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

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

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

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

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

Fibroadenoma Hypoechoic, no acoutic transmission

Core-needle biopsy

Treatment Surgical removal Cryoablation observation

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

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

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

Management History Clinical Breast Exam Breast imaging Tissue sampling Therapy

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

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

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

Breast Cyst Anechoic, well marginated, well defined posterior shadowing

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

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

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

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

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

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

Mastitis Treatment Abx Continue to breast feed Close follow-up

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

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

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

Bloody Nipple Discharge

Intraductal Papilloma Single duct Benign 4% of intraductal ca

Imaging Mammography Ultrasound MRI

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

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

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

Ultrasound Not a screening tool Palpable vs cystic Mammographic detected lesion

Central anecho, well circumscribed margins, enhanced thru transmission

Ultrasound

Malignant or Benign

Malignant vs Benign

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

MRI Pre Gad Post Gad Color Overlay

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

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

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

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

Core biopsy Vacuum Assisted

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