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04 diseases of the breast tutorial hajhamad m

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Basic knowledge for 5th year medical students

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04 diseases of the breast tutorial hajhamad m

  1. 1. Dr. Mohammed Hajhamad MB.ChB. (Egypt) M.S (Malaysia) Department of Surgery International Medical School Management and Science University
  2. 2. Contents  Introduction  Congenital anomalies  Breast trauma  Mastitis and breast abscess  Chronic inflammatory conditions  Fibrocystic disease of the breast  Cysts of the breast  Breast neoplasms  Male breast 12 February 2016 2
  3. 3. Introduction  Breasts are modified sweat gland  Lie between skin and pectoral fascia  From 2nd to 6th rib  From lateral border of sternum to anterior axillary line.  May extends: upwards till clavicle downwards till below costal margin medially to midline laterally to posterior axillary line  Breast tail 12 February 2016 3
  4. 4. Introduction  Components: 1. Epithelia elements: Responsible for milk secretion and transport. 2. Supporting tissue: Fibrous septa, extend from pectoral fascia to skin, they divides the parenchyma into lobes. 12 February 2016 4
  5. 5. Introduction  Arteries: IMA Lateral thoracic art. Pectoral branch of acromio- thoracic art. Intercostal perforators  Veins: Axillary and internal mammary Intercostal veins  Azygos  Vertebral venous plexus. (importance) 12 February 2016 5
  6. 6. Breast lymphatics  There are about 35 LN  Three main groups 1. Axillary (75%) Pectoral, subscapular, lateral, interpectoral, central and apical. 2. Internal mammary 3-4 LN along internal mammary vessels. 12 February 2016 6
  7. 7. Physiology of the breast  Hormonal control 1. Oestrogen, adrnocortical steroids and growth hormone  development of ducts. 2. Progesterone  growth of lobules. 3. Prolactin  formation of alveoli 12 February 2016 7
  8. 8. Physiology of the breast  Physiological changes 1. Puberty: cyclical hormonal activity  growth, branching of the ducts and formation of ductules. 2. Menstrual changes: there will be cyclical changes with heaviness, discomfort, increased nodularity. 3. Lactation: -Drop in oestrogen, increase sensitivity to (prolactin, GH and cortisol)  milk production. - Suckling  stimulate prolactin and oxytocin  milk ejection. 4. Menopause: the lobules gradually disappear. 12 February 2016 8
  9. 9. 12 February 2016 9
  10. 10. Congenital anomalies  Nipple 1. Athelia: absence of the nipple. Rare, usually associated with (Amazia) 2. Polythelia: supernumerary nipples occurs anywhere along mammary ridges, from axilla to groin. 12 February 2016 10
  11. 11. Congenital anomalies  Breast 1. Amazia: absence of breast. Usually unilateral. 2. Polymazia: supernumerary breasts, due to persistence of extramammary portions of the mammary ridge. 3. Infantile gynecomastia: diffuse enlargement of male breast. Bilateral or unilateral. Due to maternal sex hormones. Usually disappears within six months. 12 February 2016 11
  12. 12. Bilateral athelia and unilateral amazia 12 February 2016 12
  13. 13. Polythelia and polymazia 12 February 2016 13
  14. 14. Trauma  Results in two sequences 1. Breast hematoma usually deeply seated hard mass resembles a carcinoma 2. Traumatic fat necrosis death of fat cells  fatty acids combine with calcium  calcium soap. - cyst contains thick oily fluid - hard mass resembles carcinoma - differentiation is by biopsy. 12 February 2016 14
  15. 15. Acute lactational mastitis and breast abscess  Aetiology: Staphylococcus aureus  clotting of milk in the ducts  obstruction  stasis. Organism reaches the ducts from the suckling infant mouth through a cracked nipples.  Predisposing factors: 1- milk engorgement 2- abrasions to the nipples by suckling 3- poor hygiene 12 February 2016 15
  16. 16. Acute lactational mastitis and breast abscess  Pathology: milk engorgement  diffuse inflammation  not treated  acute mastitis  abscess.  Predisposing factors: 1- milk engorgement 2- abrasions to the nipples by suckling 3- poor hygiene 12 February 2016 16
