Transcript Benign Breast

Breast
Modified sweat glands.
Lobes and lobules of gland
in fat tissue stroma.
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Lactiferous ducts merge just
beneath he nipple to form a
lactiferous sinus. Then
individually open on nipple
Ducts emerge from acini of glands
Smaller ducts join to form lactiferous ducts
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Lobes and lobules
of gland
in fat tissue stroma.
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Ducts emerge from acini of glands
Smaller ducts join to form lactiferous ducts
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Axillary A lateral thoracic
Internal mammary A perforating
Intercostal lateral
Axillary vein
Internal mammary V
Intercostal veins
Supraclavicular nerve
Itercostal N
sympathatic
Benign Breast Disease
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Congenital Conditions
Traumatic Conditions
Infections
Aberrations of Normal Development and
Involution (ANDI)
Neoplastic
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Benign - Fibroadenoma
Congenital Conditions
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Congenital
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Supernumerary nipple
along nipple line
Supernumerary breast
Aplasia – turners,
Juvenile hypertrophy
Traumatic Conditions
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Traumatic fat necrosis
Cracks of nipple
Hematoma
Traumatic mastitis
Milk fistula
Traumatic Conditions (Fat
Necrosis)
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Follows trauma, surgery
or radiation
Small, hard mass confused with carcinoma
Focal necrosis of fat with
inflammation
Foamy lipid-laden
macrophages
Later fibrosis, calcification
Mammary fistula
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Congenital (rare)
Acquired
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Varient of MDE
Incision and drainage
of abcess in lactating
breast
Infections
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Acute
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Mastitis neonatorum
Pubertal mastitis
Traumatic mastitis
Metastatic mastits
Mammary duct ectasia
Lactational mastits
Acute suppurative
mastitis
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Chronic
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Chronic non specific
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chronic breast abscess
Hidradenitis
Pilonidal Disease
Postoperative Wound
Infections
specific
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Tuberculosis
Syphillis
Actinomycosis
Duct Ectasia and
Periductal Mastitis
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? Aetiology, age 40s - 50s, smokers
Dilatation of breast ducts - fill with stagnant
brown/green secretion - atrophy and loss of
ductal epithelium - secretion spills into periductal
tissues - inflammatory reaction (‘mastitis’)
Micro - lyphocytes, histiocytes, plasma cells
Secondary anaerobic infection, abscess
Fibrosis - slit-like nipple retraction
Duct Ectasia and
Periductal Mastitis
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Presentation
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Nipple discharge - any
colour
Nipple Retraction
Subareolar mass
Abscess
Mammary duct fistula
May mimic carcinoma
Duct ectasia
Nipple discharge - any colour
Nipple retraction
Lump
Abscess
Mammary duct fistula
•Antibiotics
• Flucloxacillin &
• Metronidaziole
• NSAID
Central duct excision
(Hadfield operation)
Operations - Hadfield’s Major
Duct Excision
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Indications :
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duct ectasia (periductal mastitis) with
recurrent episodes +/- fistulae
blood stained discharge from one or more
ducts in women > 40
Incision :
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circumareolar but < 3/5 the areolar
circumference to allow enough blood supply
include the orifice of any sinus or fistula
Operations - Hadfield’s Major
Duct Excision
Technique :
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cut the subcutaneous
tissue down to the ducts
dissect in a plane
circumfentially around the
terminal lactiferous ducts
divide the ducts close to
the nipple and remove with
a small conical wedge of
tissue
include fistulous tracts with
all granulation with excision
+/- DT closure 4/0
subcuticular
Lactational Mastitis
Bacterial Mastitis
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Cracks and fissures form
in early breastfeeding
Secondary infection with
Staph. aureus
Carried by nasopharynx
of infant
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Abscess
Chronic scar
Fever
Throbbing pain
Skin oedema
Aspiration of pus
Operation - Incision & drainage breast
abscess
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Breast abscess :
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most occur during lactation
empty the breast , allowing the baby to feed by the other
breast
drain early when there is a point of maximal tenderness needle aspiration + antibiotics may be more appropriate
Technique :
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General anaesthesia
incise
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over point of maximal tenderness or fluctuance
if near the nipple use circumareolar incision
deepen the incision until drain pus, send for M/C/S
Use counter incision in upper breast
break down loculations & take Bx (exclude inflam Ca)
+/- DT +/- kaltostat packing
supportive bra, breast feed when comfortable
Operations - Breast Excisional
Biopsy
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Indication : solid breast lump that is clinically
benign
Aim : to extract the lesion with minimal margin
and least cosmetic defect to establish a
histological Dx and remove the palpable lump.
