1

 Second to the sixth rib in the midclavicular

line
 Sternal edge and laterally the midaxillary line
 Between the two layers of superficial fascia
there are condensations of fibrous tissue; the
suspensory ligaments of Cooper

2
 Four quadrants
 Upper inner quadrant
 Upper outer quadrant (includes the axillary tail of
Spence), most common site for breast cancer
 Lower inner quadrant
 Lower outer quadrant
 Parenchyma
 Alveoli (10-100) form each lobule
 Lobules (20-40) form each lobe
 Lobes (15-20) are radially arranged segments that
are each drained by a duct; all lobes converge at
the nipple

3
4
•Internal mammary artery and the thoracoacromial, subscapular, and
lateral thoracic branches of the axillary artery
•venous drainage forms a rich subareolar plexus that drains via the
intercostal, internal mammary, and axillary veins.

5
 Interlobular lymphatic vessels into a
subareolar plexus (Sappey's plexus)
 75%  of the lymphatic vessels drain to the
axillary or so regional lymph nodes in front of
and below the axillary vein
 25 % of lymph drains to the internal
mammary nodes in the second, third, and
fourth intercostal spaces

6
 Axillary chain is important
▪ Level 1 nodes (lymph nodes located lateral to the pectoralis
minor muscle)
▪ Level 2 nodes (lymph nodes located deep to the PM)
▪ Level 3 nodes (lymph nodes located medial to the PM)
 Rotter's nodes (interpectoral)
 Internal mammary chain

7
8
9
 Nervous supply to the breast is primarily by
sensory and sympathetic nerves; little
parasympathetic innervation

10
 Changes during the menstrual cycle
-Retention of fluid may occur during the luteal phase
 Changes during pregnancy and lactation
-Lobular–alveolar growth and the development of new secretory
units ; “adenosis of pregnancy”
- Colostrum during pregnancy, true milk is not until about 2 days after
parturition
-Postlactational involution, is by lymphocytic infiltration and
hyalinization of the lobules

11
 Changes at the menopause
 Involutional changes from about 35 years, with
regression of glandular tissue and its replacement
by fat and fibrosis

12
A. Infectious and inflammatory breast diseases
 Cellulitis, mastitis: usually associated with
lactation(Staphylococcus or Streptococcus)
 Abscess: Drainage
 Chronic peri/subareolar abscess occurs at the base of
the lactiferous duct from duct ectasia with periductal
mastitis, infected cysts, infected hematoma, or
hematogenous spread from another source
 Complete excision of the sinus tract needed
 Recurrences are common

13
Lactational mastitis/abscess
 Commonly encountered during lactation
 Precipitating factors
 Crack/fissure in the nipple
 Retracted nipple (hence cleaning of the breast is a
problem)
 Oral cavity infection in the child

14
Non - lactational breast abscess
 Occurs in patients with
▪ Duct ectasia and
▪ Periductal mastitis
 Can result in mammary duct fistula
 Anaerobic bacteria is the cause in majority of
the cases

15
C/F
 Severe breast pain
 Swollen breast, tense, tender, warm to touch
(cellulitic stage)
 High grade fever with chills & rigors, soft,
cystic fluctuant mass (after breast abcess is
developed)
 Necrosis of skin, ulceration and discharge (in
untreated abscess)
16
17
Treatment
 Cellulitic stage
 Not feed the child on the affected side
 Cloxacillin 500 mg po 6 hourly for 7-10 days
 Anti-inflammatory drug such as ibuprofen 400
mg three times a day
 Good support to the breast
 For non lactational breast abscess, add
metronidazole 500 mg 3x/day for 5-7 days
18
 Breast abscess
 Incision and drainage under antibiotic cover
 Radial incision for abscess other than lower
quadrant
 Inframammary incision for lower quadrant abscess
 If both breasts are involved, breasts should be
emptied and milk that is expressed can be boiled
and given to the child

19
 Is phlebitis of the thoracoepigastric vein
 Self-limited, but anti-inflammatory agents
and warm compresses can be used

