-: Benign breast diseases comprises a number of conditions.
Mastalgia, or breast pain, being the commonest presentation.
Benign lumps in the breast,
nipple discharge,
disorders of the nipple and areola,
inflammatory conditions,
lactational and non-lactational mastitis,
congenital and growth anomalies, due to embryologic defects,
and lastly, diseases of the male breast
in the form of enlargement called gynecomastia.
Today we will be talking in detail
about clinical manifestation and treatment of benign lumps
namely fibroadenoma and phyllodes tumour.
Majority of the benign lumps
fall under the category of ANDI.
This will comprise fibroadenoma, cyst,
cyclical nodularity, sclerosing adenosis.
Other conditions leading to lumps in the breast
of benign nature include inflammatory conditions
due to fat necrosis, chronic abscesses, benign tumors,
like phyllodes tumor, lipoma,
which is very rare in the breast.
Which is quite interesting,
considering the amount of
adipose tissue present in the mammary gland.
Sometimes duct papilloma within the major milk ducts,
lesions of the nipple and areola
in the form of leiomyoma, retention cyst.
Lesions of the skin covering the memory gland
may present as sebaceous or epidermoid cyst,
and infection of apocrine glands,
known as hidradenitis suppurativa.
It is interesting to note
that breast itself is a modified apocrine gland.
Sometimes normal structures within the breast or chest wall
may mimic a lump, such as a prominent or conspicuous rib,
or intramammary lymph node.
Different manifestation of ANDI,
or aberrations of normal development and involution,
can present in three phases of memory gland,
development, maturation, and involution.
Beginning age 15 till age 25,
when memory gland is undergoing development.
Lobular development may become pronounced
and present as fibroadenoma.
Which can become giant,
that is more than five centimeter in size,
resulting in giant fibroadenoma.
Similarly, a stromal hypertrophy may become conspicuous
and present in a young girl as a dollar cent hypertrophy.
Nipple may fail to evert
and a young girl may present as nipple inversion.
In the mature age group, beginning age 25 till age 40,
we have cyclical changes of menstruation
which may become conspicuous,
presenting as cyclical mastalgia with or without nodularity.
Similarly hyperplasia of pregnancy may become prominent
and lead to blood discharge from the nipple.
In the last phase of memory gland
natural history of involution,
beginning age 35, progressing up to menopause,
we have involution of the lobule
which may result in cyst formation
which can be microcyst or macrocyst.
Involution of the ductal system may lead to its dilatation
presenting as duct ectasia.
Similarly epithelial turnover may become abnormal
and result in hyperplastic epithelium of the ductal lobule
which can progress into atypia of the ducts or lobule
known as atypical ductal hyperplasia
or atypical lobular hyperplasia.
Among the benign lumps,
fibroadenoma is the commonest type
of discrete lump in the mammary gland
presenting mostly in young girls from age 15 to age 25.
WHO considers it as a discrete benign tumor
with mixed connected tissue and epithelial proliferation.
However some experts consider it as part of ANDI.
Median age of presentation is 30,
ranging from 15 to 35.
Clinically a lady presents with a well defined discrete lump
which may be rubbery in consistency, usually non tender.
The distribution of fibroadenoma,
in the memory gland in different quadrants,
is presented on this slide.
The commonest side being the outer upper quadrant.
And you know why?
Because 50% of the ductal lobular tissue is located
in the upper outer quadrant,
hence all diseases of the memory gland
resulting from proliferation of the TDLU,
terminal ductal lobular unit,
involve upper outer quadrant.
It's part of ANDI manifestation resulting
from proliferation of the lobule is logically
comprising a mixture of epithelial proliferation
as well as stromal proliferation.
So it's a mixed lesion
of mesenchymal and epithelial origin.
The natural history is such that majority
of them are aesthetic and some of them,
about 10 to 30% of fibroadenoma have the natural history
of spontaneous regression if followed for a long time.
Some fibroadenomas may involute
around the time of menopause.
During pregnancy, some fibroadenomas have a tendency to grow
and become quite prominent
under the influence of excessive estrogen and progesterone.
Rarely, some girls may present
with multiple fibroadenomata present in both the breasts.
