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Learning Objectives
• At the end of this session you shall be able
to describe the demography, clinical
features investigations and management of
Benign Breast Conditions/ Benign Breast
Diseases.

ANDI
Aberrations of Normal Development
and Involution of the breast
• AKA fibrocystic disease, fibrocystic changes,
fibroadenosis, chronic mastitis and mastopathy

Physiology
The female breast passes through 5phases
during lifetime
1. Prepubertal
2. Post pubertal
3. Pregnancy
4. Lactational
5. Menopausal

Physiology
• The resting (non-lactating) breast, consists mostly
of fibrous & fatty tissue
• During phases of the menstrual cycle the breast
epithelium and lobular stroma undergo cyclic
stimulation.
• Estrogen mediates development of ductal tissue;
progesterone facilitates ductal branching and
lobulo-alveolar development; and prolactin
regulates milk protein production.
• Dominant process is hypertrophy and alteration of
morphology rather than hyperplasia.

Physiology
• With pregnancy, there is diminution of the
fibrous stroma to accommodate the
hyperplasia of the lobular units.
• Growth is influenced by high circulating
levels of estrogen, progesterone and
prolactin .

Physiology
• After childbirth, there is a sudden loss of the
placental hormones.
• A continued high level of prolactin is the
principal trigger for lactation.
• The actual expulsion of milk is under
hormonal control and is caused by the
contraction of the myoepithelial cells by
hormone Oxytocin.
• Stimulation of the nipple is the physiologic
signal for both the continued pituitary
secretion of prolactin and for the acute
release of oxytocin.

Physiology
• When breast-feeding ceases, there is a fall
in prolactin and no stimulus for release of
oxytocin. The breast then returns to a
resting state and to the cyclic changes
induced when menstruation begins again.

Physiology
• After menopause progressive atrophy of
lobes & ducts takes place – Involution.
• These changes include increased fat
deposition, diminished connective tissue,
and the disappearance of lobular units.

ANDI
Age group :30-50 years
Aberration in normal cyclical hormonal
effects
Cyclcial mastalgia with nodularity

ANDI Classification of Benign Breast
Disorders
Normal Disorder Disease
Early reproductive
years (age 15–25)
Lobular development Fibroadenoma Giant fibroadenoma
Stromal development Adolescent hypertrophy Phhyllodes tumor
Nipple eversion Nipple inversion Subareolar abscess
Mammary duct fistula
Later reproductive
years (age 25–40)
Cyclical changes of
menstruation
Cyclical mastalgia Incapacitating mastalgia
Nodularity
Epithelial hyperplasia of
pregnancy
Bloody nipple discharge
Involution (age 35–55) Lobular involution Macrocysts
Sclerosing lesions
Duct involution
–Dilatation Duct ectasia Periductal mastitis
–Sclerosis Nipple retraction
Epithelial turnover Epithelial hyperplasia Epithelial hyperplasia with atypia

Etiology
• Idiopathic
• Congenital
• Traumatic
• Infections /Infestation
• Autoimmune
• Neoplastic (Benign/Malignant)
• Degenerative

Idiopathic
• Hormonal
– receiving estrogens ± progestins increased
incidence.
– receiving tamoxifan an antioestogen reduced
incidence.
• Genetic- field effect” and more recently, a
“mutator phenotype” - predisposition to
mutations in some patients is the cause of
multiple breast lesions.
– Loss of heterozygosity (LOH), a finding caused
by deletions of small segments of DNA.

Idiopathic
• Mondor’s disease
• Duct ectasia/periductal mastitis
• ANDI
• Breast cysts
• Galactocele
• Fibroadenoma
• Phyllodes tumour

Congenital
Nipple
• Nipple retraction
• Cracked nipple
• Papilloma of the nipple
• Retention cyst of a gland of Montgomery
• Eczema
• Discharges from the nipple

Congenital
Breast
• Amazia
• Polymazia
• Mastitis of infants
• Diffuse hypertrophy

Traumatic
• Haematoma
• Traumatic fat necrosis

Infections
• Bacterial mastitis and Abscess.
• Chronic intramammary abscess
• Tuberculosis of the breast
• Actinomycosis

Clinical Features
• Pain
• Lump
• Nipple discharge

ANDI Pathology
• Four features that may vary in extent and degree
in any one breast-
1. Cyst formation.
2. Fibrosis. Fat and elastic tissues disappear and are
replaced with dense white fibrous trabeculae. The
interstitial tissue is infiltrated with chronic
inflammatory cells.
3. Hyperplasia of epithelium in the lining of the
ducts and acini with or without atypia.
4. Papillomatosis. The epithelial hyperplasia may
be so extensive that it results in papillomatous
overgrowth within the ducts.