Breast Excisional Biopsy
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Incisions :
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incise over the lump - adequate excision 1st priority
2nd comes aesthetic position
if possible scar hidden by bra
medial incisions more likely to develop keloid
avoid radial incisions except medially
make incision within skin that would be removed if
patient subsequently required a mastectomy
• Technique : excise lump completely without cutting into it
hold specimen with Lane or Allis tissue forceps
careful haemostasis +/- DT + L.A.
subcuticular closure
Caseous form
Sclerosing form
Fibrocaseous
Suppurative form
Tuberculosis
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Antituberculous drugs
Cold abscess
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Valvular incision
Local anti TB
Fibrocaseous
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Simple mastectomy
Anti TB
ANDI( Fibrocystic Disease)
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Developed by LE Hughes at Cardiff 1987
Replaces fibrocystic disease, fibroadenosis, etc.
Main Histological Features:
 Epithelial proliferation
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Adenosis (increase in no. of acinar units per lobule)
Epithelial Hyperplasia ( of cells) + Papilloma formation
Fibrosis
Cysts
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Retention cysts
Blue –domed cyst of Bloodgood (macrocysts)
Brodie’s tumor (microcysts)
Presentation
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Mastalgia
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Cyclical
Non-Cyclical
Lump - many causes
Periareolar Disorder
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Nipple Discharge
Nipple Retraction
Cyclical Mastalgia
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Presentation
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Median age 35 yrs
Premenstrual breast discomfort
Upper outer quadrant (often bilateral)
Relief during menstruation
Associated with nodularity
Aetiology presumably hormonal
Non-Cyclical Mastalgia
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Not related to menstrual cycle
Median age 45yrs (pre- or postmenopausal)
Unilateral, well-localised, ‘trigger spot’
Multiple Causes
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Carcinoma
Mammary Duct Ectasia
Sclerosing Adenosis (ANDI)
Painful Scar
Musculoskeletal Pain
Mondor’s Disease
Lumps
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Traumatic
 Fat Necrosis
 Organized hematoma
Inflammatory
 Mammary Duct Ectasia/Periductal Mastitis
 Chronic breast abcess
ANID
 Nodularity
 Cysts (Galactocele)
 Sclerosing Adenosis
Neoplastic
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Benign
 Lipoma
 Hard Fibroadenoma
 Giant fibroadenoma
 Phyllodes Tumour
Malignant
Nodularity
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Often bilateral, upper outer quadrant
May be cyclical
Associated with mastalgia
Histology (ANDI)
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Cysts
Fibrosis
Adenosis
Cysts
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Common, 30s-40s
Often multiple, bilateral
Present suddenly (fluid) +
pain, nodularity
Tense, less mobile than
Fibroadenoma
Involution of stroma and
epithelium
Turbid fluid (blue)
Apocrine or simple cuboidal
epithelial lining
Galactocele
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Solitary subareolar cyst
Dates from lactation
Contains milk
Can calcify
Can greatly increase in
size
Cysts of the breast
Cysts of the
breast
Ductal system
Neoplastic
Stroma
ANID
Micro
cysts
Skin cysts
Galactocele
Macro
cysts
Serous
Sebaceous
Lymphatic
Dermoid
Blood
Inflammatory
TB cold abscess
Chronic abscess
Hyadatid
Benign
Malignant
Duct
papilloma
Degeneration
of carcinoma
Papillary
cystadenoma
Degeneration
of sarcoma
Intracystic
carcinoma
Nipple Discharge
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Physiological - pregnancy/lactation
Duct Ectasia
Galactorrhoea
Duct Papilloma
Carcinoma
Cysts
Idiopathic
Galactorrhoea
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Milky discharge unrelated to lactation
Primary Physiological
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Menarche
Menopause
Stress
Mechanical Stimulation
Secondary
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Drugs: haloperidol, metoclopramide
Increased Prolactin: pituitary tumour, paraneoplastic
Management of Breast
Symptoms
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Breast Lump - always need to exclude Ca
Breast examination - Is there a lump or
localised nodularity?
Is there no lump or diffuse nodularity?