  17. 17. Acute lactational mastitis and breast abscess  Clinical picture 1. Dull aching pain, pyrexia, breast in engorged and tender. 2. Acute mastitis: high fever, sever tenderness and redness. 3. Acute abscess: throbbing pain, hectic fever, localized signs, pitting edema 4. Chronic abscess. 12 February 2016 17
  18. 18. Diffuse mastitis and abscess 12 February 2016 18
  19. 19. Treatment  Before development of abscess: - systemic antibiotics covering staph. (pencillin, cephalosporin) - breast support, reduces pain - local heat - advice breast emptying (breast bump) and or bromocriptine 2.5 mg BD.  Abscess: - drainage under anesthesia - US guided aspiration 12 February 2016 19
  20. 20. Chronic inflammatory conditions  Mammary duct ectasia  Chronic abscess  Tuberculosis 12 February 2016 20
  21. 21. Mammary duct ectasia  Unknown aetiology  Dilatation of major ducts, filled with creamy secretion with periductal inflammation.  May be asymptomatic, or - nipple discharge (bloody, serous, creamy white or yellow. - retracted nipple - acute inflammation - recurrent chronic inflammation with abscess formation.  Treatment: surgical excision of the major duct. Correction of nipple retraction. 12 February 2016 21
  22. 22. Chronic breast abscess  Result from improper treatment of an acute abscess.  The abscess is treated with prolonged antibiotics rather than adequate surgical drainage.  Its called “antibioma” where is bacteria is killed, but, pus remains in the breast with excess fibrous tissue formation.  The breast will be thickened and honeycombed with pus.  There will nipple retraction and skin puckering.  Treatment is excision (not incision). 12 February 2016 22
  23. 23. Tuberculosis of the breast  Rare disease  Usually associated with PTB or cervical TB.  Presents as either multiple cold abscess or sinuses, or nodules.  Axillary LN are enlarged and matted.  Diagnosis by biopsy (granulomma)  Treatment with antituberculous drugs.  Mastectomy for resistant cases only. 12 February 2016 23
  24. 24. Fibrocystic disease  Also known as mammary dysplasia, ANDI, fibroadenosis and chronic interstitial mastitis.  Aetiology unknown  Age 30-50 years, related to ovarian activity.  It represent a variation or aberration of normal changes during menstrual cycles, pregnancy, lactation and menopausal involution.  “ Aberration of Normal Development and Involution” ANDI 12 February 2016 24
  25. 25. Pathology  Upper outer quadrant  One or a mixture of the following: 1. Adenosis: glandular hyperplasia 2. Epitheliosis: solid epithelial hyperplasia within the small ducts. If atypical hyperplasia noted  a higher chance to develop cancer. 3. Fibrosis: replacement of elastic and fatty tissue with fibrous tissue. 4. Cyst formation: lined by epithelium and filled with clear yellow or brown fluid. (late menopausal age). 12 February 2016 25
  26. 26. Clinical picture  Asymptomatic  Palpable lump, may disappear if patient re- examined one week after menstrual cycle.  Painful nodularity: multiple painful small lumps related to menstrual cycle.  Mastalgia: usually cyclical, premenstrual, accompanied by enlargement and increased nodularity of the breasts.  Nipple discharge: clear, yellow, brown or green. 12 February 2016 26
  27. 27. Investigations  USG and mammogram  Cytology of aspirated fluid, however, not conclusive.  If solid mass  FNAC  Excisional biopsy if FNAC not available or inconclusive. 12 February 2016 27
  28. 28. Treatment It should be individualized  Exclusion of malignancy and reassurance is the most important  Cysts: can be treated by aspiration, if recur, excision.  Cyclic Mastalgia: Mild: breast support, day and night, reduce cafeen. Moderate: prolactin inhibitor e.g. bromocriptin. Sever: synthetic androgen, e.g. Danazol. 100 – 200 mg BD.  Atypical cells found in biopsy  patient should be instructed to perform monthly SBE and regular follow up. 12 February 2016 28
  29. 29. 12 February 2016 29
