begnin breast conditions

1. Benign diseases
of the breast
Presented by:
OMAGOR HERBERT
BMS/3373/153/DU

2. Brief Breast Anatomy
• The breast is a mass of glandular, fatty,
and fibrous tissues over the pectoral
muscles of the chest wall.
• attached to the chest wall by fibrous
strands called Cooper’s ligaments.
• The fatty tissue gives the breast a soft
consistency.
• The mature breast lies cushioned in
adipose tissue between the subcutaneous
fat layer and the superficial pectoral
fascia
2

3. Anatomy cont..
• The protuberant part of the human breast is generally described as
overlying the second to the sixth ribs and extending from the lateral
border of the sternum to the anterior axillary line.
• A thin layer of mammary tissue extends considerably further, from
the clavicle above to the seventh or eighth ribs below, and from the
midline to the edge of the latissimus dorsi posteriorly.
• The axillary tail of the breast is of surgical importance. In some
normal subjects it is palpable and, in a few, it can be seen
premenstrually or during lactation.

4. Anatomy cont…
• A well developed axillary tail is sometimes mistaken for a mass of
enlarged lymph nodes or a lipoma.
• lobule is the basic structural unit of the mammary gland. The number
and size of the lobules vary enormously:
• they are most numerous in young women. From 10 to over 100.
• lobules empty via ductules into a lactiferous duct, of which there are
15–20.
• Each lactiferous duct is lined with a spiral arrangement of contractile
myoepithelial cells and is provided with a terminal ampulla, a
reservoir for milk or abnormal discharges

5. Anatomy Cont.
• The ligaments of Cooper are hollow conical projections of fibrous
tissue filled with breast tissue.
• These ligaments account for the dimpling of the skin overlying a
carcinoma.

6. Nipple
• Is covered by thick skin with corrugations.
• Near its apex lie the orifices of the lactiferous ducts.
• It contains smooth muscle fibres arranged concentrically and
longitudinally; thus, it is an erectile structure, which points
outwards.

7. The areola
• Contains involuntary muscle arranged in concentric rings as well
as radially in the subcutaneous tissue. The areolar epithelium
contains numerous sweat glands and sebaceous glands, the
latter of which enlarge during pregnancy and serve to lubricate
the nipple during lactation (Montgomery’s tubercles)
7

8. 8

9. LYMPHATC DRAINAGE
The lymphatics of the breast drain predominantly into the axillary and
internal mammary lymph nodes.
The axillary nodes receive approximately 85 per cent of the drainage
and are arranged in the following groups:
• lateral, along the axillary vein;
• Anterior, along the lateral thoracic vessels;
• Posterior, along the subscapular vessels;
9

10. • central, embedded in fat in the centre of the axilla;
• interpectoral, a few nodes lying between the pectoralis major and
minor muscles;
• apical, which lie above the level of the pectoralis minor tendon in
continuity with the lateral nodes and which receive the efferents of all
• The internal mammary nodes are fewer in number. They lie along the
internal mammary vessels deep to the plane of the costal cartilages,
drain the posterior third of the breast and are not routinely dissected
10

11. • The sentinel node is defined as the first lymph node draining the
tumour-bearing area of the breast

12. Blood supply
• Perforating branches of the internal mammary artery and intercostal arteries
• Lateral thoracic and acromiothoracic branch of axillary artery including the highest
thoracic, lateral thoracic, and pectoral branches of the thoracoacromial artery.
Venous drainage
• Follows the arteries.
• Through posterior intercostal veins, venous drainage communicates with the
vertebral venous plexus of Batson, which invests the vertebrae and extends from
the base of the skull to the sacrum, can provide a route for breast cancer
metastases to the vertebrae, skull, pelvic bones, and central nervous system.
12

13. Nerve supply of breast
• is by anterior and lateral cutaneous branches of 4th to 6th intercostal
nerves.
13

14. BENIGN DISEASES OF THE BREAST
• Only 1 in 10 patients referred to surgical clinics has a carcinoma – the
remainder have a variety of conditions going under the general title
of ‘benign breast disease’.
• up to 30 percent of women will suffer from a benign breast disorder
requiring treatment at some time in their lives

15. INVESTIGATION OF BREAST SYMPTOMS
• Although an accurate history and clinical examination are important
methods of detecting breast disease, there are a number of
investigations that can assist in the diagnosis. Examination precedes
palpation and requires careful observation of the patient both with
the arms at rest and also elevated to lift the breast
• Mammography
• Ultrasound
• Magnetic resonance imaging
• Needle biopsy/cytology
15

16. The triple assessment for breast symptoms

17. 17

18. Classification
1. Congenital disorders
I. Inverted nipple
II. Supernumerary breasts/nipples
III. Non-breast disorders including Tietze’s disease (costochondritis)
IV. Sebaceous cysts and other skin conditions
V. Amazia
VI. Polymazia
VII. Diffuse hypertrophy
VIII.Mastitis of the infant
18

