BreastBreast

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

Ducts emerge from acini of glandsDucts emerge from acini of glandsSmaller ducts join to form lactiferous ductsSmaller ducts join to form lactiferous ducts

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

Ducts emerge from acini of glandsDucts emerge from acini of glandsSmaller ducts join to form lactiferous ductsSmaller ducts join to form lactiferous ducts

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

Axillary A lateral thoracicInternal mammary A perforatingIntercostal lateral

Axillary veinInternal mammary VIntercostal veins

Supraclavicular nerveItercostal Nsympathatic

Benign Breast DiseaseBenign Breast Disease Congenital ConditionsCongenital Conditions Traumatic ConditionsTraumatic Conditions InfectionsInfections Aberrations of Normal Development Aberrations of Normal Development

and Involution (ANDI)and Involution (ANDI) NeoplasticNeoplastic

Benign - FibroadenomaBenign - Fibroadenoma

Congenital ConditionsCongenital Conditions

CongenitalCongenital Supernumerary Supernumerary

nipple along nipple nipple along nipple lineline

Supernumerary Supernumerary breastbreast

Aplasia – turners, Aplasia – turners, Juvenile Juvenile hypertrophyhypertrophy

Traumatic ConditionsTraumatic Conditions

Traumatic fat necrosisTraumatic fat necrosis Cracks of nippleCracks of nipple HematomaHematoma Traumatic mastitisTraumatic mastitis Milk fistulaMilk fistula

Traumatic Conditions (Fat Traumatic Conditions (Fat Necrosis)Necrosis)

Follows trauma, Follows trauma, surgery or radiationsurgery or radiation

Small, hard mass - Small, hard mass - confused with confused with carcinomacarcinoma

Focal necrosis of fat Focal necrosis of fat with inflammationwith inflammation

Foamy lipid-laden Foamy lipid-laden macrophagesmacrophages

Later fibrosis, Later fibrosis, calcificationcalcification

Mammary fistulaMammary fistula

Congenital (rare)Congenital (rare) AcquiredAcquired

Varient of MDEVarient of MDE Incision and Incision and

drainage of abcess drainage of abcess in lactating breastin lactating breast

InfectionsInfections

AcuteAcute Mastitis neonatorumMastitis neonatorum Pubertal mastitisPubertal mastitis Traumatic mastitisTraumatic mastitis Metastatic mastitsMetastatic mastits Mammary duct Mammary duct

ectasiaectasia Lactational mastitsLactational mastits Acute suppurative Acute suppurative

mastitismastitis

ChronicChronic Chronic non specific Chronic non specific

chronic breast chronic breast abscessabscess

HidradenitisHidradenitis Pilonidal DiseasePilonidal Disease Postoperative Postoperative

Wound InfectionsWound Infections specificspecific

TuberculosisTuberculosis SyphillisSyphillis ActinomycosisActinomycosis

Duct Ectasia and Duct Ectasia and Periductal MastitisPeriductal Mastitis

? Aetiology, age 40s - 50s, smokers ? Aetiology, age 40s - 50s, smokers Dilatation of breast ducts - fill with Dilatation of breast ducts - fill with

stagnant brown/green secretion - atrophy stagnant brown/green secretion - atrophy and loss of ductal epithelium - secretion and loss of ductal epithelium - secretion spills into periductal tissues - inflammatory spills into periductal tissues - inflammatory reaction (‘mastitis’)reaction (‘mastitis’)

Micro - lyphocytes, histiocytes, plasma Micro - lyphocytes, histiocytes, plasma cellscells

Secondary anaerobic infection, abscessSecondary anaerobic infection, abscess Fibrosis - slit-like nipple retractionFibrosis - slit-like nipple retraction

DuctDuct Ectasia andEctasia andPeriductal MastitisPeriductal Mastitis

PresentationPresentation Nipple discharge - any Nipple discharge - any

colourcolour Nipple RetractionNipple Retraction Subareolar massSubareolar mass AbscessAbscess Mammary duct fistulaMammary duct fistula

May mimic carcinomaMay mimic carcinoma

Duct ectasiaDuct ectasia

Nipple retraction

Lump

Abscess

Nipple discharge - any colourNipple discharge - any colour

Mammary duct fistulaMammary duct fistula

•Antibiotics • Flucloxacillin & • Metronidaziole

• NSAID

Central duct excision(Hadfield operation)

Operations - Hadfield’s Operations - Hadfield’s Major Duct ExcisionMajor Duct Excision

