Benign Breast Disease overview of BBD and surgical management

1. Benign Breast Diseases
By: Shaheed Alaamry
General Surgery

2.  Breast, a modified sweat gland lies in superficial fascia in pectoral
region with a small extension called as axillary tail of Spence into the
axilla.

4. Surgical Importance Of Cooper Ligament
 The breast is anchored to the skin and
underlying pectoral fascia by fibrous
tissue strands.
 If malignant cells infiltrates the
ligaments it become shorter and
inelastic and pulls the skin inwards
leading to dimpling or puckering
 If malignant cells infiltrate the whole
ligament to the skin, both tumor and
skin are fixed and cannot be moved
separately.
 Clinically the skin cannot be pinched
or moved separately from tumor.

5. The Quadrants :
 The breast is divided into 4 quadrants
 Upper Outer Quadrant
 Upper Inner Quadrant
 Lower Outer Quadrant
 Lower Inner Quadrant
 75% of the breast rests in the upper outer quadrant
and this accounts for the majority of pathological
diseases to occur in this region.

6. Arterial Supply
 Perforating branches from internal
mammary artery through 2nd , 3rd &
4th intercostals spaces.
 Pectoral branches from acromio-
thoracic artery supplying mainly
posterior surface of breast.
3. Lateral thoracic artery from axillary
artery.
 Lateral perforating branches from
intercostal arteries.

7. Venous Drainage
It is of two types :
 Superficial veins, these accompany the
lymphatics.
 Deep veins, these accompany the arteries
& they are :
 Anterior intercostals perforating veins →
Internal mammary veins.
 Multiple branches → Axillary veins.
 Posterior perforating branches → Intercostals
veins.
( The last route is of surgical importance )

8.  Normally blood flows from the plexus to
the venous system because the pressure
in the plexus is higher than that in the
venous system.
 In the case of Ca breast, when the intra-
thoracic or intra-abdominal pressure is
increased by coughing or straining, the
flow of blood is reversed because these
plexus & veins are valveless.
 The blood passes from posterior
perforating branches to intercostals veins
→ vertebral venous plexus →
metastases to vertebrae, skull, pelvic
bones & C.N.S without pulmonary
metastases

9. Lymphatic Of The Breast
1. Superficial parts of the breast) skin except
nipple and AreolaDrain to the deep pectoral
plexus on the pectoral fascia.
2. Deep part of the breast :
Is drained to the deep pectoral plexus on the pectoral
fascia, then to the anterior group, central group &
apical group of axillary lymph nodes, internal
mammary (IM), and clavicular lymph nodes.

10. Lymph Nodes
Lymphatic plexus drains the breast
to mainly two areas:
 85% to Axillary Nodes
 Internal Mammary and
Supraclavicular nodes

11.  Three Lymph Node Levels in the axilla in relation to the
pectoral minor muscle :-
 Level I – Lateral to Pectoralis Minor
(Anterior, posterior & lateral groups )
 Level II – Deep to Pectoralis Minor
(Central group )
 Level III – Medial to Pectoralis Minor
(Apical group )

12. Internal Mammary L.Ns :-
 Consists of 3-4 nodes on each side, lying along the
internal mammary vessels in the first three intercostal
spaces.
 Receive part of lymph from medial half of the breast.
 Communicated with opposite side

13. Surgical Importance Of Lymphatic
Drainage Of The Breast
 All lymphatics of the breast are first drained on the
deep plexus situated on the pectoral fascia.
 In mastectomy for Ca breast, the pectoral fascia over
the pectoral major muscle should be shaved or removed
to eradicate any focus of malignant cells and avoid the
recurrence.

14. Comment
 Cancer situated in the lower inner quadrant is close to the
xiphisternum & lymphatics communicate with sub-peritoneal
lymph plexus Cancer cells may form :
 Secondary deposits in the liver by implantation.
 May spread along falciform ligament to form malignant nodules
around the umbilicus called Sister Mary Josef nodes.
 May spread through transcoelomic route and implant on the
ovary leading to Krukenbergs tumor.
 May deposit on Douglus pouch which becomes hard and fixed
frozen pelvis called Plummer’s shelf.

15. Congenital Abnormalities Of Breast
 The milk line is an ectodermal thickening appearing at 6
weeks of gestation running from axilla to the midportion
of inguinal ligament
 breast tissue with or without a nipple or just nipple and
areola alone can occur any where along the milk line
1- Athelia : absence of nipple.

16. Polythelia
• Accessory nipples found along milk
line.
• Commonly be mistaken for a wart or
mole.
• May darken during pregnancy.
• Most common site for accessory nipple
is below the breast

17. Amazia
 Congenital absence of the breast.
 May occur on one or both sides.
 It may associated with absence of the
sternal portion of the pectoralis
major muscle ( Polands syndrome).
 It is more common in males

18. Polymazia
 (Accessory breast)
 Axilla is the most common site
 May occur in the groin, buttock and thigh
  It may function normally during lactation and may
even change to malignancy.