20
1. Fibrocystic Breast Change (FBC):
▪ Stromal fibrosis, macro- and micro cysts, apocrine metaplasia,
hyperplasia, and adenosis (which may be sclerosing, blunt-duct,
or florid)
▪ Breast pain, a breast mass, nipple discharge, or abnormalities on
mammography
2. Breast Cysts
▪ Fluid-filled, epithelium-lined cavities
▪ Observed if asymptomatic
▪ Symptomatic simple cysts should be aspirated
▪ Simple cyst (clear or green fluid) and is benign
▪ A milk-filled cyst, called a galactocele, is benign
▪ A bloody cyst; if atypia or malignancy do excision
21
3. Fibroadenoma
▪ Women younger than 30 years
▪ Fibrous stromal tissue with an epithelial tissue
▪ Smooth, firm, mobile, well-circumscribed masses
▪ Simple FNAC and follow up
▪ Complex, symptomatic, > 2 cm, or enlarges 
excised

22
 Hormonal relationship is likely because
▪ Persist during the reproductive years most commonly
found in women between 15 & 35 years
▪ Increase in size during pregnancy or with estrogen therapy
▪ Usually regress after menopause.
 Two types
▪ Simple fibroadenoma no risk of breast ca.
▪ Complex fibroadenoma ed risk of ca

23
4. Phyllodes tumors / Cystosarcoma Phyllodes
 Giant fibroadenomas (misnomer)
 Is a benign tumor of the breast with predilection to attain
massive size
C/F
 Rapid growth
 Stretched shiny skin
 Red dilated veins over surface
 Bosselated surface (big nodules) few cystic areas
 Warm to touch
 Recurs locally after lumpectomy

24
Operated specimen of
cystosarcoma phylloides

25
26
 Can be differentiated from carcinoma by:
 No fixity to the skin
 No fixity to the pectoralis
 Lymph node will not be involved
 No nipple retraction
 Complications
 Necrosis of the skin and fungation
 Turn to sarcoma or carcinoma

27
Treatment
 Small
 Wide excision of the lump or subcutaneous
mastectomy
 Lumpectomy alone will lead to recurrence
 Inadequate with higher rates of local recurrence &
breast cancer
 Giant cystosarcoma
 Simple mastectomy

28
5. Fat necrosis
 Is associated with trauma or radiation therapy
 Pathogenesis
▪ Capillary ooze causes triglyceride to dissociate into fatty acids. It combines
with calcium from the blood resulting in saponification which causes
inflammatory reaction and later presents as a nonprogressive swelling in
the breast.
 Clinical Features
 Painless swelling in the breast which is smooth, hard,
 nontender and adherent to breast tissue.
 It is nonprogressive, nonregressive.
 Investigations
•FNAC shows chalky fluid with fat globules.
• Mammography to rule out malignancy.
 Differential Diagnosis Carcinoma breast.
 Treatment Excision
29
 Occurs in 30-50 years of age.
 Present as breast lump or mastalgia.
 Smooth, relatively mobile mass.
 It can mimic carcinoma clinically,
radiologically and histologically.
 No risk of malignancy.
 It is included under ANDI.
 Treatment is like ANDI.

30
 Has 3-6x higher the risk of breast cancer
 Increased risk of both ipsilateral and contralateral breast ca
 Mx
Ongoing surveillance with yearly mammography and twice-yearly
breast exams
Stop taking OCP, avoid HRT, and make appropriate lifestyle and
dietary change
Primary prevention with the selective estrogen receptor modulators
tamoxifen or raloxifene, or an aromatase inhibitor
Surgical excision

31
8. Mammary duct ectasia
▪ Common in middle aged women
▪ Smokers
▪ Dilatation of the subareolar ducts
▪ A palpable retroareolar mass, nipple discharge, or
retraction
▪ Older women
▪ Treatment involves excision of the area.