IndicationsIndications : : duct ectasia (periductal mastitis) with duct ectasia (periductal mastitis) with

recurrent episodes +/- fistulaerecurrent episodes +/- fistulae blood stained discharge from one or more blood stained discharge from one or more

ducts in women > 40ducts in women > 40 IncisionIncision : :

circumareolar but < 3/5 the areolar circumareolar but < 3/5 the areolar circumference to allow enough blood circumference to allow enough blood

supplysupply include the orifice of any sinus or fistulainclude the orifice of any sinus or fistula

Operations - Hadfield’s Operations - Hadfield’s Major Duct ExcisionMajor Duct Excision

TechniqueTechnique : : cut the subcutaneous cut the subcutaneous

tissue down to the ductstissue down to the ducts dissect in a plane dissect in a plane

circumfentially around circumfentially around the terminal lactiferous the terminal lactiferous ducts ducts

divide the ducts close to divide the ducts close to the nipple and remove the nipple and remove with a small conical with a small conical wedge of tissuewedge of tissue

include fistulous tracts include fistulous tracts with all granulation with with all granulation with excisionexcision

+/- DT closure 4/0 +/- DT closure 4/0 subcuticularsubcuticular

Lactational MastitisLactational Mastitis

Bacterial MastitisBacterial Mastitis

Cracks and fissures Cracks and fissures form in early form in early breastfeeding breastfeeding

Secondary infection Secondary infection with Staph. aureuswith Staph. aureus

Carried by Carried by nasopharynx of infantnasopharynx of infant AbscessAbscess Chronic scarChronic scar

Fever

Throbbing pain

Skin oedema

Aspiration of pus

Operation - Incision & drainage breast Operation - Incision & drainage breast abscessabscess

Breast abscess :Breast abscess : most occur during lactationmost occur during lactation empty the breast , allowing the baby to feed by the other breastempty the breast , allowing the baby to feed by the other breast drain early when there is a point of maximal tenderness - drain early when there is a point of maximal tenderness - needle needle

aspiration + antibiotics may be more appropriateaspiration + antibiotics may be more appropriate TechniqueTechnique : :

1.1. General anaesthesiaGeneral anaesthesia2.2. incise incise

over point of maximal tenderness or fluctuance over point of maximal tenderness or fluctuance if near the nipple use circumareolar incision if near the nipple use circumareolar incision deepen the incision until drain pus, send for M/C/Sdeepen the incision until drain pus, send for M/C/S Use counter incision in upper breastUse counter incision in upper breast

3.3. break down loculations & take Bx (exclude inflam Ca)break down loculations & take Bx (exclude inflam Ca)4.4. +/- DT +/- kaltostat packing+/- DT +/- kaltostat packing5.5. supportive bra, breast feed when comfortablesupportive bra, breast feed when comfortable

IndicationIndication : solid breast lump that is clinically benign : solid breast lump that is clinically benign

AimAim : to extract the lesion with minimal margin and least : to extract the lesion with minimal margin and least cosmetic defect to establish a histological Dx and remove the cosmetic defect to establish a histological Dx and remove the palpable lump.palpable lump.

Operations - Breast Operations - Breast Excisional BiopsyExcisional Biopsy

Breast Excisional BiopsyBreast Excisional Biopsy Incisions Incisions ::

incise over the lump - adequate excision 1st priority incise over the lump - adequate excision 1st priority 2nd comes aesthetic position2nd comes aesthetic position if possible scar hidden by braif possible scar hidden by bra medial incisions more likely to develop keloidmedial incisions more likely to develop keloid avoid radial incisions except mediallyavoid radial incisions except medially make incision within skin that would be removed if make incision within skin that would be removed if

patient subsequently required a mastectomypatient subsequently required a mastectomy

• Technique : excise lump completely without cutting into ithold specimen with Lane or Allis tissue

forcepscareful haemostasis +/- DT + L.A.subcuticular closure

Caseous form

Sclerosing form

Fibrocaseous

Suppurative form

TuberculosisTuberculosis

Antituberculous Antituberculous drugsdrugs

Cold abscessCold abscess Valvular incisionValvular incision Local anti TBLocal anti TB

FibrocaseousFibrocaseous Simple mastectomySimple mastectomy Anti TBAnti TB

ANDI( Fibrocystic Disease)ANDI( Fibrocystic Disease)

Developed by LE Hughes at Cardiff 1987Developed by LE Hughes at Cardiff 1987 Replaces fibrocystic disease, fibroadenosis, etc.Replaces fibrocystic disease, fibroadenosis, etc. Main Histological Features:Main Histological Features:

