Lecture for undergraduate medical students as part of General Surgery curriculum.

1. BREAST:
INTRODUCTION
Dr. Sunil K S Gaur

2. ANATOMY

3. Anatomy
• Modified sweat gland
• Within superficial fascia
• Extent: Pendulous part
• second to the sixth ribs
• lateral border of the sternum to the
mid-axillary line
• Extent: Actual
• clavicle to the seventh or eighth ribs
• midline to the edge of the latissimus
dorsi

4. Anatomy (contd.)
• Axillary tail of Spence:
• Passes to the axilla through a defect in
deep fascia k/a Foramen of Langer
• Ligaments of Cooper:
• attached firmly to the superficial fascia
and pectoral fascia
• Retromammary space

5. Anatomy (contd.
• Nipple-areola complex:
• Nipple pierced by 15-20 lactiferous
ducts
• Contains circular and longitudinal
muscles – erectile structure
• Areola is a circular pigmented area
around the nipple
• Epithelium contains numerous sweat
and sebaceous glands - Montgomery’s
tubercles

6. Anatomy (contd.)
• Secretory apparatus:
• Lobule is the basic structural unit
• Aggregate to form lobes – 15-20
• Each lobe drained by a separate
lactiferous duct
• Duct is lined with a spiral arrangement
of contractile myoepithelial cells and is
provided with a terminal ampulla –
reservoir

7. Anatomy (contd.)
• Blood supply:
• Perforating branches of Internal
MammaryArtery – 60%
• Branches from axillary artery
• Lateral thoracic artery – 30%
• Superior thoracic artery
• Pectoral branches of thoraco-acromial
artery
• Lateral branches of 2-4 intercostal
arteries

8. Anatomy (contd.)
• Lymphatic drainage:
• Axillary LN – 75%
• Level I – anterior, posterior, lateral
• Level II – central, interpectoral (Rotter’s
nodes)
• Level III – apical
• Internal mammary LN – 25%
• Hormonal influence:
• Estrogen: ductal proliferation
• Progesterone: glandular proliferation
• Prolactin: lactogenesis

9. INVESTIGATIONS

10. Mammography
• Special x-ray
• placing the compressed breast in direct
contact with ultrasensitive film
• exposing it to low-voltage, high-
amperage x-rays
• dose of radiation is approximately 0.1 cGy
– very safe investigation
• sensitivity increases with age as the
breast becomes less dense

11. Mammography (contd.)
Fibroadenoma (popcorn calcification) seen in RCC - Right cranio-caudal & RMLO - Right medio-lateral
oblique views

12. Ultrasonography
• Particularly useful in:
• young women with dense breasts
• in distinguishing cysts from solid
lesions
• Can also be used to:
• localise impalpable areas of breast
• image axilla when a cancer is
diagnosed
• for guided percutaneous biopsies of
suspicious mass or lymph nodes

13. Ultrasonography (contd.)

14. Magnetic Resonance Imaging
Working principle

15. MRI (contd.)
• MRI of the breast is useful in a
number of settings:
1. to distinguish scar from recurrence –
BCT for cancer
2. to assess multifocality and
multicentricity in Lobular Cancer
3. to assess the extent of high-grade
Ductal Cancer In Situ (DCIS)
4. best imaging modality for the
breasts with implants
5. as a screening tool in high-risk
women – family history

16. MRI (contd.)
MRI image of a patient with breast implants with a solid mass in one breast

17. Cytology/Histopathology
• Cells or tissue from suspicious areas are obtained by various techniques, stained
and examined under microscope
• Techniques:
• Fine-needle aspiration cytology (FNAC)
• Core-needle biopsy
• Incisional biopsy
• Excisional biopsy

18. FNAC
• A fine 21 or 23 G needle used to
aspirate some material from the lump
• Smeared on slide
• Fixed, stained and examined

19. Core-needle biopsy
• Special type of wide bore assembled
spring-loaded needle used to obtain
tissue samples
• Inner stylet with slot for specimen
• Outer sheath
• Specimen fixed, sectioned, stained
and analysed (examination + special
tests)
• Choice in suspected malignant breast
lump

20. Sugical biopsy
• Incisional biopsy:
• Only a small piece of lump in cut and sent for analysis
• Not used in breast diseases
• Excisional biopsy:
• Whole of the tumor is taken out and the sent for analysis
• Done for clinically confirmed benign lesions of breast

