Breast Diseases

- NEOPLASMA
- Non-Neoplasma

PALPABLE TUMOR
NON-PALPABLE TUMOR
 Palpable breast mass
 Cyst
 Solid masses :
- fibroadenoma, juvenile fibroadema
- hamartoma, adenolipoma, chondrolipoma
(consist of glandular tissue, fat, fibrous
tissue)
- hematomas
- fat necrosis
 Neoplasma

 Neoplasma jinak ( benign)

 Neoplasma ganas (malignant)

 Neoplasma NOS (No Other specified)

 Non-neoplasma

 Inflammation.

 ANDI (Aberrations of Normal Development

and Involution)

 Congenital disorder
Benign Breast Disorder (BBD)
 Some names used for common BBD
1. Cyclic nodularity:
- Fibrocystic disease
- Fibroadenosis
- Cystic hyperplasia
- Schimmelbusch`s disease
- Chronic cystic mastitis
- Cystic mastopathy
Benign Breast Disorder (BBD)

2. Giant fibroadenomatous tumours

- Giant fibroadenoma
- Cystosarcoma phyllodes
or Phyllodes tumour
- Juvenile fibroadenoma
- Serocystic disease of Brodie
 Benign breast disorder (BBD)

3. Duct ectasia / periductal mastitis

- Plasma cell mastitis
- Varicocele tumour
- Comedo mastitis
- mastitis obliterans
- Secretory disease
 Breast anatomy and physiology
 Embryology : ectodermal mammary
ridge,seventh embryonic week.
 Budding stage, at twelfthMammary ridge
extend from upper limb bud (axillopectoral
region) to lower limb bud (inguinal region)
 Nipple premordium : ventral wall thorax at 14
mm embryo stage.
 Week 13-20 develop 15-20 major duct from
epithelial bud
 Adult breast anatomy
 Location : On anterior thorax wall
 Extending from second rib (upper limit) to
sixth rib (lower limit)
 Medial site : sternal edge
 Lateral site : midaxillary line
 Extend up into the axilla via a pyramidal-
shape axillary tail ( tail of Spencher)
 Adult breast anatomy
Nipple areola :
- Orificium of lactiferous ducts

- Montgomery tubercle :
modified sebaceous gland for lubricating
Ductolobar system :
10-l00 alveoli/acini (Basic secretory unit) 40-50
lobulus15-20 lobus major ductsinus lactiferous
Nipple.
 Microscopic anatomy of ductal
system
 Major duct systemleading to Terminal
Ductal Lobular Unit (TDLU)
 TDLU :
- Extra lobular terminal duct (ETD)
- Intra lobular terminal duct (ITD)
Origin of breast disease (benign or
malignant
 Four type of lobules
 Type I : menarche  l0 alveolar buds /terminal
duct, most undifferentiatedCa insitu
 Type II : more complex, higher number of
ductules per lobulelobular carcinoma
 Type III and IV are seen during pregnancy and
lactation, and more progressive.
 Type II and III : increasing ductules around the
duct
 Type IV: fully developed acini
 Manifest of lobule type

 Type I : developed ca-insitu,

 Type II : developed lobular carcinoma

 Type III : to originate of adenomas,

fibroadenomas sclerosing
adenosis ,cyst.
 Vascular anatomy
1. Axillary artery via thoracoacromial, lateral
thoracic and subscapular arteries.
2.Subclavian artery via internal thoracic
(mammary internal) arteryanterior perforating
artery to ICS 2,3,4
3.Anterior intercostal artery : perforating
branch on lateral site.
Vein drainage from subareolar plexusintercostal
veinaxillary veininternal thoracic vein.
 Lymphatic of the breast
 Plexus lymphaticus come from
parenchymal,subareolar to anterior axillary
nodes (pectoral )central axillary and apical
nodes group
 The other way to subscapular and interpectoral
(Rotter node) node
 Small drains across to the opposite breast and
rectus sheath
 From medial site drains to internal thoracic group
in the thorax and on into mediastinal nodes.
 Nerve supply
 The innervations of breast by somatic sensory nerves
( areola and nipple) and autonomic sympathic nerves
( breast parenchyma). No parasympathic nerve supply.
 Superior : via supraclavicular sensory nerve (C3,C4)
 Lateral site : via lateral branch of thoracic intercostal nerve
(3,4)
 Medial site : via anterior branch of thoracic intercostal
nerve in pectoralis muscle
 Upper outer quadrant : via intercostobracialis nerve
(C8,T1)
 Nipple : plexus subareolar nerve received from intercostal
3,4,5 nerves.
 Physiology (microscopy,
morphology, menstrual cycle)

 Histological changes (growth and differentiation) related to

endocrine variation (sex steroid hormone level) during
menstrual cycle
 Follicular phase : FSH and LHEstrogen increased
breast epithelial proliferation.
 Luteal phase : LH Progesterone increased mammary
duct dilate, alveolar epithelial cells differentiate to secretory
cells.
 Pregnancy and lactation  prolactine,oxytocin increased
 Post menopause  aromatization androgen to estrogen.
 ANDI classification

