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OUTLINE
Anatomy (in brief)
Investigations
Anamolies
Injury to breast
Infections
Benign breast disease
Benign Neoplasms
Breast cysts
Nipple
INVESTIGATIONS
Mammography
Ultrasound
MRI
Needle biopsy/ cytology
Large-needle with vacuum system
Triple assessment
INVESTIGATIONS
Mammography Direct radiograph
Exposure to low-voltage, high amperage Xrays
Exposure of 0.1 cGy (very low)
Sensitivity increases with age
Normal mammograph does not exclude carcinoma
INVESTIGATIONS
Ultrasound: USG more useful in young women : as breast is more dense
Mammographs are difficult to interpret
Distinguish cysts from solid lesions
Locate impalpable lumps
Diagnosis of axillary pathology
USG guided aspiration and biopsy
INVESTIGATIONS
MRI Distinguish scar from recurrence for women with previous surgeries
Becoming the standard when lobular ca is diagnosed To assess the multicentricity and multifocality
Best imaging modality for women with implants
Less useful in axilla pathology
Biopsy possible but difficult than USG guided
INVESTIGATIONS
Needle biopsy / cytology To obtain histology under local ansthesia
Spring loaded core needle biosy using 21G or 23G 10 ml syringe
Multiple passes with negative suction
Fixed or dried to view under microscope
Least invasive technique of obtaining a cell diagnosis
Receptor staining is possible
False negetives: cannot differentiate invasive carcinoma from in situ
Large-needle biopsy Less sampling error
Using 8G or 11G
More helping in calcifications
ANAMOLIES
Amazia: Congenital absence of breast (unilateral/ bilateral)
More common in males
Poland’s syndrome*
Athelia Congenital absence of nipple
ANAMOLIES
Polymazia Accessory breast tissue
Along the “MILK LINE”
Axilla is the commonest site
Other sites: groin, thigh and buttocks*
They function during lactation
Treatment is excision
Polythelia Multiple nipples along the “MILK LINE”
ANAMOLIES
Micromastia: due to hypo-functioning ovary (congenital defect); breasts are smaller
Diffuse Hypertrophy (Benign virginal hypertrophy) Occurs sporadically in otherwise normal female
At puberty or first pregnancy
Enormous size (may reach upto knees when sitting)
Rarely unilateral
Pathophysiology unknown
Some response to anti-oestrogen drugs*
Plastic surgical repair is the only definitive treatment
ANAMOLIES
Gynacomastia Breast-like swelling in males*
The breast is enlarged, not the nipple and areola
Unilateral/ bilateral
Mostly Physiological Oestradiol excess
Testosterone deficiency
ANAMOLIES
Gynacomastia Pathophysiology
Oestrogen excess: may result from an increase of oestradiol from
Testicular tumors
Leydig cell / Sartoli cell tumour
Choriocarcinoma
Embryonal carcinoma
Non testicular tumors
Adrenal cortical neoplasm
Lung carcinoma
Hepatocellular carcinoma
Endocrine disorders
Hyperthyroidism
Hypothyroidism
Liver cirhosis
ANAMOLIES
Gynacomastia Pathophysiology
Androgen deficiency states
Aging
Kline-felter syndrome
Congenital anorchia
Heriditary defect in androgen biosynthesis
ACTH deficiency
Renal Failure
Secondary Testicular fauilure
Trauma
Orchitis
Crytochordism
Irridiation
Varicocoele
ANAMOLIES
Gynacomastia Pathophysiology
Drugs
Oestrogen realted activity activity (Digitalis, Anabolic steroids)
Anti-testosterone ( cemitidine, phenytoin, spironolactone, diazepam)
Enhancing oestrogen activity (reserpine, theophylline, frusemide)
Pathology Breast show fibro-fatty proliferation rather than acinar growth!!
