HEGAZY SURGERY

1. BENIGN BREAST
DISEASES
Mostafa Hegazy

2. Anatomy
Modified sweat gland between the superficial and deep
layers of the chest wall
Cooper’s Ligament Fibrous band of tissue
l

3. Hormonal Effects
Estrogen
Development of the breast and
lactiferous ducts
Progesterone
Secretory acinar tissue – lobules
Prolactin
Synergizes the effect of estrogen and
progesterone

4. Benign Breast Diseases
Congenital disorders
Traumatic
Hematoma Traumatic fat necrosis
Inflammatory & Infectious
ANDI
■ Cyclical nodularity and mastalgia
Breast cysts
Duct ectasia/periductal mastitis
Pregnancy-related:
■ Galactocele
■ Puerperal abscess
Neoplastic
 Fibroadenoma
 Phyllodes tumour
 Bengin intraductal papilloma

5. Benign Breast Diseases
 Glandular breast parenchyma
 Mass
 Asymmetric nodularity
 Pain
 Nipple-Areolar Complex
 Discharge
 Rash
 Retraction
 Surrounding breast skin
 Dimpling

6. Management
 History
 Clinical Breast Exam
 Breast imaging
 Tissue sampling
 Therapy

7. History
 Age
 Menarche
 Pregnancy
 Breast feeding
 Menopause
 Family History
 Prior biopsies
 Hormone therapy

8. Clinical Exam
 Inspection
 Skin
 Symmetry
 Masses
 Palpation
 Gland
 Axilla, Supraclavicular
spaces
 Nipple-areola complex

9. Examination of LNS
 Sitting posture
 Pulp of the fingers
 Axillary group of LNs
 Pectoral group
 Brachial group
 Subscapular group
 Central group
 Apical group
 Supraclavicular nodes

10. Congenital abnormalities
Amazia
Polymazia
Mastitis of infants
Diffuse hypertrophy
Inverted nipple
Benign Breast Diseases

11. Congenital disorders
Congenital absence of the right breast Bilateral accessory breasts.

12. Question
 22 yo female presents with a new right breast
mass. Complains of mild tenderness. No other
complaints. On physical exam, there is a 1 cm
nodule at the 2:00 position. Your diagnostic test
of choice is….
 Mammogram
 Ultrasound
 Excisional biopsy
 Incisional biopsy

13. INVESTIGATIONS IN
BREAST DISEASE

14. Triple assessment
Confident diagnosis in 99.9%

15. BREAST SONOGRAPHY
Not a screening tool
Palpable vs cystic
Mammographic detected lesion
Indications
If Mammography is uncertain
To differentiate solid from cystic lesion
If asymmetric density
Visualise lesions near chest wall.
Interventional procedures.
Evaluate site of lumpectomy.
Lesion at periphery of breast.
Evaluating after surgical augmentation.

16. Ultrasound
 Benign
 Pure and intensely
hyperechoic
 Elliptical shape (wider
than tall)
 Lobulated
 Complete tine capsule
 Malignant
 Hypoechoic, spiculated
 Taller than wide
 Duct extension
 microlobulation

17. Features of malignant lesion on
Sonomammography
STAVROS CRITERIA
 Spiculation
 Hypoechoic
 Irregular margins
 Posterior shadowing
 Depth :width ratio <1
 Microlobulation

18. MAMMOGRAPHY

19. Mammography views
Screening tool
Age of 40
Estimated reduction in mortality 15-25%
10% false positive rate
Densities & calcifications
Mediolateral oblique Craniocaudal

20. Mammography evaluation
Mass lesion
Density
Asymmetry
Malignant
Calcification
Benign
calcification
Well circumcribed –benign
Spiculated-malignant 95%
Low density benign ,high-malignant
Asymmetric involution in bbd.HRT
Trauma ,Intraductal CA
Fine ,numerous CA,only sign in early
noninvasive CA
Scattered ,round circumscribed
Ductectasia- needlelike
Arterial -parallel line
Fibroadenoma –popcorn
Microcystic disease-teacup
Fat necrosis-oilcyst calcification

