INTRODUCTION

This study comprising of 100 cases was done between 2004 and 2006 at Kurnool Medical College & Hospital, Kurnool. The study group consisted of 86 female and 14 male patients. This study was chosen, as 50-55% of women suffer from breast related disorders during their life time, and exclusion of serious pathology of the breast after evaluation, has a major reassuring effect on the patient. The objectives were to study the benign breast diseases with regard to demographic factors and its clinical presentations and to evaluate it clinically, by FNAC and histopathology to increase the accuracy of diagnosis. A prospective study of patients attending surgical OPD and also admitted to surgical wards with breast disorders was done. Patient predominantly presented with fibroadenoma and fibrocystic disease. Cases of gynecomastia, cyclical mastalgia and breast abscesses were also encountered. Most of patients underwent FNAC and a few of them had mammograms done. Treatment was mostly surgical in the form of excision, subcutaneous mastectomy, microdochotomy and incision and drainage. All the specimens were subjected to histopathological examination. Using clinical diagnosis, FNAC and histopathology increased the accuracy of diagnosis. Cases of fibroadenosis and cyclical mastalgia were treated conservatively with drugs.

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A follow up period ranging from 6 months to 2 years was analysed. Except for three cases of recurrence in fibroadenomas, rest of them have had an uneventful post treatment period. Satisfactory results were seen in conservative line of management also. In conclusion, benign breast disease is fairly prevalent with fibroadenoma and fibrocystic disease comprising most of the cases. Patients who were anxious about their breast disease had much relief after it was proved benign.

Mode of Selection of Cases
 Screening of cases by clinical examination in OPD and investigations such as FNAC and when necessary, mammogram was advised.  Patients were studied and analysed in detail, with regard to;

History Clinical Examination FNAC Mammogram (in certain cases only) Based on the provisional diagnosis, patients were subjected to surgery which was usually excision or incision and drainage as the case required. Preoperative preparation was done by giving prophylactic single dose of antibiotic in non-infected cases.

 Cases were again analysed based on; Operative findings Histopathological findings Post Operative Course and outcome.

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Patients were followed up for a maximum period of 1½ years to detect any recurrence. Breast health means more than breast cancer. It has been noted that noncancerous pathology of breast has always been neglected, compared to breast cancer inspite of the fact that benign conditions account for 90% of the clinical presentations related to the breast. About 5-55% of all women suffer from breast disorders in their life time. Benign disorders of the breast is usually seen in the reproductive period of life, is thought to be largely hormone induced and there is a dramatic fall in the incidence, after menospause due to cessation of clinical ovarian stimulation. Benign breast disease is 4-5 times more common than breast cancer. The concept of ANDI-Aberrations of Normal Development and Involution is gaining acceptance. Benign proliferations of the breast are often considered as aberrations of normal development and involution. The cyclical changes due to variations in estrogens and progesterone result in increased mitosis around days 22-24 of the menstrual cycle but apoptosis restores the balance across the cycle. ANDI, first proposed by Huges is now universally accepted. This concept allows conditions of the breast to be mapped between normality, through benign disorders to benign breast disease. So most benign breast disease are relatively minor aberrations to normal process of development, cyclical hormonal response and involution that interact throughout a women’s life. The clinician should clearly differentiate between benign and malignant conditions of the breast, and reassure the patients after serious pathology is excluded, as it has a major psychological effect on them.

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AIM
 To study distribution of benign breast disease with respect to demographic factors and to correlate relation if any, between the type of benign breast disease and quadrants.

 To correlate between clinical diagnosis and FNAC to histopathological Examination (HPE) regarding the accuracy of diagnosis.

 To do at least a one (1) year follow up, to evaluate the outcome of treatment.

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SURGICAL ANATOMY – BREAST
The mature breast is considered to be a collection of sweat glands that were modified in the course of evolution to produce milk. With the exception of the axillary tail, which lies beneath the fascia, the mammary gland is superficial to the deep fascia of the thorax. The deep surface of the breast overlies the pectorals major, the serratus anterior, and the external oblique muscles. It is attached to the overlying skin by bands of connective tissue originating between glandular fat lobules, which are called Cooper’s ligaments. The so called axilliary tail is a portion of the breast that extends into the axilla. The glandular portion of the breast is composed of fibrous, adipose and epithelial tissue and is divided into 15 to 20 lobes, which are arranged in a radial pattern. Each lobe is drained by a lobe-specific lactiferous duct. Some of these ducts may join, so that no more than 5 to 10 openings emerge on the surface of the nipple. As the collecting ducts proceeds distally from the nipple, they branch and end in terminal ductal lobular unit (TDLU) . In the mature breast, these lobules measure approximately 500 (µ) in diameter. The epidermis of the nipple and the surrounding area, the areola is a pigmented epithelium. There are many bundles of smooth muscles beneath the nipple and areola. The ducts are lined by epithelium, which varies from stratified squamous near the exit, columnar epithelium at the extralobular ductal system and simple cuboidal epithelium towards the alveoli. The ducts are surrounded by myoepithelial cells and extensively vascularised connective tissue. Around 75% of the lymphatic drainage of the breast passes to axillary lymph nodes, mainly to the anterior nodes, though direct drainage to central and or apical nodes is possible. Much of the rest of the lymphatic drainage particularly from the medial part of the breasts is to parasternal nodes along the 5

internal thoracic artery. A few lymphatics follow the intercostal arteries and drain to posterior intercostal nodes. The superficial lymphatics of the breast have connections with those of the opposite breast and the anterior abdominal wall, from the extra peritoneal tissues of which there is drainage through the diaphragm to posterior mediastinal nodes. Direct drainage to supraclavicular nodes is possible. These minor pathways tend to convey lymph from the breast only-when the major channels are obstructed by malignancy. The arterial blood supply derives from branches of the internal thoracic artery, the lateral thoracic artery, anterior intercostal arteries and the thoracoacrominal artery through a pectoral branch. The venous drainage of the breast is both superficial and deep. The superficial veins are significant because they anastomose across the midline of the anterior chest wall. The deep veins follow the course of the arterial system into the axillary, internal thoracic and intercostal veins as well as external jugular. Sensory nerves to the breast come from the fourth to the sixth thoracic segments through the anterior and lateral cutaneous branches of the intercostal nerves.

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Physiology
Early differentiation of he mammary gland anlage is under fetal hormonal control. Growth of the breast is dependent on numerous hormonal factors that occur in two sequences. First at puberty and then during pregnancy. The major influence on breast growth during puberty is by Estrogen; which brings about growth of the ductal portion of the gland system. Progesterone influences the growth of the alveolar components of the lobule. Neither hormone alone or in combination, however, is capable of yielding optimal breast growth and development. Full differentiations of the gland requires, cortisol, thyroxine, prolactin and growth hormone. Breast tissue reacts to estrogen and progesterone stimulation, not only during puberty, pregnancy and lactation, but during each menstrual cycle. As the menopausal period is approached and post menopausal period evolves, progressive atrophy of the epithelial an connective tissue components of the breast occurs. The loose connective tissue becomes dense and hyalinized and finally, the lobule is converted into ordinary stroma, which in the process of involution is replaced by fat. The role of these hormones in the causation of mammary pathologies, though suggestive, remains unclear.

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A framework of pathogenesis for the classification of benign breast disorders Reproductive period Normal process Ductal development Lobular Development Stromal Development Benign breast disorder Nipple inversion, Single duct Obstruction Fibroadenoma Juvenile Hypertrophy Mastalgia Nodularity Focal Diffuse Benign papilloma Blood stained nipple Discharge Galactocele and inappropriate lactation Cysts and sclerosing adenosis Nipple retraction Duct ectasia Simple hyperplasia Micro Papillomatosis Benign breast disease Mamillary duct fistula. Giant fibroadenoma

Development

Cyclical change

Hormonal Activity Epithelial Activity

Pregnancy and lactation

Epithelial Hyperplasia Lactation Lobular involution Ductal involution Fibrosis Dilatation Involutional Epithelial Hyperplasia

Involution

Periductal mastitis with suppuration Lobular hyperplasia with atypia Ductal hyperplasia with atypia

Clinically, the most useful system of classification of benign breast disease is based on symptoms and physical findings. Six general categories have been identified. 1. Physiologic cycle swelling and tenderness 2. Nodularity : Signigicant lumpiness, both cyclic and non cyclic 3. Mastalgia : Severe pain, both cyclic and non cyclic 4. Dominant lumps : Including gross cysts and fibroadenomas 5. Nipple discharge : Including intraductal papilloma and duct ectasia 6. Infections and inflammations : Including subareolar abscesses, lactational mastitis, breast abscesses, and Mondor’s disease.

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FIBROCYSTIC DISEASE
The phrase Fibrocystic Breast Disease (FCD) is catch-basin term

synonymous with more than 38 terms used to describe the most common type of lesion in the female breast. Here, in our study, the benign breast disorders that were considered under this category were cysts, lobular hyperplasia, cystic mastitis, fibrosclerosis, sympotomatic chronic cystic mastopathy, fibroadenomatoid hyperplasis and mammary dysplasia. Fibrocystic breast disease is noncancerous. The most common of the benign conditions of the breast is fibrocystic change (FCC) and it is defined as enhanced or exaggerated reaction by breast tissue to the cyclic up and down levels of ovarian hormones. It is a disorder of involution which as first described by Sir Astley cooper and Benjamin Brodie.

Mechanism
The involution of a lobule is dependent on the continuing presence of the surrounding specialized stroma. If there is early disappearance of stoma, the epithelial function persists and results in formation of microcysts. In the same manner there is formation of macrocysts which was described by parks, as a process in which there is obstruction of efferent ductile by fibrous or epithelial debris.

Pathology
The term Fibrocystic Cystic Disease (FCD) has been formally abandoned from a historic standpoint by the college of American Pathologists in reliance on the landmark study of benign biopsies by Dupont and Page, now the term used is fibrocystic Changes (FCC).

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This system separates various components of fibrocystic changes into 3 groups; it is a prognostic category based on recent studies. The categories are: Nonproliferative lesions Proliferative changes with no atypia Proliferative changes with atypia 70% 26% 4%

Of patients in the 30% of the study group, 4% had both atypia and proliferative changes on biopsy and do thereby appear at a five fold increased risk for breast cancer. Women were at highest risk level of developing cancer if they had cellular atypia and a positive family history for breast cancer. The conclusion from these studies states that unless proliferative changes with atypia are present, fibrocystic changes are not risk factors for cancer. Microscopic features studies on specimen tissues are: (a) cysts: They contain dark mucoid material and vary in size. (b) Adenosis: There is an overall increase in glandular tissue due to budding and multiplication of the acini. © Epitheliosis: There is hyperplasia of the epithelium, acini and the lining ducts. (d) Fibrosis: Dense white fibrous trabeculae replace the fat and elastic tissue. This leads to compression of the ducts by fibrous tissue, resulting in cyst formtion. Chronic inflammatory cells infiltrate the interstitial tissue. (e) Papillomatosis: when the epithelial hyperplasia is very extensive, it may result in papillomatous growth within the ducts. Most, if not all women experience fibrocystic disease. Cysts are more common in noncancerous breasts than cancerous (53% versus 27%). Common age group is 40-55 years. Proven cystic diseases such as palpable tumors or grossly visible cysts exceed in incidence as compared to carcinoma. Cysts usually subside and regress totally at menopause.

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Etiology
The etiology of cystic disease is attributed to oestrogen imbalance. Excess of oestrogen cause epithelial proliferation and dilatation of the mammary ducts and cyst formation. In fibrocystic disease, prolactin is also increased. So the cyclical changes of the breast tissue under die influence of these hormones, induces epithelial and stromal changes.

Sub populations of gross breast cysts
Two sub populations of gross breast are seen (i) (ii) Apocrine Attenuated

They are different with respect to bilaterality, multiplicity and recurrence rates. Apocrine cysts to be bilateral, have full columnar epithelial linings, multiple and more prone to recurrence. In contrast, attenuated cysts histologically have flattened epithelium. Biochemical properties of cysts Leis perfomed biochemical analysis on the aspirated fluid of 2213 breast cysts. Attenuated cysts have fluid contents in equilibrium with the plasma. They have ratio greater than 3 and contain albumin, nonsecretory 7S immunoglobulin (Ig) (7S8A) and low levels of apocrine proteins. Fluids aspirated from apocrine cysts contain low sodium and high potassium levels. The Na:K ratio is less than 3, and they contain US secretary IgA, high levels of apocrine cyst protein, epidermal growth factors and dehydroisoandrosterone.

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Future studies of breast cysts fluid may help to identify those types prone to recurrence as well as those prone to hyperplasia.

