Breast cancer screening = Mammogram

To detect breast cancer at an early asymptomatic stage whereby appropriate treatment could lead to cure
Reduction in mortality
o Age 50-74: Significant reduction up to 24% Arterial supply
nd
o Age <50: Not yet conclusive; reduction of 23% but only noticeable after a delay of 10 yrs Major: 1. Lateral thoracic artery (from 2 part of axillary artery)
Stand screening guidelines 2. Internal thoracic artery (from subclavian artery)
o Age 30s: Yearly breast exam by a doctor
o Age 40s: Mammogram every 2 years + yearly breast exam by a doctor Minor: 1. Posterior intercostal artery (from aorta)
nd
o Age 50s: Mammogram every year + yearly breast exam by a doctor 2. Thoracoacromial artery (from 2 part of axillary artery)
o All => monthly self breast exam (best time = 1 wk after menstrual period)

Triple assessment of a breast lesion Venous drainage

Clinical assessment 1. Circumferential areolar venous plexus
Imaging assessment 2. Internal thoracic vein
Cytological/histological assessment 3. Axillary vein
! Triple assessment is positive if any of above is positive 4. Posterior intercostal vein
! But negative only when all three negative

Anatomy of breast & axilla Fibrous septa (Coopers ligaments) interdigitate the mammary
parenchyma and extend from the posterior capsule of the breast to
Boundaries of axilla for dissection the superficial layer of fascia within the dermis => provide structural
Superior boundary Axillary vein support; Involvement of malignancy => dimpling
Posterior boundary Long thoracic nerve
Lateral boundary Latissimus dorsi muscle
Medial boundary Lateral to, deep to, or medial to pectoral minor muscle, depending on level
of nodes taken

What four nerves must be aware of during an axillary dissection?

Long thoracic nerve
Thoracodorsal nerve
Medial pectoral nerve
Lateral pectoral nerve

Lymphatic drainage of breast

Lateral: axillary lymph nodes (75%) Drains into supraclavicular and jugular nodes
Medial: parasternal nodes (internal mammary) that run with internal mammary artery
Interpectoral (Rotters nodes)

Levels of axillary lymph nodes (5 groups: anterior, posterior, medial, lateral, apical)
Level I (low) = lateral to pec minor
Level II (middle) = deep to pec minor
Level III (high) = medial to pec minor
In breast cancer, a higher level of involvement has a worse prognosis,
but the level of involvement is less important than the no. of positive lymph nodes

Rotters nodes = nodes between pec major & minor muscles; not usually removed unless they are enlarged or feel suspicious intra-operatively

Suspensory breast ligaments = Coopers ligaments => if tumor involves this => skin retraction
Differentials (age dependent)
Painless lump Painful lump
Early (post-menopausal) Area of fibroadenosis
Carcinoma Cyst
Abscess (usually in lactating women)
Younger Fat necrosis (minor trauma)
Cyst Periductal mastitis
Fibroadenoma Galactocele (lactating women)
Area of fibroadenosis (nodularity) Carcinoma (rare; ~10% & advanced)

