Thesis

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.
1
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
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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 Benign breast Benign breast
Normal process
period disorder disease
Nipple inversion,
Ductal development
Single duct
Lobular Mamillary duct
Obstruction
Development Development fistula. Giant
Fibroadenoma
Stromal fibroadenoma
Juvenile
Development
Hypertrophy
Mastalgia
Nodularity
Hormonal Activity
Cyclical change Focal
Epithelial Activity
Diffuse
Benign papilloma
Blood stained nipple
Epithelial Discharge
Pregnancy and
Hyperplasia Galactocele and
lactation
Lactation inappropriate
lactation
Lobular involution Cysts and sclerosing
Periductal mastitis
Ductal involution adenosis
with suppuration
Fibrosis Nipple retraction
Lobular hyperplasia
Involution Dilatation Duct ectasia
with atypia
Involutional Simple hyperplasia
Ductal hyperplasia
Epithelial Micro
with atypia
Hyperplasia Papillomatosis
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 70%

Proliferative changes with no atypia 26%
Proliferative changes with atypia 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) Apocrine
(ii) 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 relative risk
Apocrine metaplasia
Cysts micro and or macro
Duct ectasia
Fibrosis
Mild hyperplasia
Mastitis
Periductal mastitis
Squamous metaplasia
Hyperplasia, moderate or florid, Slightly increased risk (1.5 to 2 times)
solitary or papillary
Papilloma with fibrovascular core
Atypical hyperplasia Moderately increased risk (5 times)
Ductal
Lobular
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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) Proliferating connective tissue stroma
(ii) 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.
24
Histology
There is proliferation of loose periductal connective tissue together with

variable degrees of multiplication, elongation of, or branching of ducts.
Periductal cells, infiltration by plasma cells, lymophocytes and large
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 oestrogen levels before the gynecomastia became clinically
apparent.
25
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 oestrogen /
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 also produce
gynecomastia
26
Chemotherapeutic agents and radiotherapy can cause
gynecomastia especially in patients who have had an orchidectomy for
testicular cancer
(ii) 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.
(iii) 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
(iv) 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.
(v) 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.
(vi) 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
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
27
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.
28
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.
29
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.
30
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
31
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.
32
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.
33
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.
34
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)
37
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
38
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) Film/Screen mammography with grid
ii) 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.
40
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.
41
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.
42
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.
43
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.
45
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.
46
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.
47
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.
48
PROFORMA – BBD
Name : IP No. : D.O.A.

Age : Unit : D.O.D.
Sex : 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 : Icterus :
B.P. : Lymphadenopathy :
Pallor : Others :
LOCAL EXAMINATION (BREAST) RIGHT LEFT

Inspection:
1. Size :
2. Nipple :
3. Areola :
4. Skin over the breast :
5. Lump :
Palpation:
1. Temperature :
2. Tenderness :
3. Number :
4. Site :
49
5. Size :
6. Shape :
7. Surface :
8. Consistency :
9. Fluctuation :
10. Margin :
11. Mobility :
12. Fixity to skin / Breast Tissue/Muscle:
13. Discharge from nipple :
14. Regional Lymph nodes :
15. Mobility of the breast as a whole :
SYSTEMIC EXAMINATION:
P/A : CVS :
RS : CNS :
Provisional Diagnosis :
Investigations :
1) Blood
HB% : ESR : Blood sugar :
TC : Urea : Blood grouping :
DC : Creatinine: Others :
II) Urine : (Albumin / Sugar / Deposits) :

1. X-ray chest :
2. ECG :
3. FNAC :
4. HPE :
Final diagnosis :
Treatment :
Progress/Follow up :
50
CASE REPORT - 1
Name : Savaramma IP No. : 02439 D.O.A:17-01-05

