Benign Breast Problems-Detection and treatment

????? ???????? ????, ?????? ????????? ????, ?? ???? ???, ???? ????? ???? Not every breast lump or pain is cancer. There are many NON-CANCEROUS breast problems. THIS ARTICLE IS ABOUT BENIGN BREAST DISEASE – NON-CANCEROUS BREAST PROBLEMS AND THEIR TREATMENT. A brief introduction and management of common non-cancerous problems of breast?Breast awareness?is one of the screening tools under NCCN guidelines for women. And a need to be aware of these benign conditions is very much needed. Most of the time these conditions need expert guidance and appropriate treatment.?Many women are coming to us with great apprehension of a breast complaint being a cancerous problem. There is a need to educate women about these non-cancerous conditions, reduce apprehensions, give reassurance and explain the management options available. As a clinician we see at least 4 to 5 women with such problems in a week in our American Oncology Institute with non-cancerous problems

Introduction

The term “benign breast diseases” encompasses a heterogeneous group of lesions that may present as breast lump or beast pain(mastalgia), nipple discharge, lumpiness, and may be detected as incidental microscopic findings

More common than the malignant breast disease. Primarily seen in the reproductive period of life, our aim is to exclude malignancy and treat the symptoms

Causes-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 (aberrations of normal development and involution) involves disturbances in the breast physiology extending from a perturbation of normality to well-defined disease processes. There is often little correlation between the histological appearance of the breast tissue and the symptoms.

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.?

Fibrocystic?changes?constitute the most frequent benign disorder of the breast. Generally, affect premenopausal women between 40 and 50 years of age. The most common presenting symptoms are breast pain and tender nodularity’s in breasts.?Treatment- Simple analgesics may alleviate mild mastalgia. Drug therapy is usually only advised for patients who experience severe pain, lasting for six months, that diminishes the quality of their lives. Evening Primrose oil, Danazol, Bromocryptine,Tamoxifen,Vitameni E are various medications available to be used under the oncologist supervision. Diuretics such as chlorothiazide have been used to alleviate mild to moderate pain.

Mastalgia– 45% of women report breast pain, 21% severe. Has an unknown aetiology, and a poorly understood. Mastitis, carcinoma presenting with only mastalgia (8%).Patients who are on Hormone Replacement Therapy, caffeine, tobacco, large pendulous breasts, etc.Types-Cyclical—65%.Noncyclical—30%.Chest wall pain—5%.

Cyclical mastalgia?is most commonly observed in women in their 30s.The pain, lasts for a variable length of time.Is frequently worse in the luteal phase of the menstrual cycle. Resolves with menstruation. Associated with diffuse nodularity.The extent of pain severity may differ with each menstrual cycle.

Diagnosis?includes a thorough clinical breast examination to exclude an underlying disease process. Other conditions that need to be considered include,infection.Inflammatory breast conditions,angina.hiatus hernia,cholelithiasis. Reassurance of a benign condition is an important part of the management. Approximately 85% of women with breast pain will require no treatment. Relief from mild discomfort may be achieved through dietary changes (e.g., reduction in caffeine, salt, and saturated fat).Breast support

NON CYCLICAL PAIN:Other causes of breast pain are periductal mastitis, malignancy, cervical root pain, musculoskeletal pain, previous surgery, Tietze’s syndrome.It is unilateral, chronic, burning or dragging in nature, occurs both in pre- and postmenopausal age group. 5% of breast cancers present as pain during first presentation.?Cause has to be identified. Malignancy has to be ruled out. Avoid coffee and stress. Proper support to breasts.

Breast cysts-These occur most commonly in the last decade of reproductive life as a result of a non-integrated involution of stroma and epithelium.They are often multiple, may be bilateral and can mimic malignancy. They typically present suddenly and cause great alarm .The first investigation of palpable breast masses is frequently needle biopsy, which allows for the early diagnosis of cysts .However, 30% will recur and require re-aspiration.If there is a residual lump or if the ?uid is blood-stained, a core biopsy or local excision for histological diagnosis is advisable, which is also the case if the cyst reforms repeatedly.