History Exam Imaging Cytological/histological
Breast symptoms Inspection Mammogram FNAC => good for cyst
Breast lump - Patient undressed to waist Symmetry Not routinely sent for cytology
Breast pain - Either 2 positions: Mass lesions If bloody aspirate => send
Discrete abnormality area Sitting/Lying Architectural distortions Proceed to open biopsy when
Change in skin texture Sitting up at angle of 60 degrees Microcalcifications ! Second cyst recurrence
Nipple discharge (Suspicious features: ! Bloodly fluid in cyst
Nipple retraction Size and shape Stellate patterns, Clusters, Segmental, ! Palpable mass after aspiration
Regular and symmetrical Pleomorphic)
Past breast history Distorted Core biopsy
Previous breast surgery More useful in older women due to fatty Can see histology
Previous breast complaint Skin replacement of fibrous tissue which Stain ER, PR status
Regular breast check up Reddened or discoloured makes MMG harder to interpret HER2 mutation
Regular mammogram/ultrasound Dimpled Diagnose CA in-situ
Family history of breast canc Peau dorange Ultrasound breasts
Scarred Good at: mass lesions, cysts Excisional biopsy
O&G history Nodules Easy to use, fast, cheap
Menarche Dilated veins Operator dependent Indications of biopsy
Menstrual status Less accurate in picking up Persistent mass after aspiration
Pregnancies Nipple microcalcifications Solid mass
Age at first pregnancy Retracted Commonly used in our locality to add Blood in cyst aspirate
Breastfeeding Cracked diagnosis of breast lesion (because Suspicious lesion by MMG/USG/MRI
Ezcematous (eg Pagets) Asian breasts are very dense and Blood nipple discharge
Last menstrual period
Over-pigmented MMG likely to miss) Ulcer/dermatitis of nipple
Hormonal intake
Obvious discharge => USED IN CONJUNCTION WITH
MAMMOGRAPHY
Risk factors of CA breast
Early menarche before age 12 Palpation Cytology reporting categories
Lump => site, size, shape, consistency (Suspicious features: C1 = Inadequate
Late menopause Irregular edge, Taller than wider, Not
Pregnancy after age 30 Overlying skin => dimpled, ulcerated, C2 = Benign
compressible) C3 = Atypia, probably benign
Nulliparity (childless) peau dorange
Family history of breast cancer/Genetic Fixation C4 = Suspicious of malignancy
predisposition ( BRCA gene mutation) ! to skin: gently pinch up skin C5 = Malignant
Further = MRI, PET
History of breast biopsy showing a ! to deep tissue, ask the patient to
premalignant condition, ADH, Proliferative place her hands on her hips,
BI-RADS system (radiology categories)
fibrocystic changes, LCIS,DCIS palpate, then ask her to press,
0: Incomplete
Smoking, diet, exercise then palpate again
1: Negative
Axilla: Right hand for left axilla;
examine anterior, poster, lateral & 2: Benign finding(s)
medial walls & apex 3: Probably benign
Supraclavicular fossa 4: Suspicious abnormality
Cervical nodes 5: Highly suggestive of malignancy
Abdomen hepatomegaly 6: Known biopsy proven malignancy
Bone tenderness
Thorax
Testis if gynecomastia
More about the investigations

Mammogram always compare previous MMG

Most sensitive of proven breast imaging (Gold standard)
Purposes: diagnosis, screen the rest of the breast (plan treatment), screen contralateral breast, baseline for future f/u for contralateral breast
Two views:
o Craniocaudal (CC)
o Mediolateral oblique (MLO) for the tail
Adequacy
o Distance between nipple and pectoralis major in MLO & CC films should be similar and not differ by more than one cm
o Retromammary fat should be seen in both MLO and CC films
Exposure compare the densities on both sides
Primary features density changes, microcalcification
o Density changes: asymmetrical opacity with speculation and irregular border = malignant lesion
" Spiculated mass 95% due to malignancy; ddx: radial scar, fat necrosis, abscess
o Microcalcification: size <0.5mm, cluster, linear branching, granular pleomorphic = high risk of malignancy
" DDx: DCIS, invasive cancer, fibrocystic disease, papilloma
" C.f. macrocalcification (>0.5mm) which is benign and can be due to various pathology e.g. fat necrosis, calcified vessels, fibrocystic
disease
Secondary features architectural change, LN
o Distortion of surrounding breast glandular tissue
o Nipple retraction
o Skin thickening
o LN (well defined radiopaque lump, with central halo due to fatty contect)
st
Ultrasound 1 investigation in young patients or pregnancy, lactating patients
Used when there is a lump
o Guide procedures
o Evaluate consistency
o Problems with MMG e.g. lesion only seen in one MMG projection, palpable mass with negative MMG, MMG-difficult areas e.g. chest wall, axilla
Pitfalls: operator dependent, poor resolution, cannot detect microcalcification
Features of malignancy
o Markedly hypoechoeic
o Irregular edges
o Hypoechoeic shadowing, posterior acoustic shadowing
o Taller than wider
o High central vascularity
o Microcalcification (if large number)
 Breast cancer

