1. Breast Diseases Professor Hassan Nasrat Chairman
Department of Obstetrics and Gynecology
Faculty of Medicine
King Abudluziz University

2. Why Gynecologist should know about breast diseases
Anatomy of the Breast
Common Breast Diseases
Breast Cancer: Epidemiology,Risk factors and screening
Approach to women with common breast problem

3. For many women gynecologists are their primary health care physicians.
Why Gynecologist need to study Breast Disorders?
For many women gynecologists are their primary health care physicians.
increased awareness among women concerned about their own risk of developing breast cancer
Desire to take hormonal therapy such as contraceptive pills or hormonal replacement.

4. Anatomy of the Breast

5. Are the basic unit of the breast Each alveolus (0.2 mm in diameter).
The breast is subcutaneous gland (tubulo - alveolar gland).
glandular tissue (20%), stroma f adipose and fibrous connective tissue (80%).
The alveoli:
Are the basic unit of the breast Each alveolus (0.2 mm in diameter).
Lobule:
Each contain alveoli.
Lobes:
Each contain lobule
All are drained by a single lactiferous duct that opens at the nipple. they form the lactiferous sinuses (small reservoirs of milk)
(Cooper's ligament): Separate the lobes, it extends from the skin to the underlying pectoralis fascia.

6. The alveoli (the basic unit) each 0.2 mm in diameter
It is arranged in lobuli ( alveoli per lobule)
Twenty to 40 lobules form lobes
each lobe is drained by a single lactiferous duct
The lactiferous duct converges towards the areola to form the lactiferous sinuses
Each lobe is separated by (Cooper's ligament) that extends from the skin to the underlying pectoralis fascia.

7. The areola; is a specialized pigmented skin that surrounds the nipple; it contains sweat glands and sebaceous glands (glands of Montgomery) that hypertrophy during pregnancy. It lubricates and protects the nipple during lactation.
The innervation of the nipple and areola mediate the neurohumoral reflexes responsible for the removal of milk from the gland and the release of prolactin.
Lymphatic drainage of the breast: Approximately 75% of the lymphatic drainage goes to the regional axillary lymph nodes.

8. The alveoli
Lobule
Lobes
Anatomy of breast.

9. - Accessory breasts or nipple can occur along the breast lines which run from the axilla to the groin. { supernumerary nipples (polythelia)}
- Underdevelopment of one breast in relation to the other is a common anomaly in approximately 3-5% of population.
Breast tissue, the glandular and non-glandular elements are sensitive to the cyclic hormonal changes of menstrual cycles

10. Extensive polythelia along milk line

11. parenchymal proliferation of the ductal system
The Breast and The Menstrual cycle
Estrogen
parenchymal proliferation of the ductal system
During the follicular phase
dilatation of the ductal system and differentiation of the alveolar cells into secretory cells
Progesterone
During the luteal phase
Women often experience breast tenderness and fullness during the premenstrual period.
There is an actual increase in the volume of the breast by ml as measured by water displacement technique, due to increased blood flow, vascular engorgement and water retention.

12. Examination: Systematic approach to evaluation of breast problems
History :
The duration of symptom.
Whether there has been any change
If it is unilateral or bilateral, multiple or single.
Relation to menstruation
The patient background risk factors: most importantly age, family history of breast cancer, hormonal therapy...Etc.
Examination:
Systematic and careful examination is essential and presents a good opportunity for patient education on the proper method of self examination

13. Common benign breast diseases
Fibrocystic changes:
Fibroadenoma:
Phyllodes Tumour:
Mastitis:
Superficial thrombophlebitis (Monro's disease):
Chronic Periareolar Abscess:

14. Fibrocystic changes:
Is commonly observed throughout women reproductive life with increasing frequency from teenage to the premenopausal period.
Incidence: Approximately 10% of women under the age of 20 and up to 60-70% in the premenopausal years.
Is an exaggeration of the normal physiologic response of breast tissue to the cyclical levels of ovarian hormones.
Usually not associated with increased risk of breast cancer unless there is epithelial cell turnover.
It is unusual after the menopause unless associated with exogenous hormones.

15. Fibrocystic changes - Histologically :
Stroma: Fibrosis
Alveoli: non proliferative cystic changes
Ducts: proliferative changes including hyperplastic ductal epithelium,
adenosis and occasional papilloma formation.
The nature and type of predominate change correlates with age:
In the Twenties: more intense proliferation of the stroma (fibrosis). May lead to fibroadenoma or juvenile hypertrophy may result.
During the Thirties: both the glandular tissue and stroma respond to the cyclic changes of hormones. If excessive proliferation and hyperplasia of ducts, ductules and alveolar cells occurs, it results in cyclic pain and nodularity.
In the Forties: the lobules and ducts involutes and there is no severe pain unless a cyst increase rapidly in size giving point tenderness and lumps. Periductal mastitis and duct ectasia may develop at this stage.

