Breast Disease Overview

• In the USA, most breast disorders are non-malignant with about 80-90% of clinical presentations related to the breast being benign.
• One in two women will consult a physician about a breast disorder at some point.

Presenting Symptoms of Breast Disease:

• Palpable breast mass is the second most common presentation.
• Nipple discharge can be a symptom.
• Mastalgia is the most common presenting symptom.
• Vague thickening or nodularity may be present.
• Breast infection or inflammation may occur.
• A normal physical examination can occur with an abnormal mammogram.

Investigations for Breast Diseases:

• History, examination, and other investigations are performed.
• Ultrasound, mammogram, and biopsy can be used.

Mammography

• Radiation dose is 0.1cGy per study
• Screening starts at age 40, every 1-2 years until 50, then annually.
• Breast density decreases with age due to glandular involution, making mammography beneficial for women >35.
• Mammography is used to guide interventional procedures like needle biopsy.

Mammographic Findings Suggestive of Malignancy:

• Solid mass with or without stellate features.
• Asymmetric thickening of breast tissue.
• Microcalcifications in a linear clustering pattern.

Ultrasound

• It's radiation-free.
• Allows differentiation between solid and cystic lesions.
• Good for women with dense breasts (<35 years).
• It is operator-dependent.
• It can't detect lesions smaller than 1cm.
• Guides interventional procedures.

MRI

• It's radiation-free and costly.
• Used to screen high-risk women and distinguish cancer recurrence from operative scar after 9 months post-surgery.
• Used to evaluate breast implants.

Ductography

• Primarily used for women with nipple discharge, especially if bloody.
• Determines if intraductal papilloma is present as a small smooth filling defect.

Ductoscopy

• It uses a microendoscope for direct visualization of the ductal system.
• Used for aspiration of lavage fluid for cytological analysis.
• Allows a targeted approach to the diagnosis of intraductal breast disease.

Needle Cytology and Biopsy

• FNAC (Fine Needle Aspiration Cytology) is the least invasive method to obtain cells.
• It has a low false negative rate if the operator/pathologist are experts.
• FNAC cannot differentiate between invasive and non-invasive cancer; core biopsy is needed instead.

ANDI

• ANDI stands for Aberration of Normal Development and Involution.
• It describes benign breast disorders/diseases.
• Pathogenesis involves disturbances in breast physiology.

Fibrocystic Disorder (Fibroadenosis):

• Refers to a spectrum of histopathologic changes.
• Can present with altered nipple discharge, lumpiness, mastalgia, and lumps.

Pathology of Fibrocystic Disorder:

• Cysts are inevitable in the course of the disorder.
• Fibrosis: fat and elastic tissue are replaced with fibrous trabeculae, with infiltration by chronic inflammatory cells.
• Hyperplasia: of the ductal and acinar epithelial lining, with or without atypia and is associated with an increased risk of cancer.
• Papillomatosis: extensive hyperplasia may result in intra-ductal papillimatous growths.

Mastalgia

• It is the most common complaint among patients attending breast clinics, and reflects a benign condition (5% of cancers are painful).
• Classified as cyclical or non-cyclical.
• Cyclic mastalgia is most severe shortly before menses and relieved by its onset.
• Non-cyclic mastalgia has no related to menstrual cycle, may be associated with extra-mammary causes and is rarely associated with cancer.

Treatment of Mastalgia:

• Cyclical mastalgia is treated with reassurance, breast support, reducing methylxanthine intake and drugs.
• Evening primrose oil, NSAIDs, prolactin inhibitors, danazole, and tamoxifen are drug treatment options
• Non-cyclic mastalgia treatment includes examination to identify extra-mammary sources of pain, reassurance, and NSAIDs.

