Diseases of the breast

Diseases of the breastDr. Mohammed HajhamadMB.ChB. (Egypt) M.S (Malaysia)Department of SurgeryInternational Medical SchoolManagement and Science University

1Diseases of the Breast

Contents IntroductionCongenital anomalies Breast traumaMastitis and breast abscessChronic inflammatory conditionsFibrocystic disease of the breastCysts of the breastBreast neoplasms Male breast12 February 20162

Introduction Breasts are modified sweat glandLie between skin and pectoral fasciaFrom 2nd to 6th ribFrom lateral border of sternum to anterior axillary line.May extends:upwards till clavicledownwards till below costal marginmedially to midlinelaterally to posterior axillary lineBreast tail 12 February 20163

Introduction Components:Epithelia elements:Responsible for milk secretion and transport.Supporting tissue:Fibrous septa, extend from pectoral fascia to skin, they divides the parenchyma into lobes.

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Introduction Arteries:IMALateral thoracic art.Pectoral branch of acromio-thoracic art.Intercostal perforatorsVeins:Axillary and internal mammaryIntercostal veins Azygos Vertebral venous plexus. (importance) 12 February 20165

Breast lymphatics There are about 35 LNThree main groupsAxillary (75%)Pectoral, subscapular, lateral, interpectoral, central and apical.Internal mammary3-4 LN along internal mammary vessels.

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Physiology of the breastHormonal controlOestrogen, adrnocortical steroids and growth hormone development of ducts.Progesterone growth of lobules.Prolactin formation of alveoli12 February 20167

Physiology of the breastPhysiological changesPuberty: cyclical hormonal activity growth, branching of the ducts and formation of ductules.Menstrual changes: there will be cyclical changes with heaviness, discomfort, increased nodularity.Lactation: -Drop in oestrogen, increase sensitivity to (prolactin, GH and cortisol) milk production.- Suckling stimulate prolactin and oxytocin milk ejection.Menopause: the lobules gradually disappear. 12 February 20168

Congenital anomalies of the breast

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Congenital anomaliesNipple Athelia: absence of the nipple. Rare, usually associated with (Amazia)Polythelia: supernumerary nipples occurs anywhere along mammary ridges, from axilla to groin. 12 February 201610

Congenital anomaliesBreast Amazia: absence of breast. Usually unilateral.Polymazia: supernumerary breasts, due to persistence of extramammary portions of the mammary ridge.Infantile gynecomastia: diffuse enlargement of male breast. Bilateral or unilateral. Due to maternal sex hormones. Usually disappears within six months. 12 February 201611

Bilateral athelia and unilateral amazia

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Polythelia and polymazia

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Trauma Results in two sequencesBreast hematomausually deeply seatedhard massresembles a carcinoma Traumatic fat necrosisdeath of fat cells fatty acids combine with calcium calcium soap.- cyst contains thick oily fluid- hard mass resembles carcinoma- differentiation is by biopsy.12 February 201614

Acute lactational mastitis and breast abscessAetiology:Staphylococcus aureus clotting of milk in the ducts obstruction stasis.Organism reaches the ducts from the suckling infant mouth through a cracked nipples.Predisposing factors:1- milk engorgement2- abrasions to the nipples by suckling3- poor hygiene

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Acute lactational mastitis and breast abscessPathology: milk engorgement diffuse inflammation not treated acute mastitis abscess. Predisposing factors:1- milk engorgement2- abrasions to the nipples by suckling3- poor hygiene

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Acute lactational mastitis and breast abscessClinical picture Dull aching pain, pyrexia, breast in engorged and tender.Acute mastitis: high fever, sever tenderness and redness.Acute abscess: throbbing pain, hectic fever, localized signs, pitting edemaChronic abscess. 12 February 201617

Diffuse mastitis and abscess

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Treatment Before development of abscess:- systemic antibiotics covering staph. (pencillin, cephalosporin)- breast support, reduces pain- local heat- advice breast emptying (breast bump) and or bromocriptine 2.5 mg BD.Abscess: - drainage under anesthesia- US guided aspiration12 February 201619

Chronic inflammatory conditionsMammary duct ectasiaChronic abscessTuberculosis 12 February 201620

Mammary duct ectasiaUnknown aetiologyDilatation of major ducts, filled with creamy secretion with periductal inflammation.May be asymptomatic, or- nipple discharge (bloody, serous, creamy white or yellow.- retracted nipple- acute inflammation- recurrent chronic inflammation with abscess formation.Treatment: surgical excision of the major duct. Correction of nipple retraction.

