Benign Brest Condition
Dr. Haitham M Albar
Cardiac Surgery Resident
R1

Development
• Start @ 5 th -6 th week GA
• Accessory breast (polymastisa) or accessory nipple (polythelia) may occur along milk line
• Brest remain undeveloped in female until puberty , (under influence of hormonal effect)
• Breast remain incompletely developed until pregnancy

Cont,
• Poland’s syndrome : hypoplasia or absent of breast costal cartilage & rib defect , hypoplasia of subcutaneous tissues of the chest wall and brachysyndactyly.
• Brest hypoplasia can induce as well by ; trauma, infection , or radiation therapy
** if you find polythelia in infants look for other congenital abnormality

Anatomy
• The breasts consist of mammary glands embedded in the superficial fascia and overlying skin anterior to the pectoral muscles and the anterior thoracic wall.
• The mammary glands consist of 15 to 20 lobes & their
lactiferous ducts open in the nipple which is surrounded by a circular pigmented area of skin termed the areola.
• The lobes are separated from each other by
suspensory ligaments of breast, which are continuous with the dermis of the skin and support the breast.

Cont,
• BOUNDARIES OF THE BREAST
• 1) Upper: 2 nd rib
• 2) Lower: 6 th rib
• 3) Medial: sternal edge
• 4) Lateral: mid-axillary line
• 5) Deep:
• a.
Centrally: pectoral fascia
• b.
Laterally: serratus anterior fascia
• 6) Axillary extension: tail of Spence

Cont,
• Microscopic anatomy
• A mature breast is composed of 3 principal tissue types:
– Glandular epithelium
– Fibrous stroma and supporting structures
– Fat
• Epithelium and stroma being replaced by fat in postmenopausal women

Cont,
• The glandular apparatus is composed of a branching system of ducts, organized in radial pattern spreading outward and downward.
• Subareolar ducts widen to form lactiferous sinuses which exit through 10-15 orifices on the nipple.
• The ducts end blindly in clusters of spaces called acini. (milk forming glands)

Cont,
• Blood supply: It is supplied by branches from the axillary, internal thoracic & anterior intercostal arteries

Cont,
• Batson’s vertebral venous plexus ; which invests the vertebra & extends form the base of the skull to the sacrum >>>> may provide a route for breast cancer metastases to the vertebrae, skull , pelvic bone and CNS .

Cont,
• Lymph drainage: - The lower lateral quadrant of the breast drains into the anterior (pectoral) group of nodes. - The upper lateral quadrant of the breast drains into the apical group of nodes. - The upper medial quadrant of the breast drains into the parasternal group of nodes. - The lower medial quadrant of the breast drains into the subdiaphragmatic group of nodes. - The tail of breast is drained by the posterior
(subscapular) group of axillary nodes.
• The deep lymphatic plexus of both breasts communicate with each other.

Cont,
• Lymphatic drainage
• 75% drains to the axilla.
• Five groups of lymphnodes.
– Subclavicular nodes
– Supraclavicular nodes
– Internal mamary nodes
– Interpectoral nodes
– External mammary nodes

• Close to the chest wall on the medial side of the axilla is the long thoracic nerve.
• Provides innervation to the anterior serratus muscle.
• Division of this results in winged scapula

Cont,
• The second major nerve trunk is the thoracodorsal nerve.
• Runs at the lateral border of the axilla
• Innervates the latissimus dorsi muscle
• The medial pectoralis nerves innervate the pectoralis major muscle and are part of the neurovasvular bundle, best landmark for the axillary vein.

Cont,
• History : (as any with)
• duration, changes , associated symptoms
• Relation to menstral cycle
• Hx of breast surgery , if any pathology result
• Risk factor of cancer ; family Hx, menarche , parity, use of COC , hormonal therapy … etc

Cont,
Examination :
• inspection & palpation
• Mass identify >> location, size, consistency, contour, tenderness, and mobility should be described; a diagram of the lesion is extremely useful for future reference
• Nipples & Discharge
• LN ; axillary, supraclavicular, and infraclavicular areas

