benign breast disease - parkside · pdf filebenign breast disease –large proportion of...
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Benign Breast Disease
Mr D Banerjee MS FRCSEd FRCS
Consultant Oncoplastic Breast Surgeon
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Breast anatomy
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TRIPLE ASSESSMENT
Benign breast disease – large proportion
of presentation to breast clinic
Key point – TRIPLE ASSESSMENT
• Clinical assessment
• Imaging - U/S +/- mammography
• Cytology / histology
• FNAC, Core biopsy, punch biopsy
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Congenital abnormalities
Extra nipples and breasts• 1-5% of men and women have accessory nipples
• Develop along the milk line
Absence or hypoplasia of the breast• Associated with defect of pectoral muscles e.g.
Poland syndrome
Chest wall abnormalities• Pectus excavatum / scoliosis
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Asymmetry
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Breast development Growth begins at the
age of 10
Functional unit of the breast is the terminal duct lobular unit
Glandular tissue (lobules & ducts) are supported by fibrous stroma
Most benign conditions and almost all cancer arise in the terminal duct lobular unit
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ANDIAberrations of Normal breast Development and Involution
Most benign conditions arise on the basis of dynamic changes which occur in the breast through the three main periods of reproductive life
Development
Mature reproductive life
Involution
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Aberration of Development
Juvenile hypertrophy (stromal proliferation)
Prepubertal breast development
Fibroadenoma (lobular aberration)
• Develop from whole lobule
• Account to 13% of all breast lumps
• 60% of lumps in age <20 years
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Involution The breast stroma is replaced by fat
Less radiodense
Softer
Ptotic
The development of small breast cysts (microcysts)
focal areas of change in normal epithelium to sweat gland type epithelium (apocrine metaplasia)
Increase in the number of glandular elements (adenosis)
Increase in the number of cells lining the terminal duct lobular unit (hyperplasia)
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Disorders of mature reproductive
life
Cyclical mastalgia
Regular changes in breast tissue in relation to
the normal menstrual cycle
Relating to pregnancy – doubling of breast
weight at term
Cyclical nodularity
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ANDIAberrations of Normal breast Development and Involution
Age Normal process Aberration
<25 Breast development
Lobular Fibroadenoma
Stromal Juvenile hypertrophy
25-40 Cyclical activity Cyclical mastalgia
Cyclical nodularity
(diffuse or focal)
35-55 Involution:
Lobular MacrocystsStromal Sclerosing lesions
Ductal Duct ectasia
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Fibroadenoma
aberration rather than a neoplasm
Classification:
common fibroadenoma
giant fibroadenoma
juvenile fibroadenoma
phyllodes tumour
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Management of fibroadenomas
TRIPLE ASSESSMENT
Natural history - 5% increase in size
- 33% get smaller
- remainder stay the same
Management - Fully assess by triple assessment
- Remove fibroadenomas if >3cm
- Offer observation or excision
Relationship to breast cancer
- No increased risk
- Complex fibroadenomas
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Disorder of early reproductive life
fibroadenoma
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Disorders of involution
Breast involution begins by the age of 35
Aberrations include• Macrocyst formation
• Sclerosis
• Uneven involution
• Epithelial hyperplasia
7 % of women will have palpable breast
cysts at some point in life
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Breast cysts
Palpable cysts = approx 15% of lumps
presenting to breast clinic
Cysts = distended and involuted lobules
Most common in peri and post-
menopausal women
Characteristic “halo” appearance on
mammogram and U/S
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Management of cysts
Triple assessment
Diagnosis may be established by needle
aspiration, and then pt re-examined
1-3% of patients presenting with cysts may
have carcinomas but these are usually
incidental findings on imaging
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So far
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Nipple discharge
Causes (in order of frequency)
Physiological
Duct papilloma
Duct ectasia
Periductal mastitis
Cancer
Galactorrhoea
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Treatment algorithm for
pathological nipple discharge
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Duct ectasia
Disorder of involution
Major subareolar ducts dilate and shorten during
involution
Contain cheesy, thick material
Minimal inflammation
Presents with nipple discharge, slit-like nipple retraction
or a mass
If troublesome discharge may benefit from total duct
excision
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Gynaecomastia
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GYNAECOMASTIA
Growth of breast tissue in males = benign and usually reversible
Seen in 30-60% of pubertal boys aged 10-16 yrs
Causes Puberty
Senescent
Drugs (cimetidine, digoxin, spironolactone, statins)
Cirrhosis
Hypogonadism
Testicular tumours
Hyperthyroidism
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Breast infections
Guiding principles
Usually Staph aureus infection
Give antibiotics early
Confirm abscess by USS +/- aspiration
I & D if multi-loculated, very large or skin necrosis
If lesion is solid, need to rule out malignancy (triple
assessment) - INFLAMM BREAST CA.
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TRIPLE Assessment
Clinical RadiologicalCytology (FNA)
Histology (Core Bx)
Early Breast Cancer Advanced Breast Cancer
Surgery
Chemotherapy
Endocrine
Radiotherapy