SIGNIFICANT OTHERS. Miscellaneous Benign Breast Conditions
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1 SIGNIFICANT OTHERS Miscellaneous Benign Breast Conditions Epworth HealthCare 1 FAT NECROSIS TRAUMATIC Cell rupture Seat-Belt injury Blunt trauma Iatrogenic injury Surgery, Flaps, Radiotherapy Pathology Single droplet of Triglyceride per adipocyte Extra-cellular oil after cell rupture causes chronic inflammation and granuloma formation Hormone Sensitive Lipase - high in adipocytes, low in macrophages Presentation Palpable lump - irregular, firm, producing distortion or dimpling History of trauma, often months 2 years before Epworth HealthCare 2 1
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7 Epworth HealthCare 13 FAT NECROSIS Imaging findings Early - haematoma a superficial mass on mammography Tomo shows lobulation with well-defined margins echogenic mass with cystic spaces on U/S Later radiolucent, well-defined cyst progressive fibrosis and calcification Ultrasound - Echogenic band or mass in subcutaneous tissues Cysts with echogenic calcified wall and acoustic shadowing Diagnosis History and Imaging Biopsy is it necessary, will it make it worse? Consider FNA Management Reassurance? Aspirate oil cysts Epworth HealthCare 14 7
8 IATROGENIC INJURY After simple to complex surgery Around margins of flaps Late radiotherapy effect Risk factors are smoking, BMI >30, radiotherapy and ischaemia time Peak incidence is 2-3 years post-op Epworth HealthCare 15 8
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10 IATROGENIC INJURY After simple to complex surgery Around margins of flaps Late radiotherapy effect Risk factors are smoking, BMI >30, radiotherapy and ischaemia time Peak incidence is 2-3 years post-op Fat Grafting Adipose-derived stem cells Ischaemic fat Traumatic acquisition/delivery and cell rupture Results in increased vascularity and fat volume or fibrosis and calcification? Epworth HealthCare 19 IDIOPATHIC GRANULOMATOUS MASTITIS Presentation Palpable breast mass, often tender and peripheral DD inflammatory cancer, Lobular cancer Imaging findings Mammogram - Unilateral focal or regional asymmetry Ultrasound hypoechoic mass(es) with indistinct or irregular margins, increased vascularity, sinus tracts MRI ill-defined masses and non-mass enhancement, intense parenchymal enhancement Epworth HealthCare 20 10
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13 IDIOPATHIC GRANULOMATOUS MASTITIS Diagnosis of exclusion - Core Biopsy and Cultures Exclude: TB, Sarcoid, Fungal infection Periductal Mastitis, Fat necrosis, Vaccination Management Medical antibiotics steroids, methotrexate Surgical excision ( consider ducts) BUT Wound infection, delayed healing, recurrence Followup For wound infection and recurrence Epworth HealthCare 25 MONDOR S DISEASE Presentation Dull pain associated with an elongated mass History of nothing Or recent direct trauma (males) or surgery Or vigorous arm exercise Epworth HealthCare 26 13
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17 Epworth HealthCare MONDOR S DISEASE Pathology Palpable tender cord just beneath the skin of the breast Bowstring Imaging findings Mammography shows a tubular structure U/S shows a superficial vessel without flow +/- intraluminal thrombus Diagnosis Clinical +/- imaging Management Analgaesia? divide under LA Follow-up There is an incidence of cancer diagnosis in the next 2 years Anatomy Usually the Thoraco-Epigastric vein, sometimes Lateral Thoracic or Superior Epigastric Involves the epigastric plexus to the inguinal vessels Epworth HealthCare
18 PASH Pseudo Angiomatous Stromal Hyperplasia 1986 Presentation Breast mass palpable or on screening Often painful or tender 1/3 Pre-menopausal women Pathology Hormone-dependent collagenous expansion of the stroma Benign proliferation of myofibroblasts which are PR positive CD34 positive DD angiosarcoma, phyllodes tumour Imaging findings Round or Oval circumscribed mass, DD Fibroadenoma Diagnosis Core biopsy or excision Management Excise or observe, depending on the size and FH Epworth HealthCare
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21 DIABETIC MASTOPATHY Sclerosing Lymphocytic Lobulitis Presentation Premenopausal diabetics Usually a large hard painless breast mass Imaging findings Mammogram - ill-defined masses/densities Ultrasound - irregular hypoechoic masses, marked posterior shadowing MRI - variable Epworth HealthCare 41 Epworth HealthCare 42 21
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24 DIABETIC MASTOPATHY Pathology Prominent keloidal fibrosis and lymphocytic infiltrate DD Extra-nodal MALT lympho`ma Diagnosis Core biopsy Management Followup Sclerosing Lymphocytic Lobulitis - conservative - none Epworth HealthCare 48 24
25 JUVENILE PAPILLOMATOSIS Swiss cheese disease Pathology Usually a single cystic mass in UOQ Papillary epithelial hyperplasia, numerous cysts and dilated ducts with dense stroma (No papillomas!) Atypia in 10% Presentation Children and adolescents, but mean age 20 Firm, mobile Lump, 4 cm, suggesting Fibroadenoma FH breast cancer 1/4 Imaging findings Ultrasound - small masses with heterogenous echotexture Management/Diagnosis surgical excision Followup Yes - Note - significant subsequent cancer risk if FH and bilateral or recurrent Epworth HealthCare 49 Epworth HealthCare 50 25
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