1. Benign Breast Problems

2. Outline Introduction Anatomy Structure of the breast Classification
Initial approach to breast problems
Diagnostic workup
Conclusion
References

3. Introduction
Breast problems are a major reason why women visit the primary care physician
Breast diseases in women constitute a spectrum of benign and malignant disorders
The most common breast problems for which women consult a physician are breast pain, nipple discharge and a palpable mass.
Benign breast lesion is a non-cancerous lesion. According to American Cancer society , when tissue biopsy is examined under the microscope, nine out of every 10 women will have some type of abnormality
AAFP journal , April 15, Volume 61/ No. 8

4. Anatomy
The breast is a modified sweat gland with a mass of glandular, fatty and fibrous tissues on the pectoralis muscles in the chest wall
It is attached to the chest wall by fibrous strands called coopers ligaments
The glandular tissues of the breast consist of lobules, lobes and ducts
Fatty and fibrous tissues surround the milk producing system ( lobules and ducts)

5. Anatomy
Major hormones responsible for breast development are estrogen,
progesterone and prolactin.
The blood supply is through the internal
mammary artery, axillary artery
intercostal artery
Venous drainage is through the
Internal mammary vein,
axillary vein and
intercostal veins

6. Anatomy Lymphatic drainage Three Lymph Node Levels Nerves
Majorly to the Axillary nodes
Inter mammary and the supra clavicular lymph nodes.
Three Lymph Node Levels
Level I – Lateral and inferior to Pectoralis Minor
Level II – Deep to Pectoralis Minor
Level III – Medial to Pectoralis Minor
Rotter’s – Between Pectoralis Minor & Major
Nerves
Long Thoracic Nerve:
Serratus Anterior m.
Winged Scapula
Thoracodorsal Nerve:
Latissimus Dorsi
Intercostobrachial Nerve

7. Structure

8. 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
Schnitt, SJ. Benign breast disease and breast cancer risk: morphology and beyond. Am J surg pathology 2003;27:836

9. Classification Based On Clinical Features
Mastalgia
Cyclic
Non Cyclic
Tumors and Masses
Nodularity or glandular
Cysts
Galactoceles
Fibroadenoma
Sclerosing Adenosis
Lipoma
Harmatoma
Diabetic Mastopathy
Cystosarcoma Phylloides
AAFP journal , April 15, Volume 61/ No. 8

10. Classification Based On Clinical Features (Cont’d)
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
Mondor’s Disease
Hidradenitis suppurativa
J khosa, Benign breast disease including mastalgia ppt

11. Classification Lesions with Increased Risk of Ca Ductal hyperplasia
Sclerosing adenosis
Complex fibroadenomas
Atypical hyperplasia
Radial scars
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

12. Classification Lesions with no Increased risk of Ca
Fibrocystic disease
Duct ectasia
Solitary papillomas
Simple fibroadenomas
Mastitis or breast abscess
Galactocele
Fat necrosis
Lipoma

13. Breast Pain (Mastalgia)
Most common breast symptom for which women consult the physician
More common in premenopausal women than in post menopausal women
Can be cyclical (physiological) or non cyclical
Micheal S Sabel. Initial approach to the woman with breast problems , November 6

14. Breast Pain (Mastalgia)
Cyclic Pain ( Physiologic)
Usually Bilateral and poorly localized.
Occurs in about 60% of premenopausal women except menopausal women on hormonal replacement therapy
Often described as heaviness , swelling or tenderness that radiates to the arm and axilla
Associated with menstrual cycle , Most severe before menstruation
Has variable Duration and Resolve spontaneously after menses
Attributed to fibrocystic breast changes
Etiology unknown, thought to be related to Gonadotrophic and ovarian hormones

15. Mastalgia Non-Cyclic Pain Most common in women 40 to 50 yrs of age
Often unilateral
Usually described as sharp, burning pain localized in the breast
Occasionally secondary to the presence of Fibroadenoma and or cyst
Menstrual irregularity, emotional stress, trauma, , scars from previous biopsies and medications have been associated
Micheal S Sabel. Initial approach to the woman with breast problems , November 6

16. Evaluation & Management of Breast Pain
Mastalgia should be treated when:
It is severe enough to interfere with a woman’s life style
It occurs more than a few days every month.
History and Physical
Diagnostic work up
Mammogram
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

17. Management of Breast Pain
Treatment Goals
Alleviate pain
Reduce or relieve irregularity
Rule out cancer of the breast

18. Management of Breast Pain
Diet and Lifestyle Modification
Elimination of Methylxanthines, Caffeine and Chocolates
Reassurance
Supportive Bra
Low fat and high complex carbohydrate
Vitamin E supplementation
Evening Primrose oil
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

19. Management of Breast Pain
Pharmacological Treatment
NSAIDs
OCPs
Danazol mg per day
75% of women with non cyclic pain will be symptom free
SE: Weight gain , menstrual irregularity , acne , hirsutism
Tamoxifen 10mg
Bromocriptine – prolactin antagonist
Surgery has no role in management of breast pain
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

