3. DEVEIOPIITENT:
lt arises from the milk line, an ectodermic thickening which extends from the
axilla to the inguinal region (mid-inguinal point).
The epithelium is ectoderm (parenchyma) while connective tissue is
mesenchyme (stroma).
4.
5. Site & Extent: -
-The breast is formed of fibro-fatty tissue, lies in front of the chest wall. - lt
is considered as modified sebaceous gland, so it lies in superficial fascia.
- lt extends from the 2nd to the 6th rib & from the sternum to mid axillary
line.
6. The axillary tail of Spence: .
Arises from supero-lateral quadrant of mammary gland.
Passes through a defect in the deep fascia known as foramen of Langer to the
level of the third rib. It lies close to the axillary vessels.
7. It lies over
The Pectoralis maior (2/3):
The Serratus anterior (1/3): -
. Others are the external oblique & rectus sheath.
8. ARCHITECTURE OF THE GLAND: .
The breast is composed of acini, which collected together forming lobules.
Collections of lobules form lobes (12-20).
Each lobe is drained by a lactiferous duct into the nipple.
9. Liqaments of Cooper:
The breast is anchored to the overlying skin and to the pectoral fascia by
bands of CT called Liqaments of Copper.
10. Blood SupplY oF THE BREAST
Arterial Supply:
1. Axillary artery: through
Superior thoracic
artery
Pectoral branches of Acromio- thoracic artery.
Lateral thoracic
artery.
2. Internal Mammary artery.
3. Intercostal arteries.
11. Venous Drainage
1. Superficial Veins cross the midline.
2. Deep veins accmpany the int. mammary & intercostals arteries.
3. lntercostal veins drain into the azygous system on the Rt. side &
hemiazygous on the Lt. Side, & vertebral veins, so cancer breast spreads to
axial skeleton.
13. :
A. Paranchymal lymphatic: arranged in
two lymphatic plexus:
1=Sub areolar plexus of Sappey-
Drains:
Nipple & areola.
Superficial Part of the breast.
Then drains into the deep lymphatic plexus
14. 2. Deep lymphatic plexus: (Over the pectoral fascia).
It drains:
Sub areolar plexus of Sappey.
Rest of the skin.
Deep part of the breast.
Finally it drains into: axillary & int.
mammary lymph nodes.
15. Lymph nodes :
Axillary L.Ns: 6 Groups
1-Pectoral (Anterior) group: along the lateral border of pectoralis major
muscle.
2-Sub-scapular (Posterior) group: over subscapularis muscle.
3-Lateral (Humoral) group: around the upper part of the humerus.
4-Interpectoral (Rotor): between the two pectoral muscles.
5-Central (Basal) group: in the center of the axilla.
6-Apical group.
16.
17. N.B.
Apical Group:
Receives afferent from the previous groups.
Drains into Jugular Trunk to the blood stream.
Communicate with supraclavicular L.N.
Apical group may enlarge without affection of the
other groups as it may receive lymphatic directly
from the breast.
Distant blood metastasis can occur without affection
of supraclavicular L.N., as the malignant cells can
pass direct from apical group to Jugular Trunk.
18. Internal Mammary L.N.:
Behind the upper 4 intercostal spaces.
Receives afferent from the medial aspect of the breast.
Drains into Jugular Trunk and Thoracic duct.
Communicate with supraclavicular L.Ns.
The main pathway of spread is to the pectoral, central, then the infra
clavicular lastly to supra- clavicular in late stages.
19. II- Modern Description:
The breast drains into 3 way pathways:
75% --- to axillary lymph nodes.
20% --- to int. mammary lymph nodes.
5% --- to nodes near neck of ribs.
It claims that no role of sub areolar plexus of Sappey or sub mammary
plexuses.
20. Operative classification of axillary L.N.s: They are
arranged in three levels:
Level 1: L.N.s lateral to (below) the pectoralis minor
muscle.
Level 2: L.N.s behind the pectoralis minor muscle.
Level 3: L.N.s medial to (above) the pectoralis minor
muscle.
23. = Athelia: (very rare) - Absence of the nipple. -
Usually associated with absent breast (amazia).
= Polythelia: - Multiple nipples along either or both
milk lines (from axillae to groins) - lncidence:.2-6% of
human females have accessory nipple. -.
24.