And this may be part of a rare genetic syndrome
such as Mafucci syndrome, Carney syndrome,
or Cowden syndrome.
It has been observed that in patients following transplant
of the kidney or other organs who are kept
on immunosuppression therapy with cyclosporine,
fibroadenoma may become multiple and grow.
Cigarette smoking has been found to
be protective against fibroadenoma,
but that doesn't mean you start smoking to
prevent fibroadenoma in your breast.
So please for God's sake don't start smoking,
as a pretext for preventing fibroadenoma.
At the genetic level studies have revealed loss of BCL2,
which is an anti-apoptotic gene,
and it's loss may result in proliferation of cells
of the mesenchyme as well as
the ductal epithelium leading to fibroadenoma formation.
It is a polyclonal condition as opposed to cancer,
which is usually thought to be monoclonal in origin.
Multiple fibroadenomata is a condition where more
than five lesions are present in a breast.
It can be present in about 15% of ladies,
which could be bilateral in about 10% of all girls.
The term giant fibroadenoma is applied to a fibroadenoma
measuring five centimeter in its greatest dimension.
This can be present either in the adolescence age group,
or near the menopause in the perimenopausal period.
It is thought that multiple fibroadenomata
has a slightly increased risk for development of cancer.
The relative risk for developing cancer
for ordinary fibroadenoma varies from 1.4 to 1.7.
If it's a simple fibroadenoma,
this risk can increase to about three times
if there is an element of epithelial proliferation
or hyperplasia seen under the microscope.
If cancer develops in a fibroadenoma,
it usually takes the form of a lobular carcinoma.
Some studies have shown that both lobular,
as well as ductal carcinoma in situ,
can develop in longstanding fibroadenoma.
When a lady presents to you
with a discrete lump in the breast,
it does your duty to carry out triple assessment.
Triple assessment comprises three components,
detailed clinical evaluation
in the form of history taking,
along with clinical breast examination.
This is followed by appropriate imaging of the breast,
and pathological evaluation of the lesion
by histology, taking core biopsy.
Imaging of the memory gland comprises an ultrasound.
In a typical fibroadenoma,
we describe the lesion as wider than taller.
That is to say when lady is lying supine
on an examination ultrasound couch,
this dimension is wider, or more,
than the vertical dimension,
and this is described as wider than taller.
A classical fibroadenoma has a smooth margins
with some lobulations and almost
homogeneous echogenicity within the lesion.
This is usually hypoechoic compared to the
echogenicity of the surrounding breast parenchyma.
A more advanced type of ultrasound assessment
can be carried out using elastography which ascertains the
Young's modulus, or elasticity of the lesion.
Most fibroadenoma will be looking blue on elastography,
as opposed to orange color, or hard lesion,
on elastography in a cancer case.
Mammogram should be carried out if a lady is aged 30
and above which may demonstrate, again,
a well defined lesion in the breast.
The pathological confirmation of the lesion
can be ascertained either by
fine needle aspiration cytology,
where a fine 23 gauge needle is inserted into the lump
and cells are aspirated.
The points in favor of FNAC
for a young girl presenting with a benign lump are
that it is fairly cheap and quick to perform.
Although one should be aware of the fact
that it may have a high false negative.
And it is suitable for well defined discrete lumps
but maybe difficult to perform
in an impalpable or deeply located lesion.
On the other hand,
a large needle core biopsy is mostly preferred
by most breast experts.
It is carried out by a 14 gauge core biopsy needle.
Four to five cores are taken to ascertain the exact
histopathological nature of the disease.
A simple fibroadenoma may be shown to reveal a mixture
of fibrous stroma, usually with low cellularity,
and benign cytology of the epithelial tissue.
There's a rare type of fibroadenoma known as
complex fibroadenoma where,
besides features of fibroadenoma,
one finds a component of either sclerosing adenosis,
epithelial calcification,
papillary lesions, or cyst formation.
Some experts consider complex fibroadenoma
to carry a high risk of about, relative risk of three
for development of cancer.
Question may arise,
whether biopsy is always necessary for a young girl.
