Basic knowledge for 5th year medical students

1. Dr. Mohammed Hajhamad
MB.ChB. (Egypt) M.S (Malaysia)
Department of Surgery
International Medical School
Management and Science University

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
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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
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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.
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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)
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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.
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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
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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.
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9. 12 February 2016 9

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.
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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.
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12. Bilateral athelia and unilateral
amazia
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13. Polythelia and polymazia
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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.
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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
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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
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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.
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18. Diffuse mastitis and
abscess
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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
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20. Chronic inflammatory
conditions
 Mammary duct ectasia
 Chronic abscess
 Tuberculosis
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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.
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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).
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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.
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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
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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).
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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.
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27. Investigations
 USG and mammogram
 Cytology of aspirated fluid, however, not
conclusive.
 If solid mass  FNAC
 Excisional biopsy if FNAC not available
or inconclusive.
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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.
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29. 12 February 2016 29

30. Neoplasms of the breast
Benign Malignant
Epithelial Duct papilloma Epithelial Carcinoma
Mixed (epith +
mesenchymal)
Fibroadenoma Mixed (epith +
mesenchymal)
Lymphoma
Fibrosarcoma
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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.
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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.
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33. Management
 Ductography  the lesion will be shown
as a filling defect.
 Treated by excision of the affected duct
(microdochectomy), send specimen to
HPE.
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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.
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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).
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36. Investigations
 Exclude malignancy
 USG or mammography.
 FNAC
Treatment:
Excision and HPE to confirm diagnosis.
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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.
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40. 12 February 2016 40

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.
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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.
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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.
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44. Pathology
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 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. 12 February 2016 45
Schirrhous
inflammatory
Paget’s

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
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48. Spread
 Blood stream spread: lungs, liver,
bones, brain and bones (axial skeleton)
(posterior intercostal vein and
paravertiberal plexus of veins)
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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 %
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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
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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
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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
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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.
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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
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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.
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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
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57. Staging
 TNM staging
 Manchester staging
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58. TNM Staging
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59. 12 February 2016 59

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.
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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
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62. Early detection
 Breast self examination (BSE)
 Screening programs.
- Clinical examination and a
mammogram.
- Proven to reduce mortality, early
detection and more conservative
surgery.
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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
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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
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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.
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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
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68. Reconstruction options after
mastectomy
1. Synthetic implant
2. Myocutaneous flap
e.g. TRAM
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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.
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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.
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72. Chemotherapy
 Rapidly progressive disease
 Premenopasual women
 ER-PR negative
 Failure of hormonal therapy
 Liver metastasis
usually CMF+Doxorubicin
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73. Radiotherapy
 For pain control, especially bone
metastasis.
 To control tumor fungating
 Superior vena cava obstruction
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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.
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75. Treatment of specific problems
 Hypercalcemia
 Pathological fractures
 Cerebral metastasis (steroids +
radiotherapy)
 Spinal cord decompression
 SVC obstruction (radiotherapy)
 Pleural effusion
 Liver metastasis
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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.
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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
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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.
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80. Investigations
 LFT and hormonal testing
 Biopsy if malignancy suspected
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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.
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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.
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