Pathogenesis
Cysts are now regarded as manifestations of lobular involutions with advancing age. These are increasing numbers of cystically dilated acini seen in breast lobules. The dilated acini may involute completely or may coalesce to form smaller number of larger cysts. Some degrees of ductal obstruction by debris or epithelial hyperplasia or kinking is almost certainly necessary for the production of longer tension cysts. Hormonal mechanisms or imbalance of secretion is sufficient to explain the smaller cysts. Other associated conditions with fibrocystic disease have

histopathological features such as: • • • • •

Multiple microcysts Papillomatosis (Proliferation of ductal epithelium) Apocrine metaplasia of duct epithelium Fibrosis Adenosis

Clinical Features
The most common signs and symptoms of fibrocystic changes is pain (mastodynia) accompanied by tenderness. The pain is often bilateral and particularly noticeable during the premenstrual phases of the normal cycle. The lumpiness, nodularity, may be localized or generalized, unilateral or bilateral. Other signs of fibrocystic changes include excessive nodularity, generalized lumpiness, increased engorgement and breast density with the breast being

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described as being full and heavy and fluctuations in the size of cystic areas. Occasionally, spontaneous nipple discharges is present. These may be severe localized pain associated with rapid fluid of a simple cyst. Fine nodularity may be seen in the breast during pregnancy, lactation nearly always produces permanent relief. Cysts develop quickly, sometimes attaining considerable size within a few days and may diminish in size rapidly. Cysts are well circumscribed, soft to firm, relatively mobile, may be tender and occasionally inflamed. Otherwise, it is serous colorless and sterile.

Clinical stages of fibrocystic changes
There are 3 clinical stages of fibrocystic changes with considerable overlap from a clinical presentation standpoint. First Stage: Mazoplasia – Occurs in women in their twenties pain is mostly found in the most tender area being the indurated axillary tail. There is intense proliferation of the stroma in the mazoplasia phase. Second Stage: Adenosis - occurs in women in their thirties. Multiple breast nodules (2 – 10 mm in size) with premenstrual pain and tenderness of the breasts. There is marked proliferation and hyperplasia of ducts, ductules, and alveolar cells. Third Stages: Cystic Phase - This stage is attained usually in women in their late thirties and forties. The cysts may be solitary (cooper’s disease) or multiple (Reclus disease) lumps are cystic when palpated. They are tender, slightly, mobile and fairly well defined cysts that are deeply embedded, or a cluster or cysts can appear like a mass that mimics cancer. Normally no severe breast pain is present. But when a cyst increases in size and lump appears suddenly, it is associated with sudden onset of pain and point tenderness. The fluid aspirated from the cyst may be straw coloured, or dark brown to green. The colour varies according to the chronicity of the cyst.

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Clinical Features On examination, the breasts are nodular, the size of rice grains well delineated. The breast is usually firm and the lump can be better made out between the thumb and finger than with the palm of the hand. The lump is neither adherent to the pectoral fascia, not to the skin. A serous or dark green discharge may be present from the nipple, but there is no retraction seen. The condition is evident in one quadrant than the others. Sometimes the axillary lymphnodes are slightly enlarged and tender, but they are not hard. Very tense cysts may simulate carcinoma. Closely placed large cysts may even displace the surrounding cooper’s ligaments , producing approach skin attachment or nipple retraction (false retraction of Haagensen).

Carcinoma and Fibrocystic Disease
An increased risk of subsequent breast carcinoma ranges from 1.7 to 4.0 times normal. The histologic lesion has been divided into 3 prognostic categories as a result of recent studies. The categories are:  Non prolieferative  Proliferative changes with atypia  Proliferative changes with no atypia. Studies have shown that 70% of women with excised breast fibrocystic changes have nonproliferative changes, i.e. not associated with an increased risk for cancer.

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30% have proliferative changes, of which 26% did not have any atypia (do not seem at increased risk for breast cancer) and 4% had proliferative changes with atypia, and thereby appear to have a fivefold increased risk for breast cancer. Women were at the highest risk level of developing cancer if they had cellular atypia and positive family history for breast cancer. There was a 11-fold increase risk. Relative risk for breast cancer based on pathologic examination of benign breast tissue Category Adenosis Apocrine metaplasia Cysts micro and or macro Duct ectasia Fibrosis Mild hyperplasia Mastitis Periductal mastitis Squamous metaplasia Hyperplasia, moderate relative risk

or

florid, Slightly increased risk (1.5 to 2 times)

solitary or papillary Papilloma with fibrovascular core Atypical hyperplasia Ductal Lobular

Moderately increased risk (5 times)

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Role of Oral Contraceptives
Oral contraceptives reduce the incidence of change with minimal epithelial atypia but seem to have no effect on those with marked epithelial atypias. Use of oral contraceptives for 2 to 4 years or more is associated with a decreased frequency in fibrocystic disease. In summary, fibrocystic changes have been defined as a condition in which there are palpable lumps in the breast, usually associated with pain and tenderness, that fluctuate with the menstrual cycle and become progressively worse until menopause. The range of symptomatology is broad, based on the fluctuating response in the epithelial tissue and fat. The lesions may very in size from 1 mm to many centimeters; and the physiological nodularity is probably under hormonal control. Age, parity, genetic makeup and lactation history may all have a bearing on fibrocystic changes. Risk factors for fibrocystic changes include nulliparity, later age of natural menopause and high social class, whereas, artificial menopause, age at first birth, and parity seem to have different effects.

FIBROADENOMA
Fibroadenomas are the most common benign solid tumors of the female breast. It is merely and innocuous overgrowth of fibrous tissue with epithelial elements; an abnormality of normal development and involution.

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Frequency It represents the most common breast tumor in women younger than 25 years they may be seen anytime after puberty, but are frequent in women in their third decade. Between one third to one half of the biopsies for benign breast disease yield fibroadenoma. A study conducted by cheatle, 1 fibroadenoma is found every 25 breasts examined. In a series of 225 autopsy cases studied by Frantz, fibroadenomas were found in 9%. Origin and Natural History Fibrodenomas are considered to be an abnormality of normal

development and involution. They are hormonally responsive and may increase in size towards the end of each menstrual cycle. Recent studies have demonstrated estrogen and progesterone receptors in fibroadenomas. Biologic Behaviour The biological behaviour is widely variable with 3 broad possibilities: 1. Regression of the fibroadenoma 2. Static fibroadenomas 3. progressively growing fibroadenomas Fibroadenomas grew to 1-2 cm in size and then remained unchanged, as studied by Haagensen. Many of them stayed unchanged or disappeared on follow up. Regression is seen in later life and it is rare in older women owing to the diminishing cellularity with increasing age.

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In a study by David M Dent, 63 young women were diagnosed to have fibroadenoma. 31% resolved and a further 12% became smaller over 13-24 months single fibroadenomas had a higher tendency for regression. Special varieties 1. Giant fibroadenoma 2. Multiple successive fibroadenoma 3. Juvenile fibroadenoma 4. Fibroadenoma in pregnancy and lactation Giant Fibroadenoma An accepted definition of this entity as concluded by various studies, is a fibroadenoma with 5cm – 8cm diameter as the criteria. These tumors, unlike phyllodes tumor, develop at or immediately after puberty and attained massive size in a short period of time. It may start as a solitary nodule in breast and quickly grow to a large size. There may be multiple tumors in both breasts with one or two attaining enormous size. They are well encapsulated; with microscopic features of fibroadneoma. They do not recur if completely removed. In Haagensen’s series, the age ranged from 12-16 years and the size varied from 16-19 cms. In all the cases, local excision was curative. Multiple Fibroadenomas These are found in 16% in Haagensen’s series. In most instances, the lesions were smaller than 2 cm, occurred simultaneously and were rarely more than 2-3 in number. A rare variant in young women was that of multiple, bilateral fibroadenomas, which were either synchronous or metachronous, many of the lesions reaching the size of juvenile fibroadneoams. These can recur after removal. They may attain very large sizes. Yet they do not metastasize and thus

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do not become malignant. In a third of female patients on immunosuppression with cyclosposin A, for renal transplant, multiple fibroadenomas were seen, usually bilateral. Juvenile Fibroadenoma This term is used when giant fibroadenoma occurs in adolescent girls. Most undergo rapid growth, cause marked breast asymmetry, distortion and stretching of the nipple and skin. They are not a histological entity, but tend to be more cellular with a minimal lobular development route and have no recurrence. Fibroadenoma in Pregnancy and Lactation Moren reported a series of cases where fibroadenoma grew considerably during pregnancy. In such a type, fibroadenoma microscopically showed same type of epithelial proliferation as those of surrounding normal breast tissue. It is also observed that fibroadenomas decrease in size after pregnancy and after cessation of lactation. Many are of giant or juvenile variety and demonstrate microscopic changes of lactation similar to adjacent breast tissue, indeed the cut specimen may exude milk. Excision in best delayed until after childbirth since regression may occur and surgery is undesirable during pregnancy. Partial or total infarction and necrosis of fibroadenoma has been noted during pregnancy and lactation. The increased demand of blood by the hyperactive breast tissue leads to decreased blood supply to the fibroadenoma, thus causing infarction. Pathology The fibroadenomas appears as well encapsulated tumors. The capsule is a false capsule made up of compressed normal tissues, and it can be separated from the breast tissue.

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The cut surface is white to brown in colour and it may bulge and glisten due to increased mucous content, clefts are seen as dark line in the tumor. Microscopically It is made up of two components. (i) (ii) Proliferating connective tissue stroma Typical multiplication of ducts and acini These compounds are present in varying degree. The clefts are lined by epithelium, showing proliferative process . Essentially the histology is one of delicate cellular fibroblastic stroma enclosing glandular and cystic spaces lined by epithelium; intact round to oval glands may be present, lined by single or multiple cell layers called pericanalicular fibroadenoma. When the connective tissue undergoes extensive proliferation leading to compression of glandular lumen into slit like irregular cleft, it is called intracanalicular fibroadenoma. Tubular adenoma has scanty connective tissue and plenty of glandular elements commonly seen in lactation and hence called lactating adenoma. Clinical Features Fiboadenomas are well delineated, freely mobile tumors with rounded, lobulated or discoid configuration. They are usually rubbery and firm but, when calcified, they may be stony hard usually and confused with carcinoma when seen in elderly women. The relative mobility of fibroadenma within the breast tissue is a

characteristic feature ‘mouse in breast’. This mobility is due to the fact that it is well circumscribed and slides within the breast. Papillary carcinoma can

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occasionally mimic fibroadenoma. These can be confirmed with an FNAC and if necessary, excison biopsy. Fibroadenoma and Malignancy Benign breast lesions are classified as proliferative or nonproliferative Nonproliferative disease is not associated with an increased risk of breast cancer, whereas, proliferative disease without atypia results in a small increase in risk, 1.5 to 2.0. Atypical hyperplasia is associated with a greater risk of cancer development i.e. 4 to 5. The absolute risk of breast cancer development in women with a positive family history and atypical hyperplasia was 20% at 15 years, compared with 8% in women with atypical hyperplasia with a negative family history of breast carcinomas. No increased risk of breast cancer development was observed in women with a diagnosis of proliferative disease who used estrogen after their breast biopsies. MASTODYNIA Cyclical mastodynia affects 30-40% of the premenopausal women in western society during their reproductive years; in approximately 8% of the women it is of such severity that it significantly interferes with normal activities. As is the case with other pain dominated conditions, mastodynia has proven difficult for the community to recognize, diagnose or treat. Previously, it was considered to be more of pyschologic than a physiologic disorder. Frequency Evaluation of healthy women in the general population, self referred to a breast screening clinic. 69% reported having mastalgia, sufficient to cause distress

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and interfere with their daily routine. In south wales, Maddox and Mansel conducted a survey of working women with 585 respondents. Of these, 45% reported mild mastalgia and 2% report severe breast pain. Symptomatology and clinical Features The syndrome comprises of breast swelling, tenderness and or engorgement which typically begin during the luteal phase of the menstrual cycle, increase in intensity as menses approach and then resolve rapidly with the onset of menstrual flow. In severe cases symptoms may begin soon after menses during the follicular phase of the cycle, leaving a very brief symptom-free interval around the time of menstrual period. Cyclical mastalgia has to be differentiated from non-cyclical mastalgia, in which pain does not vary in relation to the menstrual cycle in the manner described above, and from secondary causes of breast pain such as infection, trauma or tumor, in which underlying physical causes for breast pain can be identified. Mastodynia can occur in association with a symptom complex commonly referred to as the premenstrual syndrome or it may occur in the absence of this syndrome. Often it is worse in the upper outer quadrants and is associated with a diffuse nodularity. These is no measurable relationship however, between the extent of nodularity and pain severity. Patients describe a diffuse tenderness or heaviness in the breast or breasts. It is usually bilateral, but is may be unilateral. Age Distribution Mastodynia was usually reported in the age group of over 34 years of age. It usually begins in the third decade of life and runs a chronic relapsing course

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until menopause. Only 20% of women can expect spontaneous improvement prior to menopause. Etiology It is postulated that breast pain has a hormonal origin. The is usually relieved by a disruption of the horomonal milieu, including drugs-surgery and menopause. Circulating hormone levels are normal in cyclical mastalgia patients. The theory that a relative hyperstrogenemia occurring secondary to decreased progesterone levels in the luteal phase cannot be substantiated. Dynamic testing of pituitary function using thyrotropin releasing hormone has demonstrated an increase in the dynamic release of prolactin in cyclic mastalgia patients. With normal levels of circulating hormones and a normal level of breast hormone receptors attention has been turned towards theories of altered receptor sensitivity. Cyclic mastalgia patients have an increase in plasma proportions of the esters of the palmitic and stearic saturated fatty acids, whereas the esters of the enoleic,dihomogamalenolenic (DGLA), and arachidonic polyunsaturated essential fatty acids were decreased. These essential fatty acids and metabolites are important components of cell membrance and the receptors, cell membrane associated or not, have a lipid moiety associated with the protein recognition site. Behaviour of the receptor could be significantly altered by the essential fatty acid to saturated fatty acid ratio. Increased saturation is associated with increased affinity. If patients with mastalgia have an increased ratio of saturated fatty acids, they could conceivably obtain a higher target option response to normal 23

circulating hormone levels. For instance a low-fat diet has been shown to decrease the bioavailability of prolactin without affecting the serum prolactin levels. If this is true, factors altering plasma fatty acid ratios could useful in the management of breast pain.

