003 breast pathology

8/11/2019 003 Breast Pathology

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BREAST SURGICALBREAST SURGICALPATHOLOGYPATHOLOGY


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ContentContent

1.1. The importance of breast pathologyThe importance of breast pathology

2.2. Surgical anatomySurgical anatomy

3.3. Clinical examination of the breastClinical examination of the breast

4.4. MalformationsMalformations

5.5. InflammationsInflammations6.6. Degenerative diseasesDegenerative diseases

7.7. TumorsTumorsa)a) BenignBenignb)b) MalignantMalignant

8.8. Particular forms of breast cancerParticular forms of breast cancer


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The importance of breast pathologyThe importance of breast pathology

The breast may be affected by a large variety ofThe breast may be affected by a large variety ofpathology. Both benign and malignant type of pathology,pathology. Both benign and malignant type of pathology,affect with predilection women at any age but may affectaffect with predilection women at any age but may affect

men also.men also.

Breast cancer, as well as cancer in general, remains aBreast cancer, as well as cancer in general, remains aparticular health problem despite of world wide efforts ofparticular health problem despite of world wide efforts ofresearchers and physicians and huge funds allocated forresearchers and physicians and huge funds allocated forprevention and treatment of this disease.prevention and treatment of this disease.


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Particular factors to be considered in breastParticular factors to be considered in breast

pathologypathology ::

1.1. The breast, in womenThe breast, in women,, beyond the role of breastfeedingbeyond the role of breastfeeding(which is however limited to a short period of lifetime), has(which is however limited to a short period of lifetime), has

mainly anmainly an eroticerotic andand estheticesthetic role,role, andand thereforetherefore, the, thebreast pathology has a strong echo in the mental spherebreast pathology has a strong echo in the mental sphereof the woman.of the woman.

2. Surgery, where is indicated, takes into account more andmore the psychothe psycho--affective aspect, tending to beaffective aspect, tending to be lesslessmutilantmutilant possible, butpossible, but however it must also take intoaccount the invasive nature of the disease.

3.3. The breast is anThe breast is an easily accessibleeasily accessible organ for examination,organ for examination,facilitating early detection of pathological changes.facilitating early detection of pathological changes. Thesooner a breast lesion is discovered, the smaller will be

the unpleasant consequences of the possible surgery.


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Knowing the breast anatomy is of particular importanceKnowing the breast anatomy is of particular importance

for clinician (and not only), especially in cancer cases,for clinician (and not only), especially in cancer cases,

for several reasons:for several reasons:

1.1. To be able to establish a correct diagnosis,To be able to establish a correct diagnosis,

2.2. To be able to perform adequate surgery,To be able to perform adequate surgery,

3.3. To perform the radiotherapy in indicated regions,To perform the radiotherapy in indicated regions,

4.4. To be able to foresee eventually relapses of breastTo be able to foresee eventually relapses of breast

cancer.cancer.

BREAST ANATOMYBREAST ANATOMY


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EmbryologyEmbryology

Mammary glands begin to develop from theMammary glands begin to develop from the 66thth weekweek ofof

intrauterine life from twointrauterine life from two ectodermalectodermal thickening calledthickening calledmammary crestsmammary crests. These crests are located along the. These crests are located along thelines described bylines described by SchultzeSchultze (1892) as "(1892) as "milk linesmilk lines" which" which

join thejoin the axillaryaxillary region toregion to homolateralhomolateral groin.groin.

Schultze line milk line

Along these mammary crests there are6-7 nodules, which in mammals willdevelop more pairs of mammary glands.

In humans, the caudal portion of thecrests will disappear remaining only thethoracic portion. This will determine, innormal cases, the development of one

single pair of mammary glands inpectoral region. There are cases whensupernumerary mammary glands, or

just components of the breast (eg.nipples) may develop along the milklines.


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In women, initially under the action of estrogen andIn women, initially under the action of estrogen andsubsequently in combination with progesterone,subsequently in combination with progesterone,mammary glands undergo significantmammary glands undergo significant changeschanges till to thetill to thestage of mature breast. This process generally takes 3stage of mature breast. This process generally takes 3--44years and is completed in general at the age of 16.years and is completed in general at the age of 16.

Subsequent physiological changes occur duringSubsequent physiological changes occur duringpregnancy and lactation and menopause.pregnancy and lactation and menopause.

In men, normally breasts remain almost unchanged, butIn men, normally breasts remain almost unchanged, but

size and structure changes may occur under certainsize and structure changes may occur under certainconditions under the influence of various hormonal factorsconditions under the influence of various hormonal factors((gynecomastiagynecomastia).).


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The breastThe breastLocationLocation

Breasts are located in theBreasts are located in the anteroantero--superior region of thesuperior region of thechest. In women the classical breast area is extendedchest. In women the classical breast area is extendedcraniocranio--caudal between the second and the sixth rib andcaudal between the second and the sixth rib and

in transverse direction between the margin of thein transverse direction between the margin of thesternum and the anteriorsternum and the anterior axillaryaxillary line. In men this area isline. In men this area islimited solely to the breast areola region, beinglimited solely to the breast areola region, beingrudimentary represented.rudimentary represented.

The breast is enclosed between two thin sheets ofThe breast is enclosed between two thin sheets ofsuperficial fascia of the pectorals.superficial fascia of the pectorals.

ExtensionExtension

The mammary gland area in women is extended inThe mammary gland area in women is extended incraniocranio--caudal direction between the clavicle and thecaudal direction between the clavicle and thesuperior margin of the rectussuperior margin of the rectus abdominisabdominis and inand intransverse direction between the margin at the sternumtransverse direction between the margin at the sternumandand latisimuslatisimus dorsidorsi muscle.muscle.


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Nippleareolacomplex

between the 4th

and the 5th ribs

Extension of mammary glandBreast limits


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The mammary gland has a more extended area than theThe mammary gland has a more extended area than thebreastbreast.. This aspect is very important because on thisThis aspect is very important because on thisarea pathological processes of the breast tissue mayarea pathological processes of the breast tissue mayoccur, and also for surgery becauseoccur, and also for surgery because these are the limitsthese are the limitswithin which the surgeon must perform a radicalwithin which the surgeon must perform a radical

mastectomy for breast cancer.mastectomy for breast cancer.

The axillary extension of the mammary gland (axillarytail) is of special interest because it is often affected bypathological processes. In some women this extension is

well represented and can be confused with a lipoma, anaxillary adenopathy, or a supernumerary breast. Usuallyit becomes more evident during the premenstrual period

and lactation.

The internal surface of the gland is attached to thepectoralis fascia by fibrous strips called Coopersligaments.


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External appearanceExternal appearance

Two hemispherical shape masses, whose size andTwo hemispherical shape masses, whose size andweight vary from person to person based on race, age,weight vary from person to person based on race, age,and the various physiological stages.and the various physiological stages. Generally the leftGenerally the leftbreast is bigger than the right one.breast is bigger than the right one.

In the central zone there is theIn the central zone there is the areolaareola, a, a hyperpigmentedhyperpigmentedskin area, whose size also varies from person to person.skin area, whose size also varies from person to person.

Under the areolaUnder the areolas skin there are many nervous fiberss skin there are many nervous fibers

and smooth muscles arranged in circular andand smooth muscles arranged in circular andlongitudinal layers, which by contraction decrease andlongitudinal layers, which by contraction decrease andwrinkle the surface causing elongation andwrinkle the surface causing elongation and turgorturgor of theof the

nipples.nipples.

The areola has small prominences:The areola has small prominences: the Montgomerythe Montgomerytuberclestubercles, which are large sebaceous glands which, which are large sebaceous glands which

increase in volume during pregnancy and lactation.increase in volume during pregnancy and lactation.


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areola nipple

Montomery

The nippleThe nipple, is a, is a

cylindricalcylindrical--conicalconical

prominence, of 10prominence, of 10--1212

mm length and 8mm length and 8--1010

mm in diameter. Theremm in diameter. Thereare 15are 15--2020

galactophorousgalactophorous porespores

of theof the lactiferous ductslactiferous ducts..

Breast structure


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For better guidance in locating various pathologicalFor better guidance in locating various pathologicalprocesses, the breast was arbitrary divided into fourprocesses, the breast was arbitrary divided into fourquadrants by two lines, one vertical and the otherquadrants by two lines, one vertical and the otherperpendicular through the centre of the nipple.perpendicular through the centre of the nipple.

1.1. superosupero--external (SE)external (SE) -- over 50% of breast cancers are located inover 50% of breast cancers are located in

this quadrant.this quadrant.2.2. inferoinfero-- external (IE)external (IE)

3.3. superosupero--internal (SI)internal (SI)

4.4. inferoinfero--internal (II)internal (II)

Two more quadrants are added:Two more quadrants are added:

oneone central (C)central (C) corresponding tocorresponding toretroareolarretroareolar area and thearea and theanother which is theanother which is the axillaryaxillaryextension quadrant (AEextension quadrant (AE) of the) of the

gland.gland.