ANAMOLIES
Gynacomastia Clinical features
No complaints other than enlargement of breast
May be associated with slight pain
Breast tissue can be moved over the underlying muscle
Serious psychological consequences
Can be associated with various pathologies
ANAMOLIES
Gynacomastia Treatment
Idiopathic gynacomastia resolves by itself so “wait and waitch”
Androgen deficiency: administer testosterone
Danazol, tamoxifene
No cause elicited: surgical excision by sub-areolar mastectomy
In case of suspected pathology: HPR should be sent for
INJURY TO BREAST
Haematoma: Resolving haematoma gives impression of a lump
In the absence of an overlying bruise, diagnosis is difficult unless biopsied
Traumatic Fat Necrosis: May be acute or chronic
Some sort of injury: Direct or Indirect
Diagnosis is confused with ca.
Prsents as a painless lump, firm and irregular
Some skin tethering
No retraction of nipple may be present)
No axillary lymph nodes
History of trauma*
INJURY TO BREAST
Traumatic Fat Necrosis: Pathophysiology
Trauma Focal necrosis of fat Inflammatory reaction subsequent scarring to give rise to a focus of firmer consistency
Chronic cases mimic new lumps
Treatment: Whenever in doubt excisional biopsy should be done
INFECTIONS
Acute Inflammatory Mastitis
Chronic Inflammatory Mastitis
Sub-areolar abscess
Duct ectesia / periductal mastitis
Mastitis of infants
Retromammary abscess
Tuberculosis
Syphilis
Mondor’s Disease
INFECTIONS
Acute Inflammatory Mastitis Aetiology
Acute bacterial mastitis is very common: associated with lactation
Develepment of cracks and bruises in the nipple: ascending infection
Staph aureus infection, penicillin resistant if nosocomial*
Streptococcus cuases more toxic symptoms
Blockage of one or more of the lactiferous ducts with epithelial debris*
Retracted nipple*
INFECTIONS
Acute Inflammatory Mastitis Clinical features
Acute mastitis
Redness, oedema, induration
Cellulitis Abscess
Redness, oedema and induration are somewhat localized
Fluctuation is very difficult to elicit
INFECTIONS
Acute Inflammatory Mastitis Treatment:
Cellulitis stage: breast support + local heat + analgesia + antibiotics
Feeding from the affected site can be continued if patient can manage
Absces stage: whenever pus has formed, it has to be let out
Antibiotics at this stage will lead to the formation of Antibioma*
Incision and drainage to be done*
Latest view: Repeated aspirations have the same result
Can be accomplished with USG guidance
No scar and patient can breast feed
INFECTIONS
Acute Inflammatory Mastitis Treatment:
Incision and drainage: needed only if there is marked skin thinning
Radial incision in the most prominent part
Counter-incision if it is not the dependent part
Break all loculi
Pack loosely with gauze, drain may be kept
Give firm support.
INFECTIONS
Chronic Inflammatory Mastitis Continuous antibiotic treatment
Improper drainage of the abscess
Too tight packing of the abscess cavity
Has thick fibrous cavity
May have sterile pus
May mimic carcinoma
Incision of the cavity wall and curettage of the walls
INFECTIONS
Sub-areolar abscess Not a true mastitis
Results from an infected sebaceous gland of Montogomery of areola
Or follow a furuncle near the areola
Incision and drainage of pus OR excision of the sebaceous cyst
INFECTIONS
Sub-areolar abscess/ Periductal mastitis/ Duct ectesia/ Plasma cell mastitis More common in smokers
Develops behind the nipple pointing towards the areola; avoiding the tough fibromuscular tissue of the areola
Dilatation of the larger peri-areolar ducts
Usually 6-8 ducts are involved, rest are normal
May be bilateral
Condition may mimic carcinoma with an indurated mass beneath the areola
INFECTIONS
Sub-areolar abscess/ Periductal mastitis/ Duct ectesia/ Plasma cell mastitis Duct dilatation theories:
Hormonally induced muscular relaxation of duct wall
Inadequate absorption of secretions
Obstruction of duct with squamous debris (but how bilateral?)
Smoking arteriopathy periductal inflammation damage to the duct wall duct dilatation stasis infection or healing by fibrosis*.
Cessation of smoking prolongs the long term survival.
INFECTIONS
Sub-areolar abscess/ Periductal mastitis/ Duct ectesia/ Plasma cell mastitis Clinical features
Mostly seen after menopause
Diffuse lump in the sub-areolar region
Differentiate with ca.
