Breast disorders

Breast disorders

1. BREAST DISORDERS Mrs. U SREEVIDYA, Msc . NURSING, Associate Professor, Apollo college of nursing, CHITTOOR

2. Breast Anatomy Breast Made up of milk-producing glands Supported and attached to the chest wall by ligaments Rests on pectoralis major muscle Three major hormones affect the breast Estrogen, progesterone, and prolactin

3. Parts, Shape & position of the Gland It is conical in shape. It lies in superficial fascia of the front of chest. It has a base, and apex. Its base extends from 2 nd to 6 th ribs. It extends from the sternum to the midaxillary line laterally. It has no capsule.

4. SHAPE AND POSITION OF FEMALE BREAST 2/3 of its base lies on the pectoralis major muscle , while its 1/3 of inferolateral lies on: Se rratus anterior & Ex ternal oblique muscles.

5. Nipple: It is a conical eminence that projects forwards from the anterior surface of the breast. The nipple lies opposite to 4 th intercostal space. It carries 15-20 narrow pores of the lactiferous ducts. Areola : It is a dark pink brownish circular area of skin that surrounds the nipple. SHAPE AND POSITION OF FEMALE BREAST

6. STRUCTURE OF MAMMARY GLAND It is non capsulated gland. It consists of lobes and lobules which are embedded in the subcutaneous fatty tissue of superficial fascia. It has fibrous strands ( ligaments of cooper ) which connect the skin with deep fascia of pectoralis major.

7. There are15-20 lobes in the breast. Fat covers the lobes and shapes the breast Lobules fill each lobe Sacs at the end of lobules produce milk Ducts deliver milk to the nipple

8. Breast Anatomy

9. Common breast complaints Breast pain Breast mass Nipple discharge Infection

10. BREAST PAIN (MASTALGIA)

11. Mastalgia ( mastodynia ) Mastalgia is pain and swelling of the breasts due to vascular enlargement, oedema and slight secretary engorgement of breast ducts. Painful breast seen in young women, is often cyclical but in older women it is usually acyclical . Cyclical mastalgia is the breast pain occurring for a few days before menstruation. Severe mastalgia lasts more than 7 days requires drugs and interferes with the woman’s activities. Chronic mastalgia is described when pain has lasted for more than 6 months.

12. Approximately 45% of women have mild breast pain, and 21% have severe breast pain in their lifetime . Breast cancer is found in 1.2 – 6.7% of women presenting with breast pain Incidence

13.  Cyclic mastalgia   Normal hormonal changes Particularly luteal phase of menstrual cycle  Fibrocystic disease  Increased fibrous or cystic tissue  Pendulous breasts  Stretching of Cooper’s ligaments etiology

14.  History     Unilateral vs. bilateral Cyclic vs. noncyclic Systemic or local symptoms (e.g. erythema, fever) History of trauma Clinical breast exam Evaluation Ultrasound Mammogram Diagnosis

15.  Treatment:  L i fes t y le   Eliminate caffeine Low fat diet  Supportive   Support garments (well-fitting, supportive bra, sports bra) Compresses  Medication       NSAID’s ( Aspirin , Ibuprofen , Naproxen ) OCP’s, Progestogens Danazol – 100mg BD Bromocriptine – 2.5mg , BD GnRH agonists – Goserelin – 3.6mg, monthly depot injection. Tamoxifen - IF severe mastalgia , 10mg / day Management

16. Fibrocystic disease is called adenosis, fibroadenosis , mammary dysplasia, chronic cystic mastitis. This is mammary duct and acini proliferation and cyst formation. Pathology : Cyst formation of terminal duct and acini with fibrosis of interstitial tissue and Epithelial hyperplasia. Mastalgia: Fibrocystic Disease

17.  Fibrocystic disease    Occurs in premenopausal women Results in premenstrual breast swelling/tenderness Presence of nodules/masses/lumps related to dense breast tissue or cysts Mastalgia: Fibrocystic Disease  Fibrous tissue  Cystically dilated ducts  + Calcifications  + Ductal hyperplasia

18. Diagnosis : This is the commonest breast lesion, which occurs during 30 to 50 years , rare in post menopausal women. Clinical features : Pain in the breast, bilateral lump in the breast. Pain and lump size increases premenstrually . The lump is felt as nodular, tender & thickening at one quadrant of the breast. Mammography, biopsy can be done to exclude breast cancer.

19. Treatment : This condition is self limiting and requires no active treatment . Analgesia is given for pain. Pregnancy and lactation Bring permanent relief for pain. Wearing tight brasseries is necessary to protect breasts from trauma. In cases with severe pain, Danazol -100 mg, BD, orally for 2 to 6 months.

