anatomy

Extends between the edge of sternum to mid axillary

line,from the 2-6th ribs.
Enveloped by superficial facia(camper’s)and superficial
pectoral fascia .
Overlaps the upper part of rectus muscle.
Seprated from the pectoral fascia by loose connective
tissue (sub mammary space).
Breast tail of spence enters the axilla through langers
foramen.
Skin in the areola contains sweat ,sebaceous glands in
parous women seen as small elevations (montgomery,s)
Blood supply
Internal thoracic-25%
Axillary artery-lateral thoracic
-sup. thoracic
-pectoral(from thoracoacromial)
-sub scapular
Intercostals 2ed-4th
Venous: - axillary
-intercostals ,through superficial and deep veins
that communicate with internal vertebral veins in the
epidural space through the veins of Batson.
-internal thoracic
Lymphatic drainage
groups
Axillary LN=53
-interpectoral ( Roters)
-pectoral
-central
-apical
-subscapular
-axillary vein group
Internal thoracic group
intercostal
Axillary artery
Heihgst thoracic artery
Thoracoacromial-APCD
Lateral thoracic
Subscapular
Anterior humeral circumflex
Posterior humeral circumflex
LEVELS OF LN
Level 1-lateral to pectoralis minor.
Level 2-posterior to pectoralis minor
Level 3-medial to pectoralis minor
Structure of the breast
Two components-epithelial-glandular.
-supporting tissue.
20 lobes seperated by dense connective tissue
20-40 lobules seperated by loose connective tissue.
10-100,s of acini
Lobes are seperated by cooper’s ligament.
Each lobe opens seperatly into the nipple.
Terminal ,collecting,mammary duct .
The skin containes usual adnexa.
histology
Ducts are composed from-epithilial layer
-myoepithelial layer
- basement membran
Epithium-coloumnar,cuboidal,squamous.
Breast complaints
Palpaple masses
Vague thickening,nodularity.
Nipple complaints
Pain
Change in size or appearance.
Skin changes.
Mammographic abnormalities
Breast pain
Cyclical- in 60% of females,bilateral,diffuse.
Noncyclical-unilateral,variable in location.
-trauma
-trigger point
-teitzes syndrome
- cancer
-infection
- cysts
-mondors disease
-fibroadenoma
-cardiac ,oseophageal,spinal
Nipple complaints
Retraction
Inversion
Nipple discharge
Skin changes
Nipple discharge
Unilateral?
Spontanious?
Uniductal?
Colour?
 Nipple discharge
Causes of nipple discharge
Benign (common) Malignant (less common)

Physiological causes In situ carcinoma (DCIS)