Histological types Treatment options

In-situ carcinoma Surgery Candidates for BCT
Ductal carcinoma in-situ (DCIS) Breast conservation therapy Stage I and stage II (tumors < 5cm)
o Wide local excision & axillary dissection/sentinel LN
Invasive carcinoma dissection Contraindications to BCT
Invasive ductal (NOS) (80%) o Whole breast irradiation Tumor size too large BCS will not result in good cosmetic
Invasive lobular (3%) Modified radical mastectomy +/- reconstruction result
Special types o Breast, axillary nodes (Level I, II) and nipple-areolar Where RT is contraindicated (e.g. pregnancy, SLE, previous
- Tubular/cribriform complex radiation)
- Papillary o Pec major and minor are NOT removed Cancer underneath nipple or nipple involvement (can perform
- Mucinous o Drains are placed to drain LN lumpectomy if large breasts)
- Medullary Simple mastectomy = total mastectomy (removal of Multicentric cancer (multifocal relative contraindication
breast & nipple without removal of axillary LNs) cosmesis not good)
Lobular carcinoma in-situ (LCIS)- really a Skin sparing mastectomy Extensive DCIS (often seen as diffuse microcalcification)
premalignant condition rather than cancer Nipple sparing mastectomy
(for selectively low risk pt, no nipple involvement, Axillary dissection (landmark = Pectoralis minor muscle)
Malignant non-invasive cancer prophylactic mastectomy) Level I = Lateral to pec minor
DCIS Level II = Posterior (deep) to pec minor
20-50% progress to invasive CA Breast reconstruction Level III = Medial to pec minor
Risk depends on grading Saline implants
High grade cancer may have focus of invasive TRAM Flap (Transverse rectus abdominis Complications of AD => Vessels and nerve damage
cancer within a mass of high grade cancer myocutaneous) Thoracodorsal bundle
Free TRAM Flap Long thoracic nerve
LCIS DIEP flap (Deep inferior epigastric perforator) Axillary Vein
Usually innocent bystander not calcified LD flap (Latissimus dorsi flap) Intercostobrachial nerve
1/3 bilateral Brachial Plexus
12 times increased risk of CA of both breast Radiotherapy
As precursor and risk factor Alternative to AD = Sentinel LN biopsy (find it by blue dye
THIS IS NOT CANCER Chemotherapy => CMF or CAF and/or technetium-labeled sulfur colloid)
If sentinel LN positive => removal of the rest of the axillary LN
Hormonal manipulation therapy => tamoxifen binds
estrogen receptor (S/E: endometrial cancer, DVT, PE, Indications of modified radical mastectomy + RT
cataracts, hot flushes, mood swings) Stage IIIA/IIIB
Pec muscle/fasia invasion
Molecularly targeted therapy
Positive internal mammory LN
Positive surgical margins
Pre-op staging workup
! Bilateral mammogram => for contralateral >= 4 positive axillary LNs postmenopausal
! CXR => for lung met
! LFT => for liver met Complications of MRM
! Serum calcium & ALP => if indicated, bone scan Ipsilateral arm lymphedema
! Head CT if suspect brain met Infection
! ER & PR status Injury to nerves
Skin flap necrosis
Hematoma/seroma
Phantom breast syndrome
DCIS (Ductal carcinoma in situ or intraductal carcinoma)
On MMG => finds microcalcifications
Diagnosis made by core or open biopsy
Major risk = subsequent development of infiltrating ductal carcinoma in the same breast
Treatment:
! Simple mastectomy must be performed when: >3 cm, high grade, persistent +ve margin, extensive DCIS on MMG
Axillary node dissection has no rule in DCIS (i.e. without microinvasion); some may perform sentinel LN dissection for high-grade DCIS
If simple mastectomy done for DCIS, don't need to give adjuvant therapy

LCIS = Lobular Carcinoma In Situ

No S/S or MMG findings
Diagnosis is made incidentally on biopsy
Major risk = Carcinoma of either breast (equal risk in both breasts!!!)
Most common invasive breast cancer that LCIS patients develop = Infiltrating ductal carcinoma
Treatment = close follow-up (or bilateral simple mastectomy in high risk patients)

Axillary dissection
Purpose: nodal staging (for prognosis) no survival benefit of doing AD
Routinely done in clinically palpable LN, detected on US, BrCA >= T2 (5cm)
Not required for DCIS
SLN biopsy is a new standard
# If SLN negative, the rest of axillary nodes should be negative as well
# If +ve, perform axillary clearance
# False ve rate is <5%
Complications of axillary dissection
# Lymphedema RT to axilla is contraindicated with AD as it worsens oedema
# Cellulitis (due to lymphedema)
# Shoulder stiffness
# Vessels and nerve damage
$ Thoracodorsal bundle
$ Long thoracic nerve
$ Axillary Vein
$ Intercostobrachial nerve
$ Brachial Plexus

Radiotherapy
Adjuvant to decrease local recurrence rate
Usually done 6/52 after WE
High risk of local recurrence: T3 or >=4 LN +ve
Targeted at Breast with or without internal mammary, infra/supraclavicular LN (Axillary LN are tackled during surgery)
CI: pregnancy, previous RT, patient choice
Complications: radiation injury (pneumonitis, skin changes), risk of cancers

