Surgery

Benign Breast Diseases & Other Special Clinical Conditions

Jay K. Abarrientos, M.D.
August 24, 2020

OUTLINE
- Progression:
INEFCTIOUS / INFLAMMATORY DISORDER ................................................ 1 o subcutaneous
Bacterial Infection ........................................................................................................... 1
Epidemic Puerperal Mastitis........................................................................................... 1
o subareolar
Nonepidemic Puerperal Mastitis (Sporadic) ................................................................. 1 o interlobular (periductal)
Zuska's disease ............................................................................................................... 1 o retromammary abscesses (unicentric/multicentric)
Mycotic infections ........................................................................................................... 2
Hidradenitis Suppurativa ................................................................................................ 2 - Treatment:
Mondor's Disease ............................................................................................................ 2 o Antibiotics
COMMON BENIGN DISORDERS AND DISEASES OF THE BREAST ........... 2 o Repeated aspiration of abscess is ultrasound guided
Early Reproductive Years ............................................................................................... 2 o Operative drainage is indicated if failed treatment with
Late Reproductive Years ................................................................................................ 3
repeated aspiration and antibiotic therapy
INVOLUTION .................................................................................................... 3
Nonproliferative Disorders of the Breast ...................................................................... 3
Proliferative Breast Disorders Without Atypia (Involution) .......................................... 3 Streptococcal Infections
Atypical Proliferative Lesions (Involution) .................................................................... 3 - Presentation: Diffuse superficial involvement
TREATMENT OF SELECTED BENIGN BREAST DISORDERS ....................... 3
Cyst .................................................................................................................................. 3
Fibroadenoma ................................................................................................................. 3
Sclerosing Disorder ........................................................................................................ 3
Periductal Mastitis .......................................................................................................... 4
Nipple Inversion .............................................................................................................. 4

NIPPLE DISCHARGES ..................................................................................... 4

Unilateral Nipple Discharge............................................................................................ 4
Bilateral Nipple Discharge .............................................................................................. 4

AXILLARY LYMPH NODE METASTASES IN THE SETTING OF AN

UNKNOWN PRIMARY CANCER ..................................................................... 4

BREAST CANCER DURING PREGNANCY ..................................................... 4

MALE BREAST CANCER................................................................................. 4

PHYLLODES TUMORS .................................................................................... 5

Figure 2. Streptococcal Infection Presentation
INFLAMMATORY BREAST CARCINOMA ...................................................... 5
- Treatment:
o Local wound care
INEFCTIOUS / INFLAMMATORY DISORDER o Warm compress
- Postpartum period is the most common time o IV antibiotics
- Classified as o For chronic breast infections/recurrent abscess
o Intrinsic: abnormalities of the breast ▪ Do culture (AFB, anaerobic/aerobic bacteria, fungi)
o Extrinsic: infection in an adjacent structure o Biopsy of abscess cavity
▪ periductal mastitis/infected sebaceous cyst ▪ to rule out malignancy
▪ used when antibiotic and drainage have been ineffective

Bacterial Infection
Epidemic Puerperal Mastitis
- Most common organisms:
- Caused by methicillin resistant S. aureus
o Staphylococcus aureus - Via suckling neonate
o Streptococcus species - Purulent discharges
- This warrant stopping of breastfeeding, and implementing antibiotic
Staphylococcal Infections and surgical therapy (incision & drainage)
- Presentation: point tenderness, erythema and hyperthermia
Nonepidemic Puerperal Mastitis (Sporadic)
- Involves interlobular connective tissue
- Develops into nipple fissuring/milk stasis, initiating retrograde
bacterial infection
- Emptying of the breast shortens duration of symptoms and reduces
incidences of recurring cysts
- Antibiotic treatment is satisfactory in >95% of cases

