Download - DR Adel Fathi

Pioneer of Surgery for under graduate
Breast
Anatomy of the breast
A.F.
-59-
A.F.
Pioneer of Surgery for under graduate
Breast
♣♣ Embryology:
The breast develops from two ectodermal ridges called milk
lines extending from anterior axially fold to groin.
♣♣ Gross anatomy:
1- Lie:- The whole breast:- is located within the superficial fascia of
the anterior chest wall
- The axilllary tail of Spence: - Lies deep to the axillary fascia & pass through an
opening in the deep fascia which is called foramen of langer
2- Extent:- In non-lactating: From 2-6 rib
From lateral border of the sternum to midaxillary line.
- In lactating: From the clavicle to 8th rib
From midline to the anterior border of latismus dorsi.
3- The retro mammary space:- It is a distinctive space lies between:
- The deep layer of the superficial fascia &
- The deep investing fascia of pectoralis major muscle.
- Its importance: it has loose areolar C.T. which allow mobility of the breast on the
chest wall
4- The cooper's ligaments:- It is a fibrous thickening of supportive connective tissue.
- Extends from the pectoral fascia to the skin
- Contain bl.v. and lymphatics
- The surgical importance:
1- Responsible for dimpling of the skin in case of carcinoma due to involvement of
lymphatics in it.
2- In virgin breast: attach the breast to the chest wall → providing structural support
& breast contour (pendular after pregnancy & lact. due to stretch of the lig)
5- The areola: 3 types of glands:a- Sebaceous glands -----» for lubrication of the nipple during lactation
A.F.
-60-
A.F.
Pioneer of Surgery for under graduate
Breast
b- Sweat glands.
c- Accessory mammary glands (accessory gland of montogomry)
6- The nipple:- Lie at midclavicular line in 4th intercostals space.
- The orifices of the lactiferous ducts lie near its apex
- The nipple points forward & outwards & downwards.
7- The underlying muscles:- The upper 2/3 of the breast lies on the pectoralis major.
- The infrolateral 1/3 lies on serratus anterior & external oblique.
- The lower medial part lies over the upper part of the anterior rectus sheath.
♣♣ Microscopic anatomy:
A- Mammary glands:It consists of 15 to 20 lobes of tubulo-alveolar glandular tissue which are separated by
cooper's ligaments ----» they subdivided into lobules
** The upper outer quadrant contains more glandular tissue than the remainder of the breast
------» so cancer breast more common in the upper outer quadrant.
B- Duct system:-
A.F.
-61-
A.F.
Pioneer of Surgery for under graduate
Breast
Each lobe drain in separate main lactefrous duct → form a lactefrous sinus under
areola which open separately on nipple
C- Terminal duct lobular unit (TDLU):Responsible for all breast diseases (due to it is the part which is affected by
hormones) except duct papilloma & duct ectazia
♣♣ Blood Supply:
A- ARTERIAL: (from three sources)
1- Internal thoracic (mammary) artery:
MAIN SUPPLY
- Branch of the 1st part of subclavian artery parallel to the lateral border of the sternum
- Gives anterior perforating arteries in the 2nd, 3rd & 4th intercostal spaces
2- Branches of the axially artery:1- From the first part -------» superior thoracic artery
2- From the second part -------»Lateral thoracic artery
-------»acromio thoracic artery
3- Posterior intercostal arteries:gives lateral perforating arteries supply the lateral portion of breast
B- VENOUS DRAINAGE:1- Perforating branches of the internal mammary vein.
2- Tributaries of the axillary vein.
3- Perforating branches of posterior intercostal veins.
** The posterior intercostol veins lie in direct continuity with the vertebral plexus of veins
(Batson's plexus) that surround the vertebrae and extend from the skull to sacrum .The
plexus provide an important pathway for haematogenous spread of breast cancer that
explains metastases to skull, & CNS in absence of pulmonary metastasis.
♣♣ Innervations: (Sensory)
1- Lateral & anterior cutaneous branches of 2-6 intercostal nerves (T2-T6)
2- The intercosto-brachial nerve:- Originated from the 2nd intercostal nerve → traverse the axilla → supply
sensation to the upper medial aspect of the arm & axilla
Oral Questions?
A.F.
-62-
A.F.
Pioneer of Surgery for under graduate
Breast
Axillary
artery
Divided by pectoralis
minor Ms.
1st part
2nd part
1- Superior thoracic
artery
1- Lateral thoracic art.
2- acromio thoracic art.
3rd part
1- subscapular art.
2- Ant. Circumflex
art.
3- Post. Circumflex
art.
acromio
thoracic art.
Acromial
Pectoral
Clavicular
Deltoid
branch
branch
branch
branch
Subclavian
artery
Divided by
scalenous muscle
1st part
Inferior
thyroid
Thyrocervical
trunk
Internal
mammary
art.
suprascapular
Transverse
cervical
Vertebral
art.
2nd part
3rd part
Costocervical
trunk
No branches
Nerves of surgical interest:
A- Long thoracic (Nerve of Bell): A.F.
- From 5th, 6th & 7th root
-63- Located in the medial wall of the axilla
A.F.
Pioneer of Surgery for under graduate
Breast
♣♣ Lymphatic drainage:
@ Lymphatic plexus within the breast:
A- Superficial (subareolar) lymphatic plexus of Sabby:
Drain skin, nipple, areola & superficial parenchyma → pass to parenchymatous
lymphatic plexus
B- Interlobular (parenchymatous) lymphatic plexus:
Drain the main parenchyma of the breast → pass to submammary lymphatic plexus
C- Submammary (deep) lymphatic plexus:
Drain deep parenchyma → pass to …………as below
@ From these plexus into:
I- 75% into axillary L.N.:
## Step ladder manner: Level I → Level II → Level III → subclavian lymphatic trunk → to:
Left → thoracic duct
Right → right lymphatic duct
To junction ( ) subclavian
& IJV
## If thoracic duct or right lymphatic duct obliterated by malignant cells → spread to
supraclavicular L.N.
II- 25% drains into:
1- From medial part of breast → to internal mammary L.N.
2- Some lymph vessels drain into opposite breast in advanced tumor
3- From upper part of breast → to Rotter’s L.N. (interpectoral L.N.)
4- Some lymph vessels drain into posterior intercostal L.N. (near head of ribs) → 5%
5- The lower & inner quadrant of the breast→
A.F.
-64-
A.F.
Pioneer of Surgery for under graduate
Breast
Lymphatics along medial rectus ms. → subperitoneal lymphatic → liver →
retrograde lymphatics → falciform ligament → umbilicus (Sister Jossef nodules)
→ Further, cancer cells may drop by gravity and cause metastasis in the pelvis.
♣♣ Axillary lymph nodes: (average 35)
1- Anterior (pectoral) group:
# Site: - Lie at the lateral edge of the pectoralis major along the course of the lateral
thoracic vessels on the chest wall
# Afferent: Receive lymph drainage from upper 1/2 of front of trunk (above umbilicus)
# Efferent: to central group
2- Posterior (Scapular) group:
# Site: - Lie on the subscapular vessels and their thoracodorsal branches
# Afferent: - Receive lymph drainage from upper 1/2 of the back of trunk.
# Efferent: to central group
3- Lateral (humeral) group:
# Site: - lies on lateral part of the axillary vein
# Afferent: - Receive lymph drainage from U.L.
# Efferent: to central group
4- Central (medial) group:
# Site: - embedded in fat in the center of the axilla along the intercosto-brachial nerve
# Afferent: - Receive lymph drainage from anterior, posterior and lateral group.
# Efferent: to apical group
5- Subclavicular nodes (apical group)
# Site: - lies on the medial part of the axillary vein
# Afferent: from → 1- All other groups
2- Directly from upper part of the breast
# Efferent: to subclavian lymph trunk →
** On left side: ends into thoracic duct
** On right side: into right lymphatic duct
@@ Levels of axillary lymph nodes:Level I ------» below and lateral to pectoralis minor ms.
(lateral, anterior, posterior)
Level II ------» behind pectoralis minor ms. (central, interpectoral)
Level III ----» above and medial to pectoralis minor ms. (apical)
A.F.
-65-
A.F.
Pioneer of Surgery for under graduate
Breast
Diseases of the breast
A- Benign breast diseases
1- Congenital anomalies
2- Traumatic
3- Inflammatory
4- ANDI
5- Benign tumors
B- Malignant breast diseases
4 Breast
3 Nipple
CONGENITAL ABNORMALITIES
1) Amazia: Absence of one or both breasts.
2) Polymazia: Accessory breasts along milk line
3) Micromazia: Small breasts for augmentation mamoplasty.
4) Diffuse hypertrophy: Large breasts for reduction mammoplasty.
5) Athelia: Absence of nipple
6) Polythelia: Accessory nipple along milk line.
7) Congenital retraction of the nipple:
Congenital
Etiology
Acquired
Congenital but appears at
- Traumatic fat necrosis
puberty
- chronic breast abscess
- mammary duct ectasia
- carcinoma
Time of presentation
appears at puberty
Recent
Site
25% Bilateral
Unilateral
Groove
Not surrounded
surrounded
suckling
Difficult
Not difficult
ttt
1- Drawing out the nipple
Of the cause
between finger and thumb
3- Ashford Operation: purse string of the areola.
TRAUMATIC LESIONS OF THE BREAST
A.F.
-66-
A.F.
Pioneer of Surgery for under graduate
Breast
(1) Cracked Nipple:
(2) Haematoma (most common):
(3) Traumatic Fat Necrosis:
♣♣ Etiology: Follow minor recurrent trauma e.g.
- Direct trauma: needle biopsy, sustained pressure.
- Indirect trauma: sudden contraction of pectoralis major.
♣♣ Pathology:
Trauma → hydrolysis of necrotic fat → liberation of fatty acids which combine
with calcium of local tissue fluid to form calcium soaps → hard mass
♣♣ Clinical picture:
- History of trauma
- Hard, painless and poorly defined mass.
♣♣ Investigations:
- Sonomammogram: micro calcification
- Biopsy: FNAC or tru cut.
