Benign breast disordersBenign breast disordersBenign breast disordersBenign breast disorders

EMIR T PASARIBUEMIR T PASARIBU

DIVISI ONCOLOGYDIVISI ONCOLOGYDIVISI ONCOLOGY DIVISI ONCOLOGY SURGYCAL DEPARTEMENTSURGYCAL DEPARTEMENTMEDICAL FACULTYMEDICAL FACULTYMEDICAL FACULTYMEDICAL FACULTY

Th B tTh B tThe BreastThe Breast

SURGICALLY RELEVANT ANATOMYSURGICALLY RELEVANT ANATOMY

B i St tB i St tBasic StructureBasic Structure

■■ Composed of glandular, fibrous, and adipose tissueComposed of glandular, fibrous, and adipose tissue■■ Lies within layers of superficial pectoral fasciaLies within layers of superficial pectoral fasciay p py p p■■ Each mammary gland consistsof approximately 15 to 20 lobules, each ofEach mammary gland consistsof approximately 15 to 20 lobules, each of

which has a lactiferousduct that opens on the areolawhich has a lactiferousduct that opens on the areola■■ Has ligaments that extend from the deep pectoral fascia to the superficialHas ligaments that extend from the deep pectoral fascia to the superficial

dermal fascia that provide structural support referred to as dermal fascia that provide structural support referred to as Cooper’ ligamentsCooper’ ligamentsp ppp pp p gp g■■ Frequently extends into axilla as the Frequently extends into axilla as the axillary tail of Spenceaxillary tail of Spence■■ Is partitioned into 4 quadrants by vertical and horizontal lines across the nipple Is partitioned into 4 quadrants by vertical and horizontal lines across the nipple

: Upper inner quadrant (UIQ), lower inner quadrant (LIQ), upper outer quadrant: Upper inner quadrant (UIQ), lower inner quadrant (LIQ), upper outer quadrant(UOQ), and lower outer quadrant (LOQ)(UOQ), and lower outer quadrant (LOQ)

INITIAL EVALUATION OF PATIENTS WITH POSSIBLE INITIAL EVALUATION OF PATIENTS WITH POSSIBLE BREAST DISEASEBREAST DISEASE

■■ Complete medical history, including risk factors Complete medical history, including risk factors for breast cancer . Be sure to inquire about any for breast cancer . Be sure to inquire about any

l l q yq y

history of nipple discharge or any changes in the history of nipple discharge or any changes in the size, shape, symmetry, orcountour of thebreasts.size, shape, symmetry, orcountour of thebreasts.

Physical examination :Physical examination :■■ Inspection : Note color, symmetry, size, shape, Inspection : Note color, symmetry, size, shape,

andcountour, and check for dimpling, erythema, andcountour, and check for dimpling, erythema, , p g, y ,, p g, y ,edema,or thickening of skin with a porous edema,or thickening of skin with a porous appearance appearance (pead’orange).(pead’orange).

■■ Palpation : Palpate all four quadrants, the Palpation : Palpate all four quadrants, the ll l h d d h lll l h d d h lp p qp p q

axillary lymph nodes, and the nippleaxillary lymph nodes, and the nipple--areolarcomplex for anydischarge.areolarcomplex for anydischarge.

EVALUATION OF A PALPABLE BREAST MASSEVALUATION OF A PALPABLE BREAST MASS

ApproachApproach■■If age < 30, serial physical examination with observation for 2 to 4 weeks or until next If age < 30, serial physical examination with observation for 2 to 4 weeks or until next menstrual period is an optionmenstrual period is an optionmenstrual period is an optionmenstrual period is an option

Age > 30

Ultrasound or

Aspirate non-bloody andThe mass resolves

No fluid aspirated or massPersists after aspiration

needle aspiration

The mass resolvesPersists after aspiration

Get mammogram and obtain tissue forPathologic diagnosis via FNA, needle biopsy, etc

(other options as previously discussed)

Serial physical examinations and screeningMammograms according to previously estabilished

recommendations

NondiagnosticDiagnosis obtained

Definitive treatment Definitive treatmentTailored to specific

Diagnosis withAppropriate follow-up

Definitive treatment

Obtain more tissueFor diagnosis byExcisional biopsy

Definitive treatmentTailored to specific

Diagnosis withAppropriate follow-up

Penyebab benjolan di payudaraPenyebab benjolan di payudaraPenyebab benjolan di payudaraPenyebab benjolan di payudara

