BREAST Begashaw M (MD)

Introduction Modified sweat gland - produces milk Breast ca - most common cause of death Benign conditions  discomfort  confusion with neoplastic disease

Anatomy overly -2 nd – 6 th rib - from lateral border of sternum to anterior axillary line, between clavicle & to the 7 th & 8 th ribs below Ligaments of cooper Areola  contains involuntary muscles nipple  covered by thick skin lactiferous ducts Lymphatics -axillary lymph nodes on the ipsilateral side

Anatomy

Breast lumps  DDx Cancer Fibrocystic change Fibroadenoma Fat necrosis Duct ectasia lipoma TB

Breast cyst Rare due to a nonintegrated involution of stroma & epithelium often multiple & may be bilateral Diagnosis –aspiration/ultrasound Treatment – Aspiraton

Fibroadenoma  Most common in women age < 30  C/F Nodules  smooth, rubbery, discrete, well-circumscribed, non- tender, mobile  Ixs -biopsy -ultrasound -FNA  Treatment _Generally conservative: serial observation _Consider excision if size 2-3 cm & rapidly growing

Fibroadenoama

Phyllodes Tumor _Are benign tumors _Usually occur in women over 40 years _large, massive tumor with unevenly lobulated surface and occasionally with ulceration of overlying skin _Treatment – Enucleation _ Simple mastectomy

Phyllodes Tumour

Ductectasia/ periductal mastitis is dilatation of breast ducts associated with periductal inflammation Pathogenesis _ Dilatation of lactiferous ducts  filled with a stagnant brown or green secretion  discharge _irritant reaction in surrounding tissue leading to periductal mastitis

 Clinical presentation -Nipple discharge -subareolar mass -Abscess -Mammary duct fistula/nipple retraction  Treatment -Excision of all major ducts

Investigation of a Breast Lump

Acute mastitis  is acute inflammation of the breast  Bacterial mastitis is the commonest variety of mastitis and nearly always commences acutely  associated with lactation Cause  staphylococcus aureus  Clinical presentation - Pain - Swelling - Redness - Tenderness/hotness - abscess

Treatment  Antibiotics – cloxacillin  Breast rest  breast-feeding on the opposite side only  Support breast  Local Heat/Analgesics

Breast abscess If acute infection of breast doesn’t resolve with in 48 hours/tense induration  Abscess Fluctuation is a late sign When doubt exists  incision & drainage Treatment – incision & drainage

Lactational breast abscessNonlactational breast abscess

Breast abscess drainage

Breast Carcinoma is the commonest cause of death in middle- aged women in western countries In our set up, increasing incidence is being observed

Risk Factors _ Gender -99% Female _ Age  80% >40 years old _ Prior hx of breast ca _1st degree relative _ Nulliparity, First pregnancy >30 years old, Menarche 55 yrs old _Decreased risk with lactation,Early menopause, Early childbirth _Radiation exposure _Obesity,Diet,Geography-western

Pathology Arise from the epithelium of the duct system May be entirely in situ or may be invasive Grades -Well differentiated -Moderately -Poorly differentiated Ductal carcinoma -Most common Lobular carcinoma -10 %

Breast cancer Locally advanced breast carcinoma

Nipple retraction

Spread  Local spread: increases in size & invades,involve skin,penetrate pectoral muscles & chest wall  Lymphatic spread _Axillary lymph node _Supraclavicular nodes _Contra lateral lymph nodes  Hematogenous  Bone(lumbar,Femur, thoracic vertebra, rib/skull) osteolytic) liver, lungs & brain

Clinical presentation  occurs commonly upper outer quadrant/UOQ  Local Findings _Hard, irregular lump _nipple retraction _Skin involvement with peau d’ orange _Frank ulceration & fixation to the chest wall

Signs and Symptoms 27 Most common: lump or thickening in breast. Often painless Change in color or appearance of areola Redness or pitting of skin over the breast, like the skin of an orange Discharge or bleeding Change in size or contours of breast

Signs of metastasis _Lymph node enlargement _Bone pain _cough  Chest x-ray, Serum alkaline phosphates & liver ultrasound

Prognosis - Tumor size & LN status - Invasive & metastatic potential - Histological grade - Estrogen receptor status - Patient age

Treatment  Multi disciplinary _Surgery _Radiotherapy _Medical therapy -Chemotherapy -Hormonal therapy