BENING BREAST

DISEASES

DR. GEORGE W. O. MUGENYA

MBChB, MMed, FCS (ECSA)

Learning Objectives
 Identify common causes of lumps in the breast.
 ŠKnow different methods of investigating breast
lumps.
 Š Understand clinical presentation and treatment of
benign breast lumps.
 ŠUnderstand management principles of other benign
breast conditions.
 Š Diagnose and manage infectious diseases of the
breast.
Introduction
 Breast problems are a major reason why women visit
clinicians.
 Breast diseases in women constitute a spectrum of benign
and malignant disorders.
 The most common breast problems for which women
consult a physician are breast pain, nipple discharge and a
palpable mass.
 According to American Cancer Society, when tissue biopsy
is examined under the microscope, nine out of every 10
women will have some type of abnormality.
…Introduction
 Benign conditions of the breast are relevant to
clinicians because:
 They cause symptoms which require investigation and
management.
 They are encountered in screened individual.
 They may mimic malignant conditions.
 They may be associated with an increased risk of cancer.
 They may be premalignant.
 Young women are more prone to benign breast
disorders than older women, in whom breast symptoms
are more likely to be caused by cancer.
Breast Development
 The breast is a modified sweat gland that produces
milk under hormonal influences.
 Embryologically it develops from downward
growths of ectoderm into the underlying
mesenchyme.
 They form two strips of the mammary ridges which
grow in a line extending from the embryonal axilla to
the inguinal region.
 Later branching epithelial cords appear as 15 to 25
buds, which eventually become lactiferous ducts and
associated alveoli.
…Breast Development
 These cords form the basis of the segmental pattern
of the adult breast.
 Later the lactiferous ducts become canalized and
open on to a pit in the epidermis:- future nipple.
 Further lobular development occurs at puberty, with
the ultimate development of 15 to 25 lobes, each of
which drains into a single lactiferous duct.
 These changes at puberty results from the effect of
oestrogen produced by the ovaries. 
Gross Anatomy Of The Breast
 Adult breast varies greatly in size but its base is
fairly consistent anatomically:
 Extending from 2nd to 6th rib in the mid-
clavicular line.
 Overlying pectoralis major, serratus anterior, and
external oblique muscles.
 Medially it reaches sternal edge and laterally
mid-axillary line.
 The pyramidal axillary tail extends into the
axilla.
…Gross Anatomy:

 It is made up of 15 to 25 lobules of glandular tissue

embedded in fat which accounts for its smooth
contour and most of its bulk.
 These lobules are separated by fibrous septa running
from subcutaneous tissues to the fascia of the chest
wall (ligaments of Cooper).
 Each lobule is drained by its lactiferous duct on to
the nipple (constituting a functional unit).
 The male breast is rudimentary, comprising of small
ducts without alveoli and supported by fibrous tissue
and fat.
Female Breast Anatomy

 The bulk of the breast

tissue is adipose tissue
interspersed with
connective tissue.
 Breast ducts comprise
only about 10% of the
breast mass.

9
Congenital Breast Anomalies
Athelia (absence of nipples)
Amastia (absence of breast tissue)

 Results when the mammary ridges fail to develop or completely

disappear.
An extra breast (polymastia)

 Extra nipple (polythelia)

 Occur along the milk line, but can occur in ectopic sites such as

the back, the vulva area, and the buttock.

 Accessory or ectopic breast tissue responds to hormonal

stimulation and may cause discomfort during menstrual cycles.

 These accessory tissues may undergo malignant transformation

and should be removed.

 …Congenital Breast Anomalies
 About 1-5 % of the population have
accessory nipples, and less
commonly accessory breast.
 Develops along the milk line.
 Most common site for accessory
nipple is below the breast.
 Most common site for accessory
breast is in the axilla.
 Rarely require treatment except
for cosmetic reasons.
 Subject to the same diseases as the
normal breast.
…Congenital Breast Anomalies
Benign Breast Diseases
 The five common breast symptoms recognized
by clinicians are:
 Breast lump.
 Breast pain.
 Nipple discharge.
 Nipple retraction.
 Skin changes.
 Patients may experience two or more of these
common symptoms simultaneously.
 …Benign Breast Disease (by Age)
 Clinical classification of benign breast disease in females are as follows:

Age in years Disease Signs and Symptoms

0—1 Neonatal hypertrophy Diffused swelling
10—12 Pre-pubertal mammary disc Subareolar mass
enlargement
15—30 Fibro-adenoma Mobile round mass
15—55 Cyclical mastalgia—with or Pain , maximal in the upper
without nodularity outer quadrant
40—50 Cysts (macrocysts) Sudden discrete mass
Any age Mastitis Inflamed tender mass
40+ Papillomas Bloody or serous discharges
Classification By Clinical Features
 Tumors and Masses  Mastalgia (Pain)
 Cyclic
 Nodularity or  Non Cyclic
glandular
 Cysts
 Galactocoele
 Fibroadenoma
 Sclerosing Adenosis
 Lipoma
 Harmatoma
 Cystosarcoma
...Classification By Clinical Features

