Breat Dis Orders
Breat Dis Orders
Breat Dis Orders
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
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
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.
History Onset, course & Acute Onset, & Gradual Onset, &
duration rapidly progressive slow progressive
course course
Fiver High grade fiver Low grade fiver
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.
Complication
Malignant transformation i.e. duct carcinoma
Profuse bleeding per nipple.
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:
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B- Mammography
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Options for individuals carrying the gene
BRCA1 or 2 :
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Prevention of breast cancer
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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
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3- chemoprevention
- tamoxafen
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Histological Classification of Breast Cancer
• 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
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Paget disease of nipple : Clinically resemble
eczema.
Paget's histology
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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
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
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
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