Type Cause Frequency Type Cause Frequency

Normal nodularity CommonNormal nodularity CommonProminent fat lobule Less CommonProminent fat lobule Less Common

Normal Prominent rib Less CommonNormal Prominent rib Less CommonStruktur Intra mammary Lymph node RareStruktur Intra mammary Lymph node Rare

Edge of Biopsy wound Less CommonEdge of Biopsy wound Less Commong p yg p yAssessory breast RareAssessory breast Rare

Penyebab benjolan di payudaraPenyebab benjolan di payudaraPenyebab benjolan di payudaraPenyebab benjolan di payudara

Type Cause FrequencyType Cause Frequency

Fibroadenoma CommonFibroadenoma CommonCyclical nodularity CommonCyclical nodularity Common

ANDI Cyst CommonANDI Cyst CommonANDI Cyst CommonANDI Cyst CommonGalactocele RareGalactocele RareSclerosing adenosis Less CommonSclerosing adenosis Less CommonStromal fibrosis RareStromal fibrosis RareStromal fibrosis RareStromal fibrosis Rare

Penyebab benjolan di payudaraPenyebab benjolan di payudaraPenyebab benjolan di payudaraPenyebab benjolan di payudara

Chronic infective abscess RareChronic infective abscess RareFat necrosis RareFat necrosis Rare

Inflamatory Foreign body granuloma RareInflamatory Foreign body granuloma RareInflamatory Foreign body granuloma RareInflamatory Foreign body granuloma RareMondors disease RareMondors disease Rare

D ct papiloma Less commonD ct papiloma Less commonDuct papiloma Less commonDuct papiloma Less commonBenign Giant fibroadenoma RareBenign Giant fibroadenoma Raretumours Lipoma Raretumours Lipoma Rare

G l ll bl t RG l ll bl t RGranular cell myoblastoma RareGranular cell myoblastoma Rare

Penyebab benjolan di payudaraPenyebab benjolan di payudaraPenyebab benjolan di payudaraPenyebab benjolan di payudara

Intermediat Phyllodes tumor RareIntermediat Phyllodes tumor Raretumours Carsinoma in situ Less commontumours Carsinoma in situ Less commontumours Carsinoma in situ Less commontumours Carsinoma in situ Less common

Malignant Primary tomuors CommonMalignant Primary tomuors CommonSecondary tumour RareSecondary tumour Rare

Penyebab benjolan di payudaraPenyebab benjolan di payudaraPenyebab benjolan di payudaraPenyebab benjolan di payudara

Squamous papiloma Less commonSquamous papiloma Less commonLession of the Leiomyoma RareLession of the Leiomyoma RareNipple and Retention cyst RareNipple and Retention cyst RareNipple and Retention cyst RareNipple and Retention cyst RareAreola Papilary adenoma RareAreola Papilary adenoma Rare

Sebaceous cyst Less commonSebaceous cyst Less commonLession of the Hidradenitis RareLession of the Hidradenitis RareSkin Benign and malignat RareSkin Benign and malignat RareSkin Benign and malignat RareSkin Benign and malignat Rare

skin tumours skin tumours

EVALUATION OF A PALPABLE BREAST MASSEVALUATION OF A PALPABLE BREAST MASSEVALUATION OF A PALPABLE BREAST MASSEVALUATION OF A PALPABLE BREAST MASS

Differential Dia nosisDifferential Dia nosisDifferential DiagnosisDifferential Diagnosis

■■ Infectious/inflammatory : Mastitis, fat necrosis, Infectious/inflammatory : Mastitis, fat necrosis, M d ’ diM d ’ diMondor’s diseaseMondor’s disease

■■ Benign lesions : Fibroadenoma, fibrocystic changes, Benign lesions : Fibroadenoma, fibrocystic changes, mammary duct ectasia, cystosarcoma phyllodes mammary duct ectasia, cystosarcoma phyllodes (occasionally malignant), intraductal papiloma, (occasionally malignant), intraductal papiloma, gynecomastiagynecomastia

■■ Premalignant disease : Ductal carcinomain situ (DCIS), Premalignant disease : Ductal carcinomain situ (DCIS), l b l i i i (LCIS)l b l i i i (LCIS)

gglobular carcinoma in situ (LCIS)lobular carcinoma in situ (LCIS)

■■ Malignant tumors : Infiltrating ductal, infiltrating Malignant tumors : Infiltrating ductal, infiltrating lobular, and inflammatory carcinoma ; Paget’slobular, and inflammatory carcinoma ; Paget’sDisease ; and other less common histologic types of Disease ; and other less common histologic types of breast cancerbreast cancer

INFECTIOUS / INFLAMMATORYINFECTIOUS / INFLAMMATORYMastitisMastitis

■■ Usual etiologic agent : Usual etiologic agent : Staphylococcus aureus or Staphylococcus aureus or StreptococcusStreptococcus spp.spp.