20. BREAST MASS (benign tumors )

21. More than 90% of palpable breast masses in women are, in their 20’s to early 50’s . They are usually benign . Differential Diagnosis:      Fibrocystic changes Breast cancer Breast Mass: Etiology Fibroadenoma Fat necrosis Intraductal papilloma CONDITIONS INCLUDE:

22. This is a benign tumor of epithelial fibrous tissue. The tumor becomes well capsulated. Diagnosis : Common in young women usually within 20 years. - Not normally occurs after menopause. - Multiple tumours in one or both breasts are found in 10 to 15% cases. - The breast lump is round, firm, discrete, movable and non tender. Treatment: Enucleation is done under local anesthesia followed by histologic al examination. Breast Mass: Fibroadenoma

23.  Fibroadenoma    Solitary, firm, rubbery, mobile mass Women < 30 yrs Slow growing Breast Mass: Fibroadenoma Fibroadenoma gross specimen    Firm, tan, lobulated Well circumscribed mass Variable size

24.  Intraductal papilloma   Unilateral with bloody nipple discharge Sub-areolar intraductal mass Breast Mass: Intraductal Papilloma Intraductal papillary neoplasm with fibrovascular cores lined by benign ductal and myoepithelial cells Duct ex ci s i o n

25.  Fat Necrosis Caused by trauma Tender, firm mass with indistinct borders May appear suspicious on physical exam Benign breast calcification is seen on mammography Breast Mass: Fat Necrosis Fat necrosis manifesting as a sp e culated mass Densely calcified 3-cm area of fat necrosis 2 years after blunt trauma to the breast.

26.  History      How it was discovered Duration Change in size Location Relationship of mass to menstrual cycles  Clinical breast exam Diagnosis of breast mass

27.  Initial evaluation  < 30 yr – Diagnostic ultrasound + Diagnostic mammogram  > 30 yr – Diagnostic mammogram Further evaluation Simple cyst Symptomatic – Aspirate Asymptomatic – Observe for 2-4 months Complicated cyst – Ultrasound-guided aspiration Solid mass – Core needle biopsy (CNB) or Excision No specific findings – Re-examine after two cycles Breast Mass: Evaluation

28. Fibroadenoma Breast Cancer Mammo gram

29. TREATMENT: Surgical excision and biopsy is indicated only when the mass enlarges and / or report of FNAB (Fine needle aspiration of breast) is inconclusive.

30. ABNORMAL LACTATION & NIPPLE DISCHARGE

31. ABNORMAL LACTATION ( galactorrhea ) Inappropriate secretion of milky discharge – galactorrhea Cause : hyperprolactinemia and pituitary adenoma Prolactin level - more than 25 ng/ml - can cause galactorrhea This condition is associated with amenorrhoea, oligomenorrhea and infertility.

32. Nipple Discharge Purulent : Infection, Periductal mastitis Serous or serosanguinous : Intraduct papilloma, Ductal ectasia, cancer Watery : Papilloma, Cancer Green, gray, black or tan : Duct ectasia

33. Etiology Physiologic nipple discharge Hyperprolactinemia Hypothyroidism Medication related Neurogenic stimulation Pathologic Intraductal papilloma Ductal ectasia Nipple Discharge: Etiology

34.  History        Unilateral vs. bilateral Spontaneous vs. provoked discharge Appearance of discharge Medications (e.g. antipsychotics, antidepressants) History of trauma History of amenorrhea History of hypogonadism (e.g. hot flashes, vaginal dryness)  Clinical breast exam   Attempt to elicit discharge, I dentify involved duct(s) Nipple Discharge: Evaluation

35. Initial evaluation: Breast ultrasound Mammogram IF woman > 30 yrs If Multiductal discharge Prolactin, TSH Further evaluation: Ductography Ductoscopy MRI Evaluation Ductogram

36. Management Physiologic nipple discharge  Treat underlying cause Pathologic nipple discharge  Refer to surgeon Terminal duct excision Central (total) duct excision Resection of intraductal papilloma Management

37. INFLAMMATORY BREAST CONDITIONS (infections)

38. Breast infections most commonly occur one to three months after the delivery of a baby . Other causes of infection include chronic mastitis and a rare form of  cancer  called inflammatory  carcinoma .

39. Mastitis Mastitis can occur either with or without infection. If the inflammation occurs without infection, it is usually caused by milk stasis. Mastitis  is an infection of the tissue of the breast that occurs most frequently during the time of  breastfeeding . It can occur when bacteria, often from the baby's  mouth , enter a milk duct through a crack in the nipple. In  healthy women , mastitis is rare. However, women with  diabetes , chronic illness, AIDS, or an impaired immune system may be more susceptible.

