BREAST CONDITIONS

MR MUSONDA.A.
Dip. Clinical Med, BCSC Med
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Open discussion

CLASS OBJECTIVES

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Outline

• Introduction
• Basic science
– Embryology
– Histology
– Gross anatomy
– Physiology
• Pathologies
• Management
• Conclusion

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Introduction

 Breast disease/conditions are of significance

now because of advances in diagnosis and
treatment options for breast cancer
 In fully grown up adults there is a pair

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Introduction-Breast

 Modified sweat gland located which lies in

the cushion of fat and enveloped by
superficial and deep facial of the anterior
chest wall
 Each mammary gland consists of 15-20
lobules that are drained by lactiferous ducts
that open separately on the nipple
 Influenced by the endocrine system and each
month follows a cycle of hypertrophy and
involution changes
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Developmental anatomy

 Develops from ectoderm 4-7th week of

gestation
 Base extends from 2nd to 6th ribs and from
lateral border of sternum to midaxillary line
 Divided into four quadrants

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Importance

 Lactation
 Beauty
 Sexual organ
 As a sign of maturation
 Medically; Disease/pathologies involving
breast
 Cultural

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Clinical presentation
 Pain
 Lump/s
 Skin changes
 Discharge
 Milky
 Bloody
 Watery
 Greenish
 Nipple
distortion/destruction
etc.
 Breast enlargement

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Relevant History
 Age
 Sex
 Mass
 Nipple discharge
 Breast pain-cyclic/ non
cyclic
 Gynaecological Hx
 Menarch, Age of first
child, contraceptive use
 PMHx
 Gynaecological, breast
cancer, radiation, breast
related surgery
 FHx
 Breast Ca, Ovarian Ca
 Constitutional
symptoms, in Ca
 Anorexia, weight loss,
cough, haemoptysis,
bony pain
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Pathologies

 Congenital
 Acquired
 Trauma
 Inflammatory
 Infection
 Degenerative
 Metabolic/physiological
 Tumour

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Breast disease evaluation
 Triple assessment
 Clinical evaluation
 History
 Physical examination
 Radiological evaluation
 Ultrasonography
 Cysts, solids, Calcification, circumscription
 Mammography
 Others: CT or MRI scan
 Histological
 Core biopsy or maybe
 Excision biopsy

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Congenital

 Athelia
 Amastia
 Amasia
 Polythelia
 Polymastia
 Accessory breast
 Gynaecomastia

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Infection

 Mastitis
 Lactation
 Non lactation
 TB
 Abscess
 Fungal

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Tumours

 Benign
 No potential of invasion
 Malignancy
 Potential to invade and metastasis

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Benign

 ANDI
 Aberration of normal development and involution
 Occurs due to cyclic changes of breast which is
influenced by hormones every 4-6 weekly in a
female individual

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Fibrocystic disease

 Fibrocystic disease/changes encompasses a

wide spectrum of clinical and histological
findings
 Cystic
 Breast nodularity
 Stromal proliferation
 Epithelial hyperplasia
 Result from circulating and locally produced
hormones and growth factors
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Fibrocystic disease
 Incidence greatest around 30-40 years
 Presents with cyclic pain, swelling or tenderness
 Cyclic mastalgia
 Frequently bilateral
 No associated risk for cancer

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Fibrocystic disease

 Management
 Mammogram
 Rule out cancer by FNAC or excisional biopsy
 Avoid xanthine derivatives: tea, coffee, chocolate
 Drugs:
 Diazole, a weak androgen agonist
 Or Tamoxifen, antioestrogen receptor

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 Fibroadenoma
 Most common pathology below the age 30years
 Normally round, well circumscribed, also called
‘Breast mouse’ when small
 Difficult to locate
 Firm, rubbery, mobile and usually solitary
 Those > 5cm called Giant Fibroadenoma

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Fibroadenoma

 Hormonal dependent
 Increase of breast cancer incidence
 Family history
 Excision and biopsy to rule out malignancy
 Otherwise manage conservatively
 SBE: Self Breast examination
 Follow up
 Serial radiological studies

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Phyllodes Tumour (Cystosarcoma
Phyllodes)
 A rare variant of Fibroadenoma
 Can occur at any age
 Presents as a smooth, multinodular, rounded
painless mass with overlying skin inflamed,
shiny and venous engorgement
 Size >4-5cm
 Normally has absence of axillary LNs

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Phyllodes Tumour
(Cystosarcoma Phyllodes)
 May be considered a low-grade malignancy
 Sarcoma
 Has a high rate of recurrence and increase
potential of sarcomatous transformation
 Treatment
 Triple assessment
 Wide local excision with at least 1cm margin
 Mastectomy for large tumours

