Presentation is loading. Please wait.

Presentation is loading. Please wait.

Breast.  Modified sweat glands.  Lobes and lobules of gland in fat tissue stroma.  Ducts emerge from acini of glands  Smaller ducts join to form lactiferous.

Similar presentations


Presentation on theme: "Breast.  Modified sweat glands.  Lobes and lobules of gland in fat tissue stroma.  Ducts emerge from acini of glands  Smaller ducts join to form lactiferous."— Presentation transcript:

1 Breast

2  Modified sweat glands.  Lobes and lobules of gland in fat tissue stroma.  Ducts emerge from acini of glands  Smaller ducts join to form lactiferous ducts Lactiferous ducts merge just beneath he nipple to form a lactiferous sinus. Then individually open on nipple

3  Ducts emerge from acini of glands  Smaller ducts join to form lactiferous ducts  Lobes and lobules  of gland in fat tissue stroma.

4 Axillary A lateral thoracic Internal mammary A perforating Intercostal lateral Axillary vein Internal mammary V Intercostal veins Supraclavicular nerve Itercostal N sympathatic

5

6

7

8

9 Benign Breast Disease Congenital Conditions Congenital Conditions Traumatic Conditions Traumatic Conditions Infections Infections Aberrations of Normal Development and Involution (ANDI) Aberrations of Normal Development and Involution (ANDI) Neoplastic Neoplastic Benign - Fibroadenoma Benign - Fibroadenoma

10 Congenital Conditions Congenital Congenital Supernumerary nipple along nipple line Supernumerary nipple along nipple line Supernumerary breast Supernumerary breast Aplasia – turners, Juvenile hypertrophy Aplasia – turners, Juvenile hypertrophy

11

12 Traumatic Conditions Traumatic Traumatic fat necrosis Cracks Cracks of nipple Hematoma Hematoma Traumatic Traumatic mastitis Milk Milk fistula

13 Traumatic Conditions (Fat Necrosis) Follows trauma, surgery or radiation Follows trauma, surgery or radiation Small, hard mass - confused with carcinoma Small, hard mass - confused with carcinoma Focal necrosis of fat with inflammation Focal necrosis of fat with inflammation Foamy lipid-laden macrophages Foamy lipid-laden macrophages Later fibrosis, calcification Later fibrosis, calcification

14 Mammary fistula Congenital Congenital (rare) Acquired Acquired Varient Varient of MDE Incision Incision and drainage of abcess in lactating breast

15 Infections Acute Acute Mastitis Mastitis neonatorum Pubertal Pubertal mastitis Traumatic Traumatic mastitis Metastatic Metastatic mastits Mammary Mammary duct ectasia Lactational Lactational mastits Acute Acute suppurative mastitis Chronic Chronic Chronic non specific chronic breast abscess Hidradenitis Pilonidal Disease Postoperative Wound Infections specific Tuberculosis Syphillis Actinomycosis

16 Duct Ectasia and Periductal Mastitis ? Aetiology, age 40s - 50s, smokers ? 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’) 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 Micro - lyphocytes, histiocytes, plasma cells Secondary anaerobic infection, abscess Secondary anaerobic infection, abscess Fibrosis - slit-like nipple retraction Fibrosis - slit-like nipple retraction

17 Duct Ectasia and Periductal Mastitis Presentation Presentation Nipple Nipple discharge - any colour Retraction Subareolar Subareolar mass Abscess Abscess Mammary Mammary duct fistula May May mimic carcinoma

18 Duct ectasia Nipple retraction Lump Abscess Nipple discharge - any colour Mammary duct fistula

19 Antibiotics Flucloxacillin & Metronidaziole NSAID Central duct excision (Hadfield operation)

20

21 Operations - Hadfield’s Major Duct Excision Indications Indications : duct duct ectasia (periductal mastitis) with recurrent episodes +/- fistulae blood blood stained discharge from one or more ducts in women > 40 Incision Incision : circumareolar circumareolar but < 3/5 the areolar circumference to allow enough blood supply include include the orifice of any sinus or fistula

22 Operations - Hadfield’s Major Duct Excision Technique : cut the subcutaneous tissue down to the ducts cut the subcutaneous tissue down to the ducts dissect in a plane circumfentially around the terminal lactiferous 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 divide the ducts close to the nipple and remove with a small conical wedge of tissue include fistulous tracts with all granulation with excision include fistulous tracts with all granulation with excision +/- DT closure 4/0 subcuticular +/- DT closure 4/0 subcuticular

23 Lactational Mastitis

24 Bacterial Mastitis Cracks and fissures form in early breastfeeding Cracks and fissures form in early breastfeeding Secondary infection with Staph. aureus Secondary infection with Staph. aureus Carried by nasopharynx of infant Carried by nasopharynx of infant Abscess Abscess Chronic scar Chronic scar