  30. 30. Neoplasms of the breast Benign Malignant Epithelial Duct papilloma Epithelial Carcinoma Mixed (epith + mesenchymal) Fibroadenoma Mixed (epith + mesenchymal) Lymphoma Fibrosarcoma 12 February 2016 30
  31. 31. Duct papilloma  Benign tumor from epithelial lining of main ducts near the nipple  Its can be either a lump or an ulcerated mass with bleeding discharge and bloody nipple discharge.  Can cause a retention cyst if the duct is totally blocked. 12 February 2016 31
  32. 32. Clinical features  Bloody or bloody stained nipple discharge.  A lump deep or near the areola. Pressure on it causing nipple discharge.  Sometimes, there is no swellings palpable, only discharge on pressure. 12 February 2016 32
  33. 33. Management  Ductography  the lesion will be shown as a filling defect.  Treated by excision of the affected duct (microdochectomy), send specimen to HPE. 12 February 2016 33
  34. 34. Fibroadenoma  It’s a benign neoplasm of the breast which affects both the fibrous and the glandular tissues, but fibrous element predominates.  The most common breast mass in young women  Age from 15-30 years  It can be hard (pericanalicular), tend to be small, or soft (intracanalicular), tend to be large.  Solitary or multiple, smooth surface, lobulated, well circumscribed, never attached to surrounding tissues.  Cut section shows whorled white fibrous tissue which bulges out of its surface. 12 February 2016 34
  35. 35. Clinical features  Hard type occurs in 20-30 years old  Soft type in 30-50 years old  Usually painless lump(s) which is indecently discovered.  Its small, nontender, spherical, firm, well circumscribed, with smooth surface.  High mobility is characteristic feature (breast mouse). 12 February 2016 35
  36. 36. Investigations  Exclude malignancy  USG or mammography.  FNAC Treatment: Excision and HPE to confirm diagnosis. 12 February 2016 36
  37. 37. 12 February 2016 37
  38. 38. Phylloides tumor  It’s a high cellular type of fibroadenoma which tends to grow rapidly.  Its named like that because the cut surface resembles a leaf or fern.  Its rarely malignant.  Can grow as big as 20-30 cm.  Its not attached to skin  Treatment is wide local excision  Mastectomy for huge tumor occupying the whole breast. 12 February 2016 38
  39. 39. 12 February 2016 39
  40. 40. 12 February 2016 40
  41. 41. Carcinoma of the breast  1 out of 8 women is expected to develop breast cancer sometime in her life.  It’s the most common cancer in women.  Risk increases with age  60 is the mean age of occurrence. 12 February 2016 41
  42. 42. Aetiology 1. Genetic factors: 5-10% BRCA 1 (chrom 17) BRACA 2 (chrom 13) Mother or sister BC  2.3 times risk Mother and sister BC  14 times risk 2. Endocrine factors: - early menarche <13 - late first pregnancy >30 - late menopause >50 - contraceptive pills, Unsure relationship. 12 February 2016 42
  43. 43. Aetiology 3. Precancerous lesions: - epithelial hyperplasia and duct papilloma  1.5-2 times - atypical epithelial hyperplasia  2-5 times - lobular or ductal carcinoma insitu  5-10 times. 4. Obesity: - high fatty diet - steroids 5. Previous affection of breast cancer in one side. 12 February 2016 43
  44. 44. Pathology 12 February 2016 44  Gross types 1. Schirrhous carcinoma (hard), 75% 2. Encephaloid carcinoma (brain-like), large, soft and brain-like. 3. Inflammatory carcinoma: rare, most malignant, infiltrating duct carcinoma resembles mastitis. 4. Paget’s disease: rare, intraductal carcinoma at the epithelium of a main lactiferous duct which then spreads to both skin and breast. There is nipple erosion. Mimics eczema. Carcinoma of the ducts Carcinoma of the lobules Paget’s disease Non-infilitrating (in situ) Non-infilitrating (in situ) Intraductal carcinoma (1%) IDC (75%) ILC (25%)
  45. 45. 12 February 2016 45 Schirrhous inflammatory Paget’s
  46. 46. Spread  Local spread: inside the breast, skin, muscles of chest wall and chest wall.  Lymphatic spread: - by embolism or permeation. - Mostly to axillary LN then internal mammary LN. - Supraclavecular LN involvement considered advanced disease. - Blockade of cutaneous lymphatics causes edema and pitting of breast skin, i.e. peau d’orange 12 February 2016 46