So some breast experts are of the opinion that
if a young girl presents with a discrete lump in the breast,
which is classically categorized as benign
by clinical evaluation and there is no family history
of breast or ovarian cancer, one may only carry
out a detailed high resolution ultrasound scan
and then reassure the lady without resorting to biopsy.
Let us discuss the management of fibroadenoma.
If a young girl presents with typical physical science
of a highly mobile breast mouse-like lesion,
with no family history of breast or ovarian cancer,
then we can just reassure the girl
after an ultrasound evaluation.
If fibroadenoma is less than three centimeter in size,
in young ladies below age 30, and ladies prepared to come
for regular follow up, a medical treatment can be offered
in the form of antiestrogen Tamoxifen in the dosage
of 10 milligram per day, for two to three months period,
or Ormeloxifene or Centchroman in the dosage
of 30 milligram daily for a period of, again, three months.
These drugs have been found to regress fibroadenoma
in 20 to 30% of cases.
Some unique situation arises where patient presents
with multiple lesions, and there is a real dilemma
as to operate and if operate,
how many of these lumps to be removed?
Because this may lead to multiple scars
and damage of the major milk ducts,
or nurse supply to the nipple and areola complex,
something that should be avoided in young ladies.
Medical management for multiple fibroadenomata
is usually not very successful.
We have observed the usage of Centchroman
in the dosage of 30 milligram
for a period of three months,
is associated with about 30% regression of fibroadenoma.
You may go through these publications
to learn more about the usage of Centchroman in patients
with benign conditions like mastalgia and fibroadenoma.
In our study, where we carried out a randomized trial
in young girls below age 30 presenting with fibroadenoma,
which was conformed histologically by core biopsy,
we found that Centchroman usage for three months,
achieved significant regression in majority of girls
compared to control group.
Surgical management in the form of removal of the lump
is usually recommended if lady presents above
the age of 30 to 35,
or when there is pain associated with the lump,
or if lesion is more than five centimeter in size,
a condition called Giant Fibroadenoma,
If there is restricted mobility of the lump,
or it has ill defined margins,
either on clinical examination, or on imaging.
A discordance between imaging findings and
histopathological report is also considered
an indication for surgical removal.
Girls who have family history of breast or ovarian cancer,
should be offered removal in order to reduce the chance
of a cancer being missed.
Details of the indication for a excision
are presented in this paper published
in the American Journal of Surgery.
Surgery typically consists of enucleation
in young girls below below age 30, where we place
incision closest to the lump, cut the capsule,
enucleate the lesion from within the capsule
and suture the underlying tissue
with minimal damage to the surrounding breast tissue.
Usually we do not remove the surrounding capsule
in young girls below 30
because breast tissue grows very rapidly
and fills this cavity in young ladies.
However if lady is age 30 and above, where there is a chance
of missing either a phyllodes tumor or a Frank cancer
one should resort to excision of the lump
with a rim of normal tissue around it.
After removal of a benign lump
it is a good practice to take the lump to a side room
and request one of the colleagues to bisect this lesion
and look at the features.
Classically, a typical fibroadenoma
on sectioning should look homogenous white,
or whitish gray with no cleft like spaces as seen here.
For ladies presenting with a giant fibroadenoma,
measuring more than five centimeter in size,
a special approach called Gaillard Thomas Approach,
is described where you approach the lesion by either
an inframammary crease incision,
or a lateral mammary crease incision,
lift the mammary gland and remove it from
the posterior aspect of the breast,
leaving the normal breast tissue intact.
And this is how a giant fibroadenoma looked on sectioning.
Again you see uniform, homogenous, gray white appearance
with no brown fluid coming out and no cleft like spaces
something that is indicated of phyllodes tumor.
Other modalities recommended for treatment of fibroadenoma
consists of cryoablation, where you insert a probe
and cool the lesion, convert into a ice ball,
which when melts, results in death of cells
and the dissolution of the lump.
This is especially useful for girls presenting
with multiple fibroadenoma and may avoid multiple scars.
Interstitial thermotherapy has also been
recommended using laser energy.
Vacuum assisted biopsy, sucking out cores
of the fibroadenoma, can also be carried out,
removing the fibroadenoma in pieces.
