Thesis

INTRODUCTION

This study comprising of 100 cases was done between 2004 and

2006 at Kurnool Medical College & Hospital, Kurnool. The study group

consisted of 86 female and 14 male patients.

This study was chosen, as 50-55% of women suffer from breast

related disorders during their life time, and exclusion of serious

pathology of the breast after evaluation, has a major reassuring effect

on the patient.

The objectives were to study the benign breast diseases with

regard to demographic factors and its clinical presentations and to

evaluate it clinically, by FNAC and histopathology to increase the

accuracy of diagnosis.

A prospective study of patients attending surgical OPD and also

admitted to surgical wards with breast disorders was done.

Patient predominantly presented with fibroadenoma and

fibrocystic disease. Cases of gynecomastia, cyclical mastalgia and

breast abscesses were also encountered.

Most of patients underwent FNAC and a few of them had

mammograms done.

Treatment was mostly surgical in the form of excision,

subcutaneous mastectomy, microdochotomy and incision and

drainage. All the specimens were subjected to histopathological

examination. Using clinical diagnosis, FNAC and histopathology

increased the accuracy of diagnosis. Cases of fibroadenosis and

cyclical mastalgia were treated conservatively with drugs.

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A follow up period ranging from 6 months to 2 years was

analysed. Except for three cases of recurrence in fibroadenomas, rest

of them have had an uneventful post treatment period. Satisfactory

results were seen in conservative line of management also.

In conclusion, benign breast disease is fairly prevalent with

fibroadenoma and fibrocystic disease comprising most of the cases.

Patients who were anxious about their breast disease had much relief

after it was proved benign.

Mode of Selection of Cases

Screening of cases by clinical examination in OPD and

investigations such as FNAC and when necessary, mammogram

was advised.

Patients were studied and analysed in detail, with regard to;

History

Clinical Examination

FNAC

Mammogram (in certain cases only)

Based on the provisional diagnosis, patients were subjected to

surgery which was usually excision or incision and drainage as the case

required. Preoperative preparation was done by giving prophylactic

single dose of antibiotic in non-infected cases.

Cases were again analysed based on;

Operative findings

Histopathological findings

Post Operative Course and outcome.

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Patients were followed up for a maximum period of 1½ years to

detect any recurrence.

Breast health means more than breast cancer. It has been noted

that noncancerous pathology of breast has always been neglected,

compared to breast cancer inspite of the fact that benign conditions

account for 90% of the clinical presentations related to the breast.

About 5-55% of all women suffer from breast disorders in their

life time. Benign disorders of the breast is usually seen in the

reproductive period of life, is thought to be largely hormone induced

and there is a dramatic fall in the incidence, after menospause due to

cessation of clinical ovarian stimulation. Benign breast disease is 4-5

times more common than breast cancer.

The concept of ANDI-Aberrations of Normal Development and

Involution is gaining acceptance. Benign proliferations of the breast are

often considered as aberrations of normal development and involution.

The cyclical changes due to variations in estrogens and progesterone

result in increased mitosis around days 22-24 of the menstrual cycle

but apoptosis restores the balance across the cycle.

ANDI, first proposed by Huges is now universally accepted. This

concept allows conditions of the breast to be mapped between

normality, through benign disorders to benign breast disease.

So most benign breast disease are relatively minor aberrations to

normal process of development, cyclical hormonal response and

involution that interact throughout a women’s life. The clinician should

clearly differentiate between benign and malignant conditions of the

breast, and reassure the patients after serious pathology is excluded,

as it has a major psychological effect on them.

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AIM

To study distribution of benign breast disease with respect to

demographic factors and to correlate relation if any, between the

type of benign breast disease and quadrants.

To correlate between clinical diagnosis and FNAC to

histopathological Examination (HPE) regarding the accuracy of

diagnosis.

To do at least a one (1) year follow up, to evaluate the outcome

of treatment.

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SURGICAL ANATOMY – BREAST

The mature breast is considered to be a collection of sweat

glands that were modified in the course of evolution to produce milk.

With the exception of the axillary tail, which lies beneath the

fascia, the mammary gland is superficial to the deep fascia of the

thorax. The deep surface of the breast overlies the pectorals major, the

serratus anterior, and the external oblique muscles. It is attached to

the overlying skin by bands of connective tissue originating between

glandular fat lobules, which are called Cooper’s ligaments. The so

called axilliary tail is a portion of the breast that extends into the axilla.

The glandular portion of the breast is composed of fibrous,

adipose and epithelial tissue and is divided into 15 to 20 lobes, which

are arranged in a radial pattern. Each lobe is drained by a lobe-specific

lactiferous duct. Some of these ducts may join, so that no more than 5

to 10 openings emerge on the surface of the nipple.

As the collecting ducts proceeds distally from the nipple, they

branch and end in terminal ductal lobular unit (TDLU) . In the mature

breast, these lobules measure approximately 500 () in diameter.

The epidermis of the nipple and the surrounding area, the areola

is a pigmented epithelium. There are many bundles of smooth muscles

beneath the nipple and areola. The ducts are lined by epithelium,

which varies from stratified squamous near the exit, columnar

epithelium at the extralobular ductal system and simple cuboidal

epithelium towards the alveoli. The ducts are surrounded by

myoepithelial cells and extensively vascularised connective tissue.

Around 75% of the lymphatic drainage of the breast passes to

axillary lymph nodes, mainly to the anterior nodes, though direct

drainage to central and or apical nodes is possible. Much of the rest of

the lymphatic drainage particularly from the medial part of the breasts

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is to parasternal nodes along the internal thoracic artery. A few

lymphatics follow the intercostal arteries and drain to posterior

intercostal nodes.

The superficial lymphatics of the breast have connections with

those of the opposite breast and the anterior abdominal wall, from the

extra peritoneal tissues of which there is drainage through the

diaphragm to posterior mediastinal nodes. Direct drainage to

supraclavicular nodes is possible. These minor pathways tend to

convey lymph from the breast only-when the major channels are

obstructed by malignancy.

The arterial blood supply derives from branches of the internal

thoracic artery, the lateral thoracic artery, anterior intercostal arteries

and the thoracoacrominal artery through a pectoral branch.

The venous drainage of the breast is both superficial and deep.

The superficial veins are significant because they anastomose across

the midline of the anterior chest wall. The deep veins follow the course

of the arterial system into the axillary, internal thoracic and intercostal

veins as well as external jugular.

Sensory nerves to the breast come from the fourth to the sixth

thoracic segments through the anterior and lateral cutaneous branches

of the intercostal nerves.

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Physiology

Early differentiation of he mammary gland anlage is under fetal

hormonal control. Growth of the breast is dependent on numerous

hormonal factors that occur in two sequences. First at puberty and

then during pregnancy.

The major influence on breast growth during puberty is by

Estrogen; which brings about growth of the ductal portion of the gland

system. Progesterone influences the growth of the alveolar

components of the lobule. Neither hormone alone or in combination,

however, is capable of yielding optimal breast growth and

development. Full differentiations of the gland requires, cortisol,

thyroxine, prolactin and growth hormone.

Breast tissue reacts to estrogen and progesterone stimulation,

not only during puberty, pregnancy and lactation, but during each

menstrual cycle.

As the menopausal period is approached and post menopausal

period evolves, progressive atrophy of the epithelial an connective

tissue components of the breast occurs. The loose connective tissue

becomes dense and hyalinized and finally, the lobule is converted into

ordinary stroma, which in the process of involution is replaced by fat.

The role of these hormones in the causation of mammary

pathologies, though suggestive, remains unclear.

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A framework of pathogenesis for the classification of benign

breast disorders

Reproductive period

Normal processBenign breast

disorder Benign breast

disease

Development

Ductal developmentLobularDevelopmentStromal Development

Nipple inversion, Single ductObstruction FibroadenomaJuvenile Hypertrophy

Mamillary duct fistula. Giant fibroadenoma

Cyclical change Hormonal Activity Epithelial Activity

Mastalgia NodularityFocalDiffuseBenign papilloma

Pregnancy and lactation

EpithelialHyperplasia Lactation

Blood stained nippleDischarge Galactocele and inappropriate lactation

Involution

Lobular involutionDuctal involutionFibrosisDilatationInvolutionalEpithelialHyperplasia

Cysts and sclerosing adenosisNipple retraction Duct ectasiaSimple hyperplasiaMicro Papillomatosis

Periductal mastitis with suppuration Lobular hyperplasia with atypiaDuctal hyperplasia with atypia

Clinically, the most useful system of classification of benign breast

disease is based on symptoms and physical findings.

Six general categories have been identified.

1. Physiologic cycle swelling and tenderness

2. Nodularity : Signigicant lumpiness, both cyclic and non cyclic

3. Mastalgia : Severe pain, both cyclic and non cyclic

4. Dominant lumps : Including gross cysts and fibroadenomas

5. Nipple discharge : Including intraductal papilloma and duct

ectasia

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6. Infections and inflammations : Including subareolar abscesses,

lactational mastitis, breast abscesses, and Mondor’s disease.

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FIBROCYSTIC DISEASE

The phrase Fibrocystic Breast Disease (FCD) is catch-basin term

synonymous with more than 38 terms used to describe the most

common type of lesion in the female breast. Here, in our study, the

benign breast disorders that were considered under this category were

cysts, lobular hyperplasia, cystic mastitis, fibrosclerosis, sympotomatic

chronic cystic mastopathy, fibroadenomatoid hyperplasis and

mammary dysplasia.

Fibrocystic breast disease is noncancerous. The most common of

the benign conditions of the breast is fibrocystic change (FCC) and it is

defined as enhanced or exaggerated reaction by breast tissue to the

cyclic up and down levels of ovarian hormones. It is a disorder of

involution which as first described by Sir Astley cooper and Benjamin

Brodie.

Mechanism

The involution of a lobule is dependent on the continuing

presence of the surrounding specialized stroma. If there is early

disappearance of stoma, the epithelial function persists and results in

formation of microcysts.

In the same manner there is formation of macrocysts which was

described by parks, as a process in which there is obstruction of

efferent ductile by fibrous or epithelial debris.

Pathology

The term Fibrocystic Cystic Disease (FCD) has been formally

abandoned from a historic standpoint by the college of American

Pathologists in reliance on the landmark study of benign biopsies by

Dupont and Page, now the term used is fibrocystic Changes (FCC).

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This system separates various components of fibrocystic changes

into 3 groups; it is a prognostic category based on recent studies. The

categories are:

Nonproliferative lesions 70%

Proliferative changes with no atypia 26%

Proliferative changes with atypia 4%

Of patients in the 30% of the study group, 4% had both atypia

and proliferative changes on biopsy and do thereby appear at a five

fold increased risk for breast cancer. Women were at highest risk level

of developing cancer if they had cellular atypia and a positive family

history for breast cancer. The conclusion from these studies states that

unless proliferative changes with atypia are present, fibrocystic

changes are not risk factors for cancer.

Microscopic features studies on specimen tissues are:

(a) cysts: They contain dark mucoid material and vary in size.

(b) Adenosis: There is an overall increase in glandular tissue

due to budding and multiplication of the acini.

© Epitheliosis: There is hyperplasia of the epithelium, acini and

the lining ducts.

(d) Fibrosis: Dense white fibrous trabeculae replace the fat

and elastic tissue. This leads to compression of the ducts by

fibrous tissue, resulting in cyst formtion. Chronic inflammatory

cells infiltrate the interstitial tissue.

(e) Papillomatosis: when the epithelial hyperplasia is very

extensive, it may result in papillomatous growth within the ducts.

Most, if not all women experience fibrocystic disease. Cysts are

more common in noncancerous breasts than cancerous (53% versus

27%). Common age group is 40-55 years. Proven cystic diseases such

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as palpable tumors or grossly visible cysts exceed in incidence as

compared to carcinoma. Cysts usually subside and regress totally at

menopause.

Etiology

The etiology of cystic disease is attributed to oestrogen

imbalance. Excess of oestrogen cause epithelial proliferation and

dilatation of the mammary ducts and cyst formation. In fibrocystic

disease, prolactin is also increased. So the cyclical changes of the

breast tissue under die influence of these hormones, induces epithelial

and stromal changes.

Sub populations of gross breast cysts

Two sub populations of gross breast are seen

(i) Apocrine

(ii) Attenuated

They are different with respect to bilaterality, multiplicity and

recurrence rates.

Apocrine cysts to be bilateral, have full columnar epithelial

linings, multiple and more prone to recurrence.

In contrast, attenuated cysts histologically have flattened

epithelium.

