Breast

BREAST

Porf. Dr. Alaa Jamel
FACS. MRCSI CABS mbchb

objective

1-to know the anatomy ,blood supply, lymphatic drainage of the breast.
2-to know the congenital anomaly of the breast.
3-to know what means ANDI and what that represent.
4-who you mange patient with breast disease and what means triple assessments.
5-to know the benign condition of the breast , ..
5-to know the acute and chronic inflammatory condition of the breast.
6-to know predisposing factor of breast cancer.
7-who we can do early diagnose breast cancer
8-to know the types of breast cancer.
9-To know who we can stage the disease.
10-to know the main line of treatment breast cancer
11-to know what means gynicomastia and who we can reach to the cause and who we treat


anatomy
Its modified sweet gland. lie in the superficial fascia of pectoral region; its hemispherical in shape due to high fat content .
The protuberant part of the breast overlying the second to the sixth ribs and extending from the lateral border of the sternum to the mid axillary line.

Its lie on superfascial fascia of pectoral region and rest on deep fascia (pectoral fascia).
It separate from pectoral fascia by retroMamery space which contain loos areolar tissue allowing free mobility of breast.

Anatomy and functional unit

The breast is composed of 15 to 20 lobes which
are each composed of several lobulesThe lobule is the basic structural unit of the mammary gland ,the NO. and the SIZE of the lobules vary In enormously. they are most numerous in a young women ( 10 to 100 lobules) empty via ductules into lactiferous duct of which there are (15 to 20 ) at the end of the duct small dilatation called lacterfarous sinus.
Breast has no fibrous capsule.

AXILLARY TAIL

AXILLARY TAIL

Its extend beyound the anterior axillary line and peirse the deep (pectoral) fascia to the mid axxillary line (its represent the only part of breast lie deep to the fascia). in some normal females its palpable and in a few can be see premenstrual or during lactation. A well develop axillary tail is some time mistaken for amass of enlarge l.n. orLipoma.
Upper lateral quadrent of breast
it’s the site where the commonest of ca. breast occur and a dens of brest tissue found


LIGAMENT OF COOPER
Are hollow conical projection of fibrous tissue filled with breast tissue which pass between the lobes. The apices of the cones being attach firmly to the superficial fascia(pectoral fascia) and thereby to the skin over ling the breast. These ligament account for the dimpling of the skin over lying carcinoma

AREOLA

It contains involuntary muscle .its epithelium contain numerous sweet gland and sebaceous gland.
Sebaceous gland enlarge during pregnancy and serve to lubricate the nipple during lactation( Montgomery's tubercles

THE NIPPLE

Its light brown conical projection shape located below the center of breast at the level of 4th intercostal space.Its cover by thick skin .near its apex open lactiferous duct. It contains smooth muscle fiber arranged concentrically and longitudinally thus its an erectile structure which points outwards

BLOOD SUPPLY

1-internal thoracic (memary) artery .subclavian .
2-thoroco acromial artery..axillary art.
3-lateral thoracic artery ..axillary artery
4- posterior intercostal arteries.

LYMPHATIC DREANAGE

Lymph drain 85% to the axillary L.N and 15% to the internal mammary L.N
arrange in the fallowing group
1-lateral group along the axillary vein
2-anterior group along lat.thoracic vessels
3-posterior group along sub scapular vessels
4- central embedded in the fat of center of axilla
5- interpectoral, few l.n lying between pect. Minor and pect. major muscle
6-apical group which lie above the level of pectorals muscle tendon
And received lymph from all the other group and its in continuity with supraclavicular l.n and drain to subclavian trunk

Internal mammary l.n lie along the internal mammary vessel.

3 LEVELS OF LYMPH NODES

Level 1 lateral to the pectorals minor muscle
Level 2 behind pect. Minor Muscle
Level 3 medial to the pect. Minor.