SI

IIIE

SE

PA

C

Breast quadrants


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The structure of the breastThe structure of the breast

There are four types of tissues :There are four types of tissues :

1.1. MilkMilk--producing mammary gland,producing mammary gland,2.2. Milk ducts,Milk ducts,

3.3. Fatty tissue, andFatty tissue, and

4.4. Connective and fibrous tissue, and also blood vessels,Connective and fibrous tissue, and also blood vessels, lymphaticslymphatics andand

nervesnerves..

The gland is composed of 15The gland is composed of 15--2020 lobeslobes. It is entirely. It is entirelyenveloped by fatty tissue with the exception of theenveloped by fatty tissue with the exception of theretroareolarretroareolar region.region.

The adipose layer under the skin is organized inThe adipose layer under the skin is organized in lodgeslodgesseparated by fibrous bands (Cooperseparated by fibrous bands (Coopers ligaments), which ons ligaments), which onpalpation give the feeling of a granular surface.palpation give the feeling of a granular surface. Do notDo notconfuse these fatty lodges with tumors.confuse these fatty lodges with tumors.

The gland itself is fixed to the internal surface of theThe gland itself is fixed to the internal surface of the dermdermby theby the DuretDuret crests which are of special importancecrests which are of special importancebecause via these structures the malignant process canbecause via these structures the malignant process canspread to the skinspread to the skin. When these crests are invaded by the. When these crests are invaded by thetumoral process the skin becomes fixed to the gland and ittumoral process the skin becomes fixed to the gland and itcan be retracted which is a clinical sign for cancer.can be retracted which is a clinical sign for cancer.


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Breast structure


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TheThe retromammaryretromammary layerlayer is a space by which theis a space by which themammary gland can slide on the surface of the largemammary gland can slide on the surface of the large

pectoral muscle fascia. Invasion of this layer andpectoral muscle fascia. Invasion of this layer andpenetration into the pectoral muscle, leads to fixation ofpenetration into the pectoral muscle, leads to fixation ofthe gland to the underlying muscle highlighted by thethe gland to the underlying muscle highlighted by theTillauxTillaux maneuvermaneuver..

In very rare cases, the glandular tissue may cross theretrommary fatty layer penetrating into the pectoralmuscle. This was the justification for Halsted radical

mastectomy where pectoral muscles were removedtogether with the breast.

Microscopic anatomyMicroscopic anatomy

The glandular parenchyma is divided intoThe glandular parenchyma is divided into lobes (lobes (1515--20),20),lobuleslobules andand aciniacini. In their delimitation contributes the. In their delimitation contributes thestromastroma represented by interlobular dense connectiverepresented by interlobular dense connectivetissue andtissue and intralobularintralobular loose tissue, formingloose tissue, forming septssepts alongalong

which blood vessels andwhich blood vessels and lymphaticslymphatics are passing.are passing.


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The functional units of mammary gland are theThe functional units of mammary gland are the aciniacini..

Each lob has a milk duct which opensEach lob has a milk duct which opens separatellyseparatelly at theat the

surface of the nipple. The lobes are orientatedsurface of the nipple. The lobes are orientated radiallyradiallyaround the areola.around the areola.


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Radial incisions in case of a mammary gland abscess

The lobes are orientatedThe lobes are orientated radiallyradially around the areola.around the areola.

Thats why


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Each lactiferous (milk) ductsEach lactiferous (milk) ducts has ahas a lactiferous sinuslactiferous sinuslocated at the base of the nipple. The diameter of theselocated at the base of the nipple. The diameter of theseducts is 2 to 4 mm. Inside there is a double layerducts is 2 to 4 mm. Inside there is a double layerepithelium:epithelium: cuboidcuboid cells at the level of lobules andcells at the level of lobules andcylindrical shape cells in extracylindrical shape cells in extra--lobular space. Thelobular space. The

external layer hasexternal layer has myoepithelialmyoepithelial cells.cells.

These ducts are responsible for the majority of breastThese ducts are responsible for the majority of breastpathology. It is considered that neoplastic lesions havepathology. It is considered that neoplastic lesions havethe starting point is these ducts and less in the acini.the starting point is these ducts and less in the acini.

Also the breast fibrocystic disease has the starting pointAlso the breast fibrocystic disease has the starting pointin these ducts.in these ducts.


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VascularizationVascularization andand innervationinnervation

ArteriesArteries

Internal mammary arteryInternal mammary artery (from(from subclavian arterysubclavian artery),),

Lateral thoracic arteryLateral thoracic artery ( from( from axillary artery)axillary artery)

Intercostal artery branchesIntercostal artery branches (from thoracic aorta).(from thoracic aorta).

Other sources: thoracicOther sources: thoracic supremasuprema artery, arteries ofartery, arteries of

pectoral muscles,pectoral muscles, thoracoacromialthoracoacromial artery,artery, subscapularsubscapularartery,artery, thoracothoraco--dorsal artery and superficial thoracicdorsal artery and superficial thoracicartery.artery.


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Arterial sources of the breast


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VeinsVeins

The venous drainage of the breast is organized in twoThe venous drainage of the breast is organized in twonetworks: onenetworks: one superficialsuperficial and another oneand another one deepdeep..

The superficial network forms around the areola aThe superficial network forms around the areola avenous plexus so called thevenous plexus so called the HallerHallers circle.s circle.

Through the venous system cancerous cells are carriedThrough the venous system cancerous cells are carriedto the first filtrating station: the lungs, and then towardsto the first filtrating station: the lungs, and then towardsother organs where metastases are relatively frequent:other organs where metastases are relatively frequent:

liver, bones, brain.liver, bones, brain.InnervationInnervation

Breast skin innervation is provided byBreast skin innervation is provided by brachial cutaneousbrachial cutaneousnerve and branches from thenerve and branches from the intercostal nervesintercostal nerves 4, 5, 6.4, 5, 6.

Breast parenchyma receives sympathetic branches thatBreast parenchyma receives sympathetic branches thatreach the secretory units along the intercostal nerves 2,reach the secretory units along the intercostal nerves 2,3, 4, 5 and 6.3, 4, 5 and 6.


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The lymphatic systemThe lymphatic system is of particular interest in breastis of particular interest in breast

surgery due to tumor extension mainly on this route withsurgery due to tumor extension mainly on this route withparticularly prognostic effect.particularly prognostic effect.

There is aThere is a superficialsuperficial network which collects lymph fromnetwork which collects lymph from

skin and askin and a deepdeep parenchyma network.parenchyma network.

Between those two lymphatic network there are twoBetween those two lymphatic network there are two

areas of connection, one at the areola where there is aareas of connection, one at the areola where there is a

superficial lymphatic plexussuperficial lymphatic plexus andand one subaureolarone subaureolar

(Sappey)(Sappey) and the other at the breast periphery.and the other at the breast periphery.

Along these lymphatic routes, propagation of the cancerAlong these lymphatic routes, propagation of the canceris possible from depth to surface,is possible from depth to surface, which is the base forwhich is the base for

indication toindication to remove the areola in mastectomies forremove the areola in mastectomies for

breast cancer.breast cancer.


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There are two main lymphatic drainage routes:There are two main lymphatic drainage routes:

External mammary routeExternal mammary route ((axillaryaxillary route)route) -- it drains theit drains the

lymph to thelymph to the ipsilateralipsilateral axillaryaxillary lymph nodes. 75%lymph nodes. 75%--97% of97% ofcancer cells are carried through this route.cancer cells are carried through this route. On the trajectoryOn the trajectoryof this route there is a lymph node (of this route there is a lymph node (SorgiusSorgius) located at the) located at theedge of the great pectoralis muscle.edge of the great pectoralis muscle.

Internal mammary routeInternal mammary route,, which travels along the internalwhich travels along the internalmammary arteries towards the internal thoracic lymph nodesmammary arteries towards the internal thoracic lymph nodes(internal mammary lymph nodes), located(internal mammary lymph nodes), located retrosternalretrosternal in thein the

intercostal spaces 1 to 5.intercostal spaces 1 to 5.

From here the lymph goes to:From here the lymph goes to:

SupraclavicularSupraclavicular lymph nodeslymph nodes

Cervical lymph nodesCervical lymph nodes On the left side to the thoracic duct and left lymphatic ductOn the left side to the thoracic duct and left lymphatic duct

On the right side to the right lymphatic ductOn the right side to the right lymphatic duct

To theTo the PirogoffPirogoffjugulojugulo--subclaviansubclavian confluenceconfluence

To theTo the mediastinalmediastinal lymph nodes andlymph nodes and bronchobroncho--aortic nodesaortic nodes


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Lymphatic routes


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Besides these primary routes, there are other secondaryBesides these primary routes, there are other secondaryroutes such as:routes such as:

1.1. TranspectoralTranspectoral routeroute starts from the inner surface ofstarts from the inner surface ofthe breast, passes through thethe breast, passes through the pectoralispectoralis major to themajor to theRotterRotterss interpectoralinterpectoral lymph nodeslymph nodes and then to theand then to theaxillaryaxillary apical lymph nodes.apical lymph nodes.