Biochemical properties of cysts

Leis perfomed biochemical analysis on the aspirated fluid of 2213

breast cysts.

Attenuated cysts have fluid contents in equilibrium with the

plasma. They have ratio greater than 3 and contain albumin,

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nonsecretory 7S immunoglobulin (Ig) (7S8A) and low levels of apocrine

proteins. Fluids aspirated from apocrine cysts contain low sodium and

high potassium levels. The Na:K ratio is less than 3, and they contain

US secretary IgA, high levels of apocrine cyst protein, epidermal growth

factors and dehydroisoandrosterone.

Future studies of breast cysts fluid may help to identify those

types prone to recurrence as well as those prone to hyperplasia.

Pathogenesis

Cysts are now regarded as manifestations of lobular involutions

with advancing age. These are increasing numbers of cystically dilated

acini seen in breast lobules. The dilated acini may involute completely

or may coalesce to form smaller number of larger cysts. Some degrees

of ductal obstruction by debris or epithelial hyperplasia or kinking is

almost certainly necessary for the production of longer tension cysts.

Hormonal mechanisms or imbalance of secretion is sufficient to explain

the smaller cysts.

Other associated conditions with fibrocystic disease have

histopathological features such as:

Multiple microcysts

Papillomatosis (Proliferation of ductal epithelium)

Apocrine metaplasia of duct epithelium

Fibrosis

Adenosis

Clinical Features

The most common signs and symptoms of fibrocystic changes is

pain (mastodynia) accompanied by tenderness. The pain is often

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bilateral and particularly noticeable during the premenstrual phases

of the normal cycle. The lumpiness, nodularity, may be localized or

generalized, unilateral or bilateral. Other signs of fibrocystic changes

include excessive nodularity, generalized lumpiness, increased

engorgement and breast density with the breast being described as

being full and heavy and fluctuations in the size of cystic areas.

Occasionally, spontaneous nipple discharges is present. These may be

severe localized pain associated with rapid fluid of a simple cyst.

Fine nodularity may be seen in the breast during pregnancy,

lactation nearly always produces permanent relief. Cysts develop

quickly, sometimes attaining considerable size within a few days and

may diminish in size rapidly. Cysts are well circumscribed, soft to firm,

relatively mobile, may be tender and occasionally inflamed. Otherwise,

it is serous colorless and sterile.

Clinical stages of fibrocystic changes

There are 3 clinical stages of fibrocystic changes with

considerable overlap from a clinical presentation standpoint.

First Stage: Mazoplasia – Occurs in women in their twenties pain is

mostly found in the most tender area being the indurated axillary tail.

There is intense proliferation of the stroma in the mazoplasia phase.

Second Stage: Adenosis - occurs in women in their thirties. Multiple

breast nodules (2 – 10 mm in size) with premenstrual pain and

tenderness of the breasts. There is marked proliferation and

hyperplasia of ducts, ductules, and alveolar cells.

Third Stages: Cystic Phase - This stage is attained usually in

women in their late thirties and forties. The cysts may be solitary

(cooper’s disease) or multiple (Reclus disease) lumps are cystic when

palpated. They are tender, slightly, mobile and fairly well defined cysts

that are deeply embedded, or a cluster or cysts can appear like a mass

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that mimics cancer. Normally no severe breast pain is present. But

when a cyst increases in size and lump appears suddenly, it is

associated with sudden onset of pain and point tenderness.

The fluid aspirated from the cyst may be straw coloured, or dark

brown to green. The colour varies according to the chronicity of the

cyst.

Clinical Features

On examination, the breasts are nodular, the size of rice grains

well delineated. The breast is usually firm and the lump can be better

made out between the thumb and finger than with the palm of the

hand. The lump is neither adherent to the pectoral fascia, not to the

skin. A serous or dark green discharge may be present from the

nipple, but there is no retraction seen. The condition is evident in one

quadrant than the others. Sometimes the axillary lymphnodes are

slightly enlarged and tender, but they are not hard.

Very tense cysts may simulate carcinoma. Closely placed large

cysts may even displace the surrounding cooper’s ligaments ,

producing approach skin attachment or nipple retraction (false

retraction of Haagensen).

Carcinoma and Fibrocystic Disease

An increased risk of subsequent breast carcinoma ranges from

1.7 to 4.0 times normal.

The histologic lesion has been divided into 3 prognostic

categories as a result of recent studies.

The categories are:

Non prolieferative

Proliferative changes with atypia

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Proliferative changes with no atypia.

Studies have shown that 70% of women with excised breast

fibrocystic changes have nonproliferative changes, i.e. not associated

with an increased risk for cancer.

30% have proliferative changes, of which 26% did not have any

atypia (do not seem at increased risk for breast cancer) and 4% had

proliferative changes with atypia, and thereby appear to have a fivefold

increased risk for breast cancer.

Women were at the highest risk level of developing cancer if they

had cellular atypia and positive family history for breast cancer. There

was a 11-fold increase risk.

Relative risk for breast cancer based on pathologic

examination of benign breast tissue

Category

Adenosis relative risk

Apocrine metaplasia

Cysts micro and or macro

Duct ectasia

Fibrosis

Mild hyperplasia

Mastitis

Periductal mastitis

Squamous metaplasia

Hyperplasia, moderate or florid,

solitary or papillary

Slightly increased risk (1.5 to 2

times)

Papilloma with fibrovascular core

Atypical hyperplasia Moderately increased risk (5

times)

Ductal

Lobular

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Role of Oral Contraceptives

Oral contraceptives reduce the incidence of change with minimal

epithelial atypia but seem to have no effect on those with marked

epithelial atypias. Use of oral contraceptives for 2 to 4 years or more is

associated with a decreased frequency in fibrocystic disease.

In summary, fibrocystic changes have been defined as a

condition in which there are palpable lumps in the breast, usually

associated with pain and tenderness, that fluctuate with the menstrual

cycle and become progressively worse until menopause.

The range of symptomatology is broad, based on the fluctuating

response in the epithelial tissue and fat. The lesions may very in size

from 1 mm to many centimeters; and the physiological nodularity is

probably under hormonal control.

Age, parity, genetic makeup and lactation history may all have a

bearing on fibrocystic changes. Risk factors for fibrocystic changes

include nulliparity, later age of natural menopause and high social

class, whereas, artificial menopause, age at first birth, and parity seem

to have different effects.

FIBROADENOMA

Fibroadenomas are the most common benign solid tumors of the

female breast.

It is merely and innocuous overgrowth of fibrous tissue with

epithelial elements; an abnormality of normal development and

involution.

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Frequency

It represents the most common breast tumor in women younger

than 25 years they may be seen anytime after puberty, but are

frequent in women in their third decade.

Between one third to one half of the biopsies for benign breast

disease yield fibroadenoma. A study conducted by cheatle, 1

fibroadenoma is found every 25 breasts examined.

In a series of 225 autopsy cases studied by Frantz,

fibroadenomas were found in 9%.

Origin and Natural History

Fibrodenomas are considered to be an abnormality of normal

development and involution. They are hormonally responsive and may

increase in size towards the end of each menstrual cycle. Recent

studies have demonstrated estrogen and progesterone receptors in

fibroadenomas.

Biologic Behaviour

The biological behaviour is widely variable with 3 broad possibilities:

1. Regression of the fibroadenoma

2. Static fibroadenomas

3. progressively growing fibroadenomas

Fibroadenomas grew to 1-2 cm in size and then remained

unchanged, as studied by Haagensen. Many of them stayed unchanged

or disappeared on follow up. Regression is seen in later life and it is

rare in older women owing to the diminishing cellularity with increasing

age.

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In a study by David M Dent, 63 young women were diagnosed to

have fibroadenoma. 31% resolved and a further 12% became smaller

over 13-24 months single fibroadenomas had a higher tendency for

regression.

Special varieties

1. Giant fibroadenoma

2. Multiple successive fibroadenoma

3. Juvenile fibroadenoma

4. Fibroadenoma in pregnancy and lactation

Giant Fibroadenoma

An accepted definition of this entity as concluded by various

studies, is a fibroadenoma with 5cm – 8cm diameter as the criteria.

These tumors, unlike phyllodes tumor, develop at or

immediately after puberty and attained massive size in a short period

of time. It may start as a solitary nodule in breast and quickly grow to a

large size. There may be multiple tumors in both breasts with one or

two attaining enormous size. They are well encapsulated; with

microscopic features of fibroadneoma. They do not recur if completely

removed.

In Haagensen’s series, the age ranged from 12-16 years and the

size varied from 16-19 cms. In all the cases, local excision was

curative.

Multiple Fibroadenomas

These are found in 16% in Haagensen’s series. In most instances,

the lesions were smaller than 2 cm, occurred simultaneously and were

rarely more than 2-3 in number. A rare variant in young women was

that of multiple, bilateral fibroadenomas, which were either

synchronous or metachronous, many of the lesions reaching the size of

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juvenile fibroadneoams. These can recur after removal. They may

attain very large sizes. Yet they do not metastasize and thus do not

become malignant. In a third of female patients on immunosuppression

with cyclosposin A, for renal transplant, multiple fibroadenomas were

seen, usually bilateral.

Juvenile Fibroadenoma

This term is used when giant fibroadenoma occurs in adolescent

girls. Most undergo rapid growth, cause marked breast asymmetry,

distortion and stretching of the nipple and skin. They are not a

histological entity, but tend to be more cellular with a minimal lobular

development route and have no recurrence.

Fibroadenoma in Pregnancy and Lactation

Moren reported a series of cases where fibroadenoma grew

considerably during pregnancy. In such a type, fibroadenoma

microscopically showed same type of epithelial proliferation as those of

surrounding normal breast tissue. It is also observed that

fibroadenomas decrease in size after pregnancy and after cessation of

lactation. Many are of giant or juvenile variety and demonstrate

microscopic changes of lactation similar to adjacent breast tissue,

indeed the cut specimen may exude milk. Excision in best delayed until

after childbirth since regression may occur and surgery is undesirable

during pregnancy. Partial or total infarction and necrosis of

fibroadenoma has been noted during pregnancy and lactation. The

increased demand of blood by the hyperactive breast tissue leads to

decreased blood supply to the fibroadenoma, thus causing infarction.

Pathology

The fibroadenomas appears as well encapsulated tumors. The

capsule is a false capsule made up of compressed normal tissues, and

it can be separated from the breast tissue.

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The cut surface is white to brown in colour and it may bulge and

glisten due to increased mucous content, clefts are seen as dark line in

the tumor.

Microscopically

It is made up of two components.

(i) Proliferating connective tissue stroma

(ii) Typical multiplication of ducts and acini

These compounds are present in varying degree. The clefts are

lined by epithelium, showing proliferative process . Essentially the

histology is one of delicate cellular fibroblastic stroma enclosing

glandular and cystic spaces lined by epithelium; intact round to oval

glands may be present, lined by single or multiple cell layers called

pericanalicular fibroadenoma.

When the connective tissue undergoes extensive proliferation

leading to compression of glandular lumen into slit like irregular cleft, it

is called intracanalicular fibroadenoma. Tubular adenoma has scanty

connective tissue and plenty of glandular elements commonly seen in

lactation and hence called lactating adenoma.

Clinical Features

Fiboadenomas are well delineated, freely mobile tumors with

rounded, lobulated or discoid configuration.

They are usually rubbery and firm but, when calcified, they may

be stony hard usually and confused with carcinoma when seen in

elderly women.

The relative mobility of fibroadenma within the breast tissue is a

characteristic feature ‘mouse in breast’. This mobility is due to the fact

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that it is well circumscribed and slides within the breast. Papillary

carcinoma can occasionally mimic fibroadenoma. These can be

confirmed with an FNAC and if necessary, excison biopsy.

Fibroadenoma and Malignancy

Benign breast lesions are classified as proliferative or

nonproliferative Nonproliferative disease is not associated with an

increased risk of breast cancer, whereas, proliferative disease without

atypia results in a small increase in risk, 1.5 to 2.0. Atypical hyperplasia

is associated with a greater risk of cancer development i.e. 4 to 5.

The absolute risk of breast cancer development in women with a

positive family history and atypical hyperplasia was 20% at 15 years,

compared with 8% in women with atypical hyperplasia with a negative

family history of breast carcinomas.

No increased risk of breast cancer development was observed in

women with a diagnosis of proliferative disease who used estrogen

after their breast biopsies.

MASTODYNIA

Cyclical mastodynia affects 30-40% of the premenopausal

women in western society during their reproductive years; in

approximately 8% of the women it is of such severity that it

significantly interferes with normal activities.