19. 2.Injury- hematoma and traumatic fat necrosis
3.Inflammation/infection
Bacterial mastitis
Chronic intrammamary abscess
TB of breast
Actinomycosis
Mondor’s diease
Duct ectasia/periductal mastitis
19

20. 4. ANDI (abberations of normal differentiation and involution):
-Cyclical nodularity and mastalgia
-Cysts
-Fibroadenoma
- Phyllodes tumour
-Duct ectasia/periductal mastitis
5. Pregnancy-related:
-Galactocele
-Lactational abscess 20

21. Congenital
• Amazia
• Congenital absence of the breast may occur on one or both sides. It is
sometimes associated with absence of the sternal portion of the
pectoralis major (Poland’s syndrome).
• Polymazia
• Accessory breasts have been recorded in the axilla
• (most frequent site), groin, buttock and thigh.
• They have been known to function during lactation.
21

22. 22

23. Mastitis of infants
• Mastitis of infants is at least as common in boys as in girls. On
the third or fourth day of life, if the breast of an infant is pressed
lightly, a drop of colourless fluid can be expressed; a few days
later, there is often slight milky secretion, which disappears
during the third week.
• This is popularly known as ‘witch’s milk’ and is seen only in full-
term infants.
• It is caused by stimulation of the fetal breast by prolactin in
response to the drop in maternal oestrogens and is essentially
physiological.
• True mastitis is uncommon and is predominately caused by
Staphylococcus aureus. 23

24. Diffuse hypertrophy
• Diffuse hypertrophy of the breasts occurs sporadically in otherwise
healthy girls at puberty (benign virginal hypertrophy) and, much
less often, during the first pregnancy.
• The breasts attain enormous dimensions and may reach the knees
when the patient is sitting. The condition is rarely unilateral
• This tremendous overgrowth is apparently caused by an alteration
in the normal sensitivity of the breast to oestrogenic hormones.
• success in treating it with anti-oestrogens has been reported.
• Treatment is otherwise by reduction mammoplasty
24

25. Injuries of the breast
1. Haematoma
• Haematoma, particularly a resolving haematoma, gives rise to a lump,
which, in the absence of overlying bruising, is difficult to diagnose
correctly unless it is biopsied.
2. Traumatic fat necrosis
• Traumatic fat necrosis may be acute or chronic and usually occurs in
stout, middle-aged women. Following a blow, or even indirect
violence, a lump, often painless, appears.
• A blunt impact can interfere with local blood supply and, together
with a hematoma, cause fat necrosis. Another cause is the use of
therapeutic anticoagulants in patients with very large and pendulous
breasts in which very minor trauma may precipitate extensive 25

26. Inflammatory conditions
• Bacterial mastitis
• Bacterial mastitis is the most common variety of mastitis and is associated
with lactation in the majority of cases.
• Most cases are caused by Staphylococcus aureus .
• The intermediary is usually the infant; after the second day of life, 50% of
infants harbor staphylococci in the nasopharynx.
• The affected breast, presents with the classical signs of acute
inflammation. Early on this is a generalized cellulitis but later an abscess
will form. 26

27. • Tuberculosis of the breast
• Tuberculosis of the breast, is usually associated with active pulmonary
tuberculosis or tuberculous cervical adenitis.
It occurs more often in parous women and usually presents with multiple
chronic abscesses and sinuses and a typical bluish, attenuated appearance
of the surrounding skin.
the diagnosis rests on bacteriological and histological examination.
Treatment is with anti-tuberculous chemotherapy.
Healing is usual, although often delayed.
mastectomy should be restricted to patients with persistent residual
infection.
27

28. 28

29. Actinomycosis
• Actinomycosis of the breast is rarer still. The lesions present the
essential characteristics of faciocervical actinomycosis.

30. • Mondor’s disease
• Mondor’s disease is thrombophlebitis of the superficial veins of the breast
and anterior chest wall, although it has also been encountered in the arm.
In the absence of injury or infection, the cause of thrombophlebitis is obscure.
The pathognomonic feature is a thrombosed subcutaneous cord, usually
attached to the skin.
When the skin over the breast is stretched by raising the arm, a narrow,
shallow subcutaneous groove alongside the cord becomes apparent.
The only treatment required is restricted arm movement . It is often a self-
limiting disease without any recurrence, complication or deformity.
30

31. •Duct Ectasia
• uncertain aetiology
• tends to occur most often in multiparous females who have not
breastfed also occurs in nulliparous females
• progressive dilatation of the large or intermediate ducts with
surrounding chronic inflammatory change
•
• underlying mechanism for the duct dilatation is periductal
inflammation, leading to destruction of the elastic network with
fibrosis
31