♣♣ Treatment: Excisional biopsy to exclude malignancy
(4) Mammary duct Fistula:
(5) Traumatic mastitis
(6) Open wounds
INFLAMMATIONS OF BREAST
I- Acute:1- Mastitis neonatorum
2- Mastitis of puberty
3- Mondor’s disease
4- Mastitis of milk engorgement
5- Acute breast abscess
II- Chronic:1- Non-specific: - chronic breast abscess
2- specific: - T.B., $ ,actinomycosis
I. Acute mastitis:A.F.
-67-
A.F.
Pioneer of Surgery for under graduate
Breast
1- Mastitis neonatorum:
## Etiology:
Sudden withdrawal of maternal estrogen from baby after labour stimulates newborn
pituitary to produce prolactin, which stimulates breast secretion (Witch’s milk).
‫لبن الساحره‬
## Clinical picture:
The breasts are swollen & on the 3rd and 4th day, few drops of milk fluid (Witch’s
milk) can be expressed from breast → disappears on 3rd weeks.
## Treatment: Nothing
2- Mastitis of puberty:
## Etiology: Hormonal imbalance at age of puberty
## Clinical picture:
* It is more common in males during puberty.
* Usually begins unilateral → breast is enlarged, tender & indurated.
* subsides spontaneously within 2 weeks
## Treatment: Nothing
3- Mondor’s disease
It is thrombophlebitis of superficial veins of breast & anterior chest wall (Lateral
thoracic vein)
4- Mastitis from milk engorgement (Milk Congestion):
## Etiology: Obstruction of duct by dry milk or epithelial debris
## Clinical picture:
- General:- Constitutional manifestations (low fever, headache……)
- Local:1- Enlarged, tender, tense
Due to absorption of milk pyrogens
2- Hotness
3- Dilated veins
4- NO redness
5- NO axillary L.N.
## Treatment: I- Prophylactic: see later
II- Active: As breast cellulitis
5- Acute breast abscess (Most common):
A.F.
-68-
A.F.
Pioneer of Surgery for under graduate
Breast
♣♣ Etiology:
* Predisposing factors:
1) Lactating:
1- Usually in 1st month of 1st lactation OR during weaning
2- Milk congestion due to duct obstruction.
3- Lack of hygiene of breast or cracks of nipple.
2) Non-lactating:
1- Infected haematoma
2- Degeneration of tumor
3- Patients with DM, RA and steroid therapy.
* Organisms: Staph. aureus (commonest organism) & streptococci
* Route of infection:
1) Direct (common) through milk duct or fissured nipple.
2) Blood born (rare).
♣♣ Pathology:
* Sites: a) Premammary
b) Intramammary
c) Retromammary
* Stages:
1) Stage of cellutitis
2) Stage of acute abscess formation
♣♣ Complications:
1- Damage to the breast tissue.
2- Spontaneous rupture and fistula formation.
3- Chronic breast abscess (antibioma) if badly treated.
4- Toxemia and septicemia.
♣♣ Clinical Picture:
A.F.
-69-
A.F.
Pioneer of Surgery for under graduate
Breast
1) Stage of cellulitis:
General: Constitutional manifestations (fever, headache, anorexia, malaise).
Local: - Pain mild then increases gradually.
- Redness of skin with dilated veins.
- Hotness of skin.
- Swelling: indurated, tender and ill defined.
- Axillary nodes: Enlarged, firm and tender.
2) Stage of abscess formation (After localization):
** Criteria of pus formation:1- Fever becomes hectic & toxemia is severe.
2- Pain becomes throbbing.
3- Pitting edema of the skin (1st sign).
‫هام‬
5- Pointing and pus can be squeezed from the nipple.
‫جدا‬
N.B. Fluctuation occurs late in breast as it is compressed by the‫شفو‬
septa
It occurs when breast tissue destroyed & gangrene occurs.‫ي‬
4- Fluctuation is late sign (surest sign).
♣♣ Investigation:
1. CBC: Leucocytosis.
2. U.S.
3. Aspiration cytology.
♣♣ Treatment:
I- Prophylactic:1- The mother is instructed to lactate from both breasts to avoid milk engorgement
2- ttt of retracted nipple
3- Proper wash and care of the nipple after every feed
4- Proper ttt of fissures and cracks (Local antiseptic cream)
II- Active:-
1. Stage of cellulitis and milk Congestion:
A- General:
* Antibiotics: for penicillinase resistant staph e.g. cloxacillin.
* Analgesic
* Antipyretic.
B- Local:
A.F.
-70-
A.F.
Pioneer of Surgery for under graduate
Breast
* Elevate breast (rest)
* Hot application.
Q: Weaning or not ? depend on the age of the baby if:
< 9 months → stop suckling from the diseased breast & evacuate it with breast
pump & baby use healthy side for feeding
> 9months → stop lactation & suppress secretion by bromocriptine
2. Stage of abscess formation:
a. Premammary abscess: Incision where it points (no special direction).
b. Intramammary abscess: incise & don’t wait for fluctuation.
- Radial incision: to avoid injury too many milk ducts.
- Circumareolar incision: in the skin only then radial in the breast tissue.
c. Retromammary abscess:
- It is drained through an incision in submammary fold
** Don't wait for fluctuation:6P
1- Perianal
2- Perinephric
3B
1- Breast
2- Buttock
3- Brain
3L
1- Liver
2- Lung
3- Ludwig's angina
3- Pulb space of the finger
4- Palmar space
5- Parotid
6- Prostate
** Abscess for aspiration not drainage:-
Amoebic- Brain- Cold abscess
II. Chronic mastitis
A.F.
-71-
A.F.
Pioneer of Surgery for under graduate
Breast
Chronic breast abscess = Antibioma
♣♣ Etiology: Result from mis-management of acute pyogenic abscess.
1) Giving inefficient antibiotics
2) Treating acute abscess with antibiotics alone, without drainage.
3) Bad drainage
♣♣ Complications:
* Damage to the breast tissue.
* Toxemia
* Fistula formation.
* Recurrent acute exacerbation.
♣♣ Clinical Picture:
A- History of acute abscess usually with antibiotic therapy.
B- Mass:
1) Not painful Not tender (except in exacerbation).
2) Hard due to fibrosis with rounded posterior surface.
3) Adherent to skin & deep fascia (may be associated with nipple retraction and skin
dimple due to fibrosis).
4) Peud’orange appearance due to obstruction of lymphatics by fibrosis.
5) Enlarged, firm, mobile and tender axillary nodes.
♣♣ D.D.:- From breast carcinoma
Chronic breast abscess
Breast carcinoma
1- History of acute abscess
No history
2- Slightly tender
Not tender
3- Yielding center
Not yielding
4- Rounded posterior surface
Flat
5- L.N. are firm, tender, mobile
Hard, not tender, may be fixed
♣♣ Investigations:
1- Sonomammaography: Coarse calcification.
2- Biopsy: FNAC or tru cut biopsy.
♣♣ Treatment: Excisional biopsy to exclude malignancy.
Aberrations of normal development and involution (ANDI)
A.F.
-72-
A.F.
Pioneer of Surgery for under graduate
Breast
It includes the following conditions:
Age / Stage
Normal
15-25 yr
(Developmental
Abnormal
1- Lobular development
Fibroadenoma
2- Stromal development
Adolescent breast
hypertrophy
stage)
25-40yr
(Cyclic activity
3- Nipple aversion
Nipple inversion
1- Cyclic changes of
cyclic mastalgia& nodularity
(Fibroadenosis)
menstruation
stage)
40-55 yr
(Involution stage)
2- Epithelial hyperplasia
Bloody nipple discharge
1- Lobular involution
Macrocyst
2- Duct involution
Duct ectasia
3- Epithelial turnover
Epithelial hyperplasia with
atypia
4- Stromal involution
Sclerosing lesion
FIBROADENOMA
♣♣ Def: Mixed benign tumor of epithelial & fibrous tissue origins.
(Contain fibrous and glandular tissue)
♣♣ Etiology:- Unknown
♣♣ Classification:A- Pathological:
1- Intracanalicular (soft)
2- Pericanalicular (hard)
B- Clinical:-
A.F.
1- Classical
2- Juvenile
3- Giant (>5cm)
4- Phylloid tumor
-73-
A.F.
Pioneer of Surgery for under graduate
Incidence
Breast
HARD
SOFT
( Pericanalicular)
(Intracanalicular)
More common
Less common
20-30 yr (unmarried)
30-50 yr
1- Small slowly growing (2-5 cm)
* Large rapidly growing
Pathology
N/E
2- Firm
‫خللي بالك‬
* Firm
‫خللي بالك‬
3- Not undergo other pathological
* May undergo other pathological
sequences
sequences
4- well capsulated (by 2 capsules)
* well capsulated (by 2 capsules)
5- Cut section:
- smooth NOT gritty
* Cut section:
- bulges on cutting
- Cystic areas.
- whitish surface with NO
area of hag and necrosis
** Well capsulated by two capsules:a- Inner true capsule:- sending fibrous strands dividing the mass into lobules
b- Outer false capsule:- of compressed breast tissue
** There is a plan ( ) two capsules which makes the excision very easy.
M/E
Ducts are patent and surrounded by
Loose C.T. presses on
dense fibrous
ducts and transforms
connective tissues
them into slits
(Pericanalicular)
** the fibrous bands appears as it
come from inside the duct (hence
the name Intracanalicular)
Complications
Rarely turns malignant
More common (see below)
Pathological sequences of soft fibroadenoma (Fate):1- May reach to huge size
giant fibroadenoma
2- May undergo cystic degeneration
cystadenoma
3- Intrapapillary projections
cystadenoma fungoid
4- Cystsarcoma phylloid
(Bg or Mg)
5- Malignant transformation
A.F.
sarcoma (<1%)
-74-
A.F.
Pioneer of Surgery for under graduate
Clinical picture
Breast
1- Painless
The same except:-
2- Solitary (35%)
1- Large
2- Small
2- Rapidly growing
3- Slow growing
4- Firm
5- Well defined mass
6- Highly mobile within breast
(mouse of breast)
7- Not ass. With axillary L.N.