Age : 30 years Unit : FSB - 1 D.O.D:26-01 05
Sex : Female Hospital : Govt. Gen. Hospital, Kurnool.
History :
Complaints: Pain (Dull aching / Throbbing) : Dull aching
Lump : 2 Lumps one in each breast
Discharge (Serous / Purulent / Blood / Milk) : No Discharge
Duration : 3 Months
Rate of Growth : Gradual
Others if any : -
Past h/o : Similar complaints 2 yrs back
For which she was operated
Any relation to menstrual cycles – (pain) : -
Any h/o intake of oral contraceptive pills : No
Any h/o recent lactation or pregnancy : No
Any h/o similar or related complaints in the past : No
Menstrual History : Normal (3/30)
Menarche : 12 Years
Family : Completed, 2 children
Pulse : 82 / min Icterus : No
B.P. : 120/80 mm of Hg Lymphadenopathy : No
Pallor : No

Inspection:
1. Size : Normal Increased
2. Nipple : Normal Normal
3. Areola : Normal Normal
4. Skin over the breast : Normal Stretched
5. Lump : 3x3 cms 5x5 cms
Palpation:
1. Temperature : Normal Normal
51
2. Tenderness : No No
3. Number : 1 1
4. Site : Upper outer Upper outer
5. Size : 3x3 cms 5x5 cms
6. Shape : Spherical Spherical
7. Surface : Smooth Smooth
8. Consistency : Firm Firm
9. Margin : Well defined Well defined
10. Mobility : Freely Mobile Freely Mobile
11. Fixity to skin / Breast Tissue/Muscle: Nil Nil
12. Discharge from nipple : Nil Nil
13. Regional Lymph nodes : Not enlarged Not enlarged
14. Mobility of the breast as a whole : Present Present
P/A : Normal CVS : S1 S2 +
RS : Clear CNS : Normal
Provisional Diagnosis : Bilateral Fibroadenoma

Investigations :
1) Blood
HB% : 10Gm% ESR :7mm/Hr Blood sugar : 90mg / dl
TC : 8400/mm3 Urea : 22mg/dl Blood grouping : A Positive
DC : N65L28M4B1E2 Creatinine: 1.1mg/dl
II) Urine : (Albumin / Sugar / Deposits) : Nil

1. X-ray chest : Normal
2. ECG : Normal
3. FNAC : S/o Fibroadenoma
4. HPE : Fibroadenoma (Pericanalicular)
Final diagnosis : Bilateral Fibroadenoma

Treatment : Excision on both sides
Progress/Follow up : 1 Year follow up is uneventful
52
CASE REPORT - 2
Name : Nagamma IP No. : 06749 D.O.A:16-02-05

Age : 35 years Unit : FSB 3 D.O.D:25-02-05
History :
Complaints :
Lump : Single Lump in left breast
Discharge (Serous / Purulent / Blood / Milk) : Serosanguinous Discharge
Duration : 3 months
Others if any : -
Menarche : 14 Years
Family : 2 children
Pallor : No

Inspection:
1. Size : Normal Normal
4. Skin over the breast : Normal Normal
5. Lump : - 1x2cms
Palpation:
2. Tenderness : - -
3. Number : - 1
53
4. Site : - Central
5. Size : - 1x2cms
6. Shape : - Oval
7. Surface : - Smooth
8. Consistency : - Soft
9. Margin : - Well defined
10. Mobility : - Mobile
11. Fixity to skin / Breast Tissue/Muscle: - Nil
12. Discharge from nipple : - Present
13. Regional Lymph nodes : - Not enlarged
14. Mobility of the breast as a whole : - Present
Provisional Diagnosis : Duct ectasia Left Breast

Investigations :
1) Blood
HB% : 10.2 gm% ESR : 8mm/Hr Blood sugar : 102mg / dl
TC : 8200/mm 3
Urea : 30mg/dl Blood grouping : O Positive

6. ECG : Normal
7. FNAC : S/o Duct ectasia
8. HPE : Duct ectasia
Final diagnosis : Duct ectasia Left Breast

Treatment : Microdochectomy
Progress/Follow up : Normal after 18 months follow up
54
CASE REPORT - 3
Name : Zaithun Bee IP No. : 14498 D.O.A:06-05 05

