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Benign Breast Disease. Juhi Asad, DO Sharon Rosenbaum Smith, MD Dept. of Breast Surgery. Outline. Anatomy Benign disease Management Genetics. Anatomy. Modified sweat gland between the superficial and deep layers of the chest wall Cooper’s Ligament Fibrous band of tissue. Anatomy.

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benign breast disease

Benign Breast Disease

Juhi Asad, DO

Sharon Rosenbaum Smith, MD

Dept. of Breast Surgery

outline
Outline
  • Anatomy
  • Benign disease
  • Management
  • Genetics
anatomy
Anatomy
  • Modified sweat gland between the superficial and deep layers of the chest wall
  • Cooper’s Ligament
    • Fibrous band of tissue
anatomy4
Anatomy
  • Ducts
    • Terminal ductules
      • Milking forming glands
  • Lobule
question
Question
  • Axillary lymph nodes are classified accordingly to the relationship with the
    • Axillary vein
    • Pec.major
    • Pec.minor
    • Latissimus dorsi
    • Serratus anterior
anatomy6
Anatomy
  • Axillary lymph nodes defined by pectoralis minor muscle
    • Level 1 – lateral
    • Level 2 – posterior
    • Level 3 – medial
  • Long Thoracic Nerve
    • Serratus anterior
  • Thoracodorsal Nerve
    • Latissimus Dorsi
  • Intercostalbrachial Nerve
    • Lateral cutaneous
    • Sensory to medial arm & axilla
anatomy7
Anatomy
  • Hormonal Effects
    • Estrogen
      • Development of the breast and lactiferous ducts
    • Progesterone
      • Secretory acinar tissue – lobules
    • Prolactin
      • Synergizes the effect of estrogen and progesterone
benign breast diseases
Benign Breast Diseases
  • Glandular breast parenchyma
    • Mass
    • Asymmetric nodularity
    • Pain
  • Nipple-Areolar Complex
    • Discharge
    • Rash
    • Retraction
  • Surrounding breast skin
    • Dimpling
management
Management
  • History
  • Clinical Breast Exam
  • Breast imaging
  • Tissue sampling
  • Therapy
history
History
  • Age
    • Menarche
    • Pregnancy
      • Breast feeding
    • Menopause
  • Family History
  • Prior biopsies
  • Hormone therapy
question11
Question
  • What are the risk factors that are part of the Gail Model?
    • Race
    • Age
    • Age of 1st menses
    • Age at 1st pregnancy
    • # of 1st degree relatives
    • # of biopsies
clinical exam
Clinical Exam
  • Inspection
    • Skin
    • Symmetry
    • Masses
  • Palpable
    • Gland
    • Axilla, Supraclavicular spaces
    • Nipple-areola complex
question13
Question
  • 22 yo female presents with a new right breast mass. Complains of mild tenderness. No other complaints. On physical exam, there is a 1 cm nodule at the 2:00 position. Your diagnostic test of choice is….
    • Mammogram
    • Ultrasound
    • Excisional biopsy
    • Incisional biopsy
breast mass
Breast Mass
  • Breast Cysts
    • Fluid-filled
    • 1 out of every 14 women
      • 50% multiple and recurrent
    • Hormonally influenced
    • Needle aspirated
breast mass16
Breast Mass
  • Fibroadenoma
    • Stromal and epithelial elements
    • Most common in women <30yo
    • Firm, solitary tumors
      • Multiple
      • Increase in size
    • Management
      • Biopsy
      • Excisional biopsy
breast mass18
Breast Mass
  • Phyllodes Tumor
    • Proliferation of connective tissue with ductal elements
      • Whorled and cellular stroma
    • Firm, lobulated
    • 2 to 40 cm in size
    • 10% malignant
    • Treatment
      • Wide excision
fibrocystic disease
Fibrocystic Disease
  • Clinical, mammographic and histologic findings
  • Exaggerated response from hormones and growth factors
    • Cyclical pain
    • Nodularity – upper outer quadrants
fibrocystic disease21
Fibrocystic Disease
  • Histology
    • Adenosis
    • Apocrine metaplasia
    • Fibrosis
    • Duct ectasia
    • Mild ductal hyperplasia
fibrocystic disease22
Fibrocystic Disease
  • Risk Factors
    • Dense breast
    • Sclerosing adenosis
    • Atypical ductal, papillary, or lobular hyperplasia
question23
Question
  • 34 yo female referred to you for evaluation of breast pain. The pain is burning and sharp in nature. Always present. On physical exam, dense glandular tissue bilaterally. Your working diagnosis is….
    • Cyclical breast pain
    • Noncyclical breast pain
    • cancer
breast pain
Breast Pain
  • Cyclical pain – hormonal
    • Dull, diffuse and bilateral
    • Luteal phase
    • Treatment
      • Reassurance
      • NSAIDS
      • Evening primrose oil
  • Non-cyclical pain
    • Non-breast vs breast
    • Imaging
    • Treatment
      • Reassurance
      • NSAIDS
      • Evening primrose oil
breast infections
Breast Infections
  • Mastitis
    • Generalized cellulitis of the breast
    • Ascending infection subareolar ducts
      • commonly occurs during lactation
        • Staph. aureus
    • Erythema, pain, tenderness
mastitis
Mastitis
  • Treatment
    • Abx
    • Continue to breast feed
    • Close follow-up
breast abscess
Breast Abscess
  • Abscess
    • Breast tissue
    • Treatment
      • Abx
      • Needle aspiration
      • Incision and drainage
question28
Question
  • What is the difference between spontaneous vs non-spontaneous nipple discharge?
nipple discharge
Nipple Discharge
  • Physiologic
    • Bilateral
    • Involves multiple ducts
    • Heme (-)
    • Non-spontaneous
nipple discharge30
Nipple Discharge
  • Pathologic
    • Unilateral
    • Spontaneous
    • Heme (+)
      • Most common cause intraductal papilloma
intraductal papilloma
Intraductal Papilloma
  • Single duct
  • Benign
  • 4% of intraductal ca
imaging
Imaging
  • Mammography
  • Ultrasound
  • MRI
mammography
Mammography
  • Screening tool
    • Age of 40
  • Estimated reduction in mortality 15-25%
  • 10% false positive rate
  • Densities & calcifications
calcification
Calcification
  • Macrocalcifications
    • Large white dots
    • Almost always noncancerous and require no further follow-up.
  • Microcalcifications
    • Very fine white specks
    • Usually noncancerous but can sometimes be a sign of cancer.
    • Size, shape and pattern
ultrasound
Ultrasound
  • Not a screening tool
  • Palpable vs cystic
  • Mammographic detected lesion
ultrasound44
Benign