20. Evaluation & Management of Breast Pain
AAFP journal , April 15, Volume 61/ No. 8

21. Breast Masses Normal glandular tissue of the breast is nodular
This is a general pattern or consistency of the breast which include persistent lumpiness or nodularity which is generally not abnormal when it is related to the menstrual cycle.
Dominant masses are characterized by persistence throughout the menstrual cycle

22. Breast Masses: Cysts Cystic Breast Mass
Common cause of dominant breast mass
May occur at any age, but uncommon in post menopausal women
Fluctuates with menstrual cycle
Well demarcated from the surrounding tissue
Characteristically firm and mobile
May be tender
Difficult to differentiate from solid mass
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

23. Breast Masses: Cysts Fibrocystic Breast Disease
Most common of all benign breast disease
Most common between ages
50% of women with Fibrocystic changes have clinical symptoms
53% have histologic changes
Believed to be associated the Imbalance of progesterone and estrogen.
May present with bilateral cyclic pain, breast swelling, palpable mass and heaviness

24. Fibrocystic Breast Disease
Physical Examination
Tenderness
Increased engorgement and more dense breast
Increased lumpiness / glandular
Occasional spontaneous nipple discharge
Micheal Sabel .Overview of benign breast disease. Uptodate 2008, November 14

25. Breast Cysts: Diagnostics
Mammogram
Cystic outline
No calcification
No increased density
Ultra Sonogram
Cyst
Fine Needle Aspiration
Outpatient procedure
Non bloody fluid
Cyst disappears
If bloody fluid, surgical biopsy of cyst is required
Reexamination 4-6 weeks after aspiration

26. Management of Breast Cysts
AAFP journal , April 15, Volume 61/ No. 8

27. Breast Masses

28. Breast Mass: Fibroadenomas
Simple: Second most common benign breast lesion
Benign solid tumors containing glandular as well as fibrous tissue . Usually present as well defined, mobile mass
Commonly found in women between the ages of 15 and 35 years
Cause is unknown, thought to be due to hormonal influence
May increase in size during pregnancy or with estrogen therapy
Giant: Fibroadenomas over 10cm in size
Excision is recommended
Juvenile
Variant of fibroadenomas
Found in young women between the ages of
Vary in size from cm in diameter. Usually painless, solitary, unilateral masses

29. Breast Mass: Fibroadenomas (Cont’d)
Complex
Complex fibroadenomas contain other proliferative changes such as sclerosing adenosis, duct epithelial Hyperplasia, epithelial calcification.
Associated with slightly increased risk of cancer
Dupont, WD page, DL, parl, FF, et al. Long term risk cancer in women with fIbroadenoma. NEJM 1994;331:10
Carty, NJ, Carter, c, Rubin, C et al management of fibroadenoma of the breast. Annals of royal college of surgeon England 1995:77:127
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

30. Breast Mass Phylloides Tumors: Fat Necrosis: Rapidly growing
One in four malignant
One in Ten Metastasize
Create bulky tumors that distort the breast
May ulcerate through the skin due to pressure necrosis
Treatment consists of wide excision unless metastasis has occurred
Fat Necrosis:
Rare
Secondary to trauma- often not remembered
Tender, ill defined mass
Occasionally skin retraction
Treat with excisional biopsy

31. Breast Mass Galactocele
Milk filled cyst from over distension of a lactiferous duct.
Presents as a firm non tender mass in the breast,
Commonly in upper quadrants beyond areola.
Diagnostic aspiration is often curative.
Duct ectasia:
Generally found in older women.
Dilatation of the subareolar ducts can occur.
A palpable retroareolar mass, nipple discharge,
or retraction can be present.
Tx involves excision of area

32. Breast Mass Gynecomastia:
Benign growth of the glandular tissue of the male breast.
Due to an imbalance in the estrogen to androgen activity.
May be unilateral or bilateral
Common in infancy, adolescence and adult life
Pseudogynecomastia may be seen obese individuals
Causes include; drugs, chronic dxs, metabolic, pubertal,
Hormonal, tumors, idiopathic, hypogonadism.
Braunstein, GD. Gynecomastia. NEJM 1993;328:490

33. Nipple Discharge Majority of causes are benign
Most common cause is lactational
Overstimulation also common
Prolactin secreting tumors
Hypothyroidism
Drugs
Intraductal and other carcinomas
Unilateral, spontaneous, bloody discharge is suspicious

34. Nipple Discharge Intraductal Papilloma Galactorrhea
Benign growth within ductal system
Presents as bloody nipple discharge
Excision is the only way to differentiate from carcinoma
Galactorrhea
Bilateral milky discharge
Obtain prolactin level, TSH level

35. Nipple Discharge Good history Prolactin & TSH levels Mammogram
Decrease stimulation

36. Breast Inflammation & Infections
Mastitis
Most common in lactating female
Dry, cracked fissured areola/nipple complex provides portal
for infection
Usually caused by Staph/Strep organisms
Rule out malignancy
Treat with heat, continued breast feeding,
Antibiotics for days to cover staph and strept infections

