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    Benign Breast Diseases Presentation

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    aizatamlikha
    This document provides a classification and overview of the management of benign breast diseases. It discusses various non-proliferative conditions like simple cysts and duct ectasia. Proliferative conditions without atypia include lesions like fibroadenomas and sclerosing adenosis, which are associated with a slightly increased cancer risk. Proliferative lesions with atypia like atypical ductal hyperplasia confer a higher cancer risk. Other discussed conditions include phyllodes tumors, fat necrosis, and galactoceles. Surgical excision is generally recommended for proliferative lesions and diagnosis confirmation, while most non-proliferative conditions only require monitoring.

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    Benign Breast Diseases Presentation

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    aizatamlikha
    13 views42 pages
    This document provides a classification and overview of the management of benign breast diseases. It discusses various non-proliferative conditions like simple cysts and duct ectasia. Proliferative conditions without atypia include lesions like fibroadenomas and sclerosing adenosis, which are associated with a slightly increased cancer risk. Proliferative lesions with atypia like atypical ductal hyperplasia confer a higher cancer risk. Other discussed conditions include phyllodes tumors, fat necrosis, and galactoceles. Surgical excision is generally recommended for proliferative lesions and diagnosis confirmation, while most non-proliferative conditions only require monitoring.

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    Benign breast diseases presentation

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    This document provides a classification and overview of the management of benign breast diseases. It discusses various non-proliferative conditions like simple cysts and duct ectasia. Proliferative conditions without atypia include lesions like fibroadenomas and sclerosing adenosis, which are associated with a slightly increased cancer risk. Proliferative lesions with atypia like atypical ductal hyperplasia confer a higher cancer risk. Other discussed conditions include phyllodes tumors, fat necrosis, and galactoceles. Surgical excision is generally recommended for proliferative lesions and diagnosis confirmation, while most non-proliferative conditions only require monitoring.

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    © All Rights Reserved
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    Download as pptx, pdf, or txt
    13 views42 pages

    Benign Breast Diseases Presentation

    Uploaded by

    aizatamlikha
    This document provides a classification and overview of the management of benign breast diseases. It discusses various non-proliferative conditions like simple cysts and duct ectasia. Proliferative conditions without atypia include lesions like fibroadenomas and sclerosing adenosis, which are associated with a slightly increased cancer risk. Proliferative lesions with atypia like atypical ductal hyperplasia confer a higher cancer risk. Other discussed conditions include phyllodes tumors, fat necrosis, and galactoceles. Surgical excision is generally recommended for proliferative lesions and diagnosis confirmation, while most non-proliferative conditions only require monitoring.

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    © All Rights Reserved
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    of 42

    Benign breast diseases

    Chea Chan Hooi


    Content
    Introduction
    Classification
    Management
    Introduction
    Imaging abnormalities
    Palpable lumps
    Classify based degree of cellular proliferation & atypia
    Classification
    Based on histology
    Includes
    Epithelial
     Non-proliferative
     Proliferative
     Without atypia

