This document provides an overview of breast anatomy, development, diseases, and cancer. It describes the lobules, ducts, ligaments, vasculature, and lymphatics of the breast. Benign breast diseases discussed include cysts, fibroadenomas, mastalgia, nipple discharge, and infections. Risk factors, staging, diagnosis and treatments for breast cancer are summarized, including surgery, radiation, chemotherapy and hormonal therapy. Rare conditions like Paget's disease and issues affecting the male breast are also briefly covered.

1. DISEASES
OF THE
BREAST

2. BREAST ANATOMY
• Modified sweat gland
• Breast contains 15-20 lobules
• Lobules fill each lobe
• Fat covers the lobes and shapes the
breast
• Sacs at the end of lobules produce milk
• Lactiferous ducts deliver milk to the
nipple

5. BREAST ANATOMY
• Four quadrants
• Three tissue types
• Glandular epithelium
• Fibrous stroma and supporting structures
• Fat
• Astley -Cooper ligaments
• Fibrous continuations of the superficial fascia,
which span the parenchyma of the breast to the
deep fascial layers

7. • Vasculature
– Arterial supply
• Internal mammary artery(60%)
• Lateral thoracic artery(30%)
• Intercostal arteries
– Venous return
• Sub areolar venous plexus
• Axillary vein(primary)
• Internal mammary vein
BREAST ANATOMY

11. • Subareolar plexus of Sappey
• Axillary chain 75%
• Level 1 – lateral to pectoralis minor muscle
• Level 2 – along and under pectoralis minor
• Level 3 - medial to pectoralis minor
– Rotter’s nodes
• Between pectorial minor and major muscles
– Internal mammary chain 15%
• Parasternal
• Medial
LYMPHATICS
• Infraclavicular (subclavicular) lymph nodes
– In the deltopectoral groove
• Supraclavicular lymph nodes
– Above the collarbone

13. DEVELOPMENT OF THE BREAST
The milk line (ectoderm) extends from the axilla to groin.
Along this line accessory breast or nipples may be found

14. • total lack of breast
tissue(amastia) or
of nipple(athlelia)
unusual
• supernumerary nipples
polythelia & breast
polymastia are quite
common.
CONGENITAL & DEVELOPMENTAL
ABNORMALITIES

15. DIAGNOSIS : Triple assessment
TRIPLE ASSESSMENT
PATHOLOGYHX AND
CLINICAL EXAM
IMAGING
Ultrasound
Mammography
FNAC
Core biopsy
Open biopsy

16. BENIGN DISEASES OF
THE BREAST

17. Classification Based On Clinical Features
MASTALGIA
•Cyclical
•Non Cyclical
LUMPS
•Nodularity or
glandular
•Cysts
•Galactoceles
•Fibroadenoma
•Sclerosing Adenosis
•Lipoma
•Cystosarcoma
Phylloides
NIPPLE
DISCHARGE
• Galactorrhea
• Abnormal nipple
discharge
BREAST
INFECTIONS AND
INFLAMMATION
• Lactation mastitis
• Lactation breast
abscess
• Chronic recurrent
subareolar
abscess
• Extrinsic infections
• Mondor’s Disease
• Hidradenitis
suppurativa

18. Classification Based On Histologic Types
Non Proliferative
Lesion
• Simple Cyst
• Complex cyst
Proliferative Lesions
– Without Atypia
• Ductal hyperplasia
• Fibroadenoma
• Intraductal
papilloma
• Sclerosing
Adenoma
• Radial Scars
Atypical
Hyperplasia
• Atypical ductal
hyperplasia
• Atypical lobular
hyperplasia

19. INFECTIOUS AND
INFLAMMATORY BREAST DISEASE
• CELLULITIS, MASTITIS
Most common in lactating
female
Dry, cracked fissured
areola/nipple complex
provides portal for infection
Rule out malignancy
continue breast feeding
Antibiotics for 10-14 days
to cover staph and strept
infections