Intraductal pailloma and associated Invasive carcinoma
conditions
Blood stained nipple discharge of
pregnancy
Galactorrhoea
Periductal Mastitis
Duct Ectasia
Differential diagnosis of nipple
discharge
Blody-papilloma,carcinoma,pagets,fibrocystic.
Serous-pregnancy,OCP,menses,cancer.
Green/brown-duct ectasia,fibrocystic changes.
Milky-post lactation,prolactinoma,OCP.
Purulent-abscess
galactorrhea
Pregnancy
Hypothyroidism
Pituitary tumor
Drugs-antidepressents
Cystic changes
Benign breast diseases
Developmental abnormalities
Inflammatory lesions
Epithelial and stromal proliferations
Neoplasms
The majority of the lesions that occour in the breast are
benigen,and the majority are not associated with
increasd risk of cancer.
The incidence begines to rise during the second
decade,peaks in the fourth and fifth decades.
Developmental abnormalities
-Ectopic –chest wall,axilla, vulva,unusaual sites –knee,lateral
thigh,buttock,face,ear,neck.
More prone to malignant changes at an earlier age.
-Macromastia-adolecense
-pregnancy
- Underdevelopment-congenital
-aquired
-absence-amastia ,amazia
Is usually associated with genetic disorders such as ulnar
mammary syndrome,poland’s ,turner’s ,cong adrenal
hyperplasia
mastitis
Acute –puerperal
Granulomatous mastitis-TB,sarcoidosis,Wegener’s
Foreigen body mastitis-silicone
Recuring subareolar abscess-Zuska’s disease
Mammary duct ectasia-periductal mastitis
Fat necrosis
Fibrocystic disease
Cysts-macro,micro
Solid lesions-adenosis
-epithelial hyperplasia with /out atypia
-apocrine metaplasia
-radial scar
-papilloma
Fcc’s is classified as nonproliferative,proliferative
without atypia,proliferative with atypia(atypical
hyperplasia).
Women with nonproliferative lesions have no
elevation in breast cancer risk.
Women with proliferative disease with out atypia
cary 1.9 relative risk.
Women with atypical ductal/lobular hyperplasia have
a relative risk 3.9-13.
More than 80% of patients with a diagnosis of
atypical hyperplasia do not develop invasive cancer
during their lifetimes.
cysts
Are derived from the terminal duct lobular unit.
Most are subclinical (microcysts).
 25% are palpaple (gross).
Lined by flattened epithilium ore totally absent.
Can be simple or complex.
Not associated with increased risk of carcinoma.
Complex cysts have internal ecchoes,thin
septations,thickened-irregular wall,and absent
posterior enhancement,with amalignancy rate 0.3%
Adenosis/sclerosing,microglandular
1. Is characterized by increased number or size of
glandular components,mostly involving the
lobular unit.
2. Is a proliferative disease.
3. Can manifest as a palpable mass or as a
suspicious finding at mammography.
4. Is a risk factor for invasive breast cancer
Apocrine metaplasia
Is characterised by the presence of columnar cells
with abundant granular oesinophilic cytoplasm
Epithilial hyperplasia
Ductal –mild
-moderate
-florid
-atypical
lobular
Epithelial hyperplasia
Ductal type-is the presence of more than two layers of
cuboidal cells,if mild(3-4 layers) there is no distortion or
distention of the ductal contour,does not increase the risk
of breast cancer.
If moderate->4 layers with bridging of the luminal space.
In florid –the lumin is distended or obliterated
Atypical- morphologically mimics low grade
carcinoma,women develop cancer within 10- 15 years of
the diagnosis (4-5 times the general population).
Lobular type-is the same as lobular carcinoma in situe,is
risk marker than obligatory precursor,it does not warrant
surgical therapy
Is the most common form of proliferative breast disease
Radial scar
Fibroelastic scar with entrapped ducts ,surrounded by
radiating ducts and lobules.
Displaying variable epithilial
hyperplasia,adenosis,ectasia,papillomas.
Diagnosis by mammography as spiculated lesion with
central radioluceny,or by tissue biopsy.
Uncertain significance.
Called complex if> 1cm.
Papilloma/osis
Is a benigen tumor
If peripheral are usually multiple
If central ,are usually single
Presenting as serous /serosanginous discharge
Papillomatosis is defined as a minimum of five
papillomas within a localized segment,have a higher
incidence for in situ or invasive carcinoma
Proliferative stromal lesions
Diabetic fibrous mastopathy
PASH
Diabetic mastopathy
Is an uncommon form of lymphocytic mastitis and
stromal fibrosis-immune reaction.
Occurs in both premenopausal women and rarely in
men with type one diabetes.
Clinically presents as a solitary or multiple ill
defined,painless,immobile discrete lesions in one or
both breasts.
On mammo are highly suspicious lesions
Pseudoangiomatous stromal
hyperplasia(PASH)
Is a benign myofibroblastic proliferation of
nonspecialized mammary stroma
Presents as incidental microscopic foci or clinically
evident mass.
Clinically well circumscribed,dense,rubbery mass.
Treatment is by wide local excision.
NEOPLASMS
Fibroadenoma.
Lipoma
Adenoma
Nipple adenoma
Hamartoma
Granular cell tumor
adenoma
An adenoma is pure epithilial neoplasm .
Divided into:-tubular
-lactating
-apocrine
-pleomorphic
Presents as a solitary ,multiple,discrete,freely mobile
mass <3cm
Nipple adenoma
Is a benign tumor of the ductal system.
Mimics Paget’s disease
Clinically presents as a discrete,palpaple tumor of the
papilla of the nipple,
Erosion,nipple discharge are usually seen
Histologically is characterised by proliferating ductal
structures that invade the surruonding tissue.
Treatment is complete excision.