25 Fever Throbbing pain Skin oedema Aspiration of pus

26

27 Operation - Incision & drainage breast abscess Breast abscess : Breast abscess : most occur during lactation most occur during lactation empty the breast, allowing the baby to feed by the other breast 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 drain early when there is a point of maximal tenderness - needle aspiration + antibiotics may be more appropriate Technique : Technique : 1. General anaesthesia 2. incise over point of maximal tenderness or fluctuance over point of maximal tenderness or fluctuance if near the nipple use circumareolar incision if near the nipple use circumareolar incision deepen the incision until drain pus, send for M/C/S deepen the incision until drain pus, send for M/C/S Use counter incision in upper breast Use counter incision in upper breast 3. break down loculations & take Bx (exclude inflam Ca) 4. +/- DT +/- kaltostat packing 5. supportive bra, breast feed when comfortable

28

29 Indication : solid breast lump that is clinically benign 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. Aim : to extract the lesion with minimal margin and least cosmetic defect to establish a histological Dx and remove the palpable lump. Operations - Breast Excisional Biopsy

30

31 Breast Excisional Biopsy Breast Excisional Biopsy Incisions : Incisions : incise over the lump - adequate excision 1st priority incise over the lump - adequate excision 1st priority 2nd comes aesthetic position 2nd comes aesthetic position if possible scar hidden by bra if possible scar hidden by bra medial incisions more likely to develop keloid medial incisions more likely to develop keloid avoid radial incisions except medially avoid radial incisions except medially make incision within skin that would be removed if patient subsequently required a mastectomy 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

32 Caseous form Sclerosing form Fibrocaseous Suppurative form

33 Tuberculosis Antituberculous Antituberculous drugs Cold Cold abscess Valvular Valvular incision Local Local anti TB Fibrocaseous Fibrocaseous Simple Simple mastectomy Anti Anti TB

34 ANDI( Fibrocystic Disease) Developed by LE Hughes at Cardiff 1987 Developed by LE Hughes at Cardiff 1987 Replaces fibrocystic disease, fibroadenosis, etc. Replaces fibrocystic disease, fibroadenosis, etc. Main Histological Features: Main Histological Features: Epithelial proliferation Epithelial proliferation Adenosis (increase in no. of acinar units per lobule) Adenosis (increase in no. of acinar units per lobule) Epithelial Hyperplasia ( of cells) + Papilloma formation Epithelial Hyperplasia ( of cells) + Papilloma formation Fibrosis Fibrosis Cysts Cysts Retention cysts Retention cysts Blue –domed cyst of Bloodgood (macrocysts) Blue –domed cyst of Bloodgood (macrocysts) Brodie’s tumor (microcysts) Brodie’s tumor (microcysts)

35 Presentation Mastalgia Mastalgia Cyclical Cyclical Non-Cyclical Non-Cyclical Lump - many causes Lump - many causes Periareolar Disorder Periareolar Disorder Nipple Discharge Nipple Discharge Nipple Retraction Nipple Retraction

36 Cyclical Mastalgia Presentation Presentation Median age 35 yrs Median age 35 yrs Premenstrual breast discomfort Premenstrual breast discomfort Upper outer quadrant (often bilateral) Upper outer quadrant (often bilateral) Relief during menstruation Relief during menstruation Associated with nodularity Associated with nodularity Aetiology presumably hormonal Aetiology presumably hormonal

37 Non-Cyclical Mastalgia Not related to menstrual cycle Not related to menstrual cycle Median age 45yrs (pre- or postmenopausal) Median age 45yrs (pre- or postmenopausal) Unilateral, well-localised, ‘trigger spot’ Unilateral, well-localised, ‘trigger spot’ Multiple Causes Multiple Causes Carcinoma Carcinoma Mammary Duct Ectasia Mammary Duct Ectasia Sclerosing Adenosis (ANDI) Sclerosing Adenosis (ANDI) Painful Scar Painful Scar Musculoskeletal Pain Musculoskeletal Pain Mondor’s Disease Mondor’s Disease

38 Lumps Traumatic Traumatic Fat Fat Necrosis Organized Organized hematoma Inflammatory Inflammatory Mammary Mammary Duct Ectasia/Periductal Mastitis Chronic Chronic breast abcess ANID ANID Nodularity Nodularity Cysts Cysts (Galactocele) Sclerosing Sclerosing Adenosis Neoplastic Neoplastic Benign Benign Lipoma Lipoma Hard Hard Fibroadenoma Giant Giant fibroadenoma Phyllodes Phyllodes Tumour Malignant Malignant