2.2. RetropectoralRetropectoral routeroute starts from the inner part of thestarts from the inner part of theSE quadrant, passes behind theSE quadrant, passes behind the pactoralispactoralis major towardsmajor towardsthe apical lymph nodes.the apical lymph nodes.

3.3. Intercostal routeIntercostal route -- along the intercostal vessels directalong the intercostal vessels directto the intercostal lymph nodes and from there to theto the intercostal lymph nodes and from there to theinternal mammary lymph nodes.internal mammary lymph nodes.

4.4. ContralateralContralateral axillaryaxillary routeroute -- Although rare, it is stillAlthough rare, it is stillpossible thatpossible that tumoral cells from breast to reach the lymphtumoral cells from breast to reach the lymphnodes fromnodes from contralateralcontralateral axilaaxila..

5.5. Inferior routeInferior route -- described bydescribed by GerotaGerota ((RomanianRomanianphysician and anatomist)physician and anatomist) which drains the lymph to thewhich drains the lymph to theepigastric region and diaphragmatic nodules.epigastric region and diaphragmatic nodules.


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Lymphatic drainage of the breast


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Anatomy of theAnatomy of the axillaaxilla

AxillaAxilla is a pyramidal shape structure with the tip facing the cervicalis a pyramidal shape structure with the tip facing the cervical

region which is the junction between the arm and the chest.region which is the junction between the arm and the chest.

It has a tip, a base and 4 wallsIt has a tip, a base and 4 walls

The content of theThe content of the axilaaxila is represented by:is represented by:

ArteriesArteries::

AxillaryAxillary artery,artery,

Lateral thoracic artery,Lateral thoracic artery,

SubscapularSubscapular artery,artery,

ThoracodorsalThoracodorsal arteryartery

NervesNerves::

Brachial plexus,Brachial plexus,

IntercostobrachialIntercostobrachial nerve,nerve,

ThoracicusThoracicus longuslongus (Charles Bell(Charles Bell respiratory) nerve,respiratory) nerve,

SubscapularSubscapular nerve,nerve,

ThoracodorsalThoracodorsal nerve,nerve,

Intercostal nervesIntercostal nerves

Fatty tissueFatty tissue

Lymph nodesLymph nodes

VeinsVeins::The veins areThe veins are omonimomonim

to the arteriesto the arteries


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Walls of the axil la BergBergss axillaryaxillary lymph nodes classificationlymph nodes classification


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AngloAnglo--American surgeons useAmerican surgeons use BergBergss axillaryaxillary lymphlymphnodes classificationnodes classification that divides in three main categoriesthat divides in three main categoriesbased on prognostic and their relationship withbased on prognostic and their relationship with pectoralispectoralisminor muscle:minor muscle:

Level 1Level 1 -- are lymph nodes located under the lateral edge of theare lymph nodes located under the lateral edge of thepectoralispectoralis minor (lateral posterior and anterior)minor (lateral posterior and anterior)

Level 2Level 2 -- are lymph nodes lying underneath the muscle betweenare lymph nodes lying underneath the muscle betweenthe medial and lateral edgethe medial and lateral edge

Level 3Level 3 -- lymph nodes located medial or above the medial edgelymph nodes located medial or above the medial edgeof the muscle (apical,of the muscle (apical, subclaviansubclavian))

In fact this classification is used in the TNM system forIn fact this classification is used in the TNM system formalignant breast tumors. To this group, called regional lymphmalignant breast tumors. To this group, called regional lymphnodes (N), in the TNM classification is added also thenodes (N), in the TNM classification is added also the

ipsilateralipsilateral internal mammary lymphinternal mammary lymph group.group. IntramammaryIntramammarylymph nodes are encoded aslymph nodes are encoded as axillaryaxillary lymph nodes in thelymph nodes in theTNM classification.TNM classification.

Any other metastatic lymph nodes are coded as distantAny other metastatic lymph nodes are coded as distantmetastases (M1) includingmetastases (M1) including subclaviansubclavian, or, or contralateralcontralateralcervicalcervical lymph nodes.lymph nodes.


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CLINICAL EXAMINATIONCLINICAL EXAMINATIONOF THE BREASTOF THE BREAST


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The diagnosis is based on 3 elements:The diagnosis is based on 3 elements:

1.1. HistoryHistory2.2. Clinical examinationClinical examination

3.3. ParaclinicParaclinic investigationsinvestigations

Clinical examinationClinical examination is the most important phase of theis the most important phase of thediagnosis becausediagnosis because::

1.1. In most cases it is the first method of diagnosisIn most cases it is the first method of diagnosis,,

2.2. In advanced cases the method is sufficient, theIn advanced cases the method is sufficient, thephysical signs ofphysical signs of neoplasianeoplasia being obvious,being obvious,

3.3. Local examination performed by woman itself (selfLocal examination performed by woman itself (self

examination) is the most effective method ofexamination) is the most effective method ofscreening for early detection of breast cancer if otherscreening for early detection of breast cancer if otherbetter methods are not available through a nationalbetter methods are not available through a nationalscreening program.screening program.


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40% of tumors detected at40% of tumors detected at mammographymammography can not becan not bedetected by palpation !detected by palpation !

Clinical examination just of the breast is not enough!Clinical examination just of the breast is not enough!GeneralGeneral clinical examinationclinical examination of the patient should be alsoof the patient should be alsoperformed!performed!

Local examination of the breastLocal examination of the breast

Not only the breast considered ill will be examined, butNot only the breast considered ill will be examined, butalso:also:

-- TheThe contralateralcontralateral breast,breast,

-- The bothThe both axillaeaxillae,,

-- TheThe supraclavicularsupraclavicular and cervical lymph nodesand cervical lymph nodes

The examination can be performed both in orthostatic andThe examination can be performed both in orthostatic andsupine position. The standing position is preferred.supine position. The standing position is preferred.

1.1. InspectionInspection

2.2.PalpationPalpation


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A.A. Inspection.Inspection.

The patient in front of doctor with arms hangingThe patient in front of doctor with arms hangingThe following aspects will be noted:The following aspects will be noted:

The position of the line between the two nipples.The position of the line between the two nipples. ThisThis

is supposed to be horizontal in normal cases. If thereis supposed to be horizontal in normal cases. If thereare changes in shape and volume of the breast theare changes in shape and volume of the breast theline becomes oblique.line becomes oblique.

The breast volume.The breast volume. Any expansive process in theAny expansive process in thebreast will lead to more or less increase of the breastbreast will lead to more or less increase of the breastvolume. This aspect is often observed involume. This aspect is often observed in phyllodesphyllodestumorstumors..

The shape of the breast.The shape of the breast.As long as theAs long as the tumortumor is smallis smallthere wonthere wont be any changes in breast shape. As itt be any changes in breast shape. As itgrows, alteration of breast shape will appear asgrows, alteration of breast shape will appear asirregular elevations (bulges) or asirregular elevations (bulges) or as depressions (skindepressions (skinretraction).retraction).


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Tu Phyllodes

Tu Phyllodes


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The aspect of the skinThe aspect of the skin ..

The colourThe colour can be normal. In some advanced casescan be normal. In some advanced casesand in acute inflammatory breast cancer, the colourand in acute inflammatory breast cancer, the colour

turns to reddish as in an inflammatory process makingturns to reddish as in an inflammatory process making

possible confusion with acute mastitis.possible confusion with acute mastitis. Skin surfaceSkin surface may look as anmay look as an orange peelorange peel ((peaupeau

ddorangeorange) very suggestive for breast cancer. It is caused) very suggestive for breast cancer. It is caused

by lymphatic stasis in theby lymphatic stasis in the dermderm as the lymph ducts areas the lymph ducts areblocked by the tumoral process.blocked by the tumoral process.

ExulcerationExulceration of the skinof the skin appears in advanced cases.appears in advanced cases.

Venous networkVenous network become visible being augmented inbecome visible being augmented in

advanced cases, and also inadvanced cases, and also in phyllodesphyllodes tumorstumors..

Nodules of permeationNodules of permeation appear also in advancedappear also in advanced

neglected cases.neglected cases.


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Venous network more visible


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Tumoral nodules of permeation Tumoral nodules of permeation


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Ulceration with necrosis


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Skin of orange peel

Nipple retraction


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The aspect of areolaThe aspect of areola.. The areola may be affected byThe areola may be affected by

tumoral processes like Pagettumoral processes like Pagets disease. The aspect iss disease. The aspect is

similar to ansimilar to an exemaexema..

The aspect of the nipple.The aspect of the nipple. Very suggestive for cancer isVery suggestive for cancer isthethe unilateral retractionunilateral retraction of the nipple recently installed.of the nipple recently installed.

Pathological discharge from the nipple.Pathological discharge from the nipple. It could be:It could be:

serous, brownish,serous, brownish, lactescentlactescent, purulent,, purulent, haemorrhagichaemorrhagic..