Fibroadenoma ….. felt by palm of the hand
Fibroadenosis…… felt by tips of the hand
Investigations
Sono-mammography & biopsy
Treatment
Excisional biopsy (Inoculation)
If small:
Excision
If large:
SC mastectomy + breast
reconstruction
CYSTSARCOMA PHYLLOIDE TUMORS
♣♣ Pathology:
N/E:
* Size: - Huge, soft fibroadenoma
* Surface: - lobulated (bosselated) surface
* Relation to the Surrounding: - well circumscribed & mobile
* Skin overlying:
- Stretched with dilated veins
- May ulcerate overlying skin through pressure necrosis (not infiltration) →
Extend outside the breast → Cystsarcoma fungoid
* Consistency:- variable
* C/S: - solid and cystic areas (degeneration & necrosis)
A.F.
-75-
A.F.
Pioneer of Surgery for under graduate
Breast
Solid areas leaf like projections inside the cavities (phylloides) ‫الخص‬
To diff. ( ) fungating phylloid & fungating carcinoma of breast:
1- Edge of the phylloid ulcer is tender due to exposure of the nerves while
the edge of malignant ulcer is not tender
2- Probe can be passed under the edge of phylloid ulcer which cannot be
occurs in malignant ulcer i.e. not infiltrated
Cystosarcoma
phylloids
Carcinoma of
the breast
M/E:
Resemble intracanalicular fibroadenoma with cystic degeneration and sarcomatous
tissue like stroma → May be benign or border line or malignant
♣♣ Clinical Picture: (as N/E) +
* Huge, rapidly growing mass involving
whole breast
* Axillary L.N. are NOT enlarged unless
secondarily infected.
♣♣ Investigations: sono-mammography & biopsy.
♣♣ Treatment:
A- Benign and borderline phylloids: Wide local excision with safety margin 1-2 cm
B- Malignant phylloids:- Small: wide local excision with safety margin 3 cm
- No axillary LN dissection (why?)
A.F.
-76-
A.F.
Pioneer of Surgery for under graduate
Breast
Fibroadenosis = fibrocystic disease
(Commonest breast disease)
♣♣ Incidence:1- The commonest breast disease
2- Age: - in reproductive period. NEVER before puberty or after menopause
3- Parity: - Common in unmarried, nullipara or non-lactating.
♣♣ Etiology: due to hormonal imbalance in the form of:
a. Excess estrogen and low progesterone.
b. Excess prolactin and low androgen.
♣♣ Pathology:
** Site:
- Common bilateral but may be unilateral.
- Common affects upper outer quadrant but the whole breast may be affected
** N/E:
# Affected area becomes thickened, tough and rubbery in consistency.
# Fine & coarse nodules
# Cut section:
- Soft (not gritty = carcinoma)
- White or yellow (never gray = carcinoma)
- Non-capsulated.
** M/E:
Panplasia (hyperplasia of all elements)
1) Adenosis: Increase in number of acini & ductules.
2) Epitheliosis (hyperplasia):
Increase in number of layers of epithelial cells lining lobules and ducts > 2 cell layer.
Epithelial
hyperplasia
Typical
Atypical
5 times risk
A.F.
Mild
Moderate
Florid
2-4 raw
4-8 raw
≥8 raw
-77No
risk
2 times risk
A.F.
Pioneer of Surgery for under graduate
Breast
3) Papillomatosis: Due to epithelial hyperplasia → papillomatous projections
4) Round cell infiltration: plasma cell & lymphocytes
5) Fibrosis:
- Fibrous tissue replaces fat & elastic tissue.
- Increased fibrosis & acini is called sclerosing adenosis
6) Cyst Formation:
- Microcyst: (Multiple) (the commonest)
- Macrocyst: (Single) (Blue-dome cyst of Bloodgood)
♣♣ Complications:
1- Hemorrhage in cysts.
2- Infection.
3- Carcinoma:
** Fibroadenosis is not precancerous except if there is moderate or florid
typical hyperplasia or atypical hyperplasia or sclerosing adenosis or
macrocyst
♣♣ Clinical Picture:
# Symptoms:
(1) Pain:
-Dull aching localized to the breast or shooting to arm, increase before menses
(congestion) lasts for further 2-3 days then gradually partially or completely
disappears to come again with the next cycle.
- Sometimes, pain is marked & is given the term mastodynia
(2) Nipple discharge: Serous, green or dark brown or black. (NEVER bloody)
(3) Lump: Painful either single or multiple
# Signs:
(1) Breast:
- Tender.
- Fine & coarse nodules are better felt with the tips of the fingers than with their
palmar surfaces, they are tender & mobile. (May be diffuse or localized)
A.F.
-78-
A.F.
Pioneer of Surgery for under graduate
Breast
- Milking of the breast may show nipple discharge.
(2) Axillary LN: Enlarged, tender & firm (never hard).
♣♣ Investigations:
1. Sonomammogram: reveal focal or diffuse breast masses.
2. Cytological examination of nipple discharge
3. Biopsy of breast lump.
♣♣ Differential diagnosis:
1. Mass: from other causes of masses of breast.
2. Nipple discharge: from other causes of nipple discharge.
3. Pain: from other causes of breast mastalgia.
♣♣ Treatment:
A. Conservative:
For 3-6 months.
(1) Assurance & follow up
(2) Encourage pregnancy
(3) Support breast by suitable bra
(4) Analgesic to relieve pain.
(5) Drugs:
Essential fatty acids (primrose oil)
Anti gonadotrophin (Danazole)
Anti-prolactine (Bromocryptin)
Anti estrogen (Tamoxifen)
LH/RH agonist
B. Surgery: Only indicated in presence of:
1- Severe resistant intolerable pain: SC mastectomy + breast reconstruction
2- Localized mass with suspicion of malignancy or atypical hyperplasia: excision.
3- Cysts are treated by aspiration.
A.F.
-79-
A.F.
Pioneer of Surgery for under graduate
Breast
Mammary duct Ectazia=
Plasma cell mastitis=
Comedo-mastitis
♣♣ Etiology:
Stagnation of secretion ---» epithelial ulceration ----» leakage of duct secretions into
periductal tissue ---» periductal mastitis containing plasma cell infiltration (Plasma
cell mastitis) (autoimmune disease) and anaerobic infection (found in some cases) ---» periductal fibrosis ---» nipple retraction and dilatation of ducts
♣♣ C/P:
- Stage of acute inflammation with pain & fever.
- Subareolar hard mass simulating carcinoma.
- Transverse retraction of nipple may be the only presenting feature.
- Nipple discharge: cheesy (creamy) toothpaste like.
♣♣ Investigations:
- Sonomammogram.
- Galactography (Ductography): dilatation of duct system.
- Biopsy from mass or cytological examination from discharge.
♣♣ Treatment:
- Assurance.
- Antibiotic therapy (Flucloxacillin and flagyl)
- Corticosteroids
- Nipple discharge: Total duct excision-----» subareolar cone excision (Hadfield’s
operation)
Benign tumors of the breast
A- Epithelial tumors: - (arises from duct epith.)
- duct papilloma
- Pure adenoma
B- C.T. tumors: - (arises from stroma)
- Neurofibroma
A.F.
- Lipoma
-80-
A.F.
Pioneer of Surgery for under graduate
Breast
C- Mixed:- Fibroadenoma ???????
- Adenolipoma
- Papillary cystadenoma
Duct papilloma
(The most common cause of bleeding per nipple)
♣♣ Origin: Columnar cells lining major lactiferous ducts near the nipple
♣♣ Pathology:** N/E: Small (few mm), soft, has finger like processes & long thin pedicle
** M/E: Core of vascular C.T. covered with columnar epith.
♣♣ Complications:1- Malignant transformation (duct carcinoma): Very common.
2- Bleeding per nipple: due to kink of pedicle -----» venous obstruction -----»
rupture capillaries -----» bleeding
3- Retension cyst: due to duct obstruction
♣♣ C/P:** Symptoms:1- Bleeding per nipple (Most common cause of bleeding per nipple)
2- Retroareolar mass (retention cyst)
** Signs:1) Retroareolar mass (retention cyst)
2) Differential pressure will squeeze blood from affected duct.
♣♣ Investigations:- (to localize the papilloma)
1- Benzidine test -----» bloody nipple discharge
2- Galactography (Ductography):Injection of lipidol in the duct & take x-ray film ---» filling defect
3- Ductoscopy and biopsy.
♣♣ Treatment:A- If bleeding localized to one duct: Microdochectomy
B- If bleeding not localized (very rare)
A.F.
-81-
A.F.
Pioneer of Surgery for under graduate
Breast
Total duct excision-----» subareolar cone excision (Hadfield’s operation)
CANCER BREAST
Incidence:
# General: The most common malignant tumor in female
# Age: 40-50 yr
NO age is immune after puberty
# Sex: ♀:♂= 99:1 (the commonest tumor in female)
# Side: Left > right
Bilateral-----» Synchronus (Simultaneous) 1%
-----» Metachronous 5%
# Site: Upper outer quadrant 60% -----» most of mammary tissue
# Geographic: West > east
Developed > developing
Etiology (high risk group)
2G
♣♣ Predisposing factors
2E
3D
Genetic
Endocrinal Diet
Geographeal Exposure Drugs
Diseases
1) Genetic:
A- Hereditary breast cancer:- 5- 10% of breast cancer have mutant gene inherited as AD e.g.
1- BRCA1 → tumor suppressor gene → Long arm of chromosome 17 →
In ♀ → breast, ovary, colon cancers
In ♂ → cancer prostate
2- BRCA2→ tumor suppressor gene → Long arm of chromosome 13 →
In ♂ & ♀ → breast cancer
3- P53→ tumor suppressor gene → Short arm chromosome 17 →
Li-Fraumeni syndrome: (due to mutation of P53)
L → Leukemia, lung, laryngeal cancer
A → adrenocortical carcinoma
B → Breast & brain tumors
A.F.
-82-
A.F.
