Benign Breast DiseaseBenign Breast Disease

Juhi Asad, DOJuhi Asad, DO

Sharon Rosenbaum Smith, MDSharon Rosenbaum Smith, MD

Dept. of Breast SurgeryDept. of Breast Surgery

OutlineOutline

AnatomyAnatomy

Benign diseaseBenign disease

ManagementManagement

GeneticsGenetics

AnatomyAnatomy

Modified sweat gland Modified sweat gland between the between the superficial and deep superficial and deep layers of the chest layers of the chest wallwall

Cooper’s LigamentCooper’s Ligament– Fibrous band of tissueFibrous band of tissue

AnatomyAnatomy

DuctsDucts– Terminal ductulesTerminal ductules

Milking forming glandsMilking forming glands

LobuleLobule

QuestionQuestion

Axillary lymph nodes are classified Axillary lymph nodes are classified accordingly to the relationship with theaccordingly to the relationship with the– Axillary veinAxillary vein– Pec.majorPec.major– Pec.minorPec.minor– Latissimus dorsiLatissimus dorsi– Serratus anteriorSerratus anterior

AnatomyAnatomy

Axillary lymph nodes Axillary lymph nodes defined by pectoralis defined by pectoralis minor muscleminor muscle– Level 1 – lateralLevel 1 – lateral– Level 2 – posteriorLevel 2 – posterior– Level 3 – medialLevel 3 – medial

Long Thoracic NerveLong Thoracic Nerve– Serratus anteriorSerratus anterior

Thoracodorsal NerveThoracodorsal Nerve– Latissimus DorsiLatissimus Dorsi

Intercostalbrachial NerveIntercostalbrachial Nerve– Lateral cutaneous Lateral cutaneous – Sensory to medial arm & Sensory to medial arm &

axillaaxilla

AnatomyAnatomy

Hormonal EffectsHormonal Effects– EstrogenEstrogen

Development of the breast and lactiferous ductsDevelopment of the breast and lactiferous ducts

– ProgesteroneProgesteroneSecretory acinar tissue – lobulesSecretory acinar tissue – lobules

– ProlactinProlactinSynergizes the effect of estrogen and Synergizes the effect of estrogen and progesteroneprogesterone

Benign Breast DiseasesBenign Breast Diseases

Glandular breast parenchymaGlandular breast parenchyma– MassMass– Asymmetric nodularityAsymmetric nodularity– PainPain

Nipple-Areolar ComplexNipple-Areolar Complex– DischargeDischarge– RashRash– RetractionRetraction

Surrounding breast skinSurrounding breast skin– DimplingDimpling

ManagementManagement

HistoryHistory

Clinical Breast ExamClinical Breast Exam

Breast imagingBreast imaging

Tissue samplingTissue sampling

TherapyTherapy

HistoryHistory

AgeAge– MenarcheMenarche– PregnancyPregnancy

Breast feedingBreast feeding

– MenopauseMenopause

Family HistoryFamily History

Prior biopsiesPrior biopsies

Hormone therapyHormone therapy

QuestionQuestion

What are the risk factors that are part of What are the risk factors that are part of the Gail Model?the Gail Model?

– RaceRace– AgeAge– Age of 1Age of 1stst menses menses– Age at 1Age at 1stst pregnancy pregnancy– # of 1# of 1stst degree relatives degree relatives– # of biopsies# of biopsies

Clinical ExamClinical Exam

InspectionInspection– SkinSkin– SymmetrySymmetry– MassesMasses

PalpablePalpable– GlandGland– Axilla, Supraclavicular Axilla, Supraclavicular

spacesspaces– Nipple-areola complexNipple-areola complex

QuestionQuestion

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

Breast MassBreast Mass

Breast CystsBreast Cysts– Fluid-filled Fluid-filled – 1 out of every 14 women1 out of every 14 women

