palpation Location of the mass is reported based on clock position Measure distance from the nipple Breast temperature Texture Thickness of the skin Generalized or focal tenderness Nodularity Density Dominant masses Nipple Discharge Diagnostic imaging Mammography Breast Biopsy Needle biopsy Fine needle biopsy Core needle biopsy Breast Cancer Detection Self-detection 48% Breast Imaging 41% Physician PE 11% Recommendation: Premenopausal: Monthly 7 10 days after the onset of menses Menopausal: Select a specific calendar date and perform monthly Breast self-examination Breast Imaging Mammography Detects slow growing breast cancer before it reaches a size detectable by palpation Indications: Screening for women at risk for breast CA Evaluate a questionable/ ill-defined breast mass or other suspicious change in the breast detected by breast examination Baseline breast mammogram and reevaluate patients at yearly intervals to diagnose a potentially curable breast cancer before it has been diagnosed clinically Search for occult breast CA in those with metastatic disease in axillary nodes or elsewhere from the primary origin Screen for unsuspected CA before cosmetic operations or biopsy of a mass Monitor breast CA pts. Treated with breastconserving surgery and radiation Screening American Cancer Society Women with average risk for breast CA begin mammography by 40 years old Women 20s to 30s clinical breast exam every 3 years or annually Women >40 years old annual breast exam plus mammography American Geriatric Society Annual/ biennial mammography up to 75 years old For high risk women initiation of screening must be earlier and more frequent

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Benign Breast Diseases - COO

Mammographic Abnormalities Morphologic Categories of Mammographic Abnormalities: Calcification distribution Number of calcifications Description of calcifications Mass margin Shape of mass Density of mass Associated findings Special cases Mammographic Reports Six Categories: Incomplete, needs further imaging Negative Benign finding Probably benign, short-interval follow-up recommended Suspicious finding and biopsy should be considered Highly suggestive of malignancy and appropriate action should be undertaken Known malignancy Correlation of Findings Biopsy is done on a dominant/suspicious mass despite absent mammographic findings Ultrasonography Used for focused scanning of a questionable finding/ evaluation of a mammographic finding Preferred method to distinguish between solid and cystic masses Not recommended for routine screening Ambiguous mammographic findings Silicone leak Mass in woman <30 y/o, lactating/pregnant Guidance for interventional procedures: i.e biopsy Possible role for additional imaging in highrisk individuals

Magnetic Resonance Imaging Used to assess indeterminate breast lesions detected by clinical or mammographic exam Highly sensitive but not very specific Indications: Stage tumor to r/o multicentric disease Differentiate postoperative scar from recurrence after breast conserving surgery Find lesion seen in one view of mammography Evaluate (+) axillary nodes but w/ (-) mammogram and breast examination Rule out silicone implant rupture Assess focal asymmetry Breast Tissue Evaluation Tissue Biopsy Fine Needle Aspiration Cytology Core Needle Biopsy Excision Biopsy (less accurate) FNAC 1.7% 7.1% CNB 0% 5.7%

False (+) False (-)

Indications: Characterization: Palpable abnormality

Triple Test Result Concordant test if >99% accurate If benign follow-up PE every 6 months. If malignant, refer to surgery If non-concordant, excision of breast mass.

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Benign Breast Diseases - COO

Algorithm for Management of Breast Masses in Premenopausal women

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Benign Breast Diseases - COO

Algorithm for Management of Breast masses in Postmenopausal women

Benign Breast Disorders Fibrocystic Change Most common lesions of the breast Histologically refers to: Fibrosis in the breast Cyst formation in the breast Epithelial hyperplasia in the breast 33-55 years old Associated with benign breast epithelium Clinical Findings: Asymptomatic mass Smooth and mobile Nipple discharge May be accompanied by pain or tenderness during the premenstrual phase Cyclic breast pain is the most common associated symptom Differential Diagnosis Breast CA Cysts Papillomatosis Adenosis Fibrosis Ductal epithelial hyperplasia Diagnostic Tests Mammography: no diagnostic signs Ultrasound Mass with thin walls

Smooth round shape Absence of internal echoes Posterior acoustic enhancement Fine Needle Biopsy Tissue Biopsy No cyst fluid is obtained Bloody fluid Fluid is thick Complex cyst There is an intracystic mass Mass persist after aspiration Persistent mass noted at any time during follow up Risk for Breast CA Not associate with increased risk of breast CA Unless with histological evidence of: proliferative epithelium w/ or w/o atypia Atypical ductal/ lobular hyperplasia= 5X CA in-situ=8 10 x Family history PLUS atypia = 11x Cyst plus family history = 3x Management No specific treatment required Discontinue coffee, tea and chocolate Vitamin E and B6 may be helpful Self-Breast Exam every month just after menses

