BREAT DIS ORDERS

Prepared and presented by:

Dr. Abdirahman Hori
PHD student in Benha University
 EMBERIOLOGY
• The breast is modified swear gland which is
developed from an endodermal ridge
“mammary ridge” which extends between the
anterior pectoral fold and groin.
• Normally it disappears all through except in
the front of the chest where solid columns of
epithelia pass deeply– milk duct.
 Anatomy
• Extent
 Above: at 2nd rib.
 Below: at 6th rib.
 Medially: at lateral border of sternum.
 Laterally: at anterior axillary line.
• The actual extent of the breast is important for the surgeon
who aims at removal of the whore breast for malignancy.
So it actually extends:
 Above: to the clavicle.
 Below: to bellow the costal margin.
 Medially: to the midline.
 Laterally: at posterior axillary line.
 Axillary tail of spence(3 rib) rd

• It is a prolongation from upper outer part of gland

up to axilla. It considered the only part which is
deep to the pectoral fascia through foramen of
langer. So it drains directly into posterior axillary
L.Ns.
• Areas( 6 areas)
- upper inner quadrant - lower inner quadrant.
- upper outer quadrant - lower outer quadrant
- retro- areolar part - axillary tail.
• Architecture
• Breast consists of (15-20) lobes which are arranged in readiating manner &
each is drained by a lactiferous duct. The ducts converge at the nipple. A
lobe is made up of(20-40) lobules, each of which consists of (10-100) alveoli
• The supporting tissues:
• The ducts are attached to underlying pectoral fascia by band of fibrous
tissue to the skin called (cooper’s ligament). This ligament can be involved in
fibrotic lesions leading to skin dimpling
• The ducts are surrounded by contractile myoepithelial cells which are
stimulated by oxytocin & move milk towards the nipple.
• Nipple (4th intercostal space)
• On its top 15-20 openinig, its normal direction is downward, forward and
laterally.
• Areola:
• Thick skin, pink, in julipara, blackens brown with pregnancy contains sweat
& sebaceous gland of montogomory.
 Muscle flour it lies on 3 muscles
1. Pectoralis major muscle
origin
 -sterno- costal head: Ant surface of sternum,
upper 6 costal cartilages.
 -Clavicular head medial ½ of front of the clivicle
insertion : lateral lip of biciptal groove
Nerve supply: medial and lateral pectoral nerve
Action: flexion, adduction & medial rotation
Pectoralis minor muscle
origin;
3rd,4th,5th
Insertion; coracoid process of scapula

Nerve supply; medial pectoral nerve

Action: draws the scapula downwards & forwards

2. Serratus anterior muscle

• Origin: 8 digitation with upper 8 incostatal muscles
• Insertion : medial border of the scapula
• NERVESUPPLY; nerve to serratus anterior
• ACTION; keeps the the stability of the scapula with
the use of upper limb.
• 3. External oblique muscle
Arterial supply of the breast
 Axaillary artery – lateral thoracic artery.
 Internal mammary artery--- 2,3,4 perforators.
 Intercostal perforators
Venous drainage
 Axaillary vein
 Internal mammary vein
 Intercostal veins ( which drain to Azygos system which
communicate with valveless vertebral vein). This
explains early vertebral metastasis with cancer breast.
 Lymphatic drainage
• Clasiical descreption:
1. Sub areilar plexus of Sappey: from nipple & areolar then drain to deep plexus.
2. Deep plexus(over pectoralis) from sub arelar plaxus and deep part of the glanad then drain to axillary
LNs & internalmammary through the pectoralis muscle.