16. Virginal hypertrophy, age 13.

17. symptoms and signs of fibrocystic changes
- Symptoms: cyclic premenstrual breast pain, commonly bilateral and mostly located in the upper outer quadrant of the breast.
- Signs: tenderness and ill-defined thickness "palpable lumpiness or nodularity " that are rubbery in consistency.
Larger cysts, if present, are felt as balloon filled with water.
- Investigations: rarely required

18. Fibrocystic Changes The etiologic factors
Unknown
Hormonal: No hormonal abnormalities have been found, though the possibility of imbalance of estrogen and progesterone hormones as well as abnormal prolactin secretion have been suggested.
Dietary factors: excessive consumption of methylxanthines containing foods (coffee, tea, chocolate and cola drinks)

19. Fibrocystic Changes - The management
Reassurance:
Non pharmacological treatment:
Breast Support, reduction of consumption of compounds that contain methylxanthines and tobacco, evening primrose oil administration, γ-linolenic acid a polyunsaturated fatty acid to replenish fatty acid deficiency.
Pharmacologic treatments:
- Diuretics for 2-3 days in the premenstrual days.
- Low estrogen contraceptive pills.
- Progesterone administration: during the secretory phase.
- Anti prolactin e.g. Bromocriptine (5 mg /day)
-Tamoxifen. (antiestrogen competes with estrogen for the estrogen receptors in the breast)
- Gonadotrophin releasing hormone (Gn-RH) analogs:
- Danazol: mg/day continuously
Surgical intervention: e.g. if a dominant mass, a cyst. More major surgery for cases of intractable pain or if biopsy showed a precancerous lesion.

20. Fibroadenoma The second most common benign breast lesion.
It affects women in their early twenties.
Is an aberrant growth of normal tissue rather than neoplasm.
Clinically
it is usually discovered accidentally as painless solid mass which is mobile, non tender and rubbery in consistency.
Investigations:
Ultrasound examination may be required in some cases to differentiate between a cyst and fibroadenoma.

21. Enormously enlarged right breast due to the presence of a giant fibroadenoma

22. Treatment:
Excision biopsy especially if it increases in size and in women above thirties years of age.
conservative treatment and assurance In young girls (<25 years) is appropriate.
The frequency of carcinoma within a fibroadenoma is very low, with only 119 reported cases (Yoshida 1985). Approximately 30 % of fibroadenoma regresses spontaneously and in 10-20% it decrease in size.

23. Fat Necrosis
- clinically can be confused with breast carcinoma.
- It usually follows trauma but the incident can not often be recalled by the patient.
- Is felt as a tender, firm, irregular mass that may be associated with area of ecchymosis and even skin retraction.
- The diagnosis is determined after excision biopsy.

24. Phyllodes Tumour
Is a Fibroepithelial breast tumour seen more frequently during the premenopausal age.
Histologically it has similarity to fibroadenomas but with distinct connective tissue hypercellularity with different type of connective tissue elements, pleomorphism and higher level of mitotic activity (Azzopard 1979).
The lesion is most frequently benign, in the same time it is the most frequent cause of breast sarcoma.
There have been reports of cases with benign histologic characteristics demonstrating unexpected metastases leading to subsequent patient demise. The lesion is treated by total excision with wide margin of healthy breast tissue.

25. Mastitis
Is the most common inflammatory condition of the breasts. It is seen most commonly, but not always, among nursing mothers.
The causative organisms are Staphylococcus aureus and Streptococcus species.
Clinically: fever, erythema, induration and tenderness. If neglected it may progress to form a breast abscess.
Treatment with broad spectrum antibiotics
lactation may continue from the unaffected breast while expressing the affected one in order to prevent milk engorgement.

26. Superficial thrombophlebitis (Monor's disease):
This is an uncommon inflammatory condition (Haagensen et all 1986).
It presents as acute pain or erythema in the upper lateral portion of the breast usually caused by an inflammation of the superficial veins.
It may be associated with pregnancy, breast trauma, or surgical plastic breast procedures.
The treatment is conservative with symptomatic treatment similar to superficial thrombophlebitis in any other location.