GYNECOMASTIA
Gynecomastia is a dominant problem of the male breast. The normal adult male breast consists of nipple, ductal tissue and a fibrous stroma which is accompanied by variable amount of fat. In gynecomastia the breast takes on the female form, an event that also occurs in obesity when the enlargement is due fat deposition only, and in the later it is pseudogynecomastia. Clinical Features Patients present with a breast swelling, often it is unilateral and frequently tender Patients are concerned about cosmetic appearance, pain or tenderness and but malignancy. Examination reveals a firm retroareolar disc of tissue, clearly demarcated from the surrounding tissues, and, mobile and tender on palpation. The hallmark of gynecomastia is its concentricity. When in doubt,

mammography will allow quantification of the amount of fat and breast parenchyma. Simon et al graded gynecomastia on the basis of size. The criteria for diagnosis vary. Most authorities make a diagnosis of gynecomastia when the disc of breast tissue is at least 2 cm in diameter although others have considered it gynecomastia when only 0.5 cm of breast tissue is present.

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Histology There is proliferation of loose periductal connective tissue together with variable degrees of multiplication, elongation of, or branching of ducts. and large Periductal cells, infiltration by plasma cells, lymophocytes

mononuclaear cells may occur. Acinar formation seems to occur only after long term oestrogen treatment as in klinefelter’s syndrome. The changes seen are rather quantitative than qualitative. Incidence Two studies have established that mild forms of gynecomastia are very common, although presentation as a clinical complaints is far less sequent. The overall incidence was between 10-16 years at 38% reached 65% in the 14 years old and dropped to 14% in the 16 year old. Nontal in his study of 306 men showed that an incidence of 11% in youths in their late teens, gradually increased to 51% over 50 years. Bilateral involvement was present in 63% of 94 patients in a separate study. Aetiology Because of the clear relationship between the incidence of gynecomastia and hormonal events, the rate of an endocrine abnormality in gynecomastia needs to be seriously considered. Hormonal Defects in Gynecomastia According to a number of studies, there is a relative alternation in circulating sex steroids in patients with gynecomastia. These was a transient increase in the apparent. oestrogen levels before the gynecomastia became clinically

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Moore and associates demonstrated a low delta4 androstenedione / oestrogen and oestradiol ratio(testesterone/oestrone ratio remaining normal) in the affected boys and postulated that the cause was peripheral conversion of adrenal androgens to oestrone and oestadiol. In the adult male, more testosterone is produced, but at puberty oestrogen production is thought to reach adult levels before testosterone and this results in transitory rise in the testosterone ratio. It seems that secondary gynecomastia is also due to hormonal imbalance. Only about 10% of cases are true unilateral. Unilateral gynecomastia presumes a local factor presumably related to hormone receptors or local hormone conversion, but remains an endocrinological enigma. Reports of tissue positivity vary from 10 to 90% oestrogen receptors and 20 to 75% for androgen receptors. Classification (a) Physiological Gynecomastia (i) Infantile: due to circulating maternal hormones. This resolves by 4 months of age it is usually bilateral and reassurance to the mother is all that is needed. (ii) Adolescence: This lesion is common during adolescence. Majority of cases resolve by 6 Months. (iii) Adult: Asymptomatic gynecomastia persists until a reversible underlying cause is found. (B) secondary Gynecomastia (i) Tumors: Both teratomas and seminoma testis may secrete enough estrogens to produce gynecomastia. Bronchogenic carcinoma, pituitary, hypothalamic and adrenal tumors may gynecomastia 26 also produce oestrogen /

Chemotherapeutic testicular cancer (ii)

agents

and

radiotherapy

can

cause

gynecomastia especially in patients who have had an orchidectomy for

klinefelters syndrome : Features are those of testicular atrophy, eunuchoid habitués with female distribution of hair and gynecomastia. Here gynecomastia is associated with an increased incidence of carcinoma. Hepatic failure : with the exception of drug induced changes, this is probably the most common cause of gynecomastia. The liver fails to eliminate androstenedione , which is peripherally converted to oestrogen Secondary testicular failure : Damage to the testis results in decreased androgen/ estrogen ratio. Viral orchitis most commonly due to mumps, is the most frequent cause of testicular atrophy is young men. Starvation refeeding : The cause is due to the fatty changes that occur in the livers in such patients. It is seen in prisoners of war and severely ill patients in intensive care units. Drugs : A large number of drugs can cause gynecomastia. They act via a relative increase in the oestrogenic activity or inhibition of activity. Administration of oestrogen in prostatic cancer causes gynecomastia. Drugs such as digitalis and marijuana also have the same effect as that of antiandrogens such as cyproterone used in prostatic cancer, and the side effects of cimetidine and spironolactone , resulting in gynecomastia

(iii)

(iv)

(v)

(vi)

PHYLLODES TUMOR
The phyllodes tumor a lesion limited to mammary tissue , was first described by johannis muller in 1838 and called it cystic phyllodes (leaf like) as it

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contained leaf like projections into cavities in the tumor. It can occur in any breast and occur even after excision of previously existing fibroadenoma. The term phyllodes tumor should be qualified as benign or malignant according to the histological appearances. Phyllodes tumors are mesenchymal tumors of the breast to malignant according to the histological appearances. Phyllodes tumors are mesenchymal tumors of the breast that exhibit a range of clinical and pathological presentations. When viewed as part of a broad spectrum, low grade phyllodes tumors might be conceptualized as being further along a continuum than a hypercellular fibroadenoma, while high-grade phyllodes can be through as connective-tissue that are less aggressive than most sarcomas. Phyllodes tumor has got a stroma of general architecture of fibroadenoma but its stroma is unusually cellular and sarcoma like. So microscopically it looks malignant, can recur locally on incomplete or complete removal, yet if it is low grade, it cannot metastasise and so remains as a benign tumor. Pathology The tumor well-delineated but does not have a true capsule. It is softer than a fibroadenoma. The cut surface of the solid portion of the tumor is moist and sticky and colour varies from grey, yellow to brown. Microscopically elongated epithelium lined clefts are seen. Myxoid nature is more common in phyllodes tumor and presents as areas of necrosis. The stroma shows a sarcoma like picture. It may look like fibrosarcoma or liposarcoma. Apart from sarcomatous metaplasia, histiocytic metaplasia are seen and are multifocal. Cartilage or osteoid tissue foci are seen in few cases, and if so, in an otherwise case of fibroadenoma, a diagnosis of phyllodes tumor should be made.

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Frequency, Age Distribution It is a rare condition with an incidence of 1 in 10000. it constitutes only 0.3 to 1% of all fibroepithelial tumors. Develops in the third or fourth decade of life. The mean age being 44-47 years in Haagensen series of 84 cases. There are reports of occurrences in adolescents also. Epidemiological data suggest that the incidence of phyllodes tumors may be higher in whites. Clinical Features Most patients have a smooth , round, firm, well defined, mobile, painless mass on examination. They are difficult, if not impossible to distinguish from fibroadenoma on physical examination. These are large rapidly growing, non-invasive, non-capsulated, well circumscribed tumor. Not all phyllodes tumors grow to large sizes, 1 out of 84 cases in Haagensen series were 1-3 cm in diameter. Phyllodes tumors do not invade the skin. When they grow rapidly they can cause skin necrosis due to pressure effects, if not the non involvement of skin can be demonstrated by passing a probe beneath the skin. Phyllodes Tumors and Malignancy A few phyllodes tumors become malignant. In Sunderland study, 18 cases were malignant and 9 showed metastasis out of 77 cases. Metastatic disease can involve the lungs, thigh, pleura, sacrum, axial skeleton, pancreas, central nervous system, and mandible, statistically significant correlations between tumor grade, specifically stromal over growth high mitotic rate, cytological atypia and metastatic disease – have been demonstrated in the literature.

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The designation, stromal overgrowth, a microscopic term indicating that the stroma has replaced the glandular elements of the breast, is thought to be an important determinant of metastatic potential.

DUCT ECTASIA
This is a disorder of duct involution affecting major ducts of the breast. It is a benign condition, poorly understood and has been variously named – duct ectasia and periductal mastitis were considered traditionally to be part of the same disease process. However recent studies suggest that they are different conditions. It was first recognized by Bloodgood as a distinct clinical entity in 1923. He called it as “varicococele tumor of the Breast” because of the frequent findings of palpable subareolar dilated ducts. Bloodgood described duct dilations, but noted that periductal inflammation was a frequent finding. Fugier called this, mastitis obliterans. As the principle cell in periductal inflammation was the plasma cell, it was also called “Plasma cell mastitis”. Other names such as comedo mastitis; periductal mastitis; secretary disease of the breast have also been used. Haagensen introduced the term duct ectasia as it is now known. Incidence The clinical syndrome is now well recognized and is characterized by some of the following features such as non cyclical mastalgia, nipple discharge, nipple retraction, a subareolar breast lump, a periareolar abscess and a mammary fistula. The term, duct ectasia or periductal mastitis encompasses all the pathological process, hence is the most suitable to denote this disease, which accounts for 4% of cases attending breast clinic, but is in much higher proportion in the asymptomatic form in the general population.

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Geschicker found 2.3% patients had dilated ducts in a series of 3107 women with benign disease of the breast. Two thirds of these women were over 40 years and the oldest was 72 years. Frantz and Associates found 24% cases to be duct ectasia in a series of 25 women with no history of previous breast disease. It is likely that much of what is included in these studies under periductal mastitis or duct ectasia is normal aging or duct involution which explain why in these studies the incidence increases with age. Pathogenesis Earlier it was considered that duct dilation occurred primary and subsequently periductal fibrosis, fibrous contraction and nipple retraction occurred as a secondary phenomenon due to leakage of duct contents through the damaged walls. More recently, the view is that periductal inflammation is the primary essential feature, and later resulted in duct dilation resulting from the destruction of the elastic supporting lamina of the ducts. Recent data suggest that both periductal mastitis and duct ectasia are component parts of the same disease complex and that peridcutal mastitis is the initial event and ectasia the final outcome. i) Breast Pain It is non cyclical and tends to affect younger patients, that is, those with more active periductal inflammation. The pain may precede an inflammatory mass or be an isolated symptom and antibiotics may be useful in relieving the pain. ii) Breast Mass In can be present as a breast mass. It comprises 3-4% of all benign breast masses. The masses are usually present at the periareolar margins and in

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younger patients, is often associated with overlying erythema. There is intense periductal mastitis, the ducts are surrounded by polymorph and plasma cells, lymphocytes, giant cells and granulomata. iii) Nipple Discharge It is present in 15-20% of patients with periductal mastitis or ectasia. Discharge varies from straw to cream, green to brown, and rarely blood stained. The discharge may be unilateral or bilateral, from single or multiple ducts, which may be multi coloured and sticky. iv) Nipple Retraction Periductal fibrosis occurs during the phase of chronic inflammation as tissues are destroyed and repaired. This periductal fibrosis results in changes in nipple contour. Minor degrees of nipple retraction occur early in the disease and are present in up to 75% of the patients who present with periareolar inflammation. Marked nipple retraction occurs at a later date. v) Non lactating Breast Abscess These abscesses are now more common than those occurring in the puerperium. Those developing in the periareolar region are due to periductal mastitis or duct ectasia. The age of the patients with these abscesses averages around 32.5 years. vi) Mammillary Fistula The term fistula was introduced by Atkins in 1952 to describe fistulas of the lactiferous ducts, first reported by Zuska and Associates in 1951. fistula may develop spontaneously or following biopsy for duct ectasia.

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Aetiology The aetiology of duct ectasia is unknown, but it appears to arise from long standing or smouldering inflammation of the duct wall and periductal fibrosis. For many years, pregnancy and breast feeding were considered as the aetiological factors in this condition. Now it is suspected that bacteria may have a role in the aetiology of periductal mastitis and ectasia. Organisms, particularly anaerobes, have been isolated from subareolar breast abscesses and appropriate antibiotics have proved useful in treating periareolar inflammation associated with this condition. The theory put forward suggests that infection follows stasis of secretion, which is incorrect. There is some experimental evidence to suggest an autoimmune basis and the chronic inflammatory infiltrate seen in the condition support this periductal mastitis, predominately a disease of younger women, with an increased incidence amongst smokers. Clinical and Pathological Features This condition causes symptoms over a large age group range with the peak incidence being in the age group of 40-49 years.

