The Burden of Benign Breast

Disease
• Common condition- 9 out of 10 women
attending a Breast Outpatient’s Clinic

• Usually no risk of cancer

• Need REASSURANCE
 Learning Objectives
• To understand ANDI concept
• Most benign conditions – a variation of
normal
• Mastalgia- types, clinical features, therapy
• Nipple discharge- causes, therapy
Ductolobar system
• Breast: 7-10
lobes.
• TDLU- terminal
ductal lobular
unit-functional
unit - 40
• Lobe drained by
ductal system
leading to
lactiferous sinus
opens on nipple
 Breast development

• Breast bud
elevation
• Growth &
protrusion of
nipple
• Elevation of
secondary
10-12yr 14-16yr
areolar mound
16-18yr
• Regression of
 Hormonal Control
• Estrogen
– induces duct sprouting
– stromal development
– increased vascularity (anovulatory
cycles).
• Progestrone
– lobulo alveolar development.
• Prolactin - milk secretion in primed
breast,
• Inuslin, steroids, growth hormone -
 3 Common Presentations
• Lump or Lumpiness

• Nipple Discharge

• Breast pain or Mastalgia

 The ANDI Concept
• Aberration of Normal Development &
Involution
• Old terms like Fibroadenosis or Fibrocystic
disease do not relate to clinical or
histological features
• Most benign disorders derive from minor
aberrations of normal process of
development, cyclical change and
involution
Early Lobular Fibroadenoma
reproductive development Adolescent
Stromal hypertrophy
15-25 years
development Nipple inversion
Nipple eversion
Mature Cyclical menstrual Cyclical Mastalgia
change Nodularity
25 – 40 years
Epithelial Discharge
hyperplasia of
pregnancy
Involution Lobular Macro and
involution microcyst
35 – 55 years
Duct ectasia
Duct involution
Nipple retraction
 Mastalgia
• Cyclical Pronounced Type- 40%
– Cyclical pain with premenstrual
exacerbation
– Bilateral , diffuse
– Usually with diffuse nodularity
– Heaviness and feeling of increased breast
size with cup size –15% volume rise
• Age- young and middle aged
Pain Chart
 Mastalgia
• Painful nodularity for more than 1 week
of menstrual cycle
• Normal premenstrual discomfort-
reassure
• Can be cyclical/non-cyclical/extra-
mammary
• Etiology-
– disturbance of hypothalamic control,
prolactin secretion
– role of estrogen receptor, deficiency of
essential fatty acids,
– elevation of HDL-C.
 Cyclical mastalgia
• Hormonal basis as relieved by
Menstruation
Pregnancy and lactation
Tamoxifen and Centchroman
Increased Estrogenic, Prolactin response
– Basal hormones normal
Cancer risk -
 Mastalgia
• Non-Cyclical Pain- 27%
– No relation to menstrual cycle on Pain chart
– Unilateral or bilateral
– Subareolar or Outer Upper Quadrant
– Trigger point pain
Tietze’s syndrome- 11%
Trauma (post biopsy) – 8%
Cancer - 0.5%
Musculo-skeletal- 9%
 Management of Mastalgia
• Evaluation for lump – EXCLUDE Cancer
• Reassure- 85% will be relieved
• Pain Chart for 2 menstrual cycles
• Life style modification- support bra- tight in day
light at night, exercise
• Drug Therapy
• Anti-inflammatory gel
• Local Anaesthetic with Steroid Injection for
trigger point pain
• Excision of painful nodule
• Reflex therapy
 Drug Therapy for Mastalgia
• Drug of Choice-Tamoxifen- 10 mg daily for
3 months
– Response- 98% for cyclical, 56% noncyclical
– Side effects 50% - hot flashes, vaginal
discharge
 Drug Therapy of Mastalgia
Danazol- 100 – 300 mg
Response 70% good control
Side effects – 25% wt gain, hair growth,
• Evening Primrose oil- 6 capsules
– Response 2/3rd good control
– Side effects minimal- 4%
– No benefit over placebo (Srivastava et al,
Breast 2007)
 Treatment
• Bromocriptine - 2.5 mg/d.
prolactin lowering agent.
– Side effects - nausea
,vomiting, dizziness

Br J clin pract1986;40:326
Br J surg 1978;65:724
 Meta-analysis of RCT on
Mastalgia
Brom oc ripti ne
• Wei gh ted mea n differ ence in
the p ai n scor e in fa vo ur of
Bromocr ipt ine was – 16.3 1( 95 %
C.I. −26.3 5 to −6.2 7)
• RR of pain res pon se 5.2 9( 95%
C.I., 2.5 6 to 10. 89 )
Forest Plot on Bromocriptine vs
Placebo
 Tam oxi fen
RR of p ain r el ie f = 1 .92 (95%
CI 1 .4 2 to 2 .58)