History :
Complaints :
Lump : Single Lump in right breast
Duration : 2 months
Rate of Growth : Rapid
Others if any : -
Menarche : 14 Years
Family : 3 children
Pallor : +

Inspection:
1. Size : Increased Normal
4. Skin over the breast : Stretched,dilated veins+ Normal
5. Lump : 6x8cms -
Palpation:
2. Tenderness : - -
3. Number : 1 -
4. Site Lower outer -
55
5. Size : 7x8cms -
6. Shape : Irregular -
7. Surface : Bossellated -
8. Consistency : Firm -
9. Margin : Well defined -
10. Mobility : Mobile -
11. Fixity to skin / Breast Tissue/Muscle: Nil -
12. Discharge from nipple : Nil -
13. Regional Lymph nodes : Not enlarged -
14. Mobility of the breast as a whole : Present -
Provisional Diagnosis : Phyllodes Tumor Right Breast

Investigations :
1) Blood
HB% : 8.5 gm% ESR :9mm/Hr Blood sugar : 72mg / dl
TC : 8000/mm3 Urea : 28mg/dl Blood grouping : O Positive

10. ECG : Normal
11. FNAC : S/o Phyllodes Tumor
12. HPE : Phyllodes Tumor

Final diagnosis : Phyllodes Tumor Right Breast
Treatment : Excision
Progress/Follow up : After 4 months of follow up patient dint turn up.
56
CASE REPORT – 4
Name : Yesiah IP No. : 06577 D.O.A:10-02-06

Sex : Male Hospital : Govt. Gen. Hospital, Kurnool.
History :
Complaints Pain (Dull aching / Throbbing) : Dull aching
Duration : 12 months
Others if any : -
Any h/o similar or related complaints in the past : -
Any h/o Drug intake : -
Family History : Nil Significant
Pallor : No

Inspection:
1. Size : Normal Increased
5. Lump : - 3x3cms
Palpation:
2. Tenderness : - Present
3. Number : - 1
4. Site : - Central
5. Size : - 5x3cms
6. Shape : - Spherical
57
8. Consistency : - Firm
10. Mobility : - Mobile
12. Discharge from nipple : - Nil
14. Mobility of the breast as a whole : - -
Provisional Diagnosis : Gynecomastia of Left Breast

Investigations :
1) Blood
HB% : 12 gm% ESR : 6mm/Hr Blood sugar : 110mg / dl
TC : 7600/mm3 Urea : 36mg/dl Blood grouping : AB Positive

14. ECG : Normal
15. FNAC : Gynecomastia
16. HPE : Gynecomastia
Final diagnosis : Gynecomastia Left Breast

Treatment : Subcutaneous mastectomy
Progress/Follow up : After 5 months of follow up patient is doing well
58
CASE REPORT - 5
Name : Lakshmi IP No. : 09118 D.O.A:08-03-05

History :
Complaints :
Duration : 15 days
Others if any : -
Menarche : 13 Years
Family : Not Married
Pallor : No

Inspection:
5. Lump : 3x4 cms -
Palpation:
2. Tenderness : No -
3. Number : 1 -
59
4. Site : Upper outer -
5. Size : 3x4 cms -
6. Shape : Oval -
7. Surface : Smooth -
10. Mobility : Freely Mobile -
Provisional Diagnosis : Fibroadenoma Right Breast

Investigations :
1) Blood
HB% : 11 gm% ESR :7mm/Hr Blood sugar : 86mg / dl
TC : 7200/mm 3
Urea : 20mg/dl Blood grouping : B Positive

18. ECG : Normal
20. HPE : Fibroadenoma (Intracanalicular)
Final diagnosis : Fibroadenoma Right Breast

Treatment : Excision through circum areolar incision
Progress/Follow up : 15 month follow up uneventful
60
CASE SHEET - 6
Name : Nirmala IP No. : 22053 D.O.A:22-07-05

History :
Complaints: Pain (Dull aching / Throbbing) : Dull aching
Duration : 15 days
Others if any : -
Any relation to menstrual cycles – (pain) : Yes
Any h/o similar or related complaints in the past : Yes
Menarche : 13 Years
Family : 5 children
Pallor : +