     With atypia

    Stromal
    Misc
    Non-proliferative
    Not association with cancer risk
    Terms like fibrocystic changes, fibrocystic disease,
    chronic cystic mastitis & mammary dysplasia
    Includes
    Simple cyst
    Papillary apocrine change
    Epithelial-related calcifications
    Make a definitive diagnosis and provide symptomatic
    relief
    Simple cyst
    Fluid filled, round or ovoid masses
    From terminal duct lobular unit
    Common in women 35 – 50 years old
    Present as breast masses or MMG abnormalities
    Acute enlargement  severe, localized pain
    Duct ectasia
     Benign dilatation & shortening of terminal ducts within 3cm from nipple
     Present with nipple discharge (creamy, cheesy), nipple retraction or mass
     MMG & USG
     Ductoscopy
     Pre-operative, on table
     Diagnostic & adjunct to surgery
     Surgical options
     Microdochectomy
     Single duct, circumareolar incision, lacrimal probe, at least 2 -3 cm, lay open to
    identify source
     Total duct excision
     Multiple duct, distressing symptoms, excise 2cm behind the NAC, risk of nipple
    anaesthesia, inversion & necrosis
     Bloody single duct nipple discharge
     Cancer 10%
     Papilloma
     Epithelial hyperplasia
     Warning features
     Bloody
     Single duct
     Persistent
     Mass
     New occurrence in post-menopausal
     Bloody nipple discharge in pregnancy
     Hypervascularity of developing breast tissue (benign)
     Still need TRO other causes
     Requires investigations but usually no specific treatment
    Proliferative without atypia
    Includes
    Ductal hyperplasia
    Intraductal papilloma
    Sclerosing adenosis
    Radial scar
    Fibroadenoma
    Small increased risk of developing breast cancer,
    approximately 1.5 to 2 times that of the general
    population
    Ductal hyperplasia
    A pathologic diagnosis
    Incidental finding on biopsy of MMG abnormalities or
    breast mass
    Increased number of cells within the ductal space
    Cells vary in size and shape but retain features of
    benign cells
    No additional treatment
    Risk of subsequent cancer is small
    Chemoprevention is not indicated
    Intraductal papilloma
    Presentation
     Nipple discharge
     Mass on a MMG, USG, MRI, ductogram
     Incidental
    Monotonous array of papillary cells that grow from the
    wall into its lumen
    Can harbor areas of atypia or DCIS
     Risk of malignancy even higher (36.9% vs. 7.0%)
    Metaanalysis of 34 studies, 2236 non-malignant breast
    papillary lesions diagnosed by CNB, 346 (15.7%) were
    upgraded to malignancy following excision
    Standard management after CNB diagnosis is surgical
    excision
    Incidental and ≤2 mm, an excision may not be
    necessary
    Unless there is associated atypia, there is no increased
    risk of cancer, no additional treatment needed
    Diffuse papillomatosis
    Seen on ductography
    ≥5 papillomas within a localized segment of breast
    tissue
    After excision & malignancy ruled out, no additional
    treatment needed
    Risk of subsequent cancer is small
    Chemoprevention not indicated
    Sclerosing adenosis
    Lobular lesion with increased fibrous tissue and
    interspersed glandular cells
    A mass or a suspicious MMG finding
    No treatment
    Risk of subsequent cancer is small
    Chemoprevention not indicated
    Radial scar
     AKA complex sclerosing lesion
     Pathologic diagnosis
     Present with mass or MMG abdnormalities
     MMG cannot differentiate RS from spiculated carcinoma
     Proceed with excision as
     Possibility of associated in situ or invasive carcinoma
     8 – 17% of surgical specimens at subsequent excision are positive for
    malignancy
     HPE: fibroelastic core with radiating ducts and lobules, similar to
    tubular carcinoma
     No additional treatment beyond excision
     Risk of subsequent cancer is small
     Chemoprevention not indicated
    Fibroadenoma
    Solid tumors containing glandular as well as fibrous
    tissue
    Well-defined, mobile mass on physical examination or
    a well-defined solid mass on ultrasound
    20% have multiple FAs in one breast or bilaterally
    Persist during the reproductive years, enlarge during
    pregnancy/estrogen therapy & regress after
    menopause
    Common between 15 – 35 years old
    Very slight increased risk of cancer
    The histologic features
     Slightly elevated if complex FA (adjacent, multicventric
    proliferative changes)
    FH of breast cancer
    The majority of patients with simple FAs have no
    increased risk
    Giant FA
     Histologically typical FA >10 cm in size
     Excise TRO phyllodes tumors
    401 FAs, 63 (15.7%) considered complex, follow-up 2 years, only 1/63
    developed invasive carcinoma, her initial CNB had shown ALH
    Not necessary to excise all biopsy proven, asymptomatic FA
    Disadvantages of excision biopsy
     Scarring at the incision site
     Dimpling of breast from tumour removal
     Damage the ductal system
     MMG changes (architectural distortion, skin thickening, increased
    focal density)
    Excision mandated to rule out malignant change and
    confirm the diagnosis if
    Increase in size (?phyllodes tumour)
    Symptomatic
    Cryoablation
    Alternative to surgical excision
    After CNB diagnosis has been made
    Office-based under USG guidance
     Lesions tended to disappear progressively
     75% not palpable after 12 months