NON LACTATIONAL BREAST ABCESSES
Breast abscesses in non lactating women are now more common than those occurring in the puerperium. Lactational breast abscesses can be treated successfully by recurrent aspiration and antibiotics, but it is still traditional to incise and drain non-lactational breast abscesses. The features of mastitis remain the same in spite of varies aetiologies.

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Types i) Mastitis of Infants It is due to maternal hormones acting on fetal breast. It is a rare physiological feature usually seen on the third or fourth day. If gently expressed, a drop of colorless fluid can be expressed. A few days later, a milky secretion, popularly called “Witch’s milk” appears, which subsides by third week. ii) Mastitis of Puberty Seen frequently in males, compared to females. The patient is aged around 14 years and complains of pain and swelling in the breast. The tenderness subsides in 2 weeks, but the inflammation may persist. Sometimes when the tenderness persists, local mastectomy with nipple conservation may be needed. iii) Bacterial Mastitis By far, this is the commonest verify of breast abscess. In developing countries, lactational abscesses are common, whereas, in the developed west, non lactational abscesses are usually seen. Bacteriology Common organisms causing bacterial mastitis are bacteroides (30%) staphylococcus aureus (20%). Anaerobic streptococcus (24%) while 22% of the cases yield no growth on culture. In patients with recurrent breast abscesses or mammary fistulae, anaerobic bacteria are usually isolated. Clinical Features The affected part of the breast is said to have reached the “cellullitic stage” when it presents with the classical signs of acute inflammation.

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Bundred et al have enumerated 3 causes of recurrence of non-lactational breast abscesses.  Subareolar situation  Presence of anaerobic organisms  Presence of underlying duct ectasia Haagensen described what he called mammary duct ectasia, in 1951 as an inflammatory disease of the major duct system deep to the nipple and areola. Histologically there is a periductal inflammation around dilated ducts which may contain cellular debris and lipid rich material. In the commoner chronic form, this inflammation may eventually lead to fibrosis and inflammation may eventually lead to fibrosis and atrophy of the duct system. However, it may present acutely as an abscess often caused by an anaerobic organism and effective treatment in the form of excision of the major duct system prevents recurrence. iv) Subareolar Mastits This results from the infected sebaceous gland of Montgomery and hence not a true mastitis. It can also arise from a furuncle on or near the areola. There are no constitutional symptoms. No matter how small, if a lump can be felt, pus is present, and it should be drained. Spontaneous rupture leads to chronicity or recrudescence, but not cure. v) Chronic Abscesses of the Breast Inflammatory abscesses which are subareolar or intramammary can become chronic. They follow injudicious antibiotic treatment or inadequate

35

drainage. When encapsulated within a thick wail of fibrous tissue, it cannot be easily distinguished from a carcinoma. Chronic subareolar abscess, results due to long standing nipple retraction which causes the infection to be restricted to a single obstructed duct system. The abscess which forms, ruptures and subsides only to repeat the cycle over an over again at intervals of a few months, leading to chronic mamillary fistula. Duct ectasia can also cause a fistula to form. vi) Tuberculosis of the breast Tuberculosis of the breast was first described by Sir Astley Cooper in 1829. it occurs less frequently than in other organs of the body. Reports from India have described the incidence to be between 3 to 5.3%. Tubercular breast as reported in western literature is low ranging from 0.06 to 1.6%. It is most often associated with active pulmonary tuberculosis or cervical tubercular adenitis. The diagnosis rests on the bacteriological and histological features. Healing is usually delayed. Mastectomy should be restricted to patients with persistent residual infection. vii) Retromammary Abscess Here the pus is situated in the cellular tissues behind the breast and may not be connected to the breast proper, usually due to tuberculosis of the rib, infected haematoma or chronic empyema. viii) Breast abscess in neonates and infants It is due to infection of milk induced by the transplacental passage of maternal hormones. If antibiotics do not help this condition great care must be

36

taken during surgical drainage as damage to the breast disc at the age may lead to distortion in later life. Breast abscesses are most frequently encountered during 2 or 3 weeks of life and occur more commonly in females. The disease does not occur in premature infants, presumably because of underdeveloped mammary gland. Bilateral disease is rare. The major presentation of neonatal breast abscess is localized swelling with or without accompanying erythema and warmth. The manifestation is usually not systemic and only 25% of these infants have low grade fever. Staphylococcus aureus is the major pathogen, coliform bacteria and group B streptococci are also encountered. The diagnosis of breast abscess is best made by needle aspiration of the affected site. The single most important aspect of management is prompt incision and drainage by a skilled surgeon. Long term follow up study of these cases suggest that some girls have diminished breast tissue on the affected side.

THE DIAGNOSTIC EVALUATION OF BENIGN BREAST DISEASES
Utilizing a breast oriented history and the diagnostic tries of clinical breast examination, mammography or ultrasound, and fine needle aspiration, the clinician can accurately manage most breast lesions. The common investigations available are: 1. Needle Biopsy There are two types: A) High speed drill or tru cut biopsy B) Fine needle aspiration cytology (FNAC)

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Of the two FNAC is more commonly used. A 22 gauge needle is used to enter the mass, fluid and cells are aspirated and examined microscopically for malignant or benign cells. FNAC is a quick and cost effective method for investigating benign breast disease. Dixon J.M, Forrest A.P.M and Chetty U. have performed a study that shows that FNAC when reported immediately has reduced the excision rates in benign diseases. Although its positive predictive value is close to 100%, the incidence of false negative results ranges from 5% to 25% emphasizing that FNAC cannot be used as the role criteria for determining whether a mass is benign or malignant. Problems associated with the procedure include pinpointing the lesion with the needle, obtaining adequate cytological specimen and differentiation of benign from malignant lesions. Radiologically localization of impalpable lesion for biopsy purpose is done either by double dye method or hooked wire technique. 2. Excision Biopsy Also called open surgical biopsy, is the final definite diagnostic procedure. It is used both to confirm the diagnosis and as therapy for small benign lesions. At the present time, excisional biopsy is considered to be the only definitive method of determining whether a breast mass is benign or malignant. 3. Ultrasonology The investigation can distinguish between a solid and cystic lesion. Ultrasonography is a useful adjunct to mammography in the evaluation of a localized mass. Real time ultrasonography, performed with a 7.5 mHz hand-held

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near field linear array transducer, not only differentiates solid from cystic masses, but is also useful in evaluating a nonpalpable circumscribed mass. Its specificity in the diagnosis of benign breast disease is 94%. By maintaining the ultrasound transducer in a radial orientation to the nipple and areolar complex, ultrasound can often identify a fluid filled duct responsible for the nipple discharge. 4. Mammography This may confirm or refute the clinical diagnosis and show the presence of unsuspected breast conditions which are benign. A 95% accuracy rate in the diagnosis of BBD may be achieved with mammography. It gives the clinician, added reassurance in the diagnosis of difficult cases where the clinical diagnosis is in doubt. Mammography can distinguish quite efficiently between malignancy and benign lesions, but is not reliable as ultrasonography to differentiate a cyst from a solid mass. It is suggested that FNAC may distort interpretation of the subsequent mammogram. In one study, 97% of cases, the results of mammography were false negative. In another study 74% of isolated breast masses in women younger than 30 years of age did not image on mammography. Radiographic Technique Basic craniocaudal and mediolateral oblique projections of both breasts should be taken. Certain cases may require additional views. Types of mammography are: i) ii) Film/Screen mammography with grid Xeromammography 39

Film/Screen Mammography It uses a combination of enhancing screen that converts and amplifies a low energy radiation beam into high energy photons that are in turn exposed on to a standard X-ray film. The image like an X-ray film is viewed through transmitted light and hence is a negative image. Xeromammography It uses a charged aluminium plate coated with selenium, radiation passes through the breasts which is absorbed on the plate and causes a local reduction in changes. The plate is then sprayed with blue toner, transferred to paper and heated. This produces an image which is then viewed in ambient light. Mammographic signs of benign breast disease Primary signs  Smooth outline  Round, ovoid or lobulated lesions  Homogenous, low density or transradiant lesions  Relatively coarse, smooth calcifications Secondary signs  A transradiant fat halo  Displacement of breast structures  Frequently multiple and bilateral lesions  Normal vascularity  Radiological size, equal to or larger than clinical size Exceptions like infections show hypervascularity with ill localized lesions or areas of increased density or skin edema. These may radiologically simulate carcinoma.

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Fine microcalcifications may occur in microcysts, papillomata, epithelial hyperplasia and sclerosing adenosis. In fibroadenoma, coarse and chunky cacifications occur, where as in cysts, it is “Egg shell”. Lipoma, galactocele and oil cysts of fat necrosis present as circumscribed transradiant lesions of fat density. Ductography Duct anatomy and pathology can be displayed by X-ray following infection of radio-opaque contrast medium into a major lactoiferous duct. Conditions that may be demonstrated include duct ectasia, solitary or multiple papillomata and cystic disease. The procedure is to cannulate the selected duct with a 26 gauge cannula and, water soluble contrast in injected till the patient feels a sensation of fullness in her breast. Contraindications include nipple or breast infections. Thermography The heat emission from the breast surface is measured as infra-red radiation and then recorded. It is then displayed on a photographic plate / cathode ray tube. It is based on the metabolism and vascularity of the breast tissue and is increased in infection and some malignancies. Pneumocystography Under sterile conditions, the cyst is punctured, fluid aspirated and equal volume of air introduced into the cyst. Radiographs are taken in the standard projections. An infracystic tumor can be depicted by this investigations. Stereotactic Biopsy A monographically detected non palpable lesion, particularly a solid mass, can be evaluated by stereotactic FNA cytology. Microcysts can be aspirated.

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Suspicious clustered microcalcifications, and masses can be histologically investigated by stereotactic large core-needle biopsy. This is already used by radiologists to perform core biopsy an FNAC in upright mammographic units, and the development, allowing the stereotactic excision of cylinders of breast tissue up to 2 cm in diameter, has recently led to image guided breast biopsy by surgeons and radiologists as a combined procedure. This has several advantages over wire-guided biopsy in that, it is based on an image, can be done under local anesthesia, and excise less tissue more precisely with potential cosmetic benefit. Another study concluded that it is a painless and quick outpatient procedure than needle localization or open surgical biopsy. Magnetic Resonance Mammography (MRM) Conventional mammography may not be able to detect lesions in the breast of younger women or in a previously operated breast. Moreover, susceptibility to radiation induced breast cancer in a younger patient is a potential risk. For these groups, MRM offers a potentially significant advantage. The contrast enhancement has also now become available. Moreover, biopsy gun is available for magnetic resonance-guided Fine-Needle aspiration cytology and core biopsy. Disadvantage with this investigation is cost and time consumption, also lack of availability as compared to routine dynamic scan.

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TREATMENT OF BENIGN BREAST DISEASE 1. FIBROCYSTIC DISEASE As earlier mentioned, this is a disorder of duct involution, resulting in the formation of micro and macrocysts. A clinician who is confident of the diagnosis after ruling out any discrete abnormality, can treat the patient with firm reassurance and regular reviews of the patient at different points in her menstrual cycle. Studies have shown that some women with diffuse fibroadenosis will experience resolution. Needle aspiration using a 21-23 gauge needle can be done. If no fluid is obtained from the lump area, deeper aspiration should-be tied. If it is not blood stained, aspiration to dryness is carried out. A residual lump should be excluded by repalpation. Cardinal Rules of Cysts Aspiration  The lump must disappear completely after aspiration, otherwise it must be treated as any other persistent lump.  The fluid must not be blood stained. If it is, then cytology and pneumocystography must be carried out, so also open biopsy. If recurrence of cysts occur, respiration is indicated. Cysts rarely refill after 2-3 aspirations. Hormonal Therapy One study reported a remarkable reduction (75%) in the number of cysts requiring aspiration after a course of danazol, 100mg three times a day for three months.

