Benign Breast Disease

1. Benign Breast Disease Juhi Asad, DO Sharon Rosenbaum Smith, MD Dept. of Breast Surgery

2. Outline • Anatomy • Benign disease • Management • Genetics

3. Anatomy • Modified sweat gland between the superficial and deep layers of the chest wall • Cooper’s Ligament • Fibrous band of tissue

4. Anatomy • Ducts • Terminal ductules • Milking forming glands • Lobule

5. Question • Axillary lymph nodes are classified accordingly to the relationship with the • Axillary vein • Pec.major • Pec.minor • Latissimus dorsi • Serratus anterior

6. Anatomy • Axillary lymph nodes defined by pectoralis minor muscle • Level 1 – lateral • Level 2 – posterior • Level 3 – medial • Long Thoracic Nerve • Serratus anterior • Thoracodorsal Nerve • Latissimus Dorsi • Intercostalbrachial Nerve • Lateral cutaneous • Sensory to medial arm & axilla

7. Anatomy • Hormonal Effects • Estrogen • Development of the breast and lactiferous ducts • Progesterone • Secretory acinar tissue – lobules • Prolactin • Synergizes the effect of estrogen and progesterone

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

9. Management • History • Clinical Breast Exam • Breast imaging • Tissue sampling • Therapy

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

11. Question • What are the risk factors that are part of the Gail Model? • Race • Age • Age of 1st menses • Age at 1st pregnancy • # of 1st degree relatives • # of biopsies

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

13. Question • 22 yo female presents with a new right breast mass. Complains of mild tenderness. No other complaints. On physical exam, there is a 1 cm nodule at the 2:00 position. Your diagnostic test of choice is…. • Mammogram • Ultrasound • Excisional biopsy • Incisional biopsy

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

15. Breast Cyst

16. Breast Mass • Fibroadenoma • Stromal and epithelial elements • Most common in women <30yo • Firm, solitary tumors • Multiple • Increase in size • Management • Biopsy • Excisional biopsy

17. Fibroadenoma

18. 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

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

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

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

23. Question • 34 yo female referred to you for evaluation of breast pain. The pain is burning and sharp in nature. Always present. On physical exam, dense glandular tissue bilaterally. Your working diagnosis is…. • Cyclical breast pain • Noncyclical breast pain • cancer

24. Breast Pain • Cyclical pain – hormonal • Dull, diffuse and bilateral • Luteal phase • Treatment • Reassurance • NSAIDS • Evening primrose oil • Non-cyclical pain • Non-breast vs breast • Imaging • Treatment • Reassurance • NSAIDS • Evening primrose oil

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

26. Mastitis • Treatment • Abx • Continue to breast feed • Close follow-up

27. Breast Abscess • Abscess • Breast tissue • Treatment • Abx • Needle aspiration • Incision and drainage

28. Question • What is the difference between spontaneous vs non-spontaneous nipple discharge?

29. Nipple Discharge • Physiologic • Bilateral • Involves multiple ducts • Heme (-) • Non-spontaneous

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

31. Bloody Nipple Discharge

32. Intraductal Papilloma • Single duct • Benign • 4% of intraductal ca

33. Imaging • Mammography • Ultrasound • MRI

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

37. Calcification • Macrocalcifications • 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

41. BI-RADS

42. Ultrasound • Not a screening tool • Palpable vs cystic • Mammographic detected lesion

44. Benign Pure and intensely hyperechoic Elliptical shape (wider than tall) Lobulated Complete tine capsule Malignant Hypoechoic, spiculated Taller than wide Duct extension microlobulation Ultrasound

45. Ultrasound

46. Malignant or Benign

47. Malignant vs Benign

48. MRI • High risk patients • 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

49. MRI Pre Gad Post Gad Color Overlay

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