The most suggestive for cancer is the unilateralThe most suggestive for cancer is the unilateral

spontaneousspontaneous haemorrhagichaemorrhagic dischargedischarge which appearswhich appears

especially in case ofespecially in case of intraductalintraductal papillomapapilloma..


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Pagets disease of the breast

Breast lump with nipple retraction


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The patient raises her upper limbsThe patient raises her upper limbsabove the headabove the head ..

By this maneuver, other aspects canBy this maneuver, other aspects canstand out that do not occur in initialstand out that do not occur in initialposition. This can produce changes inposition. This can produce changes in

the shape of the breast, nipplethe shape of the breast, nippleretraction or modifications becomeretraction or modifications becomemore visible.more visible.

The patient bent forward with hands onThe patient bent forward with hands onhips.hips.

In this position breasts are hanging,In this position breasts are hanging,

pathological changes can bepathological changes can beobeserved in the breast bearing aobeserved in the breast bearing amalignant process. The breast hangsmalignant process. The breast hangsless if the tumor is fixed to the pectoralless if the tumor is fixed to the pectoral

muscles or chest wall.muscles or chest wall.


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There are four stages of palpationThere are four stages of palpation

1.1. Gross palpationGross palpation described by Velpeau, trying todescribed by Velpeau, trying to

capture any tumor formation. It is only ancapture any tumor formation. It is only anorientative palpation.orientative palpation.

2.2. Palpation of finessePalpation of finesse that must follow a certainthat must follow a certainscheme not to omit any breast areas.scheme not to omit any breast areas.

3.3. TumorTumorpalpationpalpation..

4.4. Palpation of the areola and the nipple.Palpation of the areola and the nipple.

Palpation of finessePalpation of finesse

CircularCircular -- concentricconcentric

SpiralSpiral

RadialRadial

No matter which method is chosen. The breast tissue

should be compressed against the chest wall and all

quadrants should be cheeked.


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Palpation will notice the following features of thePalpation will notice the following features of the

tumortumor::

1.1. NumberNumber -- How manyHow many tumorstumors are found.are found.

2.2. LocationLocation -- MostMost tumorstumors are located in the SEare located in the SE

quadrant.quadrant.

3.3. DimensionsDimensions -- Generally, breast tumors foundGenerally, breast tumors found

incidentally on palpation are of 2incidentally on palpation are of 2--3 cm in diameter. If3 cm in diameter. If

the breast is not too voluminous, tumors can bethe breast is not too voluminous, tumors can be

detected at a diameter of 1 cm.detected at a diameter of 1 cm.

4.4. FormForm -- The form can be spherical or irregular.The form can be spherical or irregular.

5.5. ConsistencyConsistency -- Generally they are of hard consistency.Generally they are of hard consistency.6.6. SensitivitySensitivity -- Malignant tumor is not painful onMalignant tumor is not painful on

palpation (at least in the early stages and if there is nopalpation (at least in the early stages and if there is no

inflammatory process associated).inflammatory process associated).


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DupuytrainDupuytrain signsign


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Tillaux maneuver the doctor opposes to the adductionmovement of the patients arm (the pactorals muscles will

contract) and with the other hand palpating the breast he

will notice that the tumor becomes fixed as the pectoralsmuscles contract.


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Palpation of the areola and the nipple.Palpation of the areola and the nipple.

The nipple is gently grasped between the index fingerThe nipple is gently grasped between the index fingerand thumb and compressed.and thumb and compressed.

In case of a breast cancer or an intracanalicularIn case of a breast cancer or an intracanalicular

papilloma, blood may leak through the nipple.papilloma, blood may leak through the nipple.

In case of an intracanalicular papilloma, beneath theIn case of an intracanalicular papilloma, beneath the

nipple a tumor of about 1 to 1.5 cm can be feltnipple a tumor of about 1 to 1.5 cm can be felt

Nipple retraction is caused by neoplastic infiltrationNipple retraction is caused by neoplastic infiltrationand can not be reduced manually.and can not be reduced manually.

f


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Palpation of lymph nodesPalpation of lymph nodes

A: Cervical nodes on the neck

B: Supraclavicular nodes just above the collarbone

C: Infraclavicular nodes just behind the collarboneD: Axillary nodes in the armpit

AB

C

D


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BREAST MALFORMATIONSBREAST MALFORMATIONSClassificationClassification

MalformationsMalformations

Of numberOf numberOf volumeOf volume

Of shapeOf shape

MalformationsMalformations

congenitalcongenital

acquiredacquired


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Abnormalities of numberAbnormalities of number

1.1. AmastiaAmastia

Represents the congenital absence of one orRepresents the congenital absence of one orboth breasts.both breasts.

It is sometimes associated with the absence ofIt is sometimes associated with the absence ofsternalsternal portion of the largeportion of the large pectoralispectoralis majormajor(Poland Syndrome).(Poland Syndrome).

It may be associated with other malformationsIt may be associated with other malformationssuch as the absence of internal genital organs,such as the absence of internal genital organs,ribs 3ribs 3--4 or the upper limb.4 or the upper limb.

It is more frequent in men.It is more frequent in men.

AmastiaAmastia is complete if the areola and the nippleis complete if the areola and the nippleare absent.are absent.

2.2. AtheliaAthelia

Is represented by the absence of the nippleIs represented by the absence of the nippleassociated or not with the absence of theassociated or not with the absence of theareola.areola.

It may occur at a normal located breast but areIt may occur at a normal located breast but aremore frequent at supernumerary breast.more frequent at supernumerary breast.

A iA i


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3.3. AmaziaAmazia

refers to a condition where mammary gland is absent, either congrefers to a condition where mammary gland is absent, either congenitalenital

or iatrogenic acquired. The nipple and areola are present.or iatrogenic acquired. The nipple and areola are present.

4.4. PolymastiaPolymastia

It is a frequent (1It is a frequent (1--5%) congenital malformation where more than two5%) congenital malformation where more than two

breast are present.breast are present.

It can beIt can be completecomplete when all the anatomical structures of the breast arewhen all the anatomical structures of the breast are

present orpresent or incompleteincomplete when just the mammary gland is present.when just the mammary gland is present.

TheThe favoritefavorite locations are along the milk crests oflocations are along the milk crests of SchultzeSchultze. The most. The most

frequent location is thefrequent location is the axillaryaxillary region. There can be present up to 8region. There can be present up to 8

supernumerary breasts.supernumerary breasts.

It may have a familial character, being transmittedIt may have a familial character, being transmitted autosomalautosomal dominantdominant

from man to man in the same family, but can be sporadic also.from man to man in the same family, but can be sporadic also.

Supernumerary breasts may be affected by the same pathologies asSupernumerary breasts may be affected by the same pathologies as

the normal breasts.the normal breasts.


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5.5. PolitheliaPolithelia

Is the condition represented by multiple nipples associated or nIs the condition represented by multiple nipples associated or nototwith areola.with areola.

Frequency: 2%Frequency: 2%

Usually they appear symmetrically along the milk crests, but canUsually they appear symmetrically along the milk crests, but can

occur anywhere. They can be rudimentary or functional.occur anywhere. They can be rudimentary or functional.

Sometimes are associated with congenital urinary malformations.Sometimes are associated with congenital urinary malformations.May serve asMay serve as cutaneouscutaneous paraneoplasticparaneoplastic markers formarkers for urogenitalurogenitalmalignancies.malignancies.

Not of particular clinical importance unless they are affected bNot of particular clinical importance unless they are affected byymorbid processes.morbid processes.

Polithelia

Abnormalities of volumeAbnormalities of volume


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Abnormalities of volumeAbnormalities of volume1.1. AnisomastiaAnisomastia

Is due to uneven development of breasts and their asymmetricalIs due to uneven development of breasts and their asymmetricallocation. If the aesthetic defect is important it can be correctlocation. If the aesthetic defect is important it can be corrected byed byvarious operations ofvarious operations of mammoplastymammoplasty..

2.2. Atrophy of the breast (Atrophy of the breast (micromastiamicromastia))

Is characterized by an insufficient development of the breastIs characterized by an insufficient development of the breast uniuni-- ororbilaterally.bilaterally.

Is due to hormonal insufficiency or to general illnesses such asIs due to hormonal insufficiency or to general illnesses such as::tuberculosis, cirrhosis, syphilis, or other factors.tuberculosis, cirrhosis, syphilis, or other factors.

Treatment consists of treating the endocrine deficiency and alsoTreatment consists of treating the endocrine deficiency and alsosilicone implant may solve de defect.silicone implant may solve de defect.

33 Breast hypertrophy (Breast hypertrophy (macromastiamacromastia))


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3.3. Breast hypertrophy (Breast hypertrophy (macromastiamacromastia))

It is the consequence of hypertrophy based on proliferation of bIt is the consequence of hypertrophy based on proliferation of breastreastparenchyma (parenchyma (aciniacini, ducts) and the, ducts) and the stromastroma isis oedematousoedematous infiltrated.infiltrated.

