Breast diseases

Surgery
 INTRODUCTION
• The breast or the mammary gland is a
distinguish feature of mammalian .
From puberty to death , female breast is
subjected to constant physical as well as
physiological alterations that are related
to menses, gestation , pregnancy , and
menopause.
•
• One of every two women consult her
physician for breast complaints
• One of every four women will
undergo breast biopsy
• One of every nine women will
develop some variant of breast cancer
 EMBRYOLOGY
• Breast is a modified sweat gland developed as
an ingrowth from ectoderm and forms the
alveoli and ducts . The supporting vascular
connective tissue develops from mesenchyme
.
• At fifth and sixth week of fetal
development two ventral bands of thickened
ectoderm , mammary ridge , or milk line are
evident in the embryo , they extend from base
of forelimb to region of hind limb ( inguinal )
area .
• In human embryo ridges disappear early except for small
portion that persist in pectoral region
• Accessory mammary gland , and accessory nipples
may develop along the milk line.
• Mammary gland develops as an in growth of
ectoderm initiate primary buds in the underlying
mesenchyme . Primary buds initiate development of 15 to 20
secondary buds or lobes , from each lobe lactiferous duct
develops dilate forming sinus that opens into shallow
epithelial depression mammary pits
• At puberty female breast enlarge in response to
estrogen and progesterone secretion by the ovaries
 Congenital abnormalities
• 1- Amastia : Unilateral absence of the
breast
• 2- Polythelia : Supernumerary
nipple
• 3- Symmastia : medial
confluence of the breast ( webbing )
 Surgical Anatomy
• The breast is located within superficial fascia
of anterior chest wall . Composed of 15 to 20
lobes of glandular tissue of tutbuloalveolar
type . Adipose tissue interpose between
glandular lobules . Subcutaneous connective
tissue surround the gland , extend as septa
between lobes and lobules providing stromal
support . On deep layer of superficial fascia
lies posterior surfaceof the breast adjacent to
pectoral fascia
• Retromammary bursa between deep layer of
superficial fascia and deep investing fascia of
pectoralis major muscle
• Mature female breast extends from level of
second rib to mammary fold at fifth aand sixth rib ,
from lateral border of the sternum to anterior
axillary line . Posterior surface rest on pectoralis
major , serratus anterior, external oblique, and upper
end of rectus muscle . The axillary tail of Spence
extends superlaterally into anterior axillary folds .
 Breast at Maturity
• At maturity the breast is cone shape the base
is circular 10 to 12 cm diameter and the hight
is 5-7cm. There is tremendous variations in
size, contour ,and density .
 Nipple and areola
• This complex is highly pigmented with variable
corrugate areola , covered by keratinized squamous
epithelium . During pregnancy the skin is pigmented
and nipple is elevated . The nipple is composed of
smooth muscle bundles arranged radially,
circomferencially longitudinally along lactiferous
duct . Smooth muscle is responsible for nipple
erection which occurs with sensory and thermal
stimuli
•
 Blood supply
• Breast receives blood supply mainly from
• Perforated branches of internal mammary artery
• Lateral thoracic artery
• Thoracolumber artery
• Perforating branches of posterior intercostals arteries
• Venous drainage of same name as well as vertebral
venous plexus of ( Baston ) extend from base of the
skull to sacrum , route for secondary metastasis
 Lymphatic drainage of the breast
• Boundaries of lymph drainage of the axilla
•
• Axillary vein group
• Lateral group 4to 6 nodes mdial or posterior
tovein receive lymphatic from upper limb
• Anterior pectoral group
• 4to 6 nodes along the lower border of
pectoralis minor
• Scapular group
• 5to 6 nodes drainposterior wall of the axilla
• Central group
• 3to4 glands embedded in fat of the axilla
• Apical group ( Subclavicular ) 6to 12 glands
• Interpectoral ( Rotters ) 1to4 glands
between pectoral muscles pass to central
group then to apical group
• Nodes groups are assigned level according to
their relation to pectoralis minor muscle
• Level one
• Nodes lateral or below pectoralis
minor
• Anterior pectoral
• Lateral group
• Scapular
• Level two
• Nodes deep or behind pectoralis
minor
• Interpectoral
• Central
• Level three
• Nodes medial or above upper border
of pectoralis minor
• Subclavicular or apical
•
 Breast physiology
• Mammary gland development and functions are
initiated by variety of hormonal stimuli
• Estrogen ,progesterone and prolactin have trophic
effect
• Prolactin, thyroid hormones ,growth hormones for
lactogensis
• Oxytocin initiates contraction of the smooth muscle
myoepithelial cells that surround alveoli and
compress it for milk expulsion , oxytocin released is
assisted by visual, olfactory auditory stimuli that
helps nursing
 Evaluation of the patient with breast
disease
• Presentation of breast complaints
• Painless lump
• Painful lump
• Pain and tenderness no pain
• Nipple discharge
• Change in nipple and areola
• Change in breast size
• Painless lump