50% multiple and recurrent50% multiple and recurrent

– Hormonally influencedHormonally influenced– Needle aspiratedNeedle aspirated

Breast CystBreast Cyst

Breast MassBreast Mass

FibroadenomaFibroadenoma– Stromal and epithelial elementsStromal and epithelial elements– Most common in women <30yoMost common in women <30yo– Firm, solitary tumorsFirm, solitary tumors

MultipleMultiple

Increase in sizeIncrease in size

– ManagementManagementBiopsyBiopsy

Excisional biopsyExcisional biopsy

FibroadenomaFibroadenoma

Breast MassBreast Mass

Phyllodes TumorPhyllodes Tumor– Proliferation of connective tissue with ductal Proliferation of connective tissue with ductal

elementselementsWhorled and cellular stromaWhorled and cellular stroma

– Firm, lobulatedFirm, lobulated– 2 to 40 cm in size2 to 40 cm in size– 10% malignant10% malignant– TreatmentTreatment

Wide excisionWide excision

Fibrocystic DiseaseFibrocystic Disease

Clinical, mammographic and histologic Clinical, mammographic and histologic findingsfindings

Exaggerated response from hormones Exaggerated response from hormones and growth factorsand growth factors– Cyclical painCyclical pain– Nodularity – upper outer quadrantsNodularity – upper outer quadrants

Fibrocystic DiseaseFibrocystic Disease

HistologyHistology– AdenosisAdenosis– Apocrine metaplasiaApocrine metaplasia– FibrosisFibrosis– Duct ectasiaDuct ectasia– Mild ductal hyperplasiaMild ductal hyperplasia

Fibrocystic DiseaseFibrocystic Disease

Risk FactorsRisk Factors– Dense breastDense breast– Sclerosing adenosisSclerosing adenosis– Atypical ductal, papillary, or lobular Atypical ductal, papillary, or lobular

hyperplasiahyperplasia

QuestionQuestion

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

Breast PainBreast Pain

Cyclical pain – hormonalCyclical pain – hormonal– Dull, diffuse and bilateralDull, diffuse and bilateral– Luteal phaseLuteal phase– TreatmentTreatment

ReassuranceReassuranceNSAIDSNSAIDSEvening primrose oilEvening primrose oil

Non-cyclical painNon-cyclical pain– Non-breast vs breastNon-breast vs breast– ImagingImaging– TreatmentTreatment

ReassuranceReassuranceNSAIDSNSAIDSEvening primrose oilEvening primrose oil

Breast InfectionsBreast Infections

MastitisMastitis– Generalized cellulitis of the breastGeneralized cellulitis of the breast– Ascending infection Ascending infection subareolar ductssubareolar ducts

commonly occurs during lactationcommonly occurs during lactation– Staph. aureusStaph. aureus

– Erythema, pain, tendernessErythema, pain, tenderness

MastitisMastitis

TreatmentTreatment– AbxAbx– Continue to breast Continue to breast

feedfeed– Close follow-upClose follow-up

Breast AbscessBreast Abscess

AbscessAbscess– Breast tissueBreast tissue– TreatmentTreatment

AbxAbx

Needle aspirationNeedle aspiration

Incision and drainageIncision and drainage

QuestionQuestion

What is the difference between What is the difference between spontaneous vs non-spontaneous nipple spontaneous vs non-spontaneous nipple discharge?discharge?

Nipple DischargeNipple Discharge

PhysiologicPhysiologic– BilateralBilateral– Involves multiple ducts Involves multiple ducts – Heme (-)Heme (-)– Non-spontaneousNon-spontaneous

Nipple DischargeNipple Discharge

PathologicPathologic– UnilateralUnilateral– SpontaneousSpontaneous– Heme (+)Heme (+)

Most common cause intraductal papillomaMost common cause intraductal papilloma

Bloody Nipple DischargeBloody Nipple Discharge

Intraductal PapillomaIntraductal Papilloma

Single ductSingle duct

BenignBenign

4% of intraductal ca4% of intraductal ca

ImagingImaging

MammographyMammography

UltrasoundUltrasound

MRIMRI

MammographyMammography

Screening toolScreening tool– Age of 40Age of 40

Estimated reduction Estimated reduction in mortality 15-25%in mortality 15-25%

10% false positive 10% false positive raterate

Densities & Densities & calcificationscalcifications

CalcificationCalcification

MacrocalcificationsMacrocalcifications– Large white dotsLarge white dots– Almost always noncancerous and require no Almost always noncancerous and require no

further follow-up. further follow-up.

