Benign Breast Disorders

Lecture Objectives
Discuss the etiology/pathologic features of different forms of benign non-neoplastic and neoplastic breast disease. List the benign breast diseases that increase a patients risk of developing breast cancer and classify these conditions by the degree of risk.

CLINICAL PRESENTATION
Palpable lump

Inflammatory mass
Nipple discharge

Non-palpable abnormality

METHODS OF DIAGNOSIS
History Clinical Examination FNAC Trucut Biopsy Excision Biopsy Ultrasound Mammography

Incidence
Begins to rise during the second decade of life Peaks in the fourth and fifth decades.

Types of Benign Breast Disorders

Developmental abnormalities Inflammatory lesions Fibrocystic changes Stromal lesions Neoplasms.

Developmental Abnormalities
Ectopic breast (mammary heterotopia)
Supernumerary breast tissue seen mostly along the milk line; most frequent sites are the chest wall, vulva, and axilla. It may vary in its components of nipple (polythelia), areola, and glandular tissue (polymastia). Aberrant breast tissue is usually located near the breast, most commonly in the axilla. They usually have a nipple and areola and a separate duct system from that of the normal breast. When the nipple is absent, the presence of the accessory breast tissue is difficult to identify.
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Inflammatory and Related Lesions

Mastitis A variety of inflammatory and reactive changes Some of these changes are a result of infectious agents, May represent local reaction to a systemic disease Localized antigen-antibody reaction, and are classified as idiopathic.

Acute Mastitis
Usually occurs during the first 3 months postpartum as a result of breast feeding. (Puerperal or lactation mastitis) Cellulitis of the interlobular connective tissue within the mammary gland, which can result in abscess formation and septicemia. It is diagnosed based on clinical symptoms and signs indicating inflammation. Risk factors fall into two general categories:
improper nursing technique, leading to milk stasis and cracks or fissures of the nipple, which may facilitate entrance of microorganisms through the skin; and stress and sleep deprivation, which both lower the mothers immune status and inhibit milk flow, thus causing engorgement

Granulomatous Mastitis
Granulomatous reactions resulting from an infectious etiology, foreign material, or systemic autoimmune diseases Sarcoidosis Wegeners granulomatosis Tuberculosis Idiopathic granulomatous mastitis

Foreign Body Reactions

Silicone and paraffin, Used for both breast augmentation and reconstruction after cancer surgery Cause a foreign body-type granulomatous reaction in the breast. Silicone granulomas (siliconomas) usually occur after direct injection of silicone into the breast tissue or after extracapsular rupture of an implant Foreign body granulomatous response associated with multinucleated giant cells surround silicone. Fibrosis and contractions may lead to clinically apparent firm nodules that may be tender.

Recurring Subareolar Abscess

Rare bacterial infection of the breast (Zukas Disease) Triad of draining cutaneous fistula from the subareolar tissue; a chronic thick, pasty discharge from the nipple; and a history of multiple, recurrent mammary abscesses Squamous metaplasia of one or more lactiferous ducts in their passage through the nipple, probably induced by smoking Keratin plugs obstruct and dilate the proximal duct, which then becomes infected and ruptures. The inflammation eventuates in abscess formation beneath the nipple, which typically drains at the margin of the areola Abscess drainage to allow for resolution of the acute inflammation and then complete excision of the affected duct and sinus tract is successful in most cases, but abscesses may recur when the process develops in another duct

Mammary Duct Ectasia

Also called periductal mastitis Can Mimic invasive carcinoma clinically. Middle-aged to elderly parous women, Present with nipple discharge, A palpable subareolar mass, Noncyclical mastalgia, or Nipple inversion or retraction. Pathogenesis and the etiology not clear Mammary duct ectasia is usually an asymptomatic lesion and is detected mammographically because of microcalcifications. Mammary duct ectasia generally does not require surgery and should be managed conservatively

Fat Necrosis
Benign nonsuppurative inflammatory process of adipose tissue. Can occur secondary to accidental or surgical trauma, Clinically, fat necrosis may mimic breast cancer if it appears as an ill-defined or spiculated dense mass, associated with skin retraction, ecchymosis, erythema, and skin thickness Mammographic, sonographic, and magnetic resonance imaging findings may not always distinguish fat necrosis from a malignant lesion. Excisional biopsy is required if carcinoma cannot be excluded preoperatively

Fibrocystic Changes
Most frequent benign disorder of the breast. Premenopausal women between 20 and 50 years of age Multifocal and bilateral. Most common presenting symptoms are breast pain and tender nodularities in breasts. Hormonal imbalance, particularly estrogen predominance over progesterone, FCCs comprise both cysts (macro and micro) and solid lesions, including adenosis, epithelial hyperplasia with or without atypia, apocrine metaplasia, radial scar, and papilloma. Classification system first proposed by Dupont and Page
Non-proliferative lesions Proliferative lesions without atypia Proliferative lesions with atypia (atypical hyperplasia)

CYSTS
Fluid-filled, round or ovoid structures One third of women between 35 and 50 years old. Most are subclinical microcysts, In 20%25% of cases, palpable (gross) cystic change. Cysts are derived from the terminal duct lobular unit. Epithelial lining is either flattened or totally absent.]. Complex (or complicated or atypical) cyst is a sonographic diagnosis that is characterized by internal echoes or thin septations, thickened and/or irregular wall, and absent posterior enhancement In 5%5.5% of all breast ultrasound examinations. Malignancy rate of complex cysts, which is 0.3%

