congenital absence of breast in one or both breasts Polymazia Author：arab company | Size：3.39 M | View：423 | Page：71الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا كلية الطب البشري قسم الجـراحـة الدكــتـور عاصم قبطان MD - FRCS 1st lecture M.A.Kubtan1 The Breast Learning Objectives Appropriate investigation of breast disease ....
الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا كلية الطب البشري قسم الجـراحـة الدكــتـور عاصم قبطان MD - FRCS 1st lecture M.A.Kubtan1 The Breast Learning Objectives Appropriate investigation of breast disease . Breast anomalies and complexity of benign breast disease . The in-depth modern management of breast cancer . M.A.Kubtan2 Comparative and Surgical AnatomyHuman breast is overlying the chest wall between the second to the sixth ribs . It is extending from the lateral border of the sternum to the anterior axillaries line . A thin layer of mammary tissue extend from the clavicle above to the seventh or eighth rib below . From the midline to the edge of the latissmus dorsi muscle poseriorly . The axillaries tail of the breast is palpable in some normal subjects , and it may becomes palpable during pre-menstrual or during lactation .M.A.Kubtan3Continue Lobule is the basic unit of mammary gland ,number varies from 10 – 100 lobules . Lobules empty via ductules into lactiferous duct , their number 15 – 20 . Lactiferous ducts are lined by erectile myoepithelial cells with terminal ampulla .M.A.Kubtan4ContinueThe ligaments of Cooper are fibrous tissue filled with breast tissue. Areola contains involuntary muscle arranged in concentric rings. The areolar epithelium contains numerous sweat glands and sebaceous glands . During pregnancy sebaceous glands serve to lubricate the nipple during lactation ( Montgomery tubercles ) .M.A.Kubtan5Continue The nipple is covered by thick skin with corrugations. Near its apex lie the orifices of lactiferous ducts . The nipple contains an erectile smooth muscle fibers.M.A.Kubtan6Lymphatics of the BreastLymphatics drains to axillary lymph nodes , and to internal mammory lymph nodes . The axillary lymph nodes receive approximately 85% of the lymphatic fluids .M.A.Kubtan7M.A.Kubtan8Anatomy of axillary lymph nodesLateral. Anterior . Posterior . Central . Interpectoral. Apical.M.A.Kubtan9M.A.Kubtan10Investigation of breastMammography . Mammography showing a carcinoma M.A.Kubtan11M.A.Kubtan12MRI Magnetic resonance imaging M.A.Kubtan13Needle biopsy / cytologyM.A.Kubtan14M.A.Kubtan15M.A.Kubtan16M.A.Kubtan17M.A.Kubtan18Benign Breast Disease 30% of women will suffer from benign breast disorders . Most common symptoms are Pain , Lumpiness or a lump . The aim of treatment is to exclude cancer , and then to treat remaining symptoms .M.A.Kubtan19M.A.Kubtan20M.A.Kubtan21M.A.Kubtan22Congenital abnormalities Amazia : congenital absence of breast in one or both breasts. Polymazia :accessory breasts ( most frequent site ) groin , buttock and thigh . They function during lactation . Mastitis of infants common in boys as in girls .M.A.Kubtan23M.A.Kubtan24M.A.Kubtan25Injuries of breastHaematoma >>>> lump >>>> bruises . Traumatic fat necrosis >>>> acute >>>> or chronicM.A.Kubtan26Acute and sub acute inflammation of breast Bacterial mastitis less common now , mostly caused by Staphylococcus aureus . Clinical features : classical signs of acute inflammation , if not aborted later an abscess will form. Treatment in cellulitic stage broad spectrom anti biotics. If pus formed repeated aspiration pus culture and anti biotic cover , otherwise incision and drainage of breast abscess .M.A.Kubtan27M.A.Kubtan28Chronic intramammary abscessTuberculosis of the breast . Actinomycosis rare . Mondor,s disease : thrombophlebitis of the superficial veins of the breast and chest wall , it may be idiopathic , or inflammatory , or of carcinogenic origin . M.A.Kubtan29M.A.Kubtan30The nipple Nipple retraction : benign simple in 25% is bilateral . Recent retraction : may be pathological . Chronic periductal mastitis . Circumferential retraction with or without underlying lump may indicate an underlying carcinoma.M.A.Kubtan31 Discharge from the nippleA clear serous discharge may be physiological in a parous woman , or may be associated with duct papilloma. A blood stained discharge may be caused by duct ectasia, duct papilloma or carcinoma . A black or green discharge as a result of ductectasia .M.A.Kubtan32Duct ectasia / periductal mastitisDuct ectasia is dilatation of the breast duct associated with periductal inflammation .M.A.Kubtan33M.A.Kubtan34M.A.Kubtan35M.A.Kubtan36M.A.Kubtan37الجامعة السورية الدولية الخاصة للعلوم و التكنولوجيا كلية الطب البشري قسم الجـراحـة الدكــتـور عاصم قبطان MD - FRCS 2nd lecture M.A.Kubtan38Breast CystsCommonly occur in the last decade of reproductive life. They are often multiple , may be bilateral and mimic malignancy . Diagnosis can be confirmed by aspiration and ultrasound . Treatment by aspiration , 30% will recur and require further aspiration and cytological examination . Histological examination advisable .M.A.Kubtan39GalactoceleRare , usually present as a solitary sub areolar cyst , and dates from