    Transient side effects: ecchymosis, local swelling &


    discomfort
    Percutaneous vacuum-assisted ultrasound-guided
    excision
    Less effective for lesions >2 cm
    Proliferative with atypia
    AKA atypical hyperplasia
    Includes
    Atypical ductal hyperplasia (ADH)
    Atypical lobular hyperplasia (ALH)
    Have some, but not all, features of carcinoma in situ
    Reproducibility of histopathologic diagnosis is poor
    Uncommonly diagnosed as the sole pathologic finding
     ADH
     Proliferation of uniform epithelial cells with monomorphic round
    nuclei filling part but not the entire involved duct
     Shares some of the cytologic and architectural features of low-grade
    DCIS
     Associated with DCIS or cancer
     ALH/LCIS
     Monomorphic, evenly spaced, dyshesive cells filling part, but not all,
    of the involved lobule
     Can also involve terminal ducts
     Part of the same continuum of abnormality, differing only in the
    extent to which abnormal cells involve the duct lumen
     Usually excised to exclude more significant lesions (cancer or DCIS)
    RR 3.7 – 5.3 of subsequent breast cancer, worse with
    multifocality
    Both ipsilateral and contralateral breast
    Only 56 percent occurred ipsilaterally
    35% cumulative incidence of cancer after 30 years
    Proof of underlying breast tissue abnormalities
    predisposing to cancer
    Risk of cancer is higher with ALH than ADH? data are
    conflicting
    Data on effect of FH in women with AH also conflicting
    Excision upgraded diagnosis to DCIS/cancer in 10 – 30%
    of patients
    No initial role for mastectomy
    Surveillance is the best management option for women
    who have ADH, LCIS or ALH as the only abnormality
    Annual clinical examination and annual MMG for at
    least 15 years
     To detect DCIS/cancer at early stages
    Tamoxifen beneficial for women at increased risk of
    breast cancer, including those with LCIS and atypical
    hyperplasia
    Phyllodes tumour
    Most common non-epithelial neoplasm of breast
    1% of breast tumours
    Up to 30cm, average 5cm, >10cm (giant Phyllodes)
    Median age of 50s
    Believed to start from stromal tissue before acquiring
    growth of ducts & lobules (epithelial component)
    CNB for diagnosis, vs FA
    More homogenous stroma is FA
    Difficulty distinguishing between FA, benign &
    malignant phyllodes tumors
    WHO classification of phyllodes tumour
    Surgery
    WLE, margin is controversial
     1cm is enough
     2 cm margin for small (< 5 cm) tumors & 5 cm margin for large (>5
    cm) tumors?
    Tumour should not be "shelled out" (vs FA) or recurrence
    rate will be high
    Mastectomy
     If poor cosmetic outcome anticipated
     Malignant
     Recurrent
    Axilla staging and more radical breast procedures are not
    warranted
    Phyllodes tumor diagnosed after excision of a
    “fibroadenoma”
    “Watch and wait” policy
     Appears to be safe
     Local recurrence 4%
     Five year survival 96%

