HEGAZY SURGERY

1. Diseases of the breast

2. © Breast diseases 20072
Index
Breast Injuries
Breast abscess
Normal anatomy & mammography
Fibrocystic disease
Simple cysts
Mammary duct ectasia
Breast neoplasms (Classification)
Duct papilloma
Breast lipoma
Fibroadenoma
Phylloides tumour
Cancer Breast
Ductal CA (Path)
Lobular CA (Path)
Paget’s disease
Triple assessment
Mammography
Isotope bone scan
Staging of CA breast
Ca breast gross pathology

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Diagnosis of breast masses
Triple
assessment
Clinical Imaging Histopathology
Index

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Breast Injuries
Blunt breast trauma can produce
1-Breast Hematoma
Following blunt trauma
or breast surgery .
Old organized
Hematoma without
overlying skin bruising
is difficult to diagnose
correctly except by
biopsy.
DD cancer breast
2-Traumatic Fat Necrosis
Trauma Fat Necrosis
Release of Fatty Acids F.A. +
Ca Ca Soaps (FBG)
Painless irregular hard mass
with no LN in the axilla with skin
tethering and even nipple
retraction
Trauma history is a trap,
Mammography is not conclusive
DD cancer breast
Biopsy: Foamy fat laden macrophages
Index

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Breast heamatoma following surgery
Index

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Acute Inflammation of the Breast
Etiology: organisms, predisposing factors,
routes of infect.
Pathology: sites: (pre,intra or
retromammary)
Breast Abscess
Stages:
Milk engorgement: Dull ache pain,
shivering, low grade fever wedge shaped
tender induration no signs of inflammation
Cellulites: Burning pain, high grade
persistent fever diffuse swelling with
tender red induration
Pus formation: Throbbing pain ,Hectic
fever local signs localized to one sector&
overlying skin pitting oedema
Index

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Sites:
Premammary
Intramammary
Retromammary
Breast Abscess
Etiology:
Organisms:
Predisposing factors:
Routes of infect:
Treatment:
Early & After pus formation
(stop lactation)
Hilton method
Index

8. © Breast diseases 20078
A thin skin margin with no retraction of either skin or nipple. The glandular tissue is interspersed with fat
and there are relatively regular bands of suspensory ligaments known as Cooper's ligaments. Note that
the radiograph shows no dominant or irregular mass and no evidence of any microcalcifications,
both are findings which may be observed in carcinomas.
Illustration & Mammography of normal breast
Index

9. © Breast diseases 20079
The normal mammography image shows a thin, regular skin line with a diffuse, even,
soft tissue density of the general glandular tissue and fatty structures organized in a
relatively regular way by Cooper's ligaments
Normal mammography (craniocaudal)
Index

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Normal variations
Fatty breast Dense breast
Index

11. © Breast diseases 200711
Pathology
The disease consists of 4
features that vary in extent
and degree
Adenosis,
Epitheliosis (atypical
epithelial hyperplasia),
Papillomatosis,
Fibrosis sometimes-
extensive forming hard
mass (sclerosing
adenosis) simulating
cancer.
Cyst formation.
Risk of malignancy.
Fibrocystic Disease
Fibroadenosis
Index

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Gross appearance of fibrocystic
changes in the breast.
Fibrocystic disease of
the Lt. breast
Fibrocystic
Disease
Index

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Simple cysts
Multiple circumscribed low soft tissue
dense lesions seen in both breasts
Ultrasound showing the typical
features of a simple cyst: a well
defined, anechoic (black) lesion
with posterior echoic
accentuation (white)
Index

14. © Breast diseases 200714
Mammary Duct Ectasia
Periductal or plasma cell mastitis
What is ectasia?
As a woman approaches menopause the
mammary ducts, which are located under the
nipple, become dilated . This dilation is called
ectasia.
Ectasia is a benign (non-cancerous) breast
condition.
Ectasia can lead to a blockage of the ducts.
As a result, fluid may become pooled and leak
into the surrounding tissue causing chronic
inflammation. If an infection, (also referred to as
periductal mastitis) occurs, it may cause scar
tissue to develop, thus drawing the nipple
inward. In addition, this infection may cause
breast pain and thick, sticky nipple discharge
Index

15. © Breast diseases 200715
Breast Neoplasm
Classification
Benign
Epithelial
Duct Papilloma
Mesenchymal
Lipoma Fibroma
Mixed
Fibroadenoma
Malignant
CARCINOMA
Lymphoma,
Sarcoma
Index

16. © Breast diseases 200716
Duct Papilloma
Pathology Situated in one of the major
ducts near its orifice usually single but
may be multiple and peripheral (Multiple
Papillomatosis)
Clinical Picture young adult female (30-45)
presenting with blood discharge from
the nipple, on examination a fresh drop of
blood is seen on pressure at a certain point or a
palpable small fusiform retroareolar mass is felt
(retention cyst due to obstruction of the duct by
clotted blood) pressure on it produces the
discharge.
• Investigations Benzedine test discharge is
+ve for blood.
Galactography using lipiodol shows regular
filling defect
• Treatment microdochectomy Index

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Lipoma in the breast
A large circumscribed radiolucent mass with
a thin capsule (arrow) and coarse
calcification
Index