Pioneer of Surgery for under graduate
Breast
S → Soft tissue sarcoma
4- Cowden syndrome: bil. Cancer breast + cancer thyroid + polyposis of GIT
** Hereditary breast cancer ch.by:1- Young age < 30 yr
2- Mostly Bilateral
Sporadic → 70%
Familial → 20%
Hereditary → 10%
3- Multiple relatives with cancer breast (>3)
B- Familial breast cancer:1- Cancer family syndrome (Lynch II):
Breast+ Colon (FAP) + uterus+ ovary + thyroid
2- +ve family history (sister-mother-G.mother-Aunt) → ↑ 2 times risk
2) Geographical Factors:
- It is commoner in Western Europe & U.S.A., uncommon in Asia & Japan.
- This may be due to genetic or dietary factors
3) Endocrinal (Hormonal):
- Not married, null Para, elderly primigravida and non-lactating female.
- Early menarche or late menopause due to prolonged exposure to estrogen.
4) Exposure to radiation:
- Nuclear war.
- Medical purposes (diagnostic or therapeutic)
5) Drugs:
- Prolonged use of contraceptive pills > 10 years (uncertain)
- Postmenopausal hormone replacement therapy (estrogen and progesterone)
- Males with estrogen therapy for cancer prostate.
- Long-standing treatment with reserpine (anti HTN)
6) Dietary factors:
- Diet rich in saturated fatty acids predisposes to cancers.
- Obese patient because fat is an important source of estrogen production.
- Alcohol & smoking
7) Diseases:
- Previous cancer breast (6 times) (most common).
- Previous breast irradiation or operation
- Male patient with Klinfilter syndrome (XXY)
A.F.
-83-
A.F.
Pioneer of Surgery for under graduate
Breast
♣♣ Precancerous lesions
No risk
Risk 2
Risk 4-5
1- Mild hyperplasia1- 1- Moderate & florid 1- Atypical ductal
hyperplasia
2- Adenosis
Risk 10
LCIS
hyperplasia
2- 2- Sclerosing
2- Atypical lobular
adenosis
hyperplasia
3- Microcysts
3- 3- Macrocysts
4- Simple
4- 4- Complex
fibroadenoma
fibroadenoma
5- Duct ectasia
5- Duct papilloma.
Pathology:
** Site:
- Upper outer quadrant: 60 %
- Lower outer quadrant: 10%
- Upper inner quadrant: 12%
- Lower inner quadrant: 6%
- Retroareolar region: 12%
** WHO modification of Foote and Stewart pathological
classification:-
A.F.
-84-
A.F.
Pioneer of Surgery for under graduate
Breast
WHO modification of
Foote & Stewart
classification
1-
2-
Noninvasive
Invasive
Noninvasive
ductal
carcinoma in
situ (DCIS)
Noninvasive
lobular
carcinoma in
situ (LCIS)
Paget
disease
without
mass
Invasive
lobular
Invasive
ductal
Not otherwise
specified (NOS)
(80%)
Specified
Paget’s
disease of
the nipple
with mass
Rare
carcinoma
1. Squamous cell
carcinoma
Others
Sarcoma
Lymphom
2. Signet ring cell
carcinoma.
3. sweat gland
carcinoma
Scirrhous
Atrophic
scirrhous
a. Medullary (encephaloid) 4%
b. Mastitis carcinomatosis.
c. Mucinous (Colloid) 2%
d. Tubular 2%
e. Papillary 2%
A.F.
-85-
A.F.
Pioneer of Surgery for under graduate
Breast
I. Non- infiltrating carcinoma
Ductal carcinoma in situ
Lobular carcinoma in situ
DCIS is classified into:
1.
Comedo (more anaplastic):
- LCIS is accepted now as a risk
Ducts are expanded by malignant cells,
factor for development of breast
which undergo central necrosis leading
cancer rather than breast cancer.
to extrusion of a sebaceous-like material
from cut surface of tumor (cancer juice).
- Approximately 25-35% of LCIS will
develop invasive cancer
2.
Non-comedo:
1. Solid
2. Cribriform
3. Papillary
4.. Micropapillary
II. Infiltrating carcinoma
A- Invasive duct carcinoma [carcinoma not other wise specified NOS]
* The most common type 70-80%
* Characterized by absence of features seen in the more specialized forms of the
breast carcinoma {D. By exclusion}
* Moderate (average) prognosis
B- Invasive lobular carcinoma:
* Multicentricity is common more than invasive ductal
* High incidence of Contra-lateral breast involvement → synchronus (30-50%)
* N/E:- Ill defined margins
* M/E:- Sheets of single small cells which arranged concentric fashion around normal
ducts {Diagnostic} Indian file appearance
* It has better prognosis than NOS carcinoma (more hormonal depended)
A.F.
-86-
A.F.
Pioneer of Surgery for under graduate
Breast
C- Medullary carcinoma:
* N/E:- Well circumscribed
- Soft in consistency
- C/S → brain like appearance with areas of Hag & necrosis
* M/E:- characterized by Dense lymphocytic infiltration → good prognosis
* Good prognosis
D- Mucinous carcinoma:- [colloid carcinoma]
* N/E: C/S → the cut surface is glistening and gelatinous Honey comb appearance
* M/E: Abundant accumulation of extracellular mucin
* Good prognosis
E- Tubular carcinoma:
* Tubular pattern of growth
* Good prognosis (the best)
F- Papillary carcinoma:
* Finger like process contain C.T. core and covered by malignant cells
* Good prognosis
G- Mastitis carcinomatosa:* N/E
- Diffuse brawny induration of the skin of breast usually without underlying palpable
mass (only detected radiologically)
- It is due to tumor embolization of dermal lymphatics
* M/E: Very high cellularity and very little fibrosis with areas of hemorrhage and necrosis
* Very bad prognosis due to late presentation (misdiagnosis) and early spread
* Must be differentiated from acute mastitis
A.F.
-87-
A.F.
Pioneer of Surgery for under graduate
Breast
Mastitis carcinomatosa
Acute abscess
History
-
Onset
Gradual
Acute
-
Course
Slowly progressive
Rapidly progressive
-
Fever
Low grade fever
High grade fever
Examination:
* Inspection
-
Edema
> 1/3 of breast.
Sector of breast
-
Skin over
Dusky red with dilated veins
Rosy red
* Palpation
-
Tenderness
Mildly tender
Markedly tender
-
Edema
Non pitting
pitting
-
Axillary LNs
Not tender & hard
Tender & firm
Investigations
No leucocytosis
Marked leucocytosis
Treatment
No response to antibiotic during
Cured or form abscess.
1st week, biopsy should be done
H- Paget's disease of the breast:
☺☺Def: Eczema like condition of the nipple & areola occurring in old ♀ > 40y
☺☺Incidence: 1% of cancer breast
☺☺Etiology:1- intra-duct carcinoma → malignant cells migrate to skin.
2- Recently: it is considered as a carcinoma in situ.
☺☺Pathology:N/E: - Eczema like condition of the nipple & areola
- Breast mass behind the areola
M/E: It shows the following 3 features
(1) Hyperplasia of all layers of the epidermis
(2) Paget's cell:large, vaculated cells, clear cytoplasm, deeply stained small eccentric nucleus
(3) Round & plasma cell infiltration of the dermis
☺☺Staging:A.F.
-88-
A.F.
Pioneer of Surgery for under graduate
Breast
* With out mass → Cis (stage I)
* With mass → acc. To the size of the mass
☺☺Treatment:(1) No mass → wide excision of nipple and areola
(2) Mass → mastectomy + axillary clearance
** Tamoxifen if ER positive.
☺☺Prognosis: Good due to Early diagnosis & Slow rate of growth
☺☺D.D.:- From the ordinary eczema (dermitis)
Paget’s disease
Ordinary eczema
1- age
Old female
Young female
2- site
Unilateral
Bilateral
3- nipple & areola
eroded
No erosion
3- surface
No itching, no vesicles or no oozing
Itching, vesicle and oozing
4- margin
Well defined & raised
Ill defined & never raised
5- ass. Mass
May be with palpable mass
No masses
6- sequale
carcinoma
abscess
7- biopsy
Confirm the diagnosis
Confirm the diagnosis
8- treatment
Not respond to corticosteroids
Respond to corticosteroids
** Spread
A- Direct spread:1. Intrinsic: to surrounding breast tissue
** Infiltration of Cooper’s ligament: skin tethering or fixation.
** Infiltration of ducts with fibrosis: nipple retraction and deviation.
2. Extrinsic:
** To the skin causing ulceration & fungation (late).
** To deep structures: Pectoral fascia, pectoral muscles & chest wall (ribs,
intercostal muscle, serratus anterior muscle)
B- Lymphatic spread:- (by both embolization & permeation)
As before in anatomy
C- Haematogenous spread:A.F.
Bone > lung > brain > liver (BLBL)
-89-
A.F.
Pioneer of Surgery for under graduate
Breast
** Intercostal veins to vertebral plexus (Batson plexus): vertebral metastases (Lumbar vertebrae)
osteolytic→ 90%
osteosclerotic→ 5%
Mixed → 5%
D- Transcoelomic spread:Liver secondaries → Mg. cells seedling into peritoneal cavity →
1- nodules in douglos pouch …….rectal shelf of Plummer
2- nodules on ovary ……………..Krukenberg tumor
3- Mg. ascities
4- Peritoneal nodules
** Staging of cancer breast:1. TNM Staging:Tx primary tumor cannot be assessed (previously biopsy, recurrent, residual)
T0 NO evidence of primary tumor → not palpable clinically
Tis carcinoma in situ → ductal CIS
→ lobular CIS
→ paget's dis. Without mass
T1 < 2cm
Tmic→ microinvasion ≤ 1mm
T1a→ ≤ .5cm
T1b→ .5 -1cm
T1c → 1-2cm
T2 2-5 cm
T3 > 5 cm
T4 Any size with
T4a→ fixation to chest wall (ribs, intercostal ms, serratus anterior ms)
(not including pectoralis muscle)
T4b→ skin involvement (direct infiltration ,ulceration, peaud orange, satellite nodules )
(Skin dimpling or nipple retraction does not affect classifications)
T4c→ a & b
T4d→ mastitis carcinomatosis
N.B. Paget’s disease with mass is classified according to the size of the tumor.