L THE TISSUE LAYERS OF THE BREAST?FROM THE MOST SUPERFAICIAL TO THE DEEPEST

Epidermis, dermis, surefacial layer of superficial fascia, coopers ligaments ,glandular tissue. deep layer of superficial fascia, retromammary space, deep investing fascia(pectoral fascia) ,pectorals major muscle.

DIAGNOSIS OF BREAST DISEASE

Depend on triple assessment which include
1-history and clinical examination
2-radiological imaging
a-mammography
b-uls both for diagnosis and to guide biopsy
c-magnetic resonance useful in symptomatic patient with breast implant where US is not diagnostic and also used in to detect local recurrence where US and mammography are un helpful
3-biopsy usually US guided
F.N.B CYTOLOGY
CORE BIOPSY


f.N.B CYTOLOGY using a 21 G or 23 G needle and 10 ml syringe with multiple passes through the lump without releasing the negative pressure in the syringe. Disadvantage is cannot distinguish invasive cancer from carcinoma in situ
CORE BIOPSY 1-.give a definitive preoperative diagnosis
2-difrentiate duct carcinoma in situ and invasive carcinoma 3- allow the tumour to be stained for receptor status which important before commencing neoadjuvant therapy

MAMOGRPHY

Its soft tissue radiographs are taken by placing the breast in direct contact with ultrasensitive film and exposing it to low voltage and high amperage x ray .the dose of radiation is approximitly 0.1 cGY,so its very safe investigation. the sensitivity of the test increase with the age as the density of breast decrease

MAMOGRPHY

Breast cancer tend to be more radio dense than the normal tissue
Criteria that increase chance of cancer in patient without palpable mass appear in the mammography
1-microcalcification2-irregular mass with microcalcification 3- structural distortion with microcalcification 4- asymmetry with microcalcification 5- more than 5 microcalcification lcm2 6-indistict margin

Abnormalities of NIPPEL

May be absent usually associated with amazia ( congenital absence of breast)or may be multiple
Supernumerary nipple not uncommonly occur along a line extending from the anterior fold of axilla to the fold of the groin .
Nipple retraction
May be recent or old
OLD also known simple nipple inversion is of unknown atiology,25% bilateral, it may cause problem during lactation and infection may occur
Treatment
Usually unnecessary and may resolve spontaneously during pregnancy and lactation


Simple cosmetic surgery may resolve the problem.
Recent retraction may consider of pathological significant, slit like retraction of the nipple may be due to duct ectezia or chronic periductal mastitis ,but circumferential retraction with or without under ling lump may be due to carcinoma.

CRACKED NIPPLE

This may occur during lactation and may cause acute infective mastitis
PAPILLOMA OF THE NIPPLE
Treatment with excision
ECZEMA OF NIPPLE
Rare condition and often bilateral
And must be distinguish from Paget’s disease of nipple
WHO U DIFRENTIATED BETWEEN ECZEMA AND PAGET’S DS?

Aberrations of Normal Development and Involution (ANDI)

(the aberrations of normal development and involution (ANDI) classification of benign breast conditions are the following:
a) benign breast disorders and diseases are related to the normal processes of reproductive life and to involution;
(b) there is a spectrum of breast conditions that ranges from normal to disorder to disease;
(c) the ANDI classification encompasses all aspects of the breast condition, including pathogenesis and the degree of abnormality

ANDI classification of benign breast disorders Normal Disorder Disease

Early reproductive years(age 15–25 y)
NORMAL DISORDER DISEASE
Lobular development Fibroadenoma Giant fibroadenoma
Stromal development Adolescent hypertrophy Gigantomastia
Nipple eversion Nipple inversion Subareolar abscess
Mammary duct fistula
Later reproductive years(age 25–40 y)
NORMAL DISORDER DISEASE
Cyclical changes of menstruation Cyclical mastalgia Incapacitating mastalgia
Nodularity
Epithelial hyperplasia of pregnancy Bloody nipple discharge

Involution (age 35–55 y)

NORMAL DISORDER
Lobular involution Macrocysts —Sclerosing lesions

Duct involution
Dilatation Duct ectasia Periductal mastitis
Sclerosis Nipple retraction


DISCHARGE OF THE NIPPLE
its commom problem. its either normal or pathological lesion.
Normal discharge usually ;
A- occur in both nipples
B-Release when nipple squeezed.
C- never blood stained
It occur from one or more lactiferous ducts, management depend on.
1- presence of a lump.
2- presence of blood in the discharge
3- discharge from single duct or more.

