الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا كلية الطب البشري قسم الجـراحـة الدكــتـور عاصم قبطان MD - FRCS 1st lecture M.A.Kubtan

The Breast Learning Objectives Appropriate investigation of breast disease . Breast anomalies and complexity of benign breast disease . The in-depth modern management of breast cancer . M.A.Kubtan

Comparative and Surgical Anatomy Human breast is overlying the chest wall between the second to the sixth ribs . It is extending from the lateral border of the sternum to the anterior axillaries line . A thin layer of mammary tissue extend from the clavicle above to the seventh or eighth rib below . From the midline to the edge of the latissmus dorsi muscle poseriorly . The axillaries tail of the breast is palpable in some normal subjects , and it may becomes palpable during pre-menstrual or during lactation . M.A.Kubtan

Continue Lobule is the basic unit of mammary gland ,number varies from 10 – 100 lobules . Lobules empty via ductules into lactiferous duct , their number 15 – 20 . Lactiferous ducts are lined by erectile myoepithelial cells with terminal ampulla . M.A.Kubtan

Continue The ligaments of Cooper are fibrous tissue filled with breast tissue. Areola contains involuntary muscle arranged in concentric rings. The areolar epithelium contains numerous sweat glands and sebaceous glands . During pregnancy sebaceous glands serve to lubricate the nipple during lactation ( Montgomery tubercles ) . M.A.Kubtan

Continue The nipple is covered by thick skin with corrugations. Near its apex lie the orifices of lactiferous ducts . The nipple contains an erectile smooth muscle fibers. M.A.Kubtan

Lymphatics of the Breast Lymphatics drains to axillary lymph nodes , and to internal mammory lymph nodes . The axillary lymph nodes receive approximately 85% of the lymphatic fluids . M.A.Kubtan

M.A.Kubtan

Anatomy of axillary lymph nodes Lateral. Anterior . Posterior . Central . Interpectoral. Apical. M.A.Kubtan

Investigation of breast Mammography . Mammography showing a carcinoma M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

MRI Magnetic resonance imaging M.A.Kubtan

Needle biopsy / cytology M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

Benign Breast Disease 30% of women will suffer from benign breast disorders . Most common symptoms are Pain , Lumpiness or a lump . The aim of treatment is to exclude cancer , and then to treat remaining symptoms . M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

Congenital abnormalities Amazia : congenital absence of breast in one or both breasts. Polymazia :accessory breasts ( most frequent site ) groin , buttock and thigh . They function during lactation . Mastitis of infants common in boys as in girls . M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

Injuries of breast Haematoma >>>> lump >>>> bruises . Traumatic fat necrosis >>>> acute >>>> or chronic M.A.Kubtan

Acute and sub acute inflammation of breast Bacterial mastitis less common now , mostly caused by Staphylococcus aureus . Clinical features : classical signs of acute inflammation , if not aborted later an abscess will form. Treatment in cellulitic stage broad spectrom anti biotics. If pus formed repeated aspiration pus culture and anti biotic cover , otherwise incision and drainage of breast abscess . M.A.Kubtan

M.A.Kubtan

Chronic intramammary abscess Tuberculosis of the breast . Actinomycosis rare . Mondor,s disease : thrombophlebitis of the superficial veins of the breast and chest wall , it may be idiopathic , or inflammatory , or of carcinogenic origin . M.A.Kubtan

M.A.Kubtan

The nipple Nipple retraction : benign simple in 25% is bilateral . Recent retraction : may be pathological . Chronic periductal mastitis . Circumferential retraction with or without underlying lump may indicate an underlying carcinoma. M.A.Kubtan

Discharge from the nipple A clear serous discharge may be physiological in a parous woman , or may be associated with duct papilloma. A blood stained discharge may be caused by duct ectasia, duct papilloma or carcinoma . A black or green discharge as a result of ductectasia . M.A.Kubtan

Duct ectasia / periductal mastitis Duct ectasia is dilatation of the breast duct associated with periductal inflammation . M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا كلية الطب البشري قسم الجـراحـة الدكــتـور عاصم قبطان MD - FRCS 2nd lecture M.A.Kubtan

Breast Cysts Commonly occur in the last decade of reproductive life. They are often multiple , may be bilateral and mimic malignancy . Diagnosis can be confirmed by aspiration and ultrasound . Treatment by aspiration , 30% will recur and require further aspiration and cytological examination . Histological examination advisable . M.A.Kubtan

Galactocele Rare , usually present as a solitary sub areolar cyst , and dates from lactation. It contains milk . In longstanding cases its wall tend to calcify . M.A.Kubtan