39 Nodularity Often bilateral, upper outer quadrant Often bilateral, upper outer quadrant May be cyclical May be cyclical Associated with mastalgia Associated with mastalgia Histology (ANDI) Histology (ANDI) Cysts Cysts Fibrosis Fibrosis Adenosis Adenosis

40 Cysts Common, 30s-40s Common, 30s-40s Often multiple, bilateral Often multiple, bilateral Present suddenly (fluid) + pain, nodularity Present suddenly (fluid) + pain, nodularity Tense, less mobile than Fibroadenoma Tense, less mobile than Fibroadenoma Involution of stroma and epithelium Involution of stroma and epithelium Turbid fluid (blue) Turbid fluid (blue) Apocrine or simple cuboidal epithelial lining Apocrine or simple cuboidal epithelial lining

41 Galactocele Solitary subareolar cyst Solitary subareolar cyst Dates from lactation Dates from lactation Contains milk Contains milk Can calcify Can calcify Can greatly increase in size Can greatly increase in size

42 Cysts of the breast Ductal system Neoplastic ANID Macro cysts Micro cysts Stroma Duct papilloma Papillary cystadenoma Duct papilloma Papillary cystadenoma Benign Degeneration of carcinoma Degeneration of sarcoma Intracystic carcinoma Degeneration of carcinoma Degeneration of sarcoma Intracystic carcinoma Serous Lymphatic Blood Inflammatory TB cold abscess Chronic abscess Hyadatid Serous Lymphatic Blood Inflammatory TB cold abscess Chronic abscess Hyadatid Galactocele Skin cysts Malignant Sebaceous Dermoid Sebaceous Dermoid

43 Nipple Discharge Physiological - pregnancy/lactation Physiological - pregnancy/lactation Duct Ectasia Duct Ectasia Galactorrhoea Galactorrhoea Duct Papilloma Duct Papilloma Carcinoma Carcinoma Cysts Cysts Idiopathic Idiopathic

44 Galactorrhoea Milky discharge unrelated to lactation Milky discharge unrelated to lactation Primary Physiological Primary Physiological Menarche Menarche Menopause Menopause Stress Stress Mechanical Stimulation Mechanical Stimulation Secondary Secondary Drugs: haloperidol, metoclopramide Drugs: haloperidol, metoclopramide Increased Prolactin: pituitary tumour, paraneoplastic Increased Prolactin: pituitary tumour, paraneoplastic

45 Management of Breast Symptoms Breast Lump - always need to exclude Ca Breast Lump - always need to exclude Ca Breast examination - Is there a lump or localised nodularity? Breast examination - Is there a lump or localised nodularity? Is there no lump or diffuse nodularity? Is there no lump or diffuse nodularity? Triple Assessment Triple Assessment 1. FNA 1. FNA 2. U/S 2. U/S 3. Mammography 3. Mammography

46 Breast Lump – Cyst and Mx O/E discrete lump or localised nodularity present FNA cystic no blood no residual lump then no cytology no blood no residual lump then no cytology solid re- examine in 6/12 reassure re- examine in 6/12 reassure bloody fluid residual lump then do cytology & mammography bloody fluid residual lump then do cytology & mammography excisional biopsy no lump or diffuse nodularity

47 Palpable Breast Lump - Solid Mx FNA solid lump Cytology Mammography > 35 U/S Tru-cut  biopsy (lump > 2cm) Cytology Mammography > 35 U/S Tru-cut  biopsy (lump > 2cm) suspicious or carcinoma benign observe but excise if : age >35 Pt requests pain increasing size equivocal cytology observe but excise if : age >35 Pt requests pain increasing size equivocal cytology Manage as for breast cancer Panel comment : If pt need FNA/ trucut Dx of fibroadenoma otherwise need exc Bx. If tru-cut = normal breast tissue then still need histology of the lump.

48 No Palpable Breast Lump Mx no lump or diffuse nodularity age < 40 age > 40 re-examine 6/52 reassure benign Cytology Mammography U/S Cytology Mammography U/S reassure benign suspicious or carcinoma Manage as for breast cancer

49 Nipple discharge Bilateral (multiductal) Unilateral Physiological Pathological Fibroadenosis Papillomatosis Duct ectasia Physiological Pathological Fibroadenosis Papillomatosis Duct ectasia Mammography U/S Mammography U/S Uniductal Fibroadenosis Papillomatosis Duct ectasia ?? carcinoma Fibroadenosis Papillomatosis Duct ectasia ?? carcinoma Multiductal Duct papilloma Duct carcinoma Duct ectasia Chronic absces ??? fibroadenosis Duct papilloma Duct carcinoma Duct ectasia Chronic absces ??? fibroadenosis Cytology,prolactin,ductography Microdochectomy