19. Duplication Nipple Ectopic Breast

20. Diffuse Hypertrophy
 “Benign Virginal Hypertrophy” or “Adolescent
hypertrophy”.
 Occurs sporadically in healthy girls at puberty
 Alteration in the normal sensitivity to estrogen.

21. Benign Disease Of The Breast

22. Nipple Retraction
 Nipple retraction is not always related to an underlying
condition. It may be caused by:
 A variation of nipple type present since birth
 Aging
 Often will evert with stimulation.
 Successful breastfeeding is usually possible.

23. Nipple Discharge
 Can occur from one or more lactiferous ducts and majority
of causes are benign.
 It can be bloody, clear serous, purulent or green, and milky
discharge.
 Treatment depends on the presence of :
 Nipple discharge associated with a mass or skin changes
 The discharge is bloody.
 Discharge from single duct.
 Unilateral, spontaneous, bloody discharge is suspicious.

24. Causes Of Nipple Discharge

26. GALACTORRHOEA
 Primary galactorrhoea is due to:
 Stress and other factors.
 physiological inpuberty or menopause.
 Secondary galactorrhoea is due to:
 Dopamine receptor blocking agents : haloperidol, methyldopa,
chlorpromazine, metoclopramide
 hyperprolactinaemia dueTo pituitary tumours.
 Hypothyroidism.
 Drugs : oral contraceptives, atenolol, clonidine, ranitidine.
 Ectopic prolactin secreting tumours (bronchogenic carcinoma).
 Chronic renal failure.
secretion of milk not related to pregnancy or lactation. Always bilateral.

28. Galactocele
 (milk cyst) is a retention cyst containing
milk that is usually located in the
mammary glands.
 It is d.t obstruction to a duct in the
puerperium . the milk retained proximal to
the obstruction
 Can complicated with infection.
 The treatment is by Aspiration , surgical
excision of the cyst.
 Antibiotics to prevent infection

29. Mastalgia
 Cyclic mastalgia: begin since average 34 y/o,
relieved by menopause, physical activity can
increase the pain, e.g. lifting and prolonged use of
arm.
 Non-cyclic mastalgia: affects older women (mean
age 43), arises from chest wall. Breast itself or
outside the breast.

32. Acute Mastitis
 Most common in lactating women.
 Dry, cracked fissured areola/nipple complex
provides portal for infection.
 Usually unilateral and caused by Staph/Strep
organisms.
 Early stage generalised cellulitis, later on abscess
formation.
 Rule out malignancy.
 Continued breast feeding.
 Antibiotics used in the absence of pus.

33. Breast Abscess
 May present with breast swelling,
tenderness and fever.
 The breast is tender, warm, +/-
fluctuation, and may have purulent
discharge.
 Treated by surgical
drainage:
Radial incision
Circumareolar incision
N.B. if antibiotics used in the presence of undrained pus, an
Antibioma form. This is a large sterile brawny edematous
swelling which takes many weeks to resolve.

34. Chronic Intramammary Abscess
 Result from inadequate drainage of an abscess
or antibioma.
 Encapsulated pus within a thick wall of fibrous
tissue.
 Difficult to diagnosed.
 D.D : Carcinoma

35. Eczema
 Rare , occur in young people
 rash of the breast and areolar skin
 Often bilateral
 H/O eczema elsewhere on the body
 Must be distinguish from Paget’s Disease

36. Differences Between Paget’s Diseases
And Eczema Of The Nipple
Paget’s Diseases
 Unilateral
 Edge are distinct
 Itching absent
 Occur in menopausal women
 Vesicles absent
 Nipple is usually destroyed
 Underlying lump is usually
present
Eczema
 Bilateral
 Edge are indistinct
 Itching present
 Occur during lactation
 Vesicles present
 Nipple is usually intact
 No Underlying lump

37. FAT NECROSIS
 Results from injury to breast fat by Trauma, surgery,
biopsy.
 Clinically:
The patient develop severe bruising after moderately
sever trauma, When the bruise settles the woman
notice swelling which is clinically Impossible to
distinguish from carcinoma of the breast because the
Irregular mass is often attached to the skin.
 Microscopically
a central area of necrotic fat cells are surrounded by
a granulomatous reaction consisting of macrophage
cells.