Pure and intensely hyperechoic

Elliptical shape (wider than tall)

Lobulated

Complete tine capsule

Malignant

Hypoechoic, spiculated

Taller than wide

Duct extension

microlobulation

Ultrasound
slide48
MRI
  • High risk patients
    • Personal history of breast ca
    • LCIS, atypia
    • 1st degree relative with breast cancer
    • Very dense breast
  • High sensitivity (95-100%)
    • 10-20% will have a biopsy
slide49
MRI

Pre Gad Post Gad Color Overlay

diagnosis
Diagnosis
  • Fine needle aspiration
    • Cytology
  • Core biopsy
    • Image guided
    • Stereotactic
  • Excisional biopsy
    • Needle localization
slide51
FNA
  • Fast, inexpensive
  • 96% accuracy
  • Institution dependent
  • Unable to differentiate b/w in situ vs CA
core needle biopsy
Core Needle Biopsy
  • 14-18 gauge spring loaded needle
  • Tissue
  • Multiple
large core biopsy
Large Core Biopsy
  • 6-14 gauge core
  • Large samples
  • Single insertion
stereotactic biopsy
Stereotactic Biopsy
  • Suspicious mammographic abnormalities
  • Patients lay prone
excisional biopsy
Excisional Biopsy
  • Atypical lesions
  • LCIS
  • Radial scar
  • Atypical papillary lesions
  • Radiologic-pathologic discordance
  • Phyllodes
  • Inadequate tissue harvesting
high risk
High-Risk
  • Prior breast cancer
  • Family history of breast cancer
    • Ovarian cancer
    • BRCA-1 or BRC-2 gene
  • Prior mantle radiation
  • Biopsy proven of atypia or LCIS
screening
Screening
  • Prior breast cancer or atypia
    • Annual mammography
    • 6 mo CBE
  • Family Hx
    • 10 yrs younger than relative’s diagnosis
    • 6 mo CBE
  • BRCA
    • 25 yo – annual mammography
    • 6 mo CBE
genetics
Genetics
  • Early age of onset
  • 2 breast primaries or breast and ovarian CA
  • Clustering of breast CA with:
    • Male breast CA,
    • Thyroid CA,
    • Sarcoma,
    • Adrenocortical CA,
    • Pancreatic CA
    • leukemia/lymphoma on same side of family
  • Family member with BRCA gene
  • Male breast CA
  • Ovarian CA
genetics66
Genetics
  • Hereditary Breast/Ovarian Syndrome
    • BRCA 1 – chromosome 17
    • BRCA 2 – chromosome 13
  • Li-Fraumeni Syndrome
    • P53 mutation – chromosome 17
  • Cowden Syndrome
    • PTEN mutation – chromosome 10
      • Autosomal dominant pattern
slide67
BRCA
  • Account to 25% of early-onset breast cancers
  • 36%-85% lifetime risk of breast CA
  • 16-60% lifetime risk of ovarian CA
slide68
BRCA
  • BRCA 1 gene
    • Ovarian CA
  • BRCA 2 gene
    • Male breast CA
    • Prostate CA
    • Pancreatic CA
slide69
BRCA
  • Management
    • Monthly BSE -- 18yo
    • 6 mo CBE & annual mammo -- 25yo
    • Discuss risk reducing options
      • Prophylactic mastectomies
      • Salpingo-oophorectomy – upon completion of child bearing
    • 6 mo transvaginal US & CA125 – 35 yo
li fraumeni syndrome
Li-Fraumeni Syndrome
  • Mutation of p53 gene
    • Tumor suppressor
  • Premenopausal breast CA
    • Childhood sarcoma
    • Brain tumors
    • Leukemia
    • Adrenocortical CA
  • Accounts for 1% of breast CA
cowden syndrome
Cowden Syndrome
  • Major criteria
    • Thyroid CA (follicular)
    • Marcocephaly
    • Cerebellar tumors
    • Endometrial CA
    • Breast CA – 25%-50% risk
    • Skin and mucosal lesions
  • Minor criteria
    • Thyroid lesions
    • GU tumors
    • GI hamartomas
    • Fibrocystic breast
    • Mental retardation