Nipple retraction (slit like)
Nipple discharge
Clasically it is thick and creamy / but may be greenish
Bloody discharge at times
Chronic milk fistula (on and off with abscess)
No adenopathy
INFECTIONS
Sub-areolar abscess/ Periductal mastitis/ Duct ectesia/ Plasma cell mastitis Treatment:
Exclude malignancy by mammography
If unsure: excision of the mass
Antibiotics
Fistula; fistulectomy with excision of the involved duct
Recurrent plasma cell mastitis : Hadfield’s operation
Remove all the terminal ducts*
INFECTIONS
Mastitis of infants Drop of colourless fluid can be expressed on the third day of life
Witch’s milk
Seen only in full-term infants
Cause: Stimulation by prolactin from the mother’s milk
INFECTIONS
Retromammary abscess: This conditionis nothing to do with breasts
Infection arises from Infected haematoma
Tuberculosis of the ribs
Osteomyletis of the ribs
Incision and drainage by Guillard Thomas incision breast lifted and chest wall drained corrugated rubber drain kept dressing done.
Appropriate antibiotics
INFECTIONS
Tuberculosis of Breast Usually secondary to:
Pulmonary tuberculosis
Chest wall tuberculosis
Cervical lymph node tuberculosis
Mediastenal tuberculous lymphadenitis
Blood borne
Clinical features: Parous women mostly
Primary focus somewhere else in the body
Multiple chronic abscesses with bluish hue
INFECTIONS
Tuberculosis of Breast Clinical features:
Cold abscess: no or very little signs of inflammation
Discharging sinuses, may be multiple
Anti-tubercular therapy
Mastectomy only with persistent residual infection
INFECTIONS
Syphilis: All three stages can be seen in breast
Primary: Primary chancre seen on the nipple
Secondary: Mucous patches in the sub-mammary folds; with diffuse mastitis
Diffuse Syphilitic Mastitis)
Tertiary: Gumma (very rare)
INFECTIONS
Mondor’s disease Superficial thrombophlebitis of the superficial veins
No known cause
Not encountered in arm
Clinical feature: Thrombosed sub-cutaneous chord, usually attached to the skin
May be painful and tender
When arm is raised; a groove alongside the vein is seen
Treatment: Rest to the arm and firm support to the breast*
D/D: lymphatic permeation of occult malignancy to be ruled out
BENIGN BREAST DISEASE (ANDI)
Concept: Breast in in dynamic change throughout reproductive life
Super-imposed by menstrual cycles and pregnancies
Concept of ANDI was first given by L.E. Hughes et.al of Cardiff University (1987)
This concept recognizes conditions as being within a spectrum from normal to mild abnormalities to disease process.
BENIGN BREAST DISEASE (ANDI)
Pathology: The disease consists centrally of four features:
Cyst formation
Fibrosis
Hyperplasia
Papillomatosis
BENIGN BREAST DISEASE (ANDI)
Pathology: Cyst formation: Two types of cysts are found
Simple cysts: Formed due to passive diffusion of plasma through simple membrane to cause cyst
Aspirate from simple cysts are similar to plasma in Na:K ratio
These are single and do not recur with no risk of malignancy
Complex cysts: Lined by apocrine epithelium cahractereised by large columnar cells like those in sweat glands
These cysts arise from a single lobule.*
The solitary draining duct is blocked and cysts become very large
Multiple cysts: but all may not be palpable
BENIGN BREAST DISEASE (ANDI)
Pathology: Complex cysts:
Complex cysts tend to recur
May be associated with malignancy
Classic diffuse cystic disease :Schimmelbusch’s Disease
One large cyst becomes tense and blue domed: “Blue-domed cyst of Bloodgood”
Cysts usually contain greyish green desquamated cells
Cysts may contain blood due to haemorrhage
BENIGN BREAST DISEASE (ANDI)
Pathology: Fibrosis: Fat and elastic tissue is replaced by white fibrous tissue
Interstitium is infiltrated with chronic inflammatore cells
This fibrous tissue compresses the ducts and distorts the acinar patterns.