21. Breast Imaging Reporting And
Data System BI-RADS
BI-RADS
Classification
Features
0 Need additional imaging
1 Negative – routine in 1 yr
2 Benign finding – routine in 1 yr
3 Probably benign, 6mo follow-up
4 Suspicious abnormality, biopsy
recommended
5 Highly suggestive of malignancy;
appropriate action should be taken

22. Calcification
 Macrocalcifications
 Large white dots
 Almost always noncancerous and require no
further follow-up.
 Microcalcifications
 Very fine white specks
 Usually noncancerous but can sometimes be a sign
of cancer.
 Size, shape and pattern

26. BREAST MRI
 To distinguish scar from
recurrence
 Gold standard for
imaging breast with
implants
 Detection of vertebral
body metastasis &
musculoskeletal
pathology
 Visualisation of axilla

27. BREAST MRI
Indications
Radiologically dense breasts when
mammography fails.
If Axillary node +ve and breast
normal after mammo and sonography.
To rule out multifocality
multicentricity before BCS.
To assess induction chemotherapy.
Followup after BCS.
•Contrast enhanced more sensitive

28. MRI
 High risk patients
 Personal history of breast ca
 LCIS, atypia
 1st degree relative with breast cancer
 Very dense breast
 High sensitivity (95-100%)
 10-20% will have a biopsy

29. MRI
Pre Gad Post Gad Color Overlay

30. THERMAL IMAGING(DIGITAL
INFRARED)
Thermal imaging is an advanced technology that creates a visual image of the
heat pattern of breast.

31. FINE NEEDLE ASPIRATION
CYTOLOGY
 Uses 21gauge needle & 10 ml
syringe
 Multiple passes through lump
without releasing negative
pressure
 Aspirate is smeared onto slide
& fixed
 Differentiates solid & cystic
lesions

32. FNA
 Fast, inexpensive
 96% accuracy
 Institution dependent
 Unable to differentiate
b/w in situ vs CA

33. CORE NEEDLE BIOPSY
If fnac is inconclusive
Advantages
 significant core of tissue obtained
 can distinguish invasive from intra ductal
carcinoma
 Grading of tumor
 To know ER/PR and Her 2 status
Disadvantage
seeding of malignant cells along needle tract

34. Core Needle Biopsy
 14-18 gauge spring loaded needle
 Tissue
 Multiple

35. Core needle biopsy under
ultrasound guidance

37. Large Core Biopsy
 6-14 gauge core
 Large samples
 Single insertion

38. When core needle biopsy is inconclusive
Whole tumour is removed preferably
if <4 cm in size
INCISION BIOPSY
Removal of small portion of
tumour
> 4cm in size
EXCISION BIOPSY

39. Excisional Biopsy
 Atypical lesions
 LCIS
 Radial scar
 Atypical papillary lesions
 Radiologic-pathologic discordance
 Phyllodes
 Inadequate tissue harvesting

40. OPEN BIOPSY(EXCISIONAL BIOPSY)
Most accurate and the Best Diagnostic
Procedure for a Suspicious Breast Lesion.
Complete excision with a rim of normal tissue
Plan the incision in such a way that
subsequent radical surgery can easily include
the scar.
Follow Langer’s line

42. MAMMOTOME
 Used for taking
stereotactic biopsy from
mammographically
detected breast lesions that
are not clinically palpable.

44. Core biopsy Vacuum Assisted

45. DUCTOSCOPE
 A fiber optic scope less
than a millimeter thick is
inserted into the milk duct
at the nipple and threaded
deep into the breast through
the duct.
 An imaging system
displays the output of the
scope on a computer
monitor.
 Samples of epithelial cells
can be collected
onto microscope slides for
further analysis.

46. DUCTOSCPOY
INDICATIONS
 Patients with pathologic nipple
discharge
 Patients who are at high-risk for
developing cancer but have normal
breast on examination and imaging
studies.

