Benign disease of the Breast

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Benign disease of the Breast

• Gershon Efron, MD FACS FRCS
• Sinai Hospital of Baltimore

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Anatomy of the Breast

• Breast
• Lobules
• Stroma
• Nipple
• Blood supply
• Lymphatics
• Axilla

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Physiology of the Breast
Pregnancy
Normal fct.

• Pituitary
• Prolactin
• Oxytocin
• Placenta
• Estrogen
• Progesterone
• HCG

• Pituitary
• Growth hormone
• LH / FSH
• Ovary
• Estrogen
• Progesterone

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Diagnosis of Breast lesions

• History
• Age
• Family history (Cancer)
• D iscoverD uratiionD ischarge
• L ump I njuryM enstruation (menarche,
  menopause, contraceptives)P ain

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Examination of the Breast

• Inspection
• Symmetry
• Skin / nipple changes
• Bulges / retractions
• Palpation
• Breast
• Axilla
• Supraclavicular

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Examination of the BreastInspection
Peau dOrange
Puckering
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Examination of the BreastInspection
Nipple retraction
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Examination of the BreastInspection
Pagets disease of the nipple
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Examination of the BreastPalpation (Lump)

• Site (left, right, quadrant)
• Size
• Shape
• Surface (smooth, irregular)
• Sensitivity (tender, non-tender)
• Spread (skin, nodes, muscle)
• Edge (well vs. ill defined)
• Consistency (soft, firm, fluctuant)
• Mobility (mobile, fixed)
• Relationships (to anatomical structures)

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Patient Workup

• FNA vs. Core Biopsy
• Cyst aspiration
• Ultrasound
• Mammography
• MRI
• PET

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Pathology of benign Breast disease

• Congenital
• Traumatic
• Inflammatory
• Tumors

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CongenitalBreast disease
Amazia
Acessory Breast(s)
Supernumerary Nipple
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TraumaticBreast disease

• Fat necrosis
• Hematoma
• Post Surgery
• D/D Carcinoma

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InflammatoryBreast disease

• Fibrocystic disease
• Very common
• ? Hormonal origin
• Young patients (
• Fibrous tissue, cysts, nodules
• Focal, general, uni/bilateral
• Round cell infiltration
• Pain (cyclical)
• Symptoms tend to improve /disappear with
  pregnancy

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InflammatoryBreast disease

• Fibrocystic disease
• Treatment
• Cyst aspiration
• Analgesia
• Firm Bra support
• Vitamins (E, B6)
• Avoidance of caffeine
• Night time Primrose oil
• Danazole
• Bromocryptine
• Tamoxifen
• Contraceptives
• Reassurance

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InflammatoryBreast disease

• Cyst management
• Cyst aspiration
• Bloody fluid
• Residual lump (palpation or US)
• Recurrence 3

Biopsy
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InflammatoryBreast disease

• Mastitis Breast Abscess
• Cause nipple manipulation
• More common in lactation and older patients
• Signs of infection
• Staph (MRSA)

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InflammatoryBreast disease

• Mastitis Breast Abscess
• Treatment
• Antibiotics
• Aspiration orID of abscess(Biopsy the wall!)
• Milk pumpingwarm compresses

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InflammatoryBreast disease

• Mammary duct abscess
• Recurrent peri-areolar abscess formation
• ? Duct ectasia
• Fistulotomy
• Excision of the duct

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InflammatoryBreast disease

• Chronic breast infection
• Antibioma
• Tuberculosis
• Actinomycosis
• Treponema (Chancre)
• Need biopsy
• Special stains/Cx
• Tx specific to disease

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InflammatoryBreast disease

• Mastitis neonatorum
• Occurs within few weeks of birth
• Response to mothers hormone exposure (prolactin,
  estrogen)
• Resolves spontaneously
• Occasionally becomes infected

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Other inflammatorycauses of breast pain

• Mondors disease
• Thrombophlebitis lateral thoracic vein
• Tietzes disease
• Osteochondritis, usually 2nd 3rd chostochondral
  junction
• Treatment for both NSAID analgetics

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Pathology of benign Breast disease

• Tumors
• Cancer
• Nipple discharge
• Gynecomastia

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Tumorsof the breast

• Fibroadenoma
• Very common
• Young patients
• ? Hormone related
• P uberty
• P lural
• P eripheral

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Tumorsof the breast

• Fibroadenoma
• Treatment
• Observation
• Excision
• It is MALPRACTICE to operate on the (pre-)
  pubescent breast

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Tumorsof the breast

• Cystosarcoma Phylloides
• Rare
• Age /- 40
• Rarely malignant
• Large
• Mobile
• Bosselated
• Ulceration of skin

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Tumorsof the breast

• Cystosarcoma Phylloides
• Tx local excision w. margin
• May recur locally!
• If highly mitotic or recurrent Mastectomy

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Nipple discharge

• Milky, Serous, Bloody all colors of the
  rainbow
• Milky discharge
• nl. with lactation
• Galactocele
• milk, cheese, calcification
• Can become infected
• Excision
• Galactorrhea
• Pituitary tumors (prolactin)
• Hyperthyroidism
• Medications

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Nipple discharge

• Serous discharge
• Common
• Usually benign ( age 60 D/D carcinoma)
• Complete breast evaluation!
• Tx Observation
• Abstain from repeated breast manipulation
• Treatment of underlying problem

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Nipple discharge

• Bloody discharge
• Fibrocystic disease
• Ductal papilloma
• Ductal carcinoma
• Management
• With lump - treat the lump
• W/O lump - complete breast evaluation
  Ductogram Duct endoscopy
  Lacrimal probe to localize duct Duct
  excision NO FROZEN SECTION!

Age
Age 40
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Tumorsof the breast

• Gynecomastia
• Neonates
• Mothers hormones
• Puberty
• Hormonal imbalance
• Seniors
• Androgen deficiency

• General Etiology
• Idiopathic
• Endocrine
• Testicular atrophy
• Testicular tumors
• Adrenal tumors
• Hyperthyroidism
• Pituitary tumors
• Genetic
• XO, XXY,
• Liver disease
• Bronchial carcinoma
• Kidney failure
• HIV
• Medications
• Digitalis, Spironolactone, Anabolic steroids,
  Marihuana,

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Tumorsof the breast

• Gynecomastia
• Thorough history and physical!
• Endocrine workup as indicated
• Biopsy Mammogram when
• clinical suspicion
• persistence w/o clear cause
• age 60
• Tx
• Observation
• Danazole / Tamoxifen
• Excision

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Benign disease of the Breast
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