Reference: Schwartz textbook of surgery 9th edition

1. The Breast
Laguna Medical Center
Department of Surgery
Presented by: Dr. Rahul Shah
PGI, LMC

2. EMBRYOLOGY
• 5TH TO 6TH WEEK OF FETAL DEVELOPMENT
• MAMMARY RIDGES
• Each breast develops when an ingrowth of
ectoderm forms a primary tissue bud in the
mesenchyme.
• 15-20 SECONDARY BUDS: EPITHELIAL CORDS
DEVELOP
• MAJOR DUCT DEVELOP- OPEN TO SHALLOW
MAMMARY PIT
• INFANCY: MESENCHYME PROLIFERATES
FORMING PIT TO NIPPLE

3. FUNCTIONAL ANATOMY

5. Blood Supply

6. Lymph supply

7. Lymph supply

9. PHYSIOLOGY OF BREAST
Breast development and function
Hormonal stimuli:
• Estrogen: ductal development
• Progesterone: differentiation of epithelium & lobular development
• Prolactin: 1o hormonal stimulus for lactogenesis in late pregnancy &
the postpartum period.

11. Gynecomastia
• Enlarged breast in male, ductal enlarge, elongate, >epithelium
• Physiologic: neonatal, adolescence (UL) and senescence
(estrogen>testosterone)
• >2cm diameter in non-obese male
• No predisposition to breast ca except in klinefelter’s syndrome
Grade I: mild enlargement without skin redundancy
Grade IIa: moderate enlargement without skin redundancy
Grade IIb: moderate enlargement with skin redundancy
Grade III:marked breast enlargement with skin redundancy & Ptosis

12. Infectious and inflammatory disorders
Most common in postpartum period
Intrinsic or extrinsic are also common in opd
mc: periductal mastitis and infected
sebaceous cyst respectively

13. Bacterial infection
• MC: Staphylococcus and streptococcus sp.
• Abscess: Usually staph infection, redness , point tenderness and
hyperthermia
• Usually 1st few weeks of breast feeding
• Progression lead to subcutaneous, subareolar, interlobular and
retromammary abscess.
• Tx: antibiotic trial and repeated aspiration and operative drainage
• Strep inf are superficial, tx is local wound care,warm compression
and antibiotics

14. Zuska’s disease
• AKA recurrent periductal
mastitis
• Smoking is risk factor.
• Treat symptomatically with
antibiotics coupled with incision
and drainage as necessary

15. Mycotic infection
• Usually involve blastomycosis and
sporotrichosis
• Inoculated via infant while sucking
• Present as mammary abscess in
nipple areola complex
• Antifungals, may require drainage or
even partial mastectomy if persistent.
• Candida infections are usually
erythematous and scaly in
inframammary folds and axillary folds
• Treated by topical nystatin

16. Hidradentis
suppurativa
• can also occur in the nipple-
areola complex
• - originates within the
Montgomery glands or axillary
sebaceous glands.
• - Risk factor: chronic acne
• - may mimic Paget's disease of
the nipple or invasive breast
cancer.
• - Tx: Antibiotic + I&D

17. Mondor’s disease
• a benign self limited condition which is a variant of
thrombophlebitis that involves the superficial veins of the
anterior chest wall and breast.
• - SSx: acute pain in the lateral aspect of the breast or the
anterior chest wall with palpation of a tender, firm cord along
the distribution of the major superficial veins.
• - Tx: anti-inflammatory medications + warm compresses along
the symptomatic vein + Restriction of motion of the ipsilateral
extremity and shoulder + brassiere support of the breast are
important (4 to 6 weeks) or excision of vein (if not improving)

18. Mondor’s disease

19. COMMON BENIGN DISORDERS AND DISEASES OF
THE BREAST
Fibroadenoma
• seen predominantly in younger women
aged 15 to 25 years
• can be self limiting
• if greater than 3cm: consider giant
fibroadenoma
• if multiple (more than 5 lesions in 1
breast): considered as abnormal
• - tx: cryoablation, surgical removal or
observation

20. Cyclical mastalgia and nodularity
• associated with premenstrual enlargement of the breast
• physiologic.
• If Painful nodularity persists for >1 week of the menstrual cycle,
consider a disorder.
• bilateral bloody nipple discharge: can be seen in epithelial hyperplasia
of pregnancy

21. Breast cysts
• occurs when the stroma involutes too quickly, and alveoli remain: forming
microcysts & macrocysts
• - characteristics of benign lesions: sharp, smooth margins, a homogenous interior
and posterior enhancement (vs malignancy which will show irregular and jagged
margins, heterogenous interior and posterior shawoding)
• management: needle biopsy ( 1st line investigation for palpable breast masses)
• if (+) fluid on aspiration: aspirate to dryness, no need to do cytologic examination
• If after aspiration, (+) residual mass - do UTZ guided needle biopsy
• If blood stained fluid - aspirate 2 mL for cytologic examination, utz imaging and
biopsy solid areas
• If complex cyst rule out malignancy.

