BENIGN BREAST LESIONS AND PHYLLODES TUMOUR

• Embryology: Mammary ridge (groin to axilla) is of ectodermal origin
• Components of macroscopy of breast

  • 2nd to 6th rib, 15-20 lobes, Adipose, fibrous tissue, arteries, veins, lymphatic vessels, nodes, nerves, pectorals, long thoracic, thoracodorsal, smooth muscle in nipple, areola, Montgomery's glands (modified sebaceous gland in the areolar-nipple area for lubrication)
• Microscopy of breast


  Network of Terminal Ductal Lobular Units (TDLUs) per lobe, Ducts lead to lactiferous sinus and then to nipple, Cells include ductal lining epithelium, acinar milk-secreting cells, myoepithelial cells, basement membrane, and possibly stem cells, Interstitial matrix with fibroblast, scanty lymphocytes, and tissue
• Normal Breast Development: Pre-puberty mainly dense fibrous tissues with scattered epithelial lined ducts
• Puberty occurs at 9-12 years with the development of pubic hairs
• Menarche occurs at 12-13 years, menstrual cycles begin under Pituitary Gonadotrophins (LH and FSH) leading to an increase in estrogen
• Estrogen effect


  • Thelarche (new ducts by elongate and branching), formation of Terminal DuctoLobular Units (TDLUnits), fat deposition
• Hormones involved in breast development

  • Estrogen, Progesterone, Sex Hormones, T4 and T3, Insulin-like Growth Factor, local Growth Factors, Gonadotrophins
• Post-pubertal/Young adult stage: Mature breast with stroma, lactiferous ducts, lobular units, and fat. Cyclical changes in stromal and epithelial elements under hormonal stimulation, hypertrophy predominates over hyperplasia, nodularity may become prominent
• Late Luteal phase: Intralobar stromal edema in the first 5 menstrual days, acinar development in the next 2 weeks, excessive vacuolation and edema engorgement in the 3rd week leading to cyclic pain (mastalgia)
• Pregnancy leads to the formation of new acini or lobules (TDLUs), enlargement of breasts, less fibrous tissue, increased blood flow, milk production, and areolar pigmentation. Post-delivery, sudden loss of placental hormones and increased prolactin lead to lactation
• Lactation involves colostrum initially and then milk. Milk expulsion is by myoepithelial cells around ducts and TDLUs, possibly under oxytocin stimulation. Post-breastfeeding, prolactin levels drop, and the breast returns to the resting phase
• Menopause occurs at 40-55 years with ovarian function cessation, involution, decrease in epithelial elements, increase in fat, disappearance of TDLUs, but adipose tissue and fibrous tissue remain
• Clinical Features of menopause include vaso-motor effects like hot flushes, cognitive impairment, and decreased sleep. Hormone replacement therapy may result in the persistence of epithelial elements. Treatment involves supportive care and gynecological referral
• ANDI concept/Classification of Benign Disease

  • Normal, Benign Disorder, Benign Disease, Aberration in the Normal Development and Involution (Development, Cyclical change, Epithelial activity, Pregnancy, Lactation, Involution)
• Fibrocystic Breast Disease is a spectrum of clinical, mammographic, and histologic findings. It involves an exaggerated stromal and epithelial response to circulating hormones
• FibroCystic Breast Disease is a spectrum of clinical, mammographic, and histologic findings
• Pathophysiology of FibroCystic Breast Disease

  Exaggerated stromal and epithelial response to circulating hormones and local growth factors
• Pathology of FibroCystic Breast Disease

  Includes Micro & MacroCysts, Solid elements like Adenosis, Sclerosis, Epithelial Metaplasia, and Hyperplasia
• Classification of Hyperplasia

  • Non proliferative
  • Proliferative Without Atypia
  • Proliferative With Atypia (High Risk of Cancer)
  • Combination of the 3
• Cysts are fluid-filled sacs influenced by ovarian hormones, varying with menstrual phases and declining with menopause
• Clinical features of Cysts include palpable mass, managed with U/S and Aspirate for cytology
• Fibroadenoma (FA) is a benign solid stromal & epithelial tumor, common in teens, with a firm mobile mass on palpation
• Phyllodes Tumor is a biphasic proliferation of stromal connective tissue & mammary epithelium, classified as Benign, Intermediate, or Frankly Malignant
• Management of Benign Phyllodes Tumor


