Benign breast disease


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Benign breast disease

  1. 1. PROF. Amer Eltwati IRHUMA FRCS
  2. 2. Quotefailure is not falling down but in staying down ..! anonymous
  3. 3. Definition The word “breast” refers to the mammary glands, plus the additional connective tissue elements and fat that surround and support the gland.
  4. 4. INTRODUCTIONThe breast has always been the symbol of womanhoodand Ultimate fertility. As result both, disease and surgeryof the breast evoke a fear of mutilation & loss of femininity .Benign breast diseases account for about 80 % of thebreast pathologyVery few benign breast disease have an ability to becomemalignant , but the majority are treated easily with outadverse consequencesHowever management of some benign breast diseasesproven to be troublesome and associated with highpsychological morbidity
  5. 5. ANATOMYThe breast is an appendage of skin & is modifiedsweat gland, the shape of the female breast is due tothe fat contained within fibrous septa.In the adolescent & young adults the breast is firm &prominent , with the age the glandular & fibrouselement atrophies, the skin stretch & breast sags.The breast lies between the skin & pectoral fascia towhich it is loosely attached. It extends from the 2ndto the 6th ribs & from the lateral border of thesternum to the mid-axially line.A prolongation of paranchymatus tissue, the axillarytail, runs up-ward between the pectorals major andlatissmus dorsi muscles to blend with the fat of theaxilla .
  6. 6. Anatomy of the Breast
  7. 7. ANATOMY The breast glandular tissue consists of 15 to 20 lobules (clusters of milk forming glands, or acini) that enter into branching and interconnected ducts. The ducts widen beneath the nipple as lactiferous sinuses and then empty via nipple openings.. The primary secretory unit is group of saccular alveoli draining into ductless (the terminal duct- lobular Unit ). In the resting state this secret watery fluid which is believed to be reabsorbed through the walls of large ducts. The alveoli ducts are lined by single layer of epithelial cells. Myoepithelial surround the ducts, but not the lobules, they are contractile & move secretion along the duct system
  8. 8. Anatomy of the Breast
  9. 9. BLOOD SUPPLY ARTERIAL: - laterally:- this comes from branches of lateral thoracic artery and perforating branches of the intercostal arteries. Medially from perforating branches of internal mammary artery. B- VEINS:-it follows the same course of arterial supply.
  10. 10. Lymphatic drainage of the breast The understanding of the lymph drainage of the breast are of great importance for the surgeon. The lymphatic is profuse &run within the substance of the breast Medially:- to the intrenal mammary nodes Laterally:- to the nodes along the lateral thoracic vesseles ( pectoral group) & subscapular vesseles (subscapular group), from these nodes lymph passes-up through the central & apical axillary nodes to the subclavin trunk. Few lymphatic pierce the pectoral fascia & enter the chest
  11. 11. Levels of axillary nodes Pectoralis Supraclavicular minor muscle nodesPectoralis major muscle Pectoralis major muscleAxillary vein Interpectoral nodes Internal mammary nodesLatissimus dorsi muscle Abdominal nodes
  12. 12. Hormones Affecting the Breast
  13. 13. Benign breast diseases
  14. 14. INTRODUCTIONHost to a spectrum of benign and malignantdiseases.Benign breast conditions are practically auniversal phenomena among women.It accounts for 80% of clinical presentationrelated to the breast.
  15. 15. CONGENITAL & DEVELOPMENTAL ABNORMALITIESAlthough the normal location of the breast is theanterior thorax, breast tissue with or without anipple or just nipple and areola alone can occurany where along the milk lineThe milk line is an ectodermal thickeningappearing at 6 weeks of gestation running fromaxilla to the midportion of inguinal ligament
  16. 16. Development of the breast The milk line (ectoderm) extends from the axilla to groin. Along this line accessory breast or nipples may be found
  17. 17. CONGENITAL & DEVELOPMENTALABNORMALITIES total lack of breast tissue ( amastia) or of nipple (athlelia) is un unusual supernumerary nipples polythelia & breast polymasita are quite common. when polymastia is present in women, the additional breast tissue can secret milk when nipple is present.