21. FNAC vs CNB

22. Triple assessment
• In any patient who presents with a
breast lump or other symptoms
suspicious of carcinoma, the
diagnosis should be made by a
combination of
• clinical assessment
• radiological imaging
• cytological or histological analysis
• The positive predictive value (PPV) of
this combination exceeds 99.9%

23. BREAST: ANDI
Dr Sunil K S Gaur

24. ANDI: Introduction
• Aberration of Normal Development and Involution
• Over the last century, a mixture of physiological changes and disease processes
have been ascribed a variety of terminology, leading to confusion
• Coined by LE Hughes at Cardiff breast clinic in 1987
• ANDI includes variety of benign breast disorders occurring at different periods of
reproductive periods in females—early, matured and involution phase of
reproductive age group

25. Introduction (contd.)

26. Introduction (contd.)
• Breast is a dynamic structure:
• undergoes changes throughout a woman’s reproductive life -
• cyclical changes throughout the menstrual cycle
• Pathology:
• The disease consists essentially of four features that may vary in extent and degree in
any one breast.
• Cyst formation
• Fibrosis
• Hyperplasia
• Papillomatosis

27. FIBROADENOMA

28. Fibroadenoma
• Aka breast mouse
• Hyperplasia of a single lobule of the
breast
• Arise in the fully developed breast
between the ages of 15 and 25 years
• Encapsulated tumour – easily
enucleated
• No malignant potential

29. Fibroadenoma (contd.)
• Clinical features:
• Painless swelling
• Smooth, firm, nontender, well-localised
• Moves freely within the breast tissue (mouse in the breast)
• Investigations:
• Mammography – well-localized, smooth, popcorn calcification
• Ultrasound (to confirm solid nature)
• FNAC – indicated if age >25 yrs or any atypical features on imaging

30. Fibroadenoma (contd.)
• Treatment:
• Surgical excision
• Indications for surgery are:
• Size > 3 cm
• Multiple
• Giant type
• Recurrence
• Cosmesis
• Complex type
• Fibroadenoma which is small (< 3 cm)/single/age < 30 years can be left alone with
regular follow-up

31. Fibroadenoma (contd.)
• Treatment (contd.):
• Alternatives to surgery include
• Cryoablation
• Heating with high-frequency ultrasound
• Removal with a large core vacuum biopsy
system
• Giant fibroadenomas:
• >5 cm in diameter and often rapidly growing
• can be enucleated through a sub-mammary
incision

32. DIFFUSE HYPERTROPHY

33. Diffuse hypertrophy
• Occurs sporadically
• in healthy girls at puberty (benign virginal hypertrophy)
• less often, during the first pregnancy
• This tremendous overgrowth is apparently caused by an alteration in the normal
sensitivity of the breast to oestrogenic hormones
• Usually bilateral
• Treatment:
• Reduction mammoplasty
• Anti-oestrogens

34. NIPPLE INVERSION &
RETRACTION

35. Nipple “inversion”
• Congenital abnormality
• Presents at puberty
• In about 25% of cases it is bilateral
• Problems with breast-feeding and
recurrent infection (retention)
• Treatment:
• Treatment is usually unnecessary
• If interfering with lactation –
Mechanical suction devices can be
used

36. Nipple “retraction”
• Later in life
• Recent retraction of the nipple may be of
considerable pathological significance
• Secondary to duct ectasia or carcinoma
• Slit-like retraction – duct ectasia and
chronic periductal mastitis
• Circumferential retraction – indicates an
underlying carcinoma, with or without an
underlying lump

37. CYCLICAL MASTALGIA
AND NODULARITY

38. Cyclical mastalgia
• Seen in late reproductive age group
• Pain related to menstrual cycle – aggravated just before and during menses
• Feeling of “heaviness”, bilateral and diffuse
• Non-cyclical mastalgia:
• Usually due to some definable secondary or extra-mammary cause
• Investigations:
• Imaging to rule out any secondary cause of pain, especially if non-cyclical nature of pain

39. Cyclical mastalgia (contd.)
• General treatment:
• Initially, firm reassurance
• Avoiding caffeine drinks, tobacco
• Appropriately fitting and supportive
bra
• A patient symptom diary – allows the
majority of patients to adjust to the
concept of a cyclical nature
• Medical management:
1. Diclofenac gel
2. Evening primrose oil – orally as soft
capsules
3. Danazol – anti-gonadotrophin agent
4. Bromocriptine – prolactin Inhibitor
5. Tamoxifen- estrogen antagonist
6. LHRH agonist – Goserelin