As is the case with other pain dominated conditions, mastodynia

has proven difficult for the community to recognize, diagnose or treat.

Previously, it was considered to be more of pyschologic than a

physiologic disorder.

Frequency

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Evaluation of healthy women in the general population, self

referred to a breast screening clinic. 69% reported having mastalgia,

sufficient to cause distress and interfere with their daily routine. In

south wales, Maddox and Mansel conducted a survey of working

women with 585 respondents. Of these, 45% reported mild mastalgia

and 2% report severe breast pain.

Symptomatology and clinical Features

The syndrome comprises of breast swelling, tenderness and or

engorgement which typically begin during the luteal phase of the

menstrual cycle, increase in intensity as menses approach and then

resolve rapidly with the onset of menstrual flow.

In severe cases symptoms may begin soon after menses during

the follicular phase of the cycle, leaving a very brief symptom-free

interval around the time of menstrual period.

Cyclical mastalgia has to be differentiated from non-cyclical

mastalgia, in which pain does not vary in relation to the menstrual

cycle in the manner described above, and from secondary causes of

breast pain such as infection, trauma or tumor, in which underlying

physical causes for breast pain can be identified.

Mastodynia can occur in association with a symptom complex

commonly referred to as the premenstrual syndrome or it may occur in

the absence of this syndrome.

Often it is worse in the upper outer quadrants and is associated

with a diffuse nodularity. These is no measurable relationship however,

between the extent of nodularity and pain severity. Patients describe a

diffuse tenderness or heaviness in the breast or breasts. It is usually

bilateral, but is may be unilateral.

Age Distribution

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Mastodynia was usually reported in the age group of over 34

years of age. It usually begins in the third decade of life and runs a

chronic relapsing course until menopause. Only 20% of women can

expect spontaneous improvement prior to menopause.

Etiology

It is postulated that breast pain has a hormonal origin. The is

usually relieved by a disruption of the horomonal milieu, including

drugs-surgery and menopause.

Circulating hormone levels are normal in cyclical mastalgia

patients. The theory that a relative hyperstrogenemia occurring

secondary to decreased progesterone levels in the luteal phase cannot

be substantiated.

Dynamic testing of pituitary function using thyrotropin releasing

hormone has demonstrated an increase in the dynamic release of

prolactin in cyclic mastalgia patients.

With normal levels of circulating hormones and a normal level of

breast hormone receptors attention has been turned towards theories

of altered receptor sensitivity.

Cyclic mastalgia patients have an increase in plasma proportions

of the esters of the palmitic and stearic saturated fatty acids, whereas

the esters of the enoleic,dihomogamalenolenic (DGLA), and arachidonic

polyunsaturated essential fatty acids were decreased. These essential

fatty acids and metabolites are important components of cell

membrance and the receptors, cell membrane associated or not, have

a lipid moiety associated with the protein recognition site.

Behaviour of the receptor could be significantly altered by the

essential fatty acid to saturated fatty acid ratio. Increased saturation

is associated with increased affinity.

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If patients with mastalgia have an increased ratio of saturated

fatty acids, they could conceivably obtain a higher target option

response to normal circulating hormone levels. For instance a low-fat

diet has been shown to decrease the bioavailability of prolactin

without affecting the serum prolactin levels.

If this is true, factors altering plasma fatty acid ratios could useful

in the management of breast pain.

GYNECOMASTIA

Gynecomastia is a dominant problem of the male breast. The

normal adult male breast consists of nipple, ductal tissue and a fibrous

stroma which is accompanied by variable amount of fat. In

gynecomastia the breast takes on the female form, an event that also

occurs in obesity when the enlargement is due fat deposition only, and

in the later it is pseudogynecomastia.

Clinical Features

Patients present with a breast swelling, often it is unilateral and

frequently tender Patients are concerned about cosmetic appearance,

pain or tenderness and but malignancy.

Examination reveals a firm retroareolar disc of tissue, clearly

demarcated from the surrounding tissues, and, mobile and tender on

palpation.

The hallmark of gynecomastia is its concentricity. When in

doubt, mammography will allow quantification of the amount of fat and

breast parenchyma. Simon et al graded gynecomastia on the basis of

size. The criteria for diagnosis vary.

Most authorities make a diagnosis of gynecomastia when the disc

of breast tissue is at least 2 cm in diameter although others have

26

considered it gynecomastia when only 0.5 cm of breast tissue is

present.

Histology

There is proliferation of loose periductal connective tissue

together with variable degrees of multiplication, elongation of, or

branching of ducts. Periductal cells, infiltration by plasma cells,

lymophocytes and large mononuclaear cells may occur. Acinar

formation seems to occur only after long term oestrogen treatment as

in klinefelter’s syndrome. The changes seen are rather quantitative

than qualitative.

Incidence

Two studies have established that mild forms of gynecomastia

are very common, although presentation as a clinical complaints is far

less sequent. The overall incidence was between 10-16 years at 38%

reached 65% in the 14 years old and dropped to 14% in the 16 year

old.

Nontal in his study of 306 men showed that an incidence of 11%

in youths in their late teens, gradually increased to 51% over 50 years.

Bilateral involvement was present in 63% of 94 patients in a separate

study.

Aetiology

Because of the clear relationship between the incidence of

gynecomastia and hormonal events, the rate of an endocrine

abnormality in gynecomastia needs to be seriously considered.

Hormonal Defects in Gynecomastia

According to a number of studies, there is a relative alternation

in circulating sex steroids in patients with gynecomastia. These was a

27

transient increase in the oestrogen levels before the gynecomastia

became clinically apparent.

Moore and associates demonstrated a low delta4

androstenedione / oestrogen and oestradiol ratio(testesterone/oestrone

ratio remaining normal) in the affected boys and postulated that the

cause was peripheral conversion of adrenal androgens to oestrone and

oestadiol. In the adult male, more testosterone is produced, but at

puberty oestrogen production is thought to reach adult levels before

testosterone and this results in transitory rise in the oestrogen /

testosterone ratio.

It seems that secondary gynecomastia is also due to hormonal

imbalance. Only about 10% of cases are true unilateral.

Unilateral gynecomastia presumes a local factor presumably

related to hormone receptors or local hormone conversion, but remains

an endocrinological enigma. Reports of tissue positivity vary from 10 to

90% oestrogen receptors and 20 to 75% for androgen receptors.

Classification

(a) Physiological Gynecomastia

(i) Infantile: due to circulating maternal hormones. This

resolves by 4 months of age it is usually bilateral and

reassurance to the mother is all that is needed.

(ii) Adolescence: This lesion is common during adolescence.

Majority of cases resolve by 6 Months.

(iii) Adult: Asymptomatic gynecomastia persists until a reversible

underlying cause is found.

(B) secondary Gynecomastia

28

(i) Tumors: Both teratomas and seminoma testis may secrete

enough estrogens to produce gynecomastia. Bronchogenic

carcinoma, pituitary, hypothalamic and adrenal tumors may

also produce gynecomastia

Chemotherapeutic agents and radiotherapy can cause

gynecomastia especially in patients who have had an

orchidectomy for testicular cancer

(ii) klinefelters syndrome : Features are those of testicular

atrophy, eunuchoid habitués with female distribution of hair

and gynecomastia. Here gynecomastia is associated with an

increased incidence of carcinoma.

(iii) Hepatic failure : with the exception of drug induced changes,

this is probably the most common cause of gynecomastia. The

liver fails to eliminate androstenedione , which is peripherally

converted to oestrogen

(iv) Secondary testicular failure : Damage to the testis results in

decreased androgen/ estrogen ratio. Viral orchitis most

commonly due to mumps, is the most frequent cause of

testicular atrophy is young men.

(v) Starvation refeeding : The cause is due to the fatty changes

that occur in the livers in such patients. It is seen in prisoners

of war and severely ill patients in intensive care units.

(vi) Drugs : A large number of drugs can cause gynecomastia.

They act via a relative increase in the oestrogenic activity or

inhibition of activity. Administration of oestrogen in prostatic

cancer causes gynecomastia. Drugs such as digitalis and

marijuana also have the same effect as that of antiandrogens

such as cyproterone used in prostatic cancer, and the side

effects of cimetidine and spironolactone , resulting in

gynecomastia

29

PHYLLODES TUMOR

The phyllodes tumor a lesion limited to mammary tissue , was

first described by johannis muller in 1838 and called it cystic phyllodes

(leaf like) as it contained leaf like projections into cavities in the tumor.

It can occur in any breast and occur even after excision of previously

existing fibroadenoma.

The term phyllodes tumor should be qualified as benign or

malignant according to the histological appearances.

Phyllodes tumors are mesenchymal tumors of the breast to

malignant according to the histological appearances.

Phyllodes tumors are mesenchymal tumors of the breast that

exhibit a range of clinical and pathological presentations. When viewed

as part of a broad spectrum, low grade phyllodes tumors might be

conceptualized as being further along a continuum than a hypercellular

fibroadenoma, while high-grade phyllodes can be through as

connective-tissue that are less aggressive than most sarcomas.

Phyllodes tumor has got a stroma of general architecture of

fibroadenoma but its stroma is unusually cellular and sarcoma like. So

microscopically it looks malignant, can recur locally on incomplete or

complete removal, yet if it is low grade, it cannot metastasise and so

remains as a benign tumor.

Pathology

The tumor well-delineated but does not have a true capsule. It is

softer than a fibroadenoma. The cut surface of the solid portion of the

tumor is moist and sticky and colour varies from grey, yellow to brown.

Microscopically elongated epithelium lined clefts are seen. Myxoid

nature is more common in phyllodes tumor and presents as areas of

necrosis. The stroma shows a sarcoma like picture. It may look like

30

fibrosarcoma or liposarcoma. Apart from sarcomatous metaplasia,

histiocytic metaplasia are seen and are multifocal.

Cartilage or osteoid tissue foci are seen in few cases, and if so, in

an otherwise case of fibroadenoma, a diagnosis of phyllodes tumor

should be made.

Frequency, Age Distribution

It is a rare condition with an incidence of 1 in 10000. it

constitutes only 0.3 to 1% of all fibroepithelial tumors. Develops in the

third or fourth decade of life. The mean age being 44-47 years in

Haagensen series of 84 cases.

There are reports of occurrences in adolescents also.

Epidemiological data suggest that the incidence of phyllodes tumors

may be higher in whites.

Clinical Features

Most patients have a smooth , round, firm, well defined, mobile,

painless mass on examination. They are difficult, if not impossible to

distinguish from fibroadenoma on physical examination.

These are large rapidly growing, non-invasive, non-capsulated,

well circumscribed tumor. Not all phyllodes tumors grow to large sizes,

1 out of 84 cases in Haagensen series were 1-3 cm in diameter.

Phyllodes tumors do not invade the skin. When they grow rapidly they

can cause skin necrosis due to pressure effects, if not the non

involvement of skin can be demonstrated by passing a probe beneath

the skin.

Phyllodes Tumors and Malignancy

A few phyllodes tumors become malignant. In Sunderland study,

18 cases were malignant and 9 showed metastasis out of 77 cases.

31

Metastatic disease can involve the lungs, thigh, pleura, sacrum,

axial skeleton, pancreas, central nervous system, and mandible,

statistically significant correlations between tumor grade, specifically

stromal over growth high mitotic rate, cytological atypia and

metastatic disease – have been demonstrated in the literature.

The designation, stromal overgrowth, a microscopic term

indicating that the stroma has replaced the glandular elements of the

breast, is thought to be an important determinant of metastatic

potential.

DUCT ECTASIA

This is a disorder of duct involution affecting major ducts of the

breast. It is a benign condition, poorly understood and has been

variously named – duct ectasia and periductal mastitis were considered

traditionally to be part of the same disease process. However recent

studies suggest that they are different conditions.

It was first recognized by Bloodgood as a distinct clinical entity in

1923. He called it as “varicococele tumor of the Breast” because of the

frequent findings of palpable subareolar dilated ducts. Bloodgood

described duct dilations, but noted that periductal inflammation was a

frequent finding.

Fugier called this, mastitis obliterans. As the principle cell in

periductal inflammation was the plasma cell, it was also called “Plasma

cell mastitis”. Other names such as comedo mastitis; periductal

mastitis; secretary disease of the breast have also been used.

Haagensen introduced the term duct ectasia as it is now known.

