BREAST

Mammary fat

Nipple
Montgomerys tubercules Areola

Ampulla (Lactiferous sinus)

Lactiferuous ducts Acini (alveoli)

Coopers (Suspensory ligaments)

Lobules
Subcutaneous fat Lobes Nipple and subareolar musculature Interlobular connective tissue

Nerves and Vessels

Nerves
Anterior & lateral cutaneous branches of thoracic intercostals

nerve T3 to T5
Arteries
Internal thoracic artery, thoracostal artery, thorocoacromial

artery
Veins
Axillary vein, internal thoracic vein intercostals vein

Composition
Composite of connective tissue, adipose tissue, and glands (change over the time & secondary to hormonal influence) Puberty the breast increase in size Softness as the mammary glands develop More fat is deposit After a birth of a child the numbers of glands doubles,

allowing the secretion of milk.

Overproduction of estrogen, either during menstruation or at

the beginning of menopause, can make the breast tissue more tender.

Fibrocystic condition
Painful, often multiple, usually

bilateral masses in the breast.

Rapid fluctuation in the size of the

masses is common.
Frequently, pain occurs or worsens

and size increases during premenstrual phase of cycle.

Most common age is 30 to 50. Rare in postmenopausal women not

receiving hormonal replacement.

Fibrocystic condition
Differential Diagnosis

Pain, fluctuation in size, and multiplicity of lesions are the features most helpful in differentiating fibrocystic condition from carcinoma.

Diagnostic Tests

Mammography and ultrasonography should be used to evaluate a mass in a patient with fibrocystic condition. Ultrasonography alone may be used in women under 30 years of age.

Treatment

Aspiration of a discrete mass suggestive of a cyst is indicated to alleviate pain and, to confirm the cystic nature of the mass. The patient is reexamined at intervals thereafter.

Fibrocystic change in breast

Fibroadenoma of the Breast

Most common benign tumor in female breast. Its cause by increase of estrogen activity.

Round or ovoid, rubbery, discrete, relatively movable, nontender mass 1 to 5 cm in diameter.

Most common in <25 yrs old woman. No treatment is usually necessary if the diagnosis can be made by needle biopsy or cytologic examination.

Phyllodes tumor
Arise from intralobular stroma &

rarely from pre-existing fibroadenoma. Is the malignant counterpart of fibroadenoma.

Most common growth to a massive size & distending the breast. On gross section, exhibit leaf like clefts & slits.

Only about 15% are malignant & less

than 20% metastasize.

There is no ductal invasion & therefore no bleeding.

Phyllodes tumor
Treatment If benign, is treated by local excision with a margin of surrounding breast tissue. The treatment of malignant is more controversial, but complete removal of the tumor with a rim of normal tissue avoids recurrence. Because these tumors may be large, simple mastectomy is sometimes necessary. Lymph node dissection is not performed, since the sarcomatous portion of the tumor metastasizes to the lungs and not the lymph nodes.

Fat Necrosis

Uncommon and innocuous lesion significant only because it produces a mass, usually after some antecedent trauma to the breast. Is a central focus of necrotic fat cells surrounded by PMNs; later become enclosed by fibrous tissue and then scar. If untreated, the mass effect gradually disappears. The safest course is to obtain a biopsy. Needle biopsy is often adequate, but frequently the entire mass must be excised, primarily to exclude carcinoma. It is common after segmental resection, radiation therapy, or flap reconstruction after mastectomy.

Nipple Discharge

The most common causes of nipple discharge in the nonlactating breast: duct ectasia, intraductal papilloma, and carcinoma. The important characteristics of the discharge and some other factors to be evaluated by history and physical examination are as follows:

1. Nature of the discharge (serous, bloody, or other).2. Association with a mass.3. Unilateral or bilateral.4. Single or multiple duct discharge.5. Discharge is spontaneous (persistent or intermittent) or must be expressed.6. Discharge is produced by pressure at a single site or by general pressure on the breast.7. Relation to menses.8. Premenopausal or postmenopausal.9. Patient is taking contraceptive pills or estrogen.

Nipple Discharge
The most common causes of nipple discharge in the nonlactating

breast: duct ectasia, intraductal papilloma, and carcinoma.

Spontaneous, unilateral, serous, or serosanguineous discharge from

a single duct is usually caused by an intraductal papilloma or, rarely, by an intraductal cancer. factors to be evaluated by history and physical examination are as follows:

The important characteristics of the discharge and some other

1. Nature of the discharge (serous, bloody, or other).2. Association with a mass.3. Unilateral or bilateral.4. Single or multiple duct discharge.5. Discharge is spontaneous (persistent or intermittent) or must be expressed.6. Discharge is produced by pressure at a single site or by general pressure on the breast.7. Relation to menses.8. Premenopausal or postmenopausal.9. Patient is taking contraceptive pills or estrogen.

Intraductal papilloma
Neoplastic papillary growth within a

duct, most often within the principal lactiferous ducts or sinuses.

Includes serous or bloody nipple

discharge subareolar tumors or, rarely, nipple retraction.

Can be single or multiple papillary

growth. Can be related to cancer.

Is the most common cause of

bloody nipple discharge in woman younger than 50 y/o.

In most cases need surgical

procedures.

Breast Abscess

During nursing, an area of redness, tenderness, and induration may develop in the breast. The most common organism is Staphylococcus aureus.

Infection in the non-lactating breast is rare.

In the non-lactating breast, inflammatory carcinoma must always be considered.

Often, needle or catheter drainage is adequate to treat an abscess, but surgical incision and drainage may be necessary.