48. DUCTAL FLUID COLLECTION
After application of a numbing cream, a small clear
cap with a syringe attached is placed over the
nipple. This device (the nipple aspirator) is similar
to a small breast pump and is used to see if fluid
will come out of the nipple.
•To encourage fluid production,women are
instructed in breast massage and heat packs
may be used on the breasts.
•If fluid is not produced, the lavage is not performed.

49.  If fluid is obtained with the nipple
aspirator,then the lavage procedure is
started.
 One or two small dilators to help open the
duct.
 Then the ductal lavage catheter is inserted
and a small amount of lidocaine, as
anesthetic may be injected through the
catheter for comfort.

50.  Saline, is injected through the
catheter into the duct and the breast
massaged to bring ductal cells into the
chamber of the catheter.
 An empty syringe attached to the
catheter is used to collect the cells from
the catheter chamber.
 The cells are then placed in a
preservative and sent to the cyto -
pathologist where they are processed
and read much like a Pap smear.

51. DUCTOGRAPHY/GALACTOGRAPHY
A ductogram is a mammographic procedure that is
performed to help identify the breast duct that may be
the source of nipple discharge.

52. Ductal ectasia.- Craniocaudal ductogram shows a dilatedductal system.

53. Carcinoma. -craniocaudal ductogram shows an outlined intraductal
abnormality (arrow). Note the pleomorphic calcifications
(arrowheads)

54. BREAST IMAGING EMERGING
TECHNOLOGIES
 Digital mammography
 Use of FDG-PET
 Breast scintimammography
(nuclear medicine breast imaging- Miraluma
Tc-99m sestamibi compound)
 Computerised thermal imaging(CTI)
 Computerised tomographic
lasermammography (CTLM)

55. Breast imaging -emerging
technology
 Digital tomosynthesis or three dimensional
mammography
 Elastography
 Digital subtraction mammography

56. TUMOR MARKERS IN BBD
 Expression of P53 in immunohistochemical
staining identifies the sub group with maligant
potential
 Overexpresson of HER-2 in benign
proliferative lesion predicts increased risk

57. Case scenario 1
 25 year old female patient presented with a
lump in the breast.She gives a history of slow
growing lump not associated with any pain or
discharge from nipple & is very much anxious.

58. Possibilities????
 Fibro adenoma
 Phyllodes tumour
 Breast cyst
 Traumatic fat necrosis
 carcinoma

59. Fibroadenomas
 Second most common tumor of breast
 ANDI
 Represent a hyperplastic or proliferative process in a
single lobule
 Etiology is unknown, thought to be due to hormonal
influence
 Risk of malignant transformation is rare
 Resulting carcinoma is often a lobular carcinoma
 Mimic malignancy in pregnancy,HRT

60. Types
 Simple/solitary/small(2-3 cm)
 Multiple(>5)
 Juvenile-in young women between the ages of 10 -
18.
 Giant(>5cm)-rapidly growing,more common in
afro-caribbean population
 Complex -contain other histological changes such as
sclerosing adenosis, duct epithelial Hyperplasia,
epithelial calcification.
Associated with slightly increased risk of cancer

61. Clinical features
 Between the ages of 15-25 years & size of 2-3cm
 Painless lump- capsulated,smooth, firm, well
defined, nontender, BREAST MOUSE
 Confused with phyllodes
 Microscope-
intracanalicular pericanalicular

62. Diagnosis
 Clinical examination
 Ultrasound scan –circumscribed lobulated
mass
 FNAC/Core needle biopsy

63. Treatment
 conservative
 Surgery
 Very large/increasing in size
 Suspicious cytology
 Surgery is desirable
 Extracapsular excision with a 1cm rim of
normal tissue
 Newer techniques-laser ablation
&cryoablation

64. Fibroadenoma

65. PHYLLODES TUMOUR
Gk word phyllon

66. Phyllodes Tumor
 Proliferation of connective tissue with ductal
elements
 Whorled and cellular stroma
 Firm, lobulated
 2 to 40 cm in size
 10% malignant
 Treatment
 Wide excision