20. BREAST ABSCESS
May present with
breast swelling,
tenderness and fever
breast is tender , warm
and fluctuant, may
also have purulent
discharge
Treated by surgical
drainage

21. • CHRONIC SUBAREOLAR ABSCESS
– Occurs at base of lactiferous duct, and
– squamous metaplasia of duct may occur.
– Treatment requires complete excision of sinus tract.
Recurrence is common
• MONDOR’S DISEASE
– Phlebitis of the
thoracoepigastric vein
– Palpable, visible, tender cord
along upper quadrants
– Treatment self-limited, can use
anti-inflammatories if necessary

22. ANDI CLASSIFICATION

23. • FIBROCYSTIC BREASTS
– Appears to represent an exaggerated response of
breast stroma and epithelium to hormones and growth
factors.
– Dense, firm breast
tissue with palpable
lumps and frequently
gross cysts,
commonly painful and
tender to touch.
BENIGN LESIONS OF THE
BREAST

24. • CYSTS
– Fluid-filled,
epithelium-lined
cavities
– Influenced by
ovarian hormones
– Tx depends on
whether the cyst
completely
resolves after
aspiration

25. Management of Breast Cysts
AAFP journal , April 15, 2000. Volume 61/ No. 8

26. • FIBROADENOMA
– Well-defined, mobile benign tumor of breast
– Can be diagnosed by FNA
– Observation otherwise excision.
At operation they are well-encapsulated and
detach easily.

28. FIBROADENOMA

29. • PHYLLODES TUMORS
(CYSTOSARCOMA
PHYLLODES)
Rapidly growing
One in four malignant
Create bulky tumors that
distort the breast
May ulcerate through the skin
due to pressure necrosis
Treatment consists of wide
excision unless metastasis
has occurred

31. • SCLEROSING ADENOSIS
– Can simulate carcinoma both grossly and
histologically.
• EPITHELIAL AND ATYPICAL HYPERPLASIA
– Involves ducts or lobules
– higher risk of breast cancer
• PAPILLOMA
– Polyps of epithelium-lined breast ducts
– it often present with a bloody nipple
discharge.
– Treatment is total excision through a
circumareolar incision.
– Need to rule out invasive papillary
carcinoma.

32. • MAMMARY DUCT
ECTASIA
– A palpable retroareolar
mass,
– nipple discharge, or
– retraction can be present.
– Tx involves excision of
area.

33. • TRAUMATIC FAT NECROSIS
– Associated with trauma or radiation therapy to
breast.
– Can simulate cancer with mass or skin retraction.
– Bx is diagnostic

34. Pathologic nipple discharge is
persistent and spontaneous
and is not associated with
nursing.
Requires further evaluation
• Galactorrhea
– Bilateral, milky
discharge occurs
– Obtain prolactin
levels, if highly
elevated, suspect
pituitary adenoma as
one of causes.
• Bloody nipple discharge
– Most common cause
is intraductal
papilloma
– Cancer present 10%
of time.
NIPPLE DISCHARGE

36. – Cyclic pain
• Correlates with menstrual cycle.
– Non-cyclic pain
Cancer must be excluded.
MASTALGIA

37. Management of Breast Pain
 Diet and Lifestyle Modification
Elimination of Methylxanthines, Caffeine and
Chocolates
Reassurance
Supportive Bra
Low fat and high complex carbohydrate
Vitamin E supplementation
Evening Primrose oil
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

38. Management of Breast Pain
 Pharmacological Treatment
 NSAIDs
 OCPs
 Danazol 100- 400mg per day
 Tamoxifen 10mg
 Bromocriptine – prolactin antagonist
 Surgery has no role in management of breast pain
Micheal S sabel .Overview of benign breast disease. Uptodate 2008, November 14

39. AAFP journal , April 15, 2000. Volume 61/ No. 8

40. MALIGNANT
DISEASES
OF THE
BREAST

41. RISK
FACTORS
CONTROLLABLE
• Alcohol drinking
• obesity
• Nulliparous
• Elderly primi
• Hormone Replacement
• Birth control pills
UNCONTROLLABLE
• Age
• First degree relative with breast cancer
• A previous breast biopsy showing atypical
changes
• Early menarche
• Late menopause
• Having an inherited mutation in the breast
cancer genes (BRCA 1 or 2)