An obvious cause is unknown, hormonal factors being incriminatedAn obvious cause is unknown, hormonal factors being incriminated

and race (more common in black women). Another cause is theand race (more common in black women). Another cause is the

development of the mammary gland during pregnancy returning todevelopment of the mammary gland during pregnancy returning to

the normal breast volume being incomplete.the normal breast volume being incomplete.

Breasts gradually increase reaching impressive dimensions andBreasts gradually increase reaching impressive dimensions and

weight (7weight (7--8 kg), most often in addition to a normal silhouette.8 kg), most often in addition to a normal silhouette.Increased breast weight will lead to deformation by stretching aIncreased breast weight will lead to deformation by stretching andnd

ptosisptosis. They become painful and exerted traction on the chest. Skin. They become painful and exerted traction on the chest. Skin

redness is often with visible superficial venous network andredness is often with visible superficial venous network and

frequentlyfrequently intertrigointertrigo appears in theappears in the submammarysubmammary groove.groove.

Treatment in less severe forms is represented only by support wiTreatment in less severe forms is represented only by support withth

suitable bras and antisuitable bras and anti--estrogen therapy. In advanced forms theestrogen therapy. In advanced forms the

surgical treatment is recommended represented bysurgical treatment is recommended represented by mammoplastymammoplastyreduction.reduction.

44 GynecomastiaGynecomastia


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4.4. GynecomastiaGynecomastia

It is the development in excess of the breasts in men. It appearIt is the development in excess of the breasts in men. It appearssmore frequently in teenagers.more frequently in teenagers.

PhysiologicalPhysiological gynecomastiagynecomastia occursoccurs in new bornin new born,, prepubertalprepubertal and inand insenescence due to an excess of estrogen.senescence due to an excess of estrogen.

The cause is the excess of estrogen or androgen hormoneThe cause is the excess of estrogen or androgen hormonedeficiency.deficiency.

Increased estrogen levelsIncreased estrogen levels may be due either tomay be due either to hyperproductionhyperproduction(testicular or adrenal tumors) or iatrogenic (administration of(testicular or adrenal tumors) or iatrogenic (administration ofestrogens), or liver failure (cirrhosis) to metabolize the estroestrogens), or liver failure (cirrhosis) to metabolize the estrogens.gens.

Testicular endocrine insufficiencyTesticular endocrine insufficiency may have multiple causes: geneticmay have multiple causes: genetic((KlinefelterKlinefelter syndrome), hereditary (disturbances in hormonessyndrome), hereditary (disturbances in hormonessynthesis), congenital (synthesis), congenital (anorhidiaanorhidia,, cryptorchidismcryptorchidism), acquired (trauma,), acquired (trauma,orchitisorchitis,, hydrocelehydrocele,, varicocelevaricocele,, tumorstumors))

Initial treatment is conservative trying to resolve deficienciesInitial treatment is conservative trying to resolve deficiencies or byor byadministration of testosterone hormone oradministration of testosterone hormone or tamoxifentamoxifen to block theto block the

estrogen receptors. Theestrogen receptors. The subcutaneous mastectomysubcutaneous mastectomy is indicated inis indicated inrebel cases.rebel cases.


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Gynecomastia

Abnormalities of shapeAbnormalities of shape


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Abnormalities of shapeAbnormalities of shape

1.1. Inverted nippleInverted nipple

It is a relatively common abnormality and occurs mainlyIt is a relatively common abnormality and occurs mainlyduring puberty. It has an incidence of 2% in women. It isduring puberty. It has an incidence of 2% in women. It isbilateral in 25% of cases.bilateral in 25% of cases.

Nipple retraction may have different degrees of:Nipple retraction may have different degrees of:flattening,flattening, umbillicationumbillication andand invaginationinvagination . Han and. Han andHong (Han 1999) classified nipple retraction into 3Hong (Han 1999) classified nipple retraction into 3

grades as follows:grades as follows: Grade 1Grade 1 -- retracted nipple returns easily in the normal positionretracted nipple returns easily in the normal position

and this position is maintained without the need for traction.and this position is maintained without the need for traction.Slight compression or soft pinching of the skin around areolaSlight compression or soft pinching of the skin around areolacauses the nipple to return to normal position.causes the nipple to return to normal position.

Grade 2Grade 2 -- nipple can be brought to its normal position only bynipple can be brought to its normal position only bytraction and tends to retract after traction.traction and tends to retract after traction.

Grade 3Grade 3 the nipple is strongly retracted, and it is difficult tothe nipple is strongly retracted, and it is difficult toreverse back into normal position even by forced tractionreverse back into normal position even by forced traction..


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Inverted nipple


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B t t i


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2.2. BreastBreast ptosisptosis

Breasts tend to descend over time due to their own weight.Breasts tend to descend over time due to their own weight.

Breasts only support is the skin and the CooperBreasts only support is the skin and the Coopers ligaments.s ligaments.

PtosisPtosis is mainly due to weakening of supportive fibrous breastis mainly due to weakening of supportive fibrous breastelements (Cooperelements (Coopers ligament) as a result of deficiencies in thes ligament) as a result of deficiencies in thestructure of collagen and elastic tissue, or idiopathic (frequenstructure of collagen and elastic tissue, or idiopathic (frequently istly isassociated with varicose veins, hemorrhoids, hernias, flat feet,associated with varicose veins, hemorrhoids, hernias, flat feet, stretchstretchmarks, etc.) or due to ovarian hormones and thyroid disorders, emarks, etc.) or due to ovarian hormones and thyroid disorders, eitheritherdue to aging processes. Another cause is breast hypertrophy.due to aging processes. Another cause is breast hypertrophy.

It occurs mainly in postmenopausalIt occurs mainly in postmenopausal multiparousmultiparous with repeatedwith repeatedlactations.lactations.

It has 4 phases of evolution:It has 4 phases of evolution: mildmild ,, markedmarked (the nipple in normal(the nipple in normalposition, breast lower pole down),position, breast lower pole down), completecomplete (nipple is also lowered)(nipple is also lowered)

andand bulkybulky prolapseprolapse ((ptosisptosis is associated with marked hypertrophy).is associated with marked hypertrophy).

Treatment is surgical with aesthetic visa in most cases. The aimTreatment is surgical with aesthetic visa in most cases. The aim is tois torestore the breast with the nipple in the normal position and torestore the breast with the nipple in the normal position and to restorerestoreits normal shape and volume. The operation can involve the skinits normal shape and volume. The operation can involve the skin onlyonly

in mild forms, but in forms with hypertrophy a glandular reductiin mild forms, but in forms with hypertrophy a glandular reduction ison isalso necessary.also necessary.


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Level A = Normal breast

Level B = Mild breast ptosisLevel C = Moderate breast ptosis

Level D = Severe breast ptosis

Level E = Glandular or pseudo ptosis

Breast ptosis


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INFLAMATORY AFECTIONSINFLAMATORY AFECTIONS

OF THE BREASTOF THE BREAST

MastitisMastitis


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MastitisMastitis

MastitesMastites are inflammatory diseases of the breast due toare inflammatory diseases of the breast due toinfection, usually having the entrance gate the milkinfection, usually having the entrance gate the milkpores of the nipple or the skin pores.pores of the nipple or the skin pores.

The infection can affect the mammary gland and otherThe infection can affect the mammary gland and otheranatomical structures (skin, subcutaneous tissue,anatomical structures (skin, subcutaneous tissue,muscle fascia)muscle fascia) paramastitisparamastitis..

ParamastitisParamastitis can affect thecan affect the pre(supra)mammarypre(supra)mammary tissuestissues((suprammamarysuprammamary mastitismastitis) or the) or the retrommamaryretrommamarytissues (tissues (retromammaryretromammary mastitismastitis oror inframastitisinframastitis).).

When the infectious inflammatory process extends toWhen the infectious inflammatory process extends tothe whole breast we talk aboutthe whole breast we talk about panmastitispanmastitis ..

M t l i i i t d ti l i t iM t l i i i t d ti l i t i


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Most commonly incriminated etiologic agent isMost commonly incriminated etiologic agent isStaphylococcusStaphylococcus aureusaureus and Streptococcus. There mayand Streptococcus. There may

be fungal infections also.be fungal infections also.

It can beIt can be acuteacute oror chronicchronic mastitis. /mastitis. / SpecificSpecific orornonspecific.nonspecific.

Acute mastitis can occur at any age but usually duringAcute mastitis can occur at any age but usually duringlactation (lactation (puerperal mastitispuerperal mastitis).).

Mastitis may be secondary to an infected hematoma orMastitis may be secondary to an infected hematoma or

may be a metastatic abscess during a general infectiousmay be a metastatic abscess during a general infectiousdisease.disease.

