EVALUATION OF BREAST PROBLEM &

BENIGN BREAST DISEASES

3 females with age 23, 35 and 55
years respectively went to see
you for consult. All have breast
mass in one of their breast.
 What important general data from the patients
do you think are important to be able to
guide you in your diagnosis? Explain.

• Breast lump characteristics

– Changes in size over time  Diet and medications
– Change relative to
– Current medications
menstrual cycle
– History of hormone
– Duration of mass therapy
– Pain or swelling
– Redness, fever, or
discharge
 History
• Family history  Medical and
– History of breast surgical history
disease – Personal history of
– Relationship to breast cancer
patient – Previous breast
– Relative's age at masses and
onset biopsies
– Recent breast
trauma or surgery
– Recent radiation
therapy or
chemotherapy
 History
 Personal  Social history
characteristics
– Radiation and
– Age at first childbearing chemical exposure
– Age at menarche – Smoking
– Age at menopause
– Current age
– Current lactation status
– History of breastfeeding
– Number of children
 In the Physical examination, differentiate a
benign from a
malignant lesion

 Benign Mass • Malignant Mass

– Cause no skin – Hard
change – Immobile
– Smooth – Fixed to the
– Soft to firm surrounding skin/ soft
– Mobile tissues
– Well defined – Poorly defined,
margins irregular margins
How will you approach the 35 year old,
with a 2 x 2 x 2cm, firm, mobile, well
circumscribed non tender mass on the
right breast?
A mammogram was taken as seen in the picture:

BENIGN CYST
 Benign cyst: Imaging
• Mammography
– To screen the normal surrounding
breast tissue and the opposite breast for
non-palpable cancers
• Ultrasound
– to differentiate solid from cystic masses
– to provide guidance for interventional
breast procedures such as cyst
aspiration or core biopsy
– useful when a palpable mass is partially
or poorly seen on a mammogram,
especially in young women
 Radiologic difference between a benign
and malignant mass

• BENIGN  MALIGNANT
– Smooth contour
– Well-circumscribed
– Encapsulated
– With “halo sign”
– Will not change
much in shape or size
– Grow significantly
– Stellate or star-bust
shaped that
extends in all
directions
– Calcifications
 Difference in ultrasound findings
• BENIGN • MALIGNANT
• intense uniform • Irregular/spiculated
hyperechogenicity borders (“Silhouette
sign”)
• ellipsoid or wider- • taller-than-wide
than-tall (parallel) orientation
orientation along • angular margins
with a thin, • marked hypoechogenicity
echogenic capsule • posterior acoustic
• 2 or 3 gentle shadowing
lobulations and a • punctate calcifications
thin, echogenic • duct extension
capsule • branch pattern
• microlobulation.
The patient has a mother who is a breast
cancer survivor. How would you handle
such patient?
 Breast Cancer Screening Tests
• Mammogram
– is the best tool available for early breast cancer detection
– can often identify cancer before symptoms appear and can
reveal calcium deposits in the breast, which may be an
early sign of cancer

****HIGH RISK: annual mammogram beginning at an

age that is 5 to 10 years younger than the youngest
member of the family with breast cancer
 Breast Cancer Screening Tests
• Clinical breast exam
– thorough physical examination of the breasts
done by a physician or nurse practitioner
– HIGH RISK: recommended every 6 to 12 months

• Self breast exam

– identify breast abnormalities and should be
performed monthly, about one week after the end
of your period
 Breast Cancer Screening Tests
• Breast MRI
– Fore extremely dense breast tissue that make
mammograms difficult to interpret
 How will you approach the 23 year
old, with a 2 X 2 X 2cm, firm, mobile,
well circumscribed non-tender mass
in the left breast?
 Imaging of choice
• ULTRASOUND
– For patients younger than 30 years
– The patient is spared radiation exposure
– to differentiate solid from cystic masses
– to provide guidance for interventional breast
procedures such as cyst aspiration or core biopsy
 Differential Diagnosis
• Cyst
• Fibroadenoma
• Phyllodes tumor
• Lipoma
• Fat necrosis
 Management
• Cyst
– Ultrasound or cyst aspiration useful to
differentiate between solid and cystic mass.
– With aspiration, if mass does not disappear
completely or if fluid is bloody, send for cytology
and refer to surgeon.
– Re-examine breast in six weeks for recurrence.
 Management
• Fibroadenoma
– The lump may be left in place or removed, depending on
the patient and the lump.
– If left in place, it may be watched over time with physical
examinations, mammograms, and ultrasounds.
– The lump may be surgically removed at the time of an
open biopsy. (excisional biopsy)
– Alternative treatments include removing the lump with a
needle, and destroying the lump without removing it (such
as freezing, called cryoablation).
A 43 year old female
consulted because of a rapidly
growing left breast. Axilla is
negative for clinically
palpable nodes.

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• Final diagnosis
• Behavior of the above?
• Treatment?