Dan az ol
si gnifi ca nt be nefi t in th e
ameli orati on o f mas tal gia,wi th
a mea n pain scor e di ffer en ce –
20.2 3(9 5% C.I. –2 8. 12 to –
12.3 4).
Forest Plot on Tamoxifen vs
Placebo
 Ev ening p rim ros e
oil
• Ev eni ng p rim ros e oil d id
not offe r a ny ad va nt age
ove r pla ce bo in pai n re li ef ,
me an p ain scor e d if fere nc e
–2. 78 ( 95% C.I . –7 .97 to
2.4 0)
Centchroman/ Ormeloxifene
Background

• Synthesized at the Central Drug Research

Institute, Lucknow
• Marketted in India since 1992
• Included in the National Family Welfare
Programme in 1995 as an OCP
Randomized study
Aims and Objectives

• To investigate the role of Centchroman in

regression of fibroadenoma measured by
serial Ultrasound and Clinical Examination.

• To evaluate the effectiveness of

Centchroman in control of mastalgia
compared to Danazol.
 Materials and Methods (Mastalgia)

Moderate to severe mastalgia

Breast pain chart and USG pelvis

Randomization

Centchroman Danazol
30 mg alt. Day for 12 weeks 100 mg daily for12 weeks

Follow up at 24 weeks Follow up at 24 weeks

Effect of Centchroman vs. Danazol in mastalgia

7
6
5
4
VAS

3
2
1
0
0 2 4 6 8 10 12 14 16 18 20 22 24
Weeks

Danazol Centchroman
Effect of Centchroman vs. Danazol on Visual
Analogue Score in Cyclical Mastalgia:

5
Median VAS

0
0 2 4 6 8 10 12 14 16 18 20 22 24
Weeks
Danazol Centchroman
Effect of Centchroman vs. Danazol on Visual
Analogue Score in non-cyclical Mastalgia

8
7
6
Median VAS

5
4
3
2
1
0
0 2 4 6 8 10 12 14 16 18 20 22 24
Weeks
Danazol Centchroman
Effect of Centchroman vs. Danazol on nodularity

70
60
50
% Nodularity

40
30
20
10
0
0 2 4 6 8 10 12 14 16 18 20 22 24
Weeks
Danazol Centchroman
Effect of Centchroman vs. Danazol on tenderness in
mastalgia

90
% patients with tenderness

80
70
60
50 Danazol
40 Centchroman
30
20
10
0
0 2 4 6 8 10 12 14 16 18 20 22 24
Week
 Nipple discharge
• 5% of cases
• 95%of cases benign cause
• Spontaneous & bloody discharge
single/multiple ducts - significant.
• Assess for lump
• <10% bloody discharges are malignant
• Cytology-low sensitivity for cancer - 35-
45%
 Causes of Nipple Discharge
Blood Ductal hyperplasia and
papilloma, duct ectasia,
pregnancy, cancer
Serous or Watery Ductal hyperplasia, duct
ectasia

Coloured Duct ectasia, Cyst

Milk Physiological,
Galactorrhoea with
Prolactin secreting
lesions
 Causes

• Physiological –small quantity, multiple

duct, varies in color, noticed after warm
bath or manipulation.
• Intra ductal papilloma-major sub-areolar
duct,serous
or sanguineous discharge, mass felt
1/3rd of cases; microdochectomy
preferred.
• Multiple papillomas-10% cases.same
duct,nipple discharge is less common
 Causes contd.
• Juvenile papillomatosis-10-44 yrs age,
increased risk of cancer(10%).
Peripheral distribution. Wide local
excision.
• Pregnancy –bloody discharge
physiological due to increased
hypervascularity.
• Galactorrhoea –bilateral copius
mult.duct discharge not associated with
pregnancy/lactation. Take drug h/o,
S.prolactinlevel.
Bromocriptine/cabergoline -effective
treatment
 Investigations
• USG-demonstrates dilated sub
areolar
ducts.75%of lesions
seen.85%accurate.
• Mammography –age >35yrs,
presence of lump.
• Ductography –filling defect /cut off
in cases of papilloma/cancer
(60%sensitivity)
• Indicated for pt with minimal
Surgery unit 1
 Duct ectasia
• Process of involution
• Age related,42-65 yrs.
• Nipple retraction, cheesy toothpaste
like nipple discharge.
• Lesions usually sterile.
• Characteristic coarse calcification on
mammogram.
 Periductal mastitis
• Episodes of periareolar
inflammation +/- mass, periareolar
abscess, mammary duct fistula.
• Affects 18-48 yr age.
• Purulent nipple discharge with
retraction.
• Pain –non cyclical, eczema of
areola.
• Anaerobes isolated 80-100%cases.
• Smoking –damage to duct wall,
 Management