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Benign Breast Diseases - COO

Mastalgia Types of Mastalgia Cyclic Mastalgia Related to exaggerated premenstrual cycle Breast engorgement, pain, heaviness and bilateral tenderness Common in the 3rd and 4th decade of life Accounts for 2/3 of all breast pain symptoms Noncyclic Mastalgia Independent of the menstrual cycle Achy, burning soreness Intermittent/ constant Unilateral Common in the 4th and 5th decade Extramammary Pain Perceived to be breast in origin but extramammary in nature May be: Chest wall muscular pain Coastal cartilage symptoms Costochondritis Herpes zoster Rib fracture Management of Mastalgia Reassurance Medications: Anesthetics Diuretics Bromocriptine Tamoxifen Vitamins Primrose oil Mechanical support Discontinuation of hormone therapy Fibroepithelial Lesions Fibroadenoma Most Common Benign Tumor Common in women < 25 years old Rare after menopause May be single or multiple lesions Most are detected at 2 3 cm mass Physical Examination: Firm Smooth Rubbery Mobile Bilobed On Imaging: Well defined Smooth Solid mass with clear defined margins and borders Risk to Breast CA Not associated with increased risk to Breast CA Management: Conservative Complete Excision Phyllodes Tumor Rare fibroepithelial tumors Maybe: Benign 70% Borderline 7% Malignant 23% Rarely bilateral Difficult to distinguish clinically w/ fibroadenoma Management: Wide local excision w/ 1-2 cm margin Mastectomy for women with small breast Axillary node dissection not indicated Breast Conditions Requiring Evaluation Nipple Discharge Spontaneous 48% Provoked 52% = no pathologic significance Spontaneous discharge + Breast CA : 4 10% Non neoplastic causes: Galactorrhea: most common Physiologic conditions due to mechanical manipulation Parous condition Periductal mastitis Subareolar abscess Fibrocystic changes Mammary duct ectasia Neoplastic causes in non-lactating women: Solitary intraductal papilloma Carcinoma Papillomatosis Squamous Metaplasia Adenosis Extramammary causes: Hormones and drugs Important Characteristics of the Discharge Nature of Discharge Association with a mass Unilateral or bilateral Single or multiple ducts Spontaneous/ expressed Relations to menses Premenopausal/ postmenopausal Hormonal medication Nipple discharge cytology is rarely performed Surgical excision of trigger point Lacrimal probe is done Breast resection for 3 to 5 cm Patient is warned against: Possible loss of: Skin Nipple Nipple sensation deformity Inability to breast feed

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Benign Breast Diseases - COO

Erosive Adenomatosis of the Nipple Rare benign condition that mimics Pagets disease Present with pruritus, burning and pain Physical Examination: Nipple maybe ulcerated, crusting, scaling, indurated and erythematous Nipple is enlarged and prominent during menses Differential Diagnosis: Squamous Cell CA, Psoriasis, Contact Dermatitis, Seborrheic Keratosis, AdenoCA of the skin and unusual primary tumor of the nipple Local Excision is curative Fat Necrosis With a history of trauma in 50% Seen in active women Ecchymosis may be seen near the tumor Tenderness may be (+)/ (-) May spontaneously disappear Breast Abscess Lactational Abscess Common in first time breast feeders, this is true if baby is not properly latched. Lactational mastitis is due to transmission of bacteria during nursing and poor hygiene Staphylococcus aureus most common cause Management: Early stages: continue breast feeding plus dicloxacillin 250mg QID or oxacillin 500 mg QID for 7 10 days If with a local mass and with signs of systemic infection drainage and discontinue breastfeeding NonLactational Abscess Develop in young/ middle age women Due to trauma, or even hair. Abscess is evaluated with ultrasound Antibiotics and drainage is indicated if the fluid collection is > 3 ml Otherwise aspiration of the pus is enough Subareolar Abscess and Lactiferous Duct Fistula Due to obstruction of the distal ducts with inspissated debris Most common organism Staphylococcus aureus Definitive Management Excision and drainage of lactiferous duct sinus Disorders of Breast Augmentation Contraction of breast implants Scarring around the implants Causing firmness and breast distortion Implant rupture Bleeding of gel through the capsule US and MRI for diagnose if theres a leaking of breast implant: Management: Surgical removal if implants rupture

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