1. Breast

2. Modified sweat glands.
Lobes and lobules of gland
in fat tissue stroma.
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

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

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

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

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

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

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

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

15. Infections Acute Chronic Mastitis neonatorum Chronic non specific
Pubertal mastitis
Traumatic mastitis
Metastatic mastits
Mammary duct ectasia
Lactational mastits
Acute suppurative mastitis
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
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

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

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

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

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

22. Operations - Hadfield’s Major Duct Excision
Technique :
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

23. Lactational Mastitis

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

25. Fever
Throbbing pain
Skin oedema
Aspiration of pus

27. Operation - Incision & drainage breast abscess
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 :
General anaesthesia
incise
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

29. Operations - Breast Excisional Biopsy
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.

31. Breast Excisional Biopsy
Incisions :
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

32. Fibrocaseous
Caseous form
Sclerosing form
Suppurative form

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

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

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

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

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

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

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

40. Cysts 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

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

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

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

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

45. Management of Breast Symptoms
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
1. FNA
2. U/S
3. Mammography

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

47. Palpable Breast Lump - Solid Mx
FNA solid lump
Cytology
Mammography > 35
U/S
Tru-cut Ò biopsy (lump > 2cm)
suspicious or carcinoma
Manage as for breast cancer
benign
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.
observe but excise if :
age >35
Pt requests
pain
increasing size
equivocal cytology

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

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

50. Fibroadenoma Peak incidence 15-25 yrs Smooth, highly mobile
2-3 cm occasionally multiple
Benign tumour of fibrous and glandular tissue
Mono- or polyclonal (cyclosporin)

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

52. Benign tumors

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

54. Phylloides Tumour Present later - 6th decade
Mostly benign, few highly malignant with metastases
Pathology
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

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

64. Operations - Microdochectomy
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

65. Operations - Microdochectomy
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
FNA
Tru-cutÒ 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

67. Gynecomastia 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

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

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

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

71. Gynecomastia