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When a segment of the breast is involved and patients complain of pain and lump in the segment, that involved segment may be excised through a cosmetically appropriate incision. Operation is indicated when anxiety or discomfort persists after reassurance or when malignancy cannot be absolutely ruled out. MASTALGIA The pain of cyclical mastalgia is hypothesized to arise from an abnormality of lipid metabolism, thus forming the pathophysiological basis for this BBD, thus directly or indirectly acting through an effect on prolactin. Dietary fat reductions have been tried and in some studies, shown to be beneficial in reducing the symptoms, if dietary fat intake was reduced from 40% to 20% of the total caloric intake. Danazol in a phase doses of 2.5mg/day, antiprostaglandin mefenamic acid 500mg three times a day diuretic metolazone 5mg/day have also been tried with varying degrees of benefit in reducing breast engorgement and pain. FIBROADENOMA Since fibroadenomas are a disorder of lobular development and benign, they can be left alone to await spontaneous regression usually women less than 25 years are advised of its benign nature and told to await spontaneous regression. Longer than 12 months may be required for resolution of a fibroadenoma. Patients are followed up regularly and if there is any increase in size, it can be excised through a circumareolar or radial incision. Massive fibroadenoma can be treated by simple mastectomy after taking the patient’s consent. Giant fibroadenoma is treated by enucleation through an appropriate cosmetic incision. While this treatment initially results in some 44

discreapancy in breast size, the remaining breast tissue expands to virtually normal size within a year or two. When a group of women were questioned, majority preferred excision of fibroadenoma than the wait and watch policy, even though they knew it to be benign. Juvenile fibroadenomas are excised through a submammary incision. Fibroadenomas in pregnancy and lactation are not excised until after childbirth since regression is known to occur. DUCT ECTASIA This is a disorder of duct involution. It may present as a breast mass, nipple discharge, nipple retraction, abscess or fistula. Breast mass treatment is unsatisfactory. Broad spectrum antibiotics have not been of much use. A recent study has shown metronidazole, flucloxacillin or cephedrine to be effective. Biopsy is avoided as far as possible when malignancy is suspected. FNAC is done. If it is equivocal, biopsy is planned. For periductal mastitis / duct ectasia, no specific treatment is indicated. Single duct discharge is treated with microdochectomy total subareolar duct excision is done if multiple ducts are involved. The incision is given over only 1/3 of areolar circumference and no areolar flap is raised. For the nipple retraction with breast mass, observation with repeated clinical examination and mammography is advised. Mammillary Fistula Atkins opened up the tract passing down the probe placed through the fistula. This was effective, but resulted in an ugly scar. Now the procedure followed is, primary closure under antibiotic cover and results are encouraging.

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GYNECOMASTIA In majority of cases, reassurance that it is a benign self limiting condition, and that it is premalignant, will suffice. A minority of patients will require treatment either for tenderness or cosmesis. Dihydrotestosterone heptanoate has yielded good results. The

antiestrogen, tamoxifen has also shown beneficial effects in the dosage of 10mg twice daily. For pubertal gynecomastia, Danazol has shown considerable effect in treating it. Surgery Subcutaneous mastectomy can be done in all cases which require surgery. The majority of textbooks suggest a hemicircumareolar or periareolar incision. The breast lump is excised, leaving behind a small amount behind the nipple. Some still advocate use of sub-mammary incisions. PHYLLODES TUMOR Benign, low grade phyllodes tumor treated surgically by wide local excision and breast conserving surgery in a patient who desires to retain the breast. This type of excision should have negative margins for the tumor tissue as to prevent local recurrence. In a recent study local excision with recurrence was 18%. Local recurrence is almost always related to the inadequacy of the initial excision. Simple mastectomy itself is a perfect acceptable primary therapy in women with very large benign phyllodes tumors, especially in the elderly. TREATMENT OF NON LACTATING BREAST ABSCESS Reports of successful treatment of non lactational breast abscess by aspiration and antibiotics have been published. Repeated aspiration is required for complete resolution.

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A wide spectrum of both aerobic and anaerobic organisms cause non lactational breast abscess so antibiotics which are effective, include combinations of amoxycillin and clavulanic acid along with metronidazole. As most non lactating abscess are multiloculated, many patients may need repeated aspiration, or incision and drainage, if needed has to be carried out through the smallest possible incision. Definitive treatment is required if any duct involvement is present. The source of the material for the study is from the patients attending surgical out patient department and as inpatients of the surgical wards at Kurnool Medical College & Hospital, Kurnool between August 2004 and May 2006. during this period, 100 cases were studied.

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METHOD OF COLLECTING DATA Cases were selected from the OPD and from inpatients in the wards who presented with disorders of the breast. Proforma with relevant history, clinical examination and investigarions was prepared and patients were assessed. Inclusion Criteria  Patients with complaints of pain in the breast associated with or without lump or nodularity in the breast.  Presence of lump in the breast.  Nipple discharge.  Non lactating breast abscess. Exclusion Criteria  Acute lactating breast abscess.  Biopsy proven malignancy of the breast lump.

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PROFORMA – BBD
Name : Age Sex : : IP No. : Unit : D.O.A. D.O.D.

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : : : : :

History : Complaints: Pain (Dull aching / Throbbing) Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

Physical Examination: Pulse B.P. : : Icterus Lymphadenopathy Others : : :

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT

LEFT

Palpation: 1. Temperature 2. Tenderness 3. Number 4. Site : : : :

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5. Size 6. Shape 7. Surface 8. Consistency 9. Fluctuation 10. Margin 11. Mobility 13. Discharge from nipple 14. Regional Lymph nodes 15. Mobility of the breast as a whole

: : : : : : : : : :

12. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : CVS CNS : :

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : : : ESR Urea : : Blood sugar Others : : Blood grouping : :

Creatinine: : : : : :

II) Urine : (Albumin / Sugar / Deposits) 1. 2. 3. 4. X-ray chest ECG FNAC HPE

Final diagnosis Treatment Progress/Follow up

: : :

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CASE REPORT - 1
Name : Age Sex : : Savaramma 30 years Female IP No. : 02439 Unit : FSB - 1 D.O.A:17-01-05 D.O.D:26-01 05

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : Dull aching 2 Lumps one in each breast No Discharge 3 Months Gradual Similar complaints 2 yrs back For which she was operated No No No Normal (3/30) 12 Years Completed, 2 children

History : Complaints: Pain (Dull aching / Throbbing) Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Past h/o

Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

: : : : : : :

Physical Examination: Pulse B.P. : : 82 / min 120/80 mm of Hg No Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Normal Normal Normal Normal 3x3 cms

LEFT Increased Normal Normal Stretched 5x5 cms

Palpation: 1. Temperature : Normal Normal

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2. Tenderness 3. Number 4. Site 5. Size 6. Shape 7. Surface 8. Consistency 9. Margin 10. Mobility 12. Discharge from nipple 13. Regional Lymph nodes 14. Mobility of the breast as a whole

: : : : : : : : : : : :

No 1 Upper outer 3x3 cms Spherical Smooth Firm Well defined Freely Mobile Nil Nil Not enlarged Present

No 1 Upper outer 5x5 cms Spherical Smooth Firm Well defined Freely Mobile Nil Nil Not enlarged Present

11. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear Bilateral Fibroadenoma CVS CNS : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 10Gm% : 8400/mm3 :

ESR Urea

:7mm/Hr : 22mg/dl

Blood sugar

: 90mg / dl

Blood grouping : A Positive

: N65L28M4B1E2

Creatinine: 1.1mg/dl : : : : : Nil Normal Normal S/o Fibroadenoma Fibroadenoma (Pericanalicular)

II) Urine : (Albumin / Sugar / Deposits) 1. 2. 3. 4. X-ray chest ECG FNAC HPE

Final diagnosis Treatment Progress/Follow up

: : :

Bilateral Fibroadenoma Excision on both sides 1 Year follow up is uneventful

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CASE REPORT - 2
Name : Age Sex : : Nagamma 35 years Female IP No. : 06749 Unit : FSB 3 D.O.A:16-02-05 D.O.D:25-02-05

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : : : : : Single Lump in left breast Serosanguinous Discharge 3 months Gradual No No No Normal (5/30) 14 Years 2 children

History : Complaints Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

Physical Examination: Pulse B.P. : : 76 / min 120/80 mm of Hg No Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Normal Normal Normal Normal -

LEFT Normal Normal Normal Normal 1x2cms

Palpation: 1. Temperature 2. Tenderness 3. Number : : : Normal Normal 1

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4. Site 5. Size 6. Shape 7. Surface 8. Consistency 9. Margin 10. Mobility 12. Discharge from nipple 13. Regional Lymph nodes 14. Mobility of the breast as a whole

: : : : : : : : : :

-

Central 1x2cms Oval Smooth Soft Well defined Mobile Nil Present Not enlarged Present

11. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear Duct ectasia Left Breast CVS CNS : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 10.2 gm% : 8200/mm
3

: ESR Urea : 8mm/Hr : 30mg/dl Blood sugar : 102mg / dl

Blood grouping : O Positive

: N60L35M4B1E0

Creatinine: 0.8mg/dl : : : : : Nil Normal Normal S/o Duct ectasia Duct ectasia

II) Urine : (Albumin / Sugar / Deposits) 5. 6. 7. 8. X-ray chest ECG FNAC HPE

Final diagnosis Treatment Progress/Follow up

: : :

Duct ectasia Left Breast Microdochectomy Normal after 18 months follow up

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CASE REPORT - 3
Name : Age Sex : : Zaithun Bee 35 years Female IP No. : 14498 Unit : FSB 5 D.O.A:06-05 05 D.O.D:16-05-05

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : : : : : Single Lump in right breast No Discharge 2 months Rapid No No No Normal (4/30) 14 Years 3 children

History : Complaints Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

Physical Examination: Pulse B.P. : : 92 / min 116/70 mm of Hg + Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump Palpation: 1. Temperature 2. Tenderness 3. Number 4. Site : : : : : : : :

RIGHT Increased Normal Normal

LEFT Normal Normal Normal

Stretched,dilated veins+ Normal 6x8cms Normal 1 Lower outer Normal -

55

5. Size 6. Shape 7. Surface 8. Consistency 9. Margin 10. Mobility 12. Discharge from nipple 13. Regional Lymph nodes 14. Mobility of the breast as a whole

: : : : : : : : :

7x8cms Irregular Bossellated Firm Well defined Mobile Nil Nil Not enlarged Present

-

11. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear CVS CNS Phyllodes Tumor Right Breast : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 8.5 gm% : 8000/mm3 :

ESR Urea

:9mm/Hr : 28mg/dl

Blood sugar

: 72mg / dl

Blood grouping : O Positive

: N58L32M6B1E3

Creatinine: 1.6mg/dl : : : : : : Excision After 4 months of follow up patient dint turn up. Nil Normal Normal S/o Phyllodes Tumor Phyllodes Tumor

II) Urine : (Albumin / Sugar / Deposits) 9. X-ray chest 10. ECG 11. FNAC

12. HPE
Final diagnosis Treatment Progress/Follow up : :

Phyllodes Tumor Right Breast

56

CASE REPORT – 4
Name : Age Sex : : Yesiah 40 years Male IP No. : 06577 Unit : FSB 6 D.O.A:10-02-06 D.O.D:18-02-06

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : Dull aching Single Lump in left breast No Discharge 12 months Gradual Nil Significant

History : Complaints Pain (Dull aching / Throbbing) Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any h/o similar or related complaints in the past Any h/o Drug intake Family History

Physical Examination: Pulse B.P. : : 86 / min 126/70 mm of Hg No Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Normal Normal Normal Normal -

LEFT Increased Normal Normal Normal 3x3cms

Palpation: 1. Temperature 2. Tenderness 3. Number 4. Site 5. Size 6. Shape 7. Surface : : : : : : : Normal Normal Present 1 Central 5x3cms Spherical Smooth

57

8. Consistency 9. Margin 10. Mobility 12. Discharge from nipple 13. Regional Lymph nodes 14. Mobility of the breast as a whole

: : : : : :

-

Firm Well defined Mobile Nil Nil Not enlarged -

11. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear CVS CNS Gynecomastia of Left Breast : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 12 gm% : 7600/mm3 :

ESR Urea

: 6mm/Hr : 36mg/dl

Blood sugar

: 110mg / dl

Blood grouping : AB Positive

: N62L32M4B1E1

Creatinine: 0.9mg/dl : : : : : Nil Normal Normal Gynecomastia Gynecomastia

II) Urine : (Albumin / Sugar / Deposits) 13. X-ray chest 14. ECG 15. FNAC 16. HPE

Final diagnosis Treatment Progress/Follow up

: : :

Gynecomastia Left Breast Subcutaneous mastectomy After 5 months of follow up patient is doing well

58

CASE REPORT - 5
Name : Age Sex : : Lakshmi 17 years Female IP No. : 09118 Unit : FSB 1 D.O.A:08-03-05 D.O.D:16-03-05

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : : : : : Single Lump in right breast No Discharge 15 days Gradual No No No Normal (4/30) 13 Years Not Married

History : Complaints Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

Physical Examination: Pulse B.P. : : 80 / min 120/80 mm of Hg No Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Normal Normal Normal Normal 3x4 cms

LEFT Normal Normal Normal Normal -

Palpation: 1. Temperature 2. Tenderness 3. Number : : : Normal No 1 Normal -

59

4. Site 5. Size 6. Shape 7. Surface 8. Consistency 9. Margin 10. Mobility 12. Discharge from nipple 13. Regional Lymph nodes 14. Mobility of the breast as a whole

: : : : : : : : : :

Upper outer 3x4 cms Oval Smooth Firm Well defined Freely Mobile Nil Nil Not enlarged Present

-

11. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear CVS CNS Fibroadenoma Right Breast : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 11 gm% : 7200/mm
3

: ESR Urea :7mm/Hr : 20mg/dl Blood sugar : 86mg / dl

Blood grouping : B Positive

: N62L30M5B1E2

Creatinine: 1.2mg/dl : : : : : Nil Normal Normal S/o Fibroadenoma Fibroadenoma (Intracanalicular)