18. © Breast diseases 200718
Fibroadenoma
Index

19. © Breast diseases 200719
A benign fibroadenoma of the breast is distinguished by its sharp margins and lack of
microcalcifications.
There is no skin retraction or extensions into the parenchymal tissue.
Fibroadenoma
Index

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Fibroadenoma
Mammography showed 9 mm solid nodule
Ultrasound showed oval, hypoechoic and
homogeneous mass, suggesting a benign lesion
Index

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Phylloides Tumour
Index

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Cancer Breast
Index

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Pathology
Ductal Carcinoma
In situ ductal
carcinoma
Invasive ductal
carcinoma
Inflammatory
carcinoma
Index

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Pathology
Lobular carcinoma
• Lobular Carcinoma In Situ (LCIS) RR10
premenoposal 1% in biopsies
Multicenteric, bilateral
• Invasive lobular carcinoma (ILC) 10%
Bilateral in 25% of cases
Prognosis remains unaffected when the
second tumour is not synchronus.
Index

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Pathology
Paget’s Disease
Index

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Paget’s disease of the nipple

27. © Breast diseases 200727
Advancer Paget’s disease of the
nipple with axillary LNs

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Diagnosis of cancer breast
 Open biopsy with frozen section
 MRI (Indications)
 Bone scan (Indications)
Index

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Fine needle
aspiration cytology True cut tissue
biopsy
Open biopsy with
frozen section
Histopathological assessment:
Index

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Radiological
assessment:
Breast US
Breast ultrasound is used as the initial method for evaluating the following symptomatic patients:
The young patient under 30 years of age.
The pregnant patient.
Follow-up of patients with fibrocystic disease (3-6 month intervals).
Breast ultrasound is used as a complementary examination to mammography in the following
situations:
Evaluation of dense breast tissue.
Evaluation of a mass demonstrated on mammography.
Guidance of biopsy needle or needle localization (see cyst aspiration image) Index

31. © Breast diseases 200731
Radiological assessment:
Mammography
Index

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Invasive duct carcinoma giving a speculate mass on mamography
Mammography :
Cancer breast
Index

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Small (7mm) infiltrative
ductal carcinoma
Index

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Mammography demonstrating a
focal area of soft tissue density
measuring 0.8 x 2.0 cm.
Architectural distortion and
microcalcifications are also
noted.
The mass is categorized as
'highly suspicious' for
malignancy
Pathology confirmed an
infiltrating, moderately
differentiated adenocarcinoma
with an extensive intraductal component
Index

35. © Breast diseases 200735
Malignant masses are often characterized by irregular tented boundaries with retraction of other
fibrous structures and may be accompanied by local skin thickening or microcalcifications
Notice the
retracted
nipple
Index

36. © Breast diseases 200736 Cranio-codal view Medio-lateral view
Mammography showing microcalcification
Close-up view
Index

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Ductal carcinoma insitu (high grade comedo type)
Irregular linear branching microcalcification
Index

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Cluster of very small microcalcifications with or without increased local density of the
breast is an important image finding indicating malignancy.
The finding merits specific attention even if it is not accompanied by any other of the
typical findings in carcinoma such as skin retraction or irregular mass boundary
Microcalcifications in intra-duct
carcinoma
Index

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Large malignant mass with skin retraction
Mammography : Cancer breast
Index

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Vertebral metastasis from cancer
breast
Isotope bone scan
Normal Multiple bone metastasis
Index

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Staging of Breast Cancer
TNM Classification
T = Tumour
T0 Carcinoma in situ
T1 Less than 2cm
T2 Tumor diameter 2-5cm
T3 Larger than 5cm
T4 Any size invading
skin,,chest wall
N = Nodes
N0 Nonpalpable axillary LN
N1 Ipsilateral mobile LN
N2 Ipsilateral fixed LN
N3 Supraclav.Int mammary
contralateral axillary LN
M = Metastases
M0 No metastases
M1 Distant metastases
Manchester Classification
Stage I Mass confined to the breast, skin
involvement over and smaller
Stage II Same + palpable mobile one group
of LN in Ipsilateral axilla
Stage III Same + one of the following:
1- Skin invasion larger than size of the mass
2- Mobile more than one group Ax.LN
3- Mass fixed to underlying muscles&fascia
Stage IV Same + one of the following:
1-Marked skin affection nodules,ulcer…
2-Fixed Ipsilateral.ax.LN.
3- Ipsilateral.supraclavicular LN
4- Mass fixed to chest wall.
5- Distant deposits,other
breast,contralateral.axilla
Index

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“Peau d'orange"
Breast carcinoma
Index

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Breast carcinoma
This is an old specimen
and the adipose tissue
has become rather dark
It shows an ill defined
grayish tumour in the
breast, through which
run yellow streaks of
necrosis.
The nipple is retracted
& the tumour is
infiltrating the
underlying pectoral
muscle.
Index

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Breast carcinoma
Pectoralis muscle
Tumour
Axillary LNs
Index

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Advanced fungating
cancer breast
Advanced CA
breast with
malignant ulcer &
nipple retraction

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Bilateral (axillary) accessory breasts