 Bidirectional framework of ANDI

classification :
Vertical : pathogenesis based on
reproductive period
-Horizontal : degree of abnormality
(Normal, Aberration, Disease)
The basic bidirectional framework
of the ANDI classification

Horizontal : ( spectrum of severity )

Normal - Aberration - Disease

(mild abnormality) (severe abnormality)

VERTICAL : (Pathogenesis based on reproductive

period)
- Development : (15-25 years)
- Cyclical activity : (25-45 years)
- Involution : (35-55 years)
 Conditions of BBD into ANDI and non-ANDI

Stage Normal process Main clinical Disease

presentation
aberration
Early reproductive Lobular development Fibroadenoma Giant fibroadenoma
(15-25 years)
Stromal development Adolescent hypertrophy Gigantomastia
Nile eversion Nipple inversion Subareolar abscess/ mammary
duct fistula

Mature Cyclical changes of Cyclical mastalgia Incapacitating mastalgia

Reproductive menstruation nodularity
(25-40 years)
Epithelial hyperplasia of Bloody nipple discharge
pregnancy

Involution Lobular involution Macrocysts sclerosing

(35-55 years) lesions
Dutc involution Dutc ectasia Periductal mastitis/abscess
-dilatation nipple retraction
-sclerosis
Epithelial turnover Simple epithelia With athypia
Hyperplasia
Causes of lumps in the breast
Type cause

1. Normal structure  normal nodularity

prominent fat lobule
prominent rib
accessory breast
2. ANDi ---------------- - Fibroadenoma
- cyclical nodularity
- cyst
- galactocele
- sclerosing adenosis
- stromal fibrosis
 Causes of lumps in the breast
3.Inflammatory ->chronic infective abscess
fat necrosis
Mondor`s disease
Foreign body granulocytoma
4.Benign tumour duct papilloma
giant fibroadenama
lipoma
granuler cell myoblastoma
 Causes of lump in the breast
5.Intermediate tumour  Phyllodes tumour
Carcinoma in-situ
6.Malignant--------------- Primary tumour
Secondary tumour
7.Lesions of the nipple  Squamous papilloma
Retention cyst
Papillary adenoma
Leiomyoma
8 .Lesion of the skin  Sebaceous cyst
Hydradenitis
Benign and malignant skin
tumour
 Diagnosis of breast lump
Two major problem of diagnosis :
I. Whether the lump is within or out side the
spectrum of normality.
2. if abnormal, whether is benign or malignant
Triple assessment of breast lump :
1. Clinical assessment
2. Imaging assessment (USG,Mammografi,MRI)
3. Microscopic assessment (FNAB,open biopsy)
 Clinical assessment

 Anamnesis of medical history of breast

problem

 Physical examination : inspection and

palpation
 Medical history of a breast
problem
1. All woman :
- large at menarche
- number of pregnancy
- number of life births
- age at first birth
- family-history of breast cancer, or other cancers
- history of breast biopsy
2. Premenopausal woman :
- date and last menstrual period
- length and regularity of cycles
- use of oral – injection contraceptive
3. Post menopausal woman:
- date of menopause
- use of hormone replacement therapy (HRT)
 Oedema of the skin (peau d`
orange)
Pathogenesis :
There are damaged/ abnormality of the
sub-dermal lymphatic vessel, caused by:
- obstruction due to micro-organisms,
cancer cell.
- compression due to bulging mass
- distraction due to heavy mass ( breast
hypertrophy )
 Clinical assessment
 Inspection :
- skin attachment and nipple: benign and
malignant skin/nipple retraction
- summarization:
= shape and volume of the breast
= level of the both nipples (mid-upper arm)
- erythematic / redness of the skin
- oedema of the skin (peau d` orange)
 Erythema (redness) of the skin
 Inflammatory condition :
– Acute inflammation : lactational abscess, subareolar
abscess
– Chronic inflammation: unresolved lactational abscess,
foreign bodies response, autoimmune response
– Granulomatous response : fat necrosis, periductal
mastitis, cholesterol granuloma, systemic
granulomatous/tbc
 Inflammatory carcinomatosis (mama
carcinomatosis)
 Ulcer of the skin
 Inflammation prose's :
- Non-Specific condition: febrile, heavy pain,
induration's mass, non smell/non- foetor,
single fistula, more erythematous
- Specific disease : sub febrile, mild pain,
indurations and granulomatous dominant, single
to multiple fistula, with secondary infection,
non-fetor, less erythematous
 breast cancer : non febrile, more fetor, mild
to severe pain, dominant and induration mass,
less eryhtematous.
 NIPPLE DISCHARGE
 Sign and symptom:
- spontaneous or not
- single fistula , multiple fistula
- quality of discharge : hemorrhagic or
non hemorrhagic
- single breast or both of breast
CONDITIONS :
intraductal papilloma, galactorhea, periductal
mastitis and ductal ectasia, breast cancer
 Clinical assessment
 Palpation :