32. • is often symptomless, but there may be a nipple discharge, pain usually
cyclical
• contraction of the periductal fibrosis may cause retraction of the nipple raise
the suspicion of carcinoma
• dilated duct may rupture into the surrounding stroma, lipid contents promote
a persistent inflammatory reaction
• accumulation of foamy macrophages and giant cells, and fibrosis
,microscopically resemble traumatic fat necrosis
• lesion may become palpable as a firm lump 32

33. • GALACTORRHOEA
• It is secretion of milk not related to pregnancy or lactation. usually presents
as a solitary, subareolar cyst . It contains milk and in longstanding cases its
walls tend to calcify. It is always bilateral.
• Primary galactorrhoea is due to: Stress and other factors. Its physiological
in puberty or menopause. Reassurance is the treatment.
• Secondary galactorrhoea is due to: Dopamine receptor blocking agents
like haloperidol, methyldopa, chlorpromazine, metoclopramide or by
hyperprolactinaemia due to pituitary tumours.
• Treatment of cause. 33

34. • Galactocele
• Seen in lactating women, Can also develop 6-10 month after
caseation of breastfeeding
• Its due to blockage of lactiferous duct resulting in enormous
dilatation of lactiferous sinus
• It contains milk and epithelial debris within
• It’s a retention cyst due to blockage of single duct which begins
under the areola
Clinical features
Lump in lower quadrant of the breast and usually unilateral,
large, freely mobile, soft, fluctuant with smooth surface and its
non tender. It is a retention cyst-subareolar type
34

35. • It may get precipitated, inspissated/thickened or calcified where it
will mimic carcinoma breast
• If it gets infected it forms an abscess
Treatment
• Aspiration of the content.
• Excision (submammary incision).
• Abscess when formed should be drained under general
anaesthesia under cover of antibiotics
35

36. • GYNAECOMASTIA (Greek—Women Breast)
• It is hypertrophy of male breast more than usual due to increase in
ductal (epithelial) and connective tissue (stromal) elements.
• Hormonal stimulation of male breast buds at the time of puberty results
in rudimentary growth.
• The same condition occurs in old age when certain drugs (digoxin,
spironolactone, cimetidine) and conditions (cirrhosis of the liver) can, by
interfering with sex hormone metabolism, induce growth of the breast
buds.
36

37. Aberrations of normal development and
involution
• Many of the conditions that this term encompasses are not truly
diseases but rather aberrations of normal development/involution of
the breast that occur from puberty to old age.
• Highlights the relationship between normal stages of breast growth
and the aberrations which represent a true disease
• This concept has been developed and described by the Cardiff Breast
Clinic.
37

38. 38

39. Breast lump
• A breast lump is a swelling, protuberance in the breast.
• A benign discrete lump in the breast is commonly a cyst or fibroadenoma.
• True lipomas occur rarely.
• Lumpiness may be bilateral, commonly in the upper outer quadrant or, less
commonly, confined to one quadrant of one breast.
• The changes may be cyclical, with an increase in both lumpiness and often
tenderness before a menstrual period.
39

40. Mastalgia
cyclical
• Pain related to menstrual cycle
• Seen in ANDI like fibrocystadenosis
Non cyclical
• Pain due to causes other than ANDI
like periductal mastitis, malignancy,
musculoskeletal pain, previous
surgery
• Its unilateral,chronic,burning/dragging
pain
• Occurs in pre and postmenopausal
age group
40

41. Treatment of breast pain
41

42. Breast cyst
• Occur most commonly in late decade of reproductive life as a result of
involution of stroma and epithelium. May be bilateral and may mimic
malignancy
• Diagnosis can be confirmed by aspiration and or ultrasound
• Typically present suddenly and cause alarm
• Prompt dx and drainage provides immediate relief
Treatment
Aspiration of solitary cyst or small collection cyst.
Core biopsy or local excision (If residual lump is present and fluid is
blood stained) this excludes cystadenocarcinoma which is more
common in the elderly
42

43. Fibroadenoma
• A benign encapsulated tumour
• Commonly in young females 15-25 years though also occur in much older women
• Hyperplasia of a single lobule of the breast can be;
- Pericanalicular-small and hard and mainly fibrous
- Intracanalicular-large and soft and mainly cellular
• Clinical features; Painless swelling in one of the quadrants
Its smooth ,firm ,non tender, well localized and moves freely within the breast
tissue hence known as mouse in the breast
Commonly in the lower quadrant but can occur in any quadrant
43

44. 44

45. • Investigations
• Mammography-shows a well localized smooth regular shadow
• FNAC
• Ultrasound-confirms solid nature
Treatment
Enucleation, Cryoblation or Echotherapy
45