Zuska's disease
- Recurrent retro areolar infections/abscess
- Smoking is as risk factor
- Use antibiotic therapy for treatment
- Can also use incision and drainage
Figure 1. Staphylococcal Infection Presentation - If chronically infected tissue, use wide debridement
1 of 5
 Surgery | Benign Breast Diseases & Other Special Clinical Conditions
Mycotic infections COMMON BENIGN DISORDERS AND DISEASES OF THE BREAST
- Caused by blastomycosis or sporotrichosis - Wide range of clinical/pathological entities
- Inoculated by the suckling infant - Aberrations of Normal Development and Involution (ANDI)
- Patients present with pus mixed with blood in sinus tracts classification
- Treatment: o Encompasses all aspects of breast condition
o Antifungal o Pathogenesis and degree of abnormality
o Drainage of abscess ▪ Early productive years: Age 15-25
o Partial Mastectomy-persistent fungal infection ▪ Later reproductive years: Age 25-40
▪ Involution: Age 35-55
Candida Albicans
Early Reproductive Years
- Affects skin
- Erythematous, scaly lesions especially in inframammary/axillary folds
- Treatment: remove maceration and apply nystatin

Hidradenitis Suppurativa

Figure 5. Early Reproductive Years

Fibroadenoma

Figure 3. Hidradenitis Suppurativa

- Chronic inflammatory condition

- Originates within accessory glands of the Montgomery/axillary
sebaceous glands
- Mimics other chronic inflammatory states like Paget’s disease,
invasive breast cancer
- Treatment:
o Antibiotic therapy
o Incision and drainage
o Excision is used with large areas of the skin with split thickness
Figure 6. Fibroadenoma
grafts
- Predominant in younger women
Mondor's Disease o 1-2 cm
o < 1 cm is considered normal
o < 3 cm is a disorder
o > 3cm is a disease (Giant Fibroadenoma)

Gigantomastia

Figure 4. Mondor's disease

- Thrombophlebitis that involves the superficial veins of the chest wall

and breast
- String phlebitis
o thrombosed vein
o tender, cord-like structure
Figure 7. Gynecomastia
o acute pain on lateral aspect of breast or anterior chest wall
o Treatment:
- Massive stromal hyperplasia
▪ anti-inflammatory medications
▪ application of warm compress
▪ resolved in 4-6 weeks Nipple Inversion
- Disorder in the development of the major ducts
- Prevention of normal protrusion of the nipple
2 of 5
 Surgery | Benign Breast Diseases & Other Special Clinical Conditions
Ductal epithelial hyperplasia
Mammary Duct Fistula - found in >20% of breast tissue specimen
- Nipple inversion predisposes major duct obstruction - either solid or papillary
- Recurrent subareolar abscess - increases risk of cancer
- mild: 3-4 cell layer above basement membrane
Late Reproductive Years - moderate: 5 or more cell layers above BM
- Cyclical Mastalgia/Nodularity - florid: occupies at least 70% of minor duct lumen
o premenstrual enlargement
o normal Intraductal papillomas
- Cyclical pronounce mastalgia
- arise in major ducts
o painful nodularity for > 1 week of menstruation is considered
- premenopausal
as a disorder
- <0.5cm but can be as large as 5cm
INVOLUTION - symptoms: nipple discharge that are serous or bloody
Nonproliferative Disorders of the Breast
Atypical Proliferative Lesions (Involution)

Figure 11. Atypical proliferative lesions

Atypical Proliferative Disease

Figure 8. Nonproliferative Disorders of the Breast
- presents with some features of carcinoma in situ but lacks a major
Ductal Ectasia defining characteristic
- atypical ductal hyperplasia (ADH)

Figure 9. Ductal Ectasia

- Dilated subareolar ducts
- Palpable with thick nipple discharge
- Ectasia leads to stagnation of secretions, epithelial ulceration,
leakage of duct secretions into periductal tissue Figure 12. Atypical Ductal Hyperplasia
- Wide spectrum of nipple discharge, nipple retraction, inflammatory
masses and abscesses - similar to low grade ductal carcinoma in situ (DCIS)
- up to 2-3 mm in size
- composed of monotonous round, cuboidal or polygonal cells
Calcification
enclosed by basement membrane
- Calcium deposit
- Most are benign TREATMENT OF SELECTED BENIGN BREAST DISORDERS
- Caused by cellular secretions and debris, trauma and inflammation
Cyst
Proliferative Breast Disorders Without Atypia (Involution) - aspiration using 21-gauge needle
- if not bloodstained, aspirate to dryness, and no cytologic examination
is needed
- cytological examination is indicated if it is bloodstained