Puerperal mastitis:Puerperal mastitis: is a nonspecific acute inflammation ofis a nonspecific acute inflammation of


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Puerperal mastitis:Puerperal mastitis: is a nonspecific acute inflammation ofis a nonspecific acute inflammation ofthe mammary gland that occurs in the period of pregnancythe mammary gland that occurs in the period of pregnancy

and more frequently during lactation.and more frequently during lactation.

The most often involved microorganism is S.The most often involved microorganism is S. AureusAureus..through the nipplethrough the nipples pores or through skin erosions, crackss pores or through skin erosions, cracks

or sores on the nipples. The favoring factor is theor sores on the nipples. The favoring factor is the stasis ofstasis ofthe milk in the breastthe milk in the breast. Infections play only a minor role in. Infections play only a minor role inthe pathogenesis of both puerperal andthe pathogenesis of both puerperal and nonpuerperalnonpuerperalmastitis in humans and many cases of mastitis aremastitis in humans and many cases of mastitis are

completely aseptic under normal hygienic conditions.completely aseptic under normal hygienic conditions.

Prophylactic measure are very important: completeProphylactic measure are very important: completeemptying of the breast and rigorous local hygiene.emptying of the breast and rigorous local hygiene.

There are two phases of evolution:There are two phases of evolution:

1.1. Congestive phase (AcuteCongestive phase (Acute galactophoritisgalactophoritis))

2.2. Phase of collection (Breast abscesses)Phase of collection (Breast abscesses)

Clinical pictureClinical picture


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In the congestive phaseIn the congestive phase, the patient experiences, the patient experiencesintense pain in the breast, which becomes swollen.intense pain in the breast, which becomes swollen.Because of the pain the patient does not empty theBecause of the pain the patient does not empty thebreast milk leading to stasis and favor the infection.breast milk leading to stasis and favor the infection.

CelsianCelsian signs appear. The breast is increased in volume,signs appear. The breast is increased in volume,firm, very painful with local temperature increased andfirm, very painful with local temperature increased anddiffuse skin redness. The nipple can be modified and withdiffuse skin redness. The nipple can be modified and withpurulent discharge. The patient is feverish andpurulent discharge. The patient is feverish and

inflammatory painfulinflammatory painful axillaryaxillary adenopathyadenopathy may be present.may be present.

In the collection phaseIn the collection phase, the inflammatory processes, the inflammatory processesusually focus on a particular region, where the touch mayusually focus on a particular region, where the touch mayfeelfeel fluctuencefluctuence. In untreated forms infection may extend. In untreated forms infection may extendto the entire breast (to the entire breast (panmastitispanmastitis) and may spontaneously) and may spontaneouslyfistulizefistulize to the skin.to the skin.


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Acute mastitis

Celsian signs

Breast abscessesBreast abscesses : are localized breast suppurations: are localized breast suppurations


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Breast abscessesBreast abscesses : are localized breast suppurations: are localized breast suppurationsprobably related to obstruction of lactiferous ducts.probably related to obstruction of lactiferous ducts.

They can be located:They can be located:

1.1. SubcutaneousSubcutaneous

2.2. SubSub areolarareolar,, -- the most frequentthe most frequent3.3. IInterlobular (periductalnterlobular (periductal inflammationinflammation),),

4.4. RRetromametromammmararyy

5.5. CCentral (simpleentral (simple oror multiple)multiple)

Symptoms and signs: pain, redness, local swelling,Symptoms and signs: pain, redness, local swelling,

hyperthermia. Drained fluid from the nipple afterhyperthermia. Drained fluid from the nipple aftercompression leaves a yellow stain (compression leaves a yellow stain (BudinBudin signsign). There). There

may be presentmay be present axillaryaxillary inflammatoryinflammatory adenopathyadenopathy..

Different types of breast abscesses


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Different types of breast abscesses

Acute mastitis should be differentiated from otherAcute mastitis should be differentiated from other


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Acute mastitis should be differentiated from otherAcute mastitis should be differentiated from otherdiseases with similar symptoms such as :diseases with similar symptoms such as :

1.1. ParamastitisParamastitis2.2. Breast engorgementBreast engorgement ((due to expansion anddue to expansion and

pressure exerted by the synthesis and storage ofpressure exerted by the synthesis and storage of

breast milkbreast milk.).)3.3. Breast sarcomaBreast sarcoma

4.4. Inflammatory breast cancer !Inflammatory breast cancer !

TreatmentTreatment

ProphilaxyProphilaxy Compliance with local hygiene measuresCompliance with local hygiene measures

Complete emptying of breast milk at each feedingComplete emptying of breast milk at each feeding

CurativeCurative


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In congestive phaseIn congestive phase

BroadBroad--spectrum antibioticsspectrum antibiotics -- 96% of cases have favorable96% of cases have favorableevolutionevolution

Evacuation of breast milk by milking or vacuum aspirationEvacuation of breast milk by milking or vacuum aspiration

Interruption of breast feeding from that breastInterruption of breast feeding from that breast -- even weaningeven weaning

Local cold compressesLocal cold compresses

Immobilization and breast suspension plus compressionImmobilization and breast suspension plus compressiondressing.dressing.

In collection phase (In collection phase (fluctuencefluctuence))

In generalIn general anestehesiaanestehesia

Incision, evacuation, debridement, drainage, dressing. InIncision, evacuation, debridement, drainage, dressing. In

superficial abscess the skin incision may besuperficial abscess the skin incision may be arcuatedarcuated parallelparallel

with Langer lines, for a better aesthetic effect, but in profounwith Langer lines, for a better aesthetic effect, but in profounddabscesses radial incisions are indicated to avoid sectioning theabscesses radial incisions are indicated to avoid sectioning the

milk ducts.milk ducts.

PerformPerform antibiogramantibiogram !!


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Radial incisions in case of a mammary gland abscess

The lobes are orientatedThe lobes are orientated radiallyradially around the areola.around the areola.

Thats why


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Debridement Drainage

Chronic breast abscessChronic breast abscess


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Chronic breast abscessChronic breast abscess

ItIt is the consequence of an unresolved acute mastitis.is the consequence of an unresolved acute mastitis.

SignsSigns: a hard lump in the breast, infiltrating the surrounding: a hard lump in the breast, infiltrating the surroundingtissues, dimpling and puckering of the skin. Painful to touchtissues, dimpling and puckering of the skin. Painful to touchand on compression sometimes purulent nipple discharge.and on compression sometimes purulent nipple discharge.

PeuPeu d'oranged'orange and retraction of the nipple may be present.and retraction of the nipple may be present.

AxillaryAxillary lymph nodes are enlarged.lymph nodes are enlarged.

At incision: thick sterile pus surrounded by fibrous tissue.At incision: thick sterile pus surrounded by fibrous tissue.

Because of local features it is difficult to make a differentialBecause of local features it is difficult to make a differentialdiagnosis with the breast cancerdiagnosis with the breast cancer. A thorough history of the. A thorough history of thepatient could reveal an acute mastitis treated years ago.patient could reveal an acute mastitis treated years ago.

Also the skin scar present on the breast may help to makeAlso the skin scar present on the breast may help to makethe difference.the difference.

The treatment is incision or excision withThe treatment is incision or excision with histopathologicalhistopathological

examinationexamination


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BENIGN TUMORS OF THEBENIGN TUMORS OF THE

BREASTBREAST


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BreastBreast fibroadenomafibroadenoma

BreastsBreasts fibroadenomafibroadenoma (or(or adenofibromaadenofibroma) are benign) are benign


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fibroepithelialfibroepithelial tumors of the mammary gland (containtumors of the mammary gland (contain

epithelial andepithelial and stromalstromal elements). The predominance of theelements). The predominance of theepithelial component determines the name ofepithelial component determines the name of

adenoadeno fibromafibroma while the predominance ofwhile the predominance of stromalstromal

component determines the name ofcomponent determines the name of fibrofibroadenomaadenoma..

The notion ofThe notion of complexcomplex fibroadenomafibroadenoma refers to therefers to the

fibroadenomasfibroadenomas which have: cysts larger than 3 cm inwhich have: cysts larger than 3 cm in

diameter,diameter, sclerosingsclerosing lesions, epithelial calcifications andlesions, epithelial calcifications andapocrineapocrine papillary modifications.papillary modifications.

The pure adenomaThe pure adenoma is very rare being a proliferation ofis very rare being a proliferation of

only the epithelial elements. It has 2 forms:only the epithelial elements. It has 2 forms:

AcinarAcinar formform :: normal or cysticnormal or cystic acinaracinar proliferationproliferation

Tubular formTubular form :: may appear during lactation (lactation adenoma)may appear during lactation (lactation adenoma)

There are two forms ofThere are two forms of fibroadenomasfibroadenomas::


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1.1. JuvenileJuvenile fibroadenomasfibroadenomas, which appear in young, which appear in young

women and teenagers, andwomen and teenagers, and2.2. MyxoidMyxoid fibroadenomasfibroadenomas,, inin CarneyCarneys Syndrome,s Syndrome, whichwhich

is a dominantis a dominant autosomalautosomal neoplasticneoplastic syndrome whichsyndrome which

includesincludes myxomasmyxomas of the skin and mucosa andof the skin and mucosa andendocrine dysfunctions.endocrine dysfunctions.

