The breast The breast diseasedisease

The adult female breast lies between the 2-nd The adult female breast lies between the 2-nd and 6-th ribs and extend from the sternal edge and 6-th ribs and extend from the sternal edge to the medaxillary line to the medaxillary line

Breast tissue extends into the axillx as axillary Breast tissue extends into the axillx as axillary tail of spence.tail of spence.

Poteriorly rest on the fascia of pectoralis major Poteriorly rest on the fascia of pectoralis major M. and inferolaterally on the fascia of the M. and inferolaterally on the fascia of the serratus anterior M.serratus anterior M.

Coopers lig. –fibrous tissue bands support the Coopers lig. –fibrous tissue bands support the breast and extend from the pectoralis fascia and breast and extend from the pectoralis fascia and the dermis.the dermis.

BREAST ---Composed of skin –subcutaneous BREAST ---Composed of skin –subcutaneous tissue –and breast tissue. breast consist of 15 to tissue –and breast tissue. breast consist of 15 to 20 lobs of glandular tissue Subdivided into 20 lobs of glandular tissue Subdivided into lobules which-branched into—tubuloalveolar lobules which-branched into—tubuloalveolar glandsglands

Each lobe ends in a lactiferous duct, 2 to 4 mm in Each lobe ends in a lactiferous duct, 2 to 4 mm in diameter. Beneath the areola, the lactiferous ducts dilate diameter. Beneath the areola, the lactiferous ducts dilate into lactiferous sinuses and then open through a into lactiferous sinuses and then open through a

constricted orifice onto the nippleconstricted orifice onto the nipple

Blood supply—2—3—and the 4-th perforaters of the Blood supply—2—3—and the 4-th perforaters of the internal mammary artery plus lateral thoracic arteryinternal mammary artery plus lateral thoracic artery

Physical breast examination –pt-position –Physical breast examination –pt-position –insemi-setting position and her hand put on insemi-setting position and her hand put on her weist then putting her hands abovethe her weist then putting her hands abovethe head.head.

Mammogram-is apopular program for Mammogram-is apopular program for screening breast cancer.screening breast cancer.

Uses a low dose –film 0,1 rad per study.Uses a low dose –film 0,1 rad per study. Decrease sensitivity of the mammogram in---Decrease sensitivity of the mammogram in---

labular carcenoma in situ and in dense breast.labular carcenoma in situ and in dense breast. --early detection of an occult cancer before it --early detection of an occult cancer before it

reaches 5mm.reaches 5mm. --define the abnormality.--define the abnormality. --detect multicentric disease.--detect multicentric disease. --identify the synchronous cancer.--identify the synchronous cancer.

Positive mammographic signs of Positive mammographic signs of malignancy.malignancy.

--parenchymal tissue distortion.--parenchymal tissue distortion. --poorly defined mass lesion.--poorly defined mass lesion. --branching or linear microcalcefication.--branching or linear microcalcefication. --stellate opacities.--stellate opacities. Women initiate breast self-examination at Women initiate breast self-examination at

the age of 20 yrs.the age of 20 yrs. Base line mammographic examination at Base line mammographic examination at

the age of 35 yrsthe age of 35 yrs

Breast ultrasound—to diffirentiate solid from Breast ultrasound—to diffirentiate solid from cystic mass .used esp. in young Pt.cystic mass .used esp. in young Pt.

-in dense breast tissue.-in dense breast tissue. -for guide needle biopsy.-for guide needle biopsy. BIOPSY technique for solid masses.BIOPSY technique for solid masses. 1-F.N.A—high accuracy rate.1-F.N.A—high accuracy rate. False neg.—10% and false positive-1%.False neg.—10% and false positive-1%. Core needle biopsy—tissue obtained for Core needle biopsy—tissue obtained for

histologic examination.histologic examination. Excisional biopsy –give definitive therapy for a Excisional biopsy –give definitive therapy for a

benign mass.benign mass. Incisional biopsy –in large breast mass.Incisional biopsy –in large breast mass.

Figure 50.3

Ultrasound of the breast

showing a cyst

(arrow).

Figure 50.6 Corecut biopsy of breast.

Triple assessment.Triple assessment. -clinical assessment.-clinical assessment. -tissue biopsy.-tissue biopsy. -radiological imaging.-radiological imaging. -give accuracy of diagnosis---99,9%-give accuracy of diagnosis---99,9% Breast pain-Mastalgia or Mastodynia.Breast pain-Mastalgia or Mastodynia. 50% of pt seen in the clinic.50% of pt seen in the clinic. 2-groups of pt.2-groups of pt. -a-cyclical –related to menstrual cycle.-a-cyclical –related to menstrual cycle.

-b-non-ctclical –occurs in both pre. -b-non-ctclical –occurs in both pre. And post menopausal women—a-And post menopausal women—a-musculoskeletal pain.musculoskeletal pain.

b-sclerosing adenosis b-sclerosing adenosis C-post –operativeC-post –operative d-cervical root paind-cervical root pain

Aetoilogy of cyclical mastalgia.Aetoilogy of cyclical mastalgia. 1-hormonal abnormality—increased 1-hormonal abnormality—increased

oestrogen secretion or decreased oestrogen secretion or decreased progesterone production.progesterone production.

2-abnormal prolactin secretion .2-abnormal prolactin secretion . 3-water retention in the breast .3-water retention in the breast . 4-excessive caffeine ingestion 0r 4-excessive caffeine ingestion 0r

inadequate essentional fatty acid intakeinadequate essentional fatty acid intake 5-psychoneurosis.5-psychoneurosis.