40. Cyclical mastalgia with nodularity
• Aka fibrocystadenosis, fibroadenosis
• Oestrogen dependent – exaggerated response to hormones
• Diffuse, multiple, small cysts present
• If one of the cyst becomes large, presents as well-localized, transilluminant, non-
tender swelling with thin bluish capsule – bluedome cyst of Bloodgood

41. Cyclical mastalgia with nodularity (contd.)
• Clinical features:
• Bilateral, painful, diffuse nodularity
• Pain aggravated just before and during
menses
• Subsides during pregnancy and
lactation
• Investigations:
• To rule out neoplasia
• Treatment:
• General management
same as before
• Medical management
• Surgical management:
• Excision if localized disease or any large
cyst present
• If persistent severe disease –
subcutaneous mastectomy and
prosthesis placement

42. BREAST CYSTS

43. Breast cysts
• Most commonly in the last decade of
reproductive life – result of a non-
integrated involution of stroma and
epithelium.
• They are often multiple, bilateral and
can mimic malignancy.
• They typically present suddenly and
cause great alarm
• Investigation:
• USG – confirms the diagnosis

44. Breast cysts (contd.)
• Treatment:
• A solitary cyst or small collection of
cysts can be aspirated
• If there is a residual lump or if the fluid
is blood-stained
• a core biopsy or
• local excision for
• This will exclude cystadenocarcinoma,
which is more common in elderly
women.

45. SCLEROSING ADENOSIS

46. Sclerosing adenosis
• Multiple, small, firm nodules with fibrous tissue and
tiny cysts
• Arise from proliferation of terminal duct-lobule unit
often with deposition of calcium
• Clinical features:
• Recurring pain +/- breast mass
• Tender breast with palpable tender, firm mass
• Mimics carcinoma clinically, radiologically and
histologically

47. Sclerosing adenosis (contd.)
• Investigations:
• Mammography – irregular, heterogenous mass
with amorphous calcification
• MRI & guided biopsy – to rule out carcinoma
• Treatment:
• Same as cyclical mastalgia with nodularity
• Regular follow-up and screening for Ca breast

48. DUCT ECTASIA/
PERIDUCTAL MASTITIS

49. Duct ectasia/
periductal
mastitis
• Dilatation of the breast ducts associated
with periductal inflammation
• Exact cause unknown, thought to be due
to relaxation of myoepithelium
• More common in smokers
• Fibrosis eventually develops, which may
cause slit-like nipple retraction
Duct dilatation
Filled with
green/brown secretion
Irritant reaction in
surrounding tissue
Peri-ductal
mastitis/abscess/fistula

50. Duct ectasia/periductal mastitis (contd.)
• Clinical features:
• Green/brown discharge
• Tender, indurated sub-areolar mass
• Nipple retraction
• Abscess/fistula
• Investigations: Rule out cancer
• Mammogram +/- dye
• USG
• Cytology/histology

51. Duct ectasia/periductal mastitis (contd.)
• Treatment:
• Hadfield operation – cone excision of
all the major ducts
• important to shave the back of the
nipple – otherwise recurrence
• Antibiotics may be tried but are often
unsuccessful

52. OTHER
BENIGN
BREAST
DISEASES

53. CONGENITAL CONDITIONS

54. Congenital Conditions
• Amazia:
• Congenital absence of breast
• Poland’s syndrome - with absence of
the sternal portion of the pectoralis
major
• More common in males
• Athelia:
• Absence of nipples

55. Congenital Conditions (contd.)
• Polymazia:
• Presence of accessory breasts
• M/C site axilla
• Other sites groin, buttocks and thigh
• Functional during lactation
• Polythelia:
• Presence of accessory or
supernumerary nipples
• Usually along the mammary ridge
(‘milk line’)

56. Mastitis of Infants
• On 3rd-4th day of life, a drop of colourless
fluid can be expressed from the infant’s
breast
• A few days later, there is often a slight
milky secretion, which disappears during
the third week – ‘witch’s milk’
• Seen only in full-term infants
• Stimulation of the fetal breast by
prolactin in response to the drop in
maternal oestrogens and is essentially
physiological.
• True (infective) mastitis is uncommon

57. INFLAMMATORY
CONDITIONS

58. Mastitis/Abscess
• Classification by location:
• Subareolar – folliculitis or infected
gland of Montgomery
• Intramammary
• Lactational – M/C
• Non-lactational – secondarily infected
duct ectasia
• Retromammary –TB of intercostal
lymph nodes or ribs
• Classification by organism:
• Bacterial
• Tubercular – rare
• Actinomycosis – very rare