DISCHARGE OF THE NIPPLE

BLOOD STAINED
1-duct papilloma whene blood arises from a single duct
2-Intra duct carcinoma
3-paget’s disease
4-Invasive carcinoma ( rare)
Clear. intra duct papilloma
Multi colored. duct ectasia
Fibrocystic disease of breast( multiple ducts).
Milky; lactation
Hyperprolactenimea
or occasionally hypothyroidism
.estrogen replacement therapy
purulent ;breast abscess


Investigations of nipple discharge
Mamography
USG
Prolactine level
TFT (hypothyrodism)
Cytological examination of bloody nipple dishrge
Ductoscopy ( not very successful)

TREATMENT (TRIPLE ASSES.)

Must firstly exclude carcinoma by occult blood test and cytology.
And the majority of cases of nipple discharge are benign and this symptoms is rarely presenting feature of breast cancer even when blood –stain clear
Single duct or blood stain discharge required further investigation
If a lump is present it should be manage by triple assessment
In the absent of a lump the management of discharge is the fallow
Multicolored multiduct discharge. If clinical examination and mammography are normal ,a diagnosis is duct ectesia is likely and no further treatment is required.
.

Clear single –duct discharge

If mammography is normal the diagnosis is likely to be an intraduct papilloma and excision of infected duct(microductomy ) is indicated
Bloody nipple discharge
The present of blood in the discharge should be confirmed by cytology .if blood is present a mamogram( for women over 35 year of age) is performed with biopsy of any abnormal tissue.
If mammography is normal ,a microductomy is performed if a single duct can be identified .


Hadfield operation
It means core excision of major ducts
Indicated when
A- discharge from multiple ducts
B- origin of discharge is not clear

SYMPTOMS OF BREAST DISEASE

There are 5 common symptoms of breast disease that warrant urgent attention .
1-Anew discrete lump
2- nipple discharge _blood stain or persistence nipple discharge
3- nipple retraction or distortion of resent oncent
4-altered breast contour or dimpling
5-Suspected baget’s disease
Other common symptoms that required further investigation include persistence a symitrical nodularity,breast pain (mastalgia).familay history of breast cancer

PAIN IN THE BREAST(MASTALGIA)

It can be separated to cyclical and non cyclical mastalgia.
Cyclical type most common and due to alteration of normal cyclical pattern that occur during reproductive years
So it may be worse premenstrual and relieve after menstruation
Non cyclical mastalgia causes
1-breast abscess
2-carcenoma of the breast
3-Tietze's syndrome( chondritis of costal cartilage, is of unknown etiology
4-chest wall lesion….herpes zoster.


Treatment of mastalgia
Cyclical mastalgia may become significant clinical problem if the pain and tenderness interfere with women's life .beginning of treatment is reassurance that these symptoms are not associated with cancer .
Must use an appropriate fitting and supportive bra should be worn through the day and soft bra(as sport bra) at the night +avoiding caffeine may be help
If these measure not help can be use oil of evening primrose in adequate dose over 3 months will help more than one half of women
For those who have intractable pain ,anti gonadotropin hormone such as danazol or prolactin inhibitor as promocriptine .
For non cyclical mastalgia is important to exclude extra mammary causes .

DUCT ECTESIA(periductal mastitis)

This is a dilatation of the lacteferous ducts associated with periductal inflammation, the disease more common in smoking women.
This condition may associated with periductal mastitis or even abscess or fistula formation and in some cases indurate mass may appear beneath the areola which mimic carcinoma . fibrosis of ducts may develops which may cause slit-like nipple retraction.