    Wide excision of margins, esp if borderline/malignant


    Mastectomy if malignant or patient wishes
    Adjuvant therapy
    Radiotherapy considered in patients with involved
    margins & not suitable for re-excision/mastectomy
    ER & PR expression has been shown
    ?role of hormonal therapy
    Tendency to recur:
    Margins involved
    Higher grade
    Larger size
    Recurrence is considered failure of surgical
    treatment
    Re-excise or mastectomy
    Miscellaneous
    Lipoma, sebaceous cyst
    Fat necrosis
    Diabetic mastopathy
    Galactocele
    Hamartoma
    Adenoma
     Tubular
     Lactating
    Granulomatous mastitis
    Pseudoangiomatous stromal hyperplasia
    Infection
    Fat necrosis
    Trauma or surgery
    Mimics malignancy clinically & radiologically
    Look for oil cysts on imaging
    Biopsy to confirm
    No increased risk of cancer
    Excision is not necessary
    Beware of patients who detect a lump (cancer) only
    after a trivial trauma
    Diabetic mastopathy
    AKA lymphocytic mastitis or lymphocytic mastopathy
    Premenopausal women with longstanding type 1 DM
    Very hard, suspicious breast mass with a dense mammographic
    pattern
    CNB for diagnostic confirmation
    HPE
     Dense keloid-like fibrosis and periductal, lobular or perivascular
    lymphocytic infiltration
     Similar to those seen in autoimmune diseases
    Pathogenesis is unknown  ?autoimmune reaction
    No increased risk of cancer
    Excision is not necessary
    Galactocele
    Milk retention cysts
    Usually caused by obstructed milk duct
    USG/MMG appear as an indeterminate mass unless
    the classic fat-fluid level is seen
    Diagnosis based on the clinical history and aspiration
    No increased risk of cancer
    Excision not necessary
    Mammary fistula
    Hamartoma
    AKA fibroadenolipoma, lipofibroadenoma or
    adenolipoma
    Varying amounts of glandular, adipose & fibrous tissue
    Discrete, encapsulated, painless masses or incidental
    MMG findings
    Diagnosis difficult with limited tissue, as hamartomas
    do not have specific diagnostic features
    Coexisting malignancy can occur
    Excision is recommended
    Adenoma
    Pure epithelial neoplasms
    Sparse stromal elements (vs FAs)
    Well-circumscribed and lobulated
    Do not have malignant potential
    2 types
    Tubular
    Lactating
    Granulomatous mastitis
    Inflammatory mass in the breast; cause unknown
    Mistaken for non-puerperal mastitis, abscess or
    inflammatory carcinoma
    Biopsy is necessary to make a diagnosis
    Rx:
    Often self limiting but need time to resolve (9-12 mths)
    if infected, treat wt antibiotic and drain abscess if
    present.
    Surgery is not advocated due to slow wound healing
    PASH
    Benign stromal proliferation that simulates a vascular
    lesion
    Incidental MMG finding or present with
    mass/thickening
    HPE: characteristic appearance of slit-like spaces in
    the stroma between glandular units
    Can be confused with mammary angiosarcoma
    Excision biopsy recommended, esp if suspicious
    radiological findings
    No increased risk of cancer
    Infection
     Divided into
     Lactational
    5% post partum women
     1st month or during weaning
     Staph aureus
     Promote milk flow, antibiotics, analgesics, antipyretics

     Non-lactational
     Periareolar
     Young women with periductal mastitis (smoking)
     Subareolar ducts damaged by toxins + microvascular angiopathy + altered bacterial flora
     Higher recurrence rate
     Can be asso. with underlying high grade DCIS (image after resolution)
     Peripheral
     DM, RA, steroids, trauma
     Post-op
     Conflicting evidence on routine prophylactic antibiotic
     Recommended for
     Implants
     Immunosuppresed (DM, steroids, immunosuppresants, post neoadjuvant, more complicated breast surgeries
    Treatment
     Antibiotics
     Penicillin-based antibiotic
     Avoid tetracyclines, ciprofloxacin, chloramphenicol in

    lactating women
     Drainage
     Aspiration
     Under USG-guidance

     Outpatient, reviewed regularly

     I&D
     Minimal, just large enough to allow drainage

     Recurrent periareoalar non-lactational abscesses


    CNB-confirmed abnormalities that must be excised
    TRO associated malignancies:
    ADH
    ALH
    Flat epithelial atypia
    LCIS
    Papilloma
    Complex sclerosing adenosis/radial scar
    Hamartoma
    PASH
    Thank you.
    Q&A?

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