Inspection:
5. Lump : 2x3 cms -
Palpation:
2. Tenderness : + -
3. Number : 1 -
61
4. Site : Central -
5. Size : 2x3 cms -
6. Shape : Oval -
10. Mobility : Mobile -
Provisional Diagnosis : Fibro adenoma Right Breast

Investigations :
1) Blood
HB% : 8.5 gm% ESR :9mm/Hr Blood sugar : 72mg / dl
TC : 8000/mm 3

22. ECG : Normal
23. FNAC : S/o Fibrocystic disease
24. HPE : Fibrocystic disease
Final diagnosis : Fibrocystic disease Right Breast

Treatment : Excision through circum areolar incision
Progress/Follow up : one year follow up is uneventful
62
CASE REPORT - 7
Name : Malathi IP No. : 11189 D.O.A:28-04-05

History :
Complaints Pain (Dull aching / Throbbing) : Dull aching
Duration : 2 months
Others if any : -
Menarche : 13 Years
Family : 1 children
Pallor : No

Inspection:
5. Lump : - 4x4cms
Palpation:
2. Tenderness : - -
3. Number : - 1
63
4. Site : - Upper inner
5. Size : - 4x5cms
6. Shape : - Oval
8. Consistency : - Firm
10. Mobility : - Freely Mobile
12. Discharge from nipple : - Nil
14. Mobility of the breast as a whole : - Present
Provisional Diagnosis : Fibroadenoma Left Breast

Investigations :
1) Blood
HB% : 11 gm% ESR : 6mm/Hr Blood sugar : 110mg / dl
TC : 7600/mm 3

26. ECG : Normal
28. HPE : Fibroadenoma (Pericanalicular)
Final diagnosis : Fibroadenoma Left Breast

Treatment : Excision through radial incision
Progress/Follow up : No recurrence after 15 months of follow up
64
CASE REPORT - 8
Name : Ramesh IP No. : 54508 D.O.A:06-12-05

Sex : Male Hospital : Govt. Gen. Hospital, Kurnool.
History :
Complaints Pain (Dull aching / Throbbing) : Dull aching in both breasts
Lump : Single Lump in each breast
Duration : 8 months
Others if any : -
Any h/o similar or related complaints in the past : -
Any h/o Drug intake : -
Family History : Nil Significant
Pallor : No

Inspection:
1. Size : Increased Increased
5. Lump : 3x3cms 3x3cms
Palpation:
2. Tenderness : Present Present
3. Number : 1 1
4. Site : Central Central
5. Size : 3x3cms 3x3cms
65
10. Mobility : Mobile Mobile
14. Mobility of the breast as a whole : - -
Provisional Diagnosis : Bilateral Gynecomastia

Investigations :
1) Blood
TC : 6400/mm3 Urea : 32mg/dl Blood grouping : A Positive

30. ECG : Normal
31. FNAC : -
32. HPE : Gynecomastia
Final diagnosis : Bilateral Gynecomastia
Treatment : Bilateral Subcutaneous mastectomy
Progress/Follow up : Uneventful
66
CASE REPORT - 9
Name : Bharathi IP No. : 59043 D.O.A:28-12-04

Age : 40 years Unit : FSB - 2 D.O.D:08-01-05
History :
Complaints :
Lump : Lumps in both breast
Duration : 10 Months
Others if any : -
Menarche : 14 Years
Family : 1 child
Pallor : No

Inspection:
4. Skin over the breast : Stretched Normal
5. Lump : 6x6 cms 3x3 cms
Palpation:
2. Tenderness : No No
3. Number : 1 1
67
4. Site : Upper outer Lower outer
5. Size : 6x7 cms 3x3 cms
10. Mobility : Freely Mobile Freely Mobile
Provisional Diagnosis : Giant Fibroadenoma Right, Fibroadenoma Left