Pathophysiology;

dilatations of ducts…stasis…infections,,,spred infection to periductal tissue…subareolar mass. Discharge .. Fistula.,,fibrosis ,,, nipple retraction.
Sypmptoms;
Grenish discharge then purulents due to infection
Subaereolar mass
Fistula formatio
Fibrosis of duct
Nipple retraction


TREATMENT
if the condition associated with mass or recent nipple retraction Must exclude malignancy by tipple assessment.
Start with antibiotic .and if not response surgical major duct excision may need(cone excesion Hadfield operation)

BREAST CYST

These occur in last decade of reproductive life due to a non integrate involution of stromal and epithelium .they are often multiple and may be bilateral and it may mimic breast cancer
Diagnosis by aspiration and or uls after triple
assessment .
pneumocystogram can be obtained by injecting air into the cyst and then obtaining a repeat mammogram. When this technique is used, the wall of the cyst cavity can be more carefully assessed for any irregularities.

Treatment

Solitary cyst and small cyst can be aspirated and if it resolve completely and no blood stain fluid no further treatment need. about 30% recur and need another aspiration
If there's residual mass or blood stained fluid a core biopsy or excisional biopsy for histological examination


GALACTOCEL
Its rare condition ,usually present with a solitary sub areolar cyst and always dates from lactation it contains milk

FIBROADENOMA

Common benign tumour of breast, its hyper plasia of single lobules.
Mainly occur a t age 20-30years only female.
Cause; may be due to increase sensitivity to estrogen in local area of breast.
Some books say unknown causes.
May increase risk of malignancy in prolong duration and giant types 2.6% to malignant.
Types; cross ,,, soft or hard or giant
Microscopic; intacanaculi ( small and hard because contain mainly fibrous tissue) or pericanaculi (large and soft).
Clinical features; freely mobile, painful mass, no axillary lymph node.
Diagnosis ; clinically,, mammography show popcorn(macrocalcifications)
FNAC invest. Of choice.
U/S sold or cystic

FIBROADENOMA

Its a benign condition occur at age between 15 to 25 years although it may occur at older age
They arise from hyperplasia of a single lobules and usually grow up to 2-3 cm in size they are surround by well develop capsule and thus can be inoculated through a cosmotic incision
Giant fibro adenoma may occur during puberty and it may reach 5 cm or more


CLINICL FEATURE

Usually present as solitary mobile lump firm in consistency ,but some patient present with multiple lump. They are highly mobile ( breast mouse) not attach to the skin or under like structure and not associated with enlarge axillary axillary l.n , sometime cause pain and tenderness especially in premenstrual period


Most fibroadenomas are self-limiting and many go undiagnosed, so a more conservative approach is reasonable . Cryoablation and ultrasound-guided vacuum assisted biopsy are approved treatments for fibroadenomas of the breast, especially lesions <3 cm. Larger lesions are often still best removed by excisionTherefore, women should be counseled that the options for treatment include surgical removal, cryoablation, vacuum assisted biopsy, or observation

TREATMENT

All clinical F. A. must be investigated by triple assessment. those with multiple adenoma ,the largest one should undergo core biopsy.
Surgery should avoided in majority of cases but should be considered in the following circumstances
1-lump increasing in size (clinically or by uls
2-symptomatic lump(pain or tenderness)
3-patient preference


PHYLLODES TUMOUR
Phyllodes means leaf-like
This tumour have many of clinical features. Its a true neoplasm with wide rang of characteristics from benign to malignant .they arise from stromal cell of the breast and are classified as low, intermediate or high grade depending on there microscopically feature .they are rarely metastasize but can recur locally if in adequate excised.

