This presentation will help medical students

1. Clinical Presentation of Breast
Diseases
Dr. Ahmed A. Kandil,M.D.,Ph.D.
Consultant Surgeon
Ahli Arab Hospital
2018

2. Quote
Failure is not falling down but in staying
down

3. Anatomy of breast
The word “breast” refers to the mammary
glands, plus the additional connective tissue
elements and fat that surrounded and support
the gland.

4. Introduction
• The breast has always the symbol of women
hood and ultimate fertility.
• Very few benign breast diseases have an
ability to become malignant.
• The majority of benign breast diseases are
treated easily without adverse consequences.

5. Anatomy of the breast

6. Investigations
Ultrasound
Mammography
MRI
FNAB/ cytology
True cut (core) biopsy
Open incisional biopsy
Open excisional biopsy

7. Triple assessment
1) History and clinical diagnosis
2) Imaging: U/S, mammography, MRI
3) Tissue diagnosis(histopathology): FNAC, True
cut biopsy, incisional biopsy & excisional
biopsy
Accuracy about 99.9%

8. Benign Breast Disease
• Benign breast conditions are practically a
universal phenomena among women.
• It accounts for 80% of clinical presentation
related to the breast.
• They considered as “ Aberration from Normal
Development and Involution” ANDI

9. Gynecomastia – clinical features
• It is swelling of mail breast; unilateral or
bilateral
• The cause is often self evident from a full
history and examination.
• The testes should always be examined.
• If there is suspicion of a testicular tumor, U/S
and hormonal assays are requested.

10. Gynecomastia
Before After

11. Gynecomastia
Treatment of gynecomastia:
 For physiological causes reassurance is all
what is needed.
 Stop drugs causing gynecomastia.
 Subcutaneous mastectomy in troublesome
cases.
 Liposuction- assisted mastectomy

12. Fat necrosis
• This is traumatic in nature & is met with women
with large fatty breast.
• It result from injury to breast by: Trauma, surgery,
biopsy …
Clinically: Patient develop severe bruising after
trauma, when bruise settle, the women notice
swelling which is clinically cannot be distinguished
from breast carcinoma.
D.D: By histopathology.
• TTT: By surgical excision and histopathology.

13. Fat necrosis

14. Galactocele
• It is formed due to obstruction of milk duct.
• The milk retained proximal to the obstruction.
• The milk eventually becomes cheese like.
• Classically appears as a painless lump weeks
to months after stop of breast feeding.
• The commonest complication is infection.
• The treatment is by surgical excision.

15. Galactocele

16. Galactocele

17. Intra duct papilloma
• This benign lesion of lactiferous duct wall
occur centrally beneath the areola in 75% of
cases.
• They are solitary proliferation of ductal
epithelium
• The most common presentation by bloody
nipple discharge, sometimes associated with
pain.
• Treatment by wedge resection.

18. Intra duct papilloma

19. Injury to breast
• The patient develop severe bruising after
moderately severe trauma.
• When the bruise settles the women notice
swelling which is clinically impossible to
distinguish from carcinoma of breast because
the irregular mass is often attached to the skin
• TTT: By surgical excision and histopathology.

20. Duct Ectasia
• It is called also plasma cell mastitis
• It is widening of breast ducts due to
inspissation of normal breast secretion
• Mostly in women in their 40s and 50s
• It present as solitary or multiple tender
swelling in the sub or peri-areolar region
• Nipple retraction, skin adherence, edema &
axillary adenopathy may accompany a hard,
diffuse mass within the breast

21. Duct Ectasia

22. Duct Ectasia
• Palpation reveals a number of cord like
swelling which radiate from the areola
• The ducts are dilated & contains an inspissated
yellow cheesy material on cutting down
• The condition may be mistaken for a breast
cancer
• TTT: Excision and biopsy

23. Duct Ectasia

24. Fibroadenoma
• Fibroadenoma is a benign tumor composed of
stromal and epithelial elements due to hyper
plasia in a single terminal duct unit
• It is commonly seen in young women
• The cause is unknown (ANDI)
• Fibroadenoma is a well circumscribed lesion in
the breast & develop before menopause
• The tumor may grow rapidly during pregnancy or
hormonal replacement therapy, in which case
they can simulate malignancy

25. Fibroadenoma
• The fibroadenoma well capsulated and freely
mobile in breast (breast mouse)
• It is either pericanalicular, usually begins
below age of 30 years
• Or intracanalicular after 30 years
• Either breast may be affected; multiple &
successive tumors may develop in same or
contra-lateral breast

26. Fibroadenoma

27. Fibroadenoma
• Clinically, fibroadenoma may be not palpable
or palpable, oval, freely mobile, rubbery
masses.
• Size vary from 1 - 15 cm.
• The size may vary during the menstrual cycle
and during pregnancy
• In post menopausal women the size regress
and often develop calcification