Incidence

The clinical syndrome is now well recognized and is characterized

by some of the following features such as non cyclical mastalgia, nipple

32

discharge, nipple retraction, a subareolar breast lump, a periareolar

abscess and a mammary fistula. The term, duct ectasia or periductal

mastitis encompasses all the pathological process, hence is the most

suitable to denote this disease, which accounts for 4% of cases

attending breast clinic, but is in much higher proportion in the

asymptomatic form in the general population.

Geschicker found 2.3% patients had dilated ducts in a series of

3107 women with benign disease of the breast. Two thirds of these

women were over 40 years and the oldest was 72 years.

Frantz and Associates found 24% cases to be duct ectasia in a

series of 25 women with no history of previous breast disease. It is

likely that much of what is included in these studies under periductal

mastitis or duct ectasia is normal aging or duct involution which

explain why in these studies the incidence increases with age.

Pathogenesis

Earlier it was considered that duct dilation occurred primary and

subsequently periductal fibrosis, fibrous contraction and nipple

retraction occurred as a secondary phenomenon due to leakage of duct

contents through the damaged walls.

More recently, the view is that periductal inflammation is the

primary essential feature, and later resulted in duct dilation resulting

from the destruction of the elastic supporting lamina of the ducts.

Recent data suggest that both periductal mastitis and duct ectasia are

component parts of the same disease complex and that peridcutal

mastitis is the initial event and ectasia the final outcome.

i) Breast Pain

It is non cyclical and tends to affect younger patients, that is,

those with more active periductal inflammation. The pain may precede

33

an inflammatory mass or be an isolated symptom and antibiotics may

be useful in relieving the pain.

ii) Breast Mass

In can be present as a breast mass. It comprises 3-4% of all

benign breast masses. The masses are usually present at the

periareolar margins and in younger patients, is often associated with

overlying erythema. There is intense periductal mastitis, the ducts are

surrounded by polymorph and plasma cells, lymphocytes, giant cells

and granulomata.

iii) Nipple Discharge

It is present in 15-20% of patients with periductal mastitis or

ectasia. Discharge varies from straw to cream, green to brown, and

rarely blood stained.

The discharge may be unilateral or bilateral, from single or

multiple ducts, which may be multi coloured and sticky.

iv) Nipple Retraction

Periductal fibrosis occurs during the phase of chronic

inflammation as tissues are destroyed and repaired. This periductal

fibrosis results in changes in nipple contour. Minor degrees of nipple

retraction occur early in the disease and are present in up to 75% of

the patients who present with periareolar inflammation. Marked nipple

retraction occurs at a later date.

v) Non lactating Breast Abscess

These abscesses are now more common than those occurring in

the puerperium. Those developing in the periareolar region are due to

periductal mastitis or duct ectasia. The age of the patients with these

abscesses averages around 32.5 years.

vi) Mammillary Fistula

34

The term fistula was introduced by Atkins in 1952 to describe

fistulas of the lactiferous ducts, first reported by Zuska and Associates

in 1951. fistula may develop spontaneously or following biopsy for duct

ectasia.

Aetiology

The aetiology of duct ectasia is unknown, but it appears to arise

from long standing or smouldering inflammation of the duct wall and

periductal fibrosis.

For many years, pregnancy and breast feeding were considered

as the aetiological factors in this condition. Now it is suspected that

bacteria may have a role in the aetiology of periductal mastitis and

ectasia.

Organisms, particularly anaerobes, have been isolated from

subareolar breast abscesses and appropriate antibiotics have proved

useful in treating periareolar inflammation associated with this

condition.

The theory put forward suggests that infection follows stasis of

secretion, which is incorrect. There is some experimental evidence to

suggest an autoimmune basis and the chronic inflammatory infiltrate

seen in the condition support this periductal mastitis, predominately a

disease of younger women, with an increased incidence amongst

smokers.

Clinical and Pathological Features

This condition causes symptoms over a large age group range

with the peak incidence being in the age group of 40-49 years.

NON LACTATIONAL BREAST ABCESSES

35

Breast abscesses in non lactating women are now more common

than those occurring in the puerperium. Lactational breast abscesses

can be treated successfully by recurrent aspiration and antibiotics, but

it is still traditional to incise and drain non-lactational breast abscesses.

The features of mastitis remain the same in spite of varies

aetiologies.

36

Types

i) Mastitis of Infants

It is due to maternal hormones acting on fetal breast. It is a rare

physiological feature usually seen on the third or fourth day. If gently

expressed, a drop of colorless fluid can be expressed. A few days later,

a milky secretion, popularly called “Witch’s milk” appears, which

subsides by third week.

ii) Mastitis of Puberty

Seen frequently in males, compared to females. The patient is

aged around 14 years and complains of pain and swelling in the breast.

The tenderness subsides in 2 weeks, but the inflammation may persist.

Sometimes when the tenderness persists, local mastectomy with nipple

conservation may be needed.

iii) Bacterial Mastitis

By far, this is the commonest verify of breast abscess. In

developing countries, lactational abscesses are common, whereas, in

the developed west, non lactational abscesses are usually seen.

Bacteriology

Common organisms causing bacterial mastitis are bacteroides

(30%) staphylococcus aureus (20%). Anaerobic streptococcus (24%)

while 22% of the cases yield no growth on culture.

In patients with recurrent breast abscesses or mammary fistulae,

anaerobic bacteria are usually isolated.

Clinical Features

37

The affected part of the breast is said to have reached the

“cellullitic stage” when it presents with the classical signs of acute

inflammation.

Bundred et al have enumerated 3 causes of recurrence of non-

lactational breast abscesses.

Subareolar situation

Presence of anaerobic organisms

Presence of underlying duct ectasia

Haagensen described what he called mammary duct ectasia, in

1951 as an inflammatory disease of the major duct system deep to the

nipple and areola. Histologically there is a periductal inflammation

around dilated ducts which may contain cellular debris and lipid rich

material.

In the commoner chronic form, this inflammation may eventually

lead to fibrosis and inflammation may eventually lead to fibrosis and

atrophy of the duct system.

However, it may present acutely as an abscess often caused by

an anaerobic organism and effective treatment in the form of excision

of the major duct system prevents recurrence.

iv) Subareolar Mastits

This results from the infected sebaceous gland of Montgomery

and hence not a true mastitis. It can also arise from a furuncle on or

near the areola. There are no constitutional symptoms. No matter how

small, if a lump can be felt, pus is present, and it should be drained.

Spontaneous rupture leads to chronicity or recrudescence, but not

cure.

v) Chronic Abscesses of the Breast

38

Inflammatory abscesses which are subareolar or intramammary

can become chronic. They follow injudicious antibiotic treatment or

inadequate drainage. When encapsulated within a thick wail of fibrous

tissue, it cannot be easily distinguished from a carcinoma.

Chronic subareolar abscess, results due to long standing nipple

retraction which causes the infection to be restricted to a single

obstructed duct system. The abscess which forms, ruptures and

subsides only to repeat the cycle over an over again at intervals of a

few months, leading to chronic mamillary fistula. Duct ectasia can also

cause a fistula to form.

vi) Tuberculosis of the breast

Tuberculosis of the breast was first described by Sir Astley

Cooper in 1829. it occurs less frequently than in other organs of the

body. Reports from India have described the incidence to be between 3

to 5.3%. Tubercular breast as reported in western literature is low

ranging from 0.06 to 1.6%.

It is most often associated with active pulmonary tuberculosis or

cervical tubercular adenitis.

The diagnosis rests on the bacteriological and histological

features. Healing is usually delayed. Mastectomy should be restricted

to patients with persistent residual infection.

vii) Retromammary Abscess

Here the pus is situated in the cellular tissues behind the breast

and may not be connected to the breast proper, usually due to

tuberculosis of the rib, infected haematoma or chronic empyema.

viii) Breast abscess in neonates and infants

39

It is due to infection of milk induced by the transplacental

passage of maternal hormones. If antibiotics do not help this condition

great care must be taken during surgical drainage as damage to the

breast disc at the age may lead to distortion in later life.

Breast abscesses are most frequently encountered during 2 or 3

weeks of life and occur more commonly in females. The disease does

not occur in premature infants, presumably because of underdeveloped

mammary gland. Bilateral disease is rare.

The major presentation of neonatal breast abscess is localized

swelling with or without accompanying erythema and warmth.

The manifestation is usually not systemic and only 25% of these

infants have low grade fever.

Staphylococcus aureus is the major pathogen, coliform bacteria

and group B streptococci are also encountered. The diagnosis of breast

abscess is best made by needle aspiration of the affected site.

The single most important aspect of management is prompt

incision and drainage by a skilled surgeon. Long term follow up study of

these cases suggest that some girls have diminished breast tissue on

the affected side.

THE DIAGNOSTIC EVALUATION OF BENIGN BREAST

DISEASES

Utilizing a breast oriented history and the diagnostic tries of

clinical breast examination, mammography or ultrasound, and fine

needle aspiration, the clinician can accurately manage most breast

lesions.

The common investigations available are:

1. Needle Biopsy

40

There are two types:

A) High speed drill or tru cut biopsy

B) Fine needle aspiration cytology (FNAC)

Of the two FNAC is more commonly used. A 22 gauge needle is

used to enter the mass, fluid and cells are aspirated and examined

microscopically for malignant or benign cells.

FNAC is a quick and cost effective method for investigating

benign breast disease. Dixon J.M, Forrest A.P.M and Chetty U. have

performed a study that shows that FNAC when reported immediately

has reduced the excision rates in benign diseases.

Although its positive predictive value is close to 100%, the

incidence of false negative results ranges from 5% to 25% emphasizing

that FNAC cannot be used as the role criteria for determining whether a

mass is benign or malignant.

Problems associated with the procedure include pinpointing the

lesion with the needle, obtaining adequate cytological specimen and

differentiation of benign from malignant lesions. Radiologically

localization of impalpable lesion for biopsy purpose is done either by

double dye method or hooked wire technique.

2. Excision Biopsy

Also called open surgical biopsy, is the final definite diagnostic

procedure. It is used both to confirm the diagnosis and as therapy for

small benign lesions.

At the present time, excisional biopsy is considered to be the

only definitive method of determining whether a breast mass is benign

or malignant.

3. Ultrasonology

41

The investigation can distinguish between a solid and cystic

lesion.

Ultrasonography is a useful adjunct to mammography in the evaluation

of a localized mass. Real time ultrasonography, performed with a 7.5

mHz hand-held near field linear array transducer, not only

differentiates solid from cystic masses, but is also useful in evaluating

a nonpalpable circumscribed mass.

Its specificity in the diagnosis of benign breast disease is 94%. By

maintaining the ultrasound transducer in a radial orientation to the

nipple and areolar complex, ultrasound can often identify a fluid filled

duct responsible for the nipple discharge.

4. Mammography

This may confirm or refute the clinical diagnosis and show the

presence of unsuspected breast conditions which are benign.

A 95% accuracy rate in the diagnosis of BBD may be achieved

with mammography. It gives the clinician, added reassurance in the

diagnosis of difficult cases where the clinical diagnosis is in doubt.

Mammography can distinguish quite efficiently between

malignancy and benign lesions, but is not reliable as ultrasonography

to differentiate a cyst from a solid mass.

It is suggested that FNAC may distort interpretation of the

subsequent mammogram.

In one study, 97% of cases, the results of mammography were

false negative. In another study 74% of isolated breast masses in

women younger than 30 years of age did not image on mammography.

42

Radiographic Technique

Basic craniocaudal and mediolateral oblique projections of both

breasts should be taken. Certain cases may require additional views.

Types of mammography are:

i) Film/Screen mammography with grid

ii) Xeromammography

Film/Screen Mammography

It uses a combination of enhancing screen that converts and

amplifies a low energy radiation beam into high energy photons that

are in turn exposed on to a standard X-ray film. The image like an X-ray

film is viewed through transmitted light and hence is a negative image.

Xeromammography

It uses a charged aluminium plate coated with selenium,

radiation passes through the breasts which is absorbed on the plate

and causes a local reduction in changes. The plate is then sprayed with

blue toner, transferred to paper and heated. This produces an image

which is then viewed in ambient light.

Mammographic signs of benign breast disease

Primary signs

Smooth outline

Round, ovoid or lobulated lesions

Homogenous, low density or transradiant lesions

Relatively coarse, smooth calcifications

Secondary signs

A transradiant fat halo

Displacement of breast structures

Frequently multiple and bilateral lesions

Normal vascularity

43

Radiological size, equal to or larger than clinical size

Exceptions like infections show hypervascularity with ill localized

lesions or areas of increased density or skin edema. These may

radiologically simulate carcinoma.