22. Sclerosing adenosis
• Common in childbearing and perimenopausal years
• no malignant potential
• characterized by distorted breast lobules + multiple microcysts +
benign calcifications

23. Intraductal papillomas
• Seen in premenopausal women.
• - common symptom: serous or
bloody nipple discharge
• - Gross appearance: pinkish tan,
friable,
• - rarely undergo malignant
transformation & no increased
risk of breast cancer, unless
multiple

24. BREAST CANCER
• RISK FACTORS:
• increased exposure to estrogen
• radiation exposure
• increased alcohol intake
• high fat diet (increased serum estrogen levels)
• prolonged use of OCPs (particularly estrogen-plus-progesterone) and
HRT
• (+) family history of breast cancer

25. screening mammogram
• routine screening mammography starting 50 years old
age reduces mortality from breast cancer by 33%
• baseline mammography at age 35
• annual mammographic screening beginning at age 40.
• If (+) family history for breast cancer Baseline
mammogram 10 years before the youngest age of
diagnosis of breast ca among 1st degree relatives. (this
rule is modified if age of diagnosis is less than 35)

26. Signs and Symptoms
• mass (most common) : if size is 1 cm
mass has been present for 5 years
• breast enlargement or asymmetry
• nipple changes - retraction, or
discharge ( due to shortening of
Cooper's suspensory ligament)
• skin dimpling
• ulceration / erythema of the skin
• axillary mass or mets

27. • firm or hard with continued growth of the metastatic cancer.
• axillary lymph node status: most important prognostic correlate of
disease-free and overall survival
• peau d'orange (Localized edema): blocked drainage of lymph fluid
• musculoskeletal discomfort.
• Distant metastases: most common cause of death in breast cancer
patients
• Due to neovascularization (hematogenous spread) cancer cells
shed directly to axillary and intercostals veins or vertebral column via
batson’s plexus of veins.

28. Breast Ca in Situ
• Multicentricity: occurrence of a second breast cancer outside the
breast quadrant of the primary cancer (or at least 4 cm away)
• Multifocality: the occurrence of a second cancer within the same
breast quadrant as the primary cancer (or within 4 cm of it)
• Difficult to differentiate from atypical hyperplasia or cancers with
early invasion
Subtypes: DCIS and LCIS

30. Treatment
LCIS: observation, chemoprevention with tamoxifen, and bilateral total
mastectomy or may opt to do close follow up + periodic PE + bilateral
mammograms for a more conservative approach
DCIS:
• > 4 cm or disease in >1 quadrant: mastectomy
• Low-grade DCIS of the solid, cribriform, or papillary subtype that is
<0.5 cm: lumpectomy (If margins are free of disease)
• Adjuvant tamoxifen therapy has a role for DCIS pt.

31. Invasive Breast Cancer
Paget's disease of the nipple
• chronic, eryhthematous, eczemamatoid rash or ulcer
• associated with DCIS & invasive cancer.
• Pathognomonic sign: large, pale, vacuolated cells
(Paget cells) in the rete pegs of the epithelium.
• Rule out superficial spreading melanoma
• (+) s-100 antigen in immunostaining (vs paget’s
disease which is (+) in carcinoembryonic antigen
immunostaining)
• Tx: lumpectomy, mastectomy, or MRM (depending on
the extent of involvement and the presence of
invasive cancer)

32. Invasive ductal carcinoma
• Occurs in perimenopausal or postmenopausal ♀
(5th-6th decade)
• Most common carcinoma presenting as a breast
mass
• poorly defined margin, central stellate
configuration with chalky white or yellow streaks
extending into surrounding breast tissues
• macroscopic/microscopic axillary LN metastases
in 60% of cases

33. Medullary carcinoma
• Associated with BRCA1phenotype & DCIS
• Gross appearance: well circumscribed, soft &
hemorrhagic (when accompanied with a rapid
increase in size)
• PE: bulky and mass is positioned deep within the
breast.
• Can mimic a benign condition on diagnostic
imaging (looks like a fibroadenoma on UTZ)
• Occurs bilaterally in 20% of cases.
• Microscopically: dense lymphoreticular infiltrate

34. Mucinous (colloid) carcinoma
• Occurs in the elderly
• Characteristic lesion: extracellular pools of mucin
• Gross appearance: glistening & gelatinous with a firm consistency
Papillary carcinoma
• Usually occurs in the 7th decade of life
• More common in nonwhite ♀.
• defined by papillae with fibrovascular stalks and multilayered
epithelium.

35. Invasive lobular carcinoma
• Histopath: small cells with rounded
nuclei, inconspicuous nucleoli, and
scant cytoplasm; (+) intracytoplasmic
mucin, which may displace the nucleus
(signet-ring cell carcinoma).
• frequently multifocal, multicentric,
and bilateral.
• Hard to detect mammographically

36. Diagnosis of breast cancer
Mammogram
• CC and MLO views
• solid mass +/- stellate features
• asymmetric thickening of breast tissues
• clustered microcalcifications
• presence of fine, stippled calcium in & around a
suspicious lesion is suggestive of breast cancer;
occurs in 50% of nonpalpable cancers.

37. Recommendations
• normal-risk women at
20 yo breast
examination every 3
years
• at age 40 yo annual
breast examination /
mammography
• false (-)/(+) rate: 10%

38. Ductography
• Indication: is nipple discharge, (particularly when bloody)
• intraductal papillomas are seen as small filling defects surrounded by
contrast media
• Ca: may appear as irregular masses or as multiple intraluminal filling
defects

39. • Ultrasonography
• Ideal for younger patients (because of tendency to have denser
breasts – can affect results if mammography is used)

40. Breast cancer staging
• Clinically based
• tumor size correlates with the presence of axillary lymph node
metastases
• The single most important predictor of 10- and 20-year survival
rates in breast cancer is the number of axillary lymph nodes
involved with metastatic disease.

42. Treatment
A. Surgery: MRM
B. Chemotherapy :ACT (Adriamycin, Cyclophosphamide , Taxanes)
• Indications for chemo:
Spread to axillary LN
Downstage tumor before operation
C. Radiotherapy: always given with breast reconstruction surgery, high
grade cancer
D. Hormonal therapay: all women with +ER/PR receptor