39. Mammary Duct Ectasia
 It is a dilatation of the breast ducts , affects mainly large
ducts which stagnant brown or green irritant secretion
leading to periductal mastitis, or even abscess or fistula.
 Occur at 5th and 6th decades,

40. The underlying cause is unknown
 Clinically :
1. solitary or multiple tender Subareolar mass, can be
confused with carcinoma clinically & radiologically.
2. A thick, cheesy nipple discharge of any colour
3. Abscess , Tenderness and redness of the nipple and
surrounding breast tissue may also be present
4. Mammary duct fistula
5. Slit – like nipple retraction

41. Mammary Duct Ectasia treatment

43.  Fibroepithelial lesions of the breast include fibroadenoma
(FA) and phyllodes tumor (PT).
 Fibroadenomas are benign while phyllodes tumor range from
benign, indolent neoplasms to malignant tumors

44. Fibroadenoma
 Fibroadenomas are the most common benign
tumor in the breast , commonly seen in young
women.
 In 20 percent of cases, multiple fibroadenomas
occur in the same breast or bilaterally.
 The tumor forms a firm discrete mass, which is
freely mobile in the breast tissue, hence the
name (BREAST MOUSE )

45. Fibroadenoma ( Clinically )
 fibroadenomas may be nonpalpable or palpable,
oval, freely mobile, rubbery masses.
 Their size varies from smaller than 1 cm in diameter
to as large as 15 cm in diameter in the giant forms.
 the tumours may grow rapidly during pregnancy,
hormone replacement therapy, or immunosuppression, in
which case they can simulate malignancy.
 In the postmenopausal period, tumors regress and
often develop calcifications

47.  several factors that increase the suspicion of either
phyllodes tumor or future malignancy. These include
stromal mitoses, stromal overgrowth, nuclear
pleomorphism, fragmentation, adipose tissue
infiltration, or other concerns that may be raised by
the pathologist.
 The American Society of Breast Surgeons
recommends excision in these cases

49. FIBROCYSTIC DISEASE
 FDB is a common benign condition that mostly
affects women who are premenopausal.
 Cystic hyperplasia is a variant of normal cyclic
changes in the breast that occur with
menstruation.
 This hyperplasia usually presents bilaterally in the
upper outer quadrant of the breast & is most
painful in the premenstrual period

50. Pathophysiology of fibrocystic dz
 The exact cause of fibrocystic disease is
unkwon ,Hormonal basis
Oestrogen & Progesterone
Prolactin
Thyroid

51. Clinical course of FDB
 Predominantly afflicted are women with menstrual
abnormalities( nulliparous women patients with a
history of spontaneous abortions , nonusers of oral
contraceptives and women with early menarche
and late menopause).
 FDB is rare in ovulating women, multiparous
women, and patients using oral contraceptives.
 Earlv fibrocystic manifestations may occur between
the ages of 20 and 25, but most patients (70% to
75%) are in their mid 30s and 40s.

52. Diagnosis of FDB – Triple assessment
 FDB has a history of months to several years.
 Lumpiness (the lump size Changes with the
menstrual cycle)
 Breast pain and/or tenderness
 Nipple secretion- straw yellow, greenish, or bluish.
discharge is spontaneous or secretion can be
expelled from the nipple.
 Bloody Nipple secretion- when present
50-60% due to intra ductal proliferation (Papilloma)
30-40% due to carcinoma ( 64% after age 50).

59. ANDI - Abberations Of Normal
Development And Involution
 ANDI is a term used to describe a variety of benign breast disorder
occuring at different periods of reproductive age group.
 All conditions under ANDI should be carefully clinically examined
+ Sono Mammography, FNAC, Core cut biopsy to R/O malignancy

60. ANDI - Abberations Of Normal
Development And Involution
ANDI includes different aberrations and disease based on
changes in the normal three phase of physiology of the
breast:
1) Lobular development .
2) Cyclic hormonal modification .
3) Involution.
The symptoms of ANDI include lumpiness (commonly a
cyst or fibroadenoma ) and / or mastalgia , nipple
discharge

61. ANDI
Early
reproductive
years
(age 15-20)
Normal
• Lobular
development
• Stromal
development
• Nipple
eversion
Disorder
• Fibroadenoma
• Adolescent
hypertrophy
• Nipple
inversion
Disease
• Giant
fibroadenoma
• Gigantomastia

62. ANDI
Later reproductive
years
(age 25-40)
Normal
• Cyclical changes
of menstruation
• Epithelial
hyperplasia of
pregnancy
Disorder
• Cyclical
mastalgia
• Nodularity
• Bloody nipple
discharge
Disease
• Subareolar
abscess
• Mammary duc
fistula
• Incapacitating
mastalgia

63. ANDI
Involution
(age 40 -55)
Normal
• Lobular
involution
• Duct involution:
 Dilatation
 Sclerosis
• Epithelial
turnover
Disorder
• Sclerosing Lesions
• Ductal Ectasia
• Nipple Retraction
• Epihelial
Hyperplasia
Disease
• Periductal
mastitis
• Epithelial
hyperplasia
with atypia

64. Conclusion
 Benign breast problems account for the majority of
breast diseases seen in women.
 It is important to rule out breast cancer