34 Breast Benign diseases

• ANDI is Aberrations of normal development and involution.
• To address the confusion in nomenclature of benign breast disease, a concept (aberrations of normal development and involution (ANDI)) has been developed and described by the Cardiff Breast Clinic.

Aetiology - The breast is a dynamic structure that undergoes changes throughout a woman’s reproductive life and, superimposed upon this, cyclical changes throughout the menstrual cycle. The pathogenesis of ANDI involves disturbances in the breast physiology extending from a perturbation of normality to well-defined disease processes.

• Pathology - The disease consists essentially of four features that may vary in extent and degree in any one breast:
• 1 Cyst formation. Cysts are almost inevitable and very variable in size.
• 2 Fibrosis. Fat and elastic tissues disappear and are replaced with dense white fibrous trabeculae. The interstitial tissue is infiltrated with chronic inflammatory cells.
• 3 Hyperplasia of epithelium in the lining of the ducts and acini may occur, with or without atypia.
• 4 Papillomatosis. The epithelial hyperplasia may be so extensive that it results in papillomatous overgrowth within the ducts.

• Clinical features -
• A benign discrete lump in the breast is commonly a cyst or fibroadenoma.
• Lumpiness may be bilateral, commonly in the upper outer quadrant or, less commonly, confined to one quadrant of one breast. The changes may be cyclical, with an increase in both lumpiness and often tenderness before a menstrual period.
• Non-cyclical mastalgia is more common in perimenopausal than postmenopausal women.

Normal // Disorder // Disease

• 1. Early reproductive years (age 15–25 y)
• a. Lobular development // Fibroadenoma // Giant fibroadenoma
• b. Stromal development // Adolescent hypertrophy // Gigantomastia
• c. Nipple eversion // Nipple inversion // Subareolar abscess

• 2. Later reproductive years (age 25–40 y)
• a. Cyclical changes of menstruation // Cyclical mastalgia and nodularity (Fibrocystic disease of breast) // Incapacitating mastalgia
• b. Epithelial hyperplasia of pregnancy // Bloody nipple discharge // --

• 3. Involution (age 35–55 y)
• a. Lobular involution // Macrocysts // —
• b. Duct involution
• i. Dilatation // Duct ectasia // Periductal mastitis
• ii. Sclerosis // Nipple retraction // —
• iii. Epithelial turnover // Epithelial hyperplasia // Epithelial hyperplasia with atypia

• Also called as cyclic mastalgia with nodularity or fibroadenosis. 
• The term fibrocystic disease is nonspecific.Too frequently, it is used as a diagnostic term to describe symptoms, to rationalize the need for breast biopsy, and to explain biopsy results.

• Common during 4-5th decade of life, lasting until menopause 
• An exaggrated response of breast stroma and epithelium to various hormones 
• Pain, tendernes and nodularity. Breast pain is usually not a symptom of breast cancer. 
• Uncommon in <30 years ans >60 years 
• Palpable cyst or multiple small cysts 
• It subsides during pregnancy, lactation and after menopause. 

• Histological lesions of fibrocystic disease
• a) Non proliferative 
• b) Proliferative 
• i) without atypia (severe hyperplasia) 
• ii) with atypia - ADH and ALH

• Treatment - 
• Reassurance 
• Everning primrose
• Vitamin E
• Danazole (GnRH inhibitor) - 2nd line drug

• Antibiotic with USG guided repeated aspiration of aspiration
• Incision and Drainage – reserved for those who do not respond to repeated aspiration or those with thinning and necrosis of overlying tissue

Thrombophlebitis that involves the superficial veins of anterior chest wall and breast

• Unilateral discharge
• Discharge from single duct – solitary intraductal papilloma, may require surgery to establish diagnosis and to control discharge
• Discharge from multiple ducts – subareolar duct ectasia

• Bilateral discharge
• B/L milk discharge – Galactorrhea
• Nipple discharge that is bilateral and comes from multiple ducts is not usually a cause of surgery.

• Also called as duct ectasia
• A chronic relapsing form of infection may develop in the subareolar ducts of the breast
• Mixed infections that include aerobic and anaerobic skin flora.
• A series of infections with resulting inflammatory changes and scarring may lead to retraction or inversion of the nipple, masses in the subareolar area, and occasionally a chronic fistula from the subareolar ducts to the periareolar skin.

• Treatment
• - Antibiotics
• - I and D, recurrent cases
• - Excision of entire subareolar ductal complex (Hadfield Operation)

• It is superficial manifestation of an intraductal carcinoma.
• The malignancy spreads within the duct up to the skin of the nipple and down into the substance of the breast. It mimics eczema of nipple and areola.
• In Paget’s disease, there is a hard nodule just underneath the areola, which later ulcerates and causes destruction of nipple.
• Histologically, it contains large, ovoid, clear Paget’s cells with malignant features.
• BCS is difficult here, hence MRM is needed.

Eczema – begin in areola, bilateral, itching present, no underlyng lump, nipple intact

Paget’s disease – originates in nipple and secondarily invade areola, unilateral, itching absent, underlyng lump present, nipple destroyed

• Bilateral, for years – subareolar duct ectasia
• Unilateral, over months – carcinoma

• This is a benign breast disease containing both fibrous and glandular tissue.
• Also called as breast mouse
• These usually arise in the fully developed breast between the ages of 15 and 25 years.
• They arise from hyperplasia of a single lobule.
• They are surrounded by a well-marked capsule and can thus be enucleated through a cosmetically appropriate incision.
• Giant fibroadenoma - >5cm
• Juvenile fibroadenoma - large fibroadenoma that occasionally occurs in adolescents and young adults and histologically is more cellular than the usual fibroadenoma. 
• Mammography is of little help in discriminating between cysts and fibroadenomas; however, ultrasonography can readily distinguish between them because each has specific characteristics.
• A fibroadenoma does not require excision unless associated with suspicious cytology, it becomes very large or the patient expressly desires the lump to be removed.
• Treatment - Enucleation through a circumareolar incision  or submammary incision is done.