Acute mastitis
Inflammation of the breast

tissue caused by infection. Bacteria are the most common pathogen. Staphylococcal infections can lead to abscess formation.
Tx:
Cephalosporin Doxycycline

Breast Cancer
Will affect nearly 1 in 8 females during their lifetime.
Risk factors:
Family History Early Menarche Late Menopause Late First Pregnancy (after 30 years), Nulliparity

Never having breast fed.

Woman having mutation in BRCA1 & BRCA2 genes have

60%-80% chance

Presentation
Initial chief complain may be palpable breast mass. Present with abnormal mammographic findings such as

irregular masses & calcification.

Key to identifying the underlying pathology involves breast

examination & tissue biopsy of the mass.

Infiltrating Ductal Carcinoma

Ductal- is a term used for all carcinomas that cannot be sub-

classified into one of the specialized groups.

Account for the most breast cancers (70%-80%).

Invasion of lymphovascular space or nerves may be seen.

Roughly 2/3 express estrogen-progestin receptors & about 1/3

overexpress erb-B2

Classification of Breast Cancer

Ductal carcinoma in situ (DCIS)- usually arise from the terminal

duct lobular unit, filling & distorting involved lobules & underlying architecture, thereby appearing to involve duct-like spaces.
Patients are likely to develop invasive cancer if not treated.

Lobular Carcinoma
Often bilateral but less common

than infiltrating ductal carcinoma.

The cells invade individually into

stroma & are often aligned in strand or chains.

Metastasize to CSF and

elsewhere.
Nearly all of these tumors

express hormone receptors.

Lobular Carcinoma
Lobular carcinoma in situ- involves

the terminal duct lobular unit. Signet ring cell are common. Carries 25%-35% risk of developing frank breast cancer in either breast, sometimes after a latency of up to 40 yrs.
Is considered to indicate a

propensity for breast cancer rather than being a true percursor.

Inflammatory Carcinoma

Most malignant form of breast cancer (3% of all cases) The clinical findings:

Rapidly growing, sometimes painful mass that enlarges the breast Overlying skin becomes erythematous, edematous, and warm.

The diagnosis should be made when the redness involves more than 1/3 of the skin over the breast and biopsy shows infiltrating carcinoma with invasion of the subdermal lymphatics. Metastases tend to occur early and widely, and for this reason, inflammatory carcinoma is rarely curable.

Inflammatory Carcinoma

Radiation, hormone therapy, and chemotherapy are the measures most likely to be of value rather than operation. Mastectomy is indicated when chemotherapy and radiation have resulted in clinical remission with no evidence of distant metastases.

Paget Carcinoma

Is not common (1% breast cancers) It affects the nipple and may or may not be associated with a breast mass. The basic lesion is usually a well-differentiated infiltrating ductal carcinoma or a DCIS. Because the nipple changes appear innocuous, the diagnosis is frequently missed. The first symptom is often itching or burning of the nipple, with superficial erosion or ulceration. The diagnosis is established by biopsy of the area of erosion.

Medullary

1%-5% of all breast cancers . Occur at a younger age. They lack estrogen and progesterone receptors. Better prognosis.

Tubular

Present as irregular mammography densities. Carcinoma consist of wellformed tubules with low grade nuclei. Affect young females. Metastases is rare, good prognosis & hormone receptor are normally expressed.

Mucinous

Cancer cell produce mucus & grow into a jelly like tumor. Associate w/ good prognosis. Affect elderly.

Papillary

Papillary architecture & fibrovascular cores. Often express progesterone & estrogen receptors.

Inflammatory

Present as an enlarged, swollen, erythematous breast, usually w/o palpabe mass. The blockage a numerous dermal lympahtic space by carcinoma results in the clinical appearance. Most of these have distant metastases and an extremely poor prognosis.

Histologic Types of Breast Cancer

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Most Common Sites of Breast Cancer

Breast Surgery
The three surgical procedures used for breast cancer are: Lumpectomy: removal of the cancerous lump along with a

margin of surrounding tissue

Quadrantectomy: removal of the cancer and nearby tissue in a

quadrant
Mastectomy: removal of all the breast tissue & sometimes part

of the chest wall muscle with or without lymph nodes

Lumpectomy

Quadrantectomy

Mastectomy

Other Procedures
Breast cancer surgery may also include other diagnostic &

therapeutic procedures, as well as cosmetic techniques:

Wire Localization Procedure

Sentinel Node Biopsy

Port-a-Cath Implantation

Surgical Drain Placement

Breast Reconstruction Surgery

Sentinel Node Biopsy

Wire Localization Procedure

Edema of the Arm

Significant edema of the arm occurs in about 10-30% of patients after axillary dissection with or without mastectomy Judicious use of radiotherapy, with treatment fields carefully planned to spare the axilla as much as possible, can greatly diminish the incidence of edema, which will occur in only 5% of patients if no radiotherapy is given to the axilla after a partial mastectomy and lymph node dissection. Late or secondary edema of the arm may develop years after treatment, as a result of axillary recurrence or infection in the hand or arm, with obliteration of lymphatic channels.

Edema of the Arm

Infection in the arm or hand on the dissected side should be treated with antibiotics, rest, and elevation If there is no sign of recurrence or infection, the swollen extremity should be treated with rest and elevation A mild diuretic may be helpful If there is no improvement, a compressor pump or manual compression decreases the swelling, and the patient is then fitted with an elastic glove or sleeve

Breast Reconstruction

Breast reconstruction is usually feasible after total or modified radical mastectomy. The most common breast reconstruction has been implantation of a silicone gel or saline prosthesis in the subpectoral plane between the pectoralis minor and pectoralis major muscles. Alternatively, autologous tissue can be used for reconstruction. The most popular autologous technique currently is the transrectus abdominis muscle flap (TRAM flap), which is done by rotating the rectus abdominis muscle with attached fat and skin cephalad to make a breast mound.

Breast Reconstruction

THE END