Cont,
Imaging :
1. Mammography ; diagnostic & screening role
2. Ultrasound ; cystic vs solid lesion, need for biobsy & further workup , guide for FNA or achieving –ve lumpectomy margins
3. MRI ; adjunct to mammography , further evaluation & determine of metastases

Cont,
• Malignant mammographic findings:
1. New or spiculated masses
2. Clustered microcalcifications in linear or branching array
3. Architectural distortion

Cont,
• Benign mammographic findings:
1. Radial scar; FBC need biopsy to R/O cancer
2. Fat necrosis ; result form trauma , biopsy may be need it to R/O cancer
3. Milk of Calcium ; associated with FBC , caused by calcified debris in the base of acini no biopsy need it
4. Cyst ; can’t be distinguished form solid masses need US

Cont,
Biopsy :
• FNA , FNA under US guide , lumpectomy … etc

Cont,
• Palpable masses:
1. FNA ; 90% sensitive , can’t give info about grade
& invasion
2. Core biopsy ; give info about grade & invasion , if indeterminate >>> surgical biopsy
3. Excisional biopsy
4. Incisional biopsy

Cont,
• Nonpalpable lesion :
1. Stereotactic core biopsy
2. US guided biopsy
3. Needle localization excisional biopsy (NLB)

• is one of the most common symptoms for which women seek medical attention (70%)
• Always benign , however 10% associated with cancer
** features that raise suspicion with cancer are noncyclic pain in a focal area and pain associated with a mass or bloody nipple discharge **

Cont,
• Cyclic breast pain:
Often described as a heaviness or tenderness and is usually worse before a menstrual cycle. It may be maximal in the upper outer quadrant and radiate to the inner surface of the upper arm. It resolves spontaneously in 20% to 30% of women but tends to recur in 60%. Many patients experience symptomatic relief by reducing caffeine intake or by taking vitamin E, although there is no scientific evidence supporting this.

Cont,
• Noncyclic breast pain :
Described as burning or stabbing and frequently occurs in the subareolar area or medial aspect of the breast. It responds poorly to treatment but tends to resolve spontaneously in 50% of women.

Cont,
Treatment of mastalgia:
1. Topical nonsteroidal anti-inflammatory drugs
(NSAIDs) (diclofenac gel) should be considered first- line treatment
2. Tamoxifen (an estrogen antagonist) has been shown to provide good pain relief in placebo-controlled trials with tolerable side effects , although concerns over increased risks of endometrial cancer limit long-term use

Cont,
3. Danazol (a derivative of testosterone) has been shown to be efficacious and has been used historically for severe breast pain , but significant side effects (hirsutism, voice changes, acne, amenorrhea, and abnormal liver enzymes levels) limit its use
4. Bromocriptine and gonadorelin analogs should be reserved for severe refractory mastalgia due to significant side effects
5. Evening primrose oil is often used but has been shown to have no benefit over placebo in clinical trials

Cont,
• Superficial thrombophlebitis:
Superficial thrombophlebitis of the veins overlying the breast
(Mondor disease) may present as breast pain. The thrombosed vein or “cord” may be palpated. NSAIDs and hot compresses can provide symptomatic relief. Antibiotics are not generally indicated.
• Breast pain in pregnancy and lactation can occur from engorgement, clogged ducts, trauma to the areola and nipple from pumping or nursing, or any of the aforementioned sources. Clogged ducts are usually treated with warm compresses, soaks, and massage.

Cont,
• Tietze syndrome or costochondritis may be confused with breast pain. Patients are locally tender in the parasternal area. Treatment is with NSAIDs.
• Cervical radiculopathy can also cause referred pain to the breast.

Fibrocystic Breast Change (FBC) : encompasses several of the following pathologic features: stromal fibrosis, macro- and microcysts, apocrine metaplasia, hyperplasia, and adenosis (which may be sclerosing, blunt-duct, or florid).
• FBC is common and may present as breast pain, a breast mass, nipple discharge, or abnormalities on mammography.
• The patient presenting with a breast mass or thickening and suspected FBC should be re-examined in a short interval, preferably on day 10 of the menstrual cycle, when hormonal influence is lowest. Often, the mass will have diminished in size.
• A persistent dominant mass must undergo further radiographic evaluation, biopsy, or both to exclude cancer.