Modern descreption:
Lymphatics drain through axillary L.Ns & internal mammary L.Ns.
axillary L.Ns: these nodes receive a bout 75% of breast lymph. There are on average 35 lymph nodes in the
axilla that are arranged into:

3. The anterior(pectoral) group : site under cover of pectoralis major along the lateral thoracic vessels at
the lower obrder of the pectoralis.
drain: chest wall, whole breat, anterior abd. Wall above the umblicus.
2. The posterior( sub scapular) group: site: along the sub scapular vessels drain; axillary tail, posterior abd.
Wall above umbilicus.
3. The lateral (humeral) group:
site: along the axillary vein driain all the upper limb.
4. The medial (central) group:
site: central part of the axilla drain 1,2,&3.
5. The apical group:
site: extreme apex of axilla. Drain: 1,2,3,&4
Other associated lymph nodes
• Internal mammary LNs
• Interpectoral LNs of Rotter between the two pectoral muscles.
• Further lymphatic spread
• Connection of the lymphatics of the lower inner quadreant of the breast
with the peritoneum. Lymphatics peirce rectus sheath – spread to liver
leading to liver nodules. Then through ( falciform ligament)--- umblical
nodules (Josef sister’s nodules)
• NB: some malignant cell will lead to :
• Malignant ascites, kurkenberg’s tumor and malignant nodules in the douglas
pouch.
• For prognostic point of view axillary L.Ns classified by: pectoralis minor
muscle into 3 levels:
• Level1 --- L.Ns below the muscle.
• Level2--- L.Ns behind the muscle.
• Level3--- L.Ns above the muscle.
The prognostic importance with treatment of cancer breast with adjuvant
therapy.
 Congenital anomalies
The breast
1. Amasia: absence of the breast unilateral or bilateral.
2. Polymazia; accessory breast along mammary ridge the may function
during lactation.
3. Micromasia; small breast treated by augmentation mammoplasty.
4. Diffuse hypertrophy big breast treated by reduction mammoplasty.
5. Infantile gynaecometsia: diffuse enlargement of the male breast which
may be unilateral or bilateral. It is caused by the effect of circulating
maternal sex hormones. The condition is usually reversible with in 6
months, there fore requires no treatment.
The nipple:
Athelia; absence of nipple. Polythelia; accessory nipple along the mammary
ridge may be mistaken for a mole or wart.
Congenital retraction of the nipple: it must differentiated from acquired
retraction.
 Congenital retracton Acquired retraction

history Dating since birth recent

side Bilateral > 75% unilateral

mass No breast mass Presence of breast mass

sulcus absent present

Don’t forget
Causes of acquired nipple retraction due to “excessive fibrosis”
1. mammary duct ectaszia.
2. Chronic breast abscess.
3. Carcinoma of the breast.
 Traumatic diseases
• That may be clinically dificult to differentiate from
carcinoma usually follow a blunt trauma
1. Traumatic fat necrosis: trauma death of some fat
cells libration of fatty acids which combine with
calcium from local tissue fluid  calcium soaps:
- cystic containing “thick oily fluid”
- hard mass if we do biopsy the cut section will
show characteristic chalky white appearence”
 treatment : excision and biopsy
2. Breast hematoma
trauma blood clot organization  fibroisi hard mass
treatment : excision and biopsy
 Inflammatory diseases

• Acute inflammatory mastitis

• Acute lactational mastitis and acute breast abscess
• Mastitis from milk engorgement
• Incidence 1st month of 1st lactation
• Etiology; due to obstruction of duct by dry inspissated milk or epithelial debris.
• Clinical picture:
• Symptoms :
• generally : toxic symptoms( fiver, headache, malaise and anorexia) .fiver(due to
absorpt of milk proteins).
• Local :dull aching pain
• Signs: diffuse tense and tender.
• No physical signs of inflammation i.e no hotness or redness
• No axillary LNs
• Fate if neglected  acute bacterial mastitis or acute breast abscess.
 Acute bacterial mastitis

Incidence 1st month of 1st lactation i.e. fate from milk engorgement or when baby 6 months
i.e. development of incisor.
Etiology:
Predisposing factors:
Mastitis from milk engorgement
Abrations of nipple e.g. cracks or fissures.
Lack of breast hygeine
organisms: staphylococcus aureus(gram +ve0
Root of entery : organism form baby’s mouth much less common (blood born infection).
c/p: symptoms
• generally : toxic symptoms( fiver, headache, malaise and anorexia) .fiver(due to absorpt of
milk proteins).
• Local :dull aching pain but gets wore
Signs:
diffuse tense and tender.
 physical signs of inflammation i.e hotness or redness
 Axillary LNs : firm and tender
• Fate: if neglected  acute breast abscess.
 Acute breast abscess.

