fibroadenoma of breast

1. BENIGN
BREAST
DISEASES
Dr. Saba Khan
Intern
General Surgery
Unit 3

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

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.

4. Anatomy
 The breast is a specialized accessory 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 base of breast extends from 2nd - 6th rib and
from the lateral margin of sternum to the mid-
axillary line
 The glandular tissues of the breast consist of
lobules, lobes and ducts
 Fatty and fibrous tissues surround the milk
producing system (lobules and ducts)
 Each breast consists of 15 - 20 lobes, which
radiate out from the nipple

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

6. Anatomy
 Lymphatic drainage
• Majorly to the Axillary nodes
• Inter mammary and the supraclavicular lymph nodes
(parasternal and medial)
 Three Lymph Node Levels
Axillary lymph nodes defined by pectoralis minor muscle
• Level I – Lateral and inferior to Pectoralis Minor
• Level II – Deep to Pectoralis Minor
• Level III – Medial to Pectoralis Minor
Rotter’s Nodes – Between Pectoralis Minor & Major
 Nerves
• Long Thoracic Nerve:
 Serratus Anterior m.
• Thoracodorsal Nerve:
 Latissimus Dorsi
• Intercostobrachial Nerve
 Sensory to medial arm & axilla

7. Structure

8. Classification Based On Pathology
 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

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

10. Classification Based On Clinical Features
(Cont’d)
 Nipple discharge
 Duct ectasia
 Fibrocystic disease
 Duct papilloma
 Galactorrhea
 Breast infections and Inflammation
 Postpartum engorgement
 Intrinsic mastitis
 Lactation mastitis
 Lactation breast abscess
 Chronic recurrent subareolar abscess
 Acute mastitis associated with macrocystic breasts
 Extrinsic infections
 Mondor’s Disease
 Hidradenitis suppurativa

11. Relative risk of invasive breast carcinoma based on pathological
examination of benign breast tissue:
 No increased risk
 Adenosis, sclerosing or fibroid
 Cysts, macro &/or micro
 Duct ectasia
 Fibroadenoma
 Fibrosis
 Hyperplasia
 Mastitis (inflammation)
 Periductal mastitis
 Squamous metaplasia
 Slightly increased risk (1.5-2
times
 Hyperplasia, moderate or florid, solid
or papillary
 Pappiloma with a fibrovascular core
 Moderately increased risk (5
times)
 Atypical hyperplasia, ductal or
lobular
 Insufficient data to assign a risk
 solitary papilloma of lactiferous sinus
 Radical scar lesion

12. Breast Pain (Mastalgia)
More common in premenopausal women than in post
menopausal women
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

13. Breast Pain (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, MSK, scars
from previous biopsies and medications have been
associated

14. Management of Breast Pain
 Pharmacological Treatment
 NSAIDs
 OCPs
 Danazol 100- 400mg 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

15. Evaluation & Management of Breast Pain

16. 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

17. Breast Masses: Cysts
Fibrocystic Breast Disease
 Most common of all benign breast disease
 Most common between ages 20- 50
 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

18. Fibrocystic Breast Disease
 Physical Examination
 Tenderness
 Increased engorgement and more
dense breast
 Increased lumpiness / glandular
 Occasional spontaneous nipple
discharge

19. 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

20. Management of Breast Cysts

21. Breast Masses

22. 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 10 -18.
 Vary in size from 5 - 20cm in diameter. Usually painless, solitary, unilateral
masses
 Excision is recommended

23. 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

24. Breast Mass
 Phylloides Tumors:
 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

25. 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

26. 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.

27. Nipple Discharge
 Physiological cause
During pregnancy and lactation
 Intraductal Papilloma
 Benign growth within ductal system
 Presents as bloody nipple discharge
 Excision is the only way to differentiate from carcinoma
 Galactorrhea
 Secretion of milk not related to pregnancy or lactation.
 Stress & mechanical stimulation of breast
 Side-effect of drugs that enhances dopamine activity e.g. chlorpromazine,
metoclopromide & methyldopa.
 Hyperprolactinaemia due to prolactin-secreting tumor or from a secondary
source of bronchogenic carcinoma.
 Obtain prolactin level. If normal, simple reassurance
 Stop mechanical stress or ingestion of drugs
 Treatment of prolactin-secreting tumor or bronchogenic carcinoma

28. 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 10-14 days to cover staph and
strept infections

29. 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

30. 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

31. 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
 B/L or unilateral enlargement of breasts. In 50%, swelling is later accompanied
by secretion of creamy fluid similar to colostrum, which is called ‘Witch’s Milk’
 Occurs on the 3rd or 4th day of birth
 Response to mothers hormone exposure (prolactin, estrogen)
 Resolves spontaneously after 2 weeks when the estrogen level automatically
falls
 Occasionally becomes infected

32. Congenital Breast Disease
 About 1-5 % of the
population have accessory
nipples, and less commonly
accessory breast
(Polymazia)
 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

33. 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

34. Approach to Breast Problems
 Palpation
 Breast
 Axilla
 Supraclavicular

35. 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

37. Diagnostic Work Up
 Ultrasonography: First diagnostic test of choice to
differentiate a cystic mass from a solid mass
 Mammogram: A normal mammogram at any age does not
eliminate the need for further evaluation of a suspicious mass.
 FNAC: Useful for cystic lesions. If lesion is completely drained
and the fluid is not bloody or cloudy, no further evaluation is
needed
 Core Needle Biopsy: This provides a best diagnostic information for
solid palpable mass which can be visualized on the USG or
mammogram
 Excisional Biopsy
 Incisional Biopsy
 MRI

38. Triple Assessment of Breast Symptoms
In any pt. who presents with a breast lump or other symptoms
suspicious of carcinoma:

39. 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

40. Thank You !