Breast

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Breast
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• Modified sweat glands.
• Lobes and lobules of gland
• in fat tissue stroma.

Lactiferous ducts merge just beneath he nipple
to form a lactiferous sinus. Then individually
open on nipple

• Ducts emerge from acini of glands
• Smaller ducts join to form lactiferous ducts

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• Lobes and lobules
• of gland
• in fat tissue stroma.

• Ducts emerge from acini of glands
• Smaller ducts join to form lactiferous ducts

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Axillary A lateral thoracic Internal mammary A
perforating Intercostal lateral
Axillary vein Internal mammary V Intercostal
veins
Supraclavicular nerve Itercostal N sympathatic
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Benign Breast Disease

• Congenital Conditions
• Traumatic Conditions
• Infections
• Aberrations of Normal Development and Involution
  (ANDI)
• Neoplastic
• Benign - Fibroadenoma

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Congenital Conditions

• Congenital
• Supernumerary nipple along nipple line
• Supernumerary breast
• Aplasia turners, Juvenile hypertrophy

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Traumatic Conditions

• Traumatic fat necrosis
• Cracks of nipple
• Hematoma
• Traumatic mastitis
• Milk fistula

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Traumatic Conditions (Fat Necrosis)

• Follows trauma, surgery or radiation
• Small, hard mass - confused with carcinoma
• Focal necrosis of fat with inflammation
• Foamy lipid-laden macrophages
• Later fibrosis, calcification

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Mammary fistula

• Congenital (rare)
• Acquired
• Varient of MDE
• Incision and drainage of abcess in lactating
  breast

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Infections

• Acute
• Mastitis neonatorum
• Pubertal mastitis
• Traumatic mastitis
• Metastatic mastits
• Mammary duct ectasia
• Lactational mastits
• Acute suppurative mastitis

• Chronic
• Chronic non specific
• chronic breast abscess
• Hidradenitis
• Pilonidal Disease
• Postoperative Wound Infections
• specific
• Tuberculosis
• Syphillis
• Actinomycosis

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Duct Ectasia and Periductal Mastitis

• ? Aetiology, age 40s - 50s, smokers
• Dilatation of breast ducts - fill with stagnant
  brown/green secretion - atrophy and loss of
  ductal epithelium - secretion spills into
  periductal tissues - inflammatory reaction
  (mastitis)
• Micro - lyphocytes, histiocytes, plasma cells
• Secondary anaerobic infection, abscess
• Fibrosis - slit-like nipple retraction

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Duct Ectasia andPeriductal Mastitis

• Presentation
• Nipple discharge - any colour
• Nipple Retraction
• Subareolar mass
• Abscess
• Mammary duct fistula
• May mimic carcinoma

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Duct ectasia
Nipple discharge - any colour
Nipple retraction
Lump
Abscess
Mammary duct fistula
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• Antibiotics
• Flucloxacillin
• Metronidaziole
• NSAID

Central duct excision (Hadfield operation)
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Operations - Hadfields Major Duct Excision

• Indications
• duct ectasia (periductal mastitis) with
  recurrent episodes /- fistulae
• blood stained discharge from one or more ducts
  in women gt 40
• Incision
• circumareolar but lt 3/5 the areolar
  circumference to allow enough blood supply
• include the orifice of any sinus or fistula

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Operations - Hadfields Major Duct Excision

• Technique
• cut the subcutaneous tissue down to the ducts
• dissect in a plane circumfentially around the
  terminal lactiferous ducts
• divide the ducts close to the nipple and remove
  with a small conical wedge of tissue
• include fistulous tracts with all granulation
  with excision
• /- DT closure 4/0 subcuticular

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Lactational Mastitis
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Bacterial Mastitis

• Cracks and fissures form in early breastfeeding
• Secondary infection with Staph. aureus
• Carried by nasopharynx of infant
• Abscess
• Chronic scar

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Fever
Throbbing pain
Skin oedema
Aspiration of pus
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Operation - Incision drainage breast abscess

• Breast abscess
• most occur during lactation
• empty the breast , allowing the baby to feed by
  the other breast
• drain early when there is a point of maximal
  tenderness - needle aspiration antibiotics may
  be more appropriate
• Technique
• General anaesthesia
• incise
• over point of maximal tenderness or fluctuance
• if near the nipple use circumareolar incision
• deepen the incision until drain pus, send for
  M/C/S
• Use counter incision in upper breast
• break down loculations take Bx (exclude inflam
  Ca)
• /- DT /- kaltostat packing
• supportive bra, breast feed when comfortable

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Operations - Breast Excisional Biopsy

• Indication solid breast lump that is clinically
  benign
• Aim to extract the lesion with minimal margin
  and least cosmetic defect to establish a
  histological Dx and remove the palpable lump.

