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

Ducts emerge from acini of glands 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 sympathatic

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

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

Traumatic Conditions Traumatic fat necrosis Cracks of nipple Hematoma Traumatic mastitis Milk fistula

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 Congenital (rare) Acquired Varient of MDE Incision and drainage of abcess in lactating breast

Infections Acute Chronic Mastitis neonatorum Chronic non specific 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

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 Mastitis Presentation Nipple discharge - any colour Nipple Retraction Subareolar mass Abscess Mammary duct fistula May mimic carcinoma

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

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

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 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

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

Fever Throbbing pain Skin oedema Aspiration of pus

Operation - Incision & drainage 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 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 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

Fibrocaseous Caseous form Sclerosing form Suppurative form

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

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 Mastalgia Lump - many causes Periareolar Disorder Cyclical Non-Cyclical Lump - many causes Periareolar Disorder Nipple Discharge Nipple Retraction

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

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 Solitary subareolar cyst Dates from lactation Contains milk Can calcify Can greatly increase in size

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 Physiological - pregnancy/lactation Duct Ectasia Galactorrhoea Duct Papilloma Carcinoma Cysts Idiopathic

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 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 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 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 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 discharge Nipple discharge Unilateral Bilateral (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 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 Well formed capsule Delicate stroma surrounding glandular and cystic spaces Epithelium compressed and distorted by the stroma + Coarse calcification

Benign tumors

Giant Fibroadenoma Peripubertal age group > 5cm Rapid growing Esp. Asian, black women Benign tumour Occasional atypia

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 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 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 - 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 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 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) Physiological Neonatal Pubertal Involutional (senescent) Pathological Decrease production or action of testosterone

Gynecomastia Pathological Idiopathic 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) Physiological No treatment Pathological Treatment of the cause if persist excision Idiopathic excision Sub mammary Circum areolar

Gynecomastia