II) Urine : (Albumin / Sugar / Deposits) 17. X-ray chest 18. ECG 19. FNAC 20. HPE

Final diagnosis Treatment Progress/Follow up

: : :

Fibroadenoma Right Breast Excision through circum areolar incision 15 month follow up uneventful

60

CASE SHEET - 6
Name : Age Sex : : Nirmala 30 years Female IP No. : 22053 Unit : FSB 5 D.O.A:22-07-05 D.O.D:28-07-05

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : : : : : Dull aching Single Lump in right breast No Discharge 15 days Gradual Yes No No Yes Normal (3/30) 13 Years 5 children

History : Complaints: Pain (Dull aching / Throbbing) Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

Physical Examination: Pulse B.P. : : 72 / min 120/70 mm of Hg + Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Normal Normal Normal Normal 2x3 cms

LEFT Normal Normal Normal Normal -

Palpation: 1. Temperature 2. Tenderness 3. Number : : : Normal + 1 Normal -

61

4. Site 5. Size 6. Shape 7. Surface 8. Consistency 9. Margin 10. Mobility 12. Discharge from nipple 13. Regional Lymph nodes 14. Mobility of the breast as a whole

: : : : : : : : : :

Central 2x3 cms Oval Smooth Firm Well defined Mobile Nil Nil Not enlarged Present

-

11. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear CVS CNS Fibro adenoma Right Breast : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 8.5 gm% : 8000/mm
3

: ESR Urea :9mm/Hr : 28mg/dl Blood sugar : 72mg / dl

Blood grouping : O Positive

: N58L32M6B1E3

Creatinine: 1.6mg/dl : : : : : Nil Normal Normal S/o Fibrocystic disease Fibrocystic disease

II) Urine : (Albumin / Sugar / Deposits) 21. X-ray chest 22. ECG 23. FNAC 24. HPE

Final diagnosis Treatment Progress/Follow up

: : :

Fibrocystic disease Right Breast Excision through circum areolar incision one year follow up is uneventful

62

CASE REPORT - 7
Name : Age Sex : : Malathi 23 years Female IP No. : 11189 Unit : FSB 4 D.O.A:28-04-05 D.O.D:04-05-05

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : : : : : Dull aching Single Lump in left breast No Discharge 2 months Gradual No No No Normal (5/30) 13 Years 1 children

History : Complaints Pain (Dull aching / Throbbing) Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

Physical Examination: Pulse B.P. : : 86 / min 126/70 mm of Hg No Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Normal Normal Normal Normal -

LEFT Normal Normal Normal Normal 4x4cms

Palpation: 1. Temperature 2. Tenderness 3. Number : : : Normal Normal 1

63

4. Site 5. Size 6. Shape 7. Surface 8. Consistency 9. Margin 10. Mobility 12. Discharge from nipple 13. Regional Lymph nodes 14. Mobility of the breast as a whole

: : : : : : : : : :

-

Upper inner 4x5cms Oval Smooth Firm Well defined Freely Mobile Nil Nil Not enlarged Present

11. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear CVS CNS Fibroadenoma Left Breast : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 11 gm% : 7600/mm
3

: ESR Urea : 6mm/Hr : 32mg/dl Blood sugar : 110mg / dl

Blood grouping : O Positive

: N62L32M4B1E1

Creatinine: 0.6mg/dl : : : : : Nil Normal Normal S/o Fibroadenoma Fibroadenoma (Pericanalicular)

II) Urine : (Albumin / Sugar / Deposits) 25. X-ray chest 26. ECG 27. FNAC 28. HPE

Final diagnosis Treatment Progress/Follow up

: : :

Fibroadenoma Left Breast Excision through radial incision No recurrence after 15 months of follow up

64

CASE REPORT - 8
Name : Age Sex : : Ramesh 25 years Male IP No. : 54508 Unit : FSB 2 D.O.A:06-12-05 D.O.D:14-12-05

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : Dull aching in both breasts Single Lump in each breast No Discharge 8 months Gradual Nil Significant

History : Complaints Pain (Dull aching / Throbbing) Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any h/o similar or related complaints in the past Any h/o Drug intake Family History

Physical Examination: Pulse B.P. : : 72 / min 120/70 mm of Hg No Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Increased Normal Normal Normal 3x3cms

LEFT Increased Normal Normal Normal 3x3cms

Palpation: 1. Temperature 2. Tenderness 3. Number 4. Site 5. Size 6. Shape 7. Surface : : : : : : : Normal Present 1 Central 3x3cms Spherical Smooth Normal Present 1 Central 3x3cms Spherical Smooth

65

8. Consistency 9. Margin 10. Mobility 12. Discharge from nipple 13. Regional Lymph nodes 14. Mobility of the breast as a whole

: : : : : :

Firm Well defined Mobile Nil Nil Not enlarged -

Firm Well defined Mobile Nil Nil Not enlarged -

11. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear Bilateral Gynecomastia CVS CNS : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 12.2 gm% : 6400/mm3 :

ESR Urea

: 8mm/Hr : 32mg/dl

Blood sugar

: 92mg / dl

Blood grouping : A Positive

: N60L38M2B0E0

Creatinine: 1.1mg/dl : : : : : Nil Normal Normal Gynecomastia

II) Urine : (Albumin / Sugar / Deposits) 29. X-ray chest 30. ECG 31. FNAC 32. HPE Final diagnosis Treatment Progress/Follow up : : :

Bilateral Gynecomastia Bilateral Subcutaneous mastectomy Uneventful

66

CASE REPORT - 9
Name : Age Sex : : Bharathi 40 years Female IP No. : 59043 Unit : FSB - 2 D.O.A:28-12-04 D.O.D:08-01-05

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : : : : : Lumps in both breast No Discharge 10 Months Gradual No No No Normal (4/30) 14 Years 1 child

History : Complaints Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

Physical Examination: Pulse B.P. : : 86 / min 126/82 mm of Hg No Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Increased Normal Normal Stretched 6x6 cms

LEFT Normal Normal Normal Normal 3x3 cms

Palpation: 1. Temperature 2. Tenderness 3. Number : : : Normal No 1 Normal No 1

67

4. Site 5. Size 6. Shape 7. Surface 8. Consistency 9. Margin 10. Mobility 12. Discharge from nipple 13. Regional Lymph nodes 14. Mobility of the breast as a whole

: : : : : : : : : :

Upper outer 6x7 cms Spherical Smooth Firm Well defined Freely Mobile Nil Nil Not enlarged Present

Lower outer 3x3 cms Spherical Smooth Firm Well defined Freely Mobile Nil Nil Not enlarged Present

11. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear CVS CNS : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 9.4 Gm% : 7800/mm
3

Giant Fibroadenoma Right, Fibroadenoma Left

: ESR Urea : 8mm/Hr : 18mg/dl Blood sugar : 92mg / dl

Blood grouping : B Positive

: N65L28M4B1E2

Creatinine: 1.1mg/dl : : : : : Nil Normal Normal S/o Fibroadenoma Giant Fibroadenoma Right, Fibroadenoma Left

II) Urine : (Albumin / Sugar / Deposits) 32. X-ray chest 33. ECG 34. FNAC 35. HPE

Final diagnosis Treatment Progress/Follow up

: : :

Giant Fibroadenoma Right, Fibroadenoma Left Excision on both sides Normal after 18 months of follow up

68

CASE REPORT - 10
Name : Age Sex : : Achamma 26 years Female IP No. : 39765 Unit : FSB 1 D.O.A:09-08-04 D.O.D:13-08-04

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : : : : : Throbbing pain in right breast Single Lump in right breast No Discharge 3 days Rapid H/o Fever 3 days No No Lactating No Normal (4/30) 15 Years 1 children

History : Complaints: Pain (Dull aching / Throbbing) Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

Physical Examination: Pulse B.P. : : 100 / min 122/76 mm of Hg No Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Increased Normal Normal Erythematous 5x6 cms

LEFT Normal Normal Normal Normal -

Palpation: 1. Temperature 2. Tenderness 3. Number : : : Raised + 1 Normal -

69

4. Site 5. Size 6. Shape 7. Surface 8. Consistency 9. Margin 10. Mobility 12. Discharge from nipple 13. Regional Lymph nodes 14. Mobility of the breast as a whole

: : : : : : : : : :

Lower outer 6x5 cms Smooth Firm Well defined Nil Not enlarged Present

-

11. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear Right Breast Abscess CVS CNS : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 11.2 gm% : 7400/mm
3

: ESR Urea : 22mm/Hr : 26mg/dl Blood sugar : 112mg / dl

Blood grouping : O Positive

: N72L23M4B0E1

Creatinine: 1.2mg/dl : : : : Nil Normal Normal Staph.aureus sensitive to

II) Urine : (Albumin / Sugar / Deposits) 36. X-ray chest 37. ECG 38. Culture & Sensitivity Amoxycillin+clavulanic acid

Final diagnosis Treatment Progress/Follow up

: : :

Right Breast Abscess Incision & Drainage 2 months follow up is uneventful

70

CASE REPORT - 11
Name : Age Sex : : Raziya 35 years Female IP No. : 00134 Unit : FSB 1 D.O.A:02-01-06 D.O.D:04-01-06

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : : : : : Throbbing pain in right breast Single Lump in right breast No Discharge 20 days Rapid H/o Fever 20 days No No Lactating No Normal (5/30) 14 Years 2 children

History : Complaints: Pain (Dull aching / Throbbing) Lump Discharge (Serous / Purulent / Blood / Milk) Duration Rate of Growth Others if any Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

Physical Examination: Pulse B.P. : : 98/ min 118/76 mm of Hg No Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Increased Normal Normal Erythematous 3x5 cms

LEFT Normal Normal Normal Normal -

Palpation: 1. Temperature 2. Tenderness 3. Number : : : Raised + 1 Normal -

71

4. Site 5. Size 6. Shape 7. Surface 8. Consistency 9. Fluctuation 10. Margin 11. Mobility 13. Discharge from nipple 14. Regional Lymph nodes 15. Mobility of the breast as a whole

: : : : : : : : : : :

Lower outer 5x5 cms Smooth Soft Positive Well defined Nil Not enlarged Present

-

12. Fixity to skin / Breast Tissue/Muscle:

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear Right Breast Abscess CVS CNS : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 10.2 gm% : 13000/mm3 :

ESR Urea

: 26mm/Hr : 26mg/dl

Blood sugar

: 92mg / dl

Blood grouping : B Positive

: N74L21M3B1E1

Creatinine: 1.2mg/dl : : : : Nil Normal Normal -

II) Urine : (Albumin / Sugar / Deposits) 39. X-ray chest 40. ECG 41. Culture & Sensitivity

Final diagnosis Treatment Progress/Follow up

: : :

Right Breast Abscess Incision & Drainage Normal

72

CASE REPORT - 12
Name : Age Sex : : Parvathamma 20 years Female OP No. : 03113 Unit : surgery op Date:24-01-05

Hospital : Govt. Gen. Hospital, Kurnool. : : : : : : : : : : : : : Dull aching in both breasts No Discharge 2 Months Periodic Yes NA NA Yes Normal (3/30) 15 Years Not Married

History : Complaints Pain (Dull aching / Throbbing) Lump Discharge (Serous / Purulent / Blood / Milk) Duration Nature of Pain Others if any Any relation to menstrual cycles – (pain) Any h/o intake of oral contraceptive pills Any h/o recent lactation or pregnancy Any h/o similar or related complaints in the past Menstrual History Menarche Family

Physical Examination: Pulse B.P. : : 92 / min 124/90 mm of Hg No Icterus Lymphadenopathy : : No No

Pallor :

LOCAL EXAMINATION (BREAST) Inspection: 1. Size 2. Nipple 3. Areola 4. Skin over the breast 5. Lump : : : : :

RIGHT Normal Normal Normal Normal -

LEFT Normal Normal Normal Normal -

Palpation: 1. Temperature 2. Tenderness 3. Number : : : Normal Mild Normal Mild -

73

4. Site 5. Lump 6. Discharge from nipple 7. Regional Lymph nodes 8. Mobility of the breast as a whole

: : : : :

Whole Breast No Nil Not enlarged Present

Whole Breast No Nil Not enlarged Present

SYSTEMIC EXAMINATION: P/A RS : : Normal Clear Cyclical mastalgia CVS CNS : : S1 S2 + Normal

Provisional Diagnosis : Investigations 1) Blood HB% TC DC : 10.2 Gm% : 12000/mm3 :

ESR Urea

: 14mm/Hr : 26mg/dl

Blood sugar

: 98mg / dl

Blood grouping : B Positive

: N65L28M4B1E2

Creatinine: 1.2mg/dl : : : : : Nil Normal Normal S/o Fibrocystic changes -

II) Urine : (Albumin / Sugar / Deposits) 9. X-ray chest 10. ECG 11. FNAC 12. HPE

Final diagnosis Treatment Progress/Follow up

: : :

Cyclical mastalgia Eveningprim rose oil and Analgesics and reassurance Intensity of symptoms decreased and after 6 months same treatment is repeated

74

75

76

77

78

79

OBSERVATIONS
The present study of 100 cases of benign breast disease were studied during the period of study from 2004 to 2006.

