Surgery for a benign (benign) mammary tumor (synonym: breast tumor) is a surgical procedure. Nearly 90% of women will experience benign changes in breast tissue during their lifetime.
Indications (areas of application)
Mastopathy
Mastopathies are proliferative and regressive changes of the mammary gland tissue that usually occur bilaterally. They are due to hormonal imbalance. They are not true neoplasms (new growths), but result from increased growth of connective and glandular tissue. In contrast to most benign or malignant neoplasms, which usually do not cause pain, they are sometimes very painful depending on the cycle. Often, this clinical picture is impressed by changes in the tissue that feel like lumps. Symptoms: Mastodynia (cycle-dependent tightness in the breasts or breast pain) and appearance of hardening in the breast, which usually increases premenstrually Palpation (palpation examination): Diffuse hardening, the glandular body feels bumpy and nodular. Mammary sonography (ultrasound examination of the breast): Method of first choice due to high density of the glandular body: if necessary, also mammography. Histological (fine tissue)/cytological (microscopic examination of cells) examination by: Aspiration cytology or fine needle biopsy. Histopathologically, mastopathy is classified (according to Prechtel) as follows:
- Simple mastopathy (grade I) – nonproliferative lesions (frequency circa 70%); mammary carcinoma risk not increased.
- Simple proliferative mastopathy (grade II) – proliferative lesions without atypia (frequency circa 20 %); slightly increased risk of breast cancer (1.3 to 2-fold)
- Atypical proliferative mastopathy (grade III) – ductal or lobular atypical hyperplasia (frequency circa 10%); breast carcinoma risk about 2.5-5-fold increased! Thus, in the case of an atypical form, up to one in ten women with evidence of atypical hyperplasia will develop breast carcinoma in the course of ten years after clear diagnosis. Atypical hyperplasia is therefore considered precancerous (precancerous) and must be surgically removed. Indications:
- The transition of atypical hyperplasia to true in situ carcinomas (lobular and ductal carcinoma in situ; DCIS and LCIS) is smooth.
- According to a cohort study, the 10-year risk of invasive breast carcinoma is overestimated after a diagnosis of atypical ductal hyperplasia. The cumulative risk of invasive breast carcinoma was 2.6-fold higher than in women without ADH at baseline (95% confidence interval between 2.0 and 3.4).
Fibrocystic changes (synonyms: Mastopathy; fibrocystic mastopathy; Mastopathia fibrosa cystica) contain, depending on the tissue content, different forms that can be differentiated microscopically:
- Fibrosis – in fibrosis, the change in mammary tissue is primarily in connective tissue.
- Cysts – cysts (fluid-filled cavities) arise from dilated milk ducts and glandular lobules (lobules).
- Epithelial hyperplasia – this benign process is also called proliferative breast disease, because the pathological process is based on an increase in epithelial tissue. A distinction is made between atypical and simple forms of hyperplasia. In the simple form without atypia, there is a slight increase in risk for the occurrence of malignant breast carcinoma. In contrast, the risk of degeneration in atypical hyperplasia of the ducts (synonyms: atypical ductal hyperplasia, abbreviation : ADH) or glandular lobules (lobules) is increased one to five times.
- Adenosis – in adenosis there is an imbalance between connective tissue and glandular tissue, with a marked increase in glandular parenchyma. Due to the poor assessability of adenosis by mammography (dignity/biological behavior of tumors; i.e., whether they are benign (benign) or malignant (malignant)?), a biopsy (tissue sampling) is necessary. Various studies have found a slightly increased risk of carcinoma.
Fibroadenoma
- Fibroadenoma is the most common benign (benign) tumor of the breast, with a prevalence (disease incidence) of about 25% of all women. Palpation (palpation examination): usually 1-2 cm in size, painless, slidable lumps of firm consistency.Mammasonography (ultrasound examination of the breast): circumscribed, homogeneous and hypoechogenic structure; in some circumstances, the lobulated structure and a thin capsular boundary are visible. Mammography: circumscribed space-occupying lesion, i.e., a smoothly circumscribed cardiac finding that may have visible coarse-scooped calcifications (popcorn-like calcifications), depending on the age of the lesion. Histologic/cytologic examination by: Aspiration cytology (puncture cytology) or fine needle biopsy. Surgery: puncture, if necessary. The surgical procedure depends on the size. If there is a further growth tendency or after reaching postmenopause, surgery is necessary.
Mammary cyst
- The fluid-filled cavities arise from dilated milk ducts and glandular lobules (lobules). Palpation (palpation examination): usually 1-2 cm in size, painless, displaceable lumps of firm consistency. Breast ultrasonography (ultrasound examination of the breast): circumscribed, homogeneous, and hypoechogenic structure; lobulated structure and a thin capsular boundary may be visible; following ultrasound criteria that argue for or against surgery:
- Inconspicuous anechoic cysts with smooth margins and absent rim (BIRADS II) do not require treatment; occasional ultrasonography; if symptomatic, aspiration cytology.