Investigations :
1) Blood
HB% : 9.4 Gm% ESR : 8mm/Hr Blood sugar : 92mg / dl
TC : 7800/mm 3
Urea : 18mg/dl Blood grouping : B Positive

33. ECG : Normal
35. HPE : Giant Fibroadenoma Right,
Fibroadenoma Left
Final diagnosis : Giant Fibroadenoma Right, Fibroadenoma Left

Treatment : Excision on both sides
Progress/Follow up : Normal after 18 months of follow up
68
CASE REPORT - 10
Name : Achamma IP No. : 39765 D.O.A:09-08-04

History :
Complaints: Pain (Dull aching / Throbbing) : Throbbing pain in right breast
Duration : 3 days
Others if any : H/o Fever 3 days
Any relation to menstrual cycles – (pain) : No
Any h/o recent lactation or pregnancy : Lactating
Menarche : 15 Years
Family : 1 children
Pallor : No

Inspection:
4. Skin over the breast : Erythematous Normal
5. Lump : 5x6 cms -
Palpation:
1. Temperature : Raised Normal
2. Tenderness : + -
3. Number : 1 -
69
4. Site : Lower outer -
5. Size : 6x5 cms -
6. Shape : - -
10. Mobility : - -
11. Fixity to skin / Breast Tissue/Muscle: - -
Provisional Diagnosis : Right Breast Abscess

Investigations :
1) Blood
TC : 7400/mm 3

37. ECG : Normal
38. Culture & Sensitivity : Staph.aureus sensitive to
Amoxycillin+clavulanic acid
Final diagnosis : Right Breast Abscess

Treatment : Incision & Drainage
Progress/Follow up : 2 months follow up is uneventful
70
CASE REPORT - 11
Name : Raziya IP No. : 00134 D.O.A:02-01-06

History :
Complaints: Pain (Dull aching / Throbbing) : Throbbing pain in right breast
Duration : 20 days
Others if any : H/o Fever 20 days
Any relation to menstrual cycles – (pain) : No
Any h/o recent lactation or pregnancy : Lactating
Menarche : 14 Years
Family : 2 children
Pulse : 98/ min Icterus : No
Pallor : No

Inspection:
4. Skin over the breast : Erythematous Normal
5. Lump : 3x5 cms -
Palpation:
1. Temperature : Raised Normal
2. Tenderness : + -
3. Number : 1 -
71
4. Site : Lower outer -
5. Size : 5x5 cms -
6. Shape : - -
8. Consistency : Soft -
9. Fluctuation : Positive -
11. Mobility : - -
12. Fixity to skin / Breast Tissue/Muscle: - -
Provisional Diagnosis : Right Breast Abscess

Investigations :
1) Blood
TC : 13000/mm3 Urea : 26mg/dl Blood grouping : B Positive

40. ECG : Normal
41. Culture & Sensitivity : -
Final diagnosis : Right Breast Abscess

Treatment : Incision & Drainage
Progress/Follow up : Normal
72
CASE REPORT - 12
Name : Parvathamma OP No. : 03113 Date:24-01-05

Age : 20 years Unit : surgery op
History :
Complaints Pain (Dull aching / Throbbing) : Dull aching in both breasts
Lump : -
Duration : 2 Months
Nature of Pain : Periodic
Others if any : -
Any relation to menstrual cycles – (pain) : Yes
Any h/o intake of oral contraceptive pills : NA
Any h/o recent lactation or pregnancy : NA
Any h/o similar or related complaints in the past : Yes
Menarche : 15 Years
Family : Not Married
Pallor : No

Inspection:
5. Lump : - -
Palpation:
2. Tenderness : Mild Mild
3. Number : - -
73
4. Site : Whole Breast Whole Breast
5. Lump : No No
Provisional Diagnosis : Cyclical mastalgia

Investigations :
1) Blood
HB% : 10.2 Gm% ESR : 14mm/Hr Blood sugar : 98mg / dl
TC : 12000/mm3 Urea : 26mg/dl Blood grouping : B Positive