Epithelial proliferationEpithelial proliferation Adenosis (increase in no. of acinar units per lobule)Adenosis (increase in no. of acinar units per lobule) Epithelial Hyperplasia ( of cells) Epithelial Hyperplasia ( of cells) ++ Papilloma Papilloma

formationformation FibrosisFibrosis CystsCysts

Retention cystsRetention cysts Blue –domed cyst of Bloodgood (macrocysts)Blue –domed cyst of Bloodgood (macrocysts) Brodie’s tumor (microcysts)Brodie’s tumor (microcysts)

PresentationPresentation

MastalgiaMastalgia CyclicalCyclical Non-CyclicalNon-Cyclical

Lump - many causesLump - many causes Periareolar DisorderPeriareolar Disorder

Nipple DischargeNipple Discharge Nipple RetractionNipple Retraction

Cyclical MastalgiaCyclical Mastalgia

PresentationPresentation Median age 35 yrsMedian age 35 yrs Premenstrual breast discomfort Premenstrual breast discomfort Upper outer quadrant (often bilateral)Upper outer quadrant (often bilateral) Relief during menstruationRelief during menstruation Associated with nodularityAssociated with nodularity Aetiology presumably hormonalAetiology presumably hormonal

Non-Cyclical MastalgiaNon-Cyclical Mastalgia

Not related to menstrual cycleNot related to menstrual cycle Median age 45yrs (pre- or postmenopausal)Median age 45yrs (pre- or postmenopausal) Unilateral, well-localised, ‘trigger spot’Unilateral, well-localised, ‘trigger spot’ Multiple CausesMultiple Causes

Carcinoma Carcinoma Mammary Duct EctasiaMammary Duct Ectasia Sclerosing Adenosis (ANDI)Sclerosing Adenosis (ANDI) Painful ScarPainful Scar Musculoskeletal PainMusculoskeletal Pain Mondor’s DiseaseMondor’s Disease

LumpsLumps TraumaticTraumatic

Fat NecrosisFat Necrosis Organized hematomaOrganized hematoma

InflammatoryInflammatory Mammary Duct Ectasia/Periductal MastitisMammary Duct Ectasia/Periductal Mastitis Chronic breast abcessChronic breast abcess

ANIDANID NodularityNodularity Cysts (Galactocele)Cysts (Galactocele) Sclerosing AdenosisSclerosing Adenosis

Neoplastic Neoplastic BenignBenign

LipomaLipoma Hard FibroadenomaHard Fibroadenoma Giant fibroadenomaGiant fibroadenoma Phyllodes TumourPhyllodes Tumour

MalignantMalignant

NodularityNodularity

Often bilateral, upper outer quadrantOften bilateral, upper outer quadrant May be cyclicalMay be cyclical Associated with mastalgiaAssociated with mastalgia Histology (ANDI)Histology (ANDI)

CystsCysts FibrosisFibrosis AdenosisAdenosis

CystsCysts

Common, 30s-40sCommon, 30s-40s Often multiple, bilateralOften multiple, bilateral Present suddenly (fluid) Present suddenly (fluid)

++ pain, nodularity pain, nodularity Tense, less mobile than Tense, less mobile than

FibroadenomaFibroadenoma Involution of stroma and Involution of stroma and

epitheliumepithelium Turbid fluid (blue)Turbid fluid (blue) Apocrine or simple Apocrine or simple

cuboidal epithelial liningcuboidal epithelial lining

GalactoceleGalactocele

Solitary subareolar Solitary subareolar cystcyst

Dates from lactationDates from lactation Contains milkContains milk Can calcifyCan calcify Can greatly increase Can greatly increase

in sizein size

Cysts of the breastCysts of the breast

Cysts of the breast

Cysts of the breast

Ductal systemDuctal systemNeoplasticNeoplastic

ANIDANID

Macrocysts

Macrocysts

Microcysts

Microcysts

StromaStroma

Duct papilloma

Papillary cystadenoma

Duct papilloma

Papillary cystadenoma

BenignBenign

Degeneration of carcinoma

Degeneration of sarcoma

Intracystic carcinoma

Degeneration of carcinoma

Degeneration of sarcoma

Intracystic carcinoma

Serous

Lymphatic

Blood

Inflammatory

TB cold abscess

Chronic abscess

Hyadatid

Serous

Lymphatic

Blood

Inflammatory

TB cold abscess

Chronic abscess

Hyadatid

GalactoceleGalactocele

Skin cystsSkin cysts

MalignantMalignant

Sebaceous

Dermoid

Sebaceous

Dermoid

Nipple DischargeNipple Discharge

Physiological - pregnancy/lactationPhysiological - pregnancy/lactation Duct EctasiaDuct Ectasia GalactorrhoeaGalactorrhoea Duct PapillomaDuct Papilloma CarcinomaCarcinoma CystsCysts IdiopathicIdiopathic