  47. 47. 12 February 2016 47
  48. 48. Spread  Blood stream spread: lungs, liver, bones, brain and bones (axial skeleton) (posterior intercostal vein and paravertiberal plexus of veins) 12 February 2016 48
  49. 49. Hormonal receptor status  Oestrogen-positive (ER-positive): 60% of tumors have a receptors for oestrogen, they get more active under its influence. Can be suppressed by reduced estrogen or giving an anti- estrogen agents.  Progesteron-positive PR-positive tumors  ER-PR- negative, 10 % 12 February 2016 49
  50. 50. Clinical features Symptoms:  Accidental painless lump  Pricking pain, nipple retraction or bloody nipple discharge.  Presents with metastasis, axillary lump, backache, pathological fractures, dysponea, pleuritic pain, jaundice or mental changes.  During screening programs 12 February 2016 50
  51. 51. Clinical features Signs Examination should be done while upper half of the patient exposed, both breasts, axillae, arms, supraclavicular regions all examined.  Breast: - asymmetry - enlargement - skin dimpling - skin puckering - peau d’orange - skin nodule - skin ulceration 12 February 2016 51
  52. 52. Clinical features  Mass: - hard - irregular - ill-defined - restricted mobility within breast substance - fixation to skin, muscles, chest wall  Nipple: - recent retraction - change of direction 12 February 2016 52
  53. 53. Clinical features  Axillary and supraclavicular nodes - number and mobility of nodes  Distant metastasis: - chest examination - hepatomegaly - ascitis - pelvic examination for hard deposits or Krukenberg tumor. 12 February 2016 53
  54. 54. Clinical features  Paget’s disease: - pricking sensation of the nipple - superficial erosion - a tumor mass may not be palpable - commonly mistaken for eczema - biopsy is mandatory to differentiate.  Inflammatory carcinoma: - usually occurs during pregnancy or lactation - rapidly growing, sometimes painful breast swelling. - overlying skin is reed, edematous and warm. - resembles acute mastitis - poor prognosis 12 February 2016 54
  55. 55. Clinical features  Carcinoma in situ - LCIS: found by mammogram and confirmed by biopsy. Doesn’t progress to invasive type. - DCIS: present as a mass or in mammogram, should be treated by surgery. 12 February 2016 55
  56. 56. Differential diagnosis Carcinoma Cyst Fibro-cystic fibroadenoma Age >35 35-55 35-55 15-30 Pain Painless Occasionally Occasionally Painless Surface Irregular Smooth Indistinct Smooth, lobulated Consistency Hard Soft to hard Firm Firm, highly mobile LN +/- axillay LN+ Free axilla Free axilla Free axilla 12 February 2016 56
  57. 57. Staging  TNM staging  Manchester staging 12 February 2016 57
  58. 58. TNM Staging 12 February 2016 58
  59. 59. 12 February 2016 59
  60. 60. Investigation Aims: 1. Diagnosis (USG, mammogram + HPE) 2. Staging (CXR+USG abdomen), CT scan, alkaline phosphatase. 3. Special situation: bone scan (bone pain) and brain CT scan. 12 February 2016 60
  61. 61. Investigations Tools 1. Mammography: 95% accurate. Usually combined with tru cut biopsy or FNAC. - dense opacity with indefinite outlines - clustered microcalcifications. - less effective below age of 35 2. Ultrasonography: can differentiate between solid and cystic. Used in young women where mammogram is not helpful. 3. Biopsy: - Excisional - frozen section biopsy - tru-cut biopsy - FNAC 12 February 2016 61
  62. 62. Early detection  Breast self examination (BSE)  Screening programs. - Clinical examination and a mammogram. - Proven to reduce mortality, early detection and more conservative surgery. 12 February 2016 62
  63. 63. Treatment  Provided through an MDT  Depends on stage of the disease  Early vs. Advanced Early: any T2 N1 M0 or below, stage I&II (localized disease +/- micrometastasis) Primary treatment: Surgery +/- radiotherapy Advanced: more than T2 N1 M0, stage III&IV (systemic disease) Primary treatment: Chemotherapy and endocrine therapy 12 February 2016 63
  64. 64. 12 February 2016 64