  18. 18. Amastia Amastia: A rare condition wherein the normal growth of the breast or nipple does not occur. Unilateral amastia (just on one side) is often associated with absence of the pectoral muscles. Bilateral amastia (with absence of both breasts) is associated in 40% of cases with multiple congenital anomalies involving other parts of the body as well. Amastia is distinguished from amazia wherein the breast tissue is absent, but the nipple is present. Amazia typically is a result of radiation or surgery.
  19. 19. amastia
  20. 20. Mastalgia Mastalgia is breast pain and is generally classified as either cyclical (associated with menstrual periods) or noncyclic Breast pain of any type is a rare symptom of breast cancer , only 7% of breast cancer have mastalgia as the only symptom. Most mastalgia is of minor to moderate severity and accepted as part of the normal changes that occur in relation to menstrual cycle.
  21. 21. 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.
  22. 22. Mastalgia - treatment Danazol: (200-300 mg daily, slowly reduced to 100 mg daily or on alternative day, given on days 14-28 of menstrual cycle, after pain relief. Responses are usually seen within 3 months Weight gain, acne and hirsutism.
  23. 23. Gynecomastia
  24. 24. GynecomastiaGynecomastia is the growth of glandular tissue inmale breasts.The name comes from the Greek term (gyne + mastos)meaning "female-like breasts." It is a benign conditionthat accounts for more than 65% of male breastabnormalities.Gynecomastia is clearly differentiated frompseudogynecomastia, which is an accumulation ofexcess fat in a male is usually unilateral & occur in young man. there isno hormonal dysfunction in unilateral Gynecomastia.Bilateral Gynecomastia is due to systemic causes.Causes of Gynecomastia may be regarded as:
  25. 25. Primary Gynecomastia physiological causesNeonatal gynaecomastia is due to the trans-placental passage of maternaloestrogen and may be associated with a nipple dischargeknown as witchs milk. It usually resolves during thefirst few weeks of life.Pubertal gynaecomastiais the commonest male breast lesion. It can be eitherunilateral or bilateral. Reassurance is often the onlytreatment that is required. The lesion will generally settlespontaneously but may persist for months or years.Senile gynaecomastiacan be difficult to differentiate from the pseudo-gynaecomastia due to general adiposity increasingly seenin old age.
  26. 26. Secondary Gynecomastia – pathological causesPrimary testicular failure Anorchia Klinefelters syndrome or bilateral cryptorchidism.Acquired testicular failure Mumps irradiation.Secondary testicular failure hypopituitarism. Isolated gonadotrophin deficiency.Endocrine tumours Testicular adrenal pituitary.
  27. 27. Gynecomastia – pathological causes Non-endocrine tumours bronchial carcinoma Lymphoma hypernephroma. Hepatic disease alcoholic cirrhosis haemochromotosis. Drugs oestrogen agonists (spironolactone), hyperprolactinaemia (phenothiazines), Testosterone target cell inhibitors (cimetidine, cyproterone acetate)
  28. 28. Pathophysiology of breast gynecomastia Pathophysiology of breast gynecomastia.  Estradiol is the growth hormone of the breast, and an excess of estradiol leads to the proliferation of breast tissue.  Under normal circumstances, most estradiol in men is derived from the peripheral conversion of testosterone and adrenal estrone.  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.
  29. 29. Gynecomastia – clinical features
  30. 30. Gynecomastia – clinical features The cause is often self evident from a full history and examination. The testes should always be examined. Useful investigations may include a chest x-ray, full blood count and liver function test. If there is suspicion of a testicular tumour then ultrasound should be requested. Hormonal assays may confirm endocrinopathies
  31. 31. 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
  32. 32. FAT NECROSIS This is traumatic in nature & is met with women with large fatty breast Results from injury to breast fat by Trauma, surgery, biopsy…. Causes to focal fibrosis and cicatrix formation. Early: edema of the fat lobules,increased echogenicity. Post surgical scar, hematoma, seroma
  33. 33. FAT NECROSISClinically: The patient develop sever 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.
  34. 34. FAT NECROSIS
  35. 35. Treatment:by surgical excision, the excised mass is aninfiltrative yellowish white mass.