lactation. It contains milk . In longstanding cases its wall tend to calcify .M.A.Kubtan40FibroadenomaUsually arise in the fully developed breast . It is seen between the ages of 15 – 25 years . Occusionally occur in older women . It arise from hyperplasia of a single lobule and usually grow up to 2 – 3 cm in size . They are surrounded by a well marked capsule . A fibroadenoma does not require excision unless associated with suspicious cytology . Giant fibroadenoma occasionally occur during puberty , has the same treatment.M.A.Kubtan41Phyllodes tumourBenign tumour . Previously known as serocystic disease of Brodie . Or cystosarcoma phyllodes . Usually occur in women over the age of 40 years , but it can be appear in younger women . Present as a large ,some times massive tumour with unevenly bosselated surface , the remain mobile on the chest wall. Occasionally ulceration overlying skin occurs because of pressure necrosis . Histologically varies between benign and low grade malignancy ( locally malignant ) . Very rarely develop features of sarcomatous tumour . Treatment : (Enucleation – wide local excision – mastectomy )M.A.Kubtan42M.A.Kubtan43Carcinoma of the BreastThe most common cause of death in the middle aged women in western countries . In England and wales 1 in 12 women will develop the disease during their life time .M.A.Kubtan44 Breast cancer Aetiological factors Breast cancer is the most common site-specific cancer in women It is the leading cause of death from cancer for women age 40 to 44 years It is extremely rare below the age of 20 It occurs more commonly in women with a family history of breast cancer radiation exposure M.A.KubtanContinue Diet : A high intake of alcohol is associated with an increased risk of developing breast cancer. There is an association between obesity and increased breast cancer risk. Because the major source of estrogen in postmenopausal women is the conversion of androstenedione to estrone by adipose tissue, obesity is associated with a long-term increase in estrogen exposure. M.A.Kubtan46Continue Hormonal factors : Increased exposure to estrogen is associated with an increased risk for developing breast cancer , therefore factors that increase the number of menstrual cycles, such as early menarche, nulliparity, and late menopause, are associated with increased risk. M.A.Kubtan47PathologyBreast cancer may arise from the epithelium of the duct system . May be insitu , common finding in screening of breast cancer . May be massive cancer .M.A.Kubtan48Continue Degree of differentiation of tumour : Well differentiated . Moderately differentiated . Poorly differentiated . M.A.Kubtan49Current nomenclatureDuctal carcinoma most common . Lobular carcinoma 15% of cases . Mixed ( ductal & lobular ) . Rarer histological varient : Colloid carcinoma ( cells produce abundant mucin . Medullary carcinoma(marked lymphocytic reaction ) Tubular carcinoma . Inflammatory carcinoma ( rare , highly aggressive ). Carcinoma in situ (pre invasive cancer has not breached the epithelial basement membrane .M.A.Kubtan50Carcinoma in situMay be ductal ( DCIS ) . Or lobular ( LCIS ) .M.A.Kubtan51Staining Staining for oestrogen and progesteron receptors will indicate the use of adjuvant hormonal therapy with tamoxifen .M.A.Kubtan52Paget,s disease of the nippleSuperficial manifestation of an underlying breast carcinoma . It presents as an eczema like condition . The nipple is eroded slowly and eventually disappears . M.A.Kubtan53Pagets disease left breastM.A.Kubtan54The spread of breast cancerLocal spread . Lymphatic metastasis . Spread by the bloodstream .M.A.Kubtan55Clinical presentationMost breast cancer will present as a hard lump . It may be associated with indrawing of the nipple . Their may be skin involvement ( peau d,orange ). Ulceration or fixation to chest wall . Some times may present with local or distant metastasis . M.A.Kubtan56M.A.Kubtan57M.A.Kubtan58M.A.Kubtan59M.A.Kubtan60Staging of breast cancer T N M T tumour . N lymph node . M metastasis M.A.Kubtan61Prognosis of breast cancerSize of tumour . Lymph node status . Presence of distal metatasis.M.A.Kubtan62Management of operable breast cancerM.A.Kubtan63M.A.Kubtan64Types of surgical treatmentSimple mastectomy . Patey mastectomy ( simple mastectomy with axillary clearness ). Radical mastectomy .M.A.Kubtan65Conservative breast cancer SurgeryLocal excision : aimed at removing the tumour plus a rim of at least 1 cm of normal breast tissue . Quadrantectomy involves removing the entire segment of breast containing the tumour . Both of the above surgery are usually combined with axillary surgery .M.A.Kubtan66M.A.Kubtan67Supportive treatmentRadiotherapy . Adjuvant systemic therapy ( chemotherapy ). Hormonal therapy .M.A.Kubtan68GynaecomastiaIdiopathic unilateral or bilateral . Hormonal , accompanied stilbesterol therapy for prostatic cancer . Some times occusrs in patients with cirrhosis due to failure of liver in metabolizing oestrogens. M.A.Kubtan69Carcinoma of the male breast0.5% of all breast cancer . Predisposing factor gynaecomastia . Treatment surgical as in female breast .M.A.Kubtan70M.A.Kubtan71