Benign Breast Diseases

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2 Catherine N. Chinyama Benign Breast Diseases Radiology Pathology Risk Assessment Second Edition 123

3 Benign Breast Diseases

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5 Catherine N. Chinyama Benign Breast Diseases Radiology - Pathology - Risk Assessment Second Edition

6 Catherine N. Chinyama, MB ChB (Hons), FRCPath, IFCAP, LLM Consultant Pathologist Princess Elizabeth Hospital Le Vauquiedor St. Martin s Guernsey Channel Islands UK Honorary Clinical Senior Lecturer Brighton and Sussex Medical School Brighton England UK ISBN ISBN (ebook) DOI / Springer Heidelberg New York Dordrecht London Library of Congress Control Number: Springer-Verlag Berlin Heidelberg 2014 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. Exempted from this legal reservation are brief excerpts in connection with reviews or scholarly analysis or material supplied specifically for the purpose of being entered and executed on a computer system, for exclusive use by the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of the Copyright Law of the Publisher's location, in its current version, and permission for use must always be obtained from Springer. Permissions for use may be obtained through RightsLink at the Copyright Clearance Center. Violations are liable to prosecution under the respective Copyright Law. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. While the advice and information in this book are believed to be true and accurate at the date of publication, neither the authors nor the editors nor the publisher can accept any legal responsibility for any errors or omissions that may be made. The publisher makes no warranty, express or implied, with respect to the material contained herein. Printed on acid-free paper Springer is part of Springer Science+Business Media (

7 In memory of my parents Nora and James Chinyama

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9 Preface I The majority of textbooks on breast disease understandably concentrate on cancer and related prognostic factors, with minimal space devoted to benign conditions. With widespread use of screening mammography and improvements in imaging equipment, smaller and smaller cancers are being detected. This has also resulted in detection of indeterminate micro-calcification and soft tissue densities, which invariably leads to diagnostic fine needle aspiration cytology or needle core biopsy. Although most of the mammographically indeterminate lesions are benign, biopsies also detect potentially malignant lesions, which include atypical hyperplasias, lesions of undetermined malignant potential such as columnar cell change and other epithelial proliferations. These lesions require proper radiological and pathological assessment at multidisciplinary meetings for appropriate patient management. The objective of this book is to provide an overview of radiological and pathological features of benign lesions with an emphasis on screen-detected lesions, with illustrated examples. Although the radiological and pathological correlations concentrate on the screen-detected benign lesions, it was not possible to limit the discussion of the radiology and pathology to just screendetected lesions. This is because mammographic screening became routine in developed countries only in the past few decades, and there are insufficient follow-up data in the literature on patients with screen-detected benign disease. Secondly, although breast disease is arbitrarily classified into symptomatic and screen-detected, all women who attend specialised breast units invariably undergo some form of imaging, mostly mammography or ultrasound. Emphasis on screen-detected lesions also highlights the heterogeneous array of benign diseases in this age group, which in the future may create significant breast disease workloads as longevity becomes the norm in the developed world. The pathological discussions will also include possible aetiological factors and the pathogenesis of the disease processes. Most importantly, where applicable, the associated risk factors of individual conditions will be discussed based on previously published data. The assessment of the potential risk of progression to malignancy is increasingly playing an important part in the management of patients with benign breast disease. However, the discussion of risk factors related to benign lesions is not intended to alarm the reader, because the risk of progression to malignancy in most benign lesions is very small. In addition, due to the complicated nature of the studies required to determine the risk of subsequent malignancy, the majority of the risk vii

10 viii Preface I assessment is relative rather than absolute. As illustrated in the different chapters, with the exception of lesions such as atypical ductal hyperplasia, there is no consensus among investigators as to the level of risk associated with most benign lesions. The author therefore gathered both the supporting and the contradicting evidence on risk factors on individual benign lesions to give readers the opportunity to make up their own minds when making a clinical decision. The clinician should not apply these risk factors to patients without taking into account other parameters such as family history, previous history of cancer, menopausal status or use of hormonal therapy. The radiological features of benign diseases using different modalities such as mammography, ultrasonography and magnetic resonance will also be discussed. Detailed radiological techniques and routine interpretation of mammograms are extensively covered in appropriate textbooks, some of which have been included in the references in the appropriate chapters. Likewise, detailed histological techniques are not part of this book. The book should be useful to breast radiologists, surgeons, pathologists and other health workers who look after women with breast disease in their practices. Postgraduate students should find this a quick reference book. Guernsey, UK August 2003 Catherine N. Chinyama