27. Chronic Periareolar Abscess
Is an uncommon condition. More commonly seen in premenopausal women.
It presents as recurring tender erythematous nodule that develop just at the edge of the areola.
Due to chronic ductal infection secondary to obstruction of the duct by keratin and other ductal debris.
It is treated by expression but may require incision draining to prevent recurrence.

28. Breast Cancer
is the most common malignant neoplasm in women and comprises 18% of all female cancers
The incidence is increasing particularly among women aged
One in eight women will develop breast cancer during her lifetime.
Gynecologist should be able to provide basic counsel to women about screening and prevention methods for breast cancer also advise regarding potential risks of hormonal therapy e.g. HRT, or contraceptive pills in relation to the development of breast cancer.

29. By age 25
1 in 19,608 30
1 in 2525 35
1 in 622 40
1 in 217 45
1 in 93 50
1 in 50 55
1 in 33 60
1 in 24 65
1 in 17 70
1 in 14 75
1 in 11 80
1 in 10 85
1 in 9
Ever
1 in 8
Data from National Cancer Institute. Painter K: Factoring in cost of mammograms, USA Today,, Dec. 5, 1996.
Risk By Age: A Woman's Risk of Developing Breast Cancer

30. Risk factors for breast Cancer:
Reproductive factors
(Age at Menarche and Menopause, Age at first pregnancy)
Particular histological diagnosis of breast biopsies:
namely atypical hyperplasia, lobular carcinoma in situ
Family history
Particular life style factors

31. Risk factor
High Risk Feature
Relative Risk
Menarche onset
<12 yr old
1.3
Menopause onset
>55 yr old
1.5
Age at birth of first child
Nulliparous or >30
1.9
Benign breast disease
Any benign breast condition
Proliferative disease
Atypical Hyperplasia
2.0
4.0
Family history of breast cancer
Mother affected
Two first degree relatives
1.7
5.0
Obesity
90th percentile
Alcohol use
Moderate drinker
HRT
Current use, age 50-59

32. Genetic risk of breast:
Approximately 5-10% of breast cancers occur in families in which there are many women with the disease.
Two highly penetrance breast-ovarian cancer genes have been identified BRCA1 and BRCA2, Both are tumour suppressor genes inherited as an autosomal dominant
It can be transmitted through either sex and that some family members may transmit the abnormal gene without developing the cancer themselves.
Together they account for about 5% to 7% of all cases of breast and ovarian cancer and for 50% to 70% of hereditary cases of breast cancer.

33. Breast and ovarian cancer when linked to BRCA1 and BRCA2 mutation it tends to strikes early in
Inheritance of BRCA1 and BRCA2 mutation increase women lifetime risk of developing breast cancer between 50% and 85% (a seven fold increase).
In addition BRAC1 mutation increases the risk of ovarian cancer by as much as 28 fold, from 1.8% to 50% by the age 70

34. Screening for breast cancer:
Aim: To decrease mortality by detecting the disease at an early stage.
Methods:
Monthly Breast Self Examination
Mammographic Examination.

35. Mammography being performed with appropriate compression applied.

36. Normal mammogram and the process of aging.
(A) the normal breast parenchyma is seen as ill-defined white densities located predominantly behind the nipple. In young women, the breast tissue can be extremely dense with only a small amount of interspersed fat, making tumors hard to see.
(B) mammogram on the same patient several years later shows fatty replacement of most of the breast tissue.

37. An ultrasound examination of a young woman with a palpable lesion shows an echo-free simple cyst.

38. Medical prophylaxis: e.g. OCP, Tamoxifen
Preventive measure for women at genetic risk of breast and ovarian cancer:
Surveillance:
intensive surveillance program. In addition chang in life still e.g. cessation of smoking, alcohol drinking and encourage exercise
Medical prophylaxis: e.g. OCP, Tamoxifen
Prophylactic surgery: Prophylactic oophorectomy:

39. Common Presentation of Breast Problems

40. Breast pain or mastalgia.
Breast lumps.
Nipple discharge.
Presentation due to cosmetic complains e.g. too small or too large breasts…etc.

41. Breast Pain “Mastalgia”
Is defined as pain originating in the breasts. It may be localized in the breast or in a severe case may radiate to the axillae.
Should be differentiated from premenstrual breast discomfort which is not uncommon symptoms. But moderate to severe mastalgia estimated to occur in 11 % of cases.
Sometimes the symptoms are severe and can disturb daily activities, sex life and even sleep.