• Carcinoma
• Fibroadenoma
• Cyst
• Fibroadenosis
• Painful lump
• Mastitis
• Breast abscess
• Fibroadenosis
• Painless lump
• Carcinoma
• Fibroadenoma
• Cyst
• Fibroadenosis
• Painful lump
• Mastitis
• Breast abscess
• Fibroadenosis
• Change in breast size
•
• Pregnancy
• Giant fibroadenoma
• Benign hypertrophy
• Phylloid tumour
• Carcinoma
• Sarcoma
 Breast examination

•
Inspection of breast and chest
wall
Palpation of breast , axillary
lymph nodes and cervical
nodes
Abdominal examination
Chest examination
Examination of the spine
 Special investigations of the breast
diseases
• Image techniques
• Mammogrophy
• Altasound
• Ductography
• Tissue diagnosis
• Cytology
• Biopsy
• Mammography (Mammogram )
• It is breast X-Ray that could be
• A/ Conventional , low dose done in two views oblique mediolateral
and craniocaudal
• B/ Xeromammography . Image recorded on xerograph plate rather
than transparency , image produced is positive than negative
•
 Uses of mammography
• Examination of an determined mass that
presents as solitary lesion , that may be
neoplasm
• Follow up of breast cancer patiented by
segmental resection or mastectomy
• Screening program
Important signs to be seen in X-ray
– Fine calcifications micro calc ifications indicate ca
– Parenchymal distorsion
– Poorly defined mass lesion
– Stellate opacities
– Speculations
 Current guide lines for screening
• -Base line mammogram at 35 years
• - Regular mammogram from
45 years
• Ultrasongraphy of the breast
– Non ionizing radiation
– High patient acceptance
– Helpful in cystic lesion helps aspiration and provide
material for cytology
– It can differentiates between cystic lesions and solid
neoplasms
– Resolution inferior to mammogram
• Ductography ( Ductogram )
• Ductograms are performed by
injecting radiopaque contrast into
mammary duct and take X-ray breast. Its
main indication is nipple discharge
 Localization of non palpable breast
mass
• Hooked wire technique
• Stereotacticneedle technique for biopsy and
fine needle aspiration cytology
•
 Benign diseases of female breast
– Painful breast
– Inflammatory diseases of the breast
– Cystic diseases of the breast
– Prolifrative disordes
• Galactocele
 Painful breast or ( mastalgia )
• Cyclical mastalgia
• Non cyclical mastalgia
• Cyclical mastalgia
• Relaed to
menstrual cycle
• Occuring
predominantly in premenstrual phase
• Pain can affect
quality of life
 Management

• Mammogram to above 35 years

• Treated by
bromocriptine 1to 2 mgram threetims daily or
danazole 100mg three times a day or
tamoxifen 20 mg daily
 Non cyclical mastalgia
• Not related to menstrual cycle
• The breast is
heavy and painful with discomfort
• Management
• Mammogram after 35
years
• Reassurance and
psychiatric consultation
 Inflammatory diseases of the breast
• Acute mastitis
• Acute bacterial mastitis or
puerperal mastitis
• It occurs during
puerperium and lactation
• Organism gets access
through acrackin the nipple
• Common organisms
are staphylococcus and streptococcus
 presentation
• Localized painful tender breast
• Diffused painful
tender breasy
• Fever and toxicity
• Necrosis pus
formatiom and abscess formation
•
 Management
• Antibiotics
• Antipyretics and
analgesics
• Cessation of breast
feeding from affected breast
• Repeated aspirations
• Surgical drainage of an
abscess
•
 Acute non lactational mastitis
• Asegment of breast become infected and
inflamed in nonlactating woman
•
• Treatment
• Antibiotics mainly
metronidazole
• Drainage of
collecting pusor abscess
 Chronic mastitis
• Chronic specific mastitis
• Due to tuberculous infection and
granuloma formation
• Chronic non specific infection or( chronic granulomatous
mastitis )
• Granulomatous disease of unknown origin
characterized by recurrent chronic inflammation of the
breast
• Paraffin and silicon granuloma
• Liquid paraffin and silicon used in breast augmentation can
induce inflammation with abscess formation and chronic
sinus
• Chronic specific mastitis
• Due to tuberculous infection and
granuloma formation
• Chronic non specific infection or( chronic granulomatous
mastitis )
• Granulomatous disease of unknown origin
characterized by recurrent chronic inflammation of the
breast
• Paraffin and silicon granuloma
• Liquid paraffin and silicon used in breast augmentation can
induce inflammation with abscess formation and chronic
sinus
 Cystic disease can present as
• Diffuse cystic lesion
• Localized thickening
• Tension cyst
• Management
• Diagnosis
• Aspiration of the cyst fluid sent for FNAC
• Excisional biopsy
•
 Feature of cyst that should raise
suspicion of malignancy
– Bloody aspirate
– Associated solid mass
– Multiple recurrence after aspiration
• Indication of breast excision
• -Residual palpable mass after complete
aspiration
• - Association with solid component
• -Bloody cystic fluid
• -Multiple recurrence
 Fibroadenoma
• This the commonest benign breast tumour in young
adult female
• It forms well demarcated painless
smooth firm lump which is characteristically highly
mobile hence known as breast mouse
• Fibroadenoma consist of fine connective
tissue and abnormal multiplicationof duct and acini .