Palliative
Brain met
Bone mets
Chemotherapy mostly given by IV injection (bolus over few muniutes or infusion over several hours) usually once every 3 weeks; Oral drugs less effective
Neoadjuvant
Indications:
# Locally advanced breast cancer (stage III) to shrink the tumour before surgical resection
# Shrink tumours before BCT
Hormonal manipulation (endocrine therapy) less effective than chemotherapy
20% achieve complete clinical response i.e. tumour no longer palpable; Further 20% achieve complete pathological response => good prognosis
Place clip or dye into tumour before neoadjuvant therapy to guide surgery incase tumour disappears
Complications: as for CT drug
# General: Mouth ulcer, N/V, hair loss, immunosuppression
# Specific: cardiotoxicity (anthracycline), nephrotoxicity

Adjuvant
Start 3/52 after surgery
High risk features (+ve nodes, poor grade, young patients)
Premenopausal patients tend to have better response to CT than hormonal therapy
Main active agents: Anthracycline (e.g. doxorubicin, epirubicin) and taxanes (e.g. paclitaxel, docetaxel)
Common regimens: AC (anthracycline, cyclophosphamide), FAC (5-FU, anthracycline, cyclophosphamide), CMF (cyclophos, methotrexate, 5-FU)

Palliative
Anthracyclines and taxanes = mainstay
Helps to reduce load of disease to alleviate symptoms, increase survival

Hornomal therapy
1. Selective oestrogen receptor modulators (SERMs): Tamoxifen
Contraindications: PMH of CVA, DVT
Complications: menopausal symptoms (hot flushes), endometrial cancer, DVT
Beneficial effect on blood lipids (lower LDL)
Taken orally

2. Aromatase inhitibotrs: anastrazole, letrozole (non-steroidal), Aromasin (steroidal)

Only in postmenopausal patients
Decrease bone density, more expensive
Side effects: musculoskeletal pain, osteoporosis
Neutral effect on lipids

3. Estrogen receptor antagonist (Fulvestrant)

4. Surgery oophorectomy
5. Ovarian irradiation
6. Endocrine therapy - Zoladex
 Targeted therapy based on HER2 overexpression
Herceptin (trastuzumab) given for 1 year
Used in C-erbB2 positive tumours, early or late stage
Side effects: cardiomyopathy & CCF, pulmonary toxicity, infusion reaction, febrile neutropenia

Avastin (bevacizumab) => targets VEGF, used in advanced cancer

Lapatinib => targets Her-1 and Her-2, used in advanced cancer

Treatment by stage
DCIS Early breast cancer (stage 1&2) Locally advanced (stage 3) Stage 4
Same Tx as invasive cancer: WE v.s. SM T2 or less (<5cm), N1 or less (no nodes or T3 or T4 (tumour >5cm or skin/chest Systemic therapy CT, HT, or TT
Adjuvant RT (all patients other than those at low non-fixed nodes) wall involvement), N2 or N3 (fixed LN Mets specific
risk of recurrence) involvement or supraclavicular node
SLN biopsy if DICS not very certain (i.e. Locoregional therapy: SMAC or WEAC involvement) Bone RT or decompression if cord
diagnosed on Core biopsy) with postop RT compression, treat hypercalcemia
+/- hormonal therapy (only if WE) => reduce Surgical resection size and
recurrence at surgical site Adjuvant therapy = CT if tolerable and /or resectability Brain RT
HT if ER/PR +ve Pleural drain effusion
Destroy systemic micrometastases Systemic therapy Liver
If T> 2cm, N >=1 Chemo Neoadjuvant chemo
If T>1cm but <= 2cm, N=0 Adjuvant therapy CT & HT =>
intermediate; Look at the grade, if high depends on histology etc after
grade: chemo surgery => may not be done if
If T <=1cm, N=0 no chemotherapy patient has complete the course of
chemo during neoadjuvant
In general
Premenopausal => chemo +/- hormonal
Postmenopausal => hormonal +/- chemo