42. Etiology of breast pain
In the majority of cases no apparent cause can be found.
Important causes to exclude are pain originating from costochondritis junction.
mastitis or breast abscess.
The most common cause is fibrocystic changes
Cancer is infrequently present with pain. Pain is usually a late symptom of cancer..

43. Breast Pain Non Breast Pain Non Cyclic Pain
Stretching of Cooper’s ligament
Pressure from Bra
Fat Necrosis
Hydradenitis suppurative
[Focal Mastitis
Periductal Mastitis
Cysts
Mondor’s disease
Cyclic Pain
Hormonal stimulation
Non Breast Pain
Chest wall
Tietze's syndrome
Radicular pain from cervical arthritis
Non Chest Wall Pain
Gallbladder disease
Ischemic heart disease

44. Management of Mastalgia
Careful history taking and examination.
Any risk factors for breast cancer should be identified
Systemati Physical Breast examination.
In low risk patients usually no further investigations are required.
In high-risk women (>40 years) mammography and ultrasound
In most of cases management as in fibrocystic changes.
Patients with a breast lump or who fail to respond to medication or unilateral persistent pain in post-menopausal women should be referred for further evaluation

45. Nipple Discharge
Spontaneous, persistent discharge in non lactating women can be due to a variety of causes:
Although in only approximately 3% nipple discharge is associated with breast carcinoma each case should be carefully evaluated.
The main objective is to rule out underlying malignancy. It is to be noted that the color of the discharge does not differentiate a benign from a malignant process.
cytology of the discharge is important it may yield false negative results in up to 20% of cases.
Therefore the diagnosis of the underlying cause of nipple discharge requires careful evaluation, mammographic examination and eventually excision biopsy.

46. TABLE 14-1 -- Causes of Single Duct Nipple Discharge in 170 Patients (Nottingham 1988)
Diagnosis
Number (%)
Duct papilloma
77 (45)
Benign disease (for example, duct ectasia)
80 (47)
Cancer in situ
  2  (7)
No abnormality
  1  (0.6)
From Chetty U: Nipple discharge. In Smallwood JA and Taylor I, editors: Benign breast disease, Baltimore, 1990, Urban & Schwarzenberger.

47. Intraductal Papilloma
TABLE Relation Between Nipple Discharge and Diagnosis in 432 Operations from New York Medical College, 1960–1975
Discharge
Galactorrhea
Duct Ectasia
Infection
Intraductal Papilloma
Fibrocystic Disease
Cancer
Milky 2
Multicolored and sticky 46
Purulent 14
Watery 3 1 5
Serous 79 52 11
Serosanguineous 8 59 34
Sanguineous 6 45 28 20 _ __
___
TOTAL 65
186
115 50
Reprinted with permission from Pilnik S: J Reprod Med 22:286, 1979.

48. Nipple Discharge No Galactorrhea Presence of Galactorrhea
Hyperprolactinemia
From one duct
Bloody
Serosanguineous
Intraduct papilloma
Ductal carcinoma in situ
Paget’s disease of the breast
From Multiple Ducts
Fibrocystic changes
Ductal ectasia

49. Breast Lump
Breast Lump whether discrete or multiple is a common presentation and perhaps one of the most worrying for women.
The DD includes a variety of conditions.
The objective is to define cases that need further investigations

51. Discrete Solitary Lump
Age yr
Firm discrete lump
Fibroadenoma, cyst, fibrocystic changes, ductal hyperplasia, atypical ductal hyperplasia, atypical lobular hyperplasia
Age >50 yr
Firm discrete lump
Cyst, Ductal Carcinoma in situ, invasive cancer
Age < 30 yr
Firm rubbery Lump
Fibroadenoma
Diffuse Lumps (lumpy breast)
Absence of Discrete lump
Fibrocystic changes

52. Thank you

53. Lymphatics of breast.

54. This low-power photomicrograph of a lobule illustrates the centrally located terminal duct and the peripherally arranged clusters of small glandular structures grouped within a loose fibrovascular stroma. The stroma exterior to the lobule and the terminal duct is composed of collagen-rich connective tissue.

55. Classic fibroadenoma of the breast.

56. Breast biopsy from a 38-year-old woman demonstrating characteristic gross appearance of fibrocystic changes. Note multiple cysts interspersed between the dense fibrous connective tissue.

57. Examination of axilla in sitting position during breast examination.

58. BI-RAD classification of mammographic lesions.

59. Needle biopsy and aspiration with negative pressure
Needle biopsy and aspiration with negative pressure. Needle is rotated, moved back and forth, and slightly in and out to aspirate representative specimen.