■■ Most commonly occurs during early weeks of breastMost commonly occurs during early weeks of breast--f df d

y g yy g yfeedingfeeding

■■ Physical exam : Focal tenderness with erythema and Physical exam : Focal tenderness with erythema and warmth of overly ing skin, fluctuant mass Occasionally warmth of overly ing skin, fluctuant mass Occasionally

l bll blpalpable.palpable.■■ Diagnosis : Ultrasound can be used to localize an Diagnosis : Ultrasound can be used to localize an

abscess ; if abscess present, aspirate fluid for Gram abscess ; if abscess present, aspirate fluid for Gram t i d ltt i d ltstain and culture.stain and culture.

■■Treatment : Continue breast Treatment : Continue breast –– feeding and recommend feeding and recommend use of breast pump as an alternativeuse of breast pump as an alternativeC ll li i W d d IV ibi iC ll li i W d d IV ibi i■■ Cellulitis : Wound care and IV antibioticsCellulitis : Wound care and IV antibiotics

■■ Abscess : Incision and drainage followed by IV Abscess : Incision and drainage followed by IV antibioticsantibiotics

INFECTIOUS / INFLAMMATORYINFECTIOUS / INFLAMMATORYINFECTIOUS / INFLAMMATORYINFECTIOUS / INFLAMMATORY

Fat NecrosisFat NecrosisFat NecrosisFat Necrosis■■ Presentation : Firm, irregular mass of varying Presentation : Firm, irregular mass of varying

tendernesstenderness■■ History of local trauma elicited in 50% of patientHistory of local trauma elicited in 50% of patient■■ Predisposing factors : Chest wall or breast Predisposing factors : Chest wall or breast

traumatraumatraumatrauma■■ Physical exam : Irregular mass without discrete Physical exam : Irregular mass without discrete

borders that may or may not be tender ; later,borders that may or may not be tender ; later,c lla en us scars pred minatec lla en us scars pred minatecollagenous scars predominatecollagenous scars predominate

■■ Often indistinguishable from carcinoma by Often indistinguishable from carcinoma by clinical exam or mammographyclinical exam or mammography

■■ Diagnosis and treatment : Excisional biopsy with Diagnosis and treatment : Excisional biopsy with pathologic evaluation for carcinomapathologic evaluation for carcinoma

BENIGN DISEASEBENIGN DISEASEFib dFib dFibroadenomaFibroadenoma

■■ Definition : Fibrous stroma surrounds ductDefinition : Fibrous stroma surrounds duct--like epithelium and forms like epithelium and forms a benign tumor that is grossly smooth white and well circumscribeda benign tumor that is grossly smooth white and well circumscribeda benign tumor that is grossly smooth, white, and well circumscribed.a benign tumor that is grossly smooth, white, and well circumscribed.

■■ Risk factors : More common in black women than in white women.Risk factors : More common in black women than in white women.■■ Incidence : Typically occurs in late teens to early 30s; estrogenIncidence : Typically occurs in late teens to early 30s; estrogen--

sensitive (increased tenderness during pregnancy).sensitive (increased tenderness during pregnancy).■■ Signs and symptoms : Smooth, discrete, circular, mobile mass.Signs and symptoms : Smooth, discrete, circular, mobile mass.■■ Diagnosis : FNADiagnosis : FNA■■Treatment :Treatment :

If FNA i di ti f fib d d ti t i d 30 If FNA i di ti f fib d d ti t i d 30 ■■ If FNA is diagnostic for fibroadenoma and patient is under 30, may If FNA is diagnostic for fibroadenoma and patient is under 30, may observe depending on severity of symptoms and size (<3cm).observe depending on severity of symptoms and size (<3cm).