Fine microcalcifications may occur in microcysts, papillomata,

epithelial hyperplasia and sclerosing adenosis. In fibroadenoma, coarse

and chunky cacifications occur, where as in cysts, it is “Egg shell”.

Lipoma, galactocele and oil cysts of fat necrosis present as

circumscribed transradiant lesions of fat density.

Ductography

Duct anatomy and pathology can be displayed by X-ray following

infection of radio-opaque contrast medium into a major lactoiferous

duct.

Conditions that may be demonstrated include duct ectasia,

solitary or multiple papillomata and cystic disease.

The procedure is to cannulate the selected duct with a 26 gauge

cannula and, water soluble contrast in injected till the patient feels a

sensation of fullness in her breast. Contraindications include nipple or

breast infections.

Thermography

The heat emission from the breast surface is measured as infra-

red radiation and then recorded. It is then displayed on a photographic

plate / cathode ray tube. It is based on the metabolism and vascularity

of the breast tissue and is increased in infection and some

malignancies.

Pneumocystography

Under sterile conditions, the cyst is punctured, fluid aspirated

and equal volume of air introduced into the cyst. Radiographs are

44

taken in the standard projections. An infracystic tumor can be depicted

by this investigations.

Stereotactic Biopsy

A monographically detected non palpable lesion, particularly a

solid mass, can be evaluated by stereotactic FNA cytology. Microcysts

can be aspirated. Suspicious clustered microcalcifications, and masses

can be histologically investigated by stereotactic large core-needle

biopsy.

This is already used by radiologists to perform core biopsy an

FNAC in upright mammographic units, and the development, allowing

the stereotactic excision of cylinders of breast tissue up to 2 cm in

diameter, has recently led to image guided breast biopsy by surgeons

and radiologists as a combined procedure. This has several advantages

over wire-guided biopsy in that, it is based on an image, can be done

under local anesthesia, and excise less tissue more precisely with

potential cosmetic benefit.

Another study concluded that it is a painless and quick outpatient

procedure than needle localization or open surgical biopsy.

Magnetic Resonance Mammography (MRM)

Conventional mammography may not be able to detect lesions in

the breast of younger women or in a previously operated breast.

Moreover, susceptibility to radiation induced breast cancer in a

younger patient is a potential risk.

For these groups, MRM offers a potentially significant advantage.

The contrast enhancement has also now become available. Moreover,

biopsy gun is available for magnetic resonance-guided Fine-Needle

aspiration cytology and core biopsy.

45

Disadvantage with this investigation is cost and time

consumption, also lack of availability as compared to routine dynamic

scan.

46

TREATMENT OF BENIGN BREAST DISEASE

1. FIBROCYSTIC DISEASE

As earlier mentioned, this is a disorder of duct involution,

resulting in the formation of micro and macrocysts. A clinician who is

confident of the diagnosis after ruling out any discrete abnormality, can

treat the patient with firm reassurance and regular reviews of the

patient at different points in her menstrual cycle.

Studies have shown that some women with diffuse fibroadenosis

will experience resolution.

Needle aspiration using a 21-23 gauge needle can be done. If no

fluid is obtained from the lump area, deeper aspiration should-be tied.

If it is not blood stained, aspiration to dryness is carried out. A residual

lump should be excluded by repalpation.

Cardinal Rules of Cysts Aspiration

The lump must disappear completely after aspiration, otherwise

it must be treated as any other persistent lump.

The fluid must not be blood stained. If it is, then cytology and

pneumocystography must be carried out, so also open biopsy.

If recurrence of cysts occur, respiration is indicated. Cysts rarely

refill after 2-3 aspirations.

Hormonal Therapy

One study reported a remarkable reduction (75%) in the number

of cysts requiring aspiration after a course of danazol, 100mg three

times a day for three months.

When a segment of the breast is involved and patients complain

of pain and lump in the segment, that involved segment may be

47

excised through a cosmetically appropriate incision. Operation is

indicated when anxiety or discomfort persists after reassurance or

when malignancy cannot be absolutely ruled out.

MASTALGIA

The pain of cyclical mastalgia is hypothesized to arise from an

abnormality of lipid metabolism, thus forming the pathophysiological

basis for this BBD, thus directly or indirectly acting through an effect on

prolactin.

Dietary fat reductions have been tried and in some studies,

shown to be beneficial in reducing the symptoms, if dietary fat intake

was reduced from 40% to 20% of the total caloric intake.

Danazol in a phase doses of 2.5mg/day, antiprostaglandin

mefenamic acid 500mg three times a day diuretic metolazone 5mg/day

have also been tried with varying degrees of benefit in reducing breast

engorgement and pain.

FIBROADENOMA

Since fibroadenomas are a disorder of lobular development and

benign, they can be left alone to await spontaneous regression usually

women less than 25 years are advised of its benign nature and told to

await spontaneous regression. Longer than 12 months may be required

for resolution of a fibroadenoma.

Patients are followed up regularly and if there is any increase in

size, it can be excised through a circumareolar or radial incision.

Massive fibroadenoma can be treated by simple mastectomy

after taking the patient’s consent. Giant fibroadenoma is treated by

enucleation through an appropriate cosmetic incision. While this

treatment initially results in some discreapancy in breast size, the

48

remaining breast tissue expands to virtually normal size within a year

or two.

When a group of women were questioned, majority preferred

excision of fibroadenoma than the wait and watch policy, even though

they knew it to be benign.

Juvenile fibroadenomas are excised through a submammary

incision. Fibroadenomas in pregnancy and lactation are not excised

until after childbirth since regression is known to occur.

DUCT ECTASIA

This is a disorder of duct involution. It may present as a breast

mass, nipple discharge, nipple retraction, abscess or fistula.

Breast mass treatment is unsatisfactory. Broad spectrum

antibiotics have not been of much use. A recent study has shown

metronidazole, flucloxacillin or cephedrine to be effective. Biopsy is

avoided as far as possible when malignancy is suspected. FNAC is

done. If it is equivocal, biopsy is planned. For periductal mastitis / duct

ectasia, no specific treatment is indicated.

Single duct discharge is treated with microdochectomy total

subareolar duct excision is done if multiple ducts are involved. The

incision is given over only 1/3 of areolar circumference and no areolar

flap is raised. For the nipple retraction with breast mass, observation

with repeated clinical examination and mammography is advised.

Mammillary Fistula

Atkins opened up the tract passing down the probe placed

through the fistula. This was effective, but resulted in an ugly scar. Now

the procedure followed is, primary closure under antibiotic cover and

results are encouraging.

49

GYNECOMASTIA

In majority of cases, reassurance that it is a benign self limiting

condition, and that it is premalignant, will suffice. A minority of patients

will require treatment either for tenderness or cosmesis.

Dihydrotestosterone heptanoate has yielded good results. The

antiestrogen, tamoxifen has also shown beneficial effects in the dosage

of 10mg twice daily. For pubertal gynecomastia, Danazol has shown

considerable effect in treating it.

Surgery

Subcutaneous mastectomy can be done in all cases which

require surgery. The majority of textbooks suggest a

hemicircumareolar or periareolar incision. The breast lump is excised,

leaving behind a small amount behind the nipple. Some still advocate

use of sub-mammary incisions.

PHYLLODES TUMOR

Benign, low grade phyllodes tumor treated surgically by wide

local excision and breast conserving surgery in a patient who desires to

retain the breast.

This type of excision should have negative margins for the tumor

tissue as to prevent local recurrence. In a recent study local excision

with recurrence was 18%. Local recurrence is almost always related to

the inadequacy of the initial excision.

Simple mastectomy itself is a perfect acceptable primary therapy

in women with very large benign phyllodes tumors, especially in the

elderly.

TREATMENT OF NON LACTATING BREAST ABSCESS

Reports of successful treatment of non lactational breast abscess

by aspiration and antibiotics have been published. Repeated aspiration

is required for complete resolution.

50

A wide spectrum of both aerobic and anaerobic organisms cause

non lactational breast abscess so antibiotics which are effective,

include combinations of amoxycillin and clavulanic acid along with

metronidazole.

As most non lactating abscess are multiloculated, many patients

may need repeated aspiration, or incision and drainage, if needed has

to be carried out through the smallest possible incision.

Definitive treatment is required if any duct involvement is

present.

The source of the material for the study is from the patients

attending surgical out patient department and as inpatients of the

surgical wards at Kurnool Medical College & Hospital, Kurnool between

August 2004 and May 2006. during this period, 100 cases were

studied.

51

METHOD OF COLLECTING DATA

Cases were selected from the OPD and from inpatients in the

wards who presented with disorders of the breast. Proforma with

relevant history, clinical examination and investigarions was prepared

and patients were assessed.

Inclusion Criteria

Patients with complaints of pain in the breast associated with or

without lump or nodularity in the breast.

Presence of lump in the breast.

Nipple discharge.

Non lactating breast abscess.

Exclusion Criteria

Acute lactating breast abscess.

Biopsy proven malignancy of the breast lump.

52

PROFORMA – BBD

Name : IP No. : D.O.A.

Age : Unit : D.O.D.

Sex : Hospital : Govt. Gen. Hospital, Kurnool.

History :

Complaints: Pain (Dull aching / Throbbing) :

Lump :

Discharge (Serous / Purulent / Blood / Milk) :

Duration :

Rate of Growth :

Others if any :

Any relation to menstrual cycles – (pain) :

Any h/o intake of oral contraceptive pills :

Any h/o recent lactation or pregnancy :

Any h/o similar or related complaints in the past :

Menstrual History :

Menarche :

Family :

Physical Examination:

Pulse : Icterus :

B.P. : Lymphadenopathy :

Pallor : Others :

LOCAL EXAMINATION (BREAST) RIGHT LEFT

Inspection:

1. Size :

2. Nipple :

3. Areola :

4. Skin over the breast :

5. Lump :

Palpation:

1. Temperature :

2. Tenderness :

3. Number :

4. Site :

5. Size :

6. Shape :

53

7. Surface :

8. Consistency :

9. Fluctuation :

10. Margin :

11. Mobility :

12. Fixity to skin / Breast Tissue/Muscle:

13. Discharge from nipple :

14. Regional Lymph nodes :

15. Mobility of the breast as a whole :

SYSTEMIC EXAMINATION:

P/A : CVS :

RS : CNS :

Provisional Diagnosis :

Investigations :

1) Blood

HB% : ESR : Blood sugar :

TC : Urea : Blood grouping :

DC : Creatinine: Others :

II) Urine : (Albumin / Sugar / Deposits) :

1. X-ray chest :

2. ECG :

3. FNAC :

4. HPE :

Final diagnosis :

Treatment :

Progress/Follow up :

54

CASE REPORT - 1

Name : Savaramma IP No. : 02439 D.O.A:17-01-

05

Age : 30 years Unit : FSB - 1 D.O.D:26-01

05

Sex : Female Hospital : Govt. Gen. Hospital,

Kurnool.

History :

Complaints: Pain (Dull aching / Throbbing) : Dull aching

Lump : 2 Lumps one in each breast

Discharge (Serous / Purulent / Blood / Milk) : No Discharge

Duration : 3 Months

Rate of Growth : Gradual

Others if any : -

Past h/o : Similar

complaints 2 yrs back

For

which she was operated

Any relation to menstrual cycles – (pain) : -

Any h/o intake of oral contraceptive pills : No

Any h/o recent lactation or pregnancy : No

Any h/o similar or related complaints in the past : No

Menstrual History : Normal (3/30)

Menarche : 12 Years

Family : Completed, 2

children


Pulse : 82 / min Icterus :

No

B.P. : 120/80 mm of Hg Lymphadenopathy : No

Pallor : No


Inspection:

1. Size : Normal Increased

2. Nipple : Normal Normal

3. Areola : Normal Normal

55

4. Skin over the breast : Normal

Stretched

5. Lump : 3x3 cms 5x5 cms

Palpation:

1. Temperature : Normal Normal

2. Tenderness : No No

3. Number : 1 1

4. Site : Upper outer Upper outer

5. Size : 3x3 cms 5x5 cms

6. Shape : Spherical Spherical

7. Surface : Smooth Smooth

8. Consistency : Firm Firm

9. Margin : Well defined Well defined

10. Mobility : Freely Mobile Freely Mobile

11. Fixity to skin / Breast Tissue/Muscle: Nil Nil

12. Discharge from nipple : Nil Nil

13. Regional Lymph nodes : Not enlarged Not enlarged

14. Mobility of the breast as a whole : Present

Present


P/A : Normal CVS : S1 S2 +

RS : Clear CNS : Normal

Provisional Diagnosis : Bilateral Fibroadenoma

Investigations :

1) Blood

HB% : 10Gm% ESR :7mm/Hr Blood sugar : 90mg / dl

TC : 8400/mm3 Urea : 22mg/dl Blood grouping : A Positive

DC : N65L28M4B1E2 Creatinine: 1.1mg/dl

II) Urine : (Albumin / Sugar / Deposits) : Nil

1. X-ray chest : Normal

2. ECG : Normal

3. FNAC : S/o Fibroadenoma

4. HPE : Fibroadenoma (Pericanalicular)

Final diagnosis : Bilateral Fibroadenoma

Treatment : Excision on both sides

56

Progress/Follow up : 1 Year follow up is uneventful

57

CASE REPORT - 2

Name : Nagamma IP No. : 06749

D.O.A:16-02-05

Age : 35 years Unit : FSB 3 D.O.D:25-02-

05


Kurnool.