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Chronic breast abscessResult from improper treatment of an acute abscess.The abscess is treated with prolonged antibiotics rather than adequate surgical drainage.Its called antibioma where is bacteria is killed, but, pus remains in the breast with excess fibrous tissue formation.The breast will be thickened and honeycombed with pus. There will nipple retraction and skin puckering. Treatment is excision (not incision). 12 February 201622

Tuberculosis of the breast Rare diseaseUsually associated with PTB or cervical TB.Presents as either multiple cold abscess or sinuses, or nodules.Axillary LN are enlarged and matted.Diagnosis by biopsy (granulomma)Treatment with antituberculous drugs.Mastectomy for resistant cases only. 12 February 201623

Fibrocystic disease Also known as mammary dysplasia, ANDI, fibroadenosis and chronic interstitial mastitis.Aetiology unknownAge 30-50 years, related to ovarian activity.It represent a variation or aberration of normal changes during menstrual cycles, pregnancy, lactation and menopausal involution. Aberration of Normal Development and Involution ANDI12 February 201624

Pathology Upper outer quadrant One or a mixture of the following:Adenosis: glandular hyperplasiaEpitheliosis: solid epithelial hyperplasia within the small ducts. If atypical hyperplasia noted a higher chance to develop cancer. Fibrosis: replacement of elastic and fatty tissue with fibrous tissue.Cyst formation: lined by epithelium and filled with clear yellow or brown fluid. (late menopausal age). 12 February 201625

Clinical pictureAsymptomaticPalpable lump, may disappear if patient re-examined one week after menstrual cycle.Painful nodularity: multiple painful small lumps related to menstrual cycle.Mastalgia: usually cyclical, premenstrual, accompanied by enlargement and increased nodularity of the breasts.Nipple discharge: clear, yellow, brown or green. 12 February 201626

Investigations USG and mammogramCytology of aspirated fluid, however, not conclusive.If solid mass FNACExcisional biopsy if FNAC not available or inconclusive.12 February 201627

Treatment It should be individualizedExclusion of malignancy and reassurance is the most importantCysts: can be treated by aspiration, if recur, excision.Cyclic Mastalgia: Mild: breast support, day and night, reduce cafeen.Moderate: prolactin inhibitor e.g. bromocriptin.Sever: synthetic androgen, e.g. Danazol. 100 200 mg BD. Atypical cells found in biopsy patient should be instructed to perform monthly SBE and regular follow up. 12 February 201628

Neoplasms of the breast

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Neoplasms of the breastBenignMalignant EpithelialDuct papillomaEpithelialCarcinomaMixed (epith + mesenchymal)FibroadenomaMixed (epith + mesenchymal)LymphomaFibrosarcoma

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Duct papillomaBenign tumor from epithelial lining of main ducts near the nippleIts can be either a lump or an ulcerated mass with bleeding discharge and bloody nipple discharge.Can cause a retention cyst if the duct is totally blocked.

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Clinical featuresBloody or bloody stained nipple discharge.A lump deep or near the areola. Pressure on it causing nipple discharge.Sometimes, there is no swellings palpable, only discharge on pressure.12 February 201632

Management Ductography the lesion will be shown as a filling defect.Treated by excision of the affected duct (microdochectomy), send specimen to HPE.12 February 201633

Fibroadenoma Its a benign neoplasm of the breast which affects both the fibrous and the glandular tissues, but fibrous element predominates. The most common breast mass in young womenAge from 15-30 yearsIt can be hard (pericanalicular), tend to be small, or soft (intracanalicular), tend to be large.Solitary or multiple, smooth surface, lobulated, well circumscribed, never attached to surrounding tissues.Cut section shows whorled white fibrous tissue which bulges out of its surface.12 February 201634

Clinical featuresHard type occurs in 20-30 years oldSoft type in 30-50 years oldUsually painless lump(s) which is indecently discovered.Its small, nontender, spherical, firm, well circumscribed, with smooth surface.High mobility is characteristic feature (breast mouse).12 February 201635

Investigations Exclude malignancyUSG or mammography.FNACTreatment:Excision and HPE to confirm diagnosis.12 February 201636

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Phylloides tumor Its a high cellular type of fibroadenoma which tends to grow rapidly.Its named like that because the cut surface resembles a leaf or fern.Its rarely malignant.Can grow as big as 20-30 cm.Its not attached to skinTreatment is wide local excisionMastectomy for huge tumor occupying the whole breast.

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Carcinoma of the breast

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Carcinoma of the breast1 out of 8 women is expected to develop breast cancer sometime in her life.Its the most common cancer in women.Risk increases with age60 is the mean age of occurrence.