11 Preface II Since the publication of the first edition of this book in 2004, there have been a lot of advances in radiology, pathology and molecular pathology of both benign and malignant breast diseases. There are very few books on benign breast disease, which is a gap that needs to be filled, because understanding of the biological behaviour of benign breast lesions will assist the clinician and the patient to assess the risk of malignancy and formulate a follow-up strategy or take appropriate preventative measures. This book has therefore attempted to evaluate the radiological and pathological features of common benign lesions and the associated risk of subsequent breast cancer and, where possible, included the management of these lesions. Since the first edition, there has been improved understanding of the pathology of columnar cell lesions and mucocoele-like lesions, and these chapters are much longer than in the first edition. To aid better understanding of benign breast lesions, a chapter on normal breast has been included. Other new chapters include: an overview of benign breast lesions (Chap. 2 ), inflammatory lesions (Chap. 6 ) and male breast lesions (Chap. 15 ). Phyllodes tumour has been included in the chapter on fibroepithelial lesions (Chap. 10 ) as the lesion shares clinical, radiological, pathological and genetic features with the fibroadenoma. The statistics involved in risk assessment are complex, but statistics are also becoming routine in patient management. To this end, the author has expanded the chapter on risk assessment to include some definitions. This chapter also includes the different models used in risk assessment of breast cancer which will no doubt become routine as part of patients personalised medicine. The second edition also includes more radiological and pathological illustrations to reflect the heterogeneous nature of the benign lesions. Genetic assessment is becoming part of patient management for both malignant and benign lesions. Where applicable, genetic assessment is included as part of risk assessment with regards to whether a lesion is clonal and, therefore neoplastic, or polyclonal and hyperplastic. The previous edition concentrated mostly on screendetected benign lesions, and this has been rectified by discussing common symptomatic breast lesions, some of which have no associated risk to breast cancer. As multidisciplinary team management of patients is now the norm rather than the exception, this book will be valuable to doctors, nurses and other allied health professionals who look after patients with breast diseases in a multi-professional environment. St. Martin s Guernsey, UK Catherine N. Chinyama ix

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13 Discl aimer Although this book attempted to provide information on risk factors in benign diseases available at the time of going to press, rapid advances in fields of medicine such as radiology and molecular biology may negate or contradict the information published herein. In addition, most of the risk assessments documented in this book are based on studies in symptomatic patients, which may or may not be applicable to screen-detected lesions. It is therefore the responsibility of the treating physician to assess the patient s risk on an individual basis. Neither the author nor publisher assumes any responsibility for any damages arising from the use of information published in this book. xi

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15 Acknowledgements It is always harder to update or rewrite a book than write one as a fresh project. There was a lot of information to be added, deleted, cut and pasted in updating a book. For this, I am indebted to my private secretary Michelle Oland who tirelessly updated the book and filled in a lot of gaps my fountain pen had missed. I am grateful to Jodie Knight and Anne Marie Nolan at the Princess Elizabeth Hospital library for their help in obtaining reference articles for me. Finally, I wish to say thanks to my biology teacher Miss Thomas ( Auntie Mary) for her support throughout my career in medicine. I also wish to acknowledge the following publishers for granting permission to reproduce the following figures or tables in part or in full: 1. Figure 1.2 was produced and modified with permission of Patrick J. Lynch, Senior Digital Officer, Office of Public Affairs & Communications, Yale University, 2. Para BI-RADS Mammography Assessment Categories extracted from American College Radiology (ACR). Illustrated Breast Imaging Data System (Illustrated BI-RADS TM ). Third Edition. Reston [VA]: American College of Radiology; 1998, pp Reprinted with permission of the American College of Radiology. No other representation of this article is authorised without express permission from the American College of Radiology 3. Figure 7.1 from Warner JK, Kumar D, Berg WA (1998) Apocrine metaplasia: Mammographic and sonographic appearances. Am J Roentgenol 170: , Figures 7A, B & C. Reprinted with permission from the American Journal of Roentgenology 4. Figure 7.2 from Haagensen DE Jr (1991) Is cystic disease related to breast cancer? Am J Surg Pathol 15: , Fig. 1. Reproduced with permission by Lippincott Williams & Wilkins 5. Table 7.1. Part of the text in this table was obtained from Cystic Disease: Duct Ectasia: Fat Necrosis: Fibrocystic Disease of the Breast, Table 5.1. In: Problems In Breast Pathology by JG Azzopardi, 1979, pp by the permission of the publishers WB Saunders 6. Table 10.2 reproduced with permission by the NHS National Breast Screening Programme, Pathology Reporting in Breast Cancer Screening, 1997, Table 2, p Table 10.3 the numerical data in this table was obtained from Tables 2 and 3 by Page DL, Dupont WD, Rogers LW, Rados MS (1985) Atypical hyperplastic lesions of the female breast. A long term follow-up study. xiii