67. Histopathology
 Proliferation of intralobular stroma
 Fusiform fibroblast
 3 types:-
benign
borderline
malignant
(cellularity,atypia,mitoses &invasion by edges)

68. Phylloides vs Fibroadenoma
Phyllodes Fibroadenoma
Age Older(40-50y) Younger
Duration Rapid growth Slower
progression
Recurrence Common Less common
Size Large ,bosselated Smaller
Mammogram Round density with
smooth borders
Same
Ultrasound Cystic spaces +/- Same
Cytology More cellular,
malignant type
Same as low grade
phyllodes

69. Phyllodes Tumor

70. Management
Wide local excision
Benign
Borderline - Follow up
Malignant -SIMPLE MASTECTOMY

71. Traumatic Fat Necrosis
 Clinical features - Pain & lump in the breast
 Lump is hard - extensive fibrosis caused by
tissue reaction
 D.D : Carcinoma breast
 Mammography findings - density lesion; can
have calcifications; may mimic carcinoma
breast
 Treatment - excision of the lump

72. Breast cyst
 Definition – non integrated involution of breast tissue
 Age group – 30-50
 Multiple and bilateral
 Can mimic malignancy
 Confirmed by USG and
aspiration

73. Breast Cyst

74. No routine followup
No residual mass
No cyst recurrence
Surgical biopsy
Residual mass
Cyst recurrence (X3)
Non blood stained aspirate
FNAC/Surgical biopsy
Blood stained aspirate
Fine needle aspiration
Cyst
(Clinical diagnosis)
Routine followup

75. Case scenario2
 28 year old lady presenting with complaints of
pain in both her breast for the past 6 years &
increases just prior to menstruation, no pain
during her pregnancy and lactation.

76. MASTALGIA
Definition
types

77. Breast Pain
 Cyclical pain – hormonal
 Dull, diffuse and bilateral
 Luteal phase
 Treatment
 Reassurance
 NSAIDS
 Evening primrose oil
 Non-cyclical pain
 Non-breast vs breast
 Imaging
 Treatment
 Reassurance
 NSAIDS
 Evening primrose oil

78. CYCLICAL MASTALGIA
 Menstruating age group
 Hormone related-ANDI
 Dull diffuse bilateral
 Upper outer quadrant

79. ETIOLOGY
1. Relative hyperoestrogenism
2. Hyperprolactinaemia
3. Psychological
4. Caffeine
5. Abnormal lipid metabolism

80. RECENT THEORY
LOW EFA LOW PGE1
UNOPPOSED
ACTION OF
PROLACTIN

81. MANAGEMENT
1.Pain diary
2.Reassurance
3.Exclude caffeine
4.Low fat diet
5.Stop OCPs/HRT 7.drugs
6.stop smoking

82. PRIM ROSE OIL
BROMOCRIPTIN
E
GOOD
RESPONSE
DANAZO
L
TREAT 6
MONTHS
NO RESPONSE IN
4 MONTHS
GOSERELIN

83. NON CYCLICAL MASTALGIA
 CAUSES
1.musculoskeletal pain
2.teitz syndrome
3.malignancy

84. FEATURES
 Unilateral
 Chronic
 burning or dragging
 Pre and post menopausal

85. MANAGEMENT
 EXCLUDE MALIGNANCY
 TREAT THE CAUSE

86. The ANDI (Aberrations of Normal
Development and Involution )
 Breast –physiologically dynamic structure
 unifying concept of symptoms, signs, histology and
physiology
 Benign disorders are related to the normal processes of
reproductive life.
 spectrum ranges from normal to aberration to
sometimes disease.
 classification is not comprehensive

87. What is fibroadenosis?
ANDI
Age group :30-50 years
Aberration in normal cyclical hormonal effects
Cyclcial mastalgia with nodularity
 bloodgood’s bluedomed cyst