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Aetiology Genetic factors: 5-10%BRCA 1 (chrom 17)BRACA 2 (chrom 13)Mother or sister BC 2.3 times riskMother and sister BC 14 times riskEndocrine factors: - early menarche 30- late menopause >50- contraceptive pills, Unsure relationship.12 February 201642

Aetiology Precancerous lesions:- epithelial hyperplasia and duct papilloma 1.5-2 times- atypical epithelial hyperplasia 2-5 times- lobular or ductal carcinoma insitu 5-10 times.Obesity: - high fatty diet- steroidsPrevious affection of breast cancer in one side.12 February 201643

Pathology 12 February 201644

Gross typesSchirrhous carcinoma (hard), 75%Encephaloid carcinoma (brain-like), large, soft and brain-like.Inflammatory carcinoma: rare, most malignant, infiltrating duct carcinoma resembles mastitis.Pagets disease: rare, intraductal carcinoma at the epithelium of a main lactiferous duct which then spreads to both skin and breast. There is nipple erosion. Mimics eczema. Carcinoma of the ductsCarcinoma of the lobulesPagets diseaseNon-infilitrating (in situ)Non-infilitrating (in situ)Intraductal carcinoma (1%)IDC (75%)ILC (25%)

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SchirrhousinflammatoryPagets

Spread Local spread: inside the breast, skin, muscles of chest wall and chest wall.Lymphatic spread: - by embolism or permeation. - Mostly to axillary LN then internal mammary LN. - Supraclavecular LN involvement considered advanced disease. - Blockade of cutaneous lymphatics causes edema and pitting of breast skin, i.e. peau dorange12 February 201646

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Spread Blood stream spread: lungs, liver, bones, brain and bones (axial skeleton) (posterior intercostal vein and paravertiberal plexus of veins)

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Hormonal receptor statusOestrogen-positive (ER-positive): 60% of tumors have a receptors for oestrogen, they get more active under its influence. Can be suppressed by reduced estrogen or giving an anti-estrogen agents.Progesteron-positive PR-positive tumorsER-PR- negative, 10 % 12 February 201649

Clinical featuresSymptoms: Accidental painless lumpPricking pain, nipple retraction or bloody nipple discharge.Presents with metastasis, axillary lump, backache, pathological fractures, dysponea, pleuritic pain, jaundice or mental changes.During screening programs12 February 201650

Clinical featuresSigns Examination should be done while upper half of the patient exposed, both breasts, axillae, arms, supraclavicular regions all examined. Breast: - asymmetry- enlargement- skin dimpling- skin puckering- peau dorange- skin nodule- skin ulceration12 February 201651

Clinical featuresMass:- hard- irregular- ill-defined- restricted mobility within breast substance- fixation to skin, muscles, chest wallNipple:- recent retraction- change of direction12 February 201652

Clinical featuresAxillary and supraclavicular nodes- number and mobility of nodesDistant metastasis:- chest examination- hepatomegaly- ascitis- pelvic examination for hard deposits or Krukenberg tumor. 12 February 201653

Clinical featuresPagets disease:- pricking sensation of the nipple- superficial erosion- a tumor mass may not be palpable- commonly mistaken for eczema- biopsy is mandatory to differentiate. Inflammatory carcinoma:- usually occurs during pregnancy or lactation- rapidly growing, sometimes painful breast swelling.- overlying skin is reed, edematous and warm.- resembles acute mastitis- poor prognosis12 February 201654

Clinical featuresCarcinoma in situ- LCIS: found by mammogram and confirmed by biopsy. Doesnt progress to invasive type.- DCIS: present as a mass or in mammogram, should be treated by surgery.12 February 201655

Differential diagnosis CarcinomaCystFibro-cysticfibroadenomaAge>3535-5535-5515-30PainPainlessOccasionallyOccasionallyPainlessSurfaceIrregularSmoothIndistinctSmooth, lobulatedConsistencyHardSoft to hardFirmFirm, highly mobileLN+/- axillay LN+Free axillaFree axillaFree axilla

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Staging TNM stagingManchester staging12 February 201657

TNM Staging

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Investigation Aims:Diagnosis (USG, mammogram + HPE)Staging (CXR+USG abdomen), CT scan, alkaline phosphatase.Special situation: bone scan (bone pain) and brain CT scan. 12 February 201660

Investigations Tools Mammography: 95% accurate. Usually combined with tru cut biopsy or FNAC. - dense opacity with indefinite outlines- clustered microcalcifications.- less effective below age of 35Ultrasonography: can differentiate between solid and cystic. Used in young women where mammogram is not helpful.Biopsy:- Excisional - frozen section biopsy- tru-cut biopsy- FNAC12 February 201661

Early detectionBreast self examination (BSE)Screening programs.- Clinical examination and a mammogram. - Proven to reduce mortality, early detection and more conservative surgery. 12 February 201662

Treatment Provided through an MDTDepends on stage of the diseaseEarly vs. AdvancedEarly: any T2 N1 M0 or below, stage I&II(localized disease +/- micrometastasis)Primary treatment: Surgery +/- radiotherapyAdvanced: more than T2 N1 M0, stage III&IV (systemic disease)Primary treatment: Chemotherapy and endocrine therapy12 February 201663

Early cases

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Surgical optionsRadical mastectomy (Hasted mastectomy), whole breast tissue pectoralis muscles+ all axillary LN are cleared.Modified radical mastectomy (Patey), preserve the pectoralis muscles, usually followed by radiotherapy.Breast conservative surgery: combined surgery and radiotherapy: