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Breast. 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. Lobes and lobules

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Breast

Breast


Breast

  • 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


Breast

  • Lobes and lobules

  • of gland

    in fat tissue stroma.

  • Ducts emerge from acini of glands

  • Smaller ducts join to form lactiferous ducts


Breast

Axillary A lateral thoracic

Internal mammary A perforating

Intercostal lateral

Axillary vein

Internal mammary V

Intercostal veins

Supraclavicular nerve

Itercostal N

sympathatic


Benign breast disease

Benign Breast Disease

  • Congenital Conditions

  • Traumatic Conditions

  • Infections

  • Aberrations of Normal Development and Involution (ANDI)

  • Neoplastic

    • Benign - Fibroadenoma


Congenital conditions

Congenital Conditions

  • Congenital

    • Supernumerary nipple along nipple line

    • Supernumerary breast

    • Aplasia – turners, Juvenile hypertrophy


Traumatic conditions

Traumatic Conditions

  • Traumatic fat necrosis

  • Cracks of nipple

  • Hematoma

  • Traumatic mastitis

  • Milk fistula


Traumatic conditions fat necrosis

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


Mammary fistula

Mammary fistula

  • Congenital (rare)

  • Acquired

    • Varient of MDE

    • Incision and drainage of abcess in lactating breast


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

Infections


Duct ectasia and periductal mastitis

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


Duct ectasia and periductal mastitis1

DuctEctasia andPeriductal Mastitis

  • Presentation

    • Nipple discharge - any colour

    • Nipple Retraction

    • Subareolar mass

    • Abscess

    • Mammary duct fistula

  • May mimic carcinoma


Duct ectasia

Duct ectasia

Nipple discharge - any colour

Nipple retraction

Lump

Abscess

Mammary duct fistula


Breast

  • Antibiotics

    • Flucloxacillin &

    • Metronidaziole

  • NSAID

Central duct excision

(Hadfield operation)


Operations hadfield s major duct excision

Operations - Hadfield’s Major Duct Excision

  • Indications :

    • duct ectasia (periductal mastitis) with recurrent episodes +/- fistulae

    • blood stained discharge from one or more ducts in women > 40

  • Incision :

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

    • include the orifice of any sinus or fistula


Operations hadfield s major duct excision1

Operations - Hadfield’s 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


Lactational mastitis

Lactational Mastitis


Bacterial mastitis

Bacterial Mastitis

  • Cracks and fissures form in early breastfeeding

  • Secondary infection with Staph. aureus

  • Carried by nasopharynx of infant

    • Abscess

    • Chronic scar


Breast

Fever

Throbbing pain

Skin oedema

Aspiration of pus


Operation incision drainage breast abscess

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


Operations breast excisional biopsy

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.


Breast excisional biopsy

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


Breast

Fibrocaseous

Caseous form

Suppurative form

Sclerosing form


Tuberculosis

Tuberculosis

  • Antituberculous drugs

  • Cold abscess

    • Valvular incision

    • Local anti TB

  • Fibrocaseous

    • Simple mastectomy

    • Anti TB


Andi fibrocystic disease

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)

      • Brodie’s tumor (microcysts)


Presentation

Presentation

  • Mastalgia

    • Cyclical

    • Non-Cyclical

  • Lump - many causes

  • Periareolar Disorder

    • Nipple Discharge

    • Nipple Retraction


Cyclical mastalgia

Cyclical Mastalgia

  • Presentation

    • Median age 35 yrs

    • Premenstrual breast discomfort

    • Upper outer quadrant (often bilateral)

    • Relief during menstruation

    • Associated with nodularity

    • Aetiology presumably hormonal


Non cyclical mastalgia

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

    • Mondor’s Disease


Lumps

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


Nodularity

Nodularity

  • Often bilateral, upper outer quadrant

  • May be cyclical

  • Associated with mastalgia

  • Histology (ANDI)

    • Cysts

    • Fibrosis

    • Adenosis


Cysts

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


Galactocele

Galactocele

  • Solitary subareolar cyst

  • Dates from lactation

  • Contains milk

  • Can calcify

  • Can greatly increase in size


Cysts of the breast

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

Microcysts

Macrocysts

Duct papilloma

Papillary cystadenoma

Degeneration of carcinoma

Degeneration of sarcoma

Intracystic carcinoma


Nipple discharge

Nipple Discharge

  • Physiological - pregnancy/lactation

  • Duct Ectasia

  • Galactorrhoea

  • Duct Papilloma

  • Carcinoma

  • Cysts

  • Idiopathic


Galactorrhoea

Galactorrhoea

  • Milky discharge unrelated to lactation

  • Primary Physiological

    • Menarche

    • Menopause

    • Stress

    • Mechanical Stimulation

  • Secondary

    • Drugs: haloperidol, metoclopramide

    • Increased Prolactin: pituitary tumour, paraneoplastic


Management of breast symptoms

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


Breast lump cyst and mx

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


Palpable breast lump solid mx

Palpable Breast Lump - Solid Mx

FNA solid lump

Cytology

Mammography > 35

U/S

Tru-cut Ò biopsy (lump > 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 >35

  • Pt requests

  • pain

  • increasing size

  • equivocal cytology


No palpable breast lump mx

No Palpable Breast Lump Mx

no lump or diffuse nodularity

age < 40

age > 40

re-examine 6/52

Cytology

Mammography

U/S

benign

benign

suspicious or carcinoma

reassure

reassure

Manage as for breast cancer


Nipple discharge1

Nipple discharge

Nipple discharge

Unilateral

Bilateral (multiductal)

Multiductal

Uniductal

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


Fibroadenoma

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)


Fibroadenoma histopathology

Fibroadenoma - histopathology

  • Well formed capsule

  • Delicate stroma surrounding glandular and cystic spaces

  • Epithelium compressed and distorted by the stroma

  • + Coarse calcification


Benign tumors

Benign tumors


Giant fibroadenoma

Giant Fibroadenoma

  • Peripubertal age group

  • > 5cm

  • Rapid growing

  • Esp. Asian, black women

  • Benign tumour

  • Occasional atypia


Phylloides tumour

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


Duct papilloma

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


Operations microdochectomy

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


Operations microdochectomy1

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


Breast procedures operations

Breast Procedures & Operations

  • Procedures

    • FNA

    • Tru-cutÒ needle biopsy - superceded by gun Bx

  • Operations

    • Excisional biopsy

    • Microdochectomy

    • Hadfield’s Major Duct excision

    • Incision and drainage of breast abscess - often needle aspiration with antibiotics is used


Gynecomastia

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


Gynecomastia etiology

Gynecomastia (etiology)

  • Physiological

    • Neonatal

    • Pubertal

    • Involutional (senescent)

  • Pathological

  • Decrease production or action of testosterone


Gynecomastia1

Gynecomastia

  • Pathological

    • Decrease production or action of testosterone

      • Klinfelter’s syndrome

      • Testicular feminization syndrome

      • Anorchism

    • Increase production or action of estrogen

      • Pituitary tumors

      • Adrenal hypoplasia( addisson’s)

      • Testicular tumors ( Teratoma)

      • Liver failure

      • Hyperthyroidism

      • Estrogen treatment

      • Drugs

        • Reserpine, methyldopa

        • Isoniazid

        • Spironolactone

        • Tagment, primperan, H2 blockers

  • Idiopathic


Gynecomastia treatment

Gynecomastia (treatment)

  • Physiological No treatment

  • Pathological

    • Treatment of the cause

    • if persist excision

  • Idiopathic

    • excision

      • Sub mammary

      • Circum areolar


Gynecomastia2

Gynecomastia


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