History :

Complaints :

Lump : Single Lump in left breast

Discharge (Serous / Purulent / Blood / Milk) : Serosanguinous

Discharge

Duration : 3 months


Others if any : -






Menarche : 14 Years

Family : 2 children



No


Pallor : No


Inspection:

1. Size : Normal Normal



4. Skin over the breast : Normal Normal

5. Lump : - 1x2cms

Palpation:


58

2. Tenderness : - -

3. Number : - 1

4. Site : - Central

5. Size : - 1x2cms

6. Shape : - Oval

7. Surface : - Smooth

8. Consistency : - Soft

9. Margin : - Well defined

10. Mobility : - Mobile

11. Fixity to skin / Breast Tissue/Muscle: - Nil

12. Discharge from nipple : - Present

13. Regional Lymph nodes : - Not enlarged

14. Mobility of the breast as a whole : - Present




Provisional Diagnosis : Duct ectasia Left Breast

Investigations :

1) Blood

HB% : 10.2 gm% ESR : 8mm/Hr Blood sugar : 102mg / dl

TC : 8200/mm3 Urea : 30mg/dl Blood grouping : O Positive




6. ECG : Normal

7. FNAC : S/o Duct ectasia

8. HPE : Duct ectasia

Final diagnosis : Duct ectasia Left Breast

Treatment : Microdochectomy

Progress/Follow up : Normal after 18 months follow up

59

CASE REPORT - 3

Name : Zaithun Bee IP No. : 14498

D.O.A:06-05 05


05


Kurnool.

History :

Complaints :

Lump : Single Lump in right breast


Duration : 2 months

Rate of Growth : Rapid

Others if any : -






Menarche : 14 Years

Family : 3 children



No


Pallor : +


Inspection:

1. Size : Increased Normal



4. Skin over the breast : Stretched,dilated veins+ Normal

5. Lump : 6x8cms -

Palpation:


2. Tenderness : - -

60

3. Number : 1 -

4. Site Lower outer -

5. Size : 7x8cms -

6. Shape : Irregular -

7. Surface : Bossellated -

8. Consistency : Firm -

9. Margin : Well defined -

10. Mobility : Mobile -

11. Fixity to skin / Breast Tissue/Muscle: Nil -

12. Discharge from nipple : Nil -

13. Regional Lymph nodes : Not enlarged -

14. Mobility of the breast as a whole : Present -




Provisional Diagnosis : Phyllodes Tumor Right Breast

Investigations :

1) Blood

HB% : 8.5 gm% ESR :9mm/Hr Blood sugar : 72mg / dl





10. ECG : Normal

11. FNAC : S/o Phyllodes Tumor

12.HPE : Phyllodes Tumor

Final diagnosis : Phyllodes Tumor Right Breast

Treatment : Excision

Progress/Follow up : After 4 months of follow up patient dint turn up.

61

CASE REPORT – 4

Name : Yesiah IP No. : 06577

D.O.A:10-02-06


06

Sex : Male Hospital : Govt. Gen. Hospital, Kurnool.

History :

Complaints Pain (Dull aching / Throbbing) : Dull aching



Duration : 12 months


Others if any : -

Any h/o similar or related complaints in the past : -

Any h/o Drug intake : -

Family History : Nil Significant



No


Pallor : No


Inspection:

1. Size : Normal Increased




5. Lump : - 3x3cms

Palpation:


2. Tenderness : - Present

3. Number : - 1

4. Site : - Central

5. Size : - 5x3cms

6. Shape : - Spherical

62


8. Consistency : - Firm


10. Mobility : - Mobile


12. Discharge from nipple : - Nil


14. Mobility of the breast as a whole : - -




Provisional Diagnosis : Gynecomastia of Left Breast

Investigations :

1) Blood

HB% : 12 gm% ESR : 6mm/Hr Blood sugar : 110mg / dl

TC : 7600/mm3 Urea : 36mg/dl Blood grouping : AB Positive




14. ECG : Normal

15. FNAC : Gynecomastia

16. HPE : Gynecomastia

Final diagnosis : Gynecomastia Left Breast

Treatment : Subcutaneous mastectomy

Progress/Follow up : After 5 months of follow up patient is doing well

63

CASE REPORT - 5

Name : Lakshmi IP No. : 09118

D.O.A:08-03-05


05


Kurnool.

History :

Complaints :



Duration : 15 days


Others if any : -






Menarche : 13 Years

Family : Not Married



No


Pallor : No


Inspection:





5. Lump : 3x4 cms -

Palpation:


2. Tenderness : No -

64

3. Number : 1 -

4. Site : Upper outer -

5. Size : 3x4 cms -

6. Shape : Oval -

7. Surface : Smooth -



10. Mobility : Freely Mobile -








Provisional Diagnosis : Fibroadenoma Right Breast

Investigations :

1) Blood

HB% : 11 gm% ESR :7mm/Hr Blood sugar : 86mg / dl

TC : 7200/mm3 Urea : 20mg/dl Blood grouping : B Positive




18. ECG : Normal


20. HPE : Fibroadenoma (Intracanalicular)

Final diagnosis : Fibroadenoma Right Breast

Treatment : Excision through circum areolar incision

Progress/Follow up : 15 month follow up uneventful

65

CASE SHEET - 6

Name : Nirmala IP No. : 22053

D.O.A:22-07-05


05


Kurnool.

History :

Complaints: Pain (Dull aching / Throbbing) : Dull aching



Duration : 15 days


Others if any : -

Any relation to menstrual cycles – (pain) : Yes



Any h/o similar or related complaints in the past : Yes


Menarche : 13 Years

Family : 5 children



No


Pallor : +


Inspection:





5. Lump : 2x3 cms -

Palpation:


2. Tenderness : + -

66

3. Number : 1 -

4. Site : Central -

5. Size : 2x3 cms -

6. Shape : Oval -




10. Mobility : Mobile -








Provisional Diagnosis : Fibro adenoma Right Breast

Investigations :

1) Blood

HB% : 8.5 gm% ESR :9mm/Hr Blood sugar : 72mg / dl





22. ECG : Normal

23. FNAC : S/o Fibrocystic disease

24. HPE : Fibrocystic disease

Final diagnosis : Fibrocystic disease Right Breast

Treatment : Excision through circum areolar incision

Progress/Follow up : one year follow up is uneventful

67

CASE REPORT - 7

Name : Malathi IP No. : 11189

D.O.A:28-04-05


05


Kurnool.

History :

Complaints Pain (Dull aching / Throbbing) : Dull aching



Duration : 2 months


Others if any : -






Menarche : 13 Years

Family : 1 children



No


Pallor : No


Inspection:





5. Lump : - 4x4cms

Palpation:


2. Tenderness : - -

68

3. Number : - 1

4. Site : - Upper inner

5. Size : - 4x5cms

6. Shape : - Oval


8. Consistency : - Firm


10. Mobility : - Freely Mobile


12. Discharge from nipple : - Nil


14. Mobility of the breast as a whole : - Present




Provisional Diagnosis : Fibroadenoma Left Breast

Investigations :

1) Blood

HB% : 11 gm% ESR : 6mm/Hr Blood sugar : 110mg / dl





26. ECG : Normal


28. HPE : Fibroadenoma (Pericanalicular)

Final diagnosis : Fibroadenoma Left Breast

Treatment : Excision through radial incision

Progress/Follow up : No recurrence after 15 months of follow up

69

CASE REPORT - 8

Name : Ramesh IP No. : 54508

D.O.A:06-12-05


05

Sex : Male Hospital : Govt. Gen. Hospital, Kurnool.

History :

Complaints Pain (Dull aching / Throbbing) : Dull aching in both breasts

Lump : Single Lump in each breast


Duration : 8 months


Others if any : -

Any h/o similar or related complaints in the past : -

Any h/o Drug intake : -

Family History : Nil Significant



No


Pallor : No


Inspection:

1. Size : Increased Increased




5. Lump : 3x3cms 3x3cms

Palpation:


2. Tenderness : Present Present

3. Number : 1 1

4. Site : Central Central

5. Size : 3x3cms

3x3cms


70




10. Mobility : Mobile Mobile




14. Mobility of the breast as a whole : - -




Provisional Diagnosis : Bilateral Gynecomastia

Investigations :

1) Blood


TC : 6400/mm3 Urea : 32mg/dl Blood grouping : A Positive




30. ECG : Normal

31. FNAC : -

32. HPE : Gynecomastia

Final diagnosis : Bilateral Gynecomastia

Treatment : Bilateral Subcutaneous mastectomy

Progress/Follow up : Uneventful

71

CASE REPORT - 9

Name : Bharathi IP No. : 59043 D.O.A:28-12-

04

Age : 40 years Unit : FSB - 2 D.O.D:08-01-

05


Kurnool.

History :

Complaints :

Lump : Lumps in both breast


Duration : 10 Months


Others if any : -






Menarche : 14 Years

Family : 1 child



No


Pallor : No


Inspection:




4. Skin over the breast : Stretched Normal

5. Lump : 6x6 cms 3x3 cms

Palpation:


2. Tenderness : No No

72

3. Number : 1 1

4. Site : Upper outer Lower outer

5. Size : 6x7 cms 3x3 cms





10. Mobility : Freely Mobile Freely Mobile




14. Mobility of the breast as a whole : Present

Present




Provisional Diagnosis : Giant Fibroadenoma Right, Fibroadenoma Left

Investigations :

1) Blood

HB% : 9.4 Gm% ESR : 8mm/Hr Blood sugar : 92mg / dl





33. ECG : Normal


35. HPE : Giant Fibroadenoma Right,

Fibroadenoma Left

Final diagnosis : Giant Fibroadenoma Right, Fibroadenoma

Left

Treatment : Excision on both sides

Progress/Follow up : Normal after 18 months of follow up

73

CASE REPORT - 10

Name : Achamma IP No. : 39765

D.O.A:09-08-04


04


Kurnool.

History :

Complaints: Pain (Dull aching / Throbbing) : Throbbing pain in

right breast



Duration : 3 days


Others if any : H/o Fever 3 days

Any relation to menstrual cycles – (pain) : No


Any h/o recent lactation or pregnancy : Lactating



Menarche : 15 Years

Family : 1 children



No


Pallor : No


Inspection:




4. Skin over the breast : Erythematous Normal

5. Lump : 5x6 cms -

Palpation:

1. Temperature : Raised Normal

74

2. Tenderness : + -

3. Number : 1 -

4. Site : Lower outer -

5. Size : 6x5 cms -

6. Shape : - -




10. Mobility : - -

11. Fixity to skin / Breast Tissue/Muscle: - -







Provisional Diagnosis : Right Breast Abscess

Investigations :

1) Blood






37. ECG : Normal

38. Culture & Sensitivity : Staph.aureus sensitive to

Amoxycillin+clavulanic acid

Final diagnosis : Right Breast Abscess

Treatment : Incision & Drainage

Progress/Follow up : 2 months follow up is uneventful

75

CASE REPORT - 11

Name : Raziya IP No. : 00134

D.O.A:02-01-06


06


Kurnool.