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Breast Excisional Biopsy

• Incisions
• incise over the lump - adequate excision 1st
  priority
• 2nd comes aesthetic position
• if possible scar hidden by bra
• medial incisions more likely to develop keloid
• avoid radial incisions except medially
• make incision within skin that would be removed
  if patient subsequently required a mastectomy

• Technique excise lump completely without
  cutting into it
• hold specimen with Lane or Allis tissue forceps
• careful haemostasis /- DT L.A.
• subcuticular closure

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Fibrocaseous
Caseous form
Suppurative form
Sclerosing form
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Tuberculosis

• Antituberculous drugs
• Cold abscess
• Valvular incision
• Local anti TB
• Fibrocaseous
• Simple mastectomy
• Anti TB

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ANDI( Fibrocystic Disease)

• Developed by LE Hughes at Cardiff 1987
• Replaces fibrocystic disease, fibroadenosis, etc.
• Main Histological Features
• Epithelial proliferation
• Adenosis (increase in no. of acinar units per
  lobule)
• Epithelial Hyperplasia ( of cells) Papilloma
  formation
• Fibrosis
• Cysts
• Retention cysts
• Blue domed cyst of Bloodgood (macrocysts)
• Brodies tumor (microcysts)

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Presentation

• Mastalgia
• Cyclical
• Non-Cyclical
• Lump - many causes
• Periareolar Disorder
• Nipple Discharge
• Nipple Retraction

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Cyclical Mastalgia

• Presentation
• Median age 35 yrs
• Premenstrual breast discomfort
• Upper outer quadrant (often bilateral)
• Relief during menstruation
• Associated with nodularity
• Aetiology presumably hormonal

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Non-Cyclical Mastalgia

• Not related to menstrual cycle
• Median age 45yrs (pre- or postmenopausal)
• Unilateral, well-localised, trigger spot
• Multiple Causes
• Carcinoma
• Mammary Duct Ectasia
• Sclerosing Adenosis (ANDI)
• Painful Scar
• Musculoskeletal Pain
• Mondors Disease

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Lumps

• Traumatic
• Fat Necrosis
• Organized hematoma
• Inflammatory
• Mammary Duct Ectasia/Periductal Mastitis
• Chronic breast abcess
• ANID
• Nodularity
• Cysts (Galactocele)
• Sclerosing Adenosis
• Neoplastic
• Benign
• Lipoma
• Hard Fibroadenoma
• Giant fibroadenoma
• Phyllodes Tumour
• Malignant

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Nodularity

• Often bilateral, upper outer quadrant
• May be cyclical
• Associated with mastalgia
• Histology (ANDI)
• Cysts
• Fibrosis
• Adenosis

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Cysts

• Common, 30s-40s
• Often multiple, bilateral
• Present suddenly (fluid) pain, nodularity
• Tense, less mobile than Fibroadenoma
• Involution of stroma and epithelium
• Turbid fluid (blue)
• Apocrine or simple cuboidal epithelial lining

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Galactocele

• Solitary subareolar cyst
• Dates from lactation
• Contains milk
• Can calcify
• Can greatly increase in size

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Cysts of the breast
Cysts of the breast
Ductal system
Neoplastic
Stroma
Skin cysts
ANID
Galactocele
Benign
Malignant
Serous Lymphatic Blood Inflammatory TB cold
abscess Chronic abscess Hyadatid
Sebaceous Dermoid
Macrocysts
Microcysts
Duct papilloma Papillary cystadenoma
Degeneration of carcinoma Degeneration of
sarcoma Intracystic carcinoma
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Nipple Discharge

• Physiological - pregnancy/lactation
• Duct Ectasia
• Galactorrhoea
• Duct Papilloma
• Carcinoma
• Cysts
• Idiopathic

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Galactorrhoea

• Milky discharge unrelated to lactation
• Primary Physiological
• Menarche
• Menopause
• Stress
• Mechanical Stimulation
• Secondary
• Drugs haloperidol, metoclopramide
• Increased Prolactin pituitary tumour,
  paraneoplastic

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Management of Breast Symptoms

• Breast Lump - always need to exclude Ca
• Breast examination - Is there a lump or localised
  nodularity?
• Is there no lump or diffuse nodularity?
• Triple Assessment
• 1. FNA
• 2. U/S
• 3. Mammography

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Breast Lump Cyst and Mx
no lump or diffuse nodularity
O/E discrete lump or localised nodularity present
FNA
solid
cystic
bloody fluid residual lump then do cytology
mammography
no blood no residual lump then no cytology
re-examine in 6/12 reassure
excisional biopsy
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Palpable Breast Lump - Solid Mx
FNA solid lump
Cytology Mammography gt 35 U/S Tru-cut Ò biopsy
(lump gt 2cm)
suspicious or carcinoma
Manage as for breast cancer
benign
Panel comment If pt 25 - 35 need FNA/ trucut
Dx of fibroadenoma otherwise need exc Bx. If
tru-cut normal breast tissue then still need
histology of the lump.