59. Lactational BreastAbscess
• M/C variety
• Most are caused by Staphylococcus aureus
• The source is usually the infant – after the 2nd day of life
• Pathogenesis:
• Cracked nipple – ascending infection
• Blockage of lactiferous ducts – epithelial debris or inverted nipple
• Once within the ampulla of the duct, staphylococci cause clotting of milk and,
within this clot, organisms multiply

60. Lactational BreastAbscess
(contd.)
• Clinical features:
• Pain
• Diffuse oedema, erythema
• Raised temperature, tenderness Stage of cellulitis
• High grade fever
• Chills & rigor
• Throbbing pain
• Tender fluctuant swelling Stage of abscess
• Purulent nipple discharge
• Rupture
*Fluctuation is a late sign in breast abscess

61. Lactational BreastAbscess - Mx
• Investigations:
• USG breast +/- guided needle aspiration
• Pus culture and antibiotic sensitivity
testing
• TLC/DLC
• Treatment:
• Antibiotics – first empirical then
according to sensitivity
• NSAIDs – analgesia
• May continue breast-feeding if
manageable
• If abscess:
• Repeated USG guided needle aspiration –
Standard nowadays
• Incision and drainage – not recommended
as initial treatment

62. Lactational BreastAbscess – Mx (contd.)
• I & D of breast abscess:
• Indications:
• Marked thinning of skin
• Repeated aspirations and antibiotics fail to resolve
• In large abscess, a counter incision is required
• +/- corrugated rubber drain

63. Tuberculosis of breast
• Comparatively rare
• Usually secondary toTB empyema orTB of intercostal lymph nodes, ribs
• Clinical features:
• Initially there is retromammary abscess
• Later, multiple chronic abscesses in breast
• Multiple sinuses over the skin
• Typical bluish, attenuated appearance of the surrounding skin
• Matted axillary lymph nodes
• General features of tuberculosis are present

64. Tuberculosis of breast (contd.)
• Investigations:
• Diagnosis by AFB (ZN) stain or newer techniques such as PCR, CBNAAT etc.
• USG of breast and chest wall
• Chest x-ray/CT for intra-thoracic disease extension
• Blood tests
• Treatment:
• ATT (anti-tubercular therapy)
• Anti-gravity aspiration for large cold abscess
• Mastectomy (only for patients with persistent residual infection)

65. Mondor’s disease
• Mondor’s disease is spontaneous
thrombophlebitis of the superficial veins
of the breast and anterior chest wall
• Cause:
• Unknown
• Few cases due to injury or infection
• Clinical features:
• A thrombosed subcutaneous cord
attached to the skin – pathognomonic
• On raising the arm, a narrow, shallow,
subcutaneous groove
• Upper-inner quadrant is rarely involved

66. Mondor’s disease (contd.)
• Treatment:
• Restricting arm movements
• Analgesics
• Self-limiting – usually subsides within a few months without recurrence, complications
or deformity
• There are case reports of Mondor’s disease being associated with subsequent
development of malignancy, although coincidental malignancy is more likely

67. TRAUMATIC CONDITION

68. Traumatic Fat Necrosis
• Mode of injury:
• Mostly trivial trauma
• Direct – blow, seat belt trauma,
surgery, radiation etc.
• Indirect – e.g., violent contraction of
pectoralis major
• Pathogenesis:
• Chronic inflammation induced
by saponification
• Leads to fibrosis and later
calcification
Capillary ooze
Triglycerides
dissociate to fatty
acids (lipase)
FA + Calcium
(from blood)
Saponification

69. Traumatic Fat Necrosis (contd.)
• Clinical features:
• Lump – painless, nontender,
smooth, hard
• Non-progressive/non-regressive
• Mimics carcinoma – even skin
tethering, nipple retraction
• Diagnosis:
• Mammography – rule out Ca
• Biopsy to confirm
• Treatment:
• Excision

70. TUMOURS

71. PhyllodesTumour
• Aka serocystic disease of Brodie,
cystosarcoma phyllodes
• Usually occur in women over the age
of 40 years but can appear in younger
women
• Wide variation in activity:
• Totally benign – resembling a
fibroadenoma
• Locally aggressive – higher mitotic
index
• Metastatic – rare; via haematogenous
route; lungs and bones

72. PhyllodesTumour (contd.)
• Types:
1. Benign
2. Borderline
3. Malignant
• Clinical features:
• They present as a large, sometimes massive, rapidly growing tumour
• Uneven, bosselated surface
• Occasionally, ulceration of overlying skin occurs because of pressure necrosis
• Despite their size, phyllodes tumours remain mobile on the chest wall