ANDI Pathology
• Termed fibrocystic changes.
• 50 to 60 percent of normal women may have this
pattern histologically
• Lumpy breasts or non-discrete nodules do not
have breast disease.
• Fibrocystic changes detected clinically incur no
increased risk of breast cancer.

Triple Assesment
• Clinical Assessment
• Imaging Studies
• FNAC

Diagnostic Studies
Imaging Studies
• X-Ray- Diagnostic mammography
• USG- Sonomammography.
• CT
• Angiography
• MRI role evolving
• Nuclear scan

Imaging Studies
• Screening vs. Diagnostic Mammography-
1. Breast density
2. Masses
3. Calcification
4. Archetectural distortion

Imaging Studies
•
Paramet
er
Benign Suspicious
Malignant
Density Low High
Mass Round or oval well
defined
Irregular shape with
spiculated margins
Calcifica
tions
Diffusely scattered
dystrophic
calcifications large
rod-like, popcorn,
coarse, vascular, and
milk of calcium.
clustered, linear or
variously shaped
amorphous, fine
pleomorphic, and
fine-linear branching

Imaging Studies BI-RADS
• Breast Imaging-Reporting and Data System
• The BI-RADS lexicon (Terminology) is a
dictionary of descriptive terms used to
describe a mammographic, ultrasound, or
MRI findings
•

Imaging Studies BI-RADS
• BI-RADS 0 incomplete
• BI-RADS 1: negative
• BI-RADS 2 benign
• BI-RADS 3 probably benign
• BI-RADS 4: suspicious for malignancy
• BI-RADS 5 highly suggestive of
malignancy
• BI-RADS 6 known biopsy-proven
malignancy

Imaging Studies
• Sonomammography- Solid or Cystic
– For gross cysts (i.e. >4 cm) aspiration with
repeat imaging within six months.
– Suspicion of Ca.-
• If the fluid contains blood
• cyst is complex – solid component.incompletely
aspiratble.
• refilling of the same cyst after aspiration,

Fibroadenoma
• Represent a hyperplastic or proliferative process in a
single lobule
• Etiology is unknown, thought to be due to hormonal
influence
• Between the ages of 15-25 years & size of 2-3cm
• Painless lump- capsulated,smooth, firm, well
defined, nontender, BREAST MOUSE
• Microscopy-
intracanalicular pericanalicular

Fibroadenoma
• For majority, no potential for cancer
• Risk factors for subsequent cancer:
– Proliferative histology
– Complex mass
– Family history of breast cancer
– When complex and containing cysts >3mm in
diameter
– Sclerosing adenosis
– Epithelial calcification
– Papillary changes,

Fibroadenoma
• Treatment-conservative
• Surgery-
– Very large/increasing in size
– Suspicious cytology
– Surgery is desired.
– Enucleation

Phyllodes Tumor (Cystosarcoma
Phyllodes)
• Sarkoma -fleshy tumor
• Phyllon -leaf”
• A rare, predominantly benign tumor that
occurs almost exclusively in the
female breast.
• characterized by rapid growth often gains
huge size.
• Leaflike appearance when sectioned.

Pathophysiology
• Develops from connective tissue of breast.
• 85-90% of phyllodes tumors are benign and that
approximately 10-15% are malignant.
• Benign phyllodes tumors do not metastasize, grow
aggressively and recur locally.
• Like other sarcomas, malignant phyllodes tumors
metastasize hematogenously.
• Difficult to distinguish fibroadenomas, benign
phyllodes tumors, and malignant phyllodes tumors

PHYLLODES TUMOUR
• Proliferation of intralobular stroma
• Fusiform fibroblast
• 3 types:-
benign
borderline
malignant
(cellularity,atypia,mitoses &invasion by
edges)

PHYLLODES TUMOUR
Management
Wide local excision
Benign
Borderline - Follow up
Malignant -SIMPLE MASTECTOMY

Traumatic Fat Necrosis
• Clinical features - Pain & lump in the breast
• Lump is hard - extensive fibrosis caused by
tissue reaction
• D.D : Carcinoma breast
• Mammography findings - density lesion;
can have calcifications; may mimic
carcinoma breast
• Treatment - excision of the lump

Breast cyst
• Common lesions
• Age group – 30-50
• Multiple and bilateral
• Can mimic malignancy
• Confirmed by USG and
aspiration

Breast cyst
• Aspirate
• Excision biopsy if-
• Bloody aspiration
• Residual mass
• Suspicious cytology
• Recurs

Sclerosing adenosis
• Enlarged and distorted lobules with stromal
fibrosis and interspersed glandular cells
• Presents as palpable lump
• Diagnosis:
– Mammogram: calcifications, well-
circumscribed to spiculated mass
– True-cut biopsy
• Management:
– Small risk of subsequent malignancy
– Observation with annual breast exam and
mammogram

MASTALGIA
• Menstruating age group
• Hormone related-ANDI
• Dull diffuse bilateral
• More Upper outer quadrant
• Must distinguish from non breast chest pain

Mastalgia
• Breast pain is common and a symptom that
brings a woman to her physician. Usually it
is of functional origin and uncommonly is it
a symptom of breast cancer.
• Most patients with pain do not have breast
cancer.