50 Fibroadenoma Peak incidence yrs Peak incidence yrs Smooth, highly mobile Smooth, highly mobile 2-3 cm occasionally multiple 2-3 cm occasionally multiple Benign tumour of fibrous and glandular tissue Benign tumour of fibrous and glandular tissue Mono- or polyclonal (cyclosporin) Mono- or polyclonal (cyclosporin)

51 Fibroadenoma - histopathology Well formed capsule Well formed capsule Delicate stroma surrounding glandular and cystic spaces Delicate stroma surrounding glandular and cystic spaces Epithelium compressed and distorted by the stroma Epithelium compressed and distorted by the stroma + Coarse calcification + Coarse calcification

52 Benign tumors

53 Giant Fibroadenoma Peripubertal age group Peripubertal age group > 5cm > 5cm Rapid growing Rapid growing Esp. Asian, black women Esp. Asian, black women Benign tumour Benign tumour Occasional atypia Occasional atypia

54 Phylloides Tumour Present later - 6th decade Present later - 6th decade Mostly benign, few highly malignant with metastases Mostly benign, few highly malignant with metastases Pathology Pathology Variable size up to 15cm + skin ulceration Variable size up to 15cm + skin ulceration Bulbous projections (‘leaf-like’) Bulbous projections (‘leaf-like’) Stroma has greater cellularity, mitoses, nuclear pleomorphism than fibroadenoma Stroma has greater cellularity, mitoses, nuclear pleomorphism than fibroadenoma Higher grade lesions resemble sarcoma Higher grade lesions resemble sarcoma

55

56

57

58

59

60

61 Duct Papilloma Solitary benign tumour in single large duct Solitary benign tumour in single large duct Presentation Presentation Discharge (+ blood) Discharge (+ blood) Mass (clinical or XR) Mass (clinical or XR) Multiple papillae with connective tissue axis, covered with epithelial and myoepithelial cells Multiple papillae with connective tissue axis, covered with epithelial and myoepithelial cells Considered benign Considered benign

62

63

64 Operations - Microdochectomy Indications : persistent blood stained discharge from a single duct opening on the nipple -- often find papilloma of duct causing the bleeding 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 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

65 Operations - Microdochectomy Technique : make a radial incision into the nipple along the line of the probe encircling the duct orifice 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

66 Breast Procedures & Operations Procedures Procedures FNA FNA Tru-cut  needle biopsy - superceded by gun Bx Tru-cut  needle biopsy - superceded by gun Bx Operations Operations Excisional biopsy Excisional biopsy Microdochectomy Microdochectomy Hadfield’s Major Duct excision Hadfield’s Major Duct excision Incision and drainage of breast abscess - often needle aspiration with antibiotics is used Incision and drainage of breast abscess - often needle aspiration with antibiotics is used

67 Gynecomastia Enlargement of the glandular tissue of the breast 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 Unilateral or bilateral enlargement forming a disc like lesion under the nipple and areola which is freely mobile

68 Gynecomastia (etiology) Physiological Physiological Neonatal Neonatal Pubertal Pubertal Involutional (senescent) Involutional (senescent) Pathological Pathological Decrease production or action of testosterone Decrease production or action of testosterone

69 Gynecomastia Pathological Pathological Decrease production or action of testosterone Decrease production or action of testosterone Klinfelter’s syndrome Klinfelter’s syndrome Testicular feminization syndrome Testicular feminization syndrome Anorchism Anorchism Increase production or action of estrogen Increase production or action of estrogen Pituitary tumors Pituitary tumors Adrenal hypoplasia( addisson’s) Adrenal hypoplasia( addisson’s) Testicular tumors ( Teratoma) Testicular tumors ( Teratoma) Liver failure Liver failure Hyperthyroidism Hyperthyroidism Estrogen treatment Estrogen treatment Drugs Drugs Reserpine, methyldopa Reserpine, methyldopa Isoniazid Isoniazid Spironolactone Spironolactone Tagment, primperan, H2 blockers Tagment, primperan, H2 blockers Idiopathic Idiopathic

70 Gynecomastia (treatment) Physiological No treatment Physiological No treatment Pathological Pathological Treatment of the cause Treatment of the cause if persist excision if persist excision Idiopathic Idiopathic excision excision Sub mammary Sub mammary Circum areolar Circum areolar

71 Gynecomastia


Download ppt "Breast.  Modified sweat glands.  Lobes and lobules of gland in fat tissue stroma.  Ducts emerge from acini of glands  Smaller ducts join to form lactiferous."

Similar presentations


Ads by Google