C.F
Usually present as affirm discrete lump, large ,some time massive. Occasionally ulceration of overlying skin occurs because of pressure necrosis .it mobile on chest wall
.it may be metastasis via the blood stream. Despite the name of cystosarcoma phyllodes they are rarely cystic and very rarely develop feature of sarcomotous tumour

TREATMENT

All phyllod tumour should treated by wide local excision to prevent recurrence .if large tumour mastectomy with immediate reconstruction

TRUMATIC FAT necrosis

It may be acute or chronic, associated with history of trauma ,or even in direct due to contraction of pectoralis major and is common result of seat beat injury after sudden deceleration injury or surgical truma. its important because it mimic to breast carcinoma.

C.F
IT COMMONLY PRESENTED WITH FIRM IRREGULAR ,PAAINLESS LUMP. And there may be history of trauma, its often associated with skin thickening or retraction, the lump usually decrease in size with the time


TREATMENT
Mammography and US cannot distinguish it from carcinoma so best treatment by core biopsy and the palpable mass should be removed

ACUTE INFLAMATION OF THE BREAST

Classification
1-mastitis neonatorum erythema of the breast due to staph. aureas or e. coli
2-peri-areolar;associated with periductal mastitis
3-acute bacterial mastits may be lactational and non lactational

BACTERIAL MASTITIS

Its most common variety of mastitis and nearly always commences acutely ,it associated with lactation in majority of cases ,but it may occur in non lactating women ,some of those may associated with infected hematomas or periductal mastitis

Etiology;

Most cases are cause by staphylococcus aureus and if hospital acquired its penicillin resistance. stahp bacteria transmit from the mouth of the infant to the nipple of the mother.
This condition may associated with retracted nipple because of blocked of lactiferous duct by epithelial debris leading to stasis
Clinicl feature
Signs of acute inflammation and later abscess formation



Mastitis of infants;
Its equals in male and female ,condition appear in 3rd or 4th day of life ,it disappear during 3rd wks. This condition called witch's milk. its due to the effect of maternal prolactin on the fetal breast.

BREAST ABSCES

Patient with clinical or radiological evidence of pus should have aspiration performed under cover appropriate antibiotic ,repeated aspiration may be necessary and resolution of abscess can be monitored with repeated uls examination .if the abscess failed to resolve a radial or circum areolar incision done to drain the abscess and must removed all loculi that can be felt after introduced finger through the incision.
Peau d'orange
Its due to coetaneous lymph odema where the infiltrated skin tethered by the sweat ducts it cannot swell leading to an appearance like orange skin ,occasionally this appearance occur in chronic abscess.

CHRONIC INFLAMATORY ABSCES

Its occur due to inadequate drainage or using antibiotic ..its difficult to diagnosed ,its mimic ca. breast diagnosis by biopsy and histological examination
MONDOR'S DISEASE
Its thrombophlebitis of superfascial veins of breast and anterior chest wall
The pathognomonic feature is a thrombosed subcutaneous cord usually attached to the skin
Diff.diagnosis
Lymphatic permeation from an occult carcinoma of the breast
Treatment need only rest and analgesia


LUMP IN THE BREAST
95% of breast lump will be one of the four following
1-carcenoma of the breast
2- cyst
3-fibroadenoma
4- fibroadenosis
In addition the falowing less common causes need to be considerd
1.Trauma ( fat necrosis)
2.Other cyst
(A) Galactocel
(B) Abscess
(C) Cyst adenoma
(d) Retention cyst of Montgomery gland
3-other tumours
(A) Duct papilloma
(b) Sarcoma (extremely rare)
(C) Hamertoma
(D) Lipoma

BREAST TUMOUR

CLASSIFICATION
BENIGN
a-intraductal papilloma
b- phyllode tumour
C-fibroadenoma
D-cyst
2-MALIGNANT
a-primary
1. Intraductal carcinoma
2. Invasive carcinoma
3. Paget's disease of the nipple
4. Sarcoma
b-secondary
1. Direct invasion from tumour in the chest wall
2. Metastatic deposit from melanoma


CARCINOMA of brest
It’s the most common cause of death in the middle aged women in the world
1. One in nine women will develop breast cancer during their lifetime.
2. Any age may be affected but is rare below the age of 30 years.
3. One in 10 breast lump will prove to be malignant.

