COMMON BREAST DISEASES

Presented by:
Dayang Nurazilawani binti Kassim
Tham Yuen Sin
Nurul Aqilah binti Mohd Hassan
Mohamad Haziq bin Ahmad Mazuki

Supervisor:
Prof. Dr. Norlia Abdullah
ANATOMY OF THE BREAST
• Lymphatic drainage
BENIGN BREAST DISEASE
 BENIGN BREAST DISEASE
• The most common cause of breast problems; up to
30% of women suffer from benign breast disorder at
some time in their lives

• Common symptoms:
- Pain
- Breast lump

• Aim of treatment:
- To exclude cancer
- To treat any remaining symptoms
 BENIGN BREAST DISORDER
CLASSIFICATION
• Congenital disorders
- Inverted nipple
- Supernumerary breast / nipples
- Non-breast disorders
- Tietze’s disease (costochondritis)
- Sebaceous cysts and other skin conditions
• Injury
• Inflammation / infection
• ANDI (alterations of normal differentiation and involution)
- Cyclical nodularity and mastalgia
- Cysts
- Fibroadenoma
• Duct ectasia / periductal mastitis
• Pregnancy-related
- Galactocele
- Puerperal abscess
BREAST CYSTS
• Benign, fluid-filled sac within the breast
• Common in perimenopausal women
• Often multiple, may be bilateral and can
mimic malignancy
• Pathophysiology:
Hormonal changes

Excess oestrogen

Stimulate breast tissue- epithelial or stromal tissue hyperplasia

Fibrosis

Obstruction of duct

Disabling damage of lobule

Cyst formation
• Clinical presentation:
- Varies in size and may be associated with pain
- Nipple discharge may be present
- Palpation: A well circumscribed, single/
multiple, smooth and mobile, oval/ round in
shape, tender
 • Investigations:
- Mammogram - Ultrasound

A well-defined intermediate density lesion A well-defined anechoic ovoid lesion with

seen in the inner upper quadrant of the left posterior acoustic enhancement.
breast.
• Treatment : Fine needle
aspiration

- No further treatment
required if: Resolved
completely, fluid is not
blood stained

- Core biopsy/ local excision

for histological diagnosis if:
There is residual lump,
fluid is blood stained
**to exclude
cystadenocarcinoma,
common in elderly women
 BREAST LIPOMA
• One of the most common benign
neoplasms derived from fatty tissue

• The incidence accounts for approximately

16% of all mesenchymal tumours

• Clinical presentation:
- Mostly asymptomatic and coincidentally
discovered on routine mammography
- Patients may present with a painless
palpable breast lump which is soft and
mobile
- Skin tethering or fixation are not features
of lipoma
• Investigations:
- Mammogram - Ultrasound

The mass is well-circumscribed and

hyperechoic resembling the
subcutaneous tissue.
A round circumscribed radiolucent mass of
about 1 cm, surrounded by a radio-opaque
thin capsule, is identified in the retroareolar
region of the left breast.
• Treatment:
- These lesions are rarely a diagnostic or
imaging dilemma
- Enlargement of a lipoma is an indication for
biopsy
- They rarely undergo malignant transformation
and are not associated with an increased risk
of developing breast cancer
FIBROADENOMA

• Developmental aberration of terminal lobular

unit
• It is not a true neoplasm develop from a
whole lobule rather than a single cell
• It shows hormonal dependence  lactates
during pregnancy and involutes during
perimenopausal period
• Commonly affects 15- to 25-year age group
• There are 2 histological varieties of fibroadenoma
(a) Pericanalicular: mainly consists of fibrous tissue
: younger age
: firm and smaller in size

(b) Intracanalicular: consists of more glands

: older age
: less firm and larger in size

• There is no prognostic or clinical significance attached to

the two patterns and both may be seen within the same
lesion
• History of Presenting Illness
Mass : painless
: change in size during menstruation
: although small number increase in
size, most do not and >1/3 become
smaller or disappear within 2 years
: breast discharge is almost unknown
• Physical Examination:
1. Inspection : no skin changes
: smooth or bosselated surface

2. Palpation : size - 2 to 3cm

: shape - round or oval
: surface - smooth
: consistency - firm/ rubbery
: margin - definite
: mobility - most mobile of all breast
lesions “ Breast Mouse”
: No Lymph Node enlargement
• Investigations
1. Ultrasound scan
-<35-year-old
-Findings: well-defined homogeneous hypoechoic solid ovoid mass