When cystic fluid is bloodstained, 2 mL of fluid are taken for cytology. The mass is then imaged with ultrasound and any solid area on the cyst wall is biopsied by needle.?

The two cardinal rules of safe cyst aspiration are (1) the mass must disappear completely after aspiration (2) the fluid must not be bloodstained.

Fibroadenoma-It is a benign encapsulated tumor occurring commonly in young females of 15-25 years age group. Presently it is considered as hyperplasia of a single lobule of the breast (classified under ANDI). It is the most common benign tumor of the breast below 30 years of age in females. Indications for surgery are – size > 3 multiple. Giant type. Recurrence. Cosmetic. Complex type.

Phylloides Tumor: The nomenclature, presentation, and diagnosis of phyllodes tumors (including cystosarcomaphyllodes) have posed many problems for surgeons. These tumors are classified as benign, borderline, or malignant. Borderline tumors have a greater potential for local recurrence. Small phyllodes tumors are excised with a 1-cm margin of normal-appearing breast tissue.When the diagnosis of a phyllodes tumor with suspicious malignant elements is made and Large phyllodes tumors may require mastectomy. Axillary dissection is not recommended as axillary lymph node metastases rarely occur

Duct Ectasia:This is a dilatation of the breast ducts, which is often associated with periductal in?ammation,more common in smokers.The classical description of the pathogenesis of duct ectasia asserts that the ?rst stage in the disorder is a dilatation in one or more of the larger lactiferous ducts, which ?ll with a stagnant brown or green secretion. ¨These ?uids then set up an irritant reaction in surrounding tissue leading to periductal mastitis or even abscess and ?stula formation??In some cases, a chronic indurated mass forms beneath the areola, which mimics a carcinoma. Fibrosis eventually develops, which may cause slit-like nipple retraction.An alternative theory suggests that periductal in?ammation is the primary condition and, indeed, anaerobic bacterial infection is found in some cases. Treatment-1.Conservative management 2.Hadfield’s Operation- disconnect or remove part of the major nipple ducts.3.Modified central duct excision

Duct papilloma-?They are epithelium lined true polyps of breast lactiferous ducts.?Usually it is < 1 cm in size often with a small lump under areola. But can attain large size.?Vascular stalk is present usually.?Rarely a cystic soft swelling may be present underneath which is probably due to obstruction of the duct by papilloma.?Papilloma may often project out like a pedunculated mass.?Investigations Discharge study (FNAC). Injection of contrast into the duct (Ductogram).Mammography may show dense lesion under the areola.Treatment-Microdochectomy: Probed lactiferous duct is opened, and the papilloma is excised using tennis racquet incision.

Galactocele?which is rare, usually presents as a solitary, subareolar cyst and always dates from lactation.It contains milk and in longstanding cases its walls tend to calcify. Excision of the affected duct as infection and abscess formation in a galactocele is not uncommonBreast Abscess-Pus for culture and sensitivity, drainage and appropriate antibiotics with pain receivers

Breast Abscess-Pus for culture and sensitivity, drainage and appropriate antibiotics with pain receivers

Tuberculosis?is rare, associated with active pulmonary tunerculosis /cervical adenitis,presents as multiple chronic abscess and sinuses typical bluish attenuated appearance of skin . Diagnosed by histology Treatment-Anti tuberculosis treatment

Dr. Jagdishwar Goud Gajagowni

National Head, Robotic Program

American Oncology Institute, Hyderabad

MBBS, MS(General Surgery-Osmania),M.Ch(Surgcial Oncology-Kidwai)

Trained in Robotic Surgery-Rose Well Cancer Institute (Buffalo) Severance Robotic Institute(Seoul)