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BENIGN BREAST DISEASES

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Myoepithelial Cells.
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Montgomery
Glands.

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Modified Radical
Mastectomy.

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Lumpectomy.

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Intraductal
Papilloma.

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COMPREHENSIVE GYNECOLOGY

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Virginal
Hypertrophy of the
Breasts.

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Thermography.

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Simple
Mastectomy.

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Polythelia.

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Polymastia.

Radical
Mastectomy.

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Paget's Disease.

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large, modified sebaceous glands contained within the superficial fascia of

the anterior chest wall.
is a lateral projection of glandular tissue extends from
the upper, outer portion of the breast toward the axilla
average weight of the adult breast is 200 to 300 g during the menstruating
years
mature breast consists of approximately 20% glandular tissue and 80% fat
and connective tissue
mature breast consists of approximately 20% glandular tissue and 80% fat
and connective tissue
periphery of breast tissue is predominantly fat, and the central area contains
more glandular tissue
composed of 12 to 20 lobes arranged in radial fashion from the nipple
Each lobe is triangular and has one central excretory duct that opens to the
exterior at the nipple
Milk originates in the secretory cells of the alveoli. It is subsequently
transported by the branching collecting ducts of the lobules into the
lactiferous sinuses and terminally into the excretory ducts of each respective
lobe of the breast
number of lobules, between 10 and 100, in each lobe of the breast
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KEY TERMS AND DEFINITIONS

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Fibroadenomas.

Cystosarcoma
Phyllodes.

Fibrocystic
Changes.

Digital
Radiography.

Cooper's Ligaments.

Cluster.

Axillary Tail of
Spence.

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Benign Breast Diseases

Breast Anatomy

Page 1

st

are acces-sory glands located around the periphery of

the areola. Because they are structurally intermediate between true
mammary and sebaceous glands, they can secrete milk. Fibrous septa
extend from the skin to the underlying pectoralis fascia.
They are believed to offer support to the breast. Invasion of these ligaments
by malignant cells produces skin retraction, which is a sign of advanced
breast carcinoma.
Approximately 75% of the lymphatic drainage goes to regional nodes in the
axilla. The axilla contains a varying number of nodes, usually between 30 and
60
Other metastatic routes include lymphatics adjacent to the internal
mammary vessels. After direct spread into the mediastinum, lymphatic
drainage may go to the intercostal glands, which are located posteriorly
along the vertebral column, and to subpectoral and subdiaphragmatic areas.
Lymph drainage usually flows toward the most adjacent group of nodes. This
concept represents the basis for sentinel node mapping in breast cancer
average increase in volume of the premenstrual breasts is 25 to 30 mL
C

Breast Changes During Mesnstrual Cycle:

Breast tissue is sensitive to the cyclic changes in hormonal levels.
*Luteal Phase: tenderness and fullness; ductal parenchymal dilation and alveolar cell
differentiate into secretory cells
*Premenstrually: increase breast volume due to increase blood flow, vascular
engorgement, water retention
*Follicular Phase: ductal parenchymal proliferation
*Menstruation: cellular activity in the alveoli regresses, ducts decrease in size, fibrous
tissue surrounding the lobules increase
*Postmenopause: atrophy of breast and replased by variable amount of fat.
Common Anomalies
1. accessory breast or nipples
2. supernumerary nipples (polythelia) or breast (polymastia)
3. underdevelopment of one breast
4. virginal hypertrophy
Fibrocystic Change

Most common of all benign breast conditions.

An exaggeration of the normal physiologic response of breast tissue to the
cyclic levels of ovarian hormones