2. Mammogram
- >35-year-old
- Findings:
 oval shaped, well- defined soft tissue densities with smooth or
lobulated margin
 macrocalcification can be seen (popcorn appearance)

3. Needle core biopsy

- All patients ideally should undergo FNAC for tissue confirmation
• Treatment of fibroadenoma
1. < 4cm  reassurance with no follow up
needed or excision

2. > 4cm  excision

PHYLLOIDES TUMOR
• Fibroepithelial neoplasm
• Present as localized discrete masses that
clinically feel like fibroadenoma
(a) It tends to be larger (> 4cm)
(b) Common in older age group
(c) Fibrous stroma shows more cellularity than
fibroadenoma
(d) Rapidly increase in size
• Clinical feature:
- hard, mobile, bosselated lumps

• Lab investigation:
(a)Mammogram
- non-specific large rounded oval or lobulated well-
circumscribed lesion with smooth margins
(b) Ultrasound
-inhomogeneous solid appearing mass
-round-like cystic spaces
• Management
(a) Wide Local Excision
(b) Simple mastectomy (for large lesion)
MASTITIS

Lactational
mastitis
Central
Mastitis (periareolar
infection)
Non- lactational
mastitis
Peripheral Non-
Lactating Abscess
LACTATIONAL MASTITIS
• Inflammation of breast in breastfeeding women
• Usually developed within first 6 weeks of breastfeeding
• Aetiological agent: Staphylococcus Aureus,
Staphylococcus Epidermidis, Streptococcus
• Predisposing factor:
(a) Cracked nipple
(b) Improper cleaning of the nipple
(c) Infection from the mouth of baby
(d) Inadequate sucking by the baby causing milk stasis
• Clinical Features :
- Painful
- Swelling
- Erythema
- Nipple crack
- Systemic symptoms: fever, malaise
- Complication: Breast abscess
• Management :
- Antibiotic therapy: Flucoxacillin/ Co-amoxiclav
- Supportive therapy: Local heat and analgesia
(NSAID) to relieve pain
- Encourage breastfeeding from the affected
site unless there is nipple discharge - to
reduce stasis of milk
- Management of bacterial abscess: aspiration/
incision and drainage
NON- LACTATIONAL MASTITIS
1. Central (Periareolar) Infection
(a) Most commonly seen in young woman (mean
age 32 year-old)
(b) Risk factor: cigarette smoke
substance in the smoke either
directly or indirectly damage the
subareolar breast duct and damage
the tissue
(c) Clinical feature:
breast pain, erythema, periareolar swelling,
nipple discharge
(d) Treatment:
Oral antibiotics
-Co-amoxiclav
-Clarithromycin + Metronidazole
Aspiration or incision and drainage (Abscess)
Total excision of affected duct (Recurrent
cases)
Lifestyle modification - stop smoking
2. Peripheral Non-Lactating Abscess
(a) Less common
(b) Associated with underlying condition such as
Diabetes Mellitus, Rheumatoid Arthritis,
Steroid Treatment
(c) Treatment:
 Antibiotic therapy
 Needle aspiration or incision and drainage
under local anesthesia
BREAST CARCINOMA
Overview of Breast Carcinoma
• Breast cancer is the
third most common
cancer worldwide and
is the most common
cancer in women.
• In Malaysia, October is
the Breast Cancer
Awareness Month.
Overview of Breast Carcinoma
Types of breast cancer:

Invasive (70%)
-ductal (most common)
-lobular

In-situ (30%)
-DCIS
-LCIS

Others
-Inflammatory
-Paget’s disease of the nipple
-Mucinous
-Tubular
Risk Factors of Breast Carcinoma
Risk Factor Explanation
Gender Female has higher risk than male

Risk increases from the age of 40 years old (pre-menopausal)

Age
and 50 years old (post-menopausal)

• Previous history of breast cancer has elevated risk of

developing new primary breast cancer
History of Breast Ca. • LCIS and DCIS at high risk to develop invasive breast cancer
• Biopsy of proliferative disease with and without atypical
cells has increased risk to develop future breast cancer

