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Breast

Aug 24, 20253 min read

BREAST DISEASES

DR. AHMED KHAN

Diseases of the Breast

Benign Disorders

Benign Neoplasms

Malignancy

Unusual Malignant Tumors

Diagnosis (triple assessment)

I. Clinical evaluation – Breast History & Examination

II. Radiological evaluation:

III. Cytological/ histological evaluation:

  • FNAC
  • Core biopsy (U/S or Mammography guided for non-palpable mass)
  • Open biopsy- excision of the mass with surrounding healthy tissue.

Imaging for Breast Disease

  • Mammography

  • Ultrasonography

  • MRI

    • High sensitivity for breast cancer.
    • Used for screening high-risk women.
    • Optimum method of imaging breast implants and detecting implant leakage or rupture
    • Recurrent diseases

Biopsy

Anatomy of the Breast

  • Located between the subcutaneous fat and the fascia of the pectoralis major and serratus anterior muscles.

  • Extend to the clavicle above, laterally to axilla and latissimus dorsi, medially to sternum and inferiorly to the top of the rectus muscle (inframamry crease).

  • Axillary tail blends with axillary fat.

  • Made up of milk-producing glands.

  • Arranged into units known as lobules.

  • Glands connected via ducts that join to form a common drainage path, terminating at the nipple.

  • The nipple is surrounded by a ring of pigmented tissue- areola.

  • Fibro-elastic and fatty tissue provide support for the rest of the structure.

Lymphatics:

  • interlobular lymphatic vessels to a subareolar plexus (Sappey’s plexus), 75% of the lymph drains into the axillary lymph nodes.

  • Medial breast drain into the internal mammary or the axillary nodes.

Axillary Lymph Nodes

  • Level I: Lateral to the pectoralis minor muscle. Usually involved first.

  • Level II: Posterior to the pectoralis minor muscle.

  • Level III: Medial to the pectoralis minor muscle.

  • Rotter’s nodes: Between the pectoralis major and the minor muscles.

Physiology

  • Composed of glandular tissue, fibrous supporting tissue and fat.
  • Functional unit: Terminal duct, lobular unit.
  • Secretion from lobular unit drain by 12-15 major subareolar ducts.
  • Rest: Terminal duct lobular unit secrete watery fluid which is reabsorbed.
  • Pregnancy: Lobules & ducts proliferate.
  • Delivery reduces circulating estrogen and increases sensitivity to prolactin.
  • Suckling stimulates prolactin & oxytocin- ejection of milk.
  • Involution starts after 30- atrophy of glandular and fibrous tissue

Evaluation of Patients with Breast Disease

Common complaints:

  • Lump (most common)
  • Pain/ tenderness (Mastalgia)
  • Change in the breast size/ skin (redness, Peau d’orange)
  • Change in the nipple
  • Discharge from the nipple

Hormone & Growth Factor Receptors

  • ER (estrogen receptor) +ve. tumors (75%) are estrogen-dependent for growth. Depriving estrogen stops its growth (Tamoxifen).

  • PR (progesterone receptor) +ve. are hormone-dependent.

  • ER & PgR negative tumor (20-25%)- no benefit of hormone treatment.

  • HER 2 (human epidermal growth factor receptor) +ve tumors (15%) are dependent on this growth factor. This can be blocked by monoclonal antibody- Trastuzumab (Herceptin) which is used in treatment.

    • HER2 tumors have a worse outlook than HER2 negative.

  • Triple negative (ER, PR,HER2): worse prognosis.

Clinical Features

Asymptomatic (screening detected).

Symptomatic:

  • Lump 76%- painless, ill-defined, skin attachment, peau d’orange
  • Pain 5%
  • Nipple retraction (whole nipple is pulled in)
  • Discharge
  • Skin retraction (Dimpling)
  • Axillary mass

BOOK REFERENCE

PRINCIPLES AND PRACTICE OF SURGERY

6th edition:

Edited by

  • O. James Garden,
  • Andrew W. Bradbury
  • John L.R. Forsythe
  • Rowan W. Parks

PAGE NO: 302-11

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