History :

Complaints: Pain (Dull aching / Throbbing) : Throbbing pain in

right breast



Duration : 20 days


Others if any : H/o Fever 20 days

Any relation to menstrual cycles – (pain) : No


Any h/o recent lactation or pregnancy : Lactating



Menarche : 14 Years

Family : 2 children


Pulse : 98/ min Icterus :

No


Pallor : No


Inspection:




4. Skin over the breast : Erythematous Normal

5. Lump : 3x5 cms -

Palpation:

1. Temperature : Raised Normal

76

2. Tenderness : + -

3. Number : 1 -

4. Site : Lower outer -

5. Size : 5x5 cms -

6. Shape : - -


8. Consistency : Soft -

9. Fluctuation : Positive -


11. Mobility : - -

12. Fixity to skin / Breast Tissue/Muscle: - -







Provisional Diagnosis : Right Breast Abscess

Investigations :

1) Blood






40. ECG : Normal

41. Culture & Sensitivity : -

Final diagnosis : Right Breast Abscess

Treatment : Incision & Drainage

Progress/Follow up : Normal

77

CASE REPORT - 12

Name : Parvathamma OP No. : 03113

Date:24-01-05

Age : 20 years Unit : surgery op


Kurnool.

History :

Complaints Pain (Dull aching / Throbbing) : Dull aching in both breasts

Lump : -


Duration : 2 Months

Nature of Pain : Periodic

Others if any : -

Any relation to menstrual cycles – (pain) : Yes

Any h/o intake of oral contraceptive pills : NA

Any h/o recent lactation or pregnancy : NA

Any h/o similar or related complaints in the past : Yes


Menarche : 15 Years

Family : Not Married



No


Pallor : No


Inspection:





5. Lump : - -

Palpation:


2. Tenderness : Mild Mild

3. Number : - -

78

4. Site : Whole Breast Whole Breast

5. Lump : No No



8. Mobility of the breast as a whole : Present Present




Provisional Diagnosis : Cyclical mastalgia

Investigations :

1) Blood

HB% : 10.2 Gm% ESR : 14mm/Hr Blood sugar : 98mg / dl





10. ECG : Normal

11. FNAC : S/o Fibrocystic changes

12. HPE : -

Final diagnosis : Cyclical mastalgia

Treatment : Eveningprim rose oil and Analgesics and

reassurance

Progress/Follow up : Intensity of symptoms decreased and after 6

months same treatment is repeated

79

OBSERVATIONS

The present study of 100 cases of benign breast disease were

studied during the period of study from 2004 to 2006.

AGE INCIDENCE

The youngest patient in the study was 20 days old and the oldest

being 65 yrs old. Most of the patients are in the age group of 16-30

years.

Table 1 : Age and Sex Cross Tabulation

AgeSex

TotalFemale Male

Below 155 2 7

5.8% 14.3% 7.0%

16-3053 8 61

61.6% 57.1% 61.0%

31-4524 3 27

27.9% 21.4% 27.0

Above 454 1 5

4.7% 7.1% 5.0%

Total 86 14 100

CC = 126; P<.657

Chi – square for age alone = 80.96; P<.000 (highly significant)

Chi – Square for sex alone = 57.76; P<.000 (highly significant)

85

Table 2 : Mean Age of Male and Female Patients

MeanStd.

DeviationMinimum Maximum

Female 28.17 9.37 8 58

Male 27.92 14.81 8 65

Total 28.14 10.07 8 65

‘t’ = 0.081; P<.935

The mean age of male and female patients are statistically same

as ‘t’ test revealed a non-significant difference between mean ages of

male and female patients.

Graph 1 : Number of Cases According to Age and Sex

86

On the whole, the benign lesion of the breast presenting in the

2nd and 3rd decade of life was 61%.

The age incidence in the present study was compared to other

studies as shown in the table below.

Table 3 : Comparison of Case Incidence with Other Studies

Age Present seriesSofji F

Oluwole

Etim E Onuka,

Nigeria

<15 6.8% 20% 21%

16-30 61.4% 28.6% 55%

31-45 27.3% 17.3% 14%

>45 4.5% 13.5% 3%

It is more prevalent is female population than male population.

The present study consists of 100 cases of which 86 cases were

female (86%). 12 cases were males (14%).

Graph 2 : Sex Incidence

87

Symptoms of Benign Breast Disease

In this series, symptoms were analyzed as follows;

Table 4 : Distribution of the Sample by Chief Complaints

Chief Complaints Frequency Percent

Lump 49 49.0

Pain 15 15.0

Lump and Pain 28 28.0

Swelling 4 4.0

Fever and Lump 2 2.0

Nipple Discharge 1 1.0

Nipple Discharge and

Lump

1 1.0

Total 100 100.0

X2 = 140.26;P<.000 (Highly significant)

Lump found to have almost 50% incidence in the total sample

and nipple discharge with or without lump was the least. Chi square

value revealed a highly significant difference between these various

chief complaints.

In this study, patients mostly presented with lump in the breast

49%. This series was compared with the study of benign breast disease

in Nigeria by Onukak where 73 cases were studied and it was found

that painless lump formed 65.8% of cases.

88

Graph.3 Frequency of symptoms

DURATION OF SYMPTOMS

79% of patients presented within 6 months, and 15% of patients,

presented after 6 months but within 12 months 6% presented after 1

year. Younger patients presented earlier than older patients.

Table 5 : Distribution of Sample by Duration of Symptoms

Frequency Percent

<1 month 19 19.0

1-6 months 60 60.0

7-12 months 15 15.0

>12 months 6 6.0

Total 100 100.0

X2 = 68.64; P<.000 (Highly significant)

89

Graph 4 : Duration of Symptoms

SIDE OF INVOLVEMENT

This series analysed the data to determine which breast was

more involved in benign breast disease.

Table 6 : Distribution of the Sample by Side

Side Frequency Percent

Left 34 34.0

Right 45 45.0

Bilateral 21 21.0

Total 100 100.0

X2 = 8.66; P<.013 (Significant)

Incidence of benign breast disease in the study sample was

found to be significantly on the right, further confirmed by significant

Chi square value.

90

Graph 5 : Side of Involvement

Table 7 : Comparison with Oluwole and Onukak studies

Side Present Series OluwoleOnukak’s

study

Right 45% 45% 43.8%

Left 34% 41% 48%

Bilateral 21% 14% 8.2%

QUADRANT OF THE BREAST INVOLVED

The Upper outer quadrant is the most commonly involved

segment (42%) in this study. On comparing this study with that done

by Oluwole, the result was, upper outer quadrant was the most

commonly involved part of the breast. The explanation given is that, as

the maximum breast mass is situated in upper outer quadrant, breast

lesions are more commonly found in this quadrant.

91

Table 8 : Distribution of the Sample by Quadrant

Quadrant Frequency Present

UO 42 42.0

UI 12 12.0

LO 11 11.0

LI 2 2.0

Central 23 23.0

WB 7 7.0

UO & UI 1 1.0

UO & LO 2 2.0

Total 100 100.0


Majority of the patients presented with benign breast disease in

the upper outer quadrant i.e. 42% and further confirmed by a highly

significant Chi square test.

Graph 6 : Quadrants of the Breast Involved

92

Table 9 : Distribution of the Sample in Cases of Bilaterality

Quadrants Frequency Percent

Upper outer 6 27.3

Upper inner 2 9.1

Lower outer 3 13.6

Central 3 13.6

Whole breast 7 31.8

Lower Outer & Axillary

Tail1 4.5

Total 22 100.00

X2 = 7.455; P<.189 (Non-significant)

Statistically equal distribution was observed in cases with

bilaterality. Chi square test result was non-significant.

SIZE OF THE LESION

The diameter of the lumps ranged from <2 sq cms to 5+ sq cms

in the 100 cases which were analysed in this study. The smallest lesion

was 1 sq. cm (1x 1 cm) whereas the larges diagnosed was 130sq. cms

(13 x 10 cms).

93

Table 10 : Distribution of the Sample by Size of Lesion &

Clinical Conditions

Size Total

< 2 sq cm 2-5 sq cm > 5 sq cm

Fibroadenoma 2 5 41 48

Giant Fibroadenoma 2 2

Fibrocystic Disease 5 3 8 16

Plexiform Neurofibromatosis

1 1

Gynecomastia 4 9 13

Phyllodes tumor 2 2

Duct Ectasia 1 1 2

Cyclical Mastalgia 6 6

Breast Abscess 4 6 10

Total 18 10 72 100

CC = .523; P<.000

Non-significant association was observed between size of lesion

and clinical condition as CC value of .404 was found to be non-

significant P<.510.

TYPE OF BENIGN BREAST DISEASE

Relationship of various BBD to various quadrants, side, size and

number shown in the tables above.

In the present series, fibroadenoma was the commonest lesion –

48% fibrocystic disease was next with 16% and others followed in

smaller degrees.

94

Table 11 : Distribution of Sample by Provisional Diagnosis

Frequency Percent

Fibroadenoma 48 48.0

Giant Fibroadenoma 2 2.0

Fibrocystic Disease 16 16.0

Plexiform

Neurofibromatosis1 1.0

Breast Abscess 10 10.0

Gynecomastia 13 13.0

Cystosarcoma

Phyllodes2 2.0

Duct Ectasia 2 2.0

Cyclical Mastalgia 6 6.0

Total 100 100.0


Graph 7 : Frequency of Various Lesions

95

TREATMENT MODALITIES

Table 12 : Distribution of the Sample by Provisional Diagnosis

& Treatment

Treatment

Excisio

n

Drug

s

Quadra

n

tectom

y

Subcutane

ous

mastectom

y

Microdo

c

hotomy

I & D

Fibroadenoma 48 1

Giant

Fibroadenoma2

Fibrocystic

Disease5 11 1

Plexiform

Neurofibromasto

sis

1

Breast Abscess 1 10

Gynecpmastia 13

Cyclical

Mastalgia6

Duct Ectasia 1

Total 57 17 2 13 1 10

CC = .881; P,.000 (Highly-significant)

96

Graph 8 : Various Treatment Modalities

Comparison of Clinical Diagnosis, FNAC to HPE Table 13 : Accuracy of Clinical Diagnosis against FNACLesions FNAC Total

Fibroadenoma 32 1 3397.0

%3.0% 100.0

%Giant

Fibroadenoma1 2 3

33.3%

66.7%

100.0%

Fibrocystic Disease 8 15 1 24

33.3%

62.5%

4.2% 100.0%

Plexiform Neurofibromatosis

1 1

100.0%

100.0%

Cyclical Mastalgia 1 1

100.0%

100.0%

Gynecomastia 4 4

100.0%

100.0%

Duct Ectasia 1 100.0%

1 100.0%

Phyllodes Tumor 1 1

100.0%

100.0%

Total 41 3 16 1 2 4 1 38

CC=.904; P<.000 (HS)

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Table 14 : Accuracy of FNAC against HPE

Lesions HPE TotalFibroadenoma 31 1 1 33

93.9%

3.0% 3.0%

100.0%

Giant Fibroadenoma

2 1 3

66.7%

33.3% 100.0%

Fibrocystic Disease 6 6 1250.0

%50.0% 100.0

%Plexiform

Neurofibromatosis 1 1

100.0%

100.0%

Cyclical Mastalgia 1 1100.0

%100.0

%Gynecomastia 4 4

100.0%

100.0%

Duct Ectasia 1 100.0%

1 100.0%

Phyllodes Tumour 1 1

100.0%

100.0%

Total 37 3 7 1 2 4 2 56CC=.896; P<.000 (HS)

98

Comparison of Clinical Diagnosis with FNAC of Fibroadenoma

Sensitivity = 32/33= 97.0%

Comparison of FNAC with HPE of Fibroadenoma

FNAC was done in 31 out of 33 cases, which was proved by HPE.

ensitivity = 93.9%.

Comparison of Clinical Diagnosis with FNAC of Fibrocrocystic

Disease

12 cases with lesions of fibrocystic disease, examined clinically

were subjected to FNAC and 6 were proved as fibrocystic disease.

Sensitivity of clinical diagnosis = 50%

Comparison of FNAC with HPE of Fibrocystic Disease

24 cases with lesions of fibrocystic disease, proved by HPE of

which 12 were positive in FNAC also.

Histopathologic lesions proved by FNAC as fibrocystic disease

showed sensitivity of 50%.

Overall sensitivity of clinical diagnosis against FNAC = 89.45%

Overall sensitivity of FNAC against HPE is 87.22%.

99

Fibroadenoma

From the above data in this study it is evident that 2 groups of

benign breast disease i.e. Fibroadenoma and Fibrocystic disease

constitutes more than 65% of all benign breast disease.

The total number of Fibroadenomas in the present study were

the higher number constituting 48%. Hence we analyzed this lesion in

some greater detail.

Out of these 48 cases, 40 cases (83.3%) were single

fibroadenoma confined to one breast only. There were 3 cases (6.25%)

of multiple fibrodenoma. There were 3 cases (6.25%) of bilateral

fibroadenoma.