BENIGN BREAST DISEASES

Condition is most common in women between the ages of 20 and 50 and

unusual after menopause unless associated with exogenous hormone use
Clinical Manifestations of Fibrocystic Change
Cyclic bilateral breast pain
Increased engorgement and density
Excessive nodularity
Rapid change
Fluctuation in the size of cystic areas
Increased tenderness
Nipple discharge (non milky)
Pain more common in the upper outer quadrants and can radiate to the
shoulder and upper arms
Pathophysiology: cyst formation, epithelial and fibrous proliferation and fluid
retention
Differential Condition: dorsal radiculitis or chostochondritis but pain is not
cyclic (Tietze's syndrome)
Physical Examination Findings of Fibrocystic Change
Paleful peas excessive nodularity on palpation
Palpable lumpiness ill defined thickness or multiple solid areas which are
rubbery and more of two rather than three dimensional masses in
carcinoma.
Water filled balloon consistency that characterizes large cyst
Stages of Fibrocystic Change:
Stage 1: Mastoplasia
Occurs in the 20s
Breast pain is in the upper outer quadrants
Most tender area is the indurated axillary tail of Spence
Intense stromal proliferation
Stage 2: Adenosis
Occurs in the 30s
Premenstrual breast pain and tenderness
Less severe
Multiple breast nodules of varying sizes from 2-10mm
Marked proliferation and hyperplasia of the ducts, ductules and alveolar cells
Stage 3: Cystic Phase
Occurs in the 40s and there is usually no breast pain unless a cyst rapidly
expands
There is severe localized pain and point tenderness and a lump is often
palpated
Cyst are tender and can be microscopic or attain up to 5 cm diameter

COMPREHENSIVE GYNECOLOGY

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Histopathology of Fibrocystic Change

Cysts
Adenosis
Fibroplasias
Duct ectasia
Apocrine metaplasia
Ductal epithelial hyperplasia
Papillomatosis
*ductal epithelial hyperplasia and atypia and apocrine metaplasia are the histologic
findings directly associated with development of breast carcinoma (5x risk)
Diagnostic Procedures
Imaging techniques
Fine needle aspiration cytology
Histopathologic evaluation
Core needle biopsy
Excision biopsy
Treatment of Fibrocystic Change
Support bra
Diuretics premenstrual intake to relief pain
Reduction of methylxanthine (caffeine, colas, chocolate)
Oral contraceptive of progestines
Danazol for severe symptoms, given for mastalgia
- S/E: hypoestrogenic and androgenic effects
- Not continued beyond 6 mos

Bromocriptine or Tamoxifen used if danazol is ineffective

- Bromocriptine inhibits prolactin
- Tamoxifen synthetic antiestrogen used mainly for breast
carcinoma, competes with estradiol for estradiol receptors in breasr
tissue
Linoleicacid with evening primerose oil diet
GnRH agonist or total mastectomy for severe cases of fibrocystic change
Fibroadenoma
Benign breast mass which are firm, rubbery, mobile, solid and often solitary
Comprise the second most common benign breast disease
Adolescents and women in their 20s are more commonly affected
Considered as an abnormality of development rather than as true neoplasia
Clinical Manifestations of Fibroadenoma
Are accidental discoveries during bathing
BENIGN BREAST DISEASES

Painless masses
Size does not fluctuate with menstrual cycle
30% will disappear
10-12% will shrink with time
Average diameter is 2.5cm
15-20% of cases are multiple
Diagnostics for Fibroadenoma
Breast sonography
Mammography not ofeten done in women younger than 35 who are more
commonly affected by fibroadenoma
Fine needle aspiration is done to ascertain the cause of the mass
If fine aspiration fails, surgical excision is mandated
*solid masses in women older than 35, rapidly growing and/or solid breast masses
should always be removed
Treatment of Fibroadenoma
Surgical excision under local anesthesia can be carried out because these
rubbery masses are well-circumscribed and can be well delineated from
surrounding tissues
Small fibroadenomas can be managed non operatively in those younger than
35 provided three clinical parameters support the diagnosis:
- clinical examination
- imaging (ultrasound or mammography)
- FNAC
Cytology is the only means to differentiate these masses from malignant
ones
Prognosis for Recurrence and/or Malignancy of Fibroadenomas
Annual mammography screening starting age 40
Cystosarcoma Phyllodes

Relatively uncommon fibroepithelial breast tumors but have the distinction

of connective tissue hypercellularity
Represent 2.5% of fibroepithelial tumors
1% of breast malignancies
Most frequent breast sarcoma

Clinical Features of Cystosarcoma Phyllodes

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Affected women are those in their 5 decade
Masses grow fast and often have a diameter of 5cm at the time of diagnosis
COMPREHENSIVE GYNECOLOGY

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Diagnostics for Cystosarcoma Phyllodes