10. ECG : Normal
11. FNAC : S/o Fibrocystic changes
12. HPE : -
Final diagnosis : Cyclical mastalgia

Treatment : Eveningprim rose oil and Analgesics and reassurance
Progress/Follow up : 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
Age Total
Female Male
5 2 7
Below 15
5.8% 14.3% 7.0%
53 8 61
16-30
61.6% 57.1% 61.0%
24 3 27
31-45
27.9% 21.4% 27.0
4 1 5
Above 45
4.7% 7.1% 5.0%
Total 86 14 100
CC = 126; P<.657
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.
Mean Minimum Maximum
Deviation
Female 28.17 9.37 8 58
Male 27.92 14.81 8 65
Total 28.14 10.07 8 65
‘t’ = 0.081; P<.935
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
Male
60
50
40
Frequency
30
20
10
0
Below 16-30 31-45 Above
15 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

Etim E Onuka,
Age Present series Sofji F Oluwole
Nigeria
<15 6.8% 20% 21%
16-30 61.4% 28.6% 55%
31-45 27.3% 17.3% 14%
>45 4.5% 13.5% 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 Frequency Percent
Lump 49 49.0
Pain 15 15.0
Lump and Pain 28 28.0
Swelling 4 4.0
Fever and Lump 2 2.0
Nipple Discharge 1 1.0
Nipple Discharge and Lump 1 1.0
Total 100 100.0
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.
Graph.3 Frequency of symptoms
83
60
50
40
Frequency
30
20
10
0
Lump Pain Lump and Sw elling Fever and Nipple Nipple
Pain 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

Frequency Percent
<1 month 19 19.0
1-6 months 60 60.0
7-12 months 15 15.0
>12 months 6 6.0
Total 100 100.0
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 40 50 60
Frequency
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 Frequency Percent

Left 34 34.0
Right 45 45.0
Bilateral 21 21.0
Total 100 100.0
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.
85
Graph 5 : Side of Involvement
21
34
Left
Right
Bilateral
45
Table 7 : Comparison with Oluwole and Onukak studies

Side Present Series Oluwole Onukak’s study
Right 45% 45% 43.8%
Left 34% 41% 48%
Bilateral 21% 14% 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 Frequency Present
UO 42 42.0
UI 12 12.0
LO 11 11.0
LI 2 2.0
Central 23 23.0
WB 7 7.0
UO & UI 1 1.0
UO & LO 2 2.0
Total 100 100.0
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
Frequency
20
15
10
5
0
UO UI LO LI Central WB UO & UI UO & LO
Quadrants
87
Table 9 : Distribution of the Sample in Cases of Bilaterality
Quadrants Frequency Percent

Upper outer 6 27.3
Upper inner 2 9.1
Lower outer 3 13.6
Central 3 13.6
Whole breast 7 31.8
Lower Outer & Axillary Tail 1 4.5
Total 22 100.00
X2 = 7.455; P<.189 (Non-significant)
Statistically equal distribution was observed in cases with bilaterality. Chi

square test result was non-significant.
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 Total
< 2 sq cm 2-5 sq cm > 5 sq cm
Fibroadenoma 2 5 41 48
Giant Fibroadenoma 2 2
Fibrocystic Disease 5 3 8 16
Plexiform
1 1
Neurofibromatosis
Gynecomastia 4 9 13
Phyllodes tumor 2 2
Duct Ectasia 1 1 2
Cyclical Mastalgia 6 6
Breast Abscess 4 6 10
Total 18 10 72 100
CC = .523; P<.000
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 Percent
Fibroadenoma 48 48.0
Giant Fibroadenoma 2 2.0
Fibrocystic Disease 16 16.0
Plexiform
1 1.0
Neurofibromatosis
Breast Abscess 10 10.0
Gynecomastia 13 13.0
Cystosarcoma Phyllodes 2 2.0
Duct Ectasia 2 2.0
Cyclical Mastalgia 6 6.0
Total 100 100.0
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
Excision Drug Quadran Subcutaneous Microdoc I&D
90
s tectomy mastectomy hotomy
Fibroadenoma 48 1
Giant
2
Fibroadenoma
Fibrocystic Disease 5 11 1
Plexiform
1
Neurofibromastosis
Breast Abscess 1 10
Gynecpmastia 13
Cyclical Mastalgia 6
Duct Ectasia 1
Total 57 17 2 13 1 10
CC = .881; P,.000 (Highly-significant)