  Triple Assessment, Mammogram, FNAB unreliable, Trucut preferred, Excision and follow-up for at least 2 years
• Management of Intermediate Phyllodes Tumor

  Wider excision with 1cm margin, stricter follow-up due to more frequent recurrences
• Management of Frankly Malignant Phyllodes Tumor

  Mammography, U/S, Diagnosis based on rapid growth & larger size, older patient, FNA Cytology unreliable, Trucut biopsy preferred, similar to soft tissue sarcoma elsewhere, Mastectomy usually necessary, Radiotherapy, Chemotherapy as for Sarcoma
• Diagnosis: Rapid growth & larger size, Older patient, FNA Cytology – unreliable, Trucut biopsy – preferred
• Rx

  1. Similar to soft tissue sarcoma elsewhere

  2. Metastatic Workup

  3. Multidisciplinary Team discussion

  4. Mastectomy usually necessary

  5. Radiotherapy

  6. Chemotherapy as for Sarcomas (Cyclofosfamide, Vincristine, Dacarbazine)

  7. Imatinib being tried
• Marginal utility is the additional utility (satisfaction) gained from the consumption of an additional product. If you add it up for each unit you get total utility
• Phylloides tumour of left breast (Cystosarcoma phylloides of left breast)
• Nipple Discharge: Non-Lactational - Unilateral or Bilateral, Single duct or Multiple duct orifice Blood stained or Milky or purulent, +/- Fistula, Galactocoele, Milk filled cyst, Obstruction by inspissated milk may occur 6-10 months after breastfeeding. Mx: aspirate/excision if too inspissated
• Traumatic Fat Necrosis: Aetiology - Trauma, Surgery, or Radiotherapy. There may be calcification. Type 1: Elderly, ecchymosis. Mammography-?Ca. Px: biopsy mandatory. Type 2: Young, cystic and tender. Mammography-translucent cystic mass. Px: Triple Assessment. Excision ± Histology
• Lactational Abscess: Staph aureus. CFs: swollen, red and tender. Px: nipple hygiene/fluclox/I&D. Non-lactational Abscess: older woman, Mixed orgs both aerobic and anaerobic. Pathology: Periductal mastitis & ductectasia. Clinical: Smokers & Diabetics. Chronic infection → skin & nipple retraction. Fistula subareolar, Mass due to infection. Frustrating to patient and surgeon. Px: I/D & biopsy abscess wall/ Excision, antibiotics/emotional & psychological support essential
• TB Breast: Primary, Secondary: retrograde lymphatic spread from lungs, suckling with infected tonsils, rarely from bones and joints. 


  Clinical: 1 breast abscess, 2 may mimic breast Ca, 3 Nipple discharge. Mx: U/S guided needle biopsy, Anti TB Treatment
• Mastalgia: Common, ± lump. Cyclical: Aetiology: Influenced by ovarian hormones. Premenopausal 34yrs ± 3-7 days before and phased with menstrual period, relieved by menopause. Non-cyclical: Aetiology: Complex hormonal/caffeine. Px: pain chart/NSAIDs/evening Primrose oil, severe cases-Danazol, Bromocriptine, Tamoxifen
• Gynaecomastia: Pathology: ductal and stromal hyperplasia. Causes: 1) Idiopathic-majority, 2) Physiological-neonates/puberty/senile, 3) Pathological: Endocrine tumors: Adrenal/leydic cell tumor/pituitary, Non-Endocrine: bronchial ca/lymphoma, Hepatic disease: cirrhosis/haemochromatosis, Drugs: oestrogen/ARVs/Cimetidine, Primary Testicular failure: anorchia, cryptorchitis, mumps, Secondary Testicular failure: Hypopituitarism/GRHRH. Px: treat the cause
• Triple Assessment


  1. Clinical: History & Breast Examination

  2. Imaging: Sonar Mammography (BIRADS class) May need MRI, CT, PET, bone, liver

  3. Biopsy: Trucut biopsy (core biopsy). Type of B/C: Ductal or Lobular (DCISitu, LCISitu) or Invasive Ductal Ca {90%} or Lobular Ca {10%} and Degree of differentiation: Mild, Moderate or Poorly differentiated; Receptors: ER, PR, HER2, Ki67 reports
• Types of Breast Cancer

  • Ductal or Lobular (DCISitu, LCISitu)
  • Invasive Ductal Ca {90%}
  • Lobular Ca {10%}
• Degree of differentiation


  • Mild
  • Moderate
  • Poorly differentiated