MicrocalcificationsMicrocalcifications– Very fine white specks Very fine white specks – Usually noncancerous but can sometimes be Usually noncancerous but can sometimes be

a sign of cancer.a sign of cancer.– Size, shape and patternSize, shape and pattern

BI-RADSBI-RADS

BI-RADS BI-RADS ClassificationClassification

FeaturesFeatures

00 Need additional imagingNeed additional imaging

11 Negative – routine in 1 yrNegative – routine in 1 yr

22 Benign finding – routine in 1 yrBenign finding – routine in 1 yr

33 Probably benign, 6mo follow-upProbably benign, 6mo follow-up

44 Suspicious abnormality, biopsy Suspicious abnormality, biopsy recommendedrecommended

55 Highly suggestive of malignancy; Highly suggestive of malignancy; appropriate action should be takenappropriate action should be taken

UltrasoundUltrasound

Not a screening toolNot a screening tool

Palpable vs cysticPalpable vs cystic

Mammographic detected lesionMammographic detected lesion

UltrasoundUltrasound

BenignBenign– Pure and intensely Pure and intensely

hyperechoichyperechoic– Elliptical shape (wider Elliptical shape (wider

than tall)than tall)– LobulatedLobulated– Complete tine capsuleComplete tine capsule

MalignantMalignant– Hypoechoic, Hypoechoic,

spiculatedspiculated– Taller than wideTaller than wide– Duct extensionDuct extension– microlobulationmicrolobulation

UltrasoundUltrasound

Malignant or Benign

Malignant vs Benign

MRIMRI

High risk patientsHigh risk patients– Personal history of breast caPersonal history of breast ca– LCIS, atypiaLCIS, atypia– 11stst degree relative with breast cancer degree relative with breast cancer– Very dense breastVery dense breast

High sensitivity (95-100%)High sensitivity (95-100%)– 10-20% will have a biopsy10-20% will have a biopsy

MRIMRI

Pre Gad Post Gad Color Overlay

DiagnosisDiagnosis

Fine needle aspiration Fine needle aspiration – CytologyCytology

Core biopsyCore biopsy– Image guidedImage guided– StereotacticStereotactic

Excisional biopsyExcisional biopsy– Needle localizationNeedle localization

FNAFNA

Fast, inexpensiveFast, inexpensive

96% accuracy96% accuracy

Institution dependentInstitution dependent

Unable to differentiate Unable to differentiate b/w in situ vs CAb/w in situ vs CA

Core Needle BiopsyCore Needle Biopsy

14-18 gauge spring loaded needle14-18 gauge spring loaded needle

TissueTissue

Multiple Multiple

Large Core BiopsyLarge Core Biopsy

6-14 gauge core6-14 gauge core

Large samplesLarge samples

Single insertionSingle insertion

Core biopsy Vacuum Assisted

Stereotactic BiopsyStereotactic Biopsy

Suspicious Suspicious mammographic mammographic abnormalitiesabnormalities

Patients lay pronePatients lay prone

Stereo ViewStereo View

Excisional BiopsyExcisional Biopsy

Atypical lesionsAtypical lesions

LCISLCIS

Radial scarRadial scar

Atypical papillary lesionsAtypical papillary lesions

Radiologic-pathologic discordanceRadiologic-pathologic discordance

PhyllodesPhyllodes

Inadequate tissue harvestingInadequate tissue harvesting

High-RiskHigh-Risk

Prior breast cancerPrior breast cancer

Family history of breast cancerFamily history of breast cancer– Ovarian cancerOvarian cancer– BRCA-1 or BRC-2 geneBRCA-1 or BRC-2 gene