Hyperplasia: Hyperplasia of epithelium of ducts and acini Hyperplasia of both glandular and connective tissue
Ductal lumen may get full of cells
Can be a pre-malignant condition if epitheliosis is more
Papillomatosis: Hyperplasia may be extensive enough to cause papillomatous growth within the ducts
BENIGN BREAST DISEASE (ANDI)
Clinical feature: A benign discrete lump in the breast is commonly a cyst or fibroadenoma
Lumpiness : described by patient as heaviness in the upper outer quadrant
Mastalgia: Cyclical mastalgia with nodularity (fibrocystic disease)
Non-cyclical mastalgia
BENIGN BREAST DISEASE (ANDI)
Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Aetiology: It is an Aberration in normal involution (ANI) of breast
Hyper-oestrogenism
Increased estrogen OR
Decreased progesterone
Exessive caffeine
Inadequate essential fatty acids
Pathology: Cyst formation
Fibrosis
Hyperplasia
Papillomatosis
BENIGN BREAST DISEASE (ANDI)
Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Clinical feature:
Cyclical mastalgia: breast pain has a definitive relation to the menstrual cycle
40% of the patients present with cyclical mastalgia in breast clinic
Discomfort lasts for a varying period of time (for months) then disappears, to relapse again after years
Pain is mostly located in the upper-outer quadrant
May radiate to axilla, chest wall or side of the arms
No mammographic findings
BENIGN BREAST DISEASE (ANDI)
Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Clinical feature:
Lumps or lumpiness: The next mode of presentation
Upper-outer quadrant
Just before menstruation both lump and pain increase with tenderness
On examination: Nodular lesion with lumps, lumps are inseparable
Best palpated between thumb and fingers
Easily movable lumps, not adherent
No axillary lymph nodes enlarged
No retraction of nipple
BENIGN BREAST DISEASE (ANDI)
Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Management of cyclical mastalgia
Breast pain monthly diary
Re-assurance
Breast support
Evening primrose oil
Danazol
Bromocriptine
Tamoxifene
MedroxyProgesterone
Oral contraceptives
Avoid conception for three months when using bromocriptine and danazol
BENIGN BREAST DISEASE (ANDI)
Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Management of lumpy breast
In case of no discrete lump (supported by mammography)
Reassurance
Ask the patient to come in different phase of cycle*
In case of lumps
Mammography and USG to exclude other conditions
Biopsy from a single or multiple lumps
BENIGN BREAST DISEASE (ANDI)
Fibrocystic disease / Cyclical mastalgia with nodularity /Fibroadenosis Management of lumpy breast
Surgical management:
Indications:
Intolerable pain
Lump inspite of best conservative management
Presence of concomitant malignancy cannot be excluded
Older patients causing anxiety
Excision biopsy by circumareolar incision
If not possible then sub-mammary of Gaillard Thomas
In case of failure then radial or curved incision over Langer’s line
BENIGN BREAST DISEASE (ANDI)
Sclerosing adenosis: It is an AND of normal breast
Characterised by terminal duct and myo-epithelial proliferation
Distorted glandular proliferation: loss of normal lobular architecture
May be multifocal
May calcify: mimics carcinoma
Causes mastalgia :perineural invasion causing “trigger spot zones”
Causes mastalgia rather than lump
Lump: smooth relative mobile mass
Treatment: Reassurance and management of mastalgia
NON-CYCLICAL MASTALGIA
Cyclical nodularity: Mass rather than pain, being the chief complaint
Teenagers mostly affected /premenopausal women may sometimes be affected
A large and uncomfortable swelling develops in the upper outer quadrant
Vague discomfort may be associated
Examination: Diffuse nodular swelling with tenderness
Management: Reassurance: may resolve by next cycle
Mammography
Aspiration cytology in older women
NON-CYCLICAL MASTALGIA
No co-relation with the menstrual history
More commonly seen in peri-menopausal women
Less understood
Mostly felt in the medial quadrant of breasts
Described as “burning” or “dragging”
Sometimes well localized at “trigger spot zones”
May be associated with Periductal mastitis
50% doesn’t arise from breast.