In this series, the upper outer quadrant was involved in 42%, with

upper inner quadrant involvement in 12%, lower outer quadrant in 11%

and lower inner quadrant in 11% and lower inner quadrant in 2%.

The central quadrant was affected on 23% in this series.

From this study, the most frequently involved quadrant was the

upper outer quadrant.

This study also compared the values of involvement of each

breast to fibrodenoma. It was found that Right breast in fibroadenoma

was involved in 45% and left breast in 34% cases and 21% cases-

bilatral, where as in Oluwole (New York), right breast involved in 45%,

left breast 42%, Bilateral involvement in 14% of cases.

In our study, bilaterality was more compared to Oluwole’s study

as we have included cyclical mastalgia in our study.

100

In this study we had 3 cases of recurrent fibroadenoma which

were operated 4½ and 2 years respectively in the first two cases and

the third case recurred after 9 months and was proved by FNAC as

fibroadenosis.

This study could not assess relationship with oral contraceptives

an none of our patients took oral contraceptives.

The commonest age group of occurrence of fibroadenoma

in this series was 16-30 years. The earliest age at which this tumor

occurred in this study was 13 years and the oldest was 46 yrs.

This study found that lump alone was the most common

mode of presentation 49%.

Lump and pain presented in 28% of patients.

Two cases of Fibroadenoma had a lactation breast abscess 10

and 12 years of ago respectively, which was drained and they had

uneventful post operative recovery.

Cases of Bilateral Fibroadenoma – opted to undergo surgery on

both sides in the same sitting.

Two cases had family history of benign breast disease among

first degree relatives for which surgery was done.

21 number of cases among 84 female patients studied were

unmarried.

Fibrocystic Disease

In this series, it was found that the fibrocystic disease

constituted 16 cases i.e. 16%. This was comparable to the study of

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Oluwole who had 20% Fibrocystic disease in his series. It was also

evident that Fibroadenoma was more common in India than Fibrocystic

disease, the possible explanation being early menarche, early marriage

and multiparity of Indian women.

Fibrocystic disease was more frequent in this series between 16-

25 years.

On analyzing the symptomatology, most patients

presented with lump in breast, followed by lump and pain, similar to

that the benign disease in general.

Involvement of the side of the breast and specific quadrant

in the breast almost followed that of benign breast disease in general.

The upper outer quadrant was commonly (42%) involved.

Most of the lesions of fibrocystic disease were between 2-4

cm in diameter and surface was nodular. Mobility was restricted in

majority of cases, while few were freely mobile.

This study encountered no family history of benign beast

disease in 24 cases of fibrocystic disease.

Three patients had history of similar complaints tin the

past. Of these, 2 cases lesions were present in the opposite breast and

in 1 case on same side.

Out of 16 cases of fibrocystic disease, 15 cases were

treated conservatively with capsule of evening primrose oil or tab

Danazol for all cases for 3 months. Both responded well. But symptoms

recurred after stopping evening primrose oil. But cases on danazol 100

mg OD for cyclical mastagia, reported 50% reduction in 1-2 weeks and

asymptomatic by the end of 1 month. Patients with nodularity were put

on 200-400 mg danazol and they reported resolution of nodules by end

of 3 months. Some patients discontinued the treatment as drugs were

102

costly, and insisted on surgical excision which was done later. Some of

the patients were patients were anxious and not comfortable even

after reassurance. Hence they were treated surgically but most

educated women who were reassured, settled with conservative line of

management.

Breast Abscess

This study encountered 10 cases (10%) of non-lactating breast

abscess. The earliest case presentation was 2 days since the onset of

symptoms, and one case presented with 14 days history. Average time

of presentation was 3-6 days. Of these, 3 cases were neonates and

children aged between 20 days, 8 months and 12 years respectively.

Among adults, the oldest patient was 65 years. All the patients were

treated by incision and drainage, under the coverage of antibodies.

Gynecomastia

This series had a total of 13 patients (13%) the duration of

symptoms varied from 2 months to 1 year, most patients in the age

group of 20 years, Most of them presented with enlarged breast and

pain. There was no history of drug ingestion or any demonstrable cause

of Gynecomastia. They were treated by subcutaneous Mastectomy. The

indication for surgery in this study was mainly cosmesis and persistent

pain.

Phyllodes Tumor

This study encountered 2 cases (2%) of phllodes tumor (Benign

variety). Both cases measured 30 sq, cms in size. One patient

underwent simple mastectomy and another one underwent wide

excision, one case was clinically and by FNAC –diagnosed as

Fibroadenoma and underwent excision of the lesion and HPE turned out

to be phyllodes tumor. The other case was diagnosed as giant

fibroadenoma clinically and by FNAC, but HPE proved it to be low grade

phyllodes tumor.

103

Duct Ectasia

In this series there were 2 cases (2%) of duct ectasia which

presented in 3rd decade and another one in 4th decade. One case

presented with lump, pain and serous discharge. This case which

presented was diagnosed as duct ectasia clinically and on FNAC, and

ductogram was also done. The case underwent Microdochectomy. HPE

reported as Duct ectasia. The other case presented with lump and pain.

Clinically suspected to be fibroadenoma and FNAC suggested

Fibroadenoma, traumatic fat necrosis. Patient underwent

quadrantectomy and HPE reported it as duct ectasia.

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SUMMARY AND CONCLUSION

The present study of benign breast disease in a teaching

hospital revealed that they were more frequent than generally

expected. They were most frequent in the reproductive age group and

in the upper outer quadrant with Fibroadenoma being the most

frequent problem. There was good correlation between clinical

diagnosis, FNAC to HPE with respect to Fibroadenoma and fibrocystic

disease. Surgical treatment and medical line of management

respectively for these cases were successful with resolution of pre-

operative symptoms.

The present trend of conservative management of most benign

breast disorders has reduced number of surgical procedures for these

conditions. However in view of the anxiety regarding symptoms,

distance to be traveled, poor socioeconomic conditions leading to

difficulty in follow up quite a few patients opt for an early surgical

method of resolution of symptoms.

Hundred cases were analyzed over a period of 2 years. On

analyzing the age incidence, it was found that the commonest age of

occurrence was between 16-30 yrs. (54%) and about 95% before 5th

decade of life, average age of 28.17 yrs and standard deviation of +

9.37 yrs was observed. This illustrates the fact that benign breast

disease commonly affects adolescents and young adults. Other studies

also showed that the adolescent and young adults commonly affected

than the older individuals, more than 45 years of age. The occurrence

of benign breast disease after 45 yrs of age was 5% in this series.

It was found that 86% were female cases when compared to 14%

of male cases.

105

Patients presented with symptoms of lump with pain,

enlargement of breast or discharge. The usual and commonest mode of

presentation was lump alone – 49% and lump and pain 28%. These 2

symptoms contributed to77% of patient s complaints.

79% of the patients presented within 6 months of the

onset of the symptoms. This early presentation could partially be due

to the greater awareness of the disease of the breast and fear that

lump could be malignant

The right breast was involved in 45% of cases and left in

34% of cases and bilateral in 21% of cases.

It was found that the upper outer quadrant was commonly

involved this was also supported by Oluwole series (New York) which

also reported involvement of outer and upper quadrant commonly.

Most of the lesions in this series were more than 5 sq cms. Most

of the lesions were excised under general anesthesia.

Fibroadenoma was the commonest lesion with 48%. Fibrocystic

disease was the next commonest with 16% of cases. These figures

correlate with those of Oluwole[New York] who found Fibroadenomas

in 48% and Fibrocystic disease in 24% of cases. The next common

lesion was gynecomastia constituting 13% of cases in this study.

In patients with Fibroadenoma the upper outer quadrant

was involved in 42% of the patients. The commonest age of

occurrence in this series was 16-30 yrs, Fibroadenomas commonly

presented as lump in the breast in 49% of the patients. Bilateral

Fibroadenomas were seen 6.25% cases and multiple Fibroaenomas

also in 6.25% cases. In this series one case had foci of calcification in

case of Fibroadenoma.

106

16% of cases had Fibrocystic disease as compared to 24% of

cases in Oluwole, New York, Fibroctstic disease commonly occurred

between 16-30 yrs of age. Most of the patients with fibrocystic disease

presented with lump in breast followed by lump and pain. Involvement

of the side and quadrant were similar to that of benign breast disease

in general.

Ten cases of breast abscess were treated by incision and

drainage with antibiotic coverage. 13 patients had gynecomasita. Most

were in the age group of 15-25. Most presented with enlargement of

the breast with pain. There was no history of drug ingestion. All were

treated by subcutaneous masectomy.

Two cases of phyllodes tumor were seen, of which none of them

had recurrence. Two cases of duct ectasia were treated by

microdochectomy. In this study there were 4 cases of family history of

similar complaints among the first degree relatives.

Seven cases gave past history of similar complaints which

were treated surgically, 5 cases had lesion in the opposite breast and 2

cases in the same breast.

Diagnosis of benign breast disease were made by clinical

examination and investigation procedures. Routine investigations were

done for all patients and when required mammography was done.

Comparison of clinical diagnosis and FNAC to HPE of

Fibroadenoma and fibrocystic disease was done. Clinical diagnosis and

FNAC of Fibrodenoma and for Fibrocystic disease has sensitivity of 87%

each when compared to Histopathological examination.

107

Most of the cases of benign breast disease occurred in

reproductive age group (95%).

The standard treatment advocated was followed for all cases,

where necessary minor adjustments were made. Surgical treatment

was the main mode of treatment. For most of the cases circumareolar

incision was used, the follow up was from 3 months to 11/2 yrs. Present

study encountered one case of recurrence of Fibroadenoma which was

proved by FNAC as Fibroadenosis and hence was treated

conservatively.

108

STATISTICAL METHODS APPLIED

Following statistical methods were employed in the present study

Contingency Table analysis

Independent samples ‘t’ test

Chi-square test

Contingency Table Analysis

The contingency table analysis procedure (Cross tabs) forms two-

way and multiway tables and provides a variety of tests and measures

of association for two-way tables. The structure of the table and

whether categories are ordered determine what test or measure to

use. Crosstabs statistics and measures of association are computed for

two-way tables only. If you specify a row, a column and a layer factor

(control variable), the crosstabs procedure forms one panel of

associated statistics and measures for each value of the layer factor

(or a combination of values for two or more control variables). For

example, if GENDER is a layer factor for a table of MARRIED (Yes, no)

against LIFE (is life exciting, routine, or dull), the results for a two-way

table for the females are computed separately from those for the

males and printed as a panels following one another.

The Independent-samples ‘t’ Test

This procedure compares means for two groups of cases. Ideally,

for this test, the subjects should be randomly assigned to two groups,

so that any difference in response is due to the treatment (or lack of

treatment) and not to other factors. This is not the case if you compare

average income for males and females. A person is not randomly

assigned to be a male or female. In such situations, you should ensure

that differences in other factors are not masking or enhancing a

significant difference in means. Difference in other factors are not

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masking or enhancing a significant difference is means. Differences in

average income may be influenced by factors such as education and

not by sex alone.

Chi-square Test

The chi-square test procedure tabulates a variable into

categories and computes a chi-square statistic. This goodness-of-fit

test compares the observed and expected frequencies in each

category to test either that all categories contain the same proportion

of values or that each categories contains a user-specified proportion

of values.

All the statistical calculations were performed using the software

SPSS for Windows (Statistical presentation system, software, SPSS inc,

1999, New York) version 10.0.

110

LIST OFABBREVIATOINS USED

B _ Bilateral BA _ Breast Abscess BP _ Blood Pressure C _ Central CM _ Cyclical Mastalgia CNS _ Central Nervous

System CP _ Cystosarcoma

Phyllodes CVS _ Cardio Vascular System DC _ Differential count DE _ Duct Ectasia DOA _ Date of Admission DOD _ Date of Discharge DP _ Duct Papilloma ECG _ Electro cardiogram ESR _ Erythrocyte

Sedimentation Rate F _ Female FA _ Fibroadenoma FC _ Fibrocystic Disease FNAC _ Fine Needle Aspiration

Cytology G _ Gynecomastia GFA _ Giant Fibroadenoma H/o _ History of HB% _ Haemoglobin% IP No _ In Patient Number L _ Left LI _ Lower Inner LO _ Lower Outer M _ Male Mon _ Months NA _ Not Applicable NM _ Not Married P/A _ Per Abdomen PN _ Plexifrom

Neurofibromatosis R _ Right RS _ Respiratory System TC _ Total Count UI _ Upper Inner UO _ Upper Outer WB _ Whole Breast

111

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