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ƥ Majority of surgical consultation for Breast complaints
ultimately prove to have a benign origin.
ƥ Surgeonƞs role in management of Benign Breast
Disease includes:
ƥ Assessment of Breast Cancer Risk
ƥ Breast Cancer Screening
ƥ Providing Specific Diagnosis
ƥ Treatment/Management
ANATOMY
ƥ Develops from Ectoderm Milk Streak
ƥ Lobules and Ducts
ƥ The breast glandular tissue consists of 15 to 20 lobules
(clusters of milk forming glands, or acini) that enter into
branching and interconnected ducts. The ducts widen
beneath the nipple as lactiferous sinuses and then empty
via nipple openings.
ANATOMY
ƥ Blood Supply
ƥ Branches of Internal Mammary Artery,
Intercostal arteries, Axillary Artery
ƥ Venous drainage via Internal Mammary,
Intercostal, Axillary Veins
ƥ Lymphatic Drainage
ƥ 97% to Axillary Nodes
ƥ Internal Mammary and Supraclavicular nodes
ANATOMY
ƥ Three Lymph Node Levels:
ƥ Level I ƛ Lateral to Pectoralis Minor
ƥ Level II ƛ Deep to Pectoralis Minor
ƥ Level III ƛ Medial to Pectoralis Minor
ƥ Rotterƞs ƛ Between Pectoralis Minor & Major
ƥ Nerves
ƥ Long Thoracic Nerve
ƥ Serratus Anterior m.
ƥ Winged Scapula
ƥ Thoracodorsal Nerve
ƥ Latissimus Dorsi
ƥ Intercostobrachial Nerve
ANATOMY
Benign Breast Disease
ƥ Work up of Breast Mass
ƥ Breast Pain
ƥ Glandular Breast Parenchyma
ƥ Nipple-Areolar Complex
ƥ Breast Skin
BREAST MASS
ƥ Four Phases of Management
ƥ CBE
ƥ Breast Imaging
ƥ Tissue Sampling
ƥ Treatment
ƥ Palpable mass is most common presentation
ƥ Mammogram/Sonogram/MRI
ƥ FNA/Core biopsy/Excisional biopsy
Breast Pain (Mastodynia)

ƥ More common during reproductive years


(premenopausal)
ƥ Association with cancer is uncommon
ƥ Cyclic pain associated with Fibrocystic changes
ƥ Noncyclic pain associated with infection or cancer if
associated with mass or bloody nipple discharge.
ƥ Tx: NSAIDs, Eve primrose oil, OCP, avoid caffeine
K  
ƥ Cysts
ƥ Simple cyst may be observed or aspirated
ƥ Bloody aspirate ƛ send for cytology
ƥ Fibrocystic Changes
ƥ Not considered Ơdiseaseơ
ƥ No increase risk of cancer
ƥ Common finding >50%
K  
ƥ Fibroadenoma
ƥ Most common mass in <30 y/o
ƥ Smooth, firm, rounded, mobile
ƥ Definitive dx by core or excisional bx.
ƥ Change size with menses, pregnancy
ƥ Excise if growing or >30 y/o
ƥ Long-term risk = 2.17 for cancer (IDC)
K  
ƥ Cystosarcoma Phyllodes
ƥ 10% malignant
ƥ Resembles Fibroadenoma
ƥ Tx is WLE
ƥ Gynecomastia
ƥ Associated with THC, spironolactone
ƥ Liver Failure
ƥ Idiopathic
Nipple/Areolar Complex
ƥ Nipple D/C
ƥ Nonspontaneous, B/L, multiple ducts, greenish,
milky is likely benign.
ƥ Spontaneous, unilateral, bloody, serous is
worrisome.
ƥ Meds ƛ TCAs, Reglan, Verapamil, Reserpine
ƥ Galactorrhea ƛ r/o Prolactinoma
ƥ Intraductal Papilloma ƛ not premalignant
ƥ Most common cause of bloody nipple d/c
ƥ Diffuse papillomatosis has increased risk of cancer
ƥ Mammo/sono/ Ductogram
ƥ Ductal excision
Breast Skin
ƥ Mastitis/Abscess
ƥ S. Aureus
ƥ Inflammatory Breast Cancer
ƥ Mondorƞs Dz.
ƥ Painful, cordlike superficial thrombophlebitis
Benign Breast Disease
ƥ NONPROLIFERATIVE
ƥ FIBROCYSTIC CHANGES
ƥ NO INCREASED RISK

ƥ PROLIFERATIVE
ƥ PAPILLOMATOSIS
ƥ 1-2X INCREASED RISK OF CANCER

ƥ ATYPICAL PROLIFERATION
ƥ ATYPICAL HYPERPLASIA
ƥ 4-5X INCREASED RISK OF CANCER
Atypical Hyperplasia
ƥ Marked proliferation and atypia of the epithelium, either
ductal or lobular.

ƥ Found in 3% of benign breast biopsies

ƥ Associated with a 13% subsequent development of breast


cancer (4x risk factor)

ƥ Some may be an under-diagnosed ductal carcinoma in situ.

ƥ Excisional Biopsy ƛ do not need clear margins


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