88. Fibrocystic Disease
 Clinical, mammographic and histologic
findings
 Exaggerated response from hormones and
growth factors
 Cyclical pain
 Nodularity – upper outer quadrants

89. Fibro-cystic Disease of the Breast
synonyms
Fibrocystic changes
Cystic Mastopathy
Chronic cystic disease
Mazoplasia
Cooper’s disease
Fibroadenomatosis
Reclus’s disease

90. Fibrocystic Disease
 Risk Factors
 Dense breast
 Sclerosing adenosis
 Atypical ductal, papillary, or lobular hyperplasia

91. ETIOLOGY
 Endocrine
 Disturbance of hypothalamic pituitary gonadal steroid
axis
 Altered prolactin profile
 Non endocrine
 Methylxanthines
 Stress catecholamines
 High saturated fat diet
 Iodine deficiency

92. Pathomorphology
 Fibrosis
 Cyst formation
 Adenosis
 Epitheliosis
 Papillomatosis
 Apocrine metaplasia

93. PATHOLOGICAL CLASSIFICATION
1 .NONPROLIFERATIVE LESIONS
Cysts and apocrine metaplasia
Duct ectasia
Mild ductal epithelial hyperplasia
Calcifications
Fibroadenoma
II. PROLIFERATIVE BREAST DISORDERS WITHOUT ATYPIA
Sclerosing adenosis
Radial and complexing sclerosing lesions
Moderate and florid ductal epithelial hyperplasia
Intraductal papilloma
III. ATYPICAL PROLIFERATIVE LESIONS
Atypical lobular hyperplasia(ALH)
Atypical ductal hyperplasia(ADH)

94. Clinical features
 lump
 Cyclical mastalgia
 Nipple discharge

95. Diagnosis
Triple assessment
Mamography

96. Treatment
Rule out malignancy
manage as cyclcial mastalgia

97. Surgical Treatment
Indications
a) intractable pain
b) florid epitheliosis on fnac
c) Blood good cyst

98. surgery
1. Excision of the cyst or localized excision of the
diseased tissue
2. Subcutaneous mastectomy with prosthesis placement

99. CASE SCENARIO 3
 30 year old female came to OP with
complaints of lump in both the breasts.Also
complains of discharge from both the breasts.

100. Possibilities???
 MALIGNANCY??
 Duct papilloma
 Duct ectasia
 Fibrocystic disease

101. Nipple Discharge
 Physiologic
 Bilateral
 Involves multiple ducts
 Heme (-)
 Non-spontaneous

102. Nipple Discharge
 Pathologic
 Unilateral
 Spontaneous
 Heme (+)
 Most common cause intraductal papilloma

103. Discharge from more than one duct
blood stained : duct ectasia
black/green : duct ectasia
purulent : infection
Serous : fibrocystic disease
duct ectasia
Milk : lactation
hypothyroidism
pituitary tumours
drugs

104. Approach to a patient
CLINICAL EXAMINATION
 Nature of discharge
 Mass present or not
 Unilateral or bilateral
 Single or multiple duct
 Spontaneous/expressed
 Relation to menstruation
 Pre/post menopausal
 Taking ocp/estrogen

105. Investigations
discharge analysis for malignant cells and occult blood

106. Mammography
 FNAC BIOPSY

107. Treatment
REASSURANCE
MICRODOCHECTO
MY
HADFIELD

108. DUCT ECTASIA
 Dilatation of the breast ducts associated with
chronic inflammatory response in the periductal
tissue

109. Pathogenesis
Duct
dilatati
on
Discharge
to
periductal
tissues Periducta
l mastitis
fistula
fibr
osis
abcess

110. Microscopy
foam cells
inflammatory cells

111. Clinical features
 Older age group
 Smokers
Nipple discharge: bilateral multifocal
,thick,opalascent,variable colour