Strict histologic criteria appear to have poor correlation in terms of
differentiating benign from malignant types
Flow cytometry improved the predictive value in differentiating the biologic
nature
Treatment for Cystosarcoma Phyllodes
Wide excision
Intraductal Papilloma
Benign microscopic but may reach 2 to 3 mm extending radially from the
alveolar margin
Most affected patients are in the perimenopause
Classic symptom is spontaneous and intermittent bloody nipple discharge
Watery, serous or serosanguineous
Amount is variable
Most common location is beneath the areola
These are difficult to palpate as they are small and soft
Diagnosis of Intraductal Papilloma
Circumferential radial pressure is applied on different areas of the areola
To determine whether the discharge comes from a single or multiple lobes
If it comes from a sigle lobe the condition may be intraductal papilloma or
carcinoma
If the source is from multiple lobes the condition is more likely malignant
Galactography is a radiologic imaging echnique in which the involved duct
may be identified by injecting contrast media into the dust via small catheter
Treatment of Intraductal Papilloma
Excisional biopsy of the duct and a small amount of surrounding tissue
Prognosis for malignancy or Recurrence of Intraductal Papilloma
Should be excised despite their tendency to regress in the postmanopause
Decrease in size in the premenopause because of a twofold risk for
carcinoma
Fat Necrosis

Rare but important lesion

Can be mistaken for breast carcinoma
Usual cause is trauma
Clinical features of Fat Necrosis
Firm, tender, indurated and ill-defined
BENIGN BREAST DISEASES

Surrounding area maybe ecchymotic

There is liquefaction and the lesion becomes cystic
Skin retraction may also be present

Diagnostic Aids for Fat Necrosis

Mammography demonstrate fine, stippled, calcification and stellate
contractions
Treatment of Fat Necrosis
Excision biopsy
Prognosis for Malignancy or Recurrence of Fat Necrosis
Does not lead to subsequent breast carcinoma
Nipple Discharge: Significant
A feature of both malignant and benign breast conditions
Present in10-15% of cases of benign diseases
Present in less than 3% of cases of carcinoma
Chances of benignity are increased if the discharge emanates only from one
duct
Medically significant discharge: spontaneous and persistent in a non lactating
woman
2 common cause of spontaneous non milky discharge:
- intraductal papilloma
- fibrocystic change
Color of discharge does not differentiate whether the cause is malignant or
benign
Clear, serous, serosanguineous or bloody discharges have been associated
with malignant lesions
Gross or microscopic blood in the nipple discharge should be considered
potentially as malignant until ruled out
Mammography is done prior to excisional biopsy in a woman with any type
of persistent nipple discharge.
KEY POINTS

One out of eight women (12.5% of American females) develops carcinoma

of the breast if she lives beyond age 90.

The breast consists of approximately 20% glandular tissue and 80% fat and
connective tissue.

Lymph drainage of the breast usually flows toward the most adjacent
group of nodes. This concept represents the basis for sentinel node
mapping in breast cancer. In most instances, breast cancer spreads in an
COMPREHENSIVE GYNECOLOGY

Page 4

Mutations in
family of genes have been identified that confer a
lifetime risk of breast cancer that approaches 85%.
and
genes are involved in the majority of inheritable cases of breast cancer.
These genes function as tumor suppressor genes, and several mutations
have been described on each of these genes.

The frequency of breast carcinoma increases directly with the patient's

age; 85% occur after 40 years of age.

The classic symptom of fibrocystic changes is cyclic bilateral breast pain.

The signs of fibrocystic changes include increased engorgement and
density of the breasts, excessive nodularity, rapid change and fluctuation in
the size of cystic areas, increased tenderness, and occasionally
spontaneous nipple discharge.

Approximately 5% to 10% of breast cancers have a familial or genetic link.

Genetic predisposition to develop breast carcinoma has been recognized in
some families. In these families breast cancer tends to occur at a younger
age and there is a higher prevalence of bilateral disease.
B

Clinical evidence of fibrocystic changes is discovered in breast examination

of approximately one in two premenopausal women.

Risk factors identify only 25% of women who will eventually develop breast
carcinoma.