■■ If FNA is nondiagnostic, patient is over 30, or is symptomatic, must If FNA is nondiagnostic, patient is over 30, or is symptomatic, must excise mass. The mass is well encapsulated and can be shelled out excise mass. The mass is well encapsulated and can be shelled out ppeasily at surgery.easily at surgery.

BENIGN DISEASEBENIGN DISEASE

Mondor’s DiseaseMondor’s Disease

■■ Definition : Superficial thrombophlebitis of lateral thoracic or Definition : Superficial thrombophlebitis of lateral thoracic or ■■ Definition : Superficial thrombophlebitis of lateral thoracic or Definition : Superficial thrombophlebitis of lateral thoracic or thoracoepigastric vein.thoracoepigastric vein.

■■ Predisposing factors : Local trauma, surgery,. Infection, Predisposing factors : Local trauma, surgery,. Infection, repetitive movements of upper extremity.repetitive movements of upper extremity.

P s t ti A t i i ill s i s t f l t l P s t ti A t i i ill s i s t f l t l ■■ Presentation : Acute pain in axilla or superior aspect of lateral Presentation : Acute pain in axilla or superior aspect of lateral breast.breast.

■■ Physical exam : Tender cord palpated.Physical exam : Tender cord palpated.■■ Diagnosis : Confirm with ultrasound.Diagnosis : Confirm with ultrasound.■■ Diagnosis : Confirm with ultrasound.Diagnosis : Confirm with ultrasound.■■Treatment :Treatment :

■■ Clear diagnosis by ultrasound : Salicylates, warm compresses,Clear diagnosis by ultrasound : Salicylates, warm compresses,limit motion of affected upper extremity. Usually resolveslimit motion of affected upper extremity. Usually resolvespp y ypp y ywithin 2 to 6 weeks.within 2 to 6 weeks.

■■ If persistens, surgery to divide the vein above and below theIf persistens, surgery to divide the vein above and below thesite of thrombosis or resectthe affected segment.site of thrombosis or resectthe affected segment.

l d d d l d d d ■■ Ultrasound nondiagnostic or an associated mass present :Ultrasound nondiagnostic or an associated mass present :Excisional biopsy.Excisional biopsy.

BENIGN DISEASEBENIGN DISEASE

Fibrocystic Changes Fibrocystic Changes

■■ Usually diagnosed in 20s to 40sUsually diagnosed in 20s to 40s■■ Usually diagnosed in 20s to 40s.Usually diagnosed in 20s to 40s.■■ Presentation : Breast swelling (often bilateral), Presentation : Breast swelling (often bilateral),

tenderness, and/or pain.tenderness, and/or pain.Physical exam : Discrete areas of nodularity within Physical exam : Discrete areas of nodularity within ■■ Physical exam : Discrete areas of nodularity within Physical exam : Discrete areas of nodularity within fibrous breast tissue.fibrous breast tissue.

■■ Evaluation : Serial physical examination with Evaluation : Serial physical examination with documentation of the fluctuating nature of the documentation of the fluctuating nature of the documentation of the fluctuating nature of the documentation of the fluctuating nature of the symtoms is usually sufficient unless a persistent symtoms is usually sufficient unless a persistent discrete mass is identified ; definitive diagnosticdiscrete mass is identified ; definitive diagnostic

i s s i ti bi s ith th l i l tii s s i ti bi s ith th l i l tirequires aspiration or biopsy with pathologic evaluation.requires aspiration or biopsy with pathologic evaluation.

Fibrocystic ChangesFibrocystic Changes

■■ Symtoms thought to be of hormonal etiology and tend Symtoms thought to be of hormonal etiology and tend to fluctuate with the menstrual cycle.to fluctuate with the menstrual cycle.

■■ Associated with a group of characteristic histologic Associated with a group of characteristic histologic findings, each of which has a variable relative findings, each of which has a variable relative risk risk for the development of cancer.for the development of cancer.

d h d k f b d h d k f b Not associated with an increased risk for breast Not associated with an increased risk for breast cancer unless biopsy reveals lobular or ductal cancer unless biopsy reveals lobular or ductal hyperplasia with atypia.hyperplasia with atypia.