Follow-up
Symptoms & P/E 3-monthly for first 2 years; 6-monthly for the next 3 years; yearly for another 5 years
MMG: same breast 1yr post-op; then 2-yearly bilateral MMG for life
CEA and CA15-3 in some centres
 >510 mm=T1b
Triad of error for misdiagnosed breast cancer >15 mm=T1a T3 >50 mm
Age < 45 years
Self-diagnosed mass
Negative mammogram Primary Tumor (T)
th
TMN staging: (AJCC 7 edition) TX Primary tumor cannot be assessed T1 Tumor 20 mm in greatest dimension T4 Tumor of a
T0 No evidence of primary tumor T1mi Tumor 1 mm in greatest dimension wall and/o
T0 T1, T2, T3 T4
Tis dimension
Carcinoma in situ T1a size
Tumorwith
> 1 mm but 5extension
mm in greatesttodimension Note: Inva
TX Primary tumor cannot be assessed T1 Tumor 20 mm in greatest T4 Tumor of any direct the chest wall as T4
T0 No evidence of primary tumor Tis (DCIS) Ductal
T1mi Tumor 1 mm in greatest carcinoma in situ
dimension and/or to the skinT1b (ulceration
Tumor > 5 mm but
orskin
10 mmnodules)
in greatest dimension
T4a Extension
Tis Carcinoma in situ T1a Tumor > 1 mm but Tis5(LCIS)
mm in greatest
Lobular carcinomadimension
in situ Note: Invasion T1c of the
Tumordermis
> 10 mm alone
but 20 mmdoes not qualify
in greatest dimensionas T4 pectoralis
Tis (DCIS) Ductal carcinoma in situ T1b Tumor > 5 mm but
Tis (Pagets)
10 mmPagetsin greatest
disease of thedimension
nipple NOT associatedT4a
with Extension to T2 the
Tumorchest wall,
> 20 mm but not
50 mm including only pectoralis
in greatest dimension T4b Ulceration
Tis (LCIS) Lobular carcinoma in situ T1c Tumor > 10 mm but 20 mm in greatest
invasive dimension
carcinoma and/or carcinoma in situmuscle
(DCIS adherence/invasion
T3 Tumor > 50 mm in greatest dimension edema (in
Tis (Pagets) Pagets disease of the nipple NOT and/or LCIS) in the underlying breast parenchyma.
T4b Ulceration and/or ipsilateral satellite nodules and/or edema do not me
associated with invasive carcinoma and/or carcinoma T2 Tumor > 20 mm but 50 mmCarcinomas
in greatest in the breast parenchyma associated
dimension (including peau dorange) of the skin, which do not meet the T4c Both T4a a
in situ (DCIS and/or LCIS) in the underlying breast with Pagets disease are categorized based on
T3 Tumor > 50 mm in greatest dimension the
criteria for inflammatory carcinoma
size and characteristics of the parenchymal disease, T4d Inflammat
parenchyma. T4c
although the presence of Pagets disease should still Both T4a and T4b Classificati
be noted T4d Inflammatory carcinoma

NX Regional lymph nodes cannot be assessed (for example, previously removed) AN ATO MIC S TAG E / PRO G N O S TIC G RO UP S
N0 No regional lymph node metastases
N1 Metastases to movable ipsilateral level I, II axillary lymph node(s) Distant Metastases (M) Stage 0 Tis N0 M0
N2 Metastases in ipsilateral level I, II axillary lymph nodes that are clinically Stage IA
M0 fixed or matted; or in clinically detected* T1* N0 M0
No clinical or radiographic evidence of distant
ipsilateral internal mammary nodes in the absence of clinically evident axillarymetastases
lymph node metastases Stage IB T0 N1mi M0
Note
N2a Metastases in ipsilateral level I, II axillary lymph nodes fixed to one another
cM0(i+) (matted)
No clinical or to
or radiographic other
evidence structures
of distant T1* N1mi M0
* T1 includ
N2b Metastases only in clinically detected* ipsilateral internal mammary nodes metastases, but deposits of molecularly orclinically evident
and in the absence of Stage IIA T0 N1** M0 ** T0 and T
level I, II axillary lymph node metastases microscopically detected tumor cells in circulating T1* N1** M0 are exclu
blood,
N3 Metastases in ipsilateral infraclavicular (level III axillary) lymph node(s) with orbone marrow, level
without or other I,
nonregional nodallymph node
II axillary T2 N0 M0
IB.
involvement; or in clinically detected* ipsilateral internal mammary lymph node(s)tissue that
withare no larger than 0.2
clinically mm in a patient
evident level I, II axillary t M0 inclu
without symptoms or signs of metastases Stage IIB T2 N1 M0
t The desig
lymph node metastases; or metastases in ipsilateral supraclavicular lymph node(s) with or without axillary or internal
mammary lymph node involvement M1 Distant detectable metastases as determined by T3 N0 M0 clinical.

