Benign breast diseases

VASCULATURE
The arterial supply is from the
internal thoracic artery, via
perforating branches, and
axillary artery, via the long
thoracic and thoracoacromial
branches.

Venous drainage is mainly to

the axillary vein, as well as the
internal thoracic, lateral
thoracic, and intercostals
veins.
Lymphatic drainage

>75% of breast lymphatic

drainage is to axilla
The other group of lymph node
which drains breast is internal
mammary lymph nodes
Axillary node grouped in to 5
1. Lateral, 2.Anterior,
3. Posterior, 4. Central,
5. Apical,
This lymph nodes groups has
three levels
Axillary lymph nodes are classified according to their
anatomic location relative to the pectoralis minor
muscle.
1. Level I nodes. Lateral to the pectoralis minor
muscle
2. Level II nodes. Posterior to the pectoralis minor
muscle
3. Level III nodes. Medial to the pectoralis minor
muscle and most accessible with division of the
muscle
4. Rotter's nodes. Between the pectoralis major and
the minor muscles
A pectoralis major muscle
B axillary lymph nodes:
levels I
C axillary lymph nodes:
levels II
D axillary lymph nodes:
levels III
E supraclavicular lymph
nodes
F internal mammary lymph
nodes
 ANDI CLASSIFICATION OF BENIGN BREAST
DISORDERS
Normal Disorder disease
Early Lobular development Fibroadenoma Giant fibroadenoma
reproductive
years (15-25
years)

Stromal Adolescent gigantomastia

development hypertrophy

Nipple eversion Nipple inversion Subareolar abscess

Mammary duct
fistula
Late reproductive Normal Disorder disease
years
(25-40 years )

Cyclical changes of Cyclical mastalgia Incapacitating

menstruation mastalgia

Epithelial Bloody
hyperplasia of nipple
pregnancy dischage
Involution Normal Disorder disease
(35-55 years)

Lobular involution Macrocysts

sclerosing lesion

Duct involution

Dilatation Duct ectasia Periductal mastitis

sclerosis Nipple retraction

Epithelial turnover Epithelial Epithelial

hyperplasia hyperplasia with
atypia
 Classification
Non proliferative disorder of the breast
Cyst and apocrine metaplasia
Duct ectasia
Mild ductal epithelial hyperplasia
Calcifications Fibroadeoma and related lesions
Proliferative breast disorder with atypia
Sclerosing adenosis
Radial and complex sclerosing lesion
Ductal epithelial hyperplasia
Intraductal papillomas
Atypical proliferative lesion
Atypical lobular hyperplasia
Atypical ductal hyperplasia
• Risk for malignancy
• No increased risk in fibroadenoma,intraductal
papilloma, sclerosing adenosis

• 1.5-2 fold rise in epithelial hyperplasia

• 4 fold rise in atypia with hyperplasia

 Fibroadenoma
• Benign solid tumors comprising of stromal and
epithelial components
• 15% of all palpable breast lumps
• Mostly in females younger than 30 years of age
• ANDI involving a lobule
 Clinical features
• Most growth arrested by 2-3cm; may reach >10cm
• Highly mobile, firm, non-tender, and often palpable
breast mass.
• Multiple in 15%- 20 %
• Bilateral in 20%
•Axillary lymph nodes not palpable
Types:
• Juvenile (rapid epithelial and stromal growth)
• Complex (with fibrocystic changes)
• 10-15% will increase in size progressively
• Spontaneous infarction – pregnancy/lactation
• Reports of regression 20-25%
• Risk of carcinoma: rare (in complex
fibroadenoma and atypia in microscopy)
 Investigations
Investigation
Ultrasonograph
s Mammography
FNAC

Well-circumscribed firm mass, solid mass the cut surface appears lobulated and bulging
Investigations
Mammary dysplasia /cyclicalmastalgia with nodularity
SCHIMMELBUSCHS DISEASE: diffuse small multiple cysts.
 Surgical management
• Subcutaneous mastectomy with prosthesis
placement
• Excision of cyst or localised excision of diseased tissues
Indication:
• Intractable pain
• Florid epithliosis in FNAC
• Bloodgood cyst
• Persistant bloody discharge
• Psychological reason
o MAMMOGRaM
• treatment
• ANDI Terminal ductules and acini with proliferation of
stroma often with deposition of calcium
• Number of normal duct is increased than number of
normal lobule

• No risk of malignancy
• Investigation : stereotactic /core needle biopsy
• Treatment: conservative
ANTIBIOMA
Biopsy
 Fat necrosis
• Benign nonsuppurative inflammatory process of
adipose tissue.
• Occur secondary to accidental or surgical trauma,
• May be associated with carcinoma,
• Any lesion that provokes suppurative necrotic
degeneration, such as mammary duct ectasia and,
to a lesser extent, fibrocystic disease with large cyst
formation
• Clinically, fat necrosis may mimic breast cancer

• Appears as an ill-defined or spiculated dense mass,

associated with skin retraction, ecchymosis, erythema,
and skin thickness .