AETIOLOGY

1. AGE it increase with age
2. Genetic factor
a-family history
b-gene carriage……BRCA1 and BRCA2 these are autosomal dominant genes
3. Hormonal factors
Mostly due to exposure to estrogen
a-gender women are 100 time more common than male
b-menarche and menopause
early menarche and late menopause ,associated with high risk
c-parity ..nilliparous women higher risk from multiparous.breast feeding decrease the chance
d-hormone replacement therapy ..may slightly increase the risk.



4-Benign breast disease
A number of benign breast disease increase risk of malignancy as present of duct hyperplasia increase risk fivefold.
5-Radiation exposure
Exposure to ionizing radiation in adolescence or early child hood can cause marked increase the risk.

PATHOLOGY

Breast cancer may arise from the epithelium of the duct system any where from the nipple to the terminal duct unit which is in the breast lobule.
Carcinoma which arise in the TDLU(terminal duct lobular unit)but which have not penetrated through the basement membrane are known as carcinoma in situ.which are 2 type
1-duct carcinoma in situ which be classified to low, intermediate, or high grade
2-lobular carcinoma in situ

TYPES

1-DUCT CARCINOMA most common type
2-LOBULAR CARCINOMA 15%
Invasive lobular carcinoma is commonly multifocal and often bilateral
3-inflamatory carcinoma is rare, highly aggressive and it present as painful, swollen breast, worm, and coetaneous odema


SPREAD
LOCAL the tumour enlarge and involve other portion of breast. involvement skin, S.C tissue lead to skin dimpling ,retraction of the nipple and ulceration and invade pectoralis muscle and the chest wall
Lymphatic it occur primarily to the axillaryl.n and internal mammary l.n. then spread to the supra clavicular , abdominal, midiastinal and then to the opposite axilla
Blood stream most commonly to the lung. Liver and bone vertebrae femur ribs (osteolytic) and to the brain ovaries and supra renal gland

CLINICL FEATURE

Most frequently affect upper lateral quadrant ,but it may affect any part of breast. Most of patient present as abreast lump which may be associated with nipple retraction , change in breast contours nipple discharge .dimpling of skin cutaneous odema

Peau d'orange;

Its due to cutanous lymph odema.where the infiltrated skin is tethered with sweat gland, it cannot swell. leading to an appearance like orange skin. this condition may occur in chronic abscess.
Late odema of arm is one complication of breast cancer it may occur at any time from month to years, now a day this condition rare because axillary clearance and radiotherapy rarely used now










When this condition occur must put in our mind that recurrence may occur to axilla because recurrence may cause obstruction to venous flow and lymphatic of axilla.
Edematous limb more susceptible to infection and if infection occur a propt treatment with antibiotic need.
Edematous limb treated by rest elevation and pneumatic compression device may be useful.

PROGNOSTIC FACTORS

1-axillary l.n status
2-tumour grade
3-tumour size
4-N.P.I (Nottingham prognostic index)
Is calculated as N.P.I =O.2*diameter(cm)+grade+nodal status
Tumour score between 1-3
Other prognostic factors are presence of lympho vascular invasion, hormonal receptors(ER and PR)

INVESTIGATION

Diagnosis of breast cancer depend on triple assessment
Staging investigation
Depend on the size of tumour and the presence of other symptoms. The fallowing invest. may be indicate to assess the extent of spread
1-F.B.C.
2-LIVER F.T.
3-CXR
4-ISOTOP BONE SCAN
5-LIVER ULS


STAGING
Use the T.N.M classification
T= tumour size
N=L.N involvement
M=metastasis