pathology : milk engorgement +staph. infection pus

clinical picture:
• generally : toxic symptoms( fiver, headache, malaise and anorexia) .NB
hectic fiver i.e. flactuent and desnot the basalline at the same day
• Local :throbbing pain more at night
Signs:
 localized tense and tender.
 physical signs of inflammation i.e hotness or redness of the skin.
 Axillary LNs : firm and tender.
 pitting oedema of skin overlying the abscess.
 flucuation is very late.
 Acute bacterial Mastitis
mastitis carcinomatosa

History Onset, course & Acute Onset, & Gradual Onset, &
duration rapidly progressive slow progressive
course course
Fiver High grade fiver Low grade fiver

inspection Skin over Firey red Dusky red

palpation Tenderness Marked tenderness Mild tenderness

Axillary LNs Firm and tender hard not tender

Treatment A.B cured no response

 Treatment Acute lactational mastitis and acute breast abscess

Prophylactic treatment
• Correct hygeine of breast during lactation
• Paint the nipple with topical soothing creams
• The breast should be evacuated completely with each lactation.
Active treatment:
Stage of milk engorgement & acute bacterial mastitis i.e. before
suppuration(no abscess)
1. Local heat “hot application”
2. Support of the breast
3. An antibiotic against staphylococci e.g. flucloxacillin or
cephalosporin.
4. The advise ability of weaning
-if baby is >9m  stop feeding, the agent in common use is “
parlodel” 2.5mg bid.
- If baby < 9m  continue feeding with healthy breast & regular
evacuation of diseased one by using a pump.
 Stage of acute abscess formation
• i.e. after suppuration(don’t wait flactuation)
• Anaesthesia: general Anaesthesia
• Incision: incision and drainage according the type of abscess:
1. Supra mammary abscess incision any where.
2. Intramammary abscess it may be
- Radial: radiating for areolar
- Circum-arelar: at margin of areola 1st then radial
incision is done so better cosmatic.
3. Retro mammary abscess: incision in sub-mammary fold.
• Technique:
1. Surgeon’s finger breaks all loculi to form single cavity.
2. Pus evacuation for culture and sensitivity.
3. Dreain is brought out through the most dependent part
2.Non lactational mastitis : the most common non lactational
mastitis is that which compllicates mammary duct ectasia.
3. Rare types of mastitis:
1. Infected hematoma
2. Infected tumors
3. Mastitis neonatorum (male and female):It is due to
retention of mother hormones i.e. (maternal prolactine)
stimulates lactation in infant. c\p: swollen breasts on 3 rd
and 4th day wiw drops of milk (witch’s milk). It subsides
with in 2-3 weeks.
4. Mastitis of puberty (male only)
The condition affects adolescent boys  pain +swelling of the
breast, which becomes indurated but suppuration never occur.
 Chronic inflammatory diseases
Mammary duct ectasia( mast cell mastitis).
 Difinition: dilatation of major ducts of the breast.
 Etiology: unknown
 Pathology: chronic inflammation of ducts system leads to dilation
of major ducts which are filled by creamy secretion( atrophic
epithithelium + fatty material) Surronded by plasma cells
c\p
 Age: around or after menopause.
 Mass: hard mass, may be associated with nipple retraction, peau
d’orange..etc so similar to cancer breast.
 Discharge creamy white or may be blood stained.

• Treatment: excision and biopsy (to exclude malignance).

