Category Archives: Breast Disease

Giant fibroadenoma of the Breast

Giant Fibroadenoma of the Breast

  • Rare and generally occur in women age 15-20 years old.
  • Rapid growth
  • Can exceed 5 cm
  • Observation is not recommended for some patients because the rapid growth can lead to further problems (infarction, deformities)
  • Giant Fibroadenoma should be excised also to exclude a phyllodes tumor in addition to preventing futher problems of infarction and deformities.

When is a galactogram done?

Galactogram = Ductogram

Usually done for spontaneous unilateral bloody nipple discharge.  Sometimes it is done for serous (clear) discharge.

90% of the women with unilateral bloody nipple discharge = benign intraductal papilloma, a solitary discrete intraductal mass.  However if multiple masses are discovered in the duct, the more likely the diagnosis will be ductal carcinoma in situ (DCIS).

Regardless of single mass or multiple mass, a surgical biopsy (excisional biopsy) is required for diagnosis.  Methylene blue dye can assist the surgeon in removing the duct in the OR.

Facts about Phyllodes tumors

Phyllodes tumors of the breast:

  • Not easily distinguished from fibroadenomas on physical exam and even challenging on radiological studies
  • Rarely involve the nipple-areolar complex
  • Most are in the upper outer quadrant
  • Central phyllodes tumors may present with bloody nipple discharge or nipple retraction
  • Few have been reported in men
  • Primary goal for treatment of phyllodes tumor is to achieve a wide negative margin with a rim of at least 1 cm of uninvolved tissue.
  • Total mastectomy may be required for lesions too big to achieve a 1 cm margin without markedly deforming the breast or for repeated local recurrences


Fibrocystic breasts

Fibrocystic breasts are made of tissue that feels bumpy and nodular in texture.  It is a relatively common process.  More than 50% of women experience fibrocystic breast changes during their lives.  It used to be called Fibrocystic Breast Disease.  Now it’s more common to call it Fibrocystic Breast Changes – which are considered normal changes.  Symptoms may be pain and lumpiness and can be worse just before menstruation.

Treatment includes limiting caffeine, decreasing fat in the diet, and consider evening primrose oil which is a form of linoleic acid.


Gynecomastia of the male breast

  • Gynecomastia is the benign hypertrophy of the male breast
  • asymptomatic or painful
  • unilateral or bilateral
  • just below the areolar region

Age distribution

3 peaks

  • transiently during neonatal period due to motherly estrogrens
  • puberty
  • adulthood

Causes of Gynecomastia

  • Illicit drug use, especially marijuana
  • Renal, Liver disease
  • Neoplasms
  • Hyperparathyroidism

Gynecomastia’s association with cancer

  • Testicular cancer
  • BRCA2 genetic multation may lead to male breast cancer

Diagnostics for Gynecomastia

For the older patient with no obvious etiology consider:

  • LFT
  • BUN
  • Creatinine
  • Thyroid hormone
  • Prolactin level
  • Testosterone
  • Bilateral mammorgram
  • FNA (fine needle aspiration) can be diagnostic or core needle biopsy, usually not a need for excisional biopsy.  Thus an excisional biopsy wouldn’t be a first line diagnostic tool in gynecomastia.

Paget’s Disease of the Breast

Paget’s Disease of the Breast

  • Diagnosis can be confirmed with a punch biopsy the nipple areolar complex.
  • Classically present with eczematous changes of the nipple which can progress to bleeding and ulceration.
  • More than 90% of patients have underlying carcinoma (in situ or invasive)
  • Cancer involving skin and nipple.
  • Treatment: mastectomy traditionally.  But could be nipple areolar excision with central lumpectomy with radiation therapy (breast conservation therapy) – similar results.
  • 50% of patients with Paget’s disease will present with palpable mass.
  • May be a role for MRI – deeper breast tissue disease may be missed radiographically and MRI can help detect.

What is breast conservation therapy?

A lesser amount of surgery than mastectomy.  Lumpectomy

Paget’s diease of the breast is also known as?

  • Paget’s disease of the nipple
  • Mammary paget disease


Nipple Discharge

Unilateral Nipple Discharge – spontaneous and persistent

  • Associated with a increased risk of carcinoma.
  • Can be clear, serous, serosanguinous or bloody
  • Nipple aspirate cytology isn’t popular as a diagnostic
  • Most common etiologies are intraductal papilloma and mammary duct ectasia
  • Doesn’t matter what’s found on radiology, open surgical biopsy is preferred
  • Directed duct excision plus excision of the surround area after ductogram.  Rule out papillary carcinoma of the breast.
  • Central duct excision (non-directed duct excision) is not as accurate.
  • If the lesion is deep, radiologist may help with needle localization with excision
  • DCIS = Ductal Carcinoma In Situ is the malignancy most commolny found in intraductal lesions with pathological nipple discharge.
  • Papillary carcinoma of the breast is a subset of DCIS.

Intraductal Papilloma

  • Benign
  • Most common cause of bloody nipple discharge
  • A single intraductal papilloma doesn’t increase the risk of breast cancer, but multiple papillomas does increase the risk slightly.

Mammary duct ectasia

  • Milk ducts beneath the nipple become dilated, thickened, and filled with fluid and thus have some discharge
  • Benign
  • Often improves without treatment.


Breast Masses in Children

Breast Masses in Children and Adolescence

Classification of the breast masses in children/adolescence

The process in parethesis below represents an example.

  • Physiological (Gynecomastia)
  • Inflammatory (Abscess)
  • Benign neoplastic (Fibroadenoma, Cystosarcoma phyllodes)
  • Primary malignant (Cystosarcoma phyllodes)
  • Secondary malignant (Lymphoma)

Neonatal breast nodules

Usually due to stimulation by maternal hormones

Cystosarcoma Phyllodes

  • Fibroadenomas and cystosarcoma phyllodes are the most common lesions of the breast in childhood.
  • Cystosarcoma phyllodes present as either benign or malignant but 95% in children are benign.

Best test for initial assessment in pediatric patients with breast mass?


Then what modality for diagnosis of the breast mass?

Fine needle aspiration.  FNA is preferred over core needle biopsy because of the possibility of deformity of the breast in the future with core needle biopsy.

What about excision biopsy in the pediatric breast?

Excisional biopsy should be avoided as an initial diagnostic procedure because the developing breast bud can be mistakenly removed, leading to deformity.

Pseudoangiomatous stromal hyperplasia

PASH = PseudoAngiomatous Stromal Hyperplasia

  • Presents as a distinct mass, area of thickening of breast tissue, or as an incidental finding
  • Biopsy is necessary to confirm diagnosis
  • Excision with negative margin (ie. 1 mm) is treatment – recurrence rate is low (7%) and no further treatment necessary
  • There are findings on mammogram and ultrasound by biopsy is needed for diagnosis.