Numerous epidemiologic studies have found an increased risk of

developing breast carcinoma in women with benign breast disease only if
there is associated atypical epithelial hyperplasia. This risk varies from
twofold to fivefold, depending on the degree of epithelial hyperplasia.

calcifications.

orderly fashion within the axillary lymph node basin based on the anatomic
relationship between the primary tumor and its associated regional
(sentinel) nodes.

Fibroadenomas are most frequently present in adolescents and women in

their 20s.

Once a woman has developed carcinoma of one breast, her risk is

approximately 1% per year of developing cancer in the other breast.

Approximately 30% of fibroadenomas will disappear, and 10% to 12%

become smaller after many years.

Approximately 75% of intraductal papillomas are located beneath the

areola. Often these tumors are difficult to palpate because they are small
and soft.

Women with a high risk of breast cancer have proven options that can
decrease their risk of breast cancer. Both tamoxifen and raloxifene
significantly decrease the relative risk of developing breast carcinoma.

Present methods of screening for breast carcinoma are not ideal.

Nevertheless, screening tests result in a reduction of mortality from breast
cancer of approximately 25% to 30%.

Physical examination is excellent as a screening procedure but extremely

poor in predicting the histopathology of the lesion. Studies have
demonstrated 30% to 40% of breast masses suspected by palpation to be
malignant were found after biopsy to be benign. Conversely, 15% to 20%
of benign-appearing masses during a physical examination subsequently
are discovered to be carcinoma by histopathology.

The 5-year survival rate of a woman whose breast carcinoma is believed to

be localized to the breast with negative axillary nodes is 85%. In contrast,
the 5-year survival rate is only 53% when axillary nodes are positive.

The number of women receiving screening mammography has increased

dramatically over the past 10 years. Mammography is not as precise in
younger women or in women with dense breasts secondary to
fibroglandular tissue. Mammography is most sensitive in older women in

Nipple discharge is a complaint of 10% to 15% of women with benign

breast disease. However, nipple discharge is present in less than 3% of
women with breast carcinoma.

at

Bloody discharge from the nipple, gross or microscopic, should be

considered to be related to carcinoma until this diagnosis has been ruled
out.

The importance of determining the cause of

discharge from
the nipple is to rule out carcinoma. The color of the nonmilky discharge
does not differentiate a benign from a malignant process.
p

Intraductal papilloma and fibrocystic changes are the two most common
causes of spontaneous nonmilky nipple discharge.
Fat necrosis caused by trauma may present as a firm, indurated, poorly
defined mass that has a mammographic appearance of stippled

BENIGN BREAST DISEASES

COMPREHENSIVE GYNECOLOGY

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which the majority of the breast is composed of fatty tissue.

Present studies demonstrate that screening mammography reduces breast

cancer mortality by approximately 33% in women 50 to 70 years of age.

For screening mammography, two views of each breast are performed: the
mediolateral oblique (MLO) and the craniocaudal (CC). The MLO is the
most effective single view because it includes the greatest amount of
breast tissue and is the only view that includes all of the upper outer
quadrant and axillary tail.

Mammographic signs of carcinoma include isolated clusters of fine,

irregular calcifications or poorly defined masses with irregular contours.

Double-reading of a mammographic study by two independent observers

improves the breast cancer detection rate by approximately 10%.
Obviously, it also increased the cost of screening. Computer-aided
diagnosis shows promise of potentially detecting lesions that would not be
identified by double-reading.

The radiation dose to the breast by state-of-the-art mammography

equipment is 0.1 rad (0.001 Gy) for a two-view examination.

The most important use of ultrasound is to differentiate a cystic breast

mass from a solid mass.

Ultrasound should not be used as a sole imaging technique for breast

disease. Because of its lack of sensitivity and specificity for early breast
carcinoma, it should not be used in an attempt to detect subclinical
disease.

Digital technology has multiple advantages compared with conventional

mammography. Image acquisition, display, and storage are much faster,
and image manipulation through adjustments in contrast, brightness, and
electronic magnification of selected regions enables radiologists to obtain
superior views.

Digital technology makes it possible to subtract various layers of

computerized imagery in order to examine suspicious areas and improve
the ability to detect and diagnose breast carcinoma. Digital mammography
is particularly helpful in screening women with very dense breasts and
breast implants. With the ability to manipulate the images, digital
mammography will reduce the number of women recalled for more
images.