• History of breast cancer among young first degree

Family History relatives
• Carriers of BRCA1 and BRCA2 gene mutation
Risk Factors of Breast Carcinoma
Risk Factor Explanation
• Multiple exposures to the chest at an early age (<20 y/o)
Radiation Exposure
• Contralateral breast can develop cancer after high dose
radiation used for breast cancer treatment
• Hodgkin’s lymphoma receiving high dose radiotherapy
• First full-term pregnancy at age >30 years old
• Nulliparity at 40 years old
Reproductive • OCPs before first full term pregnancy
Factors • Combination hormone replacement therapy
• Early menarche (<12y/o)
• Late menopause (>55y/o)
As viewed in mammography. Higher breast density has less
Breast Density complete involution of lobules, thus more cells are
susceptible to malignant transformation

Lifestyle
• BMI >25 kg/m2 has increased risk
• Alcohol
 Risk Factors Stratification of
Breast Carcinoma
Low Risk
Alcohol consumption
Reproductive factors:
- Increasing age at first full-term
pregnancy (> 30 y/o)
- Hormone replacement therapy
- Oral contraceptive pill usage
Obesity
Moderate Risk High Risk
Personal history of invasive breast
cancer
Increasing age from 40 years old
Lobular Carcinoma In Situ (LCIS) and
Ductal Carcinoma In Situ (DCIS)
Reproductive factors:
Benign breast disease with atypical
- Early menarche (<12 y/o) hyperplasia
- Late menopause (>55 y/o)
- Nulliparity
Ionising radiation
Carrier of BRCA1 and BRCA2 gene
Benign breast disease with proliferation mutation
without atypia
Significant family history i.e. first degree
Dense breast family member with breast cancer
 Signs & Symptoms of Breast
Carcinoma
Asymptomatic: detected on mammography screening
Local:
– Breast lump (all or some parts of the breast)
– Often painless
– Nipple changes: displacement, destruction, retraction, deviation, discharge,
eczema
– Overlying skin changes: peau d’orange, tethering, fixation, fungating ulcer
– Lumps in the axilla
Constitutional: loss of appetite, loss of weight
Metastatic features: bone pain, dyspnoea, jaundice, nausea
 Signs & Symptoms of Breast
Carcinoma
Most common is
E.g. Peau
lump or thickening
d’orange,
of the breast,
tethering,
often painless
fixation, ulcer

Inflamed or
scarring of duct
Indicates
inflammatory
carcinoma

Shortening of Blood discharge

Cooper’s
ligament
 Investigation

Clinical
Imaging Pathology
assesment
• History • Mammogram • FNAC
• Physical • Ultrasound • Core biopsy
examination • MRI
 Mammogram

• Useful for asymptomatic women aged >35

years old
• Consist of 2 views a) Craniocaudal b)
Mediolateral oblique
• Abnormal features include
– Dense opacity mass which spiculated with
irregular outline
– Present of microcalcification
Dense opacity
mass which
spiculated with
irregular outline

Present of
microcalcification
 Breast Imaging Reporting and
Data System (BIRADS)

1- no changes
2- Benign finding
3- Probably benign finding
4- Suspicious abnormality
5- Highly suggestive malignancy
6- Confirm 100% malignant changes
 Ultrasound

• First line breast imaging for women aged < 35

years old (due to dense breast tissue)
• Adjunctive ultrasound can be offer to all
symptomatic breast patient regardless the age
• Can differentiate between cystic from solid
lesions
• Abnormal features :
 Irregular
outline/edge

Hypoechic
lesion
 Magnetic resonance imaging (MRI)

• May be considered when other imaging

modalities are unreliable
• Example :
1. Invasive lobular cancer
2. Genetic high risk (BRCA1 or BRCA2)
3. Diagnosis of recurrence
4. Follow up after neo adjuvant treatment
5. Women with dense breast
TNM staging for breast cancer
 Early Breast
Cancer
The cancer has
not spread
beyond the
breast or the
axillary lymph
nodes

Locally Advanced Breast Cancer

The cancer size >5cm or there is
skin/chest wall involvement and
with/without regional LN involvement.