Fibroadenoma
- self-limiting
- ultrasound: guided core needle biopsy for accurate diagnosis
Figure 10. Proliferative Breast Disorders Without Atypia - Cryoablation, Ultrasound Guided Vacuum Assisted-biopsy is used for
lesions <3cm
Sclerosing adenosis - larger lesions are removed by excision
- prevalent during childbearing and perimenopausal years
- no malignant potential Sclerosing Disorder
- distorted breast lobules - clinical significance is that it mimics cancer
- can be observed as long as imaging features and pathologic findings - can be observed with PE, mammography and gross pathological
are concordant examination
- excisional biopsy and histologic examination are done to exclude
Radial scars, complex sclerosing lesions cancer
- characterized by central sclerosis, epithelia proliferation, apocrine
metaplasia, and papilloma formation
- Lesions up to 1cm = radial scars
- larger lesions= complex sclerosing lesions
3 of 5
 Surgery | Benign Breast Diseases & Other Special Clinical Conditions
Periductal Mastitis
- painful and tender masses behind nipple-areola complex are
aspirated
- fluid is obtained for culture
- antibiotic treatment
- presence of pus may need repeated aspiration
- surgical treatment

Nipple Inversion Figure 14. Bilateral nipple discharge (milky & bloody)
- result of shortening of the subareolar duct
- complete division of these ducts AXILLARY LYMPH NODE METASTASES IN THE SETTING OF AN
- Complications: UNKNOWN PRIMARY CANCER
o altered nipple sensation - Axillary lymph node metastases consistent with breast cancer has
o nipple necrosis 90% probability from occult breast cancer
o postoperative fibrosis with nipple retraction - 1% of breast cancer had axillary LN metastases as an initial
presentation
NIPPLE DISCHARGES - Fine needle aspiration biopsy/core needle biopsy can be used to
Two types: establish diagnosis when large axillary lymph node is identified
1. Unilateral nipple discharge - When metastatic cancer is found, immunochemical analysis may
2. Bilateral nipple discharge classify the cancer as epithelial, melanocytic, or lymphoid
- Search for primary cancer includes careful examination of:
Unilateral Nipple Discharge o Thyroid
- Found in different clinical situations o Breast
- Suggestive of cancer if spontaneous, unilateral, localized in a single o Pelvis
duct o Rectum
- Women >40 years old - Hormone receptors (estrogen or progesterone) – suggestive of
- Bloody, associated with mass breast cancer metastases
- A trigger point in the breast may be present so that the pressure - Diagnostic mammography, ultrasonography, MRI for primary occult
around the nipple-areola complex induces discharge from a single lesion
duct - Chest radiograph and liver function test
o Mammography and ultrasound may be indicated for further
evaluation BREAST CANCER DURING PREGNANCY
o Ductogram – performed by cannulating a single discharging - 1 in every 3000 pregnant women
duct with a small nylon catheter or needle and injecting about - 75% with axillary LN metastases
1 mL of water-soluble contrast - Average age: 34 years old
- Nipple discharge associated with cancer may be clear, bloody, or - Ultrasonography and Needle biopsy for diagnosis
serous - Mammography – rarely indicated because of its decreased sensitivity
- Definitive diagnosis depends on excision biopsy of the duct and any during pregnancy and lactation
associated mass lesion - Once diagnosed, the following are performed
o CBC
o Chest X-ray (Shielded abdomen)
o Liver function tests
- Treatment is Modified Radical Mastectomy (MRM) during the 1st
and 2nd trimester; there may be increased risk of spontaneous
abortion
- Chemotherapy is given during 2nd and 3rd trimester
o 12% risk of birth defect, and spontaneous abortion if
chemotherapy is given in the 1st trimester
- Radiation therapy is given after the fetus is delivered due to its
deleterious effects
Figure 13. Unilateral nipple discharge (bloody) - 30% of benign conditions are encountered
o Galactoceles
Bilateral Nipple Discharge o lobular hyperplasia
o lactating adenoma
- Benign condition
o mastitis/abscess
- Multiductal
- Women <39 years old
MALE BREAST CANCER
- Milky or blue green
- <1% of all breast cancer occur in men
- The prolactin-secreting pituitary adenomas are responsible for
- Highest incidence in North Americans and the British (1.5% in all
bilateral nipple discharge in <2% of cases
male cancer); Jewish and African-American men also have a high
o Serum prolactin are elevated
incidence
o Plain radiographs of sella turcica/ thin section of CT scan are
- 20% preceded by gynecomastia
indicated and required
- Associated with
o radiation exposure
o estrogen therapy
o testicular feminizing syndromes
o Klinefelter’s syndrome