42. Breast Cancer Location

43. Ductal Carcinoma in Situ-DCIS
• Confined to ductal cells.
• No invasion of the underlying basement membrane.
• Chance of recurrence 25-50% in 5 years,
• Tx
– Mastectomy an option if there is a substantial risk of
local/regional recurrence
– Wide excision alone suitable if <25mm, favorable histology, and
the margins are clear
– Node dissection not necessary (nodal disease < 1%)

44. DCIS

45. Lobular Carcinoma in Situ-LCIS
• Not detectable on mammography
– Most commonly found incidentally
• Risk of invasive breast cancer in 20 years is
15- 20% bilaterally
• Tx
– Careful follow-up
– Bilateral masectomy may be considered if other risk
factors are present such as family history or prior
breast cancer, and also dependent on patient
preference.

46. INVASIVE BREAST CANCERS
• Tubular carcinoma (grade 1 intraductal),
• Colloid or mucinous carcinoma, and
• Papillary carcinoma
Favorable histologic
types (85% 5-year
survival rate)
• Medullary ,
• invasive lobular, and
• invasive ductal carcinoma
Less favorable types
• Inflammatory breast carcinomaLeast favorable type

47. Favorable histologic types
• 2% of all invasive breast cancers
• Generally diagnosed by mammography
• Long-term survival aproaches 100%
Tubular
carcinoma
• 3% of all invasive breast cancers
• Bulky, mucinous tumor with characteristic microscopic features
• 5 and 10 year survival rates are 73 and 59 percent, respectively
Mucinous
(colloid)
carcinoma
• <2% of all invasive breast cancers
• Generally presents in 7th decade, and is a slowly progressive
disease
• 5 and 10 year survival rates are 83 and 56 percent, respectively
Papillary
carcinoma

48. Less Favorable Histologic Types
• 4% of all invasive breast cancers
• Soft, hemorrhagic bulky presentation
• Metastases to axillary nodes in 44%
• 5 and 10 year survival rates are 63 and 50 percent respectively
Medullary
carcinoma
• Most common and occurs in 78% of all invasive breast cancers.
• Metastases to axillary nodes in 60%
• 5 and 10 year survival rates are 54 and 38 percent respectively
Invasive ductal
carcinoma
• 9% of all invasive breast cancers
• Metastases to axillary nodes in 60%
• 5 and 10 year survival rates are 50 and 32 percent respectively
• Higher incidence of bilaterality
Invasive lobular
carcinoma

49. INFLAMMATORY CARCINOMA
• 1.5-3% of breast cancers
• Characteristic clinical features of erythema, peau d’orange,
and skin ridging with or without a palpable mass.
• Commonly mistaken for cellulitis.
– Will generally fail antibiotics before being diagnosed
• Disease progresses rapidly, and more than 75% of patients
present with palpable axillary nodes.
• Distant metastatic disease also at much higher frequency
than the more common breast cancers.
• 30% 5 year survival rate
• Requires chemotherapy treatment immediately

51. HPE-CA BREAST
• Fine-needle aspiration
– Sensitivity is 80-98%, specificity 100%
• Core-needle biopsy
• Incisional biopsy
– For large (>4 cm) lesions for whom pre-op
chemotherapy or radiation will be desirable.
• Excisional biopsy
– Removal of entire lesion and a margin of normal
breast parenchyma

52. MAMMOGRAM
Comparison CC View
Left Right

54. THERMOGRAPH
• Thermograph is one of
the newest ways to
detect breast cancer.
• Thermograph is a
thermal image of the
breast tissue.
• It can also detect
cancer before the
traditional
mammogram can.
• Picture from breastthermography.com