Graph 8 : Various Treatment Modalities
60
50
40
Frequency
30
20
10
0
Excision
I&D
Microdoc
Quadran
Subcutaneous
Drugs
mastectomy
Treatment
Comparison of Clinical Diagnosis, FNAC to HPE

Table 13 : Accuracy of Clinical Diagnosis against FNAC
Lesions FNAC Total
Fibroadenoma 32 1 33
97.0% 3.0% 100.0%
Giant Fibroadenoma 1 2 3
33.3% 66.7% 100.0%
Fibrocystic Disease 8 15 1 24
33.3% 62.5% 4.2% 100.0%
Plexiform
1 1
Neurofibromatosis
100.0% 100.0%
91
100.0% 100.0%
Gynecomastia 4 4
100.0% 100.0%
Duct Ectasia 1 100.0%
1 100.0%
Phyllodes Tumor 1 1
100.0% 100.0%
Total 41 3 16 1 2 4 1 38
CC=.904; P<.000 (HS)
Table 14 : Accuracy of FNAC against HPE

Lesions HPE Total
Fibroadenoma 31 1 1 33
93.9% 3.0% 3.0% 100.0%
Giant Fibroadenoma 2 1 3
66.7% 33.3% 100.0%
Fibrocystic Disease 6 6 12
50.0% 50.0% 100.0%
Plexiform
1 1
Neurofibromatosis
100.0% 100.0%
100.0% 100.0%
Gynecomastia 4 4
100.0% 100.0%
Duct Ectasia 1 100.0%
1 100.0%
Phyllodes Tumour 1 1
100.0% 100.0%
Total 37 3 7 1 2 4 2 56
CC=.896; P<.000 (HS)
92
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%.
93
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.
94
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
95
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
97
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.
98
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
99
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.
100
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%).
101
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 study encountered one case of
recurrence of Fibroadenoma which was proved by FNAC as Fibroadenosis and
hence was treated conservatively.
102
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
103
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 user-
specified 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.
104
LIST OFABBREVIATOINS USED
B _ Bilateral
BA _ Breast Abscess
BP _ Blood Pressure
C _ Central
CM _ Cyclical Mastalgia
CNS _ Central Nervous System
CP _ Cystosarcoma Phyllodes
CVS _ Cardio Vascular System
DC _ Differential count
DE _ Duct Ectasia
DOA _ Date of Admission
DOD _ Date of Discharge
DP _ Duct Papilloma
ECG _ Electro cardiogram
ESR _ Erythrocyte Sedimentation Rate
F _ Female
FA _ Fibroadenoma
FC _ Fibrocystic Disease
FNAC _ Fine Needle Aspiration Cytology
G _ Gynecomastia
GFA _ Giant Fibroadenoma
H/o _ History of
HB% _ Haemoglobin%
IP No _ In Patient Number
L _ Left
LI _ Lower Inner
LO _ Lower Outer
M _ Male
Mon _ Months
NA _ Not Applicable
NM _ Not Married
P/A _ Per Abdomen
PN _ Plexifrom Neurofibromatosis
R _ Right
RS _ Respiratory System
TC _ Total Count
UI _ Upper Inner
UO _ Upper Outer
WB _ Whole Breast
105
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.
106
Journals
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Coll Surg Ednils 1995;40:25.
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5) Hughes L.Bacaterodies and breast abscess. Lancet 1976;ii: 198-9.
6) Patey DH. Thackray AC. Pathology and treatment of mammary duct
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7) Dharkar Rs, Kanhere N II, Vaishya ND. Tuberculosis breast: J Ind Med
Assos 1968; 50:208.
8) Singh A, Gupta SK. Tuberculosis of breast. Ind J Surg 1980; 42: 432 – 37.
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Schaffer and Avery’s – Disease of the newborn, 6th edition, 364.
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combined physical examination, mammography, and fine- needle
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15) Parker SH, Lovin JD, Jobe WE, et al. Nonpalpable breast lesions:
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17) Fischer U, Vosshenrich R, Doler W et al. MR imaging guided breast
intervention – experience with two systems. Radiology 1995; 195:593.
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mastodynia in patients with fibrocystic breast disease. Acta obstet
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19) Preece PE, Hanslip JI, Gilbert L et al. Evening primrose oil (Effamol) for
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108