  36. 36. Duct Ectasia This condition has several stages of involvement & vanity of names include (plasma- cell mastitis, comedo mastitis, & chronic abscess simulating carcinoma). It is benign lesion may be virtually impossible to differentiate from carcinoma by it is gross appearance
  37. 37. Duct Ectasiais a widening of the ducts of the breast, a conditionthat occurs most frequently in women in their 40sand 50s. A thick and sticky discharge, usually grayto green in color, is the most common symptom.Tenderness and redness of the nipple andsurrounding breast tissue may also be present.Sometimes, scar tissue forms around the abnormalduct, leading to a lump that may be initiallymistaken for cancer.
  38. 38. Duct Ectasia Microscopically -The periductal elastic tissue is destroyed & the surrounding tissue are infiltrated with lymphocytes & plamsa cell
  39. 39. Duct EctasiaClinically:-this condition present as solitary or multiple tender swelling in the sub or Peri-areolar region of the breast.- Nipple retraction, skin adherence, edema & axillary adenopathy may accompany a hard, diffuse mass within the breast- palpation reveals a number of cord like swelling which radiate from the areola.- the ducts are dilated & contain an inspissated yellow cheesy material that can be expressed like toothpaste from the cut end of a duct.- occasionally, the inflammatory response are so acute that skin changes occur & the condition may be mistaken for a breast abscess.
  40. 40. Duct EctasiaTreatment : Small volume discharge is managed conservatively Socially embarrassing discharge is treated by Major duct excision
  41. 41. GalactoceleCystically dilated terminal ductulesthat are filled with milk and lined bydouble layer of breast epitheliumand myoepithelium.Classically appears as a painlesslump weeks – months aftercessation of breast feeding.
  42. 42. GALACTOCELEIt is probably formed by obstruction to a duct inthe puerperium . the milk retained proximal tothe obstruction eventually becomes cheese-like.The common complication of this type ofswelling is infection.The treatment is by surgical excision.
  43. 43. INTRA-DUCTAL PAPILLOMA This benign lesions of the lactiferous duct wall occur centrally beneath the areola In 75% of cases. They most commonly produce a bloody nipple discharge, some times associated with Pain They are solitary proliferation of ductal epithelium Intraductal papillomas should be treated by excision of a duct as a wedge resection.
  45. 45. FIBROADENOMAFibroadenomas are benign tumors composed of stromaland epithelial elements. The tumors are commonly seenin young women.Fibroadenoma is a common well - circumscribed lesionof the breast & develop in the breast prior tomenopause.Pericanalicular tumors usually being found below the ageof 30 & intracanalicular tumors there after.Either breast may be affected and multiple & successivetumors may develop in the same or contra-Lateralbreast.
  46. 46. FIBROADENOMAThe preicanalicular tumor forms a firm discretemass, which is freely mobile in the breasttissue, hence the name (BREAST MOUSE )The intracanalicular tumors tends to be softer &may grow to such size that there is necrosis ofthe overlying skin. To such a condition theterms serocystic disease of bordie OR cystisarcomaphylloides OR Giant fibroadenoma have been given.However despite the implication of malignancyin the later term, the tumor is benign.
  47. 47. FIBROADENOMAPathophysiology: Fibroadenomas are benign tumors that represent a hyperplastic or proliferative process in a single terminal ductal unit; their development is considered to be an aberration of normal development. The cause is unknown. Approximately 10% of fibroadenomas disappear each year, and most stop growing after they are 2-3 cm in size. Fibroadenomas may involute in postmenopausal women, and coarse calcifications may develop. Conversely, the tumors may grow rapidly during pregnancy, during hormone replacement therapy, or during immunosuppression, in which case they can simulate malignancy. Fibroadenoma variants include juvenile fibroadenoma, which occurs in female adolescents.