T= tumour sizeT1,T2,T3,T4. Tis—no palpable tumour

T1-less than2 cm .t2 –2-5cm .t3 5-10cm .t4 more than 10 cm or any tumour invading skin or chest wall
N=L.N involvement no—no nodal metastasis n1—mobile epsilateral axillary l.n --,N2 –fixed epsilateral axillary l.n,N3—supraclavicular epsilateral l.n
M=metastasis M0 on distant metastasis,M1distant metastasi

TREATMENT

Two basic principles of treatment are
1- to reduce the chance of local recurrence
2-reduce the risk of metastasis spread
The treatment options for each woman depend on the
1- size and location of the tumor in her breast,
2-the results of lab tests (including hormone receptor tests),
3- the stage (or extent) of the disease.
5-woman's age and menopausal status,
6-her general health,
7-and the size of her breasts.


Methods of Treatment
Methods of treatment for breast cancer are local or systemic.
Local treatments are used to remove, destroy, or control the cancer cells in a specific area. Surgery and radiation therapy are local treatments.
Systemic treatments are used to destroy or control cancer cells throughout the body. Chemotherapy and hormonal therapy are systemic treatments. A patient may have just one form of treatment or a combination. Different forms of treatment may be given at the same time or one after another.

Treatment of early breast cancer will usually involve surgery with or without radiotherapy

Systemic therapy such as chemotherapy or hormonal therapy is added if there are adverse prognostic factor such as l.n invasion
At the other end a locally advanced or metastatic disease is usually treated by systemic therapy to palliate symptoms

Type of surgery

Simple MASTECTOMY, BREAST SPARING SURGERY, LUMPECTOMY(REMOVE LUMP +SOME NORMAL TISSUE around it and some l.n of axilla

Simple Mastectomy(remove all breast +some of l.n) indicated to

a-large tumour in relation to breast size
b-center tumour beneath or involve nipple
C-multifocal tumoure
d- local recurrence
E-patient preference .

modified radical mastectomy (remove whole breast+most of l.n+lining over the chest muscle

radical mastectomy (Halsted radical mastectomy)remove breast+chest muscle +all of the l.n+and som additional fat and skin.
For many years, this operation was considered the standard one for with breast cancer, but it is very rarely used today and only in cases of advanced cancer in which the cancer has spread to the chest muscles.


surgical management of the axilla
Axillary l.n status is the most important prognostic indicator in the treatment of invasive breast cancer ,so axillary surgery should performed on all patient with operable breast cancer .there are 2 surgical option

SENTINEL L.N BIOPSY

Its first axilley l.n draining the cancer field is identified, excised and examined for metastasis
Patient with negative sentinel l.n require no further axillary surgery
1-axillary sampling
A minimal 4 node should be removed for histological analysis. If one of these l.n involve so further treatment is necessary by axillary clearance or radiotherapy
2-axillary clearance
Normally carried out to the level 2 which include node lateral and deep to pectorals minor.

ADJUVANT SYSTEMIC THERAPY

A-hormonal therapy
Is used to keep cancer cells from getting the hormones they need to grow
Tamoxifen is the most widely used it reduce annual recurrence rate by 25%and 17% reduced annual rate of death .
Its mostly affected on estrogen receptor + disease(ER)
Other hormonal agents is LHRH agonist which produce reversible ovarian suppression

CHEMOTHERAPY

6 monthly cycle of cyclophophamide,methotrexade,and 5 fluorouracil (CMF) will achieve 25% reduction in the risk of relapse over 10 to 15 year period. its use to pre and pos menopausal and poor prognosis women

Radiotherapy

Used high energy rays to kill cancer cells and stop them from growing. use either external radiation or implant radiation)treatment given 5 days aweekfor5 to 6 week.
Radiation alone or with chemotherapy or hormonal therapy is some time used before surgery to destroy cancer cells and shrink the tumor.