37. Breast Inflammation & Infections
Abscess
May present with breast swelling, tenderness and fever
On PE, breast is tender , warm and fluctuant, may also have
purulent discharge
Treated by surgical drainage

38. Breast Inflammation & Infections
Mondor’s Disease
Phlebitis of the thoracoepigastric and lateral thoracic vein
Palpable, visible, skin retraction over tender extending to chest wall
Spontaneous or related to trauma
Ultrasound may be helpful in confirming this diagnosis.
Treatment self-limited, can use NSAIDs
Mammogram if over 35yo to r/o malignancy

39. Breast Inflammation & Infections
Chronic Subareolar Abscess
Occurs at base of lactiferous duct, and squamous
metaplasia of duct may occur.
Sinus tract to areola develops
Treatment requires complete excision of sinus tract
Recurrence is common
Mastitis Neonatorum
Occurs within few weeks of birth
Response to mothers hormone exposure
(prolactin, estrogen)
Resolves spontaneously
Occasionally becomes infected

40. Congenital Breast Disease
About 1-5 % of the population have accessory nipples, and less commonly accessory breast
Usually develop along the milk line
Most common site for accessory nipple is below the breast
Most common site for accessory breast is in the axilla
Rarely require treatment except for cosmetic reasons
Subject to the same diseases as the normal breast.
J Micheal Dixon .ABC of breast diseases. 3 rd edition BMJ 2005
Gershon Efron. Benign breast disease ppt , google health search

41. Approach to Breast Problems
History
Age
Family history (Cancer)
Onset
Duration Discharge
Frequency
Lump , Nodules Trauma
Menstruation (menarche, menopause, contraceptives) Pain
Inspection
Symmetry
Skin / Nipple Change
Bulges / Retractions

42. Approach to Breast Problems
Palpation
Breast
Axilla
Supraclavicular

43. Breast Examination
The breast examination starts with inspection of both breast
Sitting up with arms in relaxed position,
Both arms raised over the head
Hands on the hips
Complete regional lymph node examination while patient is in the sitting position.
Bimanual may be done while patient is still in the sitting position, useful in patient with large pendulous breast
Complete with the patient in a supine position, with the arms raised above the head, breast exam can be accomplished with either concentric circles, radial approach, or vertical strip approach
Areas examined should extend from the clavicle superiorly to the rib cage inferiorly and from the sternum medially to the mid axillary line laterally
Micheal S Sabel. Initial approach to the woman with breast problems , November 6

44. Breast Examination

45. Diagnostic Work Up Ultrasound Mammography FNA vs. Core Biopsy
Incisional biopsy
Excisional biopsy
Cyst aspiration
MRI

46. Diagnostic Work Up
Ultrasonography: First diagnostic test of choice to differentiate a cystic mass from a solid mass
Mammogram: Not routinely done in women younger than 35yo, however not inappropriate in a suspicious mass in younger women
Digital mammography is superior to conventional
A normal mammogram at any age does not eliminate the need for further evaluation of a suspicious mass.
MRI: Not indicated for the work up of undiagnosed mass. Reserved for diagnostic dilemmas and should be used with discretion due to false positive results
FNA: Useful for cystic lesions. If lesion is completely drained and fluid not bloody or cloudy, no further evaluation needed
Micheal S Sabel. Initial approach to the woman with breast problems , November 6

47. Diagnostic Work Up
Core Needle Biopsy: This provides a best diagnostic information for solid palpable mass which can be visualized on the USS or mammogram
Excisional Biopsy: Useful in cases where core needle biopsy is non diagnostic, non concordant with imaging results or yield any high risk changes
Incisional Biopsy: useful when core needle biopsy is not helpful in confirming diagnosis
Micheal S Sabel. Initial approach to the woman with breast problems , November 6

48. BI-RADS Classification
BI-RADS Classification – features
0 - 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

49. Conclusion
Benign breast problems account for the majority of breast problems seen in women
Breast complaints need careful assessment with thorough history and physical as well as diagnostic work up if indicated
Women with breast problems can present with a mass, pain, nipple discharge or skin changes. They can also be asymptomatic
It is important to rule out breast cancer
Micheal S Sabel. Initial approach to the woman with breast problems , November 6

50. References 1. AAFP journal , April 15, 2000. Volume 61/ No. 8
2 Schnitt, SJ. Benign breast disease and breast cancer risk: morphology and beyond. Am J surg pathology 2003;27:836
3.J khosa, Benign breast disease including mastalgia ppt
4. Dupont, WD page, DL, parl, FF, et al. Long term risk cancer in women with fIbroadenoma. NEJM 1994;331:10
5. Carty, NJ, Carter, c, Rubin, C et al management of fibroadenoma of the breast. Annals of royal college of surgeon England 1995:77:127
6. Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14
7. J Micheal Dixon .ABC of breast diseases. 3 rd edition BMJ 2005
8.Gershon Efron. Benign breast disease ppt , google health search
9. Micheal S Sabel. Initial approach to the woman with breast problems , November 6
10. Braunstein, GD. Gynecomastia. NEJM 1993;328:490