Nx
A.F.
Regional L.N. cannot be assessed e.g. previously removed
-90-
A.F.
Pioneer of Surgery for under graduate
Breast
No
No regional L.N. metastasis
N1
Ipsilateral mobile axillary L.N.
N2
a→ Ipsilateral matted axillary L.N.
b→ Ipsilateral internal mammary L.N. without axillary L.N.
N3
a→ ipsilateral infraclvicular L.N.
b→ Ipsilateral internal mammary with axillary L.N.
c → ipsilateral supraclavicular L.N.
Mx
metastasis cannot be assessed
M0
no evidence of metastasis
M1
distant metastasis or contralateral breast or L.N.
2- AJCC staging: (American Joint Committee Cancer)
Tis
0
T0
T1
N0
I
N1
II
N2
T2
T3
II
T4
III
III
III
N3
Stage 0→ Tis N0 M0
IV
M1
Stage ΙV→ any T any N with M1
Stage 0
NON invasive cancer breast
Stage Ι & ΙΙ
early cancer breast
Stage ΙΙΙ
locally advanced cancer breast
Stage ΙV
metastatic advanced cancer breast
3. Manchester staging:
A.F.
-91-
A.F.
Pioneer of Surgery for under graduate
Breast
Tumor
Axillary LNs
Metastases
Stage I
Mobile breast mass
No
No
Stage II
Mobile breast mass
* Mobile
No
* Ipsilateral
Stage III
* Skin involvement
* Fixed
* Pectoralis major involvement
* Ipsilateral
* No chest wall involvement
* + Ipsilateral
No
supraclvicular
Stage IV
* Skin involved: cancer-en cuirasse
* Contralateral LN
* Pectoralis major involvement
* Contralateral
* Chest wall involvement
supraclavicular
BLBL
** Grading:G1: Well diff.
G2: Moderate diff.
G3: Undiff.
** Skin manifestations:
(pathology & C/P ‫(يكتب مع‬
I. Due to Direct infiltration:
1) Skin dimpling, Tethering & Puckering:- (earliest sign) ( NOT pathognomonic)
# Dimpling:- Pulling of the skin at one point
- Due to direct infiltration and contracture of Cooper's ligament
# Tethering:- Induced dimpling e.g. when the patient leans forward or elevates her arm.
- Due to partial infiltration of Cooper’s ligament
# Puckering:- Extensive dimpling (Pulling of skin at more than one point on distant interval)
- Due to direct infiltration of multiple Cooper's ligament
2) Skin fixation, ulceration & fungation
3) Nipple retraction: Due to infiltration and fibrosis of the main milk ducts.
4) Paget's disease of nipple: see before
II. Due to lymphatic involvement:
A.F.
-92-
A.F.
Pioneer of Surgery for under graduate
Breast
5) Peau d’orange: (NOT pathognomonic)
- It is thick non-pitting edematous skin but pitted at sites of hair follicles
- Due to lymphatic compression (not permeation) of the skin by tumor
6) Cancer en cuirasse (very late sign):
(pathognomonic)
- The skin is very thick, hard, leathery, indurated, metalic brownish simulating shields
of wars affecting breast , chest wall & back
- Due to extensive lymphatic obstruction of the skin.
7) Cancerous satellite nodules (late sign): (pathognomonic)
- Due to lymphatic permeation to the skin.
8) Mastitis carcinomatosa: It is due to tumor embolization of dermal lymphatics
9) Malignant edema of upper limb (brawny arm)
- The arm is dusky red, hard, non-pitting
- Due to
* Preoperative: - extensive lymphatic infiltration of axillary LNs,
* Postoperative: - extensive surgical axillary clearance or radiotherapy
III. Due to venous involvement:
10) Dilated veins: Due to venous obstruction
Clinical picture:
♣♣ Symptoms:
A- Asymptomatic:- discovered accidentally during screening programs
B- Symptomatic:1. Mass (commonest presentation):
Painless mass in breast or in axilla discovered accidentally during bathing.
2. Pain: (Very Rare 10%):
- Late due to infiltration of nerves, infection of mastitis carcinomatosa
3. Nipple discharge:
- Bloody discharge in duct carcinoma
- Past like in comedo carcinoma
- Necrotic discharge in degenerating carcinoma
4. Skin & nipple manifestations……. ‫تشرح‬
5. Manifestations of metastasis: e.g.
A.F.
-93-
A.F.
Pioneer of Surgery for under graduate
Breast
a. Brain: headache, blurring of vision and projectile vomiting.
b. Bone: back ache, pathological fracture.
c. Lung: pain, cough, haemoptysis and dyspnea if effusion.
d. Liver: pain, mass, may be jaundice.
♣♣ Signs:
A) General examinations:
A- In early cancer breast: No abnormality detected
B- In advanced cancer breast:
1. General condition: anemia – cachexia – Jaundice (liver 2ries)
2. Head and neck: skull metastasis – congested neck veins in mediastinal L.N.
3. Chest: signs of pleural effusion or mediastinal L.N.
4. Abdominal examination:
- Palpable periumlical lymph nodes (Sister Mary-Josef node).
- Hepatomegaly
- Ascites.
- Back for 2ries
5. P/R or P/V: nodules in the Douglas’ pouch or Krukenberg’s tumor.
6. Bone: for tenderness, swelling & pathological fracture.
7. U.L.: for edema
B) Local examination:
Inspection:
* Breast: compared to healthy side
- It appears smaller and higher.
- It protrudes to lesser extent on leaning forward.
- It ascends to a higher level on raising the arm up.
* Nipple & areola: may show
1- Deviation: normally downward, forward and laterally.
2- Displacement: means change of position either above or below normal level
3- Depression (retraction)
4- Destruction (Paget’s disease = malignant eczema).
5- Discharge (on squeezing).
Palpation: 6- Discoloration.
** The mass:
A.F.
-94-
A.F.
Pioneer of Surgery for under graduate
Breast
- Hard, irregular, not tender, with flat posterior surface.
- It is felt by both tips of fingers & palmar surface of hand.
- May be fixed to the breast tissue, underlying structure or the overlying skin.
- ill defined or may be will Circumscribed edge
** Draining lymph nodes: Hard, early mobile & later on fixed.
** The arm: lymphedema of arm (brawny arm).
Tripple assessment of
breast cancer
Clinical examination
Sono-mammography
‫هام جدااااا شفوي‬
Tru-cut biopsy
Investigations
To confirm malignancy
Radiological
1- Mammogram
2- Xerograghy
3- galactography
4-Thermography
5- U.S.
6- MRI
7-PET
Investigations:
A.F.
To detect metastasis
Histopathological
Cytology
Needle
-95-
Preoperative assessment
Special invetigations
Biopsy
1- Tumor markers
2- Hormonal receptor
3- Gene study
Surgical
A.F.
Pioneer of Surgery for under graduate
Breast
A- To confirm malignancy:-
I- Radiological
(1) Ultrasonography:
1- Localizes masses in large dense breasts and pregnant breasts
2- Differentiate between solid and cystic swellings.
3- Single or multiple
4- Detect enlarged axillary LNs.
5- U/S guided needle biopsy.
(2) Mammography: (low voltage, high amplitude plain X-ray)
** Values:
A- Screening: above 40yr /1-2yr → for high risk group
B- Diagnostic: (above 30yr)
1- Detection of small subclinical tumor especially in large breasts
2- Detection of Occult carcinoma
3- Detection of multiplicity and bilaterality of cancer breast
4- Differentiate between benign and malignant masses.
5- Preoperative localization to site of biopsy for impalpable mass.
6- Postoperative follow up of breast treated with CBS or contralateral breast
7- Paget's dis. To detect the mass
** Multicentric (presence of more than one tumor in separate quadrants of breast)
** Multifocal (presence of more than one tumor in the same quadrant of breast)
** Views:
- The breast is put ( ) 2 blades of the machine then take 3 films:Craniocaudal and mediolateral and oblique (for axillary tail) views
** Mammographic features of:
a. DCIS: microcalcifications (most common mammographic features)
b. LCIS: no microcalcifications.
c. Invasive cancer breast: will show site and size of tumor then differentiate between:
A.F.
-96-
A.F.
Pioneer of Surgery for under graduate
Breast
Malignant
Mass
4
Benign
1- Irregular speculated mass.
- Smooth border.
2- Heterogonous
- Homogenous.
3- Hyperdense
- Hypodense.
4- Microcalcifications → < 0,5mm
- Macrocalcifications or
(Detected by magnifying lens)
microcalcifications (diffuse
* clustered→ arranged in groups
scattering cresentic ‘tea-
a. Linear, branching in duct carc.
cupping’)
b. Coarse granular type with regular
outline in medullary carc.
Around the
1- Perifocal haziness.
mass
(due to immune cell around the mass)
2
- NO
2- Radiological size < clinical size
- Radiological size = clinical
(due to lymphocytic infiltration around
size
the mass w felt by palpation & not seen
on radiology) (Le Borgne’s law)
Parenchyma
4
1- Disturbed architecture
- Preserved.
2- Prominent vascular system.
- Normal.
3- Prominent duct system.
- Normal.
4- Microcalcifications in parenchyma
- No.
Nipple & skin 1- Nipple retraction.
- No.
2- Skin thickened due to edema.
2
- No.
** Disadvantages:1- Precancerous if repeated in short time
2- Not done in young age < 30 years due to more glandular tissue of the breast which is
more dense → less contrast ( ) the lump and the breast
3- Cannot diff. ( ) fibrosis & recurrence after conservative breast surgery
4- False result 10-20% of cases
(3) MRI:
A.F.
-97-
A.F.