N3a Metastases in ipsilateral infraclavicular lymph node(s) classic clinical and radiographic means and/or Stage IIIA T0 N2 M0 t If a patie
histologically proven larger than 0.2 mm systemic
N3b Metastases in ipsilateral internal mammary lymph node(s) and axillary lymph node(s) T1* N2 M0 IV and re
N3c Metastases in ipsilateral supraclavicular lymph node(s) T2 N2 M0 neoadjuv
T3 N1 M0 t Stage de
imaging
M0 No clinical or radiographic evidence of distant metastases T3 N2 M0 metastas
M1 Distant detectable metastases as determined by classic clinical and radiographic means and/or histologically proven Stage IIIB T4 N0 M0 out with
disease p
larger than 0.2 mm T4 N1 M0 has not r
Choice of Treatment(s) T4 N2 M0 t Postneoa
-Type of initial surgical treatment Stage IIIC Any T N3 M0 or yp p
- Age if there i
- Menopausal Status
Stage IV Any T Any N M1 neoadjuv

- Tumour size
- Number of involved lymph nodes
- Tumour grade
- Oestrogen receptor status Financial support for AJCC 7th Edition Staging Posters
provided by the American Cancer Society
- Her2 gene amplification
Benign breast lesions

Classification
Physiological swelling & tenderness Premenstrual breast tenderness with mild swelling.
Result from variation in plasma concentration of
gonadotrophic and ovarian hormones.
Fibroadenosis

Nodularity Fibrocystic Changes/ Fibroadenosis

A dense, irregular and bumpy "cobblestone" consistency Not a disease but general term that refers to a
More marked in UOQ group of anomalies, symptoms
Persistent intermittent breast discomfort Anomalies of development and
o Breast(s) feel full involution(ANDI). Women of the 30 - 40 year
o Dull, heavy pain and tenderness age group.
o Mastalgia As age progresses, cysts become more
o Premenstrual tenderness and swelling frequent. Patients can also develop areas of
o Breast discomfort improves after each menstrual such pronounced nodularity that the presence
period of a lump may be felt.

Mastalgia Cyclical
Non-cyclical
Muscular pain
Costochodritis
Non-specific
Nipple discharge Galactorrhea- milk Additional investigation to consider
Abnormal nipple discharge Ductogram
- Blood/Brown Ductoscopy
o Papilloma
o Papillary Cancer
- Yellowish/Green
o Infection
o Abscess
- Serous/Colourless
o Physiological
o Ductual Ectasia
Breast infections Postpartum engorgement Mastitis may progresss to abscess
Lactational mastitis and breast abscess Needle aspirations
Chronic recurrent subareolar abscess Incision & drainage
Acute mastitis associated with macrocystic breasts Antibiotics
Extrinsic infections - Cellulitis Chronic abscess from duct ectasia requires duct
excision
Palpable lump Most common presentation. Rarer:
Clinically benign breast lesions that are distinct, Lipoma
persistent and relatively unchanging. Fat Necrosis
Most common lesions include Diabetic Mastopathy
1. Macrocysts
2. Galactoceles
3. Fibroadenomas
Cyst Accumulations of fluid
Commonest breast lumps in
Women between age 30 and 50 typically round or oval
and smooth edges
Complex cysts contain debris
Aspiration to confirm nature
Hormonal variations
o Normal menstrual cycles
o Post-menopausal (HRT)

Fibroadenoma
Presentation Management
Most common benign tumors. Will not regress with time, but tends to grow.
Any time after puberty, but occur most frequently in the twenties- thirties Estimated incidence of malignancy is .12-.3%
Painless, well circumscribed, freely movable tumors with a rounded, If confirmed on core biopsy, then observation with serial USG or
lobulated or discoid configuration. Mammography.
Also known as Breast mouse Giant fibroadenoma is an entity to refer to lesions more than 5 cm and
Multiple in 10-15%, and can become quite large. may display rapid growth and requires excision usually in young girls.

Galatocele
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

Proliferative breast disease = increased risk of developing carcinoma

Slight increased risk (x1.5 to 2)
Moderate/florid epithelial hyperplasia
Sclerosing adenosis/radial scar
Small duct papilloma
Moderate increased risk (x4 to 5)
Atypical ductal hyperplasia
Atypical lobular hyperplasia