  65. 65. Surgical options 1. Radical mastectomy (Hasted mastectomy), whole breast tissue pectoralis muscles+ all axillary LN are cleared. 2. Modified radical mastectomy (Patey), preserve the pectoralis muscles, usually followed by radiotherapy. 3. Breast conservative surgery: combined surgery and radiotherapy: <4 cm tumor - WLE ( 2 cm safety margins) - SLNB (+/-) Axillary clearance - postoperative radiotherapy 12 February 2016 65
  66. 66. Adjuvant therapy  Adjuvant chemotherapy: - to kill all micrometsasis - CMF regimens: cyclophsphamide, methotrexate and 5-fluorouracil X6  Adjuvant hormonal therapy: - antioestrogen, e.g. Tamoxifen mg BD for 5 years. 12 February 2016 66
  67. 67. Follow up  To detect and treat complications of mastectomy. (lymphodema, psychiatric disorder).  Detection of local recurrence or distant metastasis. 1%/year. Annual mammogram.  To give patients instructions: - not to get pregnant for 5 years - to use non-hormonal contraceptive 12 February 2016 67
  68. 68. Reconstruction options after mastectomy 1. Synthetic implant 2. Myocutaneous flap e.g. TRAM 12 February 2016 68
  69. 69. 12 February 2016 69
  70. 70. Advanced breast cancer  More than T2 N1 M0 or stage III&IV  Aim is palliative  It’s a systemic disease, so, chemotherapy and endocrine therapy are the primary options, surgery and radiotherapy are secondary options. 12 February 2016 70
  71. 71. Endocrine therapy  Postmenopausal women  ER-PR positive tumors 1. Tamoxifen (Nolvadex) 2. Oopherectomy for premenopausal women. 3. Progestins (medroxyprogesterone acetate) as second line therapy. 4. Aminoglutethmide, mainly for patients with bone metastasis. 12 February 2016 71
  72. 72. Chemotherapy  Rapidly progressive disease  Premenopasual women  ER-PR negative  Failure of hormonal therapy  Liver metastasis usually CMF+Doxorubicin 12 February 2016 72
  73. 73. Radiotherapy  For pain control, especially bone metastasis.  To control tumor fungating  Superior vena cava obstruction 12 February 2016 73
  74. 74. Role of surgery  Mastectomy for local control (toilet mastectomy) and to remove unpleasant or odorous tissue.  Internal fixation of pathological fractures  Urgent decompression and stabilization of vertebral bone fractures. 12 February 2016 74
  75. 75. Treatment of specific problems  Hypercalcemia  Pathological fractures  Cerebral metastasis (steroids + radiotherapy)  Spinal cord decompression  SVC obstruction (radiotherapy)  Pleural effusion  Liver metastasis 12 February 2016 75
  76. 76. Prognosis  Factors determines prognosis 1. Type of tumor 2. T-stage 3. Size, mobility, number and location of involved LN. 4. Presence of distant metastasis 5. Hormone receptor status 6. Site of tumor, medial half vs. lateral half. Why? 7. Tumor proliferation index. 12 February 2016 76
  77. 77. 12 February 2016 77
  78. 78. Aetiology Primary Infantile Pubertal Senile Secondary Orchidectomy Feminizing testicular tumors and suprarenal tumors Chronic liver disease Drugs, cimetidine, digoxin, spironolactone. Ectopic hormonal production, bronchogenic carcinoma 12 February 2016 78
  79. 79. Clinical features  Unilateral or bilateral breast enlargement without tenderness  Usually there is subareolar mass (disc) which is soft and mobile.  Examination should include abdomen and testis. 12 February 2016 79
  80. 80. Investigations  LFT and hormonal testing  Biopsy if malignancy suspected 12 February 2016 80
  81. 81. Treatment  Most cases (physiological) require no treatment, reassurance. Neonatal and adolescent resolve spontaneously.  Secondary gynecomastia, treat the underlying cause  Persistent gynecomastia, causing embarrassment can be treated with subcutaneous mastectomy. 12 February 2016 81
  82. 82. 12 February 2016 82
  83. 83. Male breast cancer  Rare  Because no breast tissue (fat) become rapidly attached to skin and chest wall, easily ulcerating.  Must be differentiated from gynecomastia  Staging is same as female breast cancer, but castration is the principal means for hormonal control  Prognosis is general worse than female breast cancer. 12 February 2016 83
  84. 84. 12 February 2016 84

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