112. Duct Ectazia complication
 Breast abcess
Tender subareolar mass
 Mammary duct fistula

113. Duct Ectazia complication
 slit like retraction of nipple

114. Investigations
 If mass or nipple retraction is present rule out
malignancy
Mammography
Cytology,histopathology

115. Cytology of discharge: foam cells
Ductography: ectatic ducts

116. Treatment
 Antibiotic
flucloxacillin and metronidazole

117. Bloody Nipple Discharge
Intraductal Papilloma
Single duct
Benign
4% of intraductal ca

118. INTRA DUCTAL PAPILLOMA
 Size: usually less than 0.5 cm, may be as
large as 5cm
 Site: lactiferous duct within 4 to 5 cm from
nipple orifice
 Gross: Pinkish tan friable ,attached to the
wall by a stalk

119.  Proliferative breast disease without atypia
 polyps of epithelium lined duct

120. Microscopy
Fibrovascular core
Papilloma
Duct

121. Clinical features
 Nipple discharge :unilateral,blood stained,from a
single duct
 Palpable mass/density lesion in mammography

122. Investigations
 Ductography :filing defect

123. Treatment
Surgery
 less than 30 yrs:microdochectomy
 more than 45 yrs:major duct
excision(Hadfield)

124. CASE SCENARIO 4
 24 year old lactating female presented in OP
with throbbing pain in the left breast and
fever…

125. Inflammatory & Infectious
 AcuteBacterial mastitis
 Chronic intramammary abscess
 Tuberculosis of the breast
 Syphilis Actinomycosis
 Mondor’s disease
 Duct ectasia/periductal mastitis
 Galactocele

126. Mastitis
 Mastitis
 Generalized cellulitis of the
breast
 Ascending infection
subareolar ducts
 commonly occurs during
lactation
 Staph. aureus
 Erythema, pain,
tenderness
 Treatment
 Abx
 Continue to breast feed
 Close follow-up

127. BBD IN PREGNANCYAND LACTATION
BACTERIAL MASTITIS
Types
1. Subareolar abscess
2. Intramammary abscess
3. Retromammary abscess

128. AETIOLOGY
 Staph aureus – penicillin resistant if hospital acquired
 Streptococus
Ascending infection from a sore and cracked nipple

130. TREATMENT
 Flucloxacillin or co-amoxiclav
 Support of the breast,local heat,& analgesics
 Incision & drainage
 Now recommended is repeated aspiration under antibiotics
 continue breast feeding
 close follow up
 Antibioma if I&D not done
 DD-inflammatory carcinoma of breast

131. OPERATIVE DRAINAGE OF A
BREASTABSCESS
 Local anaesthesia
 Radial or circumareolar incision
 drainage
 Septa is disrupted & wound is packed

132. MONDOR’S DISEASE
 Thromboplebitis of superficial veins of the breast & chest
wall
 Aetiology not known
 C/F – thrombosed subcutaneous cord
 DD – breast cancer
 Treatment – antiinflamatory medication
warm compresses & support
restriction of movement
symptoms persist - excision

133. Thrombosed subcutaneous cord

134. GALACTOCELE

135.  Definition
 Pathogenesis-inspissated milk
 c/f-pain & lump
 Diagnosis-needle aspiratation

136. Management

137. OTHER INFECTIOUS CONDITIONS
 Tuberculosis of breast
 Syphilis of the breast
 Actinomycosis

138. TUBERCULOSIS OF BREAST
 Multiple c/c abscess &
sinuses
 Bluish attenuated apearance
of surrounding skin
 Diagnosis
 Treatment

139. SYPHILIS OF THE BREAST
 Primary chancre of nipple
 Secondary lesions – diffuse mastitis

140. Male breast
 Contains only ducts
 No alveoli

141. BENIGN BREAST LUMPS IN MALES
 Gynaecomastia
 Fibroadenoma
 Phyllodes tumour
 Epidermal inclusion cysts
 Sub cutaneous leiomyoma
 Sub areolar abscess
 Intra mammary lymph node

142. GYNAECOMASTIA

143. ‫حجازى‬ ‫مصطفى‬
Thank You
Thank you
‫حجازى‬‫مصطفى‬