25. =Gonqenital retraction of the nipple:
Acquired retractionCon-qenital Retraction
RecentSince birthHistory
unilateralbilateralSide
Presence, of breast mass
Present
No breast massMasse
Can not be pulledCan be pulledPulling
It must be differentiated from acquired
retraction
TTT: o - Frequent pulling of
nipple
o - Ashford's operation: purse string suture around the
nipple
26. +Causes of acquired nipple
retraction:
1. Cancer breast) circumfrential retraction.
2. Mammary duct ectasia.
3.Chronic breast abscess or chronic inflammation (eg.TB).
4. Retraction at puberty (simple nipple inversion) of unknown etiology
(bilateral in 25Yo of cases).
28. 1- Amazia:
Absence of the breast usually unilateral.
2- Polymazia: (Supernumerary breast)
Occur in: axilla, groin or thigh (along
mammary ridge ).
May be mistaken and diagnosed as lipoma especially when there is no visible
nipple
29.
30. 3-Micromazia:
May be unilateral or bilateral.
4- Diffuse Hypertrophy of the Breast: areola.
Due to abnormal sensitivity to estrogen hormone.
Occurs at puberty or during 1st pregnancy.
Hypertrophy of stroma and fat.
Treatment: Reduction mammoplasty to reduces size
of breast with preservation of nipple and areola .
32. l.Breast Hematoma.
Following blunt trauma or breast surgery. . lf there is no external bruising, a
deeply seated old hematoma may form a hard mass that greatly resembles
breast carcinoma. . Biopsv will confirm the diagnosis.
33. 2. Cracked Nipple:
a.Aetiology:
Bad hygiene of breast during lactation.
Trauma by baby teeth.
b.Clinical picture:
Pain and bleeding during suckling.
c.Treatment:
1. Prophylactic:
Daily washing and dryness of the nipples.
Usage of nipple shield in case of retracted nipple.
2. Established cases:
Stop lactation from this breast.
Empty the breast by a breast pump.
Antibiotics.
Soothing agent e.g. (lanolin ointment - tincture Benzoin. Co.).
Apply local antiseptics cream.
34.
35. 3. Traumatic Fat Necrosis:
Aetiology:
Direct or indirect trauma.
Follow subcutaneous infusion.
Pathology:
Trauma causes Fat hydrolysis causing liberation of Glycerol (absorbed)
and Fatty acid, which when combines with Calcium it forms Ca soap
Calcium soap: induces a F.B. reaction with aggregation of phagocytes,
fibroblasts and giant cells.
Cut section: show characteristic chalky white appearance, without
the yellow specks and gritty texture like that of carcinoma.
36.
37.
38. Clinical picture:
No clear history of trauma in 50% of the cases.
Painless hard mass with retraction of the nipple
and dimpling of the skin (very suspicious of
malignancy).
Treatment:
Excisional biopsy
39. 4. Milk Fistula:
Aetiology:
Incision of a lactating breast (for breast abscess ).
Rupture of breast abscess
Treatment:
Stop the lactation.
If the discharge continues, excise the fistula
together with the affected sector.
45. A. Acute Mastitis:
1. Mastitis Neonatorum:
Aetiology:
Due to presence of maternal galactogouge hormone in infant
blood.
Stimulation of infant pituitary to secrete prolactin hormone due
to sudden withdrawal of maternal oestrogen hormone after
labour.
Clinical picture:
Breast enlargement on; 3'd or 4th day with breast discharge
"Witch milk
lt is seen only in full developed infants.
Subside on the 3rd week.
However, secondary infection may occurs causing abscess
formation.
Treatment:
Needs no treatment. If abscess occurs : drainage should be done
46. 2. Mastitis of Puberty:
Aetiology:
Hormonal imbalance.
Clinical picture:
Usually unilateral.
Affect both male and female at the age of puberty.
Breast: swollen, indurated, painful, but suppuration does not
occur.
Subsides spontaneously.
Treatment:
Needs no treatment.
47. 3. Traumatic Mastitis: See before.
4. Metastatic Mastitis:
Occur as a complication of mumps.
Usually unilateral, and commoner in females.
48. 5. Lactation Mastitis: Milk engorgement (non suppurative):
Aetiology:
Obstruction of lactiferous ducts.
Clinical picture:
Fever: due to milk proteins absorption.
Affected lobe: become indurated and tender→sector mastitis.
Complication:
Suppuration may occur on top causing abscess formation.
Treatment:
Antibiotics: to guard against infection.
Regular breast evacuation by breast pump.
Stop the lactation.
Breast elevation and hot application (foments).