AGE INCIDENCE The youngest patient in the study was 20 days old and the oldest being 65 yrs old. Most of the patients are in the age group of 16-30 years. Table 1 : Age and Sex Cross Tabulation Sex Female 5 5.8% 53 61.6% 24 27.9% 4 4.7% 86 Male 2 14.3% 8 57.1% 3 21.4% 1 7.1% 14

Age Below 15 16-30 31-45 Above 45 Total CC = 126; P<.657

Total 7 7.0% 61 61.0% 27 27.0 5 5.0% 100

Chi – square for age alone = 80.96; P<.000 (highly significant) Chi – Square for sex alone = 57.76; P<.000 (highly significant)

80

Table 2 : Mean Age of Male and Female Patients Std. Deviation 9.37 14.81 10.07

Mean Female Male Total ‘t’ = 0.081; P<.935 28.17 27.92 28.14

Minimum 8 8 8

Maximum 58 65 65

The mean age of male and female patients are statistically same as ‘t’ test revealed a non-significant difference between mean ages of male and female patients. Graph 1 : Number of Cases According to Age and Sex

Female 60 50 Male

Frequency

40 30 20 10 0 Below 15 16-30 31-45 Above 45

Age Groups

On the whole, the benign lesion of the breast presenting in the 2nd and 3rd decade of life was 61%. 81

The age incidence in the present study was compared to other studies as shown in the table below.

Table 3 : Comparison of Case Incidence with Other Studies Age <15 16-30 31-45 >45 Present series 6.8% 61.4% 27.3% 4.5% Sofji F Oluwole 20% 28.6% 17.3% 13.5% Etim E Onuka, Nigeria 21% 55% 14% 3%

It is more prevalent is female population than male population. The present study consists of 100 cases of which 86 cases were female (86%). 12 cases were males (14%). Graph 2 : Sex Incidence

86 Female Male 14

82

Symptoms of Benign Breast Disease In this series, symptoms were analyzed as follows; Table 4 : Distribution of the Sample by Chief Complaints Chief Complaints Lump Pain Lump and Pain Swelling Fever and Lump Nipple Discharge Nipple Discharge and Lump Total X2 = 140.26;P<.000 (Highly significant) Lump found to have almost 50% incidence in the total sample and nipple discharge with or without lump was the least. Chi square value revealed a highly significant difference between these various chief complaints. In this study, patients mostly presented with lump in the breast 49%. This series was compared with the study of benign breast disease in Nigeria by Onukak where 73 cases were studied and it was found that painless lump formed 65.8% of cases. Frequency 49 15 28 4 2 1 1 100 Percent 49.0 15.0 28.0 4.0 2.0 1.0 1.0 100.0

Graph.3 Frequency of symptoms

83

60 50 40

Frequency

30 20 10 0 Lump Pain Lump and Pain Sw elling Fever and Nipple Nipple Lump Discharge Discharge and Lump

Chief Complaints

DURATION OF SYMPTOMS 79% of patients presented within 6 months, and 15% of patients, presented after 6 months but within 12 months 6% presented after 1 year. Younger patients presented earlier than older patients.

Table 5 : Distribution of Sample by Duration of Symptoms <1 month 1-6 months 7-12 months >12 months Total Frequency 19 60 15 6 100 Percent 19.0 60.0 15.0 6.0 100.0

X2 = 68.64; P<.000 (Highly significant)

84

Graph 4 : Duration of Symptoms

>12 months 7-12 months Duration 1-6 months <1 month 0 10 20 30 Frequency 40 50 60

SIDE OF INVOLVEMENT This series analysed the data to determine which breast was more involved in benign breast disease.

Table 6 : Distribution of the Sample by Side Side Left Right Bilateral Total X2 = 8.66; P<.013 (Significant) Incidence of benign breast disease in the study sample was found to be significantly on the right, further confirmed by significant Chi square value. Frequency 34 45 21 100 Percent 34.0 45.0 21.0 100.0

85

Graph 5 : Side of Involvement

21

34

Left Right Bilateral

45

Table 7 : Comparison with Oluwole and Onukak studies Side Right Left Bilateral Present Series 45% 34% 21% Oluwole 45% 41% 14% Onukak’s study 43.8% 48% 8.2%

QUADRANT OF THE BREAST INVOLVED The Upper outer quadrant is the most commonly involved segment (42%) in this study. On comparing this study with that done by Oluwole, the result was, upper outer quadrant was the most commonly involved part of the breast. The explanation given is that, as the maximum breast mass is situated in upper outer quadrant, breast lesions are more commonly found in this quadrant.

86

Table 8 : Distribution of the Sample by Quadrant Quadrant UO UI LO LI Central WB UO & UI UO & LO Total Frequency 42 12 11 2 23 7 1 2 100 Present 42.0 12.0 11.0 2.0 23.0 7.0 1.0 2.0 100.0

X2 = 109.28; P<.000 (Highly significant) Majority of the patients presented with benign breast disease in the upper outer quadrant i.e. 42% and further confirmed by a highly significant Chi square test. Graph 6 : Quadrants of the Breast Involved

45 40 35 30 25 20 15 10 5 0 UO UI LO LI Central WB UO & UI UO & LO

Frequency

Quadrants

87

Table 9 : Distribution of the Sample in Cases of Bilaterality Quadrants Upper outer Upper inner Lower outer Central Whole breast Lower Outer & Axillary Tail Total X2 = 7.455; P<.189 (Non-significant) Statistically equal distribution was observed in cases with bilaterality. Chi square test result was non-significant. Frequency 6 2 3 3 7 1 22 Percent 27.3 9.1 13.6 13.6 31.8 4.5 100.00

SIZE OF THE LESION The diameter of the lumps ranged from <2 sq cms to 5+ sq cms in the 100 cases which were analysed in this study. The smallest lesion was 1 sq. cm (1x 1 cm) whereas the larges diagnosed was 130sq. cms (13 x 10 cms).

88

Table 10 : Distribution of the Sample by Size of Lesion & Clinical Conditions Size 2-5 sq cm 5 3 Total > 5 sq cm 41 2 8 1 4 1 6 4 18 9 2 1 6 72 48 2 16 1 13 2 2 6 10 100

Fibroadenoma Giant Fibroadenoma Fibrocystic Disease Plexiform Neurofibromatosis Gynecomastia Phyllodes tumor Duct Ectasia Cyclical Mastalgia Breast Abscess Total CC = .523; P<.000

< 2 sq cm 2 5

10

Non-significant association was observed between size of lesion and clinical condition as CC value of .404 was found to be non-significant P<.510.

TYPE OF BENIGN BREAST DISEASE Relationship of various BBD to various quadrants, side, size and number shown in the tables above. In the present series, fibroadenoma was the commonest lesion – 48% fibrocystic disease was next with 16% and others followed in smaller degrees.

89

Table 11 : Distribution of Sample by Provisional Diagnosis Frequency 48 2 16 1 10 13 2 2 6 100 Percent 48.0 2.0 16.0 1.0 10.0 13.0 2.0 2.0 6.0 100.0

Fibroadenoma Giant Fibroadenoma Fibrocystic Disease Plexiform Neurofibromatosis Breast Abscess Gynecomastia Cystosarcoma Phyllodes Duct Ectasia Cyclical Mastalgia Total

X2 = 134.4; P<.000 (Highly significant) Graph 7 : Frequency of Various Lesions

60 50 40 Frequency 30 20 10 0 FA GFA FC PN BA GFA CP DE CM Provisional Diagnosis TREATMENT MODALITIES Table 12 : Distribution of the Sample by Provisional Diagnosis & Treatment Treatment Quadran Subcutaneous

Excision

Drug

Microdoc

I&D

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s Fibroadenoma Giant Fibroadenoma Fibrocystic Disease Plexiform Neurofibromastosis Breast Abscess Gynecpmastia Cyclical Mastalgia Duct Ectasia Total 48 2 5 1 1 11

tectomy 1

mastectomy

hotomy

1

10 13 6 1 1

57

17

2

13

10

CC = .881; P,.000 (Highly-significant) Graph 8 : Various Treatment Modalities
60 50 40

Frequency

30 20 10 0 Excision Subcutaneous mastectomy Microdoc Quadran Drugs I&D

Treatment

Comparison of Clinical Diagnosis, FNAC to HPE Table 13 : Accuracy of Clinical Diagnosis against FNAC
Lesions Fibroadenoma Giant Fibroadenoma Fibrocystic Disease Plexiform Neurofibromatosis Cyclical Mastalgia FNAC 32 97.0% 1 33.3% 8 33.3% 1 3.0% 2 66.7% 15 62.5% 1 100.0% 1 1 4.2% Total 33 100.0% 3 100.0% 24 100.0% 1 100.0% 1

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100.0% Gynecomastia Duct Ectasia Phyllodes Tumor Total 41 3 1 100.0% 16 1 2 4 1 4 100.0% 1 1

100.0% 4 100.0% 100.0% 100.0% 1 100.0% 38

CC=.904; P<.000 (HS) Table 14 : Accuracy of FNAC against HPE
Lesions Fibroadenoma Giant Fibroadenoma Fibrocystic Disease Plexiform Neurofibromatosis Cyclical Mastalgia Gynecomastia Duct Ectasia Phyllodes Tumour Total 37 3 1 100.0% 7 1 2 4 2 6 50.0% HPE 31 93.9% 1 3.0% 2 66.7% 6 50.0% 1 100.0% 1 100.0% 4 100.0% 1 1 1 3.0% 1 33.3% Total 33 100.0% 3 100.0% 12 100.0% 1 100.0% 1 100.0% 4 100.0% 100.0% 100.0% 1 100.0% 56

CC=.896; P<.000 (HS)

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Comparison of Clinical Diagnosis with FNAC of Fibroadenoma Sensitivity = 32/33= 97.0% Comparison of FNAC with HPE of Fibroadenoma FNAC was done in 31 out of 33 cases, which was proved by HPE. ensitivity = 93.9%. Comparison of Clinical Diagnosis with FNAC of Fibrocrocystic Disease 12 cases with lesions of fibrocystic disease, examined clinically were subjected to FNAC and 6 were proved as fibrocystic disease. Sensitivity of clinical diagnosis = 50%

Comparison of FNAC with HPE of Fibrocystic Disease 24 cases with lesions of fibrocystic disease, proved by HPE of which 12 were positive in FNAC also. Histopathologic lesions proved by FNAC as fibrocystic disease showed sensitivity of 50%. Overall sensitivity of clinical diagnosis against FNAC = 89.45% Overall sensitivity of FNAC against HPE is 87.22%.

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Fibroadenoma From the above data in this study it is evident that 2 groups of benign breast disease i.e. Fibroadenoma and Fibrocystic disease constitutes more than 65% of all benign breast disease. The total number of Fibroadenomas in the present study were the higher number constituting 48%. Hence we analyzed this lesion in some greater detail. Out of these 48 cases, 40 cases (83.3%) were single fibroadenoma confined to one breast only. There were 3 cases (6.25%) of multiple fibrodenoma. There were 3 cases (6.25%) of bilateral fibroadenoma. In this series, the upper outer quadrant was involved in 42%, with upper inner quadrant involvement in 12%, lower outer quadrant in 11% and lower inner quadrant in 11% and lower inner quadrant in 2%. The central quadrant was affected on 23% in this series. From this study, the most frequently involved quadrant was the upper outer quadrant. This study also compared the values of involvement of each breast to fibrodenoma. It was found that Right breast in fibroadenoma was involved in 45% and left breast in 34% cases and 21% cases-bilatral, where as in Oluwole (New York), right breast involved in 45%, left breast 42%, Bilateral involvement in 14% of cases. In our study, bilaterality was more compared to Oluwole’s study as we have included cyclical mastalgia in our study.

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In this study we had 3 cases of recurrent fibroadenoma which were operated 4½ and 2 years respectively in the first two cases and the third case recurred after 9 months and was proved by FNAC as fibroadenosis. This study could not assess relationship with oral contraceptives an none of our patients took oral contraceptives. The commonest age group of occurrence of fibroadenoma in this series was 16-30 years. The earliest age at which this tumor occurred in this study was 13 years and the oldest was 46 yrs. This study found that lump alone was the most common mode of presentation 49%. Lump and pain presented in 28% of patients. Two cases of Fibroadenoma had a lactation breast abscess 10 and 12 years of ago respectively, which was drained and they had uneventful post operative recovery. Cases of Bilateral Fibroadenoma – opted to undergo surgery on both sides in the same sitting. Two cases had family history of benign breast disease among first degree relatives for which surgery was done. 21 number of cases among 84 female patients studied were unmarried.