• Breast Cysts frequently present as tender masses or as smooth, mobile, well-defined masses on palpation. If tense with fluid, its texture may be firm, resembling a solid mass. Aspiration can determine the nature of the mass (solid vs. cystic) but is not routinely necessary. Cyst fluid color varies and can be clear, straw-colored, or even dark green.
• Cysts discovered by mammography and confirmed as simple cysts by ultrasound are usually observed if asymptomatic.
• Symptomatic simple cysts should be aspirated. If no palpable mass is present after drainage, the patient should be evaluated in 3 to 4 weeks. If the cyst recurs, does not resolve completely with aspiration, or yields bloody fluid with aspiration, then mammography or ultrasonography should be performed to exclude intracystic tumor. Nonbloody clear fluid does not need to be sent for cytology.

• is the most common discrete mass in women younger than 30 years of age. They typically present as smooth, firm, mobile masses.
1. They enlarge during pregnancy and involute after menopause.
2. They have well-circumscribed borders on mammography and ultrasound.
3. They may be managed conservatively if clinical and radiographic appearance is consistent with a fibroadenoma and is less than 2 cm. If the mass is symptomatic, greater than 2 cm, or enlarges, it should be excised.

A. Lactation
• Lactation is the most common physiologic cause of nipple discharge and may continue for up to 2 years after cessation of breastfeeding. In parous nonlactating women, a small amount of milk may be expressed from multiple ducts. This requires no treatment.

Cont,
B. Galactorrhea
Galactorrhea is milky discharge unrelated to breast-feeding. Physiologic galactorrhea is the continued production of milk after lactation has ceased and menses resumed and is often caused by continued mechanical stimulation of the nipples.
1.
Drug-related galactorrhea is caused by medications that affect the hypothalamic-pituitary axis by depleting dopamine (tricyclic antidepressants, reserpine, methyldopa, cimetidine, and benzodiazepines), blocking the dopamine receptor (phenothiazine, metoclopramide, and haloperidol), or having an estrogenic effect (digitalis). Discharge is generally bilateral and nonbloody.
2. Spontaneous galactorrhea in a nonlactating patient may be due to a pituitary
prolactinoma. Amenorrhea may be associated. The diagnosis is established by measuring the serum prolactin level and performing a computed tomography (CT) or
MRI scan of the pituitary gland. Treatment is bromocriptine or resection of the prolactinoma.

Cont,
C. Pathologic nipple discharge
Pathologic nipple discharge is either bloody or spontaneous, unilateral, and originates from a single duct. Normal
physiologic discharge is usually nonbloody, from multiple ducts, can be a variety of colors (clear to yellow to green), and requires breast manipulation to produce.
1. Pathologic discharge is serous, serosanguineous, bloody, or watery. The presence of blood can be confirmed with a guaiac test.
2. Cytologic evaluation of the discharge is not generally useful.

Cont,
3.Malignancy is the underlying cause in 10% of patients.
4. If physical examination and mammography are negative for an associated mass, the most likely etiologies are benign intraductal papilloma, duct
ectasia, or fibrocystic changes. In lactating women, serosanguinous or bloody discharge can be associated with duct trauma, infection, or epithelial proliferation associated with breast enlargement.

Cont,
5. A solitary papilloma with a fibrovascular core places the patient at marginally increased risk for the development of breast cancer. Patients with persistent spontaneous discharge from a single duct require a surgical microdochectomy, ductoscopy, or major duct excision.
• Microdochectomy: Excision of the involved duct and associated lobule. Immediately before surgery, the involved duct is cannulated, and radiopaque contrast is injected to obtain a ductogram, which identifies lesions as filling defects. The patient is then taken to the operating room, and the pathologic duct is identified and excised, along with the associated lobule.

Cont,
• Ductoscopy utilizes a 1-mm rigid videoscope to perform an internal exploration of the major ducts of the breast. Once a ductal lesion is identified, this single associated duct with the lesion is excised.
• Major duct excision may be used for women with bloody nipple discharge from multiple ducts or in postmenopausal women with bloody nipple discharge.
It is performed through a circumareolar incision, and all of the retroareolar ducts are transected and excised, along with a cone of tissue extending up to several centimeters posterior to the nipple.

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