 2.chronic breast abscess
Non specific [chronic pyogenic breast abscess]
• Definition: fate of improper treatment of acute
abscess
• Aetiology: prolonged use of antibiotics>killing of
bacteria >sterile pus>antibioma
• Pathalogy:
 cavity;containing sterile pus,
 wall;thick fibrous wall
• Clinical picture; mass[hard mass, may be associated
with nipple retraction, peau d’ orange so similar to
cancer breast.
• Discharge: no discharge
 *D.D;
Chronic Cancer breast
abscess
toxaemia Low grade absent
fever
Post surface rounded flat
History of A.b +ve -ve

Treatment: excision&biopsy [to exclude malignancy]

Specific (T.B)
• Definition; arare disease with active pulmanory T.B
• Aetiology: tubercle bacilli (T.B).
• Pathology: T.B granuloma
• C/P
 history: of (night sweat, night fiver,loss of weight,
loss of appetite).
 Mass multiple nodules of the breast.
 Axillary L.Ns: enlarged & matted.
• Treatment: Anti TB drugs + excision for resistant
cases
 Fibrocystic disease of the breast
FIBROADINOSIS
 Mammary dysplasia, mastopathy chronic intrestitial mastitis
but misnomer as no evidence of inflammation,
ANDI(Aberration of Normal Development & Involution)
 Incidence: this is the most frequent disorder of the breast,
the outer quadrant of the breast is the commonest site of
affection.
 Aetiology: unknown but may be due to over sensitivity of
oestrogenic receptors.
 Pathology: an image of pathological action oestrogen on
breast.
 Macroscopic picture :
 site: localized or diffuse side: unilateral/bilateral
 Fibrocystic cont…
 Microscopic picture:
Adenosis: inc. number of acini
Epitheliosis: hyperplasia of epithelial lining the ducts 
atypical hyperplasis pre-cancerous. Ductal papilloma
(localized epitheliosis).
Fibrosis : fibrous tissue replaces the fat i.e sclerosing adenosis.
NB fibroadenoma is localized form of fibrosis & adenosis.
Cystic formation:
 microcyst : degenerating cyst.
 Macrocyst: retention cyst due to obstruction by epitheliosis
from inside or fibrosis from outside, some times
papillomatosis are seen in the cyst from excess epithelial
proliferation.
 Clinical picture
• Age: after puberty or before menaopause
Symptoms: maybe asymptomatic
• Pain(mastalgia): dull ache inc. before and dec. after menses.
• Discharge: clear or yellow but sometimes brown or green.
• mass : painful & fixed to breast tissue
Signs: tender breast tissue
Discharge by patient her self
Mass firm or fine nodules by tips of fingers
Investigation ( the aim is to exclude cancer )
U/S and soft tissue mammography
Aspiration & cytology
Biopsy and histopathology
 Treatment
Medical treatmen (the main ttt)
 Reassurance of the pt.
 Advic the pt to stop caffeine e.g. stop coffe, tea, alcohol, and
chocolate
 Sedevatives and tranquilizers.
 Support the breast by light braces to dec. pain
 Parlodel( anti prolactine)0: 2.5mg bid
 Danazol (synthethic androgen) 100-200mg Bid
 Tamoxfen (anti estrogen0 10 mg once daily

Surgical treatment ; excision and biopsy

Follow up : with atypical hyperplasia , discovered by biopsy should

be instructed to perform a monthly self examination
 Breast Neoplasm
• Benign :
Epithelial duct papilloma
mixed:(Epithilial & fibrous tissue) fibroadenoma.
• malignant.
Duct papilloma
Incidence: common at young women.
Aetiology: benign tumor of epithelial cells, it may be from the star i.e. de novo
or top of excessive localizaion of epitheliosis of fibroadenosis.
Pathology
 macrocopic picture :usually single & arises from main lactiferous duct near
the nipple.
 Microscopic picture: core of very vascular C.T covered by hyperplastic
epithelial layer.
Clinical picture
 Age: 30-40 years
 Symptoms: bleeding per nipple, retroareolar mass i.e. retention cyst.
 Duct papilloma con….
Singns:
 localize the duct by palpation of each quadrant.
 Retro areolar mass i.e. retention cyst.

Complication
 Malignant transformation i.e. duct carcinoma
 Profuse bleeding per nipple.

Investigation: ductography retoareolar filling diffect in major duct.