NON-CYCLICAL MASTALGIA
Management: Exclude extra mammary causes like chest pain*
Non- steroidal analgesics
Injection with local ansthetics in the trigger spots
Surgical excision of trigger spot zone (NOT WIDELY ACCEPTED)
BENIGN NEOPLASMS
Fibroadenoma The most common tumour female breast
It is composed of both glandular and fibrous tissue
Aetiology: It is AND May be seen along with Fibroadenosis (ANI)
Pathology Increased sensitivity to oestrogen
More common in blacks
Mostly spherical; may be multinodular
They typically stop growing after 2 to 3 cm size
May harbor lobular carcinoma in situ
BENIGN NEOPLASMS
Fibroadenoma Types:
The Pericanalicular (hard fibroadenoma): it is firmer, smaller and moves well within the breast tissue “BREAST MOUSE”
The Intracanalicular (Soft fibroadenoma): is relatively less firm, grows larger with profuse connective tissue “INTRADUCTAL MYXOMA”
Both variants can co-exist
BENIGN NEOPLASMS
Fibroadenoma Clinical features
The pericanalicular occurs in younger females (15 to 30 yrs)
The intracanalicular affects older age group (30 to 50 yrs)
Painless, slow growing solitary lump (pain when associated fibroadenosis)
Mostly seen in the lower part of the breast
Multiple may be present; 10% cases
Intracanalicular can grow large causing pain due to stretching skin
No discharge per nipple
BENIGN NEOPLASMS
Fibroadenoma On examination:
No visible swelling ( large intracanaliclar may be visible)
Freely mobile; more in young girls*
Firm consistency
No axillary lymph nodes
Treatment: Present trend: women under 25 yrs of age, routine excision is avoided
The fibroadenoma grows upto 3 cm in 5 yrs
Thereafter gradually become smaller
BENIGN NEOPLASMS
Fibroadenoma Treatment:
In case of suspected pathology: excision biopsy is the treatment of choice
Enucleation of the pericanacular variety
Excision of the intracanalicular variety
Peri-areolar or Sub mammary incision (Gaillard Thomas’s incision)
If not possible then radial or curved incision over Langer’s lines
BENIGN NEOPLASMS
Giant fibro-adenoma Grows more than 5 cm in size
Bimodal age of presentation (at puberty and peri-menopause)
More common in blacks
Epithelial hyperplasia and atypia
Characterised by rapid growth
Differentiate from phyllodes tumour, Benign virginal hypertrophy
On examination: Enlarged breast
Displaced nipples
Stretched and shiny skin
Dilated veins
Skin necrosis may occur
Treatment: Enucleation
BENIGN NEOPLASMS
Phyllodes Tumour Also called Cystosarcoma Phyllodes, Serocystic Disease Of Brodie or Benign
Cystosarcoma
Mostly seen in premenopausal women (40yrs age)
Show a wide range of histology From an almost benign condition resembling fibroadenoma
To the ones with high mitotic index
Tumour has irregular projections: cause for recurrences
Clinical features: Presents as massive tumour
Unevenly bosselated surface
BENIGN NEOPLASMS
Phyllodes Tumour Clinical features:
Pressure necrosis of overlying skin
Or warm, red, shiny skin with dilated veins
Normal nipple
Firm consistency
Smooth margins
Not fixed: the stretched skin can be picked up
No axillary lymph node involvement
Known for local recurrence
BENIGN NEOPLASMS
Phyllodes Tumour Treatment:
Younger women (Benign end of spectrum): Simple enucleation
Older patients (Malignant end of the spectrum) :Wide excision with 1 cm margin or more
Recurrences: mastectomy with recostruction
BENIGN NEOPLASMS
Duct Papilloma Benign tumour, usually small
Arising from ther lining epithelium of lactiferous duct
It may too small for clinical palpation, but may obstruct a duct for cyst formation
Not a pre-cancerous condition*
Usually single and unilateral
Papillonama has a stalk
Papilloma vs papillomatosis (epithelial hyperplasia without a stalk)
BENIGN NEOPLASMS
Duct Papilloma Clinical features
Age 30 to 50 yrs
Bloody discharge: commonest presentation
Small and soft lump palpable beneath the areola or nipple; often difficult
Discharge from the affected duct on pressing the lump
May present with a cystic swelling; due to impalpable lump blocking the duct
No lymph nodes are affected
BENIGN NEOPLASMS
Duct Papilloma Treatment:
Complete excision of the affected duct Microdochectomy
Wedge resecteion
If not palpable then gently probe the affected duct
Carry on the resection with 1mm distance from the probe
Papilloma is mostly situated 4-5 cm away from the nipple
BENIGN NEOPLASMS
Papillary cystadenoma: Swellings or lumps are composed of cysts
Into these cysts papillomatous processes extend
Cysts are almost filled with these papillomatous processes
Swelling feels soft: not cystic
Management Excision and biopsy
Benign condition
BREAST CYSTS
Type I Classification
A FROM THE DUCTS: Fibroadenosis
Blue domed cyst of Bloodgood
Galactocoele
Serocystic disease of Brodie
Papillary cystadenoma
Intradeuctal papillary carcinoma
BREAST CYSTS
Type I Classification
B FROM THE STROMA Blood Cyst (encapsulation of haematoma)
Lymphatic cyst
Hydatid cyst
Colloid Degeneration of carcinoma
BREAST CYSTS
Type II Classification
A FROM MAMMARY DYSPLASIA Fibroadenosis
Cyclical nodularity
Bluedomed cyst of Bloodgood
Sclerosing adenosis
B RETENTION CYSTS Galactocoele
BREAST CYSTS
Type II Classification
C FROM TUMOURS
Benign Papillary cystadenoma
Serocystic disease of Brodie
Malignant Intracystic papillary carcinoma
Colloid or mucinous carcinoma
Medullary carcinoma
D MISC Lymphatic cyst
Hydatid cyst
Blood cyst
BREAST CYSTS
Clinical presentation Mostly seen in the last decade of reproductive life*
Usually single in presentation, or just single cyst is palpable
Relation to menstruation
Sudden appearance (subclinical state)
Mammography
Aspiration of cyst (for confirmation of diagnosis)
Treatment: Aspirate when in doubt
Blood, mass after aspiration or recurrence: malignancy
No blood; no mass after aspiration : Benign nature (Mostly Fibroadenosis)
Follow up after 2 months
BREAST CYSTS
Treatment: Diagnosis in Doubt / multiple cyst: excision and biopsy
Theoritically: Patients with breast cysts are at increased risk of malignancy
BREAST CYSTS
Galactocoele: Accumulation of milk and amorphous epithelial debris
Blockage of main duct
Presents as sub-areolar cyst
Presents in patients who have just cased breast feeding
Management: Excision of the affected duct
NIPPLE
Nipple retraction Causes:
Benign horizontal inversion
Duct ectesia
Carcinoma
Post surgical
Types: Slit-like: Duct ectesia
Circumferential: Carcinoma /Post surgical
May cause retention of secretions
NIPPLE
Nipple retraction Treatment:
Spontaneous resolution during pregnancy or lactation
Mechanical suction device
Simple cosmetic surgery
Ducts will have to be divided
NIPPLE
Discahrge per Nipple:
A. Discharge from the surface Paget’s disease
Skin diseases (eczema, psoriasis)
Rare cuases (chancre)
B. Discharge from a single duct
Blood stained Intraduct papilloma
Intraduct carcinoma
Duct ectesia
Serous (any-colour) Fibrocystic disease
Duct ectesia
Carcinoma
NIPPLE
Discahrge per Nipple:
C. Discharge from more than one duct
Blood- satined Carcinoma
Ectesia
Fibrocystic disease
Black or green Duct ectesia
Purulent Infection
Serous Fibrocystic disease
Duct ectesia
NIPPLE
Discahrge per Nipple: Management: Mammography in those more than 35 yrs of age
Microdochectomy: Probe and remove a single duct upto 5cm
Hadfield operation: Cone excision of the major ducts* Patient will not be able to breastfeed
Underlying pathology to be dealt with
NIPPLE
Other conditions: Cracked nipple: fore-runner of acute mastitis
Breast feeding should be rested for 48 hrs
Milk to be evacuated with a breast pump
Resume feeding as soon as possible
Papilloma of nipple: Same features as cutaneous papilloma
Excision with tiny disc of skin
Eczema: Usually associated with eczema elsewhere in the body
0.5% hydrocortisone