55. Staging and Prognosis
Primary Tumor
• T1 = Tumor < 2
cm. in greatest
dimension
• T2 = Tumor > 2
cm. but < 5 cm.
• T3 = Tumor > 5
cm. in greatest
dimension
• T4 = Tumor of any
size with direct
extension to chest
wall or skin
Regional Lymph
Nodes
• N0 = No palpable
axillary nodes
• N1 = Metastases
to movable
axillary nodes
• N2 = Metastases
to fixed, matted
axillary nodes
Distant Metastases
• M0 = No distant
metastases
• M1 = Distant
metastases
including
ipsilateral
supraclavicular
nodes
–

56. – Clinical Stage I T1 N0 M0 S
t
a
g
e
– Clinical Stage IIA T1 N1 M0 I 93%
– T2 N0 M0 II 72%
– Clinical Stage IIB T2 N1 M0 III 41%
– T3 N0 M0 IV 18%
– Clinical Stage IIIA T1 N2 M0
– T2 N2 M0
– T3 N1 M0
– T3 N2 M0
– Clinical Stage IIIB T4 Any N M0
Clinical Stage IV any T Any N M1

58. TREATMENT
• Modalities (palliative vs. curative)
– Surgery
• Local treatment
– Radiation
• Local treatment
– Chemotherapy and hormonal therapy
• Systemic treatment

59. SURGERY
– Breast conservation therapy (BCS)
• Stage I, stage II,
• Lumpectomy, axillary lymphadenectomy/Sentinel lymph node biopsy, and
postoperative radiation therapy
• Local recurrence more than mastectomy so follow up important
– Simple mastectomy
• All breast tissue is removed, axillary contents not removed
• Treatment for non-invasive breast cancer
– Modified radical mastectomy (MRM)
(most common mastectomy procedure for invasive breast cancer)
• Entire breast and axillary contents are removed
• Pectoralis muscles remains
– Halsted radical mastectomy
• Removes breast, axillary contents, and pectoralis major muscle
• Cosmetically deforming

61. RADIOTHERAPY
• Utilized for primary and metastatic disease
• Useful in breast conservation therapy to
reduce rate of recurrence.

62. CHEMOTHERAPY
– All patients with axillary node involvement are candidates
– patients with negative axillary node involvement who are high
risk by other prognostic indicators.
– Example treatment is 6 months of cyclophosphamide,
methotrexate or adriamycin, and flourouracil along with
paclitaxel.

63. HORMONAL THERAPY
– Tamoxifen 20mg o.d.
• Generally taken for five
years in patients with
estrogen receptor
positive tumors.
• As effective as
chemotherapy in post-
menopausal patients with
estrogen receptor positive
tumors

64. PAGET’S DISEASE
• Uncommon
• Usually involves the nipple
• Histologically, vacuolated cells are seen in the epidermis.
• D/D- eczema
• It is generally associated with an underlying
intraductal or invasive carcinoma.
– Mammography should be performed
• About 30% of patients have axillary node metastasis at
diagnosis.
• Mastectomy is the standard of treatment

65. PAGET DISEASE

67. THE MALE BREAST
• GYNECOMASTIA
– Prepubertal gynecomastia
– Pubertal gynecomastia
• Occurs in 60-70% of pubertal
boys.
– Senescent gynecomastia
• 40% of aging men have this to
some degree.
Drugs, such as steroids,
digitalis, hormones,
spironolactone, and
antidepressants can cause
this.

68. PATHOPHYSIOLOGY OF BREAST
GYNAECOMASTIA
The basic mechanisms of gynecomastia
are
: a decrease in androgen production,
an absolute increase in estrogen
production,
and an increased availability of
estrogen precursors for peripheral
conversion to estradiol.

69. • MALE BREAST CARCINOMA
– <1% of male cancers
– Average age of diagnosis is 63.6 years old
– Painless unilateral mass that is usually subareolar with skin
fixation, chest wall fixation,, and ulceration.
– Mostly ductal carcinoma
– Males generally present at later stage than woman
THE MALE BREAST