BENIGN BREAST DISEASES

The ability of MRI to differentiate benign from malignant tissue may help
to reduce the frequency of breast biopsy, especially in women with dense,
fibroglandular breasts. MRI has been proven effective in detecting new
tumors in women with previous lumpectomy because it can accurately
distinguish between scar tissue and cancerous lesions.

If the aspirated fluid from a breast cyst is clear and no residual mass is
palpated immediately after the procedure and again 1 month later, no
further workup is necessary.

Palpable lesions can be evaluated by several techniques. The type of

technique used depends on many factors, including the location and size of
the lesion as well as the patient's and physician's preference. Options
include incisional or excisional biopsy, as well as core-needle biopsy.

The incidence of carcinoma in biopsies corresponds directly with the

patient's age. Approximately 20% of breast biopsies in women age 50 are
positive, and this figure increases to 33% in women age 70 or older.

Breast cancer is usually asymptomatic before the development of

advanced disease. Breast pain is experienced by only 10% of women with
early breast carcinoma.

The classic sign of a breast carcinoma is a solitary, solid, three-dimensional,

dominant breast mass. The borders of the mass are usually indistinct.

Bilateral breast carcinoma occurs in approximately 1% of all newly

diagnosed cases. The prevalence of bilateral breast cancer is twofold
greater in lobular neoplasia.

Infiltrating ductal carcinoma is the most common breast malignancy.

Microscopic metastatic disease occurs early via both hematogenous and

lymphatic routes. For example, 30% to 40% of women without gross
adenopathy in the axilla will have positive nodes discovered during
histologic examination. With the additional assessment tools of
immunohistochemical staining for the presence of cytokeratin and serial
sectioning of axillary nodes, 10% to 30% of patients considered to have
negative nodes by standard histologic analysis are found to be node
positive.

Approximately two thirds of all women with breast carcinoma eventually

develop distant metastatic disease regardless of the type of initial therapy.

Three major objectives of treating breast carcinoma are control of local

COMPREHENSIVE GYNECOLOGY

Page 6

disease, treatment of distant metastasis, and improved quality of life for

women treated for the disease.

Breast conservation is a frequent choice for the control of local disease.

Sentinel node resection is becoming standard practice in the treatment of
early stage breast cancer. Chemotherapy is used not only for patients with
proved metastatic disease, but also for women at high risk for the
development of primary or recurrent disease.

Recent emphasis on conservative surgery plus radiation therapy to control

multifocal cancer in the same breast and on reconstructive surgery after
mastectomy has improved the quality of life of women with breast
carcinoma.

The initial size of the breast carcinoma is the single best predictor of the
likelihood of positive axillary nodes. The presence and number of axillary
node metastasis is the single best predictor of survival.

The primary therapy for the vast majority of women with stages I and II
breast cancer is conservative surgery, which preserves the breast, followed
by radiation therapy.

Another conservative approach to the treatment of breast cancer involves

the use of sentinel lymph node mapping as an alternative to axillary
dissection.

Adjuvant systemic chemotherapy decreases the odds of dying from breast

cancer during the first 10 years following diagnosis by approximately 25%.

When estrogen receptors are positive, approximately 60% of breast

cancers will respond to hormonal therapy. If estrogen receptors are
negative, less than 10% of tumors respond to a hormonal manipulation.

Adjuvant chemotherapy has been shown to improve disease-free and

overall survival in all patients with operable breast cancer with the
exception of select node-negative patients with small (less than 1 cm)
tumors that have no high-risk features.

Approximately 10% to 20% of women treated with combination

chemotherapy experience a complete remission for about 18 months.

The major effect of multiagent systemic therapy has been on the diseasefree interval rather than the effect on overall survival. In general, multipleagent chemotherapy has greater effect than single-agent chemotherapy,
especially in the premenopausal woman. Tamoxifen has the greatest effect
BENIGN BREAST DISEASES

in postmenopausal women.
*Go has a purpose for your life and it involves far more
than earning a living*
mitsiko 05.20.10

COMPREHENSIVE GYNECOLOGY

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