Growth stops when the lesion reaches 3cm in
diameter . Fibroadenoma could be soft as well as
giant when very big in size
 Phylloid tumour ( Cystosarcoma
phylloides )
• Leaf like mass of tumour tissue which projects into
cyctic cavities and has sarcomatous appearance of
stroma on microscopy . The tumour is fibroepithelial
in origin
• Clinically the tumour present as a rapidly
growing unilateral breast mass in women age 40to50
years
• Management
• Small tumour is treated by wide
local excision larger tumour is treated by mastectomy
 Diseases of nipple and areola
• Ductectasia is a condition characterized by dilatation of the
major ducts which is filled with inspissated creamy secretion
and by periductal inflammation in which round cells
predominate . The condition can produce one of the
following
• Bloody ,serous, creamy nipple discharge from one or more
ducts
• Nipple retraction or inversion
• Acute inflammation in a breast segment which may lead to
non lactational mastitis
• Chronic inflammation of a localize area ( plasma cell mastitis
)
• Retroareolar lump
 Management
• Ductectasia is treated by excision of the
affected ducts and surround tissue
 Duct papilloma
• Duct papilloma arises from the epithelium of the
main duct usually within 1cm from the nipple .
Bleeding from single point on the nipple is important
characteristic , and involved duct has dilated slit like
orifice
• Management
• Mammogrophy
• Ductography
• Surgical excision of the involved duct
•
 Carcinoma of the breast
• Etiology
• Types of breast cancer
• Biological behavior
• Diagnosis
• Staging of breast cancer
• Screening of breast cancer
• Treatment of patient with breast cancer
 Incidence
• The commonest cancer in women after lung
cancer
• In U.K. 7% women develop cancer of the
breast .
• Incidence varies with countries ,
common in high social class
 Etiology
• The cause is unknown
• Risk factors
• Affected first degree relative inherited as autosomal
dominant triat through chromosome 17
• Dietary factor . There is casual relationship existing
between dietary mammalian fat and breast cancer
• Obesity
• Hormonal
• Nulliparity
 Types of breast cancer
• Non invasive carcinoma ( Carcinoma in situ )
• Invasive carcinoma
•
• Non invasive carcinoma ( carcinoma in situ )
• Confine to duct and acini
• Not penetrating basement membrane of the epithelium
• Of two types ductal and lobular
• A/ Ductal carcinoma in situ : Mammographically detected
cancer
• B/ Lobulr carcinoma in situ : Incidental finding in biopsy
specimen
 Invasive breast cancer
• Pagets disease of the breast
• Invasive ductal carcinoma
• Invasive lobular carcinoma Adenoidcystic
carcinoma
• Sarcomas
• Pagets disease of the nipple
• It is an intrductal carcinoma presented as
chronic eczematoid eruption of the nipple . An intra
ductal carcinoma often involves epidermis of the
nipple and areola
• An intraepithelial tumour compose of single
small group of clear cells with large vesicle and
prominent nuclii . the pathognominic feature is
presence of very large vaculated cells Pagets cells
• Invasive ductal carcinoma
• Compsed of 90% of invasive breast
cancer the majority not otherwise specified .
Other types include medullary , colloid,
papillary and tubular
• Invasive lobular carcinoma
• Responsible of 10% of invasive breast
cancer characterized by bilaterality
,mulicentrility
 Biological behavior of breast cancer
• Invasive breast cancer spread locally to adjacent
breast tissue and then to regional lymph nodes and
then to blood stream or direct to blood stream .