80% 0f pt in the clinic with mastalgia 80% 0f pt in the clinic with mastalgia req. no treatment --- just reassurance.req. no treatment --- just reassurance.

1-anti-oestrogen drug as tamoxifin 10 1-anti-oestrogen drug as tamoxifin 10 mg tablet dialy.mg tablet dialy.

2-anti-gonadotrophin drug as danazol –2-anti-gonadotrophin drug as danazol –400mg dtaly.400mg dtaly.

3-prolactin-antigonist—bromocriptin.3-prolactin-antigonist—bromocriptin. 4-primrose oil—unsaturated fatty acid.4-primrose oil—unsaturated fatty acid.

Breast lump.-about 40% of pt present in Breast lump.-about 40% of pt present in the clinic .the clinic .

History; 1-lump duration.History; 1-lump duration. 2-pain . 3-change in size. 4-relation to 2-pain . 3-change in size. 4-relation to

mensis.mensis. Fibro-adenoma.—derived from the breast Fibro-adenoma.—derived from the breast

lobule.lobule. Originated from –connective tissue and Originated from –connective tissue and

epithelium epithelium -its size -3cm but gaint fibroadenoma-5cm.-its size -3cm but gaint fibroadenoma-5cm.

In 10% of pt have multiple In 10% of pt have multiple fibroadenomas.fibroadenomas.

Dx by FNA .Mammogram is of little Dx by FNA .Mammogram is of little value.value.

Gaint fibroadenoma – 5 up to 10cm .Gaint fibroadenoma – 5 up to 10cm . Occur in extremes of reproductive Occur in extremes of reproductive

age .age . 14---18yr and the45—50 yr age.14---18yr and the45—50 yr age.

Commonly –typical hypocellular stromal and Commonly –typical hypocellular stromal and epithelial component.epithelial component.

Phy llodes tumour.(phyllodes sarcoma or Phy llodes tumour.(phyllodes sarcoma or cystosarcoma.cystosarcoma.

Has much more cellularity ,pleomorphism Has much more cellularity ,pleomorphism and mitotic activity plus atypia.and mitotic activity plus atypia.

-age of the pt –30 –50yr but rare in young pt.-age of the pt –30 –50yr but rare in young pt. Axillary L.N.enlargment is rare.Axillary L.N.enlargment is rare. Treatmen-wider exceion with safety margine Treatmen-wider exceion with safety margine

–1cm even mastectomy may be done–1cm even mastectomy may be done

Galactocele-occur during lactation or Galactocele-occur during lactation or when recently stopped breast feeding.when recently stopped breast feeding.

Aspiration—will resolve the problem.Aspiration—will resolve the problem. Sclerosing adenosis-peri-neural tissue Sclerosing adenosis-peri-neural tissue

invasion-.invasion-. -trigor- spot zone causing mastalgia.-trigor- spot zone causing mastalgia. Fat necrosis—due to trauma . May Fat necrosis—due to trauma . May

confused with cancer Dx by FNA.confused with cancer Dx by FNA. Lipoma –fat tissue in the breast.Lipoma –fat tissue in the breast.

Breast cyst –are frequently confused Breast cyst –are frequently confused with cyclical nodularity.with cyclical nodularity.

Most cyst size about 2—3mm due to Most cyst size about 2—3mm due to aberation of normal lobular physiology.aberation of normal lobular physiology.

Pt compl. Of pain that may relate to Pt compl. Of pain that may relate to menstrual cycle.menstrual cycle.

Treatment-by aspiration surgical Treatment-by aspiration surgical excesion –cyst recurrence or blood excesion –cyst recurrence or blood stained aspirationstained aspiration

Bacterial breast infection (Br. Abscess).Bacterial breast infection (Br. Abscess). Staph. Aureus and strep. Species –are Staph. Aureus and strep. Species –are

the most micro-organism are present in the most micro-organism are present in nipple discharge from an infected nipple discharge from an infected breast.breast.

Symptoms- piont of tenderness, Symptoms- piont of tenderness, erythema, hyperthermia.erythema, hyperthermia.

Related to lactation, and occur within Related to lactation, and occur within the few weeks of breast-feeding.the few weeks of breast-feeding.

Classification.Classification. -subcutaneous.-subcutaneous. -subareolar-subareolar -interlobullar.-interlobullar. -retromammary abscess.-retromammary abscess. Also into—1-unicentric 2-multicentric.Also into—1-unicentric 2-multicentric. Pre-oper. Ultrasound—may be requeredPre-oper. Ultrasound—may be requered Surgical treat. –Circumareolar incision or Surgical treat. –Circumareolar incision or

incision paralleling Langers lines.incision paralleling Langers lines.

Staph aureus infection---more localized Staph aureus infection---more localized and deep in the breast.and deep in the breast.

Strep. Infection-usually more superficial.Strep. Infection-usually more superficial. In chronic breast infection –requered In chronic breast infection –requered

cultures for 1-acid-fast bacilli cultures for 1-acid-fast bacilli 2-anaerobic and 3-aerobic bacteria 2-anaerobic and 3-aerobic bacteria

4-fungi.4-fungi. Biopsy is req.during drainage to rule out Biopsy is req.during drainage to rule out

underlying breast Cancer.underlying breast Cancer.