Types
• Cyclical mastalgia.
• Noncyclical mastalgia.

Cyclical mastalgia
• Normal ovarian hormonal influences on breast
glandular elements frequently produce cyclical
mastalgia.
• It is most common in women in their mid-30s
• Pain is dull, diffuse
• Bilaterally symmetrical in the upper outer
quadrants.
• It is predominantly experienced in the luteal phase
of the menstrual cycle and abates
with menstruation.

Noncyclical mastalgia
1.Non breast etiology specific significant
breast condition
• Cervical radiculopathy,
• Costochondritis,
• Intercostal muscle strain.
• Gastroesophageal reflux disorder,
symptomatic gallstones,
• Cardiovascular disease,
• Pulmonary pathology

Noncyclical mastalgia
2.Specific breast conditions:
• Breast cyst
• Breast cellulitis (mastitis) .
• Inflammatory breast cancer,
• Ca. Breast

MASTALGIA:MANAGEMENT
• Pain diary
• Reassurance
• Exclude caffeine
• Low fat diet
• Stop ocps/HRT
• Stop smoking
• Precise fitting of a bra
• Drugs

MASTALGIA:Drugs
1. Definitely effective-
1. Danazol, bromocriptine, and tamoxifen
2. Possibly effective-
1. Linoleic acid in the form of evening primrose
oil.
2. Iodine and vaginal progesterone
3. Definitely ineffective- vitamin E
4. Insufficiently studied-
medroxyprogesterone acetate, caffeine
avoidance, and progesterone
5. For refreactory Gnrh agonist analogues.

Duct Papilloma
• Proliferative breast disease without atypia
• Polyps of epithelium lined duct
• Bloody discharge
• Microdochectomy

Duct ectasia
• Characterized by distention of subareolar ducts
• Presence of yellowish-orange material within
these ducts.
• Penetration of the duct wall by this material may
produce acute inflammatory changes in the
surrounding tissues.
• Periductal fibrosis and nodule formation
• Stromal hyperplasia can result in nipple retraction
or in palpable lesions requiring biopsy to
distinguish from breast carcinoma.
•

Duct ectasia
• Histologically, crystalline oval and round
structures thought to be lipid in origin are present
in the lumen.
• Histologically, the surrounding tissue may contain
fibroblasts nearly exclusively or predominantly
fibroblasts with admixture of glandular
epithelium.
• Clear, cloudy, blue, green or black nipple
discharge
• Duct excision

Breast Abscess /Mastitis
• Flucloxacillin or co-amoxiclav
• Support of the breast,local heat,&
analgesics
• Incision & drainage
• Now recommended is repeated aspiration
under antibiotics
• continue breast feeding

MONDOR’S DISEASE
• Thromboplebitis of superficial veins of the breast
& chest wall
• Aetiology not known
• C/F – thrombosed subcutaneous cord
• DD – breast cancer
• Treatment – anti-inflammatory medication
warm compresses & support
restriction of movement
symptoms persist - excision

Virginal Hypertrophy
• Huge enlargement.
• Teens
• Reduction mastoplasty
• Mastectomy

Diabetic Mastopathy
• Aka. Lymphocytic mastopathy or
lymphocytic mastitis
• Localized or diffuse areas of fibrosis
occurring in patients with diabetes
• May be due to secondary autoimmune
reaction from effects of hyperglycemia on
connective tissue
• Seen in up to 13% of patients with diabetes
mellitus type 1
•

Diabetic Mastopathy
• Painless mass, seen in long-standing
diabetes mellitus type 1
– Mammogram: solid mass with asymmetric
density
– Ultrasound: irregular hypoechoic mass
– CNB
• Management:
– Excision not needed as there is no increased
risk for breast cancer
– Known to recur after surgical removal
– Annual mammogram

Galactocele
• In lactating.
• A retention cyst containing milk.
• An obstruction of a lactiferous duct →
accumulation of epithelial cells and milk →
distention of the duct → cyst formation
• Palpable, firm mass in the subareolar
region
• no fever or pain
• needle aspiration reveals milky contents

Galactocele
– Mammogram:
• Complex cystic masses
• With fat/fluid levels (from the layering of portions
of retained milk)
– Ultrasound:
• Typically, a homogeneous hypoechoic lesion with
acoustic attenuation, well-defined margins, and thin
walls
– Most cases resolve spontaneously.
– Increased breastfeeding, warm compresses, and
massage
– Repeated needle aspiration or surgical excision:
for symptomatic cysts

Risk of Malignancy
• Benign breast epithelial lesions are grouped
histologically as -
1. Nonproliferative- associated with no
increased risk of breast cancer.
2. Proliferative without atypia increase of
1.5-2%
3. Atypical hyperplasia >2% increase .