Pioneer of Surgery for under graduate
Breast
1- To diff. ( ) fibrosis & recurrence after conservative breast surgery
2- Imaging breast of female with implant
3- in diagnosis of occult carcinoma of the breast
(4) Xerography:It is similar to mammography but the image is received on selenium plate (Easier to
read – more accurate)
(5) Galactography (Ductography):
(6) Positron emission tomography (PET): The most sensitive but most expensive
II- Histopathological
A- Cytology:1- Exfoliative cytology: From nipple discharge (for malignant cells)
2- Scrape cytology: for paget’s disease
B- Biopsy:- (The most important single diagnostic investigation)
I. Needle biopsy:
Trucut needle biopsy
FNAC = ABC
As in thyroid except
Can differentiate between
Can not differentiate between non
non invasive and invasive
invasive and invasive cancer
cancer breast
breast
II. Surgical biopsy:
1- Incision biopsy: if tumor > 5cm (part of tur. Is excised)
2- Excision biopsy: if tumor < 5cm
Then, specimens are diagnosed through:
** Frozen section: (intraoperative). If malignant, proceed to mastectomy
** Paraffin section: Routinely post-mastectomy for breast mass & L.N.
III- Special investigations
A.F.
-98-
A.F.
Pioneer of Surgery for under graduate
Breast
A- Tumor markers:- (They are prognostic than diagnostic)
CA 15-3 (more accurate)
CEA
B- Hormonal receptors status (ER, PR)
** Value:1- It is assessed for primary tumor or axillary LNs in occult breast cancer
2- Affects the prognosis and line of treatment
** Results:50% → ER +ve & PR +ve
25% → ER -ve & PR -ve
20% → ER +ve & PR -ve
5% → ER -ve & PR +ve
C- Gene study: BRCA1 - BRCA2 – P53 - HER2/neu
B- To detect metastases:
1. Lung: Plain X-ray - C.T. chest
2. Brain: CT scan & better MRI & Fundus examination
3. Liver: 1- Liver function tests
2- U/S, C.T., MRI
3- Isotope scanning
4. Bone:
1- Bone survey (Plain X-ray): (specific but not sensitive)
- Not sensitive → detect metastasis late > 6 month
- More specific
2- Bone scan (99T pyrophosphate): (sensitive but not specific)
- More sensitive → detect metastasis early < 6 month
- Bone metastasis appears as hot nodule to be excluded from:1- Osteomylitis
3- Old fracture
2- Osteoarthritis
4- Pagets dis. of bone
C- For preoperative assessment:-
‫استامبه‬
Screening and early detection of cancer breast
A.F.
-99-
investigations ‫يكتب مع‬
A.F.
Pioneer of Surgery for under graduate
Breast
♣♣ Indications: For high risk group ‫تشرح‬
I- Education program:Periodic self-examination of the breast (the most important):
- Each female > 20 years should examine herself in front of a mirror (1 week
after menses) for:
a. Change in size or level of the breast.
b. Dimpling of skin & retraction of nipple.
c. Palpable mass in the breast or in the axilla.
II- Screening program:A- Physical examination
B- Mammographic examination : done every 2 years
D- Genetic study: BRCA1- BRCA2- P53
Differential diagnosis:
1- Mass: should be differentiated from other causes of hard mass in breast.
2- Nipple discharge: should be differentiated from other causes of nipple discharge.
3- Nipple retraction: should be differentiated from other causes of nipple retraction.
4- Paget’s disease should be differentiated from ordinary eczyma.
5- Mastitis carcinomatosa should be differentiated from acute breast abscess.
Treatment of cancer breast
Stage 0 (carcinoma in situ)
A) Ductal carcinoma in situ:
@ Localized carcinoma in situ (< 4 cm)
- Wide local excision with safety margin at least 1 cm.
- Tamoxifen if ER positive
@ Widespread carcinoma in situ (> 4 cm)
- Simple mastectomy + reconstruction + Axillary lymphadenectomy (why?) as
invasive carcinoma is most frequently found in large, high grade DCIS lesions
- Tamoxifen if ER positive.
B) Lobular carcinoma in situ (LCIS): either→
A.F.
-100-
A.F.
Pioneer of Surgery for under graduate
Breast
** LCIS is accepted now as a risk factor for development of breast cancer rather
than breast cancer →
1. Close follow up:- because LCIS is considered a risk factor
2. Tamoxifen
3. Prophylactic bilateral mastectomy:- Because LCIS has high rate of multicentericity and bilaterality
- Especially in high risk factor (+ve family history) OR extreme anxiety
- No need for axillary clearance
C) Paget’s disease: As before
Stage I & II
I- Surgical treatment
A. Conservative breast surgery
** Indications:
Early cancer breast (T0- T1- T2 < 4 cm-T2 > 4cm in large breast- N0- N1- M0)
** Contraindications:
1- T3, T4, N2, N3, M1
2- Multicentric disease (a high incidence of local recurrence).
3- Persistent positive margins after reasonable surgical attempts.
4- Diffuse microcalcification in mammography
5- Extensive intraductal component
6- Pregnancy in 1st & 2nd trimester (radiotherapy can not be delivered).
7- C.I. for radiotherapy e.g. collagen disease
** Technique:A- 1ry tumor:
1- Wide local excision = tylectomy = lumpectomy = tumerectomy:
Remove palpable lesion with 1cm safety margin of surrounding breast tissue.
2- Segmentectomy:
As lumpectomy + removal of overlying skin & underlying pectoral fascia
3- Quadrantectomy (best in upper outer quadrant):
QUART
= QUadrantectomy
+ Axillaryofdissection
+ RadioTherapy
Removal
of the entire quadrant
breast which
contains tumor
A.F.
-101-
A.F.
Pioneer of Surgery for under graduate
Breast
TART = Tumerectomy + Axillary dissection + RadioTherapy
B- Lymph nodes: (Through separate incision in axilla)
# +ve L.N. → axillary clearance → Remove level I,II, III
# -ve L.N. (clinically & radiologically) → Sentinel L.N. biopsy OR sampling
1- Sentinel node biopsy:
- Injection of patent blue (blue dye) into the tumor or the skin overlying it, allows
identification of the sentinel node (which will be stained blue by dye
- Value: If sentinel L.N. +ve → axillary clearance
If sentinel L.N. –ve → no further axillary clearance
2- Axillary node sampling: At least 4 impalpable L.Ns from any level excised
B. Mastectomy: + Breast reconstruction
** Indication: Cases contraindicated for conservative breast surgery.
** Technique:
1. Radical mastectomy: (Halsted operation)
Remove the whole breast tissue + overlying skin + pectoralis muscles (major and
minor) + full axillary dissection (level I, II, III).
* Remove breast then axilla → Halsted operation.
* Remove axilla then breast → Holly myer operation.
2. Modified radical mastectomy:
i. Patey’s operation:
- It is a radical mastectomy with preservation of pectoralis major.
ii. Auchen-closs operation:
- It is a radical mastectomy with preservation of pectoralis major & minor
- Level III LNs are not dissected.
3. Total mastectomy:
Complete removal of the breast including nipple and areola and pectoral major fascia
4. Simple mastectomy:
Complete removal of the breast including nipple and areola with preservation of
pectoral fascia.
A.F.
-102-
A.F.
Pioneer of Surgery for under graduate
Breast
## In total and simple mastectomy, we do not dissect axillary LNs so we give post-operative
irradiation to draining lymph nodes (axilla, mediastinum & supraclavicular region) (Mc
Whirter’s technique).
5. Skin sparing mastectomy:
- Complete removal of the breast including nipple and areola, pectoral fascia and
axillary LN clearance
- Skin envelope is preserved for immediate reconstruction
6. Nipple and areola sparing mastectomy:
As skin sparing mastectomy with preservation of nipple and areola if tumor > 2cm
away from nipple and areola.
7. Extended radical: (not done now)
- It is a radical mastectomy + removal of Internal mammary LN + Supraclavicular LN
8. Super radical: (not done now)
- As extended radical + removal of mediastinal LNs.
9. Toilet mastectomy:
As simple but indicating in ulcerating and fungating tumor
10. Subcutaneous mastectomy:
As nipple and areola sparing but it was done in benign condition with more thick skin
Breast reconstruction:
I- Autologous (Autogenous) Tissue Reconstruction
1. Latissimus Dorsi Myocutaneous Flap: Based on thoracodorsal artery
2. Transverse Rectus Abdominus Myocutaneous (TRAM) Flap:
Based on superior epigastric artery
3- Myomammary flap from opposite side
4- Microvascular Free Flaps:
e.g. gluteus maximus free flap based on superior gluteal vessels.
II- Prosthetic Reconstruction
1. Breast silicon Implants → inserted under pectoralis major
2. Tissue Expander Implants
A.F.
-103-
A.F.
Pioneer of Surgery for under graduate
Breast
Nipple and areola reconstruction:
1- From other side
2- Skin graft from labia minora
3- Tattooing
II- Post-operative radiotherapy
# Technique: External radiation: 5000 rad 5 days/week over 5 weeks (25 cycles)
# Indications:
1- After conservative breast surgery: (given within 1 month)
2- After all types of mastectomy: (Except extended & super radical mastectomy)
(Given within 6 month)
1- Size of tumor > 4 cm
2- Node positive tumors > 4
3- High grad tumor (GIII)
III- Hormonal therapy
# Indications: If ER & PR +ve
# Technique:
A- Ablative: (surgical)
1- Bil. oophrectomy (resection or irradiation):
Only in premenpause OR 5 years postmenpause
2- Adrenalectomy & hypophesectomy: obsolete now
B- Additive: (medical)
1- Tamoxifen (Nolvadex, Tamofen): (1st line drug)
** Mech. Of action:It competes with estrogen for cytoplasmic estrogen receptors (anti-estrogen)
** Dose: 10 mg twice daily for 5 years
** Side effects:1- Hot flashes
2- Decrease vaginal discharge.
3- N & V
4- DVT and cataract.
5- ↑↑ risk of endometrial carcinoma
A.F.
-104-
A.F.