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Intraductal Papilloma

 Intraductal papilloma
 Benign solitary polypoid lesion involving
epithelium of major subareolar ducts
 Presents with bloody discharge in premenopausal
women
 Major differential; Intraductal carcinoma
 Treatment
 Excision of involved duct

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OTHER BENIGN CONDITIONS

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Galactocele

 Occurs when lactation is stopped due to

blocked lactiferous duct filled with
inspissated milk and desquamated epithelial
cells
 Presents as a round well-circumscribed,
mobile, tender subareolar mass
 Treatment
 Needle aspiration
 Excision if cyst cannot be aspirated

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 Mastitis and Breast abscess
 Common in lactating women, due to inspissated
of milk, obstruction and secondary infection
 Mastitis, development of generalised infection
 Breast abscess, infection localised leading to pus
formation
 Most common organisms in lactating women
 Staphylococcus aureus and epidermidis
 Others streptococcus and diptheroid species

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Mastitis and Breast abscess

 In non-lactating women, especially smokers

 Staph aures, anaerobes, Bacteroides
 Presentation;
 Febrile, with painful, erythematous swollen breast
 Treatment
 Culture breast milk
 Antibiotics
 Abscess needs drainage, I & D

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 Mammary duct ectasia
 Subacute inflammation of ductal system
characterised by dilated mammary ducts,
inspissated secretions and marked periductal
inflammation
 Yellowish nipple discharge
 Occurs mainly after menopause
 Has noncyclical breast pain-mastodynia
 Treatment-Excision and biopsy of subareolar
duct

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 Fat Necrosis
 Presents as an ecchymotic, tender, firm, ill
defined mass often with skin or nipple retraction
 Need to be differentiated from carcinoma
 May have history of trauma, even surgery
 Treatment
 Excision and biopsy to differentiate from carcinoma
 Otherwise observe

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Gynaecomastia
(Gigatomastia/Megalomastia)
 Benign proliferation of male breast glandular
tissue
 Types
 Physiological
 Newborn
 Puberty
 Senescent
 Drug induced
 Pathological

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Gynaecomastia
 Types
 Drug induced
 Use of oestrogens, digoxin, thiazides, phenytoin, cimetidine,
theophylline, ‘chamba’, spironolactone
 Pathological
 Cirrhosis, renal failure, malnutrition, hyperthyroidisms,
testicular tumours, hypogonadism
 Treatment
 Manage cause by removing the insulting agent
 Subcutaneous mastectomy
 Assurance

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Breast Malignancy

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Malignancy

 Most common non skin skin in the US

 Incidence increases with age
 One of the leading cause of death in the US
among 40-45 year old women and world wide
 Breast cancer is a systemic disease

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Risk factors
 Sex; Female > male  History of breast biopsy
 Increase in age  Atypical ductal or lobular
 First degree relatives hyperplasia on histology
 Genetic predisposition of biopsy taken
 p53 suppressor gene  DCIS or LCIS
mutation  Early menarche or late
 BRCA 1/ BRCA 2 menopause
 Prior history of cancer  Oral contraceptives
 Radiation exposure  Oestrogen replacement
 Alcohol consumption therapy

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Clinical presentation

 Non palpable mass, noted only on

mammogram,
 Palpable mass
 Skin changes
 Nipple discharge
 Metastatic disease: LYMPHADENOPATHY,
chest, liver-jaundice, bone pain and
pathological fractures

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Breast Cancer a systemic
disease

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Histological types

 Intraductal 80%
 Lobular 5-10%
 Paget’s disease of the breast 1-3%
 Inflammatory breast cancer 1-4%
 Sarcoma
 Lymphoma

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Sites of common spread

 Lymph nodes • Spreads via

 Lungs – Venous
– Lymphatics
 Bones
– Contiguous
 Liver
 Brain

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Radioisotope scan for bone
metastasis

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Management

 Triple assessment
 Multidisciplinary
 Surgeons
 Physicians
 Nurses
 Radiologists
 Multimodal treatment
 Prognosis depends on stage of disease

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 Management
 Treatment modalities
 Surgery
 Wide local excision
 Various types of mastectomy
 Axillary LN dissection
 Chemotherapy
 Neo adjuvant and/or adjuvant
 Radiotherapy
 Hormonal therapy
 Depending on receptors

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Conclusion

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Safe
Breast
Examinatio
n- a must
for every
woman

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 References
 Skandilakis surgical anatomy,
 The Monte Raid Surgical
Handbook, 2005
 Oxford Handbook of Clinical
surgery, 2002
 An Introduction to the
Symptoms and Signs of
Surgical disease, 1997
 MRCS Part B OSCEs Essential
Revision Notes, 2010

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