32
 Commonest cause of bloody discharge from nipple
 It is usually single, from a single lactiferous duct
 It blocks the duct causing ductal dilatation
 Single papilloma is not premalignant.
 But multiple papilloma's in many ducts can be premalignant
 Treated by central duct excision

33
34
10. Gynecomastia : hypertrophy of breast tissue in men
▪ Prepubertal : rare
▪ Pubertal
▪ Senescent
▪ Drugs & Alcohol and marijuana abuse
▪ Tumors
▪ Manifestation of systemic diseases
Treatment : based on the cause after ruling out cancer

35
 Mastalgia: Most women (70%)
 Cyclic pain
▪ 2/3 of breast pain is cyclical
▪ Bilateral, most severe at UUQ
▪ Correlates with the menstrual cycle and is usually worse just before
the menses.
▪ The stimulation of ductal elements by estrogen, stimulation of the
stroma by progesterone, and/or stimulation of ductal secretion by
prolactin all contribute to cyclical pain during the menstrual cycle.
▪ Cyclical breast pain can also be associated with pharmacologic
hormonal agents (eg, postmenopausal hormone therapy or oral
contraceptive pills).
▪ Treatment includes support with a bra and analgesics, if severe

36
Noncyclic pain
 Has no such pattern & 10% due to cancer
 Is more likely to be unilateral and
variable in its location in the breast

Treatment
▪ Restrict caffeine intake
▪ Wear a supportive bra
▪ NSAIDS
▪ Vitamin E and evening primrose oil (3 
g/day)
▪ Severe cases: tamoxifen or danazol
▪ Bromocriptine and gonadorelin analogs
 to decrease milk production
 DDX
Large pendulous breasts – Neck &
shoulder pain & headache may be
present, as well as a rash under
the pendulous breast.
 Diet, lifestyle – Caffeine,
Nicotine(smoking)
 HRTspontaneously resolve over
time.
 Ductal ectasia
 Mastitis
Inflammatory breast cancer
 Hidradenitis suppurativa –present
as breast nodules and pain.
 Other – pregnancy,
thrombophlebitis, macrocysts,
prior breast surgery, and a variety of medications
37
 Types
 Normal milk production (lactation)
 Physiologic nipple discharge (galactorrhea)
▪ Is defined as non-pathologic nipple discharge unrelated to
pregnancy or breast-feeding.
▪ manifested as bilateral milky nipple discharge involving
multiple ducts. May also be unilateral and a variety of colors.
▪ Caused by hyperprolactinemia secondary to medications,
endocrine tumors (pituitary adenoma), endocrine
abnormalities, or a variety of medical conditions
 Pathologic (suspicious) discharge
38
 Pathologic (suspicious) discharge
 Discharge other than milk may be due to a pathological
process in the breast.
 Unilateral, uniductal, persistent, and spontaneous.
 It can be serous (clear or yellow), sanguinous (bloody), or
serosanguinous (blood-tinged).
 The most common cause is a papilloma (52-57 %)
 The remaining cases are caused by ductal ectasia or
other benign changes (14 to 32 %).
 Malignancy is found in 5 to 15 % of cases of pathologic
nipple discharge  most commonly DCIS.
 Age is predictive of the risk of cancer in women with nipple
discharge. 39
 History
 Discharge  Appearance, spontaneous or
provoked, unilateral or bilateral
 Medication use
 A history of recent trauma
 Recent onset of amenorrhea or other symptoms
of hypogonadism (hot flashes, vaginal dryness)
should prompt consideration of
hyperprolactinemia
40
 P/E
 A complete breast examination should be performed.
 Specific goals of the examination:
▪ Detect skin changes  symmetry, breasts contour, position of the nipples,
scars, and vascular pattern, skin retraction, dimpling, edema or erythema,
ulceration or crusting of the nipple, and changes in skin color
▪ Tenderness
▪ Elicit discharge from a nipple and identify the involved duct or ducts.
▪ Detect enlarged axillary or supraclavicular lymph nodes
▪ Delineate and document breast masses
▪ In particular, the skin covering the breast and nipple areolar complex should
be examined for lesions that may be staining the woman's clothes and
mimicking nipple discharge. Some examples are Paget disease, insect bites,
local infections, and eczema.
41
 Ix
 Periareolar ultrasound.
 Mammogram for women ≥30 years of age
  Multiductal discharge  pregnancy test,
prolactin levels, RFT & TFT, & follow-up if
abnormal
 FNAC
 Skin punch biopsy, core needle biopsy

42
 Mx
 Physiologic Discharge
▪ If from drugs- reassure the pt or use alternative drug for severe
cases

43
44
45