Pioneer of Surgery for under graduate
Breast
2- LH/RH agonist: - (Zoladex)
Stimulate gonadotrophin production then block release of FSH & LH → ↓ estrogen &
progesterone from the ovary
3- Aromatase enzyme inhibitors: - (Aminoglutethemide) (Femara):It inhibits peripheral conversion of adrenal androgen into estrogen by inhibition of
aromatase enzyme so, decrease extra ovarian estrogen = medical adrenalectomy
4- Progestins: (gestagen)
Progesterone → -ve feed back mech → -- LH
IV- Chemotherapy
# Indications:
1- Positive L.N. even one L.N.
2- tumor > 1cm with –ve ER & PR
# Technique:
It is given either:
A- Adjuvant therapy (post-operative):
6 cycle one cycle every 21 days
1- FAC:- 5 FU + Adriamycin + Cyclophosphamide
2- TAC:- Toxol + Adriamycin + Cyclophosphamide
3- CMF:- Cyclophosphamide + Methotrexate + 5- Fluorouracil
4- CMF VA:- …… + Vincristine + Adriamycin
5- CMF VP:- ……. + Vincristine + Predinsone
B- Neo-adjuvant therapy (pre-operative):
- CMF (3-4 cycles) pre-operative → then 6 cycles post-operative
** Advantages:Reduction the size of the tumor → breast conservation can be done
A.F.
-105-
A.F.
Pioneer of Surgery for under graduate
Breast
Stage III
First
Neo adjuvant chemotherapy (3-4 cycles)
** Advantages:1- Reduction the size of the tumor → breast conservation can be done
2- Early treatment of systemic disease
Surgical
Then
Either mastectomy or conservative breast surgery …… as before
Then
Post operative chemotherapy (6 cycles)
Then
Post operative radiotherapy
N.B.
Hormonal therapy:-
Tamoxifen 10 mg twice daily for ER +ve case
Stage IV
A- Palliative systemic therapy:-
(Main line of treatment)
chemotherapy
Hormonal therapy
Visceral metastasis
Skeletal metastasis
ER –ve
ER +ve
Rapid course
Slow course
Fit patient
Elderly or unfit patients
B- surgical:** For 1ry tumor: Palliative toilet mastectomy → for pain, ulceration, infection
** For metastases:
a. Laminectomy for spinal cord compression.
b. Internal fixation of pathological long bone fractures.
C- radiotherapy:-
A.F.
Palliative on:-
-106-
A.F.
Pioneer of Surgery for under graduate
Breast
1- Breast if the tumor is not removed for pain.
2- Painful
bone or brainfactors
metastases.
Prognostic
for cancer breast
I- I- Patient related factors
1- Age: Worse prognosis in young patient due to stimulatory effect of sex hormones on tumor
2- Sex: Worse prognosis in male because:
1- Early fixation being no bulk of breast tissue.
2- Early metastasis to axillary lymph nodes.
3- Difficult operation due to insufficient skin available.
3- Pregnancy: Worse prognosis due to:
1. Low level of suspicion based on, young patient age.
2. Nodular changes in the breast during pregnancy making mammographic
imaging less accurate.
4- Obesity: Bad prognosis due to:1- ↑↑ estrogen stores
2- ↓↓ immunity
3- Difficult application of adjuvant therapy
II- Tumor related factors
1- L.N.:- (The most important and accurate single prognostic factor)
1- Involved or not: - Node-positive → bad prognosis
2- Number of L.N.:3- Size:- ≤ 1cm better , ≥ 2cm worse
4- Discrete or matted:- discrete better than matted
5- level
2- Site: Tumor in lower inner quadrant has the worst prognosis due to early dissemination:* Internal mammary on both side
* Peritoneum, liver, trans coelamic
3- Size: Worse prognosis in larger tumor because it disseminates early to regional LN
4- Pathological type:
** Tumors of bad prognosis:
1. Infilterating duct carcinoma.
2. Paget’s with mass.
3. Mastitis carcinomatosis (worst prognosis)
A.F.
-107-
A.F.
Pioneer of Surgery for under graduate
Breast
** Tumor of good prognosis:
1. Medullary
2. Mucinous
3. Tubular
4. Lobular
5. Papillary
6. Paget’s without mass
5- Metastasis: Presence of distant metastases markedly worsens the prognosis.
6- Skin and nipple invasion: Has worse prognosis
7- Staging: Stage I more better prognosis than stage IV
8- Nottingham prognostic index (NPI):
- It is combination of 3 factors (size-grade-stage)
NPI= (0.2 x size of tumor in cm) + Grade + Stage
Good → < 3.4
Moderate → 3.4-5.4
Poor → > 5.4
9- Biological markers:
1. Hormone receptor status: +ve ER & PR → good prognosis
2. Cell kinetics:
Low S-phase tumors have a more favorable prognosis (S-phase means active cell division)
3. Ploidy:
Diploid tumors have a more favorable prognosis than aneuploid tumors.
4. Tumor-associated angiogensis:
Over expression of vascular endothelial growth factor (VEGF) have poor prognosis
5. C-erb- B2, & human epidermal growth receptors (HER-2/neu): have worse prognosis.
6. P53 oncogene: P53 + ve tumors have good prognosis.
A.F.
-108-
A.F.
Pioneer of Surgery for under graduate
Breast
SWELLINGS OF BREAST
A- Solid swellings:A- Traumatic: 1- Traumatic fat necrosis
2- Calcified hematoma
B- Inflammatory:
1- Chronic non-specific breast abscess
2- Chronic specific breast abscess (Gumma, T.B.)
C- ANDI:
1- Hard fibroadenoma
2- Plasma cell mastitis (mammary duct ectazia)
D- Malignant tumor: Cancer breast (scirrhous or sarcoma)
B- Cystic swellings:(I) Acinar (duct system)
1- Cyst of Fibroadenosis (solitary or multiple).
2- Cyst sarcoma phyloid
3- Galactocele (milk cyst).
* Etiology: Retention cyst due to blockage of a milk duct by inspissated milk
4- Retention cyst due to duct papilloma
5- Intracystic papilliferous carcinoma
6- Papillary cystadenoma
(II) Interacinar (stroma)
1- Traumatic: Blood cyst.
2- Inflammatory: Acute breast abscess - Cold abscess.
3- Neoplastic: degenerated carcinoma
4- Parasitic: Hydatid cyst
5- Skin cysts: dermoid cyst, sebaceous cyst, lymphatic cyst etc.
C- Causes of massive breast swelling:
1- Diffuse hypertophy (gigantomastia)
2- Elephantiasis of the breast
3- giant soft fibroadenoma
4- Cystosarcoma Phylloides
5- Medullary carcinoma
6- Sarcoma
A.F.
-109-
A.F.
Pioneer of Surgery for under graduate
Breast
♣♣ Clinical approach:
A- History:
A- Personal history:
1- Age
15-25yr → most of fibro-adenoma
25-40yr (reproductive period) → Fibroadenosis.
>50y → most of Carcinoma (no age is immune)
2- Risk factors of cancer breast: - Western, white – Unmarried - Smoking or alcohol
B- Present history:
1- Pain:
Cyclic→ Fibroadenosis
Throbbing→ abscess
Early painless & late painful → cancer
Dull aching pain → duct ectasia
2- Swelling:
Slowly progressive & accidental discovered → fibroadenoma or cancer
Toxic manifestations (fever, headache, malaise) → abscess
Trauma → traumatic
3- Nipple discharge:
1- Bloody discharge:
1- Duct papilloma (most common cause)
2- Duct carcinoma
2- Serous, green, brown or black discharge: fibroadenosis
3- Purulent discharge: breast abscess.
4- Milky: Galactocele
5- Greenish or creamy paste discharge: Mammary duct ectasia.
4- Manifestations of metastasis: e.g.
a. Brain: headache, blurring of vision and projectile vomiting.
b. Bone: back ache, pathological fracture.
c. Lung: pain, cough, haemoptysis and dyspnea if effusion.
d. Liver: pain, mass, may be jaundice.
A.F.
-110-
A.F.
Pioneer of Surgery for under graduate
Breast
C- Past history:
- breast cancer of the other breast
- benign breast disease
- exposure to radiation
- Postmenopausal hormone replacement ttt
D- Obstetric history:
- nullipara
Risk factors of cancer
breast
- non-lactating
E- Family history:
- +ve family history
F- Menestrual history:
- Early menarche
- Late menopause
- COC > 10 yrs
B- Examination:
## General:
A- Manifestations of metastasis: in cancer breast
1. Chest: signs of pleural effusion or mediastinal L.N.
2. Abdominal examination:
- Palpable periumlical lymph nodes (Sister Mary-Josef node).
- Hepatomegaly
- Ascites.
3. P/R or P/V: nodules in the Douglas’ pouch or Krukenberg’s tumor.
4. Bone: for tenderness, swelling & pathological fracture.
B- Manifestations of toxemia (Fever – rigors) : in abscess
## Local:
1- Skin →
- Dimpling & retraction of the nipple → chronic breast abscess or cancer
- Cancer encuirasse – satellite nodules – fungation or ulceration → cancer
- Skin redness → in abscess
A.F.
-111-
A.F.
Pioneer of Surgery for under graduate
Breast
2- Mass →
- Consistency → either cystic or solid by paget test or fluctuation test
- Edge – surface – mobility
* In cancer
- Hard, irregular, not tender, with flat posterior surface.
- May be fixed to the breast tissue, underlying structure or the overlying skin.
* In fibroadenoma
Firm - Well defined mass - Highly mobile within breast (mouse of breast)
* In acute abscess:
- Swelling: indurated, tender and ill defined.
- Pitting edema of the skin (1st sign).
- Fluctuation is late sign (surest sign).
- Pointing and pus can be squeezed from the nipple.
* In fibroadenosis:
Fine & coarse nodules are better felt with the tips of the fingers than with their
palmar surfaces, they are tender & mobile. (May be diffuse or localized)
3- Discharge: if associated with discharge or not ….. as above
4- L.N.