Nipple Discharge

• Third most common presenting breast complaint.
• Classified as physiological, pathological, or galactorrhea.
• Physiological discharge occurs during lactation and is typically milky, persisting up to one year after breastfeeding.
• Pathologic discharge is spontaneous from a single duct and non-lactational.
• It may be bloody, brownish, serous, or greenish.
• Causes include intra-ductal papilloma, duct ectasia, fibrocystic disease, and cancer.
• The likelihood of cancer is increased if the discharge developed in postmenopausal women or if there is an underlying mass.

Work Up and Treatment of Nipple Discharge:

• If a mass is present, investigate that first.
• Cytological and microbiological examination of the discharge can be done.
• Ductography and ductoscopy can be done
• For benign causes where the discharge is localized to a single duct, excise the diseased duct (microdochectomy).

Galactorrhea

• Bilateral and multi-ductal, and usually spontaneous.
• May be evoked by sexual stimulation, chest wall trauma, drugs, or pituitary tumor or hypothyroidism
• Diagnose it via serum prolactin, thyroid function test, kidney function test, and head MRI.

Breast Mass

• Second most common breast complaint.
• Causes can be benign or malignant.

Benign Causes:

• Cysts
• Breast abscess
• Fat necrosis
• Fibroadenoma
• Phylloides tumor
• Galactocele
• Duct ectasia

Malignant Causes:

• Carcinoma (commonest)
• Sarcoma
• Lymphoma

Work Up for Breast Mass:

• Triple Assessment

Triple Assessment:

• Combines clinical history and examination, imaging, and pathology.
• Imaging includes ultrasound and mammography.
• Pathology involves core cut biopsy and/or FNAC.

Bacterial Mastitis/Breast Abscess:

• Bacterial breast infections are rare except during lactation.
• Caused by staphylococci and less commonly by streptococci.

Pathogenesis:

• Ascending bacterial infections from the cracked nipple.
• Mammary duct blockage by debris with secondary bacterial infection.
• Blood-borne infection (rare).

Clinical Features:

• Pain, tenderness, erythema, and swelling develop over a breast sector with fever and rigor.
• If not treated, purulence develops and collection inside the breast occurs.
• If antibiotics are given in the presence of pus, an indurated mass, an "antibioma" may develop, taking longer to resolve.

Diagnosis:

• Usually evident clinically; U/S aids in diagnosis.
• At the early cellulitic stage: intravenous antibiotics (usually penicillin or cephalosporin), breast support, rest, emptying.
• If abscess develops: it should be drained either by frequent aspiration.
• A portion can be sent for histopathology.

Duct Ectasia (Periductal Mastitis)

• Dilation of mammary ducts with periductal inflammation.
• Dilation of one or more lactiferous ducts which become filled with stagnant secretion, causing inflammatory reactions.
• Periductal inflammation is the primary insult.
• Association is present with smoking and diabetes due to vasculopathy or an increase in bacterial virulence

Clinical Features:

• Nipple discharge (greenish or brown), painful retro-areolar mass, abscess, fistula, and nipple retraction (frequently slit-like).

####Treatment:

• Quit smoking and get diabetes under good control
• Antibiotics should cover both aerobes and anaerobes.
• Surgery in the form of major duct excision (Hadfield operation) may be needed.

Mondor's Disease:

• Thrombophlebitis involving one of the superficial veins of the breast and anterior chest wall.
• Etiology: obscure, but some cases have been associated with trauma to the breast or anterior chest wall.
• A tender cord is felt along the line of one of the major veins when the woman is asked to raise her arm, a groove appears alongside the tender cord.
• Involves superior epigastric, thoracoepigastric, and/or lateral thoracic veins.
• Differentiate from permeation of cutaneous lymphatics by an underlying carcinoma.
• It is benign and self-limiting, resolving in 4-6 weeks

Treatment:

• Restriction of vigorous arm activity, breast support, and NSAIDs are satisfactory. The involved venous segment may be excised in refractory cases.

Galactocele:

• A milk-filled, well-circumscribed cystic swelling that is easily movable within the breast.
• It usually occurs after cessation of lactation or when the feeding frequency has decreased significantly.
• It's thought that inspissated milk within the lactiferous ducts are responsible.
• May get infected.