  48. 48. FIBROADENOMA - Pathology This swelling has been variously regarded as a simple hyperplasia of epithelial and / or connective tissue elements or as a composite neoplasm of the breast in which the epithelial & mesnchymal components grow simultaneously
  49. 49. FIBROADENOMAClinical Features: On clinical examination, 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. Most commonly, the tumors are removed surgically when they are 2-4 cm in diameter. In young women, the tumors are usually palpable. In older women, the tumors typically appear as a mass on mammograms, and the tumor may be palpable or nonpalpable. The size of fibroadenomas also can vary during the menstrual cycle and during pregnancy. In the postmenopausal period, tumors regress and often develop calcifications
  50. 50. FibroadenomaTypes Natural historySolitaryFew (< 5 / breast ) Majority remain small & staticMultiple (> 5 / breast ) 50% involute spontaneouslyGiant (> 4 / 5 cms) & Juvenile No future risk of malignancy
  51. 51. DIAGNOSIS : Triple assessment Triple AssessmentHx and clinical pathologyexam Imaging FNAC Ultrasound Core biopsy Mammography Open biopsy
  52. 52. FIBROADENOMA - investigation Breast, fibroadenoma Sonogram. demonstrates a hypoechoic mass with smooth partially lobulated margins that are typical of a fibroadenoma.
  53. 53. FIBROADENOMA - investigation Breast, fibroadenoma. Craniocaudal mammograms obtained 1 year apart demonstrate a newly developing mass in the outer part of the breast.
  54. 54. FIBROADENOMATreatmentReassurance of the patientExcisional biopsy
  55. 55. TreatmentThe natural history of these lesions has recently beenelucidated and has resulted in a change in managementpolicy.Over a 2 year period approximately 20% slowly increase insize, 10% reduce in size, 20% completely resolve and 50%remain static.With knowledge of this natural history a conservativemanagement policy can often be adopted. In those <35 years and with a triple assessment supporting the diagnosis then observation with regular review is acceptable. In those > 35 years and in younger patients requesting it, excision biopsy should be considered.
  56. 56. Management algorithm for Fibroadenomas F ib ro a d e n o m a ( c li n i c a l d i a g n o s i s ) T r i p le a s s e s s m e n t A ll r e s u lt s c o n c u r r R e s u lt s d o n o t c o n c u r r M u lt i p le f i b r o a d e n o m a s G ia n t fib ro a d e n o m a / A g e < 3 0 y e a rs A g e > 3 0 y e a rs ( S e le c t i v e t r i p le a s s e s s m e n t ) J u v e n i le f i b r o a d e n o m a C li n i c a l o b s e r v a t i o n f o r 2 y e a r s E x c is io n E x c i s i o n o f la r g e s t E x t r a c a p s u la r E x c i s i o n w ith r i m o f n o r m a l tis s u e C li n i c a l o b s e r v a t i o n o f r e s tN o c h a n g e / s h rin k a g e / d is a p p e a re n c e In c r e a s e i n s i z e / A t p a tie n t r e q u e s t D is c h a rg e w ith a d v ic e o n B S E E x t r a c a p s u la r E x c i s i o n
  57. 57. Cystosarcoma phyllodes (CSP)Cystosarcoma phyllodes (CSP) is a rare, predominantlybenign tumor that occurs almost exclusively in thefemale breast. Its name is derived from the Greek wordssarcoma, meaning fleshy tumor, and phyllo, meaningleaf.Grossly, the tumor displays characteristics of a large,malignant sarcoma, takes on a leaflike appearance whensectioned, and displays epithelial cystlike spaces whenviewed histologically (hence the name).Because most tumors are benign, the name may bemisleading. Thus, the favored terminology is nowphyllodes tumor.
  58. 58. Cystosarcoma phyllodes (CSP)
  59. 59. Pathophysiology of CSPPathophysiology: Phyllodes tumor is the most commonly occurring nonepithelial neoplasm of the breast, and it occurs only in the female breast. It has a sharply demarcated, smooth texture and is typically freely movable. It is a relatively large tumor, and the average size is 5 cm. However, lesions more than 30 cm in size have been reported.
  60. 60. Cystosarcoma phyllodes (CSP)
  61. 61. Cystosarcoma phyllodes (CSP)
  62. 62. TREATMENT of CSPSurgical Care: In most cases, perform wide local excision with a rim of normal tissue If the tumor/breast ratio is sufficiently high to preclude a satisfactory cosmetic result by segmental excision total mastectomy, with or without reconstruction, is an alternative. More radical procedures generally are not warranted Perform axillary lymph node dissection only for clinically suspicious nodes. However, virtually all of these nodes are reactive and do not contain malignant cells.