FibroadenomaFibroadenoma is the most frequent benignis the most frequent benign tumortumor of theof the

breast. Young females under 40 years age arebreast. Young females under 40 years age arepredominantly affected. In 10predominantly affected. In 10--15% of cases they are15% of cases they aremultiple.multiple.

Even they are considered benign, yet they have aEven they are considered benign, yet they have apotential of malignant transformation (mostlypotential of malignant transformation (mostlysarcomatoussarcomatous) in percentage of 3) in percentage of 3--4%. Patients with4%. Patients withmultiplemultiple fibroadenomasfibroadenomas or complex types have a higheror complex types have a higher

risk (twice) of breast cancer.risk (twice) of breast cancer.

Fib dFib d t h l i lif tit h l i lif ti


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FibroadenomasFibroadenomas represent a hyperplasic or proliferativerepresent a hyperplasic or proliferative

process started from a terminal milk duct. The cause isprocess started from a terminal milk duct. The cause is

unknown.unknown.

AproximativellyAproximativelly 10% of them disappear in a year and the10% of them disappear in a year and the

grate majority stop their evolution after they reach 2grate majority stop their evolution after they reach 2--3 cm3 cmin diameter. They can regress in postmenopausal periodin diameter. They can regress in postmenopausal period

or they calcify. On the other hand they can rapidly growor they calcify. On the other hand they can rapidly grow

during pregnancy, during treatment with substitutiveduring pregnancy, during treatment with substitutive

feminine hormones or during immunosuppressantfeminine hormones or during immunosuppressant

treatment, when they can simulate a breast cancer.treatment, when they can simulate a breast cancer.

There is no racial predilectionThere is no racial predilection

FibroadenomasFibroadenomas may be located anywhere in the breast.may be located anywhere in the breast.

Cli i l i tCli i l i t


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On inspection nothing can be noticed when they areOn inspection nothing can be noticed when they aresmall. As they grow a bulge under the skin can besmall. As they grow a bulge under the skin can be

observed. In giant forms (observed. In giant forms (phyllodesphyllodes tumorstumors) the breast is) the breast is

highly modified with distended skin, with marble likehighly modified with distended skin, with marble likeappearance, with visible vascular network.appearance, with visible vascular network.

On palpation, theOn palpation, the fibroadenomafibroadenoma has some characteristichas some characteristic

features that makes it easy to diagnose and differentiatefeatures that makes it easy to diagnose and differentiatefrom otherfrom other tumorstumors. There is a tumour of about 1. There is a tumour of about 1--5 cm5 cm

diameter, of harddiameter, of hard--elastic consistency, with smoothelastic consistency, with smooth

surface, well delimited from surrounding tissues, painless,surface, well delimited from surrounding tissues, painless,and the most important feature: very mobile.and the most important feature: very mobile.

In theIn the axillaaxilla there are no pathological enlarged lymphthere are no pathological enlarged lymph

nodes.nodes.


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Oth ff ti f diff ti l di iOth ff ti f diff ti l di i


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Other affections for differential diagnosis are:Other affections for differential diagnosis are:

1.1. Breast cystsBreast cysts elastic consistency, also mobile but on ultrasoundelastic consistency, also mobile but on ultrasound

examination the content is fluid in contrast withexamination the content is fluid in contrast with fibroadenomafibroadenoma

which is solid. At fine needle aspiration fluid can be obtained.which is solid. At fine needle aspiration fluid can be obtained.

2.2. SclerocysticSclerocystic mastopathymastopathy feeling likefeeling like lead shots" under thelead shots" under the

skin on palpation, ultrasound shows multiple small cysticskin on palpation, ultrasound shows multiple small cystic

formations of various sizes, usually symmetrical, often painful,formations of various sizes, usually symmetrical, often painful,

sometimes with greenish nipple discharge.sometimes with greenish nipple discharge.

3.3. BreastBreast lipogranulomaslipogranulomas poorly delimitated mass with reducedpoorly delimitated mass with reduced

mobility due to chronic inflammatory process, possiblymobility due to chronic inflammatory process, possibly

associated with axillary inflammatoryassociated with axillary inflammatory adenopathy.adenopathy.

4.4. LipomasLipomas have softer consistency and are more superficialhave softer consistency and are more superficial

5.5. Other tumors of the breastOther tumors of the breast

TreatmentTreatment


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SimpleSimple fibroadenomasfibroadenomas are tumors wellare tumors well incapsulatedincapsulated whichwhich

can be easilycan be easily enucleatedenucleated. The operation of election is a. The operation of election is alumpectomylumpectomy with a margin of security of 1 cm around thewith a margin of security of 1 cm around thetumor, and in cases of multiple or diffusetumor, and in cases of multiple or diffuse fibroadenomasfibroadenomas aaquadrantectomyquadrantectomy can be performed. In complex cases acan be performed. In complex cases askin sparingskin sparing mastectomymastectomy can be performed.can be performed.

The surface section of theThe surface section of the fibroadenomafibroadenoma has a pearlyhas a pearly


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The surface section of theThe surface section of the fibroadenomafibroadenoma has a pearlyhas a pearlywhite color which is bulging under the effect of elasticwhite color which is bulging under the effect of elastic

fibers while in malignant tumor the section area is flatfibers while in malignant tumor the section area is flatsometimes with yellow spots and hard calcified areas.sometimes with yellow spots and hard calcified areas.

Prognosis is favorable but keep in mind that the risk ofPrognosis is favorable but keep in mind that the risk of

breast cancer is twice as higher in women with history ofbreast cancer is twice as higher in women with history ofoperatedoperated fibroadenomafibroadenoma and the risk ofand the risk of sarcomatoussarcomatoustransformation is about 3%.transformation is about 3%.

Cancer

Fibroadenoma


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FibrocysticFibrocystic mastopathymastopathymastosesmastoses

( Reclus( Reclus diseasedisease))

Proliferative lesion that occurs in women around age 30,Proliferative lesion that occurs in women around age 30,b t b tb t b t


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but can be seen at any age.but can be seen at any age.

Endocrine factors are involved:Endocrine factors are involved: hyperfoliculinemiahyperfoliculinemia,,hyperthyroidism, genital or thyroid dysfunctions.hyperthyroidism, genital or thyroid dysfunctions.

GrossGross appearanceappearance:: multiple cysts of various sizes, filledmultiple cysts of various sizes, filled

with clear or cloudy yellowwith clear or cloudy yellow--brown liquid, surrounded bybrown liquid, surrounded byscleroussclerous tissue. Predominant one of the two components.tissue. Predominant one of the two components.

MicroscopicMicroscopic appearanceappearance: micro: microcysts surrounded by fibroticcysts surrounded by fibroticwallswalls,, withwith cylindrical secretory epitheliumcylindrical secretory epithelium withwithmitochondriamitochondria andand multiple granules, hypo or atrophicmultiple granules, hypo or atrophicbreast tissuebreast tissue;; epithelial changes mayepithelial changes may transform intotransform intomalignamalignancyncy..

ClinicalClinical:: embarrassmentembarrassment or localor local painpain, spontaneous or, spontaneous orprovoked, especially duringprovoked, especially during menstruationmenstruation. Palpation. Palpationreveals tumorreveals tumorss (sizes(sizes fromfrom mmmm toto 22--3 cm) disseminated or3 cm) disseminated orgrouped, uni or bilateral (usually), mobile, firm, slightlygrouped, uni or bilateral (usually), mobile, firm, slightlypainful, increase in menstrual period. Axillary adenopathypainful, increase in menstrual period. Axillary adenopathyusually is absentusually is absent..

FibrocysticFibrocystic mastopathymastopathy


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FibrocysticFibrocystic mastopathymastopathy

Only in 5% of cases, changes can be considered at riskOnly in 5% of cases, changes can be considered at risk


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Only in 5% of cases, changes can be considered at riskO y 5% o cases, c a ges ca be co s de ed at sof developing cancer.of developing cancer.

TreatmentTreatment

1.1. In early or localized forms in women under 35 yearsIn early or localized forms in women under 35 years --

conservative treatmentconservative treatment hormones, local applicationshormones, local applications((MastoprofenMastoprofen)) -- after pregnancy and lactation theafter pregnancy and lactation thedisease may regress.disease may regress.

2.2. In rapidly growing forms or in case of ineffectiveIn rapidly growing forms or in case of ineffectivemedication treatmentmedication treatment -- quadrantectomyquadrantectomy..

3.3. For diffuse forms that include all the glandFor diffuse forms that include all the gland --

subcutaneous mastectomysubcutaneous mastectomy


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Breast cystsBreast cysts

Cysts areCysts are the most common "tumors" of the breastthe most common "tumors" of the breast..


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Cysts are rare in women over 50 years and generally doCysts are rare in women over 50 years and generally do

not have any relationship with breast cancer.not have any relationship with breast cancer.