46. Fibrocystadenosis (fibrocytic disease of the
breast/mammary dysplasia)
• Its due to ANDI of breast causing : Fibrosis, cyst formation, glandular
proliferation(Adenosis), hyperplasia(epitheliosis and Papillomatosis
Its an oestrogen dependent condition
One of the cysts may get enlarged to become a clinically palpable well
localized swelling-bluedome cyst of bloodgood
Diffuse small multiple cysts in fibrocystadenosis is called as
schimmelbusch’s disease .
46

47. • Clinical features
• Presentation is most common in menstruating age group
Bilateral ,painful ,diffuse ,granular ,tender swelling better felt with
palpating fingers and poorly felt with the palm
Not fixed to the skin,muscle or chest wall
Pain and tenderness are more during menstration(cyclical mastalgia)
It subsides during pregnancy ,lactation and after menopause
Dicharge from nipple when present will be serous or greenish(due to
mixture of serous exudates and ductal epithelial cell debris
47

48. Treatment
-Conservative
Oil of evening primrose, Gamolenic acid, Danazol, NSAIDS, Tamoxifen
-Surgery
Subcutaneous mastectomy
Excision of the cyst
48

49. Phylloides tumour (cystosarcoma phylloides/serocystic
disease of Brodie)
• It varies from almost a benign condition to a locally aggressive.
• usually occur in women over the age of 40 years but can appear in younger
Women.
• They present as a large, sometimes massive, tumour with an unevenly
bosselated surface.
• sometimes with a metastatic potentiality to lungs through blood.
49

50. Types
• Benign phylloides is commonest and needs excision
• Borderline phylloides is intermediate in nature needs wide local
excision with 1cm margine
• Malignant phylloides which is rare but an aggressive sarcoma
spreading through the blood commonly to lungs and needs total
mastectomy without axillary nodal addressing
It carries a poor prognosis
50

51. Depending on mitotic index and degree of pleomorphism they
are graded as low grade to high grade tumours.
• Gross ;large capsulated area with cystic spaces and cut surface shows
soft ,brownish , cystic areas,
• Microscopy ;it contains cystic spaces with leaf like projections hence the
name
• Cells show hypercellularity and pleomorphism
• It may be a variant of intracanalicular fibroadenoma of the breast
51

52. Treatment
-Excision or subcutaneous mastectomy
-Total mastectomy if malignant(sarcoma)
52

53. Duct papilloma
• Usually single lactiferous duct commonest cause of nipple discharge
and it causes ductal dilatation by blocking the duct
Clinical Features
• Papilliferous swelling usually near the nipple orifice
• Blood stained discharge from the nipple is common but it can also be
serous or serosanguinous
• A single papilloma is not premalignant but multiple ones in many
ducts can be premalignant
• Study of discharge and ductogram may be needed
53

54. 54

55. Disorders of the nipple
• Nipple retraction
• This may occur at puberty or later in life.
• It may cause problems with breast-feeding and infection can occur,
especially during lactation, because of retention of secretions.
A slit-like retraction of the nipple may be caused by duct ectasia and
chronic periductal mastitis, but circumferential retraction, with or
without an underlying lump, may well indicate an underlying carcinoma
• Treatment is usually unnecessary and the condition may
spontaneously resolve during pregnancy or lactation.
55

56. 56

57. • Cracked nipple
• This may occur during lactation and be the forerunner of acute
infective mastitis. If the nipple becomes cracked during lactation, it
should be rested for 24–48 hours and the breast should be emptied
with a breast pump
• Papilloma of the nipple
• Papilloma of the nipple has the same features as any cutaneous
papilloma and should be excised with a tiny disc of skin.
57

58. • Retention cyst of a gland of Montgomery
• These glands, situated in the areola, secrete sebum and if they
become blocked a sebaceous cyst forms.
• Eczema
• Eczema of the nipples is a rare condition and is often bilateral; it is
usually associated with eczema elsewhere on the body. It is treated
with 0.5% hydrocortisone
58

59. Discharges from the nipple
• A clear, serous discharge may be ‘physiological’ in a parous woman or
may be associated with a duct papilloma or mammary dysplasia.
Multiduct, multicoloured discharge is physiological and the patient
may be reassured.
• A blood-stained discharge may be caused by duct ectasia, a duct
papilloma or carcinoma. A duct papilloma is usually single and
situated in one of the larger lactiferous ducts; it is sometimes
associated with a cystic swelling beneath the areola.
• A black or green discharge is usually the result of duct ectasia and its
complications
59

60. References
• Bailey’s and love short practice of surgery. 27th edition,
• KUMAR AND CLARK, Clinical surgery. 3rd edition
• SRB’S Manual of surgery. 4th edition.
60