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 Final diagnosis:
Phyllodes tumor
• most commonly occurring nonepithelial
neoplasm of the breast
• represents only about 1% of tumors in the
breast
• rare, predominantly benign tumor
• sharply demarcated smooth texture
• typically freely movable
• relatively large tumor (average size:5 cm)
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 Final diagnosis:
Phyllodes tumor
• firm, mobile, well-circumscribed, nontender
breast mass
• tends to involve the left breast more commonly
than the right breast
• overlying skin may display a shiny appearance
and be translucent enough that underlying
breast veins are visible
• physical findings are similar to fibroadenoma
(mobile masses with distinct borders)
• manifest as larger masses and with rapid growth

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 Treatment: Phyllodes tumor

• Surgery
– wide local excision with a rim of normal
tissue
– if high tumor:breast ratio: total mastectomy
w/ or w/o reconstruction
– if (+) clinically suspicious nodes: axillary
lymph node dissection

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A 55 year old female
consulted because of
bloody nipple discharge
1. Differentiate a physiologic
from pathologic nipple
discharge
2. Describe the maneuver
how to localize the involved
duct.
3. Diagnosis? Treatment?

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 Physiologic vs. Pathologic nipple
discharge
• Discharge only with • Spontaneous
compression • Associated with a
• Usually bilateral, mass
Involvement of • Usually unilateral,
multiple ducts confined to one duct
• More viscous • usually serous,
bloody or clear, and
• milky to yellow, gray, has a watery
brown, or dark green consistency

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 Nipple discharges that are usually benign

Suspicious nipple discharges

http://www.breastdiagnostic.com/anatomy.html
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Contrast ductogram mammography

• retrograde injection of contrast medium

into a discharging duct, with subsequent
mammographic imaging of the breast in
at least 2 planes
• allows for visualization and localization of
involved duct and lesion

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 Diagnosis: Intraductal Papilloma

- benign wart-like growth in a major lactiferous

duct of the breast
- usually affects women aged 35-55 years
- usually located close to the nipple
- signs & symptoms
- nipple discharge: clear, sticky or bloody
- breast pain
- breast lump
- breast enlargement
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 Treatment: Intraductal Papilloma

• Excision of involved duct

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 2 ladies age 20 and 48 years respectively
consulted because of bilateral breast
tenderness.

• In the 20 year old, what is your foremost

consideration? Fibroadenoma

• In the 48 year old, what is your foremost

consideration? Fibrocystic breast change
How do you differentiate the diagnosis in 1 from
that of 2?
Fibroadenoma
• women less than 30 years of age
• firm, rubbery, freely mobile with
well-defined borders
• tender in the days before a period
or grow bigger during pregnancy
• approximately 10 percent of fully
recede each year
• fibroadenoma growths are
usually painless, but size and
location of the growth can cause
breast tenderness or pain.
Fibrocystic change
• 35-50 (premenopausal)
• dense, irregular and bumpy
"cobblestone" consistency in the
breast tissue
• premenstrual tenderness and
swelling
• result of prolonged cyclic
stimulation of repeated
menstrual cycle
• breasts feel full
• fibrous growth between the
breast glands or cyst formation
within the glands, this condition
is called atypical hyperplasia.
 How will you manage the 20 year old?

• Conservative management – follow-up every

6 months (until complete regression)

• Pain or tenderness or unusually large tumors

- excision
The 48 year old had surgery showing the gross
finding, What is your treatment?
 Treatment of Fibrocystic change

• Pain management
• Aspiration of cystic lesions
• Supportive bra in the week before their menses
• Eliminating caffeine, alcohol and reducing salt intake
• Taking vitamin E (400-800 IU daily) and A (150,000 IU daily)
may help some women
• Using diuretics during the week before the menstrual period
can help ease uncomfortable, swollen breasts.
Treatment of Fibrocystic change

• Birth control pills – regulate estrogen and progesterone

levels
• Bromocriptine - reduces prolactin release and
suppresses breast milk production after pregnancy
• Danazol -severe cases, inhibits the production of
hormones called gonadotrophins by the pituitary gland
How will you approach the 55 year old menopausic,
with 2 cm diameter, mobile, firm non tender mass on
the right breast.
Postmenopausal

Bilateral mammography

Biopsy
 Role of imaging modality in this case?

• mammography more helpful in older women because breast

tissue undergoes fatty replacement with age and masses are
more easily visible; young women have more fibrous tissue
making mammogram harder to interpret

• the primary purpose of the mammogram is to screen the

normal surrounding breast and the opposite breast for
nonpalpable cancers

Diagnosis - Cyst
 FNAc revealed NEGATIVE FOR MALIGNANT
CELLS. How will
You manage the patient.
• Annual mammography
• clinically suspicious mass – excisional biopsy
( distinct mass - should be removed and sent for examination for
malignancy because mammograms and cytologic needle
biopsies can have falsely negative results and can miss cancer)