Risk of Malignancy
1. No increased risk of breast cancer.
1. Fibrocystic changes
2. Periductal fibrosis
3. Hamartomas
4. Lipomas
5. Phylloides tumors
6. Neurofibromas
7. Duct ectasia
8. Hematomas and fat necrosis
9. Granulomas and mastitis

Risk of Malignancy
2. 1.5-2% increased risk of breast cancer.
1. Fibroadenomas
2. Hyperplasia without atypia
3. Papillomas, papillomatosis
4. Radial scar
5. Blunt duct adenosis
6. Sclerosing adenosis

Risk of Malignancy
3. >2% increased increased risk of breast
cancer.
1. Atypical hyperplasia
2. Lobular Carcinoma in situ:

Increased Risk of Malignancy
• Non-proliferative disease
• Proliferative disease without atypia
• Benign breast disease nor otherwise
specified
• Atypical hyperplasia not otherwise
specified
• Adenosis
• Atypical deutal hyperplasia
• Atypical lobular typerplasia
• Cysts not ohterwise specified
• Fibroadenoma
• Papilloma
1.17
1.76
2.07
3.93
2.00
3.28
3.92
1.55
1.41
2.06

Take home messages
• Benign breast diseases are common but
present diversely
• Lump, pain and nipple discharge are
common findings.
• Triple assessment
• It is important to distinguish between them
to determine the likelihood of cancer and
the best course of treatment.
• Management ranges from frequent
monitoring to surgical excision.

MCQ
• Discrete breast lump with tenderness over
entire breast in 18 year old female is most
likely -
• a) Fibroadenosis
• b) Fibroadenoma
• c) Ca breast
• d) Mastalgia

MCQ
• Discrete breast lump with tenderness over
entire breast in 18 year old female is most
likely -
• a) Fibroadenosis
• b) Fibroadenoma
• c) Ca breast
• d) Mastalgia

MCQ
• A 45 year old woman presents with a hard
and mobile lump in the breast. Next
investigation is :--
• A. FNAC
• B. USG
• C. Mammography
• D. Excision biopsy

MCQ
• A 45 year old woman presents with a hard
and mobile lump in the breast. Next
investigation is :--
• A. FNAC
• B. USG
• C. Mammography
• D. Excision biopsy

MCQ
• Best diagnostic method for breast lump is -
• a) USG
• b) Mammogram
• c) Biopsy
• d) FNAC

MCQ
• Best diagnostic method for breast lump is -
• a) USG
• b) Mammogram
• c) Biopsy
• d) FNAC

MCQ
• 44 years female. A mass in her right breast while taking a
shower a month ago, and it has now grown to double the
size.
• Multinodular, firm 5 cm x 5 cm mass mobile and painless.
The skin over the mass appears to be stretched and shiny
• Ultrasound well-circumscribed hypoechoic mass with
some cystic components
• What diagnosis is likely in core needle biopsy ?
A. Fibroadenoma
B. Breast abscess
C. Phyllodes tumor
D. Duct ectasia
E. Fat necrosis

MCQ
• 44 years female. A mass in her right breast while taking a
shower a month ago, and it has now grown to double the
size.
• Multinodular, firm 5 cm x 5 cm mass mobile and painless.
The skin over the mass appears to be stretched and shiny
• Ultrasound well-circumscribed hypoechoic mass with
some cystic components
• What diagnosis is likely in core needle biopsy ?
A. Fibroadenoma
B. Breast abscess
C. Phyllodes tumor
D. Duct ectasia
E. Fat necrosis

MCQ
• A 24-year-old woman, mass in 3-cm mass in the left
upper quadrant. The mass is firm, mobile, and has well-
defined margins. There are no skin or nipple changes
noted. She reports occasional tenderness and denies nipple
discharge. There is no lymphatic involvement.
Mammography shows a dense lesion. What is the most
likely cause of the patient's presentation?
• A. Ductal carcinoma in situ (DCIS)
• B. Fibroadenoma
• C. Phyllodes tumor
• D. Inflammatory carcinoma
• E. Invasive ductal carcinoma

MCQ
• A 24-year-old woman, mass in 3-cm mass in the left
upper quadrant. The mass is firm, mobile, and has well-
defined margins. There are no skin or nipple changes
noted. She reports occasional tenderness and denies nipple
discharge. There is no lymphatic involvement.
Mammography shows a dense lesion. What is the most
likely cause of the patient's presentation?
• A. Ductal carcinoma in situ (DCIS)
• B. Fibroadenoma
• C. Phyllodes tumor
• D. Inflammatory carcinoma
• E. Invasive ductal carcinoma

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