  64. 64. FIBROCYSTIC DISEASEThis is the most common lesion of the femalebreast.Cystic lobular hyperplasia & fibrocysticdisease of the breast are the two commonacceptable description.Cystic hyperplasia is a variant of normal cyclicchanges in the breast that occur withmenstruation.This hyperplasia usually presents bilaterally inthe upper outer quadrant of the breast & ismost painful in the premenstrual period
  65. 65. Fibrocystic Breast DiseaseMost benign breast conditionIncidence-varying, related to age Menstruating years-20% 30-50% in premenopausal yearsSynonyms- Mammary dysplasia, Cystic disease, Cyclic Mastopathy, Cystic Hyperplasia
  66. 66. Pathophysiology of fibrocystic diseaseThe exact cause of fibrocystic disease is unkwonHormonal basis Oestrogen & Progesterone Prolactin ThyroidMethylexanthionesTrauma- NOT A CAUSE
  67. 67. Pathophysiology of fibrocystic diseaseOestrogen & Progesterone Oestrogen predominance over progesterone is considered causative Serum levels of Oestrogen high Luteal phase is shortened Progesterone level decreased to 1/3 normal, and women with progesterone deficiency carry a five fold risk of premenopausal breast cancer Corp. Lut. Deficiency / Anovulation in 70% Patients with Pre Menstrual Tension syndrome more likely to develop FDB
  68. 68. Pathophysiology of fibrocystic diseaseProlactin- levels are increased in 1/3 of women with FDB Probably due to Oestrogen dominance on pituitaryThyroid – Suboptimal levels sensitize mammary epithelium to Prolactin stimulationMethylexanthiones- Increased intake of coffee, tea, cold drinks chocolate is associated with development of FDB
  69. 69. PathomorphologyOestrogens stimulate proliferation ofconnective and epithelial tissues.The polymorphism of fibrocystic diseaseis documented by : fibrosis, cyst formation, epithelial proliferation, and lobular-alveolar atrophy
  70. 70. Clinical Course of fibrocystic diseaseFDB represents a clinical problem in approximately 30% ofpatients.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.Early fibrocystic manifestations may occur between the ageof 20 and 25 years, but most patients (70% to 75%) are intheir mid 30s and 40s.
  71. 71. Clinical Course of fibrocystic disease Incidence of FBD60%50%40%30% 50%20%10% 20% 10%0% Under 21 Years Menstrual years Pre-menopausal
  72. 72. Clinical Course of fibrocystic diseaseClinically, three phases of fibrocystic diseasecan be recognized- Phase I - Moderate stromal fibrosis, beginning hardness of breast tissue and premenstrual breast tenderness Phase II - Progressive fibrosis leading to increased hardening and tenderness, cyst formation, moderate modularity Phase III - Pronounced fibrosis and tenderness, macrocyst formation
  73. 73. Diagnosis of fibrocystic disease triple assessment Symptoms and Signs - Fibrocystic disease has a history of many months to several years. Fibrocystic disease is rare in ovulating women, multiparous women, and patients using oral contraceptives. Breast pain (mastodynia) and/or tenderness is observed in the majority of patients. In 40% to 60% of patients these are associated with irregular menses, dysmenorrhea, menometrorrhagia, or ovarian cysts.
  74. 74. Diagnosis of fibrocystic diseaseNipple secretion- In one third of patients with FDB, discharge is spontaneous or secretion can be expelled from the nipple. The cytological features may include amorphous material (fat, proteins), ductal cells, erythrocytes, and / or foam cells. the fluid is straw yellow, greenish, or bluish. In 2-3% carcinoma is diagnosedBloody Nipple secretion- when present 50-60% due to intra ductal proliferation (Papilloma) 30-40% due to carcinoma ( 64% after age 50).
  75. 75. Diagnosis of fibrocystic diseaseMammography – Patients with early fibrocystic change show small areas of increased density on the mammographic film.These are irregular and scattered, with varying degrees of density. As disease progresses, dark areas may occur along with the whitish grey areas, and microcalcifications may also become prominent. These calcifications can be single or multiple small flecks located in intraductal or periductal stroma or in entire lobules.