Similarly radiofrequency ablation by
radio frequency energy has also been utilized with success.
Now we come to another variety of benign lesion,
presenting as a discrete mass in the memory gland,
called Phyllodes tumor.
It was first described by Mr. Mueller
who called it Cystosarcoma phyllodes because
on sectioning he found cyst like, cleft like spaces
giving a typical fern leaf-like pattern
hence the name Cystosarcoma phyllodes.
It presents in relative later period of reproductive years
of life typically in age group 30 to 40 years of life.
It usually presents as large, smooth bosselated mass
with dilated conspicuous prominent veins,
with a stressed skin over it.
Ulceration of the underlying skin is a rare phenomenon
unless lesion is left untreated for a long time.
On imaging, as well as on sectioning,
you will find cleft like spaces,
which are typically seen in phyllodes tumor,
and help in distinguishing it from typical fibroadenoma,
which is uniformly smooth in architecture.
It has well defined margins on ultrasound or demography
and there is marked vascularity around the lesion
and in the lesion due to angiogenesis.
It is usually benign in majority
of condition in its behavior.
However some patients may have an intermediate
or borderline behavior,
and about 10% of thyroid tumor
may have, frankly, malignant nature.
It is usually aggressive in its growth pattern
and is associated with a very high incidence
of local recurrence if it is removed incompletely,
in the range of 10 to 40%
of all patients with thyroid tumor.
It rarely involves lymph nodes only in about 2% cases or so.
Word Health Organization has described
the following grades of phyllodes tumor,
these are benign, borderline, and malignant.
Based on these features in the stroma,
the cellular atypia, stromal overgrowth,
number of miosis per 10 hyper field,
and the presence of tumor in the margin.
Please note that majority
of the phyllodes tumor you will see
in practice will fall in this category of benign phyllodes.
This slide emphasizes to you the recurrent nature
of some phyllodes tumor if incompletely treated.
Like this girl presented with fifth recurrence
and she presented with a huge mass of 21 centimeter
by eight centimeter across.
The principle of excision for phyllodes tumor
are a wide margin of at least two centimeter,
or a round lesion.
And we should also remove the skin overlying the tumor
and, which will include nipple and areola,
and underlying pectoralis major muscle.
This component of removing the overlying skin
and underlying muscle, help in reducing
the recurrence to almost zero.
On sectioning atypical phyllodes tumor presents
with these cleft like spaces,
and brown fluid, Coca-Cola like fluid,
leaks on sectioning the lesion.
So if you remove a discrete lump
and section it and find these cleft like spaces
with some brown fluid coming out,
you should suspect a phyllodes tumor.
And take a tissue from the rim of the lesion just in case
if it proves to be thyroids
and we have done incomplete removal
there may be a recurrence later on.
Radical surgery is usually recommended
for phyllodes tumor in order to reduce the chance
of recurrence to almost negligible.
So typically we carried out two centimeter margin excision
with overlying skin and underlying pectoralis major muscle,
leaving behind a punched out ulcer like appearance
where you see the pectoralis minor muscle fibers
in the tumor bed.
This can be closed by approximation of the tissue,
by tension sutures, or if the defect is large,
then you can cover it with an appropriate myocutaneous flap,
or even a free flap based on
microvascular plastic reconstructive technique.
So some of the publications where we have found
that radical surgery,
without actually dissection,
can achieve almost a guarantee against a recurrence.
And we have called it radical mastectomy SANS,
SANS is a French word which means without.
So we do not require axillary lymph node dissection
because phyllodes tumor typically does not spread
to into lymph nodes.
Adjuvant radiotherapy and chemotherapy is reserved
for patients who have recurrence of the phyllodes tumor
or who have malignant features
on final histological evaluation.
In summary, benign lumps of the breast are fairly common.
Fibroadenoma being the commonest type of benign lump,
especially in young girls.
We should reassure them about the benign nature
after ruling out cancer by triple assessment.
If a phyllodes tumor is identified,
either suspected on imaging or on biopsy,
we should treat it by radical surgery
in order to prevent recurrence.
Thank you.