28. Fibroadenoma
Diagnosis:
• Triple assessment
Treatment:
• Reassurance of the patient
• Excisional biopsy

29. Fibroadenoma
mammography
mammography
ultrasound

30. Fibrocystic disease
• This is the most common lesion of the female
breast
• Incidence varying related to age; in menstruating
years 20% ,while in premenopausal years 30-50%
• The most common acceptable description are:
Cystic lobular hyperplasia
Fibrocystic disease of breast
fibroadenosis

31. Fibrocystic disease

32. Fibrocystic disease
• Cystic hyperplasia is a variant of normal cyclic
changes in the breast that occurs with
menstruation
• This hyperplasia usually present bilaterally in
the upper outer quadrant of the breast and is
painful in the premenstrual period

33. Fibrocystic disease
• The exact cause of fibrocystic disease is unknown
• But it is agreed that it is of hormonal basis
• Estrogens stimulate proliferation of connective
and epithelial tissues or (ANDI)
• The polymorphism of fibrocystic disease is
documented by:
Fibrosis
Cysts formation
Epithelial proliferation
Lobular-alveolar atrophy

34. Fibrocystic disease
Three clinical courses of fibrocystic disease are
recognized:
Phase I: Moderate stromal fibrosis, beginning of
hardness of breast tissue and premenstrual breast
tenderness
Phase II: Progressive fibrosis leading to increased
hardness and tenderness, cyst formation, moderate
nodularity
Phase III: Pronounced fibrosis and tenderness,
macrocyst formation

35. Clinical picture of fibrocystic disease
• Fibrocystic disease has a history of many
months to several years
• The main complaint is breast pain
• Nipple discharge of green or dark secretion
present in > 30% of cases
• Rarely sensation of a mass or nodularity

36. Fibrocystic disease
mammography mammography
ultrasound

37. Treatment of fibrocystic disease
Medical Surgical
Diet therapy: Surgical treatment for removal of the
lump in most severe cases
Caffeine restriction, diuretics
Iodine containing agents
Vit E & B6
Dihydroergotamine
Antiprolactin drugs
Hormones:
Low estrogen, combined OC piles
Progesterone in the luteal phase, Danazol

38. Breast Cancer- Introduction
• Breast cancer is the second cause of cancer
deaths in women
• Breast cancer can also occur in men, but it is
far less common
• In the last 20 years, doctors have made great
strides in early diagnosis and treatment of the
disease and reducing breast cancer deaths
• Yet there is more reason for optimism than
ever before

39. Breast Cancer

40. Breast Cancer

41. Etiology
• Age - Child bearing & fertility
• Genetic factor - breast feeding
• Gender - benign duct disease
• Dietary factor - geographical
• Menarche & menopause
• Endocrine factors
• Radiation of chest area

42. Pathology of breast cancer
• Pathologically, breast cancer divided into 2
types depending on their origin
Ductal carcinoma
Lobular carcinoma

43. Ductal carcinoma in situ (DCIS)
• Proliferation of malignant epithelial cells
confined to duct system & and does not
invade the basement membrane or
surrounding tissues
• Two histological types of ductal carcinoma in
situ:
Comedo or solid type
Papillary or cribriform type

44. DCIS

45. Invasive duct carcinoma
• Malignant epithelial cells invade the basement
membrane of a duct & infiltrate the surrounding breast
tissues
• Different morphological types of invasive duct
carcinoma are:
 Scirrhous carcinoma
 Medullary carcinoma
 Tubular carcinoma
 Mucinous carcinoma
 Papillary carcinoma
 Adenoid carcinoma

46. Invasive duct carcinoma

47. Lobular carcinoma of breast
• 10 – 20% of all cases
• Subdivided into in situ and invasive forms
depending on whether basement membrane
of lobule has been invaded by tumor cells or
not

48. LCIS
Invasive In situ

49. Inflammatory carcinoma of breast
• Rare variety
• Present as painful and swollen breast
• Highly aggressive
• Axillary lymph nodes involved quite early
• Frequently occurs during lactation so often called
lactational carcinoma
• Mimics breast abscess & biopsy confirms the
diagnosis
• Progress is grave

50. Inflammatory carcinoma of breast

51. Symptoms and signs of CA breast
When the disease is discovered early, have more
treatment options and better chance for cure
Lump of the breast or thickening in the breast,
often the lump is painless
Bloody discharge from the nipple
Retraction or indentation of the nipple
Change in the size of contours of the breast
Flattening or indentation of the skin over the
breast

52. Symptoms and signs of CA breast
• In advanced cases, pitting edema in the skin
like the skin of an orange
• May be enlarged axillary lymph nodes due to
malignant spread
• In advanced cases, ulceration of skin or even
bleeding from ulcer surface
• Signs of systemic metastasis

53. Paget disease of nipple
• Superficial manifestation of underlying breast
cancer
• Usually unilateral
• Present as eczema like condition of nipple &
areola
• Nipple erodes slowly & eventually disappears
• Clinically felt as palpable mass in subareolar area
• Better prognosis than majority of lesions due to
its early presentation

54. Paget disease of nipple
• It is consider stage I breast cancer
• Treated by simple mastectomy
• Axillary clearance when needed
• Oncology treatment

55. Paget disease of nipple

56. Thank you
Ahli Arab Hospital Family