50. Incidence:
Common in lactating females especially in early lactation
or during weaning.
Aetiology:
Predisposing Factors:
Milk engorgement.
Fissures, cracks in the nipple and areola.
Organisms:
Staph. aureus → localized inflammation.
Strept. → diffuse inflammation.
51. Route of Entry:
Direct through the fissures and cracks.
Along the lumen of the ducts.
Lymphatic.
Blood borne
52. It passes into two stages:
Cellulitis (pre-suppurauive) stage.
Abscess (suppurauive) stage.
55. Complications:
1-Toxemia: bacteraemia, pyaemia & septieemia.
Damage to the breast tissue.
-3-Spontaneous rupture → chronic fistula.
-4-Chronic breast abscess (Antibioma).
56. Clinical picture:
I- Stage of Cellulitis:
General constitutional symptoms.
Local:
-Breast is: painful, red, hot and tender.
-Axillary L.N.: enlarged and tender.
58. II. Abscess (suppurative) stage:
Breast is: painful, swollen, tender, red and hot with dilated
veins on the surface.
Axillary L.Ns.: enlarged and tender.
Suppuration is known by:
Hectic fever.
Marked edema.
Fluctuation is late, so do not wait for it to drain the
abscess.
Needle Aspiration confirms the diagnosis
59. Treatment:
1. Pre-suppurative stage:
Antibiotics.
Hot fomentations.
Support of breast.
Evacuation of milk.
Inhibition of lactation by:
Stilbosterol 5mg T.D.S. for 3 days
Bromocription 2.5mg B.D.S. for 5 days
Cabergoline (dostinex 0.5 mg) ½ tab twice a week
Together with laxative and diuretics.
60. 2. Suppurative Stage:
Supramammary abscess:
Drained where it points.
Intramammary abscess:
Drained either by:
a - Incision radiating from nipple to avoid injury of milk ducts.
b- Circumareolar incision:
More cosmetic.
Done at margin of areola
Dividing skin only then a long hemostat is pushed into abscess
cavity.
The abscess cavity is explored by the finger to break all septa and
drain all pockets.
c- Counter incision may be made in dependent position.
62. Chronic Mastitis:
1. Chronic Breast Abscess:
Aetiology:
Follow acute abscess due to:
Inadequate antibiotic therapy (Antibioma).
Inadequate drainage.
Pathology:
Inadequate therapy of acute suppurative mastitis renders the pus
sterile and surrounded by dense fibrosis
63. Clinical picture:
Firm indurated breast mass.
Retracted nipple.
Dimpling and Puckering of the skin.
Peu d’ orange appearance.
Should be differentiated from cancer.
64. Treatment:
Excision of the whole mass for frozen section.
Drainage is not curative because:
The wall of the abscess is rigid.
Inadequate drainage.
The cavity persists after drainage
65. 2. Tuberculosis Mastitis
:
It is a rare condition, and it is usually secondary to
tuberculous lymph adenitis of axilla.
It is commonly associated with pulmonary TB. It is
common in Negroes female.
66. Clinically, the lesion takes the form of a tender mass or
masses
which may be mistaken for tumor or fibroadenosis. In
early cases, clinical diagnosis is impossible, however,
diagnosis will be easy in late stages when these masses
become adherent to the skin with multiple sinuses
discharging caseous material.
Treatment includes anti-TB drugs, excision of the
affected part of breast or simple mastectomy in extensive
cases
67. 3. Syphilitic Mastitis:
This is an extremely rare affection of the breast.
Primary syphilis may presented by chancre of the nipple.
Secondary syphilis may be presented by mucous patches
and ulceration of the sub-mammary fold.
Gumma of tertiary syphilis is a surgical curiosity.
Treatment could be achieved by anti-syphlitic drugs.
68. 4. Actinomycosis:
It is arare affection of the breast.
Breast usually affected by extension of the lesion from the lung
through the chest wall.
Clinically it presents with indurated breast masses with skin sinuses
discharging sulpher granules.
Treatment includes big doses of penicillin, iodides and excision of the
affected parts or of the whole breast.
69. 5. Plasma Cell Mastitis (Mammary duct
ectazia):
Definition:
Ducts in the nipple and under the areola are dilated with cellular and
fatty material.