Treatment:

• Needle aspiration of the mass produces thick, creamy material and can be both diagnostic and therapeutic.
• Surgery is reserved for those cysts that can't be aspirated or those that became infected.

Fat Necrosis

• A hard mass develops in the breast following trauma.
• It may mimic cancer clinically, especially if the history of trauma is lacking.
• On mammogram, it appears as an abnormal density with microcalcifications.
• Histologically, the lesion is composed of lipid-laden macrophages, fibrosis, and chronic inflammatory cells.
• The lesion has no malignant potential but may need to excised or biopsied if cancer can't be excluded.

Fibroadenoma

• A benign solid tumor composed of stromal and epithelial elements.
• Arises from hyperplasia of single breast lobule.
• It has no malignant potential.
• Appears in teenage girls and women during their early reproductive lives
• Rarely seen as new masses after age 40-45
• Clinically, it is firm and freely mobile with a lobulated surface.
• Large growths are called giant fibroadenomas.
• Ultrasound scan can differentiate fibroadenoma from cyst and allow needle biopsy if needed.
• Mammography shows a radio-opaque well-defined lobulated lesion.

Treatment:

• Excision is required if larger than 3cm, associated with suspicious findings on history, a patient requests it, and for women >35 years old.
• The mass is encapsulated and can be easily enucleated.
• Cryoablation can be done using a small incision.
• Cryoablation and observation may be used for small lesions.
• Significant percentage of fibroadenomas will decrease in size and will no longer be palpable.
• However, many will remain palpable, especially if >2 cm.

Breast Cysts

• Fluid-filled, epithelium-lined cavity with variable sizes and numbers.
• Develops commonly in women older than 35 years.
• The incidence rises sharply until reaching menopause, when it declines.
• Cysts in postmenopausal women are mostly related to exogenous hormone administration.
• Pathogenesis is not well-understood.
• Related to non-integrated involution of stroma and epithelium.
• Breast cysts are under the influence of ovarian hormones; explains their variation and fluctuate with the menstrual cycle.

Treatment:

• Aspiration (may be under ultrasound guidance) is performed and if fluid is Not blood-stained, No residual mass is palpated and the cyst is Not complex, the fluid is discarded
• Surgical excision is done when Aspiration fails and if cyst recur twice after aspiration or if the cytology is suspicious.

Gynecomastia (G)

• An enlarged breast in the male.
• Ductal structures of the male breast enlarge, elongate, and branch with a concomitant increase in epithelium.
• In the non-obese male, breast tissue measuring at least 2 cm in diameter must be present for diagnosis.
• Dominant masses or areas of firmness, irregularity, and asymmetry suggest breast cancer.
• Mammography and ultrasonography are used to differentiate breast tissues.

Physiologic G.

• It occurs during three phases of life: the neonatal period, adolescence, and senescence.
• Common to these phases is an excess of circulating estrogens in relation to circulating testosterone.
• Neonatal G. caused by the action of placental estrogens on neonatal breast tissues.
• In adolescence, there is an excess of estradiol relative to testosterone.
• Senescence: The circulating testosterone level falls, resulting in relative hyperestrinism.

Common Medications Causing Gynecomastia

• Antiandrogens: Example spironolactone.
• Antibiotics: Examples include isoniazide, ketoconazole, and metronidazol.
• Antihypertensives
• Diuretics: Example spironolactone
• Hormones: Androgens, anabolic steroids, estrogens, growth hormone

Treatment:

• In neonates and adolescents it usually resolves spontaneously.
• Withdrawal of the causative drug may revert it.
• Treatment of an underlying disorder .
• In hypoandrogenic states, G. may regress with testosterone administration.
• Danazole is very effective.
• Surgery: Is done in the form of subcutaneous mastectomy, nipple and areola preservation.
• Liposuction may be useful for early stages.