- consistency : tender, rubbery/ cyst, hard

- surface : smooth , irregular margin
- mobility : mobility to surrounding
tissue
 Imaging assessment

 Ultrasonografi (USG)
- Strong to distinguish solid and cystic mass
- could be mention benign and malignant

 Mammography : accurate to diagnostic

malignant ( 95-98%)

 Magnetic resonance imaging (MRI) : could be

assess the extension of tumour cells
 MICROSKOPIC ASSESSMENT
 Less traumatic/non-traumatic (closed
biopsy)
- FNAB/ FNAC : Fine Needle Aspiration
biopsy/ cytology : sel assessment only
- Core biopsy/ trucut-biopsy : more
spacemen of stromal to evaluate
 Traumatic assessment ( open biopsy):
- incisional biopsy
- excisional biopsy
 Triple diagnostics
I. Clinical assessment : anamnesis/ history
Inspection, palpation
II. Imaging assessment :
USG, or
Mammography, or
MRI
III. Microscopic assessment :
FNA or core-biopsy/Tru-cut biopsy
Incisional biopsy
Excisional biopsy
 Management of nipple discharge
 Spontaneous discharge investigation (clinical examination,
mammography / usg )
 Normal condition single duct discharge suspicious or troublesome
surgery
 Normal condition  single duct not suspicious or troublesome
reassurance
 Normal  multiple duct discharge distressing symptom surgery
 Normal multiple duct discharge not distressing reassurance
 Abnormal condition investigation for mass lesion or mammographic/
usg abnormality.
 Identification of discharge :
– Quality of discharge : haemorrhagic or non-haemorrhagic
– Time : spontaneous or intermittent
– Number of origin : one orificium or multiple orificium
Condition : cystic disease, breast cancer, intraductal papilloma,
mastitis
 Management of nipple retraction
 Nipple retraction  investigation (clinical
examination and mammography/USG)
 Normal  reassure
 Abnormal  investigation as for mammography/
usg abnormality or mass lesion
 Condition: infection, scar post trauma/ infection,
breast cancer, congenital/ abnormal development,
displacement due to mass sub- areola
 Management of breast infection
 Non lactational infection, hidradenitis suppurativa
( s.aureus, enterococcus sp, anaerobic organism,
streptococ sp,bacteroides sp) co-amoxy +clave
(No penicillin allergy), combination of cephradine
or erythromycin and metronidazole hydrochloride
(positive penicillin allergy)
 Neonatal lactational skin associated
(staphylococcus aureus) Co-amoxyclav ( No
penicillin allergy), erythromycin (positive penicillin
allergy)
 Abscess  incision + drainage ( penrose drain) +
antibiotics, analgesia or anti-inflammation,
 Management of breast pain
(Mastalgia -BBD)
Etiology hypothesis Treatment
 Essential fatty acid (EFA) deficiency evening prime rose
oil (EPO)
 Dietary methylxanthine  caffeine restriction
 Increased gonadotrophin danazol ( antigonadotrophin)
 Hyperprolactinemia  bromocriptine (dopamine agonist)
 Luteal insufficiency  progesteron/progestogens
 Hyperoestrogenism  androgen/ anti-oestrogen
(tamoxifen) / LHRH agonist
 Local inflammation or fibrosis  local steroid injection
 Miscellaneous treatment  pyridoxin, thyroid hormon,
vitamin A,HRT
 Management of cyst
 Accurate Diagnostic assessment by clinic al examination and USG
 USG : cystic formation or cystic plus intracystic mass .
 Mammography for intracystic lesion ,or residual mass post aspiration,
recurrent cyst.
 Aspiration : non-hemorrhagic secret  no-further cytology
examination.
 Aspiration : hemorrhagic cyst or light cyst / watery cyst  absolutely
cytology examination
 FNAB for recidual mass and intracystic lesion
 Treatment option:
- Surgery : residual mass, intracystic lesion, persistent recurrent
( froozen section at that time of surgery, waiting for
Histologic finding)
- Hormonal treatment : danazol, antiestrogen, EPO ?
 Skin and nipple retraction
- chronic abscess  periductal mastitis:
shortening of the duct skin and
nipple retraction
- large cyst or fibroadenoma arising centrally
display and shortening of the ductskin and
nipple retraction
- Cicatrix post trauma  skin retraction/skin
dimpling
- Breast cancer : invasion/infiltration of cancer cell to
the duct (nipple retraction),or to the Cowper
ligament (skin retraction,dimpling of the skin).
 Common breast diseases
 Breast pain = Mastalgia
 Mastitis = Periductal mastitis
 Cystic disease ( macrocyst, galactorrhoe)
 Fibroadenoma, Giant fibroadenoma
 Tumor phylloid ( benign and malignant phylloid
tumour
 Mamma aberrant (supernummery of the breast)
 Gynecomastia
 Breast cancer
 Hyperplasia or hypertrophy of the breast.