 Breast infections and  Acute mastitis

Inflammation associated with
 Intrinsic mastitis macrocystic breasts
 Postpartum  Extrinsic infections
engorgement  Mondor’s Disease
 Lactation mastitis  Hidradenitis

 Lactation breast suppurativa

abscess  Nipple discharge
 Chronic recurrent  Galactorrhoea

subareolar abscess  Abnormal discharge

Classification By Risk To Cancer
 Lesions with no  Fat necrosis
Increased risk of Ca  Lipoma

 Fibrocystic disease  Lesions with Increased

 Duct ectasia Risk of Ca
 Ductal hyperplasia
 Solitary papillomas
 Sclerosing adenosis
 Simple
 Complex
fibroadenomas
 Mastitis or breast
fibroadenomas
 Atypical hyperplasia
abscess
 Radial scars
 Galactocoele
Conditions Which Mimic Malignancy

 Benign conditions which mimic malignancy:

 Eczema of the nipple:-Mistaken for Paget’s disease

of the nipple.
 Mammary duct ectasia:- Bloody nipple discharge,

nipple retraction, skin changes.

 Non-puerperal mastitis:- Palpable mass, skin

tethering.
 Sclerosing adenosis:- Discrete mass, micro-

calcification on mammography.
 Solitary papilloma of the ducts:- Discrete mass,

bloody or serous discharge.

1. Breast Pain (Mastalgia)

 Most common breast symptom for which women

consult clinicians.
 More common in premenopausal women than in
post menopausal women.
 Can be cyclical (physiological) or non cyclical.
…Breast Pain (Mastalgia)
 Cyclic Pain ( Physiologic)
 Usually Bilateral and poorly localized.
 Occurs in about 60% of premenopausal women except
menopausal women on HRT.
 Often described as heaviness , swelling or tenderness that
radiates to the arm and axilla.
 Associated with menstrual cycle (more pre-menstrual)
 Has variable duration and resolve spontaneously.
 Attributed to fibrocystic breast changes.
 Etiology unknown, thought to be related to Gonadotrophic
and ovarian hormones.
…Mastalgia

 Non-Cyclic Pain
 Most common in women 40 to 50 yrs of age.
 Often unilateral.
 Usually described as sharp, burning pain localized in the
breast.
 Occasionally secondary to the presence of fibroadenoma
and or cyst.
 Menstrual irregularity, emotional stress, trauma, scars
from previous biopsies and medications have been
associated.
…Management of Breast Pain
 Diet and Lifestyle Modification
 Elimination of Methylxanthines, Caffeine and
Chocolates
 Reassurance

 Supportive Bra
 Low fat and high complex carbohydrate
 Vitamin E supplementation
 Evening Primrose oil
…Management of Breast Pain
 Pharmacological Treatment
 NSAIDs
 OCPs (Oral contraceptive pills)
 Danazol 100- 400mg per day
 75% of women with non cyclic pain will be symptom
free
 SE:
Weight gain , menstrual irregularity , acne , hirsutism
 Tamoxifen 10mg per day

 Bromocriptine – prolactin antagonist

 NB: Surgery has no role in management of breast pain.