Adenosis
Proliferative lesion Increased number or size of glandular components, Mostly involving the lobular units. Various types of adenosis
Sclerosing adenosis of the breast is defined as a benign lobulocentric lesion of disordered acinar, myoepithelial, and connective tissue elements, which can mimic infiltrating carcinoma both grossly and microscopically Can manifest as a palpable mass or as a suspicious finding at mammography. Microglandular adenosis Apocrine (adenomyoepithelial) adenosis Tubular adenosis of the breast is another and rare variant of microglandular adenosis

Metaplasia
Presence of columnar cells with abundant granular, eosinophilic cytoplasm and luminal cytoplasmic projections or apical snouts. Cells line dilated ducts or can be seen in papillary proliferations. Younger women.

Epithelial Hyperplasia
Epithelial hyperplasia (ductal or lobular type) is one of the most challenging FCCs to diagnose properly. Difficult to distinguish from carcinoma changes.

Stromal Lesions
Diabetic Fibrous Mastopathy Pseudoangiomatous Stromal Hyperplasia of the Breast

Neoplasms
Fibroadenoma Lipoma Adenoma Nipple Adenoma Hamartoma Granular Cell Tumor

Fibroadenoma
Most common lesion of the breast; it occurs in 25% of asymptomatic women Peak incidence is between the ages of 15 and 35 years. C Aberrations of normal development and involution Lesion is a hormone-dependent neoplasm that lactates during pregnancy and involutes along with the rest of the breast in perimenopause Direct association has been noted between oral contraceptive use before age 20 and the risk of fibroadenoma Epstein-Barr virus might play a causative role in the development of this tumor in immunosuppressed patients

Fibroadenoma
Highly mobile, firm, non-tender, and often palpable breast mass. Most frequently unilateral, in 20% of cases, multiple lesions occur in the same breast or bilaterally. Devlops from the special stroma of the lobule. I Postulated that the tumor might arise from bcl-2-positive mesenchymal cells in the breast, in a manner similar to that proposed for solitary fibrous tumors Approximately 50% of fibroadenomas contain other proliferative changes of breast, such as sclerosing adenosis, adenosis, and duct epithelial hyperplasia. Simple fibroadenomas are not associated with any increased risk for subsequent breast cancer. However, women with complex fibroadenomas may have a slightly higher risk for subsequent cancer Fibroadenomas in older women or in women with a family history of breast cancer have a higher incidence of associated carcinomaJuvenile fibroadenoma is a variant of fibroadenoma that presents between 10 and 18 years of age, usually as a painless, solitary, unilateral mass >5 cm. It can reach up to 15 or 20 cm in dimension, so although it is an entirely benign lesion, surgical removal is recommended

Phyllodes Tumour
Phyllodes tumor is a fibroepithelial tumor of the breast with a spectrum of changes. Benign phyllodes tumor is usually difficult to differentiate from fibroadenoma. Hypercellular stroma with cytologic atypia, increased mitoses, and infiltrative margins of the lesion are the most reliable discriminators to separate lesions with recurrence and malignant behavior. Important to recognize phyllodes tumor because it should be excised completely with clear margins to obviate any chance of local recurrence. In cases of recurrent disease, mastectomy is often performed.

Lipoma
Benign, usually solitary tumor composed of mature fat cells. Well-circumscribed, smooth or lobulated mass that is soft and usually nontender. FNA biopsy of these lesions reveals fat cells with or without normal epithelial cells. Mammography and ultrasound scanning give negative results, unless the tumor is large Patient is normally followed through palpation after 6 months. Diagnosis is not certain or the lesion grows rapidly, the tumor should be surgically removed

ADENOMA
Pure epithelial neoplasm of the breast. Divided into tubular, lactating, apocrine, ductal, and so-called pleomorphic (i.e., benign mixed tumor) Lactating adenoma is the most prevalent breast mass during pregnancy and puerperium. Presents as a solitary or multiple, discrete, palpable, freely movable small breast mass (<3 cm). Tumor may spontaneously involute, surgical removal may be necessary Tubular adenoma (also termed pure adenoma)
solitary, well-circumscribed, firm mass. It may resemble the appearance of noncalcified fibroadenoma radiographically. irregular microcalcifications are prominent on mammography and ultrasonography

Both lactating and tubular adenomas, (the true breast adenomas) can be distinguished from fibroadenoma and nipple adenoma by the presence of scant stroma in the former

Nipple Adenoma
Florid papillomatosis of the nipple ducts or erosive adenomatosis Benign tumor of the ductal epithelium that often clinically mimics Pagets disease Pathologically may be misinterpreted as an adenocarcinoma. Typically, nipple adenoma presents as a discrete, palpable tumor of the papilla of the nipple. Erosion of the nipple and nipple discharge are usually seen. Histologically, the tumor is characterized by proliferating ductal structures that invade the surrounding stroma. Generally, a biopsy is necessary for diagnosis. Nipple adenoma can be successfully treated by complete excision of the tumor with normal surgical margins.