Prior mantle radiationPrior mantle radiation

Biopsy proven of atypia or LCISBiopsy proven of atypia or LCIS

ScreeningScreening

Prior breast cancer or atypiaPrior breast cancer or atypia– Annual mammographyAnnual mammography– 6 mo CBE6 mo CBE

Family HxFamily Hx– 10 yrs younger than relative’s diagnosis10 yrs younger than relative’s diagnosis– 6 mo CBE6 mo CBE

BRCABRCA– 25 yo – annual mammography25 yo – annual mammography– 6 mo CBE6 mo CBE

GeneticsGenetics

Early age of onsetEarly age of onset2 breast primaries or breast and ovarian CA2 breast primaries or breast and ovarian CAClustering of breast CA with:Clustering of breast CA with:– Male breast CA, Male breast CA, – Thyroid CA, Thyroid CA, – Sarcoma, Sarcoma, – Adrenocortical CA, Adrenocortical CA, – Pancreatic CA Pancreatic CA – leukemia/lymphoma on same side of familyleukemia/lymphoma on same side of family

Family member with BRCA geneFamily member with BRCA geneMale breast CAMale breast CAOvarian CAOvarian CA

GeneticsGenetics

Hereditary Breast/Ovarian SyndromeHereditary Breast/Ovarian Syndrome– BRCA 1 – chromosome 17BRCA 1 – chromosome 17– BRCA 2 – chromosome 13BRCA 2 – chromosome 13

Li-Fraumeni SyndromeLi-Fraumeni Syndrome– P53 mutation – chromosome 17P53 mutation – chromosome 17

Cowden SyndromeCowden Syndrome– PTEN mutation – chromosome 10PTEN mutation – chromosome 10

Autosomal dominant patternAutosomal dominant pattern

BRCABRCA

Account to 25% of early-onset breast Account to 25% of early-onset breast cancerscancers

36%-85% lifetime risk of breast CA36%-85% lifetime risk of breast CA

16-60% lifetime risk of ovarian CA16-60% lifetime risk of ovarian CA

BRCABRCA

BRCA 1 geneBRCA 1 gene– Ovarian CAOvarian CA

BRCA 2 geneBRCA 2 gene– Male breast CAMale breast CA– Prostate CAProstate CA– Pancreatic CAPancreatic CA

BRCABRCA

ManagementManagement– Monthly BSE -- 18yoMonthly BSE -- 18yo– 6 mo CBE & annual mammo -- 25yo 6 mo CBE & annual mammo -- 25yo – Discuss risk reducing optionsDiscuss risk reducing options

Prophylactic mastectomiesProphylactic mastectomies

Salpingo-oophorectomy – upon completion of child Salpingo-oophorectomy – upon completion of child bearingbearing

– 6 mo transvaginal US & CA125 – 35 yo 6 mo transvaginal US & CA125 – 35 yo

Li-Fraumeni SyndromeLi-Fraumeni Syndrome

Mutation of p53 geneMutation of p53 gene– Tumor suppressorTumor suppressor

Premenopausal breast CAPremenopausal breast CA– Childhood sarcomaChildhood sarcoma– Brain tumorsBrain tumors– LeukemiaLeukemia– Adrenocortical CAAdrenocortical CA

Accounts for 1% of breast CAAccounts for 1% of breast CA

Cowden SyndromeCowden Syndrome

Major criteriaMajor criteria– Thyroid CA (follicular)Thyroid CA (follicular)– MarcocephalyMarcocephaly– Cerebellar tumorsCerebellar tumors– Endometrial CAEndometrial CA– Breast CA – 25%-50% riskBreast CA – 25%-50% risk– Skin and mucosal lesionsSkin and mucosal lesions

Minor criteriaMinor criteria– Thyroid lesionsThyroid lesions– GU tumorsGU tumors– GI hamartomasGI hamartomas– Fibrocystic breastFibrocystic breast– Mental retardationMental retardation