Breast

1. Breast

2. 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

3. Lobes and lobules • of gland in fat tissue stroma. • Ducts emerge from acini of glands • Smaller ducts join to form lactiferous ducts

4. Axillary A lateral thoracic Internal mammary A perforating Intercostal lateral Axillary vein Internal mammary V Intercostal veins Supraclavicular nerve Itercostal N sympathatic

9. Benign Breast Disease • Congenital Conditions • Traumatic Conditions • Infections • Aberrations of Normal Development and Involution (ANDI) • Neoplastic • Benign - Fibroadenoma

10. Congenital Conditions • Congenital • Supernumerary nipple along nipple line • Supernumerary breast • Aplasia – turners, Juvenile hypertrophy

12. Traumatic Conditions • Traumatic fat necrosis • Cracks of nipple • Hematoma • Traumatic mastitis • Milk fistula

13. 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

14. Mammary fistula • Congenital (rare) • Acquired • Varient of MDE • Incision and drainage of abcess in lactating breast

15. 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

16. 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

17. DuctEctasia andPeriductal Mastitis • Presentation • Nipple discharge - any colour • Nipple Retraction • Subareolar mass • Abscess • Mammary duct fistula • May mimic carcinoma

18. Duct ectasia Nipple discharge - any colour Nipple retraction Lump Abscess Mammary duct fistula

19. Antibiotics • Flucloxacillin & • Metronidaziole • NSAID Central duct excision (Hadfield operation)

21. 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

22. 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

23. Lactational Mastitis

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

25. Fever Throbbing pain Skin oedema Aspiration of pus

27. 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

29. 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.

31. 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

32. Fibrocaseous Caseous form Suppurative form Sclerosing form

33. Tuberculosis • Antituberculous drugs • Cold abscess • Valvular incision • Local anti TB • Fibrocaseous • Simple mastectomy • Anti TB

34. 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)

35. Presentation • Mastalgia • Cyclical • Non-Cyclical • Lump - many causes • Periareolar Disorder • Nipple Discharge • Nipple Retraction

36. Cyclical Mastalgia • Presentation • Median age 35 yrs • Premenstrual breast discomfort • Upper outer quadrant (often bilateral) • Relief during menstruation • Associated with nodularity • Aetiology presumably hormonal

37. 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

38. 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

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

40. 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

41. Galactocele • Solitary subareolar cyst • Dates from lactation • Contains milk • Can calcify • Can greatly increase in size

42. 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

43. Nipple Discharge • Physiological - pregnancy/lactation • Duct Ectasia • Galactorrhoea • Duct Papilloma • Carcinoma • Cysts • Idiopathic

44. Galactorrhoea • Milky discharge unrelated to lactation • Primary Physiological • Menarche • Menopause • Stress • Mechanical Stimulation • Secondary • Drugs: haloperidol, metoclopramide • Increased Prolactin: pituitary tumour, paraneoplastic

45. 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

46. 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

47. 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

48. 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

49. 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

50. 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)