Fibrocystic Disease In this series, it was found that the fibrocystic disease constituted 16 cases i.e. 16%. This was comparable to the study of Oluwole who had 20% Fibrocystic

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disease in his series. It was also evident that Fibroadenoma was more common in India than Fibrocystic disease, the possible explanation being early menarche, early marriage and multiparity of Indian women. Fibrocystic disease was more frequent in this series between 16-25 years. On analyzing the symptomatology, most patients presented with lump in breast, followed by lump and pain, similar to that the benign disease in general. Involvement of the side of the breast and specific quadrant in the breast almost followed that of benign breast disease in general. The upper outer quadrant was commonly (42%) involved. Most of the lesions of fibrocystic disease were between 2-4 cm in diameter and surface was nodular. Mobility was restricted in majority of cases, while few were freely mobile. This study encountered no family history of benign beast disease in 24 cases of fibrocystic disease. Three patients had history of similar complaints tin the past. Of these, 2 cases lesions were present in the opposite breast and in 1 case on same side. Out of 16 cases of fibrocystic disease, 15 cases were treated conservatively with capsule of evening primrose oil or tab Danazol for all cases for 3 months. Both responded well. But symptoms recurred after stopping evening primrose oil. But cases on danazol 100 mg OD for cyclical mastagia, reported 50% reduction in 1-2 weeks and asymptomatic by the end of 1 month. Patients with nodularity were put on 200-400 mg danazol and they reported resolution of nodules by end of 3 months. Some patients discontinued the treatment as drugs were costly, and insisted on surgical excision which was done 96

later. Some of the patients were patients were anxious and not comfortable even after reassurance. Hence they were treated surgically but most educated women who were reassured, settled with conservative line of management. Breast Abscess This study encountered 10 cases (10%) of non-lactating breast abscess. The earliest case presentation was 2 days since the onset of symptoms, and one case presented with 14 days history. Average time of presentation was 3-6 days. Of these, 3 cases were neonates and children aged between 20 days, 8 months and 12 years respectively. Among adults, the oldest patient was 65 years. All the patients were treated by incision and drainage, under the coverage of antibodies. Gynecomastia This series had a total of 13 patients (13%) the duration of symptoms varied from 2 months to 1 year, most patients in the age group of 20 years, Most of them presented with enlarged breast and pain. There was no history of drug ingestion or any demonstrable cause of Gynecomastia. They were treated by subcutaneous Mastectomy. The indication for surgery in this study was mainly cosmesis and persistent pain. Phyllodes Tumor This study encountered 2 cases (2%) of phllodes tumor (Benign variety). Both cases measured 30 sq, cms in size. One patient underwent simple mastectomy and another one underwent wide excision, one case was clinically and by FNAC –diagnosed as Fibroadenoma and underwent excision of the lesion and HPE turned out to be phyllodes tumor. The other case was diagnosed as giant fibroadenoma clinically and by FNAC, but HPE proved it to be low grade phyllodes tumor. Duct Ectasia In this series there were 2 cases (2%) of duct ectasia which presented in 3rd decade and another one in 4th decade. One case presented with lump, pain and

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serous discharge. This case which presented was diagnosed as duct ectasia clinically and on FNAC, and ductogram was also done. The case underwent Microdochectomy. HPE reported as Duct ectasia. The other case presented with lump and pain. Clinically suspected to be fibroadenoma and FNAC suggested Fibroadenoma, traumatic fat necrosis. Patient underwent quadrantectomy and HPE reported it as duct ectasia.

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SUMMARY AND CONCLUSION
The present study of benign breast disease in a teaching hospital revealed that they were more frequent than generally expected. They were most frequent in the reproductive age group and in the upper outer quadrant with Fibroadenoma being the most frequent problem. There was good correlation between clinical diagnosis, FNAC to HPE with respect to Fibroadenoma and fibrocystic disease. Surgical treatment and medical line of management respectively for these cases were successful with resolution of pre-operative symptoms. The present trend of conservative management of most benign breast disorders has reduced number of surgical procedures for these conditions. However in view of the anxiety regarding symptoms, distance to be traveled, poor socioeconomic conditions leading to difficulty in follow up quite a few patients opt for an early surgical method of resolution of symptoms. Hundred cases were analyzed over a period of 2 years. On analyzing the age incidence, it was found that the commonest age of occurrence was between 16-30 yrs. (54%) and about 95% before 5th decade of life, average age of 28.17 yrs and standard deviation of + 9.37 yrs was observed. This illustrates the fact that benign breast disease commonly affects adolescents and young adults. Other studies also showed that the adolescent and young adults commonly affected than the older individuals, more than 45 years of age. The occurrence of benign breast disease after 45 yrs of age was 5% in this series. It was found that 86% were female cases when compared to 14% of male cases. Patients presented with symptoms of lump with pain, enlargement of breast or discharge. The usual and commonest mode of presentation was lump

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alone – 49% and lump and pain 28%. These 2 symptoms contributed to77% of patient s complaints. 79% of the patients presented within 6 months of the onset of the symptoms. This early presentation could partially be due to the greater awareness of the disease of the breast and fear that lump could be malignant The right breast was involved in 45% of cases and left in 34% of cases and bilateral in 21% of cases. It was found that the upper outer quadrant was commonly involved this was also supported by Oluwole series (New York) which also reported involvement of outer and upper quadrant commonly. Most of the lesions in this series were more than 5 sq cms. Most of the lesions were excised under general anesthesia. Fibroadenoma was the commonest lesion with 48%. Fibrocystic disease was the next commonest with 16% of cases. These figures correlate with those of Oluwole[New York] who found Fibroadenomas in 48% and Fibrocystic disease in 24% of cases. The next common lesion was gynecomastia constituting 13% of cases in this study. In patients with Fibroadenoma the upper outer quadrant was involved in 42% of the patients. The commonest age of occurrence in this series was 16-30 yrs, Fibroadenomas commonly presented as lump in the breast in 49% of the patients. Bilateral Fibroadenomas were seen 6.25% cases and multiple Fibroaenomas also in 6.25% cases. In this series one case had foci of calcification in case of Fibroadenoma.

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16% of cases had Fibrocystic disease as compared to 24% of cases in Oluwole, New York, Fibroctstic disease commonly occurred between 16-30 yrs of age. Most of the patients with fibrocystic disease presented with lump in breast followed by lump and pain. Involvement of the side and quadrant were similar to that of benign breast disease in general. Ten cases of breast abscess were treated by incision and drainage with antibiotic coverage. 13 patients had gynecomasita. Most were in the age group of 15-25. Most presented with enlargement of the breast with pain. There was no history of drug ingestion. All were treated by subcutaneous masectomy. Two cases of phyllodes tumor were seen, of which none of them had recurrence. Two cases of duct ectasia were treated by microdochectomy. In this study there were 4 cases of family history of similar complaints among the first degree relatives. Seven cases gave past history of similar complaints which were treated surgically, 5 cases had lesion in the opposite breast and 2 cases in the same breast. Diagnosis of benign breast disease were made by clinical examination and investigation procedures. Routine investigations were done for all patients and when required mammography was done. Comparison of clinical diagnosis and FNAC to HPE of

Fibroadenoma and fibrocystic disease was done. Clinical diagnosis and FNAC of Fibrodenoma and for Fibrocystic disease has sensitivity of 87% each when compared to Histopathological examination. Most of the cases of benign breast disease occurred in reproductive age group (95%).

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The standard treatment advocated was followed for all cases, where necessary minor adjustments were made. Surgical treatment was the main mode of treatment. For most of the cases circumareolar incision was used, the follow up was from 3 months to 11/2 yrs. Present hence was treated conservatively. study encountered one case of recurrence of Fibroadenoma which was proved by FNAC as Fibroadenosis and

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STATISTICAL METHODS APPLIED Following statistical methods were employed in the present study • • • Contingency Table analysis Independent samples ‘t’ test Chi-square test

Contingency Table Analysis The contingency table analysis procedure (Cross tabs) forms two-way and multiway tables and provides a variety of tests and measures of association for two-way tables. The structure of the table and whether categories are ordered determine what test or measure to use. Crosstabs statistics and measures of association are computed for two-way tables only. If you specify a row, a column and a layer factor (control variable), the crosstabs procedure forms one panel of associated statistics and measures for each value of the layer factor (or a combination of values for two or more control variables). For example, if GENDER is a layer factor for a table of MARRIED (Yes, no) against LIFE (is life exciting, routine, or dull), the results for a two-way table for the females are computed separately from those for the males and printed as a panels following one another. The Independent-samples ‘t’ Test This procedure compares means for two groups of cases. Ideally, for this test, the subjects should be randomly assigned to two groups, so that any difference in response is due to the treatment (or lack of treatment) and not to other factors. This is not the case if you compare average income for males and females. A person is not randomly assigned to be a male or female. In such situations, you should ensure that differences in other factors are not masking or enhancing a significant difference in means. Difference in other factors are not

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masking or enhancing a significant difference is means. Differences in average income may be influenced by factors such as education and not by sex alone.

Chi-square Test The chi-square test procedure tabulates a variable into categories and computes a chi-square statistic. This goodness-of-fit test compares the observed and expected frequencies in each category to test either that all categories contain the same proportion of values or that each categories contains a userspecified proportion of values. All the statistical calculations were performed using the software SPSS for Windows (Statistical presentation system, software, SPSS inc, 1999, New York) version 10.0.

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LIST OFABBREVIATOINS USED
B _ BA _ BP _ C _ CM _ CNS _ CP _ CVS _ DC _ DE _ DOA _ DOD _ DP _ ECG _ ESR _ F _ FA _ FC _ FNAC _ G _ GFA _ H/o _ HB% _ IP No _ L _ LI _ LO _ M _ Mon _ NA _ NM _ P/A _ PN _ R _ RS _ TC _ UI _ UO _ WB _ Bilateral Breast Abscess Blood Pressure Central Cyclical Mastalgia Central Nervous System Cystosarcoma Phyllodes Cardio Vascular System Differential count Duct Ectasia Date of Admission Date of Discharge Duct Papilloma Electro cardiogram Erythrocyte Sedimentation Rate Female Fibroadenoma Fibrocystic Disease Fine Needle Aspiration Cytology Gynecomastia Giant Fibroadenoma History of Haemoglobin% In Patient Number Left Lower Inner Lower Outer Male Months Not Applicable Not Married Per Abdomen Plexifrom Neurofibromatosis Right Respiratory System Total Count Upper Inner Upper Outer Whole Breast

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BIBLIOGRAPHY
TEXT BOOKS:
1. Short practice of Surgery – Bailey & Love, 24rd edition, 2. An introduction to the symptoms and signs of the surgical disease N. Browse, 3rd edition. 3. A manual on Clinical Surgery – S.Das, 6th edition. 4. A Practical Guide to Operative Surgery – S.Das, 4th edition. 5. Text book of Operative Surgery – Farquharson, 9th edition. 6. Grays Anatomy – 38th edition. 7. Regional & Applied Anatomy – Last, 10th edition. 8. Synopis of Surgical Anatomy– Lee McGregor, 12th edition. 9. Text book of Surgery – Sabiston 17th edition. 10. Principles of surgery – Schwartz. 8th edition. 11. Essential Surgical Practice – Sir Alfred Cuschieri, 4th edition. 12. William Boyd ; Pathology for Surgeons 8th edition. 13. Jamieson and Kay : A text book of surgical physiology : 4th edition. 14. C.D. Haagenson : Diseases of Breast : 2nd edition.

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Journals
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15) Parker SH, Lovin JD, Jobe WE, et al. Nonpalpable breast lesions: stereotactic automated large-core biopsies. Radiology 1991; 180: 403. 16) Drew PJ, Monson JRT. Magnetic resonance mammography. Br J Surg 1996; 83: 1316. 17) Fischer U, Vosshenrich R, Doler W et al. MR imaging guided breast intervention – experience with two systems. Radiology 1995; 195:593. 18) Doberl A, Tobiassen T, Rassussen T. Treatment of recurrent cyclical mastodynia in patients with fibrocystic Gynecol Scan 1984; 123: 177-84. 19) Preece PE, Hanslip JI, Gilbert L et al. Evening primrose oil (Effamol) for mastalgia. In: Horrobin DF, ed Clinical uses of Essential Fatty Acids. Montreal: Eden Press 1982; 147-54. 20) Mansel RE, Wiseby JR, Hughes L. The use of danazol in the treatment of painful benign breast disease: Preliminary results. Postgrad med J 1979: 5: 61-5. 21) Anderch B, Hahn L. Bromocriptine and premenstrual tension: a clinical and hormonal study; Pharmatherapeutica 1982; 3: 107-13. 22) Kullander S, Svanberg L. Bromocriptine treatment of the premenstrual syndrome. Acta obstet Gynecol Scand 1979; 58: 375-8. 23) Kern WH, Clark RW. Retrogression of Fibroadenomas of the breast. Am J Surg 1973; 126: 59-2. 24) Srivastava A, Griwan MS, Shanna LK et al. A safe technique of major duct excision. JR coll Surg Edinb 1995; 40:35. 25) Bundred NJ, Dixon JM, Chetty U, Forrest APM. Mammillary Fistula. Br J Surg 1987; 74: 466 – 8. 26) Grabb WC, smith JW. Gynaecomastia in. Oxford test book of Surgery, Oxford 1994; Oxford Medical publications, 842-3. 27) Moffat CJC, pinder SE, Dixon AR et l. Phyllodes tumors of the breast: a clinicopathological review of 32 cases. Histopathol 1995; 27: 205 – 8. breast disease. Acta obstet

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