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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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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

  • of gland

in fat tissue stroma.

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

Axillary A lateral thoracic

Internal mammary A perforating

Intercostal lateral

Axillary vein

Internal mammary V

Intercostal veins

Supraclavicular nerve

Itercostal N


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

Mastitis neonatorum

Pubertal mastitis

Traumatic mastitis

Metastatic mastits

Mammary duct ectasia

Lactational mastits

Acute suppurative mastitis


Chronic non specific

chronic breast abscess


Pilonidal Disease

Postoperative Wound 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



Mammary duct fistula



    • Flucloxacillin &
    • Metronidaziole

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


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


Caseous form

Suppurative form

Sclerosing form

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



Skin cysts





  • Serous
  • Lymphatic
  • Blood
  • Inflammatory
    • TB cold abscess
    • Chronic abscess
  • Hyadatid





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
  • 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




bloody fluid

residual lump

then do cytology

& mammography

no blood

no residual lump

then no cytology

re-examine in 6/12


excisional biopsy

palpable breast lump solid mx
Palpable Breast Lump - Solid Mx

FNA solid lump


Mammography > 35


Tru-cut Ò biopsy (lump > 2cm)

suspicious or carcinoma

Manage 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.

  • 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






suspicious or carcinoma



Manage as for breast cancer

nipple discharge1
Nipple discharge

Nipple discharge


Bilateral (multiductal)







Duct ectasia

Duct papilloma

Duct carcinoma

Duct ectasia

Chronic absces

??? fibroadenosis



Duct ectasia

?? carcinoma





  • 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
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
  • 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
  • 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