GalactorrhoeaGalactorrhoea

Milky discharge unrelated to lactationMilky discharge unrelated to lactation Primary PhysiologicalPrimary Physiological

MenarcheMenarche MenopauseMenopause StressStress Mechanical StimulationMechanical Stimulation

SecondarySecondary Drugs: haloperidol, metoclopramideDrugs: haloperidol, metoclopramide Increased Prolactin: pituitary tumour, Increased Prolactin: pituitary tumour,

paraneoplasticparaneoplastic

Management of Breast Management of Breast SymptomsSymptoms

Breast Lump - always need to exclude Breast Lump - always need to exclude CaCa

Breast examination - Is there a lump or Breast examination - Is there a lump or localised nodularity?localised nodularity?

Is there no lump or diffuse nodularity?Is there no lump or diffuse nodularity? Triple AssessmentTriple Assessment

1. FNA1. FNA 2. U/S2. U/S 3. Mammography3. Mammography

Breast Lump – Cyst and Breast Lump – Cyst and MxMx

O/E discrete lump or localised nodularity presentO/E discrete lump or localised nodularity present

FNAFNA

cysticcystic

no bloodno residual lumpthen no cytology

no bloodno residual lumpthen no cytology

solidsolid

re-examine in 6/12

reassure

re-examine in 6/12

reassure

bloody fluid

residual lump

then do cytology

& mammography

bloody fluid

residual lump

then do cytology

& mammography

excisional biopsyexcisional biopsy

no lump or diffuse nodularity

no lump or diffuse nodularity

Palpable Breast Lump - Solid Palpable Breast Lump - Solid MxMx

FNA solid lumpFNA solid lump

CytologyMammography > 35U/STru-cut biopsy (lump > 2cm)

CytologyMammography > 35U/STru-cut biopsy (lump > 2cm)

suspicious or carcinomasuspicious or carcinoma

benignbenign

observe but excise if :• age >35• Pt requests• pain• increasing size• equivocal cytology

observe but excise if :• age >35• Pt requests• pain• increasing size• equivocal cytology

Manage as for breast cancerManage as for breast cancer

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.

No Palpable Breast Lump No Palpable Breast Lump MxMx

no lump or diffuse nodularity

no lump or diffuse nodularity

age < 40age < 40age > 40age > 40

re-examine 6/52re-examine 6/52

reassurereassure

benignbenign

Cytology

MammographyU/S

Cytology

MammographyU/S

reassurereassure

benignbenign

suspicious or carcinomasuspicious or carcinoma

Manage as for breast cancerManage as for breast cancer

Nipple dischargeNipple discharge

Nipple dischargeNipple discharge

Bilateral (multiductal)Bilateral (multiductal) UnilateralUnilateral

Physiological

Pathological

Fibroadenosis

Papillomatosis

Duct ectasia

Physiological

Pathological

Fibroadenosis

Papillomatosis

Duct ectasia

Mammography

U/S

Mammography

U/S

Uniductal Uniductal

Fibroadenosis

Papillomatosis

Duct ectasia

?? carcinoma

Fibroadenosis

Papillomatosis

Duct ectasia

?? carcinoma

MultiductalMultiductal

Duct papilloma

Duct carcinoma

Duct ectasia

Chronic absces

??? fibroadenosis

Duct papilloma

Duct carcinoma

Duct ectasia

Chronic absces

??? fibroadenosis

Cytology,prolactin,ductographyCytology,prolactin,ductographyMicrodochectomyMicrodochectomy

FibroadenomaFibroadenoma

Peak incidence 15-25 yrsPeak incidence 15-25 yrs Smooth, highly mobileSmooth, highly mobile 2-3 cm occasionally multiple2-3 cm occasionally multiple Benign tumour of fibrous and glandular tissueBenign tumour of fibrous and glandular tissue Mono- or polyclonal (cyclosporin)Mono- or polyclonal (cyclosporin)

Fibroadenoma - Fibroadenoma - histopathologyhistopathology

Well formed capsuleWell formed capsule Delicate stroma Delicate stroma

surrounding glandular surrounding glandular and cystic spacesand cystic spaces

Epithelium Epithelium compressed and compressed and distorted by the distorted by the stromastroma