On palpation they are mobile with smooth surface and ofOn palpation they are mobile with smooth surface and ofelastic consistency. Can be or not painful.elastic consistency. Can be or not painful.

They are related toThey are related to papillomaspapillomas tumor type. Thetumor type. The histologichistologicfeatures are offeatures are of apocrineapocrine metaplasiametaplasia (the inner lining layer(the inner lining layerof large cysts is composed ofof large cysts is composed of apocrineapocrine cells).cells).

IntraoperativeIntraoperative they look dark ("blue dome cysts")they look dark ("blue dome cysts")

Can be treated by simple evacuation throughCan be treated by simple evacuation through fine needlefine needleaspiration or excision.aspiration or excision. Needle aspiration in most cases isNeedle aspiration in most cases isguided by ultrasound. When extracted fluid does notguided by ultrasound. When extracted fluid does not

contain blood,contain blood, cytotlogicalcytotlogical examination is nod neededexamination is nod neededbecause there is no suspicion of cancer but when blood isbecause there is no suspicion of cancer but when blood ispresent in fluid it must be examinedpresent in fluid it must be examined cytologicallycytologically..

In most cases cyst evacuation by aspiration is theIn most cases cyst evacuation by aspiration is the

definitive treatment method.definitive treatment method.

Breast cyst on ultrasound examination


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Cyst excision


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GalactoceleGalactocele

A cystic tumor that contains milky substancewhich appears usually during breast feedingperiod. Once lactation has ended, the cyst willdisappear on its own without intervention

. It is

. It isusually located beneath areola, and due tousually located beneath areola, and due toabrupt suppression of lactationabrupt suppression of lactation


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IntracanalicularIntracanalicular papillomapapilloma

IntracanalicularIntracanalicular papillomaspapillomas are cell proliferation in theare cell proliferation in the


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t aca a cu a pap o asp p a e ce p o e at o t epmammary ductsmammary ducts..

Gross appearanceGross appearance:: IntraductalIntraductal vegetations of a fewvegetations of a fewmm, red multi ramified, epithelium developed in themm, red multi ramified, epithelium developed in theducts, located in the center of the gland andducts, located in the center of the gland and subareolarsubareolar

region. The ducts are enlarged but with thin walls andregion. The ducts are enlarged but with thin walls andcontain a brownish fluid.contain a brownish fluid.

Microscopic appearanceMicroscopic appearance: vascular axis covered by: vascular axis covered by

cylindrical epithelium (cylindrical epithelium (papillomapapilloma). At the periphery). At the peripheryhyperplastichyperplastic alterations are present. Focal areas ofalterations are present. Focal areas ofhemorrhage and necrosis are also present. Canhemorrhage and necrosis are also present. Canaccommodateaccommodate atypical hyperplasiaatypical hyperplasia andand ductalductal

carcinoma in situcarcinoma in situ. If the epithelium is double layer. If the epithelium is double layercolumnar cell, it becomescolumnar cell, it becomes noninvasive papillarynoninvasive papillarycarcinoma.carcinoma.

Clinical pictureClinical picture::


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Common in women aged between 30Common in women aged between 30--50 years, with:50 years, with:

1.1. Serous orSerous or serosero--sanguinoussanguinous discharge for long periods of time,discharge for long periods of time,2.2. Small, round tumor under the nipple, that does not adhere to theSmall, round tumor under the nipple, that does not adhere to the

skin,skin,

3.3. Traction of the nipple mobilizes the tumor (related to milk ductTraction of the nipple mobilizes the tumor (related to milk duct),),

4.4. Serous orSerous or serosero--sanguinoussanguinous discharge on nipple compression,discharge on nipple compression,

5.5. NoNo axillaryaxillary adenopathyadenopathy..

MultipleMultiple intraductalintraductal papillomaspapillomas occur in approximatelyoccur in approximately

10% of cases, tend to occur in the younger patients and10% of cases, tend to occur in the younger patients andare less often associated with nipple discharge.are less often associated with nipple discharge.

Paraclinical diagnosis:

Ultrasound examinationUltrasound examination MamographyMamography

GalactographyGalactography

MammaryMammary ductoscopyductoscopy

Cytological examination of nipple dischargeCytological examination of nipple discharge

TratamentTratament :: Deciding on the appropriate surgery is problematic due to


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Deciding on the appropriate surgery is problematic due tothe difficulty in discriminating between intraductalpapilloma and breast cancer.

When the lesion is located to a single duct,microdochectomy gives satisfactory results in younger

patients with a minimal interference with the breast. Inolder patients where breast-feeding is not required, majorduct excision may be preferable.

When a specific duct cannot be identified then blind

excision of the retro-areolar ductal system is usuallyperformed (central quadrantectomy) followed byhistological examination.

Prognosis: the incidence of malignancy (invasive or in situ)associated to papilloma varies between 1 and 23% Asolitary papilloma is not thought to be a pre-malignantlesion and is considered by some to be an aberrationrather than a true disease process.

Multiple intraductal papillomas are more susceptible todevelop carcinoma.

I t li l ill dil t d


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Ultrasound examination

intracanalicular papilloma

GalactographyGalactography

Intracanalicular papilloma - dilated

duct (3 mm ) at a distance of 1.5 cmfrom the nipple

DuctoscopyDuctoscopy
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DuctoscopyDuctoscopy


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NIPPLE DISCHARGENIPPLE DISCHARGE

Nipple discharge is an event that causes discomfort andNipple discharge is an event that causes discomfort and

anxiety to women.anxiety to women.

In this area significant progress have been madeIn this area significant progress have been made inin

recent years through the development of diagnosticrecent years through the development of diagnostic

procedures.procedures.

Physiopathology:


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The causes that lead to discharge from the nipple are not yet

fully elucidated. In most cases it is associated with endocrinedisorders and/or certain drug treatments. They are oftenassociated to ductal ectasy and/or fibrocystic changes in the

mammary gland. Changes are often bilateral.

A less common noncancerous etiology is the ductal ectasyassociated with periductal inflammatory process(galactophoritis)

The most common cause is the intraductal proliferation ofductal epithelium as a result of a hyperplastic process,micropapillar proliferation, papillomas and/or ductalcarcinomas.

The vast majority of intraductal changes that produce nippledischarge are located in the first 1-4 cm of the lactiferous

duct from the nipple.


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Nipple discharge- causes

FrequencyFrequency:: -- 33--8%8%..

Mortality and morbidityMortality and morbidity :: the vast majority of patients healthe vast majority of patients heal


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Mortality and morbidityMortality and morbidity :: the vast majority of patients healthe vast majority of patients heal

after surgery. If the etiology is the cancer, mortality rate isafter surgery. If the etiology is the cancer, mortality rate isthe same as in case of other breast cancers. Of course, inthe same as in case of other breast cancers. Of course, incase of early diagnosis (occult) the prognosis is evencase of early diagnosis (occult) the prognosis is evenbetter.better.

RaceRace:: there are no differences between races.there are no differences between races.

SexSex : Nipple discharge can occur in both sexes but is more: Nipple discharge can occur in both sexes but is morecommon in women. When it occurs in young men is due tocommon in women. When it occurs in young men is due to

aa ductalductal ectasyectasy similar to that ofsimilar to that of gynecomastiagynecomastia withoutwithouthormonehormone--related disorders. But, breast cancer is morerelated disorders. But, breast cancer is morecommon in men with nipple discharge.common in men with nipple discharge.

AgeAge: disease can occur at any age.: disease can occur at any age.

Subclinical nipple discharge occurs more frequently inSubclinical nipple discharge occurs more frequently inwomen who use birth control pills and substitutive hormonewomen who use birth control pills and substitutive hormone

therapy.therapy.



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In most cases, nipple discharge are bilateralIn most cases, nipple discharge are bilateral

The aspect of the discharge may be:The aspect of the discharge may be:

Clear (aqueous)Clear (aqueous)

Serous (yellowish)Serous (yellowish)

LactescenteLactescente (white)(white)

SeroSero--sanguinolentsanguinolent

SanguinolentSanguinolent

To be considered nipple discharge, discharges must takeTo be considered nipple discharge, discharges must takeplace outside the period of lactation, to be spontaneous andplace outside the period of lactation, to be spontaneous andpersistent.persistent.

Suspicion of cancer increases if the discharge is locatedSuspicion of cancer increases if the discharge is locatedonly at one breast, from a single pore and isonly at one breast, from a single pore and is sanguinolentsanguinolent..

Also if a tumor can be felt on palpation and if the patient isAlso if a tumor can be felt on palpation and if the patient isover 50 years old.over 50 years old.

After investigations, when suspected lesions are notAfter investigations, when suspected lesions are notmalignant, in 73% of cases, nipple discharge regressmalignant, in 73% of cases, nipple discharge regress


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malignant, in 73% of cases, nipple discharge regressa g a t, 3% o cases, pp e d sc a ge eg essspontaneously within 5 years.spontaneously within 5 years.

Investig

003 breast pathology

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