  76. 76. Diagnosis of fibrocystic diseaseUltrasonography - Particularly useful in delineating solid from cystic breast masses. Ultrasound of cystic masses characteristically defines a mass with a uniform outer margin demonstrating no asymmetry or unusual thickness of the wall. The central part of the mass shows no echoes, and there is posterior wall enhancement.
  77. 77. Diagnosis of fibrocystic diseaseNeedle aspiration biopsy – Indicated in patients with breast mass, a lump like structure,, a hard dense area or any abnormal tissue areas, as defined by clinical examination, mammography or USG. In patients at high risk of breast cancer, needle aspiration should be performed when the slightest suspicion arises. In women with fibrocystic disease, ductal epithelium consists of cohesive cells with a scant rim of cytoplasm and round or oval small, slightly hyper chromatic nuclei. Connective (fibrous) tissue is usually predominant.
  78. 78. Treatment of fibrocystic disease Medical-  Surgical- Goal- Intervention indicated To stop progression when- To relieve pain FBD is increasing in To reverse changes size Soften breast tissue Serous / Indicated when- Serosanguineous / FDB not increasing in bloody discharge size occurs No nipple discharge Patients are No psychological pshychologicaly effect disturbed
  79. 79. Treatment of fibrocystic disease Medical- Hormones Danazol OC pills- Remains the most Users are protected from effective therapy FBD Progestogen potency Basis- ovarian supression should be high Dose-200-600mg/day Progestogens - To be given in the luteal phase for 9-12 months About 80% get relief but 40% require restart of therapy
  80. 80. Treatment Medical- Ineffective modalities Hormones- Diet therapy-Caffeine Low Oestrogen restriction Diuretics Combined OC pills Iodine containing Progestogens in the agents luteal phase Thyroid hormone Evening Primrose oil Antioestrogens- Vitamin E & B6 Tamoxifen Dihydroergotamine Androgens-Danazol Antiprolactin drugs 82
  81. 81. Treatment of fibrocystic disease  Medical- Hormones - Danazol Efficacy of Danazol100% 90% 80% 90% 70% 81.40% 60% 75% 50% 40% 30% 47% 20% 10% 0% 200mg 400mg 100-800mg 200-400mg
  82. 82. Surgical treatmentsurgical removal of lumps, in most severecases of benign fibrocystic breast disease
  83. 83. MASTITIS
  84. 84. MASTITISBreast mastitis is an infection that commonlyaffects women who are breast-feeding(especially during the first two months afterchildbirth) but can occur in all women at anytime.Mastitis is a benign condition that can usuallybe treated successfully with antibiotics.Inflammation can be caused by many types ofinjury including : infectious agents and their toxins, physical trauma or chemical irritants
  85. 85. SIGNS AND SYMPTOMS OF MASTITISPart or all of the breast is intensely: painful, hot, tender, red, and swollen.Some patients can pinpoint a definite areaof inflammation, while at other times theentire breast is tender. - feel tired, run down,achy, have chills .feel like flu .A breastfeeding mother who thinks she hasthe flu probably has mastitis.
  86. 86. SIGNS AND SYMPTOMS OF MASTITIS chills or feel feverish, or temperature 38c or higher. These symptoms suggest an infection. Feeling progressively worse, the breasts are growing more tender, and the fever is becoming more pronounced. Other signs of mastitis: cracked or bleeding nipples, stress or getting run down, missed feedings or longer intervals between feedings.
  88. 88. TREATMENT OF MASTITISMastitis usually requires treatment.Treatment formastitis may require the following: Antibiotics are usually prescribed by a physician to help clear up the infection. Use warm water on the infected area of the breast before breast-feeding to help stimulate let-down (the milk ejection reflex). Breast-feed or pump frequently, using both breasts. Lactation consultants recommend first breast- feeding from the unaffected breast until let-down (milk ejection reflex) occurs and then switch to the breast with mastitis. Breast-feed only until the breast is soft. Apply icy compresses to the breasts after breast- feeding to relieve pain and swelling. Drink fluids and get enough rest. Analgesia to control the pain.