T t t T t t ■■Treatment :Treatment :■■ For cases with a classic history or absence of a For cases with a classic history or absence of a persistent mass : Conservative management ; options persistent mass : Conservative management ; options i l d t id l tii l d t id l ti i fl t d i fl t d include nonsteroidal antiinclude nonsteroidal anti--inflammatory drugs inflammatory drugs (NSAIDs), oral contraceptive pills (OCPs),danazol, or (NSAIDs), oral contraceptive pills (OCPs),danazol, or tamoxifen, tobacco, cola drinks).tamoxifen, tobacco, cola drinks).

If single dominant cyst aspirate fluid ; may discard If single dominant cyst aspirate fluid ; may discard ■■ If single dominant cyst, aspirate fluid ; may discard If single dominant cyst, aspirate fluid ; may discard if green or cloudy but must send to cytology and if green or cloudy but must send to cytology and excise cyst if bloody.excise cyst if bloody.

BENIGN DISEASEBENIGN DISEASE

Cystosarcoma PhyllodesCystosarcoma Phyllodes

■■ A variant of fibroadenomaA variant of fibroadenoma■■ A variant of fibroadenoma.A variant of fibroadenoma.■■ Majority are benign.Majority are benign.■■ Patients tend to present later than those with fibroadenoma Patients tend to present later than those with fibroadenoma

(>30 years).(>30 years).■■ Characteristics : Indistinguishable from fibroadenoma by Characteristics : Indistinguishable from fibroadenoma by

ultrasound or mammogram. ultrasound or mammogram. The distinction between the two entities can be made on the The distinction between the two entities can be made on the basis of their histologic features (phylloides tumors have more basis of their histologic features (phylloides tumors have more basis of their histologic features (phylloides tumors have more basis of their histologic features (phylloides tumors have more mitotic activity). Most are benign and have a good prognosis.mitotic activity). Most are benign and have a good prognosis.

■■ Exam : Large, freely movable mass with overlying skin changes.Exam : Large, freely movable mass with overlying skin changes.■■ Diagnosis : Definitive diagnosis requires biopsy with pathologic Diagnosis : Definitive diagnosis requires biopsy with pathologic

l til tievaluationevaluation■■ Treatment :Treatment :

■■ Smaller tumors : Wide local excision with at least a 1Smaller tumors : Wide local excision with at least a 1--cm cm margin margin margin margin ■■ Larger tumors : Simple mastectomyLarger tumors : Simple mastectomy

BENIGN DISEASEBENIGN DISEASEBENIGN DISEASEBENIGN DISEASE

Intraductal PapillomaIntraductal PapillomaIntraductal PapillomaIntraductal Papilloma

■■ Definition : A benign local proliferation of ductal Definition : A benign local proliferation of ductal g pg pepithelial cells.epithelial cells.

■■ Characteristics : Unilateral serosanguinous or bloody Characteristics : Unilateral serosanguinous or bloody nipple discharge.nipple discharge.pp gpp g

■■ Presentation : Subareolar mass and / or spontaneous Presentation : Subareolar mass and / or spontaneous nipple discharge.nipple discharge.

■■ Evaluation : Radially compress breast to determine which Evaluation : Radially compress breast to determine which ■■ Evaluation Radially compress breast to determine which Evaluation Radially compress breast to determine which lactiferous duct expresses fluid ; mammography.lactiferous duct expresses fluid ; mammography.

■■ Diagnosis : Definitive diagnosis by pathologic evaluation Diagnosis : Definitive diagnosis by pathologic evaluation of resected specimenof resected specimenof resected specimenof resected specimen

■■ Treatment : Excise affected duct.Treatment : Excise affected duct.

GalaktokelGalaktokelGalaktokelGalaktokel

-- Fitzwilliams 1845, kista berisi susuFitzwilliams 1845, kista berisi susu-- sering pada masa laktasisering pada masa laktasig pg p-- bersamaan dengan duct ectasia danbersamaan dengan duct ectasia dan

recurrent sub areola absesrecurrent sub areola absesecu e t sub a eo a absesecu e t sub a eo a abses-- klinis timbul massa tanpa nyeri setelahklinis timbul massa tanpa nyeri setelah

beberapa minggu/ bulan menyapihbeberapa minggu/ bulan menyapihbeberapa minggu/ bulan menyapihbeberapa minggu/ bulan menyapih-- dapat hilang sendiri a setelah aspirasidapat hilang sendiri a setelah aspirasi-- lokasi tersering sub areolalokasi tersering sub areola-- lokasi tersering sub areolalokasi tersering sub areola