Hard fixed and not tender → cancer
Soft, mobile and tender → abscess
5- Arm edema → in cancer
B- Investigations:
## By triple assessment →
A- Clinical examination .. as before
B- Sonomammography
U.S. → value → see cancer breast
Mammography → to diff ( ) bg & malignant …….. discuss
C- biopsy → …….. discuss
## If malignancy proved other specific investigations for malignancy:
Metastatic work up
ER & PR …… discuss
Tumor marker ….. discuss
Gene study …… discuss
A.F.
-112-
A.F.
Pioneer of Surgery for under graduate
Breast
♣♣ Treatment:
A- ttt of Fibroadenoma:
Pericanalicular→ Inoculation
Intracanalicular→
If small: Excision
If large: SC mastectomy + breast reconstruction
B- ttt of Cystsarcoma phylloide
A- Benign and borderline phylloids: Wide local excision with safety margin 1-2 cm
B- Malignant phylloids:- Small: wide local excision with safety margin 3 cm
- No axillary LN dissection (why?)
C- ttt of Breast abscess
Acute → drainage & antibiotics
Chronic → excision
D- ttt of Cancer:
A- Early cancer breast…….. ‫عناوين‬
B- Advanced cancer breast ……. ‫عناوين‬
C- Metastatic cancer breast…….. ‫عناوين‬
A.F.
-113-
A.F.
Pioneer of Surgery for under graduate
Breast
NIPPLE DISCHARGE
♣♣ Etiology:
I- Physiological:
1. New born: mastitis neonatorum
2. Serous discharge: during pregnancy.
3. Milky discharge: during lactation.
II- Pathological:
1- Bloody discharge:
1- Duct papilloma (most common cause)
2- Duct carcinoma
3- Trauma
4- Bleeding tendency
5- Fulminate streptococcal infection
2- Necrotic discharge: Degenerative carcinoma
3- Serous, green, brown or black discharge: fibroadenosis
4- Purulent discharge: breast abscess.
5- Milky:
- Galactorrhea
- Galactocele
- Contraceptive pills
6- Greenish or creamy paste discharge: Mammary duct ectasia.
♣♣ Clinical approach:
A- History:
A- Personal history:
1- Age
25-40yr (reproductive period) → Fibroadenosis.
>50y → most of Carcinoma (no age is immune)
2- Risk factors of cancer breast: - Western, white – Unmarried - Smoking or alcohol
A.F.
-114-
A.F.
Pioneer of Surgery for under graduate
Breast
B- Present history:
1. Nature of discharge …… as above
2. Associated with pain or not:
Cyclic→ Fibroadenosis
Throbbing→ abscess
Early painless & late painful → cancer
Dull aching pain → duct ectasia
3. Associated with mass or not:
Slowly progressive & accidental discovered → cancer
Toxic manifestations (fever, headache, malaise) → abscess
Trauma → traumatic
C- Past history:
- breast cancer of the other breast
- Uses of OCs.
- Drugs as phenothiazines, tricyclic antidepressants, metoclopramide.
- Diseases: hypothyroidism, pituitary adenoma
E- Family history:
- +ve family history
B- Examination:
## General:
A- Manifestations of metastasis: in cancer breast
B- Manifestations of toxemia (Fever – rigors) : in abscess
## Local:
1- Differential pressure to localize the originating duct → either Single or multiple duct:
Single → duct papilloma or duct carcinoma
Multiple → trauma or fibroadenosis or duct ectasia
2- Examine the mass: according to the criteria of the mass:
- Consistency → either cystic or solid by paget test or fluctuation test
- Edge – surface – mobility
* In cancer
- Hard, irregular, not tender, with flat posterior surface.
- May be fixed to the breast tissue, underlying structure or the overlying skin.
A.F.
-115-
A.F.
Pioneer of Surgery for under graduate
Breast
* In acute abscess:
- Swelling: indurated, tender and ill defined.
- Pitting edema of the skin (1st sign).
- Fluctuation is late sign (surest sign).
- Pointing and pus can be squeezed from the nipple.
* In fibroadenosis:
Fine & coarse nodules are better felt with the tips of the fingers than with their
palmar surfaces, they are tender & mobile. (May be diffuse or localized)
3- Skin examination:
- Skin manifestations of cancer breast
- Redness & hotness in cancer breast
4- L.N.
Hard fixed and not tender → cancer
Soft, mobile and tender → abscess
C- Investigations:
1- Benzedine test: To detect occult blood in the discharge.
2- Sonomammography: To detect impalpable mass.
3- Ductography: To diagnose duct papilloma and duct carcinoma.
4- Ductoscopy
5- Cytology and biopsy of mass if present.
6- Serum prolactine level. If persistent elevated, search for pituitary adenoma.
7- If associated with mass: biopsy is done …….. discuss
8- If malignancy proved other specific investigations for malignancy: …… discuss
♣♣ Treatment:
Hedley-Atkins management
A.F.
-116-
A.F.
Pioneer of Surgery for under graduate
Breast
MASTALGIA
A- Acyclic:- (breast pain not related with menstrual cycle)
I- Non-breast origin:1. Angina pectoris.
2. Lung disease (Pneumonia, pleurisy).
3. Cervical and thoracic spondylosis
4. Thoracic outlet syndrome
5. Gall stones
6. Tietze’s disease: Idiopathic painful swelling of 2nd or 3rd costal cartilages
7. Mondor's disease (thrombophelebitis of lat. Thoracic vein)
II- Breast origin:1. Fibroadenosis (commonest).
2. Milk engorgement.
3. Acute breast abscess.
4. Carcinoma (only 10%)
♣♣ Treatment:
- ttt of the cause
- Simple analgesics & assurance
- If focal → local analgesia (topical NSAID gel)
- If diffuse → firm brass – mild analgesia- GLA (gamma linoleic acid)
B- Cyclic:- (breast pain related with menstrual cycle)
1- Premenstrual tension
2- Neurosis
3- Salt and water retention
4- Hormonal imbalance with hyper-estrogenemia
5- Essential FA / polyunsaturated F.A imbalance:- GLA (Gama linoleic acid) is mediator for prolactine
- On its ↓↓ → exaggerated end organ response even with normal serum prolactine
- ttt with primose evening oil was found to improve
♣♣ Treatment:
GLA (R/ Premalive tab)
- Reassurance ± tranquilizers
- General (↓ coffee- exercise- will fitted brass)
- If use oral COC change to IUD
- Drugs
A.F.
-117-
Danazole
Bromocryptin (anti-prolactine)
Tamoxifen
LH/RH agonist
A.F.
Pioneer of Surgery for under graduate
Breast
DISEASES OF THE MALE BREAST
(1) Mastitis of Puberty
(2) Mastitis from local irritation.
(3) Fibroadenosis & Fibroaedema: (as in female)
(4) Carcinoma of the Male Breast (< 1% of all breast cancer)
(5) Gynaecomastia
♣♣ Def:This is hypertrophy of the male breast, resembling that of a female due to an excess of
estrogen in relation of circulating testosterone.
♣♣ Types:
(I) Primary: idiopathic may be:
1- Neonatal Gynaecomastia: Due to maternal sex hormones
2- Pubertal Gynaecomastia: Due to imbalance of estrogen and androgen.
3- Senile Gynaecomastia: (50-70 years) Due to imbalance of LH/FSH.
(II) SECONDARY:
1. Congenital: Klinefilter’s syndrome
2. Traumatic: Atrophy of testis due to trauma, after castration.
3. Inflammatory: - Atrophy of testis due to orchitis e.g. mumps.
- Leprosy due to bilateral testicular atrophy
4. Neoplastic: Atrophy of testis due to noeplasms.
5. Suprarenal tumors or bronchogenic carcinoma: Ectopic hormonal production.
6. Metabolic: Liver cirrhosis: due to failure of liver to metabolize estrogens
7. Drugs: Estrogen, (for cancer prostate), digitalis, INH, Aldactone & cimetidine
♣♣ Clinical picture:
- Bilateral, retroareolar, discoid, mobile, tender mass.
- D.D: From Cancer male breast. In the latter there is a very early loss of motility, hard,
ulcerating, eccentric and unilateral with nipple retraction.
♣♣ Treatment:
1ry: If huge, do S.C mastectomy through circumareolar incision
2ry:- - Treatment of cause e.g. Androgen deficiency: testosterone.
- When it is progressive and does not respond to other therapies → SC mastectomy
A.F.
-118-
A.F.
Pioneer of Surgery for under graduate
Breast
ORAL QUESTIONS
Q: hormones acting on the breast?
Estrogen → duct development
Progesterone → lobular development & epith. proliferation
Prolactin → milk production
Oxytocin → milk ejection
Q: Why breast carcinoma has a circumscribed edge?
Because of the difference of consistency ( ) the hard malignant mass & the soft breast
tissue
Q: Causes of supraclavicular L.Ns enlargement:
On the Rt. Side: cancer breast & cancer liver.
On the Lt. side: Cancer breast - Cancer lung - GIT cancer - Hypernephroma.
Q: Halsted:1- Halsted operation of the breast (radical mastectomy)
2- Halested theory in breast
3- Halsted repair of hernia
4- surgical gloves
Q: What is meant by significant & non- significant L.Ns ?
Significant
Insignificant
1- Enlarged > 1cm.
Enlarged < 1cm.
2- Hard.
Firm.
3- Painless.
Tender.
4- Matted.
Discrete.
5- Not responding to antibiotics.
Responding to antibiotics.
6- 2ry to malignancy.
2ry to inflammation.
Q: Tumors which prefer bone metastasis:
1- Cancer breast → osteolytic (90%) → Lumbar
2- Cancer prostate → osteosclerotic (80%) → Lumbosacral spine
3- Cancer thyroid → base of the skull
A.F.
-119-
A.F.
Pioneer of Surgery for under graduate
Breast
Q: Criteria of ideal L.N. biopsy:
1- Site: cervical is more preferred then axillary then inguinal
2- The L.N. should be significant:
1- Enlarged > 1cm.
2- Hard.
3- Painless.
4- Matted.
5- Not responding to antibiotics.
3- Intact capsule
4- Intact L.N. (not crushed)
5- L.N. should be sent fresh for immune histochemical studies
6- Excision biopsy is preferred than incision biopsy
A.F.
-120-
A.F.