Treatment microduchectomy: excision of the affected duct through circum

areolar incision
 If there is a lump, the excision is easy
 If there is no lump the duct is identified by insertin a blunt tipped needle
The excised specimen should be histologically examined
 FIBROADENOMA
Incidence: the common est breast mass
Etiology: benign tumor of epithelicell +fibrous tissue, it may
be from the start de novo.
• Or on top of exessive localizaion of adenoisi and fibrosis
of fibroadenosis.
Pathology
• The tumor is well capsulated
 True capsule; showing fibrous bands dividing it into
lobules
 False capsule : formed by compressed breast tissue.
There are two types: hard and soft.
 2 types of fibroadenoma

Hard fibroadenoma Soft fibroadenoma

(per-canalicular) (intr-canalicular)
N/E picture Attached to its capsule by Attached to its capsule by
one pedicle multiple pedicle

Microscopic picture Ducts are surronded by Ducts are compressed by

fibrous tissue fibrous tissue

Clinical picture
Age 20-30 30-50
symptoms Painless mass, slow rate of Painless mass, rapid rate of
growth i.e. malignancy is growth i.e. malignancy is
never common
Signs Firm & not tender, well soft& not tender
defined edge, mobile &no
NLs enlargement
Malignancy Never Liable to turn to sarcoma
 NB: cystosarcoma phylloides

The name
• The term dystsarcome, how ever is a misnomer as many
are not cystic & it is not sarcoma.
• It better termed “Phylloides tumor”
• It was so named by “Brodie” who was used the wards
phylloides because the cut surface resembles a leaf or fan.
Pathology
• It is higly cellular type of fibroadenoma that tends to grow
rapidly
Examination :
 -it is giant soft fibroadenoma
 Ulcerate through skin but not attached to it
 No axillary LNs except if infected.
Treatment: wide local excision or simple mastectomy.
• Investigation : soft tissue mammography
• Treatment :
• Hard fibroadenoma: excision & biopsy
• Soft fibroadenoma: if small excision & biopsy
if large:simple mastectomy.
 Breast Cancer Risk Factors
unalterable factors
Age
GENDER - All
Reproductive
women are
at risk History
Family/Personal
History

Menstrual
Race History
Radiation
Treatment with Genetic
DES Factors
 Breast Cancer Risk Factors
that can be controlled
Obesity
Obesity
All Not
Not having
having
Exercise
Exercise women are
women are children
children
at risk

Breastfeeding
Breastfeeding
Birth Control
Birth Control
Hormone Pills
Alcohol Replacement
Therapy
 Methods of screening:

A- Breast self examination

- no significant reduction in mortality
- difficult to teach
- may induce anxiety

6/21/23 38
 B- Mammography

1- screening of high risk groups

- +ve family history
- 2.5 times greater risk
2- hormone replacement therapy
- mammography before starting
- 2 yearly
3- patients with atypical hyperplasia
- 2 yearly from age 35-40
- annually from age 40-50
- 18 monthly above 50
4- positive gene testing

6/21/23 39
 Options for individuals carrying the gene
BRCA1 or 2 :

1- regular screening starts at

- the age of 35 or 5 years younger than the youngest family
member

- biannual mammography up to the age of 40 + annual

clinical examination

- 40-50 annual mammography

- after 50 years 18 monthly
2- bilateral prophylactic mastectomy
3- prophylactic oophrectomy

6/21/23 40
 Prevention of breast cancer

1- life style modification

- weight control &

weight reduction
- smoking cessation
- decrease alcohol

6/21/23 41
 Prevention of breast cancer

2- preventive surgery
- oophrectomy in certain conditions
and age
- prophylactic mastectomy
- personal history of breast cancer
- strong family history
- multiple previous breast biopsies
- LCIS or atypical hyperplasia

6/21/23 42
 3- chemoprevention
- tamoxafen

4- prevention of risk factors:

- exposure to radiation
- age at 1st child delivery
- artificial earlier menopause
- parity
- lactation
- hormone replacement therapy HRT
6/21/23 43
 5- surgery for breast cancer is better done
in the 2nd half of the cycle → better
prognosis

6/21/23 44
 Histological Classification of Breast Cancer

Cancers of the Mammary Gland can be Classified:

1. Histogenesis – duct, lobule (acini)

2. Histologic Characteristic – adenocarecinoma, epidermoid CA, etc.
3. Gross Characteristic – Scirrhous, colloid, medullary, papillary, tubular
4. Invasive Criteria – Infiltrating, in-situ
 Pathology of breast cancer
• Breast cancer arises in terminal duct ( lobular unit )

• Histological classification
1- Non-invasive
- ductal ca. Insitu 6%
- lobular ca. Insitu 0.2%
2- Invasive
- no special type 68%
- special types
- lobular
classical3%
variants7%
- tubular 3%
- cribriform 3%
- medullary 3%
- mucinous 2%
- microinvasive 2%
- papillary 1%
6/21/23 - other rare types 1.8% 46
 Histological Classification of Breast Cancer

Non-infiltrating (In-situ) Carcinoma of duct and lobules:

• Increase diagnosis due to mammography
• DCIS : LCIS (3:1)

1. LOBULAR CARCINOMA in SITU:

• Considered as a risk factor
• Observed only in females, premenopousal
• No involvement of the basement membrane
• Tx: 1. Close observation
2. Hormonal treatment (Tamoxifen/aromatase inhibitor) for 5 years
3. Surgery (bilateral mastectomy) w/or without immediate
reconstruction
 Histological Classification of Breast Cancer

Infiltrating Carcinoma of the Breast:

1. Paget’s disease of the nipple (1%):
• Primary carcinoma of mammary duct that invaded the skin
• Chronic eczematoid lesion of the nipple
• Tenderness, itching, burning and intermittent bleeding
• Palpable mass in the subareolar area
• PAGET cells:
» Characterictic cells
» Large cell w/ clear cytoplasm and binucleated
• 80% non-infiltrating CA
• 100% 5yr survival
 Paget's disease

6/21/23 49
Paget disease of nipple : Clinically resemble
eczema.
 Paget's histology

6/21/23 51
Paget cells:
These cells have
abundant clear
cytoplasm and
appear in the
epidermis either
singly or in
clusters.
Paget’s Dz -large Paget's cells of Paget's disease of breast have
abundant clear cytoplasm and appear in the epidermis either
singly or in clusters. The nuclei of the Paget's cells are atypical
and, though not seen here, often have prominent nucleoli. This dz
often involves the nipple and areola. The dz starts as intraductal
but extends to skin.
 Histological Classification of Breast Cancer
2. Scirrhous carcinoma: (fibrocarcinoma, sclerosing CA):
– 78% (most common)
– Increased Desmoplastic response to invading CA cells (protective)
– Neoplastic cells are arranged in small clusters or in single rows occupyning
a space between collagen bundles
– Originate in the myoepithelial cells of the mammary duct
– Desmoplastic ---> shortend Cooper’s ligament ---> dimpling over the
tumor

3. Medullary carcinoma:
– 2-15%
– Large round cancer cells arranged in broad plexiform mass surrounded by
lymphocytes and lymphatic follicles
– Soft, bulky and large tumors w/ necrotic areas
– 5 year survival = 85 – 90%
– Good prognosis
 Histological Classification of Breast Cancer
4. Mucinous (Colloid) carcinoma:
– 2%
– Soft, bulky w/ ill defined borders
– Cancer cells floats in large mucinous lakes
– Cut surface is glistening, glaring and gelatinous

5. Tubular carcinoma
– Well differentiated
– Ducts lined by a single layer of well differentiated cancer cells
– Absence of myoepithelial w/ well defined basement membrane
– Common in premenopausal and detected w/ mammography
– 5 yr survival ---> 100% if the CA contain 90% or more of tubular
components
Histological Classification of Breast Cancer
6. Papillary carcinoma:
• 2 %; present in 7th decade
• Thrown into papilla w/ well defined fibrovascular stalks and
multilayered epithelium
• Has the lowest frequency of axillary nodal involvement; has the
best 5 and 10 yrs survival rates
• Even if w/ axillary metastases, it is still indolent and slowly
progressive disease than the common adenocarcinoma