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INTRODUCTION

A prospective study of patients attending surgical OPD and also admitted

Patient predominantly presented with fibroadenoma and fibrocystic

Most of patients underwent FNAC and a few of them had mammograms

Treatment was mostly surgical in the form of excision, subcutaneous

In conclusion, benign breast disease is fairly prevalent with fibroadenoma

Mode of Selection of Cases

 Screening of cases by clinical examination in OPD and investigations such

Based on the provisional diagnosis, patients were subjected to surgery

 Cases were again analysed based on;

The concept of ANDI-Aberrations of Normal Development and Involution

ANDI, first proposed by Huges is now universally accepted. This concept

So most benign breast disease are relatively minor aberrations to normal

 To study distribution of benign breast disease with respect to

 To correlate between clinical diagnosis and FNAC to histopathological

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

The mature breast is considered to be a collection of sweat glands that

The glandular portion of the breast is composed of fibrous, adipose and

Around 75% of the lymphatic drainage of the breast passes to axillary

Early differentiation of he mammary gland anlage is under fetal hormonal

The major influence on breast growth during puberty is by Estrogen;

Breast tissue reacts to estrogen and progesterone stimulation, not only

As the menopausal period is approached and post menopausal period

The role of these hormones in the causation of mammary pathologies,

Clinically, the most useful system of classification of benign breast disease is

Six general categories have been identified.

1. Physiologic cycle swelling and tenderness

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

Fibrocystic breast disease is noncancerous. The most common of the

The involution of a lobule is dependent on the continuing presence of the

In the same manner there is formation of macrocysts which was described

Nonproliferative lesions 70%

Microscopic features studies on specimen tissues are:

The etiology of cystic disease is attributed to oestrogen imbalance. Excess

Sub populations of gross breast cysts

Two sub populations of gross breast are seen

Apocrine cysts to be bilateral, have full columnar epithelial linings,

In contrast, attenuated cysts histologically have flattened epithelium.

Biochemical properties of cysts

Leis perfomed biochemical analysis on the aspirated fluid of 2213 breast

Cysts are now regarded as manifestations of lobular involutions with

Other associated conditions with fibrocystic disease have

The most common signs and symptoms of fibrocystic changes is pain

Fine nodularity may be seen in the breast during pregnancy, lactation

Clinical stages of fibrocystic changes

There are 3 clinical stages of fibrocystic changes with considerable overlap

First Stage: Mazoplasia – Occurs in women in their twenties pain is mostly

Second Stage: Adenosis - occurs in women in their thirties. Multiple breast

Carcinoma and Fibrocystic Disease

An increased risk of subsequent breast carcinoma ranges from 1.7 to 4.0

The histologic lesion has been divided into 3 prognostic categories as a

The categories are:

Relative risk for breast cancer based on pathologic examination of benign

Oral contraceptives reduce the incidence of change with minimal

In summary, fibrocystic changes have been defined as a condition in

The range of symptomatology is broad, based on the fluctuating response

It is merely and innocuous overgrowth of fibrous tissue with epithelial

It represents the most common breast tumor in women younger than 25

In a series of 225 autopsy cases studied by Frantz, fibroadenomas were

Origin and Natural History

Fibrodenomas are considered to be an abnormality of normal

The biological behaviour is widely variable with 3 broad possibilities:

1. Regression of the fibroadenoma