++ Coarse calcification Coarse calcification

Benign tumorsBenign tumors

Giant FibroadenomaGiant Fibroadenoma

Peripubertal age Peripubertal age groupgroup

> 5cm > 5cm Rapid growingRapid growing Esp. Asian, black Esp. Asian, black

womenwomen Benign tumourBenign tumour Occasional atypiaOccasional atypia

Phylloides TumourPhylloides Tumour

Present later - 6th decadePresent later - 6th decade Mostly benign, few highly Mostly benign, few highly

malignant with metastasesmalignant with metastases PathologyPathology

Variable size up to 15cm Variable size up to 15cm ++ skin ulcerationskin ulceration

Bulbous projections (‘leaf-Bulbous projections (‘leaf-like’)like’)

Stroma has greater Stroma has greater cellularity, mitoses, nuclear cellularity, mitoses, nuclear pleomorphism than pleomorphism than fibroadenomafibroadenoma

Higher grade lesions Higher grade lesions resemble sarcomaresemble sarcoma

Duct PapillomaDuct Papilloma

Solitary benign tumour Solitary benign tumour in single large duct in single large duct

PresentationPresentation Discharge (Discharge (++ blood) blood) Mass (clinical or XR)Mass (clinical or XR)

Multiple papillae with Multiple papillae with connective tissue axis, connective tissue axis, covered with epithelial covered with epithelial and myoepithelial cellsand myoepithelial cells

Considered benignConsidered benign

Operations - Operations - MicrodochectomyMicrodochectomy

IndicationsIndications : persistent blood stained : persistent blood stained discharge from a single duct opening on discharge from a single duct opening on the nipple -- often find papilloma of duct the nipple -- often find papilloma of duct causing the bleedingcausing the bleeding

TechniqueTechnique : squeeze the breast and : squeeze the breast and nipple until a drop of discharge is seennipple 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

Operations - Operations - MicrodochectomyMicrodochectomy

TechniqueTechnique : make a radial incision into the : make a radial incision into the nipple along the line of the probe encircling nipple along the line of the probe encircling the duct orificethe duct orifice

Dissect the skin of the areolaaway from the underlying breast for approx 1cm on each side of the probe and excise the breastsegment containing the probe using scissors commencing behind the duct orifice andcontinuing into the breast.

haemostasis & closure

Breast Procedures & Breast Procedures & OperationsOperations

ProceduresProcedures FNAFNA Tru-cutTru-cut needle biopsy - superceded by gun needle biopsy - superceded by gun

BxBx

OperationsOperations Excisional biopsyExcisional biopsy MicrodochectomyMicrodochectomy Hadfield’s Major Duct excisionHadfield’s Major Duct excision Incision and drainage of breast abscess - often Incision and drainage of breast abscess - often

needle aspiration with antibiotics is usedneedle aspiration with antibiotics is used

GynecomastiaGynecomastia

Enlargement of the Enlargement of the glandular tissue of glandular tissue of the breastthe breast

Unilateral or bilateral Unilateral or bilateral enlargement forming enlargement forming a disc like lesion a disc like lesion under the nipple and under the nipple and areola which is freely areola which is freely mobilemobile

Gynecomastia (etiology)Gynecomastia (etiology)

PhysiologicalPhysiological NeonatalNeonatal PubertalPubertal Involutional Involutional

(senescent)(senescent) PathologicalPathological Decrease Decrease

production or action production or action of testosteroneof testosterone

GynecomastiaGynecomastia PathologicalPathological

Decrease production or action of Decrease production or action of testosteronetestosterone

Klinfelter’s syndromeKlinfelter’s syndrome Testicular feminization syndromeTesticular feminization syndrome AnorchismAnorchism

Increase production or action of estrogenIncrease production or action of estrogen Pituitary tumorsPituitary tumors Adrenal hypoplasia( addisson’s)Adrenal hypoplasia( addisson’s) Testicular tumors ( Teratoma)Testicular tumors ( Teratoma) Liver failureLiver failure HyperthyroidismHyperthyroidism Estrogen treatmentEstrogen treatment DrugsDrugs

Reserpine, methyldopaReserpine, methyldopa IsoniazidIsoniazid SpironolactoneSpironolactone Tagment, primperan, H2 blockersTagment, primperan, H2 blockers

IdiopathicIdiopathic

Gynecomastia (treatment)Gynecomastia (treatment) PhysiologicalPhysiological No No

treatmenttreatment PathologicalPathological

Treatment of the Treatment of the cause cause

if persist excisionif persist excision Idiopathic Idiopathic

excisionexcision Sub mammarySub mammary Circum areolarCircum areolar

GynecomastiaGynecomastia