Fibroadenoma Usually arise in the fully developed breast . It is seen between the ages of 15 – 25 years . Occusionally occur in older women . It arise from hyperplasia of a single lobule and usually grow up to 2 – 3 cm in size . They are surrounded by a well marked capsule . A fibroadenoma does not require excision unless associated with suspicious cytology . Giant fibroadenoma occasionally occur during puberty , has the same treatment. M.A.Kubtan

Phyllodes tumour Benign tumour . Previously known as serocystic disease of Brodie . Or cystosarcoma phyllodes . Usually occur in women over the age of 40 years , but it can be appear in younger women . Present as a large ,some times massive tumour with unevenly bosselated surface , the remain mobile on the chest wall. Occasionally ulceration overlying skin occurs because of pressure necrosis . Histologically varies between benign and low grade malignancy ( locally malignant ) . Very rarely develop features of sarcomatous tumour . Treatment : (Enucleation – wide local excision – mastectomy ) M.A.Kubtan

M.A.Kubtan

Carcinoma of the Breast The most common cause of death in the middle aged women in western countries . In England and wales 1 in 12 women will develop the disease during their life time . M.A.Kubtan

Breast cancer Aetiological factors Breast cancer is the most common site-specific cancer in women It is the leading cause of death from cancer for women age 40 to 44 years It is extremely rare below the age of 20 It occurs more commonly in women with a family history of breast cancer radiation exposure M.A.Kubtan

Continue Diet : A high intake of alcohol is associated with an increased risk of developing breast cancer. There is an association between obesity and increased breast cancer risk. Because the major source of estrogen in postmenopausal women is the conversion of androstenedione to estrone by adipose tissue, obesity is associated with a long-term increase in estrogen exposure. M.A.Kubtan

Continue Hormonal factors : Increased exposure to estrogen is associated with an increased risk for developing breast cancer , therefore factors that increase the number of menstrual cycles, such as early menarche, nulliparity, and late menopause, are associated with increased risk. M.A.Kubtan

Pathology Breast cancer may arise from the epithelium of the duct system . May be insitu , common finding in screening of breast cancer . May be massive cancer . M.A.Kubtan

Continue Degree of differentiation of tumour : Well differentiated . Moderately differentiated . Poorly differentiated . M.A.Kubtan

Current nomenclature Ductal carcinoma most common . Lobular carcinoma 15% of cases . Mixed ( ductal & lobular ) . Rarer histological varient : Colloid carcinoma ( cells produce abundant mucin . Medullary carcinoma(marked lymphocytic reaction ) Tubular carcinoma . Inflammatory carcinoma ( rare , highly aggressive ). Carcinoma in situ (pre invasive cancer has not breached the epithelial basement membrane . M.A.Kubtan

Carcinoma in situ May be ductal ( DCIS ) . Or lobular ( LCIS ) . M.A.Kubtan

Staining Staining for oestrogen and progesteron receptors will indicate the use of adjuvant hormonal therapy with tamoxifen . M.A.Kubtan

Paget,s disease of the nipple Superficial manifestation of an underlying breast carcinoma . It presents as an eczema like condition . The nipple is eroded slowly and eventually disappears . M.A.Kubtan

Pagets disease left breast M.A.Kubtan

The spread of breast cancer Local spread . Lymphatic metastasis . Spread by the bloodstream . M.A.Kubtan

Clinical presentation Most breast cancer will present as a hard lump . It may be associated with indrawing of the nipple . Their may be skin involvement ( peau d,orange ). Ulceration or fixation to chest wall . Some times may present with local or distant metastasis . M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

M.A.Kubtan

Staging of breast cancer T N M T tumour . N lymph node . M metastasis M.A.Kubtan

Prognosis of breast cancer Size of tumour . Lymph node status . Presence of distal metatasis. M.A.Kubtan

Management of operable breast cancer M.A.Kubtan

M.A.Kubtan

Types of surgical treatment Simple mastectomy . Patey mastectomy ( simple mastectomy with axillary clearness ). Radical mastectomy . M.A.Kubtan

Conservative breast cancer Surgery Local excision : aimed at removing the tumour plus a rim of at least 1 cm of normal breast tissue . Quadrantectomy involves removing the entire segment of breast containing the tumour . Both of the above surgery are usually combined with axillary surgery . M.A.Kubtan

M.A.Kubtan

Supportive treatment Radiotherapy . Adjuvant systemic therapy ( chemotherapy ). Hormonal therapy . M.A.Kubtan

Gynaecomastia Idiopathic unilateral or bilateral . Hormonal , accompanied stilbesterol therapy for prostatic cancer . Some times occusrs in patients with cirrhosis due to failure of liver in metabolizing oestrogens. M.A.Kubtan

Carcinoma of the male breast 0.5% of all breast cancer . Predisposing factor gynaecomastia . Treatment surgical as in female breast . M.A.Kubtan

M.A.Kubtan