Advance breast cancer

 Staging investigation
• Patient who is presenting with clinically
advance breast cancer

Liver
Chest x ray
ultrasound

CT scan of
CT or MRI of
thorax and
brain
abdomen
 Pathology
Fine needle aspiration cytology
• Provides cell for cytology
• Can differentiate benign and malignant tumor
• Cannot differentiate carcinoma in situ with
invasive carcinoma
Core biopsy
• Provides tissue for histology
• Can differentiate carcinoma in situ with
invasive carcinoma
• Able to detect oestrogen receptor (ER),
progesterone receptor (PR), Human epidermal
growth factor receptor(HER-2)
 Sentinel lymph node biopsy
• Indication :
1. Clinically non palpable axillary lymph node
2. Unifocal tumour ≤ 3cm
Step : Radioisotope + blue dye will be inject
either under the nipple into the skin over the
cancer or around the cancer  Detect by
hand-held probe or stained blue or
scintigraphy
If positive, dissect the lymph node
 Treatment
Local therapy
Systemic therapy
(surgery)

Breast conserving
surgery (BCS) Chemotherapy Endocrine therapy
Mastectomy with
axillary lymph node
surgery
with/without breast
reconstruction
Neo-adjuvant
Wide local excision
and axillary lymph
node surgery,
adjuvant
radiotherapy Adjuvant
 Breast conserving surgery
• The aim is to remove the cancer completely in
as small a volume of tissue as possible
• It involves excising the tumor with 1 cm
margin of macroscopically normal tissue
• It combines with SLNB or axillary clearance
• Radiotherapy must be given as an adjunct to
prevent recurrence
Indication of breast conserving surgery
• Single tumour which <4cm in diameter with
proper tumor breast ratio
• Possible to excise the tumor with tumor free
margin without disrupting the breast
cosmetically
• No contraindication for radiotherapy (ex:
pregnancy)
 Modified radical mastectomy
with/without breast reconstruction
• Indication :
1. Large or multicentric tumour and mobile
axillary lymph node
2. When radiotherapy is not available/ wish
avoid radiotherapy
3. Who elect to have a mastectomy
4. When breast conservation would result to an
unacceptable cosmetic result
 Treatment
Local therapy Systemic
(surgery) therapy

Breast Mastectomy
conserving Endocrine
with axillary Chemotherapy
surgery (BCS) therapy
lymph node
surgery
with/without
Wide local breast Neo-adjuvant
excision and reconstruction
axillary lymph
node surgery,
adjuvant Adjuvant
radiotherapy

Palliative
 Chemotherapy
• Example regime is FAC (5-Fluoroucil,
adriamycin, cyclophosphomide) over 6 cycle
every 21 days. Others are AC
(Adriamycin,Cyclophosphomide)
• Side effects : Loss of hair, fatigue, lethargy,
nausea and vomitting,
Adjuvant Chemotherapy ( after surgery)
• Following surgery, adjuvant chemotherapy should
be offered to all women with any of the following
risk factors especially in pre-menopausal women:
1. one or more positive axillary lymph nodes
2. Estrogen receptor(ER) negative disease
3. tumor size >2cm
4. HER-2 3+
Neo-adjuvant Chemotherapy
• Given before surgery in case of operable
locally advance breast cancer
• The aim is to downsize the tumor so that
surgery can be perform
 Adjuvant anti-HER2
• Targeted therapy directed against HER2
protein.
• Over-expression of HER-2 has been associated
with poorer prognosis.
• Example: Trastuzumab (Herceptin)
 Endocrine therapy
Tamoxifen Aromatase inhibitor (letrozole,
anastrozole, exemestane)

• Selective oestrogen receptor • Block the conversion of

modulator androgen into oestrogen in
• Should be offered to all post menopausal women
women with ER positive • May be considered as an
early invasive breast cancer option in post menopausal
women with ER positive early
breast cancer
• Effective in pre and post • Only for post-menopausal
menopausal women women

Side effects: menopause Side effects: Mild menopause

symptom in pre-menopausal symptom , Muscular aches,
women Osteoporosis, bone fracture
 Follow up

• The suggested follow-up schedule is as follows:

-3 monthly for the first 1 year
-6 monthly for the next 5 years
-An annual review thereafter
• Annual mammography for patients with early breast
cancer who has undergone treatment to detect
recurrence or contralateral new breast cancer
 REFERENCES
1. Bailey and Love's Short Practice of Surgery; 26th edition. Edited by N. S.Williams, C. J. K.Bulstrode and P.
R.O'Connell.
2. Ramírez-Montaño, L., Vargas-Tellez, E., Dajer-Fadel, W. L., & Espinosa Maceda, S. (2013). Giant lipoma
of the breast. Archives of plastic surgery, 40(3), 244-6.
3. https://radiopaedia.org/articles/simple-breast-cyst-1
4. https://radiopaedia.org/articles/breast-lipoma
5. CPG BREAST CANCER
6. Principle and Practice surgery