7. Adenoid cystic carcinoma:

• Indestinguishable from adenoid cystic carcinoma of the salivary
gland
• Rare axillary involvement.
Histological Classification of Breast Cancer
8. Carcinoma of Lobular origin:
• 10% of breast CA; LCIS – 3%
• Small cell w/ round nucleus, inconspicuous nucleoli and scant,
indistinct cytoplasm.
• Arises from the terminal ducts and acini
• Similar to colloid CA were mucin displaced the nucleus,
resembling signet-ring carcinoma of the GIT.
• High propensity for bilaterality (35-60%), multicentricity (88%)
and multifocality

9. Squamous Carcinoma:
• Metaplasia w/in the lactiferous duct system
• Similar to epidermoid CA of the skin
• Metastasize thru the lymphatic
Histological Classification of Breast Cancer
10. Sarcoma of the Breast: (Fibrosarcoma, liposarcom,
leiomyosarcoma, malignant fibrous histiocytoma, etc.)
– Large, painless breast mass w/ rapid growth
– Mammography ---> false (-)
– Grossly: --> it lacks the cut gabbage surface of phyllodes
– Histologically:
» Spindle cell neoplasm that grows expansile and it’s
margin either pushes or infiltrate adjacent structures
» It invades the fat and tend to intervene between the
glandular aspect of the breast parenchyma and expands
the lobules and intralobular spaces
– Treatment: --> total mastectomy
Histological Classification of Breast Cancer
11. Lymphoma of the Breast:
• Similar to other malignant lymphoma
• Mastectomy w/ axillary LN sampling
• Tx: radiotherapy / chemotherapy

12. Inflammatory Carcinoma of the Breast

• 1.5 – 3%
• Clinically: erythema, Peau-d’ orange, skin ridging w/ or w/o a
mass. Skin is warm sometimes scaly and indurated (cellulitis),
nipple retract.
• Diagnosis: biopsy
• Histologically: ---> no predominant histological type.
» Subdermal lymphatic and vascular channels are permeated w/
highly undifferentiated tumor
» Characteristically: ---> absence of PMN and lymphocyte near
the tumor
• Rapid growth and majority has (+) cervical LN and distant
metastasis
 Benign vs. Malignant
Chief Benign Characteristics Malignant
Complaint Characteristics
Breast mass Multiple lesions Single lesion
“Rubbery” Hard
Mobile Immovable
Well circumscribed border Irregular borders

Nipple discharge Bilateral Unilateral

Multiductal Uniductal
Milky Bloody, Clear, or Colored
Spontaneous
Persistent
Skin changes Retraction
Dimpling
Thickening
 Patient Workup

• FNA vs. Core Biopsy

• Cyst aspiration & cytology
• Ultrasound
• Mammography
• MRI
• PET
 BREAST CANCER DIAGNOSIS:

2—IMAGING
3—METASTATIC WORK UP

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 Imaging
• Mammography
• Ultrasound
• MRI
 Mammography
• Screening tool
– Age of 40
• Estimated reduction in
mortality 15-25%
• 10% false positive rate
• Densities & califications
 Mammography - Reporting

BIRADS - Breast Imaging Reporting and Data System

Category Assessment Recommendations
0 Incomplete Additional views
1 Negative Routine - 12 months
2 Benign Routine - 12 months
3 Probable Benign F/U short term - 6 mos.
4 Suspicious Biopsy considered
5 Cancer suggested Appropriate action
 BI-RADS
BI-RADS Features
Classification

0 Need additional imaging

1 Negative – routine in 1 yr
2 Benign finding – routine in 1 yr
3 Probably benign, 6mo follow-up
4 Suspicious abnormality, biopsy
recommended
5 Highly suggestive of malignancy;
appropriate action should be taken
 Staging of breast ca
TNM staging
T=RUMOR N=NODE M=METASTASIS

Tis= Ca in situ or Paget’s disease N0= No palpable L.Ns. M0= No distant

T0= no evidence of 1ry tumor. N1= mobile axillary L.Ns. metastasis
T1= <2cm N2= fixed axillary L.Ns. M1= distant metastasis.
T2= 2-5cm N3= palpable homolateral
T3= >5cm supraclavicular L.Ns
T4= Any size with extension to
chest wall
 Staging of breast ca
U.I.C.C (union of international
cancer center) staging
Stage UICC category
Stage1 Early breast Ca with no L.Ns.
Stage2 Early breast Ca with mobile L.Ns.
Stage3 Advanced breast Ca with fixed L.Ns.
Stage4 metastatic
 Treatment of breast cancer