• Antibiotics –
anaerobes/staph.cover.Initially and for
recurrent attacks(2 wk course).
• Aspiration of pus/conservative drainage
• Surgery-nipple discharge/ ,retraction
subareolar abscess-(initial
antibiotics, surgery after 6weeks)
fistula
recurrence after prev.Sx
 Radical duct excision

• Peri-areolar incision 1/3rd

circumference.
• Plane deep to sub. cut venous
plexus.
• Undersurface of nipple bared
completely
• Hemostats behind ductal cone 3&9
o’clock.
• Ignore peripheral dilated ducts.
• Remove 3 cm cone of breast tissue
 Fistulectomy

• Remove the nipple opening of duct

• Heal by granulation. (Atkins
BMJ,1955)
• Probe the fistula and emerge from
nipple.
• Radial elliptical incision 1cm wide.
• Primary closure under antibiotic
cover.
 Summary
• Benign breast conditions are very common
• Usually need simple reassurance after
excluding cancer
• Most conditions can be managed at Primary
care level
 HRT and Benign breast disease
• Increased epithelial hyperplasia of ducts
and lobules ± Atypia
• Increased Mastalgia
• Growth of Papillomatosis
• Increased cyst formation
• Growth of Fibrodenoma
Mucocele of
breast
 Lipoma
• Avg.45 yrs
• Smooth lobulated, mobile mass
• PSEUDOLIPOMA-cancer shortens
Cooper’s ligaments, fat lobules bunched
up
• USG/mammogram-circumscribed
translucent area, compressing
surroundings
• When in doubt –excise
Filariasis of breast
 Risk of Breast cancer in BBD
No risk Simple cyst, duct ectasia,
papilloma, hyperplasia
without atypia
Relative risk Moderate hyperplasia,
1.5 to 2 papillomatosis
Relative risk Atypical ductal or lobular
4 to 5 hyperplasia
Relative risk Lobular carcinoma in situ
8 t 10
 Triple Assessment
Careful history – hormones, relation with
menstrual cycle, pregnancy or lactation
1.Clinical Breast Examination
2.Imaging- Ultrasound / Mammography
3.Fine needle aspiration cytology(FNAC)
or Core Biopsy
Sensitivity for a lump = 100%
Galactocele Aspiration
 Galactocoele
• Cyst filled with milk
• Follows abrupt artificial /natural (wks-
months) cessation of lactation
• Pre existing cyst connects with ductal
system & fills with milk
• Painless, smooth, mobile swelling near
areola
• Cured with single aspiration
• USG preferred imaging
 Breast Cysts

True cysts–
– ANDI-micro/macro cysts

– Juvenile cysts
– Secondary cysts-galactocele, fat
necrosis,
hematoma, implant related
– Papillary tumors
To differentiate from- duct
ectasia/periductal
mastitis,phylloides,carcinoma,hydati
 The Lady with a Lump
• DISCRETE LUMP
– Fibroadenoma
– Phyllodes tumour
– Nipple Adenoma and Papilloma
– Breast cyst and Galactocele
ILL DEFINED LUMP
Cyclical Nodularity
Fat necrosis
NORMAL STRUCTURES
Prominent Rib
Intramammary lymph node
Prominent fat lobule
Edge of Breast or Biopsy scar
 Management
• USG, mammogram >35yrs.
• Needle aspiration
– Bloody then cytology
– Residual-USG guided aspiration
• Complex cysts with solid component not
to be aspirated.
• Mammogram-a week after intervention
to assess rest of parenchyma.
• Persistent mass/blood stained fluid
/recurrent–excise.
 Causes
• 7-10% of women develop cysts in
lifetime
• Etiology unclear, part of involution
• Role of hyperestrogen, increased
prolactin
• Role of HRT
• More in left breast, upper outer
quadrant.
• Ages 40-50yrs, elderly tend to be
cancer
 Pathogenesis
• Apocrine epithelium of terminal ductal
lobular unit
• Excess secretion &osmotic effects-
microcyst
• Macrocysts-type1-active-ICF like
type2-flat epithelium-
ECFlike
 Treatment
Surgery for spontaneous single duct
discharge with-
1. bloody character
2.persistent >2/week
3.age >40
4.presence of lump
Age> 45, with mult.duct discharge –
radical duct excision.