4 of 5
 Surgery | Benign Breast Diseases & Other Special Clinical Conditions
- Peak incidence in 6th decade of life; rarely seen in young males - Evaluation of the number of mitoses and the presence or absence of
- A firm non-tender mass requires investigation invasive foci at the tumor margins may help identify a malignant
o Skin or cell wall fixation is particularly worrisome tumor
- > 85% - infiltrating ductal carcinoma; <15% DCIS - Treatment:
- Staged in the same way as female breast cancer o Excision with a margin of normal-appearing breast tissue (1
- Same survival rate as women cm)
- Treatment is surgical – Modified Radical Mastectomy o Large phyllodes tumor require mastectomy
- 80% are hormone receptor positive – adjuvant tamoxifen o Axillary LN dissection is not recommended because ALN
- Chemotherapy for hormone receptor negative, large primary tumors, metastases rarely occur
multiple positive nodes, and locally advance disease
INFLAMMATORY BREAST CARCINOMA
- Stage IIIB
- <3% of breast CA
- Characterized by skin changes of brawny induration, erythema
with a raised edge, and edema (Peau d’orange)

Figure 15. Male patient with breast cancer

PHYLLODES TUMORS

Figure 18. Skin changes in inflammatory breast CA

Figure 16. Patient’s breast with phyllodes tumor

-
- The nomenclature presentation and diagnosis – (including
cystosarcoma phyllodes) posed many problems for surgeons
- Classified as Figure 19. Skin changes in inflammatory breast CA
o Benign
o Borderline – have greater potential for local recurrence - Permeation of the dermal lymph vessel by cancer cells seen in skin
o Malignant biopsy
- Sharply-demarcated from the surrounding breast tissue, compressed - There may be an associated breast mass
and distorted - Mistaken for a bacterial infection of the breast
- Bulk of these tumors are connective tissue which have mixed - >75% present with a palpable axillary lymphadenopathy
gelatinous, solid and cystic areas (sites of infarction and necrosis) - Distant metastases are also frequently present
- Gross alterations give the gross-cut tumor surface its classical leaf- - Treatment:
like (Phyllodes) appearance o Surgery alone and surgery with adjuvant radiation therapy have
- Stroma has greater cellular activity than fibroadenoma produced disappointing results
- Most malignant Phyllodes tumors o However, neoadjuvant chemotherapy with anthracycline-
o Liposarcoma containing regimen with a dramatic regression in up to 75%
o Rhabdomyosarcoma o Followed by Modified radical mastectomy to remove residual
cancer form chest wall and axilla
o Adjuvant radiation therapy of the chest wall, the
supraclavicular, internal mammary and axillary lymph nodes
basin
▪ this multi-modal approach results in a five-year survival
rates that approach about 30%

Figure 17. Phyllodes tumor specimen

5 of 5