• Depending on the relative preponderance of the fibrous and the glandular tissue two types of fibroadenomas are described:
• „„ Pericanalicular type (hard fibroadenoma)—the proliferation of fibrous tissue is more than the glandular element. The tumor may feel firm and is freely mobile within the breast tissue.
• „„ Intracanalicular type (soft fibroadenoma)—proliferation of glandular tissue is more preponderant than the fibrous tissue and the lump may appear soft in feel.

• Also called as cystosarcoma phylloides or serocystic disease of brodie.
• Phyllodes tumors are usually sharply demarcated from the surrounding breast tissue, which is compressed and distorted. Connective tissue composes the bulk of these tumors, which have mixed gelatinous, solid, and cystic areas. Cystic areas represent sites of infarction and necrosis. These gross alterations give the gross cut tumor surface its classical leaf-like (phyllodes) appearance.

• • They occur in premenopausal women (30-50 yrs).
• • It is usually unilateral, grows rapidly to attain a large size with bosselated surface.
• • Swelling is smooth, nontender, soft, fluctuant with necrosis of skin over the summit due to pressure.
• • Skin over the breast is stretched, red and with dilated veins over it. Tumor is warmer, not fixed to skin or deeper muscles or chest wall. Nipple retraction is absent. Lymph nodes are usually not involved.
• • Tumor grows rapidly; undergoes necrosis at various places; causes cystic areas.
• • Recurrence is common

Phylloides tumor arises from intralobular stroma

• Benign
• Boderline
• Malignant – Stromal overgrowth, cellular atypia, high number of mitosis.

• Phylloides tumor are larger in size, whorled stroma forms larger clefts lined by epithelium that resembles cluster of leaflike structures
• The stroma of a phyllodes tumor generally has greater cellular activity than that of a fibroadenoma.
• Rapid growth
• Occurs in older population compared with fibroadenoma

• Small phyllodes tumors - excised with a margin of normal-appearing breast tissue.
• Large phyllodes tumors may require mastectomy.
• Axillary dissection is not recommended because axillary lymph node metastases rarely occur.

• Complete surgical excision of the entire tumor with a margin of normal tissue is advised.
• When the tumor is large with respect to the size of the breast, total mastectomy may be required.
• If mastectomy is performed and the margins are negative, radiation therapy is not recommended. If the margins are concerning or close, if the tumor involves the fascia or chest wall, or if the tumor is very large (>5 cm), irradiation of the chest wall is considered.
• If only wide local excision is performed, adjuvant radiation therapy is recommended.
• As with other soft tissue sarcomas, regional lymph node dissection is not required for staging or locoregional control.

• Gynecomastia refers to an enlarged breast in the male.
• In the nonobese male, breast tissue measuring at least 2 cm in diameter  must be present before a diagnosis of gynecomastia may be made. 
• Mammography and ultrasonography are used to differentiate breast tissues.

Neonatal gynecomastia - caused by the action of placental estrogens on neonatal breast tissues. 

Adolescence gynecomastia - excess of estradiol relative to testosterone. (usually unilateral)

Senescence gynecomastia - circulating testosterone level falls, which results in relative hyperestrinism. (usually bilateral)

• I. Estrogen excess states - true hermaphroditism, testicular tumors, endocrine disorders (hyperthyroidism, hypothyroidism),, cirrhosis
• 2. Androgen deficiency states - Senescence, klinefelter's syndrome, Kallmann syndrome, testicular failure (trauma, orchiditis, cryptorchidism), Renal failure
• 3. Pharmacological causes -  Anabolic steroids, diazepam, Marijuana, Ketoconazole,  Digoxin, Isoniazide,  Spironolactone, Cimetidine, Oestrogen, Antineoplastic agents [@ A Dai, Marijuana Khau, DISCO Aau]

• Grade 1: mild breast enlargement without skin redundancy;
• Grade IIa: moderate breast enlargement without skin redundancy;
• Grade IIb: moderate breast enlargement with skin redundancy; and
• Grade 3: marked breast enlargement with skin redundancy and ptosis.

Symmetrical enlargement and projection of breast bud in a girl before the average age of 12 years, unaccompanied by other changes of puberty. It may be unilateral, should not be confused with neoplastic growth, does not need biopsy.

Carcinoma breast is not usually tender, is asymmetrically located, beneath or beside the areola, and may be fixed to the overlying dermis or to deep fascia

• 1. Treatment of cause
• - androgen deficiency - testosterone administration
• - Medications - discontinue medicines if possible.
• - Endocrine defects - specific therapy.

2. Surgical treatment - local excision, liposuction or subcutaneous mastectomy.

• Begin with upright sitting position
• Inspect breast for mass, asymmetry and skin changes, dimpling, edema
• Nipple inspected for retraction, inversion or excoriation
• Inspect by stretching the arms above head or tensing the pectoral muscles
• Palpation of regional LN on sitting position
• Palpation of breast in lying position with arm stretched above the head – don’t palpate the breast in sitting position- inaccurate interpretation due to breast overlapping