Etiology
Unknown
Theories
a) Milk is a sequestrated antigen, so in multipara milk may escape from
milk ducts during lactation ) Ag-Ab reaction ) fibrosis ) traction on the
ducts ) dilated ducts.
b) Anaerobic periductal infection followed by major duct dilatation
Pathology:
Obstruction of the duct system → subacute inflammation with plasma
cells and lymphocytes infiltration.
Fibrosis→ shortening of ducts→ nipple retraction (mistaken from
carcinoma).
70. Clinical picture:
Type of patient . Middle-aged female . More common in smokers.
Hard diffuse mass in breast.
Nipple retraction.
Discharge per nipple: creamy green paste.
Enlarged axillary L.Ns.
Treatment:
Excision biopsy is indicated to differentiate it from
Breast Cancer.
71. 6. Mondor’s Disease:
Definition:
It is a Thrombophelibitis of the superficial veins of the
breast.
May occur in the veins of anterior abdominal wall or the
arm.
Aetiology: Unknown
Treatment:
Restriction of arm movement.
Spontaneous resolution without recurrence, complications
or deformity.
72. Aberrations of Normal Development and Involution (ANDI):
(Fibroadenosis, Chronic interstitial mastitis, Mammary dysplasia, Fibrocystic disease )
73. The commonest breast diseases of female breast
Aetiology:
Hormonal imbalance: in the form of excess estrogen and
low progesterone.
This leading to aberrations of normal cycles of development and
involution breast tissues
74. Pathology:
MAC:
It may affect the whole breast or localized to
one sector.
The affected areas become thickened, tough and
rubbery in consistency.
The cut section is whit or yellow (never gray) may show
cystic areas with dominant large one (Blue domed cyst of
Bloodgood).
75. MIC: Four characteristic lesions:
1. Epithelial proliferation:
Epitheliosis: hyperplasia of cells lining the duct
& acini → multiple rows.
Papillomatosis: papillary projection inside the
duct.
Adenosis: increase number of acini.
76. 2. Cyst formation: 2 types
(A)Retention cyst:
Due to obstruction of ducts by fibrosis and
epitheliosis.
Large solitary cyst: Bloodgood cyst.
(B) Degeneration cyst:
- Due to degeneration of cells in center of acini.
- Small cyst.
77. 3. Fibrosis: Periacinar and Periductal.
4. Round cell infiltration by lymphocytes & plasma
cells: (chronic mastitis).
78. Clinical picture:
Incidence:
The commonest disease of female breast.
At any age in reproductive period (25-45 years).
Common in unmarried, nullipara or non lactating
multiparous female.
79. Symptoms:
1. Pain:
Dull aching breast pain.
Mild to severe.
Increases before menstruation.
Decreases after menstruation.
Improved by pregnancy & lactation.
2. Swelling:
Tender mass or masses in the breast.
3. Discharge per nipple:
Clear serous, green, brown or black in color.
80. Signs:
Breast:
The disease may be unilateral or bilateral diffuse or
localized.
Tender mobile mass or masses within the breast.
Better felt by tips of the fingers.
Vaguely felt by the palmer aspect of the fingers.
These masses are due to:
* Cyst formation.
*Areas of glandular hyperplasia and fibrosis.
Axillary L.N.:
Enlarged, firm and tender.
81. Differential diagnosis: (from breast cancer)
The following are in favor of fibroadenosis:
Bilateral.
Multiple.
Better felt by tips of the fingers.
Vaguely felt by the palmer aspect of the fingers.
No recent retraction of nipple.
Axillary L.Ns: tender & never hard.
82. Etiology of breast abscess include:
a- Mostly in lactating women.
b- Due to Staph from baby mouth.
c- Bod hygiene.
d- All of the above
83. Signs of pus formation ore the following except:
a- Hectic fever.
b- Edema of overlying skin.
c- No response to medical treatment for 48 hours.
d- Fluctuation occurs early in breast abscess.
84. Best treatment of chronic breast abscess is:
o- Prolonged antibiotic courses.
b- Repeated aspiration.
c- incision and drainage.
d- Excision of the whole abscess.
85. The commonest route of infection of breast abscess
is:
o- Along blood vessels
b- Retrograde infection along lymphatic vessels
c- Along natural passages (nipple)
d- Along artificial passages like fissures or crocks of nipple
and areola
e- Local extension from infection of the chest wall muscles or
ribs
86. Mondor's diseose is:
a- An obscure type of thrombophlebitis particularly
effecting veins of the breast.
b- Lymphedema of the arm.
c- Chondritis of a costal cartilage.
d- Pectus excavatum.