73. PhyllodesTumour (contd.)
• Investigations:
• Mammography
• Core-needle biopsy – to confirm
diagnosis and grade
• If malignant – metastatic work-up
• Treatment:
• Wide local excision – with 1 cm margin
• Mastectomy –
• massive
• recurrent
• malignant

74. Duct Papilloma
• Epithelium lined true polyps of
lactiferous ducts
• Usually <1 cm but can attain large
size
• May cause duct obstruction
• Clinical features:
• Blood-stained nipple discharge
• Mass with a stalk inside the duct
• May project out of nipple if large

75. Duct Papilloma (contd.)
• Investigations:
• Ductogram
• USG
• Ductoscopy – Newer technique
• Treatment:
• Micro-dochectomy – duct is probed
and excised with a ‘tennis racquet
incision’

76. MISCELLENEOUS

77. Galactocele
• Blockage of lactiferous duct resulting
in retention of milk within the sinus
• Usually seen in lactating mothers
during weaning period of infant
• Clinical features:
• Large, soft, fluctuant lump with
smooth surface
• Can become infected
• May get calcified

78. Galactocele (contd.)
• Investigations:
• USG
• Aspiration
• Treatment:
• Aspiration
• Excision – if recurrent
• If abscess – incision & drainage

79. Antibioma
• Inadequately drained abscess treated only by antibiotics
• Becomes sterile, gets covered by fibrous tissue and calcified
• Clinical features:
• Painless, smooth, non-tender, hard, fixed to breast tissue
• Investigation:
• Rule out Ca breast
• Treatment:
• Excision

80. NIPPLE DISCHARGE

81. Nipple Discharge: Causes

82. Nipple Discharge
• May be ‘physiological’ – parous woman, clear, serous discharge from multiple
ducts
• If a lump is present, it should always be given priority in diagnosis and treatment
• Investigations: Exclude cancer
• Discharge study
• Mammography
• Guided biopsy if lump present

83. Nipple Discharge (contd.)
• Treatment:
• Treat cause
• Microdochectomy – if single duct identified
• Hadfield operation – if multiduct discharge or diseased
duct can not be identified

84. Galactorrhoea
• Secretion of milk not related to
pregnancy or lactation
• Can be:
• Primary
• Secondary
• Primary galactorrhoea:
• Puberty or menopause
• Continued production after lactation
has ceased
• Secondary galactorrhoea:
• Pituitary tumours – Prolactinoma
• Bronchogenic carcinoma
• Hypothyroidism
• Drugs – Dopamine receptor blocking
agents such as –
• Haloperidol
• Methyldopa
• Metoclopramide

85. Galactorrhoea (contd.)
• Treatment:
• Treat tumour if present
• Stop offending drug
• Bromocriptine – Dopamine receptor
agonist (inhibits prolactin)

86. GYNAECOMASTIA

87. Introduction
• Hypertrophy of male breast due to
increase in ductal (epithelial) and
stromal (connective tissue) elements
• Due to excess of oestrogen
(relative/absolute)
• Can be:
1. Unilateral
2. Bilateral
1. Physiological
2. Pathological

88. Physiological Gynaecomastia
1. Neonatal gynaecomastia:
• Action of maternal oestrogen
• Disappears in a few weeks
2. Adolescent gynaecomastia:
• Excess estradiol relative to
testosterone
• Usually unilateral; asymmetric if
bilateral
• Regress spontaneously
3. Senescent gynaecomastia:
• Fall in testosterone levels in old age
• Usually bilateral

89. Pathological Gynaecomastia
1. Relative oestrogen excess
• Failure of testosterone synthesis
• Anorchia
• Trauma, castration
• Infections – Mumps, leprosy
• Klinefelter’s syndrome (47XXY)
2. Absolute oestrogen excess
• Testicular tumours
• Brnchogenic and transitional cell
carcinoma
• Adrenal cancer, CAH
• Liver cirrhosis
3. Drugs
• DES
• Gonadotrophins
• Corticosteroids
• Cimetidine
• Digitalis
• Spironolactone

90. Gynaecomastia –Treatment
• Treat cause
• Surgical management
• Indications
• Persist > 1 yr
• Continued growth
• Suspected malignancy
• Psychological/cosmetic
• Options
• Liposuction with minimal glandular
excision
• Subcutaneous mastectomy
• Mastectomy – if malignancy

91. RISK OF
MALIGNANCY

92. THANKYOU