BREAST RECONSTRUCTION

Its either immediate or delay type
The most common type of reconstruction is using a silicon gel implant under pectorals major muscle
Typical reconstruction involve the use of myocutanous flap of latissimus dorsi or rectus abdominis muscle augmented where necessary with a silicon implant
Reconstruction for an individual depend on several factors which are
1-breast size
2-adiquancy of skin flap
3-whether radiotherapy is planned or has previously been used
4-abdominal size and previous abdominal operation;
What are the complication of implant??


Paget's disease of the nipple

Its occurs in the middle aged and elderly women it represent as

UNILATERAL red, bleeding, eczematous lesion of the nipple and areolar epithelium. its associated with an intraduct carcinoma of the underlying breast of 50%of cases. which may or may not form of palpable mass
Diagnosis by biopsy

Treatment

Treatment will determined by any underlying breast cancer detecting on clinical examination or radiological investigation .
Surgical management include mastectomy and axillary surgery for lesion associated with invasive carcinoma .

Breast Cancer During Pregnancy

Incedence ; 1 of every 3000 pregnant women, axillary lymph node metastases 75%
The average age 34 years.
25% of the breast nodules developing during pregnancy and lactation will be cancerous. Mammography is rarely indicated because of its decreased sensitivity during pregnancy and lactation;
however, the fetus can be shielded if mammography is needed.

radiation cannot be considered until the fetus is delivered.

A modified radical mastectomy can be performed during the first and second trimesters of pregnancy, even though there is an increased risk of spontaneous abortion after first-trimester anesthesia.
During the third trimester, lumpectomy with axillary node dissection can be considered if adjuvant radiation therapy is deferred until after delivery. Lactation is suppressed.
Chemotherapy administered during the first trimester carries a risk of spontaneous abortion and a 12% risk of birth defects. There is no evidence of teratogenicity resulting from administration of chemotherapeutic agents in the second and third trimesters


. For this reason, many clinicians now consider the optimal strategy to be delivery of chemotherapy in the second and third trimesters as a neoadjuvant approach, which allows local therapy decisions to be made after the delivery of the baby.
Pregnant women with breast cancer often present at a later stage of disease
because breast tissue changes that occur in the hormone-rich environment of pregnancy obscure early cancers. However, pregnant women with breast cancer have a prognosis, stage by stage, that is similar to that of non pregnant women with breast cancer.

GYNAECOMASTIA

Gynecomastia is enlargment of breast male; Physiologic gynecomastia usually occurs during three phases of life:
neonatal period,
adolescence,
senescence.
Common to each of these phases is an excess of circulating estrogens in relation to circulating testosterone.
Neonatal gynecomastia is caused by the action of placental estrogens on neonatal breast tissues,
adolescence, there is an excess of estradiol relative to testosterone, senescence, the circulating testosterone level falls, which results in relative hyperestrinism


During puberty, the condition often is unilateral and typically occurs between ages 12 and 15 years.
In senescent gynecomastia is usually bilateral.
In the nonobese male, breast tissue measuring at least 2 cm in diameter mustbe present before a diagnosis of gynecomastia may be made. Mammography and ultrasonography are used to differentiate breast tissues

increase level of estrogen and increase adipose tissue.

Causes
1-drugs as digoxin,cimetidin
2-liver cirrhosis
3-renal failure
4-hypogonodism
5-supra renal tumour
6-testicular tumour
7-Idiopathic


CARCENOMA OF THE MALE BREAST
This account for less than 1% of all cases of breast cancer .it affect old age group.
It present with firm, painless subareolar lump
Treatment is by extended mastectomy with lymph node clearance.
Prognosis is worse than in women
Post operativ radiotherapy reduce local recurrence but dose not affect over all survive
Most tumour response to tamoxifen .for advance disseminated disease chemotherapy can produce reasonable palliation.















Other tumours of the breast
;
Lipoma ; a true lipoma is very rare
Sarcoma of the breast;
Its usually of the spindle- cell variety and account for 0.5% of malignant tumour of the breast .it tend to occur in ypnger women between the ages of 30 and 40 years.
Treatment ; simple mastectomy fallowed by radiotherapy .

THANK YOU