Benign and premalignant breast disease

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•37• Chapter 4 Benign and Premalignant Breast Disease F . Dedey Introduction Breast disease is one of the most common conditions presenting at outpatient clinics worldwide (1) and this also pertains in Ghana.2, 3, 4 Most of these (72 - 93 percent) are benign.1, 2, 3, 5, 6 Although females are more commonly affected,1, 4, 6 some males are also seen with benign breast disease.6 Benign breast diseases are now regarded as ‘Aberrations of Normal Development and Involution’ (ANDI), reflecting the wide spectrum of disorders and diseases which it encompasses. It includes benign diseases without any risk of malignancy (non proliferative breast disease), and those with malignant potential (proliferative breast disease). Non proliferative diseases include common conditions such as fibrocystic changes, cysts, duct ectasia and mastitis. Others are mild hyperplasia, squamous metaplasia, apocrine metaplasia and adenosis. Proliferative diseases include fibroadenoma, moderate/florid hyperplasia, microglandular adenosis, sclerosing adenosis , papilloma (fibrovascular core), atypical ductal hyperplasia and atypical lobular hyperplasia.7 One of the aims in the management of these diseases is to identify those with a risk of malignancy and manage them appropriately so as to significantly reduce the incidence and mortality of Breast Cancer. Assessment Breast disease is usually assessed with the triple assessment. This includes : • clinical assessment involving the history and physical examination, •38• Chapter 4 • radiological assessment involving ultrasound and mammogram usually, • biopsy. Clinical Assessment In assessing the patient clinically, certain factors related to the patient may serve as pointers to benign disease. Some of these factors include : Age - younger patients tend to have benign disease (2,6) Sex – breast disease is commoner in females and tends to be more often benign, but males may also have benign breast disease commonly gynaecomastia. Duration – patients with a long history usually have benign disease Pregnancy or lactation may predispose to certain benign conditions commonly mastitis or breast abscesses. Menopausal status – benign conditions are more common in premenopausal women. The symptoms the patient presents with, also helps one to determine which type of breast disease the patient has. Breast pain, one of the most common symptoms of breast disease3,4 may be diffuse or specific. It may also be cyclical or not. Majority of patients presenting with pain have benign disease.4, 8 Another common symptom of benign breast disease, breast lumps,3, 4 may be discrete or generalized. Changes in the size of the lump may occur over time. They tend to be more common in the upper outer quadrant of the breast. Nipple discharge is also a common symptom.3, 4 It may be milky or a non milky discharge (clear/ green/ brown/ bloody/ purulent). The discharge may either be unilateral or bilateral, and from solitary or multiple ducts. It occurs more commonly in women with benign breast disease such as fibrocystic changes, intraduct papilloma, duct ectasia, galactorrhea and infection as compared to women with cancer. In the case of the latter the discharge is often bloody. Pathologic nipple discharge is usually spontaneous, persistent and from a single duct or bloody. 9 In a study of the profile of breast diseases in a self referral clinic in Ghana involving 748 patients, the three most common symptoms at presentation were breast pain, lumps and nipple discharge.3 •39• Benign and Premalignant Breast Disease Some of the other symptoms patients may present with include nipple retraction which may be unilateral or bilateral, and tends to be longstanding in benign breast disease, but could also be of recent onset in some conditions. Skin changes such as redness, rashes, ulcers or swelling may also be present. Tenderness, differential warmth and axillary lymphadenopathy may be detected. Other associated symptoms may be fever, malaise, anorexia, vomiting, night sweats and weight loss. Examination should pay particular attention to the characteristics of any lumps present such as the edges which are usually well defined, the consistency which is often soft or firm, the mobility which is freely mobile without any attachments to surrounding structures and skin and nipple changes and axillary lymph node enlargement. Radiological Assessment This involves the use of various radiological techniques to image the breast. The modalities most often employed include: Ultrasound This may detect solid or cystic masses and the cystic ones could be either simple or complex. Benign features include a wider than tall mass, thin echogenic capsule, intense & uniform hyperechogenecity, macro lobulations and smooth margins. Mammogram This uses low dose radiation to examine the breasts and may be either for diagnostic or screening purposes. A...