- Low-echo, so-called thickened cysts with smooth margins and absent rim (BIRADS III) usually obviate the need for surgery; however, puncture is required to rule out a solid tumor .
- Complicated cysts with intracystic growth and perfusion detectable by Doppler sonography require surgery.
Cytological examination by: Aspiration cytology Surgery: surgery is not required. If symptoms are present, cysts can be punctured.
Phylloid tumor
- Phylloid tumor (synonyms: cystosarcoma phylloides; phylloides tumor) is a very rare mammary tumor in adult women (03-1% of all mammary gland tumors). It is considered a special form of fibroadenoma. It grows larger than fibroadenoma, grows faster and finger-shaped, as if infiltrating, into the surrounding area. This growth has also led to the name cystosarcoma phylloides, as the rare sarcomas (very malignant, flesh-like soft tissue tumors) of the breast show similar growth. The tumors can become very large and lead to significant deformities of the breast. 85% of phylloid tumors are benign (benign) and arise from intralobular or periductal stroma. Palpation (palpation examination): usually larger than fibroadenomas and easily palpable like them; surface irregular; phylloid tumor may extend out through the skin in a “cauliflower-like” fashion. Mammary sonography: shows, for example, partially homogeneous echo-poor structures and stretches of echo-tight structuring with echo-poor to echo-poor disaggregations in lobulated structuring Mammary sonography and mammography: both imaging methods are insufficient in differentiating them from fibroadenoma! Histological examination by: Fine needle biopsy. Phylloid tumors can be or become benign (benign), “borderline” (borderline) or malignant (malignant). In approximately 85% of cases, a phylloid tumor is benign Surgery: Therapy of benign phylloid tumors consists of complete removal of the tumor (excisional biopsy) with a safety margin of 10 mm. Note: Histopathological (fine tissue) classification into benign, malignant or borderline tumors is performed on the surgical specimen.
Intraductal papilloma
- This benign process occurs primarily within the mammary ducts (intraductal) of the mammary gland. The papilloma is usually accompanied by a watery, yellow or often hemorrhagic (bloody), or milky secretion. Palpation (palpation examination): not palpable Mammasonography (ultrasound examination of the breast): only large intraductal papillomas are detectable sonographically! Mammography: in this case galactography (contrast imaging of the mammary ducts); papillomas are conspicuous as ductal recesses or ductal breaks. Differentiation between a benign papilloma and a papillary carcinoma is not possible by galactography! Cytological examination of the hemorrhagic secretion. Surgery: excision is necessary! For surgery, dye is injected into the secreting ducts so that the ducts to be removed can be verified and extirpated intraoperatively.
Contraindications
For example, in the presence of atypical hyperplasia and existing general disease, the risk of surgery should be weighed against the consequences of conservative treatment (wait-and-see approach with diagnostic monitoring).
Before surgery
- Classification and diagnosis – Palpation (palpation) of the breast and imaging techniques (breast sonography; mammography) usually allow a tentative diagnosis to be made, which may be confirmed by aspiration cytology or fine-needle biopsy – possibly ultrasound-guided. The further procedure is based on the result of the histological (fine tissue) examination.
- Discontinuation of anticoagulants (anticoagulants) – in consultation with the attending physician, drugs such as Marcumar or acetylsalicylic acid (ASA) must usually be temporarily discontinued to minimize the risk of bleeding during surgery.
- Anesthesia – usually the procedure is performed under general anesthesia for an open surgical procedure, so the patient must be fasting.
The surgical procedure
The goal of surgery for a present benign tumor in the mamma is the complete removal of the benign (benign) neoplasia (neoplasm), so that a possible risk of malignancy is massively reduced. Especially in young women, the preservation of lactation ability (milk production) is important. If necessary, special surgical techniques are used for this purpose. Surgical access, depending on the location of the tumor, by perimammary incision, in which the surgeon cuts just outside the areola in a semicircle, or by local incision. This is followed by removal of the tumor in toto (in its entirety). If there is a suspicion for malignancy (malignancy): After removal of the tumor, a histological (fine tissue) examination is immediately performed using the so-called frozen section to ensure complete removal “in healthy tissue”. If necessary, resection is performed.
After surgery
- Follow-up examination – after the surgery, a follow-up examination should be performed to monitor the surgical results and, if necessary, to diagnose and subsequently treat complications.
- Antibiotics – the use of antibiotics may be indicated in some circumstances to prevent bacterial infection.
Possible complications
- Bleeding and hematoma (bruising) – secondary bleeding may occur as a result of surgery.
- Infections – in rare cases, the wound area may become inflamed.
- Recurrence – recurrence of the tumor is possible; probability of recurrence depends on the type of benign tumor.
