Breast lump and breast carcinoma in women.pptx

Breast lumps and cancer

1. Breast lump Dr Massam

2. Objectives By the end of this session, students are expected to be able to: Describe the Surgical anatomy of the breast Describe the different types and clinical features of breast lumps Identify relevant investigations used to diagnose breast lumps Explain the management of the different types of breast lumps

3. Surgical Anatomy of the Breast Breast is a modified sweat gland occupies the pectoral region from the 2nd to the 6th rib vertically, and from the lateral border of sternum to the midaxillary line, horizontally. It is hemispherical, and lies in the superficial fascia planes. It is composed of fatty tissue and does the function of secreting milk. T he entire breast is a subcutaneous structure.

4. Surgical anatomy cont… Lymphatic drainage of the breast The axillary lymph nodes usually receive >75% of the lymph drainage from the breast. The rest is derived primarily from the medial aspect of the breast, flows through the lymph vessels that accompany the perforating branches of the internal mammary artery, and enters the parasternal (internal mammary) group of lymph nodes.

5. Surgical Anatomy cont… Lymphatic drainage..... Pectoral nodes: Anterior, located along the lower border of the pectoralis major inside the anterior axillaries fold. These nodes drain anterior chest wall and much of breast. Central group : It is the node most easily properly clinically palpable in axilla. R eceive lymph drainage both from the axillary vein, external mammary, and scapular groups of lymph nodes, and directly from the breast;

6. Surgical Anatomy cont… Apical-also called as subclavicular. It lies most superior and deep to pectoralis minor R eceive lymph drainage from all of the other groups of axillary lymph nodes; Subscapular nodes: Posterior, located along the lateral border of the scapula; palpated deep in the posterior axillary fold. D rain the posterior chest wall and a portion of the arm. Lateral nodes: Located along the upper humerus . Drain most of the arm. Interpectoral node It lies between pectoralis major and minor. Receive lymph drainage directly from the breast.

7. Surgical Anatomy cont… Blood Supply, drainage and Innervation Arterial supply is by the thoracic branches of the axillary arteries and from the internal mammary and intercostals arteries. Venous drain is through the axillary and mammary veins. Nerve supply of breast is by anterior and lateral cutaneous branches of 4th to 6th intercostal nerves.

8. Surgical Anatomy cont… The breast is divided into four quadrants by drawing imaginary longitudinal and transversal lines which cross at the nipple Upper outer Upper inner Lower outer Lower inner The region around the nipple is known as the periareola .

9. Definition of breast lump A breast lump is a mass that develops in the breast.  Breast lumps vary in size and texture and may cause pain. Some are not found until a physical or imaging exam