  90. 90. BREAST ABSCESSThis condition is usually found duringlactation . as role the infecting organism is : staphylococcus aureus, and less commonly streptococcus pyogenes .the usual mode of infection is via the nipple,the infection being carried by suckling infantin the nasopharynx.The infection is at first limited to the segmentdrained by the lactiferous duct but it maysubsequently spread to involve other areas ofthe breast.
  91. 91. BREAST ABSCESSCAUSES : Staphylococcus aureus and streptococcal species are the most common organisms isolated in puerperal breast abscesses. Nonpuerperal abscesses typically contain mixed flora (S aureus, streptococcal species) and anaerobes.
  92. 92. BREAST ABSCESSCLINICAL FEATURESSYMPTOM Localized breast area edematous, erythematous, warm, and painful History of previous breast abscess Associated symptoms of fever, vomiting, and spontaneous drainage from the mass or nipple May be lactating
  93. 93. BREAST ABSCESSCLINICAL FEATURESSIGNS Localized breast area erythematous, hot, edematous, and extremely painful Most commonly found in the areolar or periareolar area Fluctuance of the mass May have associated fever or axillary lymphadenopathy Discharge with palpation from nipple or mass Nipple inversion
  94. 94. Investigations1-Ultrasound: used to localize the abscess2. FNAC: used to exclude underlying carcinoma especially in chronic Breast abscess where the abscess become encapsulated with a thick fibrous capsule & the condition can’t be distinguished from a carcinoma without a biopsy.3. Needle Aspiration: to confirm presence of pus.4. Mammogram: to exclude underlying carcinoma.
  95. 95. BREAST ABSCESS MANAGEMENT1- If the patient present in the cellulitis stage the patient should be treated with an appropriate Antibiotic.2- Breast rested with feeding on the opposite side only.3- The milk should be expressed from the healthy segments of the affected breast.4- Support of the breast5- Local heat & analgesia to relive the pain.6- If the infection doesn’t resolve within 48 h, the breast should be incised & drained.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.
  96. 96. BREAST ABSCESSMANAGEMENT7.If pus is present at the time of presentation, which can be confirmed by Needle aspiration, Incision & Drainage is done which can be achieved by :  Simple Needle Aspiration: using a wide pore needle under local anesthesia.  Guided drainage: under image control with radiological or ultrasound techniques a tube drain can be inserted & left until the cavity has collapse.  Surgical drainage: it is the most certain method, not only can all loculi be reached, but also dead tissue can be removed. The cavity is then dressed regularly & left open to heal by 2ry intention.  Excision of all of the major ducts in case of Periductal Mastitis .
  97. 97. BREAST ABSCESS Prevention  Taking care of Breasts during pregnancy & Lactation  Stop lactating from cracked nipple.  Treating Mastitis in its early stages with appropriate medication & duration.  Drainage of Post-traumatic Hematoma.  Excision of Sebaceous Cyst.  Self Examination for any masses or tenderness.  Control of concomitant disease that increase the tendency to get infections such as DM
  98. 98. MANAGEMENT
  99. 99. BREAST ABSCESSLactational breast abscess Non-lactational breast abscessUsually due to Staph. aureus Occur in periareolar tissueUsually peripherally situated Culture yield - Bacteroides, anaerobic strep,Surgery may be pre-empted by early enterococcidiagnosis Usually manifestation of duct ectasia / periductalAttempt aspiration mastitisIf no pus - antibiotics Occur 30- 60 years , More common in smokersIf pus present consider repeated Often give history of recurrent breast sepsisaspiration or incision and drainage Repeated aspiration is the treatment of choiceConsider biopsy of cavity wall Metronidazole and flucloxacillinContinue breast feeding from Drain through small incision if non-resolvingopposite breast Definitive treatment when quiescent withNo need to suppress lactation antibiotic prophylaxis Usually a major duct excision = Adairs operation Spontaneous discharge or surgical excision can result in mammary fistula
  100. 100. CONCLUSIONBenign breast disorders & diseases are commonThe aetiopathogenesis is complex and not fullyunderstoodLump and pain are the most common complaintsEvaluation is done by Triple assessmentHistological risk factors for future malignancy arerelative and not absolute risk factorsTreatment is based on the natural history of clinicalproblemsTreatment must be tailored to individual needs