Regional nodes commonly affected are lower axillary
group then central to apical and supraclaveicular
group of lymph nodes . From internal mammary
group of lymph nodes lymphatic could spread to
mediastinaland pleural nodes
• Haematogenous spread direct into
circulation then deposit in specific orgasm bones,
lung and liver
 Factors affect prognosis
• Biological behavior
• Size of the tumour
• Lymph nodes involvement
• Degree of differentiation
• Presence of hormone receptors
 Diagnosis of breast cancer
• By screening
• Clinical presentation
• Screening of breast cancer
• Due to the fact that breast cancer can present
as an incurable stage this had lead to interest in
earlier detection of the disease
• Methods of screening are
• Breast self examination
• Breast clinical examination
• Mammography
 Clinical diagnosis
• Clinical presentation
• Fine needle aspiration ccytology
• Mammography
• Tissue biopsy, Tru cut, excisional or incisional
 Clinical presentation
• Breast lump that is painless or with discomfort
• Common in the upper quadrant
• Nipple retreaction ,inversion.or bloody nipple
discharge
• Dimpling or puckering of the skin
• On palpation hard irregular mass is felt
• Localadvanced disease present with
• Skin ulceration
• Skin infiltration edema. Peou de orange
• Fixed mass
• Palpable hard axillary nodes
• Fine needle aspiration cytology ( F.N.A.C.)
• Provides material for cytology
• Differentiates solid from cystic lesions
• Mammography
• Has sensitivity of 90%
• Cancer appears as microcalcification or
dense opacity
• Tissue biopsy by Tru cut, excisional or incisional for
histological confirmation
 Triple assessment of cancer of the
breast
• Clinical examination
• Mammography
• F.N.A.C
 Staging of the breast cancer
• The staging of the breast cancer is an attempt to predict
potential survival from objective data . The two common
systems are
• Manchester system
• T.N.M ( Tumor Nodes .Metastasis )
• Number of physical and radiological parameters must be
evaluated
• Comperhensive history and examination
• Bilateral breast image
• Clinical pathological laboratory evaluation
• Abdominal ultrasound
• X-Ray chest
• Skeletal survey
 Hormone receptors
• Within cytosole of the cells of breast cancer
are specific protein that bind and transfere
steroid into cell nucleus to exert specific
hormonal effect two types of receptors
estrogen receptors and progesterone
receptors
 Treatment of breast cancer
• Treatment of carcinoma in situ
• Treatment of early breast cancer
• Treatment of locally advanced cancer
• Treatment of metastatic cancer
 Modules of treatment of cancer of the
breast
• Loco regional treatment
• A/ To breast
• B/ Axilla
• By
• Surgery
• Radiotherapy
• Breast : types of surgery done in ca breast
• Excisional biopsy
• Lumpectomy
• Mastectomy simple, modified radical and radical
• Axilla : types of surgery done in axilla
– Lymph node sampling
– Axillary clearance
 Radiotherapy
• Radiotherapy to breast and chest wall
• Radiotherapy to axilla
•
• Systemic treatment
•
• Chemotherapy
• Hormonal therapy
• Immunotherapy
• Treatment of noninvasive cancer of the breast (
Ca insitu )
 Lobular carcinoma in situ
• Lobular carcinoma in situ is considered as a risk
factor than true cancer therefore it is managed by
closed follow up
• Breast self examination six monthly
• Breast physician examination six
monthly
• Annual mammography
• Or
• Bilateral mastectomy with immediate
reconstruction if not willing to run the risk
 Ductal carcinoma in situ
• True cancer treated by
• Excision only , lumpectomy

• Excision of the lump,

irradiation to breast and chest wall
• Simple mastectomy
 Treatment of invasive breast cancer
• - Early stage breast cancer stage ( 1 and 11 )
• A/ Breast conservative therapy
• Lumpectomy, axillary dissection
and d breast irradiation
• B/ Simple mastectomy and reconstruction
• C/ Modified radical mastectomy and reconstruction
• PLUS
• Adjuvant systemic therapy
• Chemotherapy
• Hormonal therapy
• Locally advanced cancer ( stage 111 A&B )
• Stage 111A
• Modified radical mastectomy and
reconstruction
• Axillary dissection
• Post operative radiotherapy chest
wall and axillla
• Stage 111B
• Induction chemotherapy
• Modified radical mastectomy
• Disseminated breast cancer ( stage 1V )
• The plan of management in disseminated
cancer is to offer palliative treatment mainly
symptomatic treatment and to manage local or
systemic complication ie spinal collapse local
fractures hypercalcimia increase intracranial
pressure
• Systemic chemotherapy
• Hormnal therapy
• Immunotherapy
• Local treatment according to specific complication