• Mammographic,USS and MRI imaging findings : may

not always distinguish fat necrosis from a malignant
lesion.

• Histologically: characterized by anuclear fat cells

often surrounded by histiocytic giant cells and foamy
phagocytichistiocytes

• Treatment : Excisional biopsy, if carcinoma cannot be

excluded preoperatively
NIPPLE DISCHARGE
NIPPLE DISCHARGE
 Blood and Serosangious Discharge
• Due to epithelial hyperplasia, duct papilloma,
malignancy.

• Rare due to duct ectasia

• >55years age increase risk of malignancy

• Incidence of cancer is 3% below 40yrs, 10%

between 40-60 and 32% over 60yrs
 Intraductal Papilloma
• Rare,occurs in middle-age.
• ANDI of lactiferous ducts
• Variant of epithelial hyperplasia (fibrocystic disease)
• Presents as blood-stained or serous nipple
discharge.
• Usually solitary lump <1cm with a small lump in the areola
• papiliferous projections near nipple origin,vascular stalk
usually present
 Investigations

Discharge study
FNAC
Ductogram
mammography
 TREATMENT
•MICRODOCHECTOMY Via tennis racket
incision
Risk for carcinoma:

•
Management

• MELHEM NOVEL MODIFIED BREAST DUCTAL SYSTEM EXCISION

Mastitis
• Types.
Subareolar :
• Common in non lactating women
• Infection of montgomery tubercles or furuncle of areola,
due to cracked nipples
• Red inflamed edematous areola with a tender
swelling .may have nipple retraction
• Treatment: incision and drainage by subareolar
incision
Retromammary:
due to tb/suppuration of intercoastal lymph
nodes/ribs
 Breast Abscess

Classification:
Breast abscesses can be classified into :
• Lactational
• Non - lactational

Non- lactating breast abscesses can be further divided into

▪ Central (periareolar) infection
▪ Peripheral Infection
 Lactating Infection
• Usually develops within the first 6 weeks of
breastfeeding or occasionally, during weaning.
• 3% of lactating mothers
• Causative organism: Staphylococcus aureus
occasionally staph epidermidis and
streptococci
• Drainage of milk from the affected segment often
reduced, causing stagnant milk to become infected.
Risk factors:
• Cracked nipples
• Retracted nipple
• Infection from mouth of baby
• Improper cleaning of nipples
• Hematoma getting infected
Presenting features :
continuous throbbing pain, swelling, tenderness and
a cracked nipple or skin abrasion, brawny
induration,purulent nipple discharge, fluctuant
swelling
 Non-Lactating Infection
Central or periareolar infections
• This is most commonly seen in young women
(mean age 32 years)
• Cause : periductal mastitis
• Risk factor : smoking
Peripheral Non-lactating abscess
These are less common than peri-areolar
abscesses
• sometimes associated with an underlying
condition, such as diabetes, Rheumatoid
arthritis, steroid treatment, or trauma.
Clinical features :
• Breast pain
• Erythema
• Peri-areolar swelling and tenderness
and/or nipple retraction in relation to the
affected duct
 Investigations
• Ultrasonography breast

Treatment

1.Antibiotics

2.Repeated aspirations

3.Incision and drainage

• MASTALGIA
Breast pain that interferes with daily activities of
the patients
Galactocele
• Serum chemistry
• LFT
• Thyroid function test
• Renal function test
• Total or free testosterone level, serum prolactin, LH,
oestradiol, dehydroepiandrostenone sulphate levels to
evaluate a patient with possible feminization syndrome
• Urinary 17 ketosteroid
• Beta HCG
• Imaging Studies :
• USG breast, Testicular USG
• Mammography
• MRI for pituitary gland
• CT scan for adrenal
 Treatment
• Reassurance (if psysiological)
• Treatment of cause (stop drugs)
• Medical therapy(danazol,clomiphene
citrate,tamoxifen)
• Surgical therapy
 Surgery
Indicated in patients in whom the gynaecomastia
causes distress and psychological trauma, when
there is no underlying treatable condition and when
hormonal treatment is failed

• Open subcutaneous mastectomy

• Endoscopic assisted subcutaneous mastectomy
• Liposuction assisted mastectomy
• Ultra sound assisted liposuction
 References

Schwartz's principle of surgery, 10th edition

Sabiston principle of surgery 19th edition