• observe but excise if
• age gt35
• Pt requests
• pain
• increasing size
• equivocal cytology

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No Palpable Breast Lump Mx
no lump or diffuse nodularity
age lt 40
age gt 40
re-examine 6/52
Cytology Mammography U/S
benign
benign
suspicious or carcinoma
reassure
reassure
Manage as for breast cancer
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Nipple discharge
Nipple discharge
Unilateral
Bilateral (multiductal)
Uniductal
Multiductal
Physiological Pathological Fibroadenosis
Papillomatosis Duct ectasia
Duct papilloma Duct carcinoma Duct
ectasia Chronic absces ??? fibroadenosis
Fibroadenosis Papillomatosis Duct ectasia ??
carcinoma
Mammography U/S
Cytology,prolactin,ductography
Microdochectomy
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Fibroadenoma

• Peak incidence 15-25 yrs
• Smooth, highly mobile
• 2-3 cm occasionally multiple
• Benign tumour of fibrous and glandular tissue
• Mono- or polyclonal (cyclosporin)

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Fibroadenoma - histopathology

• Well formed capsule
• Delicate stroma surrounding glandular and cystic
  spaces
• Epithelium compressed and distorted by the stroma
• Coarse calcification

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Benign tumors
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Giant Fibroadenoma

• Peripubertal age group
• gt 5cm
• Rapid growing
• Esp. Asian, black women
• Benign tumour
• Occasional atypia

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Phylloides Tumour

• Present later - 6th decade
• Mostly benign, few highly malignant with
  metastases
• Pathology
• Variable size up to 15cm skin ulceration
• Bulbous projections (leaf-like)
• Stroma has greater cellularity, mitoses, nuclear
  pleomorphism than fibroadenoma
• Higher grade lesions resemble sarcoma

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Duct Papilloma

• Solitary benign tumour in single large duct
• Presentation
• Discharge ( blood)
• Mass (clinical or XR)
• Multiple papillae with connective tissue axis,
  covered with epithelial and myoepithelial cells
• Considered benign

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Operations - Microdochectomy

• Indications persistent blood stained discharge
  from a single duct opening on the nipple -- often
  find papilloma of duct causing the bleeding
• Technique squeeze the breast and nipple until
  a drop of discharge is seen

cannulate the duct using a lacrimal probe and
secure in place with 3/0 suture passed through
the skin along side the duct opening
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Operations - Microdochectomy

• Technique make a radial incision into the
  nipple along the line of the probe encircling the
  duct orifice

Dissect the skin of the areola away from the
underlying breast for approx 1cm on each side of
the probe and excise the breast segment
containing the probe using scissors commencing
behind the duct orifice and continuing into the
breast. haemostasis closure
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Breast Procedures Operations

• Procedures
• FNA
• Tru-cutÒ needle biopsy - superceded by gun Bx
• Operations
• Excisional biopsy
• Microdochectomy
• Hadfields Major Duct excision
• Incision and drainage of breast abscess - often
  needle aspiration with antibiotics is used

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Gynecomastia

• Enlargement of the glandular tissue of the breast
• Unilateral or bilateral enlargement forming a
  disc like lesion under the nipple and areola
  which is freely mobile

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Gynecomastia (etiology)

• Physiological
• Neonatal
• Pubertal
• Involutional (senescent)
• Pathological
• Decrease production or action of testosterone

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Gynecomastia

• Pathological
• Decrease production or action of testosterone
• Klinfelters syndrome
• Testicular feminization syndrome
• Anorchism
• Increase production or action of estrogen
• Pituitary tumors
• Adrenal hypoplasia( addissons)
• Testicular tumors ( Teratoma)
• Liver failure
• Hyperthyroidism
• Estrogen treatment
• Drugs
• Reserpine, methyldopa
• Isoniazid
• Spironolactone
• Tagment, primperan, H2 blockers
• Idiopathic

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Gynecomastia (treatment)

• Physiological No treatment
• Pathological
• Treatment of the cause
• if persist excision
• Idiopathic
• excision
• Sub mammary
• Circum areolar

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Gynecomastia