Benign Breast Complaints
Osama Hussein, MD, PhD Associate Professor Surgical Oncology
23 Dec., 2013
OBJECTIVES
To appreciate the epidemiological disease pattern of benign vs. Malignant breast conditions
To be able to diagnose and provide management for frankly benign conditions
To be able to pick up and refer suspicious lesions for proper specialized health carte
Breast Complaint
Breast is a unique body site
Differential diagnosis of breast complaint can be depicted as:
cancer or not cancer !
General practitioner should be familiar with these Benign conditions
Fibrocystic diseases Periductal mastitis / Duct ectasia Lactational mastitis / Breast abscess Fibroadenoma / Phylloids tumor Radial scar / Sclerosing adenosis Fat necrosis Breast cysts Papilloma Galactorrhea Granulomatous conditions (TB, Diabetic, others)
Diagnosis of Breast Complaints
Age
Course, duration of illness
Physical examination
Radiology
Biopsy
AGE IN YEARS
RA
TE O
F B
REA
ST C
AN
CER
AGE DISTRIBUTION OF BREAST CANCER
Arbitrary graph
AGE
Before puberty: almost no risk
Below 35 years: low risk of cancer
Premenopausal: high risk, high morbidity
Postmenopausal: higher risk, lower morbidity
COURSE / DURATION
Since when: Days vs. Weeks vs. Years
Complaint passed one period or not yet
Fluctuating course
PHYSICAL EXAMINATION
Cystic vs. Solid
Skin manifestations = advanced cancer
Cancer hard or firm, benign soft or rubbery but
EXCEPTIONS EXIST !!
Benign lesions that might mimic cancer
Radial scar
Traumatic fat necrosis
Diabetic fibrous mastopathy
Granulomatous mastitis
Malignant lesions that might mimic benign
Lobular carcinoma in situ
Medullary carcinoma
Tubular carcinoma
Phylloid tumor
Breast Complaint
Lump (mass)
Pain (Mastalgia)
Nipple discharge
Workup of breast mass
35 years or younger:
According to clinical suspicion; may include assurance, ultrasonography, FNAC &/or excision
Over 35 years old:
Triple assessment with clinical mammographic and microscopic examination is required
Mastalgia
Cyclic Mastalgia
Non-cyclic Mastalgia
Cyclic Mastalgia
At first visit, ask the patient to document the symptoms in a calendar to verify the cyclic pattern
Cyclic Mastalgia
Related to menstrual cycle (isolated or a part of PMTS)
Young age
Worse at luteal phase, better with onset of menses
Diffuse, bilateral, heaviness or soreness
Non cyclic Mastalgia
Middle age
Localised
Sharp, burning
Underlying cause
Cyclic Mastalgia
Reassurance
Breast support
Primrose oil
Tamoxifen
Danazol
Morrow M. Am Fam Physician. 2000 Apr 15;61(8):2371-8, 2385.
Nipple Discharge
I. Galactorrhia (milk, systemic disease)
II. True nipple discharge (watery, coloured, serous or bloody, local cause):
a. Physiological
b. Pathological
Physiological Discharge
No palpable masses
Multiductal
Upon squeezing
Serous, white, yellow or green
Pathological Discharge
May be associated with a mass
May be uniductal
May be spontaneous
May be WATERY or bloody
Diagnostic Workup of Nipple Discharge
If a mass, deal with the mass
If older than 35 years, obtain mammography
If unilateral or bloody, refer to surgical consultation
Cytology is often not helpful
Fibrocyctic Changes (FCC)
Hormone dependent changes (i.e. Do not diagnose FCC in menopausal women !)
Variable combination of adenosis, hyperplasia, fibrosis, sclerosing adenosis, cyst formation and atypia
Presents with mastalgia, masses, discharge or a combination of these symptoms
Sclerosing adenosis.
Guray M , Sahin A A The Oncologist 2006;11:435-449
2006 by AlphaMed Press
Ductal epithelial hyperplasias.
Guray M , Sahin A A The Oncologist 2006;11:435-449
2006 by AlphaMed Press
Radial scar.
Guray M , Sahin A A The Oncologist 2006;11:435-449
2006 by AlphaMed Press
Fibrocyctic Changes (FCC)
Risk of malignancy is related to the degree of hyperplasia
Adenosis, cysts, fibrosis etc are not risky
Florid (marked) hyperplasia is associated with moderate risk
Hyperplasia with atypia is associated with high risk
Atypical Hyperplasia
Adenosis and florid epithelial hyperplasia associated with cellular atypical changes i.e. monotonous cells with increased N/C ratio
Carcinoma in Situ
Extensive form of atypical hyperplasia i.e. The same morphology at wider extent
Guray M , Sahin A A The Oncologist 2006;11:435-449
2006 by AlphaMed Press
NORMAL
DUCT PAPILLOMA
PERIDUCTAL MASTITIS
DUCT ECTASIA
COMMON PATHOLOGY OF THE BREAST MAJOR DUCTS
Osama Hussein
PERIDUCTAL MASTITIS / DUCT ECTASIA
Chronic inflammation of the major terminal ducts of the breast (retroareolar) with or without dilation (ectasia).
Younger age (mastitis), middle age (ectasia)
Often due to mixed aerobic and anaerobic microorganisms
Presents with multicoloured discharge, recurrent inflammation or abscesses
PAPILLOMA
Affects the major terminal ducts leading to obstruction and dilation which may be palpable.
Leads to unilateral, unifocal bloody nipple discharge
TRAUMATIC FAT NECROSIS
An area of dense fibrosis that presents as a localised, firm to hard, irregular swelling
Differentiation from cancer is by biopsy
History of trauma is not helpful in diagnosis
Common after autologous breast reconstruction
BREAST ABSCESS
Non-lactational abscess is usually due to periductal mastitis / duct ectasia
Lactational abscess is more common and is usually due to colonisation of babys mouth with staphylococcus aureus.
Treatment is early drainage and parentral antibiotics
BREAST ABSCESS
BEWARE OF INFLAMMATORY BREAST CARCINOMA AS A DIFFERENTIAL DIAGNOSIS
OF BREAST INFLAMMATION !
Breast Cyst
Fluid filled structure
Arise from terminal duct structure, tend to be peripheral
Aspirate, cytological examination of clear fluid is not indicated
Bloody aspirate or solid component may be associated with cancer
K/Na > 1.5 might be associated with risk of cancer
Management of Breast Cysts
Aspiration
Surgical biopsy if:
o Bloody aspirate
o Residual solid area after aspiration
o Recollection twice or more
RESOURCES www.pubmed.gov
1: Vaidyanathan L, Barnard K, Elnicki DM. Benign breast disease: when to treat, when to reassure, when to refer. Cleve Clin J Med. 2002 May;69(5):425-32.
PMID: 12022387
2: Guray M, Sahin AA. Benign breast diseases: classification, diagnosis, and management. Oncologist. 2006 May;11(5):435-49.
PMID: 16720843
3: Morrow M. The evaluation of common breast problems. Am Fam Physician. 2000 Apr 15;61(8):2371-8, 2385. Review.
PMID: 10794579
Questions
Tel. : +2 (010) 9981 5110
Thanks