40. P r es enta t i o n About 1%-3% of  breastfeeding  mothers develop mastitis.  Unilateral, swollen, wedge-shaped area of breast Pain, redness, induration (hardening) Systemic symptoms (high fever, malaise, chills) Causes: Milk that is trapped in the breast is the main cause of mastitis. Other causes include: A blocked milk duct.  If a breast doesn't completely empty at feedings, milk ducts can become clogged. The blockage causes milk to back up, leading to breast infection. Bacteria entering the breast.  

41. Signs and Symptoms : Signs and symptoms of mastitis can appear suddenly. They may include: Erythematous area on breast with well localized pain Fever, chills , myalgias, flu like symptoms Breast tenderness or warmth to the touch Breast swelling Thickening of breast tissue, or a breast lump Pain or a burning sensation continuously or while breast-feeding Skin redness, often in a wedge-shaped pattern Generally feeling ill Fever of 101 F (38.3 C) or greater

42. Investigations : clinical breast examination Ultrasound mammography Treatment : Rest, fluids Analgesia and antibiotics . For simple mastitis without an abscess, oral antibiotics are prescribed.  Cephalexin  and  dicloxacillin Dicloxicillin - 500mg QID x 10-14days - Continue frequent breast feeding If an abscess is present, it must be drained Under local anesthetia . The abscess can be drained near the surface of the skin either by aspiration with a needle and syringe or by using a small incision. 

43. BREAST ABSCESS Breast abscess is a painful build-up of pus in the breast caused by an infection. It mainly affects women who are breastfeeding. It  is a localised collection of pus in the breast tissue. Signs and Sym p toms : The signs and symptoms of breast abscesses are: a tender swelling or lump in an area of the breast; pain in the affected breast; redness, warmth, swelling, and tenderness in an area of the breast; fever; muscles aches; and feeling generally unwell.

44. CAUSES: Breast abscesses are usually caused by a bacterial infection, which often occurs when a woman is breast feeding. OTHER CAUSES: Breast abscesses can also develop in women who are not breast feeding . Risk factors can include: injury to the breast; cracked nipples; having diabetes or problems with immune system; nipple piercing; and breast implant surgery.

45. Treatment : US guided needle aspiration for abscesses < 3 cm Analgesia and antibiotics General anaesthesia for larger periareolar or retroareolar abscess. Surgery for large abscess with complications. Investigations : clinical breast examination Ultrasound Needle biopsy

46. PERIDUCTAL MASTITIS Plasma cell mastitis or Mammary duct ectasia ( milk  duct  in the  breast  widens and its walls thicken ) Benign disorder with dilated or ectatic ducts with retained secretions Signs and symptoms : Younger women – cellulitis or recurrent subareolar abscesses Perimenopausal and post menopausal – nipple discharge, nipple retraction or subareolar mass Treatment : Analgesia, antibiotics and follow up with surgeon

47. HYDRADENTIS SUPPURATIVA It results in Chronic inflamma tion involving obstruction of sweat glands . Hidradenitis suppurativa  is a skin condition that causes small, painful lumps to form under the skin. The lumps can break open, or tunnels can form under the skin. The condition mostly affects areas like, the armpits, groin, buttocks and breasts.

48. Treatment : Treatments include: Warm compresses NSAIDs (nonsteroidal anti-inflammatory drugs).  They include: Aspirin Ibuprofen Naproxen Incision and drainage

49. ANTIBIOTICS Treatment Dicloxacillin 250 mg four times a day x 10-14 days Or Cephalexin 500 mg four times a day x 10-14 days Or Clindamycin 300 mg four times a day x 10-14 days

50. INFLAMMATORY BREAST CANCER Inflammatory breast cancer (IBC) is rare and accounts for only 1-5% of all breast cancers. Highest mortality Although it is often a type of invasive ductal carcinoma , it differs from other types of breast cancer. caused by cancer cells blocking lymph vessels in the skin causing the breast to look " inflammed .“

51. Symptoms include, B reast swelling, ( breast enlargement ) Purple or red color of the skin, and dimpling or thickening of the skin of the breast so that it may look and feel like an orange peel. Warmth, Tenderness, and discolouration of overlying skin Often, feel a lump

52. Diagnosis: If inflammatory breast cancer (IBC) is suspected, the following imaging tests may be done: Mammogram Breast ultrasound Breast MRI (magnetic resonance imaging) scan Biopsy Treatment: Chemotherapy Surgery Radiation therapy Hormone therapy