2. Breast Masses: Cyst
 Cystic Breast Mass
 Common cause of dominant breast mass.
 May occur at any age, but uncommon in post
menopausal women.
 Fluctuates with menstrual cycle.
 Well demarcated from the surrounding tissue.
 Characteristically firm and mobile.
 May be tender.
 Difficult to differentiate from solid mass.
…Breast Masses: Cyst
 Fibrocystic Breast Disease
 Most common of all benign breast disease.
 Most common between ages 20- 50.
 50% of women with fibrocystic changes have
clinical symptoms.
 53% have histologic changes.
 Believed to be associated the imbalance of
progesterone and estrogen.
 May present with bilateral cyclic pain, breast
swelling, palpable mass and heaviness.
…Breast Cysts: Diagnostics
 Physical Examination  Ultra Sonogram
 Tenderness
 Cyst
 Increasedengorgement and
more dense breast  Fine Needle Aspiration
 Increased lumpiness /  Outpatient procedure
glandular  Non bloody fluid
 Occasional spontaneous
nipple discharge
 Cyst disappears
 Mammogram  If bloody fluid, surgical
 Cystic outline biopsy of cyst is required
 No calcification  Re-examination 4-6 weeks
 No increased density after aspiration
3. Breast Mass: Fibroadenomas
 Simple: Second most common benign breast lesion:-
 Benign solid tumors containing glandular as well as
fibrous tissue.
 Usually present as well defined, mobile mass.
 Common in women between the ages of 15 and 35 years.
 Cause is unknown, thought to be due to hormonal
influence.
 May increase in size during pregnancy or with estrogen
therapy
 Giant: Fibroadenomas over 10cm in size:-
 Excision is recommended.
…Breast Mass: Fibroadenomas
 Juvenile
 Variant of fibroadenomas
 Found in young women between the ages of 10 -18.
 Vary in size from 5 - 20cm in diameter. Usually painless,
solitary, unilateral masses.
 Excision is recommended
 Complex
 Complex fibroadenomas contain other proliferative
changes such as sclerosing adenosis, duct epithelial
hyperplasia and epithelial calcification.
 Associated with slightly increased risk of cancer.
4. Other Breast Masses
 Phylloides Tumors:
 Rapidly growing.
 One in four malignant.
 One in Ten Metastasize.
 Create bulky tumors that
distort the breast.
 May ulcerate through
the skin due to pressure
necrosis.
 Treatment consists of
wide excision unless
metastasis has occurred.
 Fat Necrosis:
 Rare.
 Secondary to trauma-
often not remembered.
 Tender, ill defined mass.
 Occasionally skin
retraction.
 Treat with excisional
biopsy.
…Other Breast Masses
 Galactocoele
 Milk filled cyst from over distension of lactiferous duct.
 Presents as a firm non-tender mass in the breast.
 Commonly in upper quadrants beyond areola.
 Diagnostic aspiration is often curative.
 Duct ectasia:
 Generally found in older women.
 Dilatation of the subareolar ducts can occur.
 A palpable retro-areolar mass, nipple discharge,
or retraction can be present.
 Treatment involves excision of area.
5. Breast Mass: Gynaecomastia
 Benign growth of the glandular tissue of the male
breast.
 Due to an imbalance in the estrogen to androgen
activity.
 May be unilateral or bilateral.
 Common in infancy, adolescence and adult life.
 Pseudogynecomastia may be seen in obese
individuals.
 Causes include; drugs, chronic diseases, metabolic,
pubertal, hormonal, tumors, idiopathic,
hypogonadism.
…Breast Mass: Gynaecomastia
Physiological Gynaecomastia Secondary Gynaecomastia:
 Infantile (neonatal): due  Drugs: Stilbestrol use,
to circulating maternal oestrogens, etc.
hormone; lasts 6 months  Reduced testosterone
 Pubertal: breast enlarges production: anorchia,
at puberty and may castration, Klinefelters
resemble female breast. Syndrome, leprosy.
 Due to high oestradiol:  Increased oestrogens
testosterone rations; production: testicular
resolves within 2 years. teratoma, bronchial
 Senile: reduced carcinoma, pituitary and
testicular function with adrenal tumours.
increased production  Liver failure: failure to
oestrogen in fat. metabolise oestrogen.
6. Nipple Discharge
 Majority of causes are benign.
 Most common cause is lactational.
 Overstimulation also common.
 Prolactin secreting tumors.
 Hypothyroidism.
 Drugs.
 Intraductal and other carcinomas.
 Unilateral, spontaneous, bloody discharge is
suspicious.
…Nipple Discharge
 Intraductal Papilloma
 Benign growth within ductal system.
 Presents as bloody nipple discharge.
 Excisionis the only way to differentiate from
carcinoma.
 Galactorrhoea
 Bilateral milky discharge.
 Obtain prolactin level, TSH level.
7. Breast Inflammation & Infections

 Mastitis
 Most common in lactating female.
 Dry,cracked or fissured areola/nipple complex
provides portal for infection.
 Usually caused by Staph/Strep organisms.
 Rule out malignancy.
 Treat with heat, continued breast
feeding, antibiotics for 10-14 days to
cover staph and strept infections.
…Breast Inflammation & Infections

 Abscess
 May present with breast swelling, tenderness and
fever
 On P/E, breast is tender , warm and fluctuant.
 May also have purulent discharge.
 Treated by surgical drainage
…Breast Inflammation & Infections

 Mondor’s Disease
 Phlebitis of the thoracoepigastric and lateral thoracic
vein.
 Palpable, visible, skin retraction over tender extending
to chest wall.
 Spontaneous or related to trauma.
 Ultrasound may be helpful in confirming
this diagnosis.
 Treatment: Self-limiting, can use NSAIDs.
 Mammogram if over 35years to r/o
malignancy.
…Breast Inflammation & Infections

 Mastitis Neonatorum
 Occurs within few weeks of birth.
 Response to mothers hormone exposure
(prolactin, estrogen).
 Resolves spontaneously.
 Occasionally becomes infected.
Investigation Of Breast Lump

 Diagnosis is made by Triple Assessment:

 Clinical Evaluation of the lump and regional nodes
 Age
 Accurate history
 Physical examination
 Imaging
 Ultrasound—under 35 years, distinguishes cysts from
solid lesions
 Mammography— over 35 years, sensitive but 5% may be
missed
 MRI—can be used in breasts with implants; can
distinguish post surgery scars
…Investigation Of Breast Symptoms:

 …Diagnosis is made by Triple Assessment:

 Pathological evaluation:
 Cytology
 FNAC

 Histology
 Trucut biopsy (Core biopsy)
 Open biopsy
 Incisional

 Excisional
 THE END

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