Triple assessment
• Clinical examintaion + mammogran & U/s + histological biopsy.
A. operable (early) less thanT2,N1,M0 or stage 1,2 as U.I.C.C.
• Different surgical operation +adjuvent systemic therapy if +ve axillary LNs.
• Stage1: Modified radical mastectomy of (Patey) + follow up (to detect local recurrence ant
metastasis+ any post operative complication).
• Time after ttt then every 3 months at 1st 2 years the every 4months for the next 3years then
yearly.
• Stage 2 Modified radical mastectomy of (Patey) + adjuvant systemic therapy.
Radiotherapy: to dec. local recurrence
to 1. mediastinal region for internal mammary LNs.
2. supraclavicular region for supraclivicular LNs.
Chemotherapy: to dec. blood borne meatastasis by
1. CMF: Cyclophosphamid, Methotrexate and 5 Flurouracil.
2. Adriamycin.
indicated with ER-ve females
Hormonal: to dic. Growth of the tumor
By Tamoxifen or Anastrazole
Endicated with ER +ve female.
 Surgical operation
1. Conservative breast surgery
Wide local excision with 2 cm safety margin then sentinel lymph node
biopsy.
• Indication:
1. Small masses <4cm
2. Big breast
3. Young female
4. Peripheral lesions
Contra indication: the reverse of indication+ pregnancy and collagen
vascular disease.
Sentinel lymph node biopsy:
The Sentinel lymph node is localized pre-operative by injection of a
blue dye near the tumor. The dye will pass to the 1ry node draining the
tumor area, which can be detected by gamma camera then biopsy &
histopathologically examined.
2. Modified radical mastectomy of (Patey) most widely accepted.
Same as Halsted but:
1) We preserve pectoralis major muscle
2) Pectoralis minor either removed or cut at its insertion or retracted to
expose the axilla.
3. Radical mastectomy of (Halsted)
 Removal of:
1) Elliptical part of slin with nipple & areola.
2) Whole breast tumor
3) 2 Pectolais muscles.
4) All axillary LNs & fat medial to axillary vein.
 Preservation of:
1. Axillary vessels .
2. Cephalic vein.
3. Nerve of serratus anterior.
4. Nerve to latissmus dorsi .
4. Extended radical mastectomy( not done nowadays).
Same as Halsted + removal internal mammary LNs through
median sternotomy.
NB: post operative complications
1. Hematoma or wound infection
2. Oedema of upper limb: early pitting odema (within few
days) due to removal of excess lyphatics.
Late non pitting odema(within few months) due to:
1. Recuurence of axillary LNs.
2. Arm infection.
3. Axillary radioltherapy.
3. Bridle scar limitation of abduction.
NB: breast reconstruction either silicon prosthesis or
myocutaneous flap as rectus abdomins or latissmus dorsi flap.
 B. inoperable (advanced) more thanT2,N1,M0
or stage 3,4 as U.I.C.C.
Stage

ttt Stage 3 Stage 4

local ttt The main Radiotherapy to any malignant
Radiotherapy to mediastinum , deposit.
supraclaivicular and axilla .

Surgical palliate simple Surgical excision of skin nodules.

mastectomy Internal fixation for pathologica
fracture

Systemic ttt In ER –ve and failure of HT The main

CMC & Adrimycin Chemotherapy
CMC & Adrimycin

60% of breast Ca is ER+ve Endocrinal

Tamoxafen 1st line Tamoxafen,Anastrazole
Anastrazole 2nd line
 Treatment of metastasis
 Liver metastasis chemotherapy
 Brain metastasis radiotherapy+ corticosteroid
to Dec. intracranial lesion
 Lung metastasis chemotherapy + chest tube
for pleural effusion.
 Bone metastasis Radiotherapy+ internal
fixation if pathological fracture