Triple Assessment
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1. FNA
2. U/S
3. Mammography
Breast Lump – Cyst and Mx
O/E discrete lump or localised nodularity present
FNA
solid
cystic
no blood
no residual lump
then no cytology
bloody fluid
residual lump
then do cytology
& mammography
re-examine in 6/12
reassure
no lump or
diffuse nodularity
excisional biopsy
Palpable Breast Lump - Solid Mx
FNA solid lump
Cytology
Mammography > 35
U/S
Tru-cut biopsy (lump > 2cm)
suspicious or carcinoma
Manage as for breast cancer
benign
Panel comment :
observe but excise if :
• age >35
• Pt requests
• pain
• increasing size
• equivocal cytology
If pt 25 - 35 need FNA/ trucut Dx of
fibroadenoma otherwise need exc Bx.
If tru-cut = normal breast tissue then still
need histology of the lump.
No Palpable Breast Lump Mx
no lump or
diffuse nodularity
age < 40
age > 40
re-examine 6/52
benign
reassure
Cytology
Mammography
U/S
benign
suspicious or carcinoma
reassure
Manage as for breast cancer
Nipple discharge
Nipple discharge
Unilateral
Bilateral (multiductal)
Physiological
Multiductal
Pathological
Fibroadenosis
Papillomatosis
Duct ectasia
Fibroadenosis
Papillomatosis
Duct ectasia
?? carcinoma
Uniductal
Duct papilloma
Duct carcinoma
Duct ectasia
Chronic absces
??? fibroadenosis
Mammography
U/S
Microdochectomy
Cytology,prolactin,ductography
Fibroadenoma
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Peak incidence 15-25 yrs
Smooth, highly mobile
2-3 cm occasionally multiple
Benign tumour of fibrous and glandular tissue
Mono- or polyclonal (cyclosporin)
Fibroadenoma - histopathology
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Well formed capsule
Delicate stroma
surrounding glandular
and cystic spaces
Epithelium compressed
and distorted by the
stroma
+ Coarse calcification
Benign tumors
Giant Fibroadenoma
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Peripubertal age
group
> 5cm
Rapid growing
Esp. Asian, black
women
Benign tumour
Occasional atypia
Phylloides Tumour
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Present later - 6th decade
Mostly benign, few highly
malignant with metastases
Pathology
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Variable size up to 15cm +
skin ulceration
Bulbous projections (‘leaf-like’)
Stroma has greater cellularity,
mitoses, nuclear
pleomorphism than
fibroadenoma
Higher grade lesions resemble
sarcoma
Duct Papilloma
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Solitary benign tumour in
single large duct
Presentation
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Discharge (+ blood)
Mass (clinical or XR)
Multiple papillae with
connective tissue axis,
covered with epithelial
and myoepithelial cells
Considered benign
Operations - Microdochectomy
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Indications : persistent blood stained
discharge from a single duct opening on the
nipple -- often find papilloma of duct causing the
bleeding
Technique : squeeze the breast and nipple
until a drop of discharge is seen
cannulate the duct using a
lacrimal probe and secure in
place with 3/0 suture passed
through the skin along side the
duct opening
Operations - Microdochectomy
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Technique : make a radial incision into the
nipple along the line of the probe encircling the
duct orifice
Dissect the skin of the areola
away from the underlying breast
for approx 1cm on each side of
the probe and excise the breast
segment containing the probe
using scissors commencing
behind the duct orifice and
continuing into the breast.
haemostasis & closure
Breast Procedures & Operations
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Procedures
 FNA
 Tru-cut needle biopsy - superceded by gun Bx
Operations
 Excisional biopsy
 Microdochectomy
 Hadfield’s Major Duct excision
 Incision and drainage of breast abscess - often needle
aspiration with antibiotics is used
Gynecomastia
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Enlargement of the
glandular tissue of the
breast
Unilateral or bilateral
enlargement forming
a disc like lesion
under the nipple and
areola which is freely
mobile
Gynecomastia (etiology)
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Physiological
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Neonatal
Pubertal
Involutional
(senescent)
Pathological
Decrease production
or action of
testosterone
Gynecomastia
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Pathological
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Decrease production or action of testosterone
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Klinfelter’s syndrome
Testicular feminization syndrome
Anorchism
Increase production or action of estrogen
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Pituitary tumors
Adrenal hypoplasia( addisson’s)
Testicular tumors ( Teratoma)
Liver failure
Hyperthyroidism
Estrogen treatment
Drugs
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Reserpine, methyldopa
Isoniazid
Spironolactone
Tagment, primperan, H2 blockers
Idiopathic
Gynecomastia (treatment)
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Physiological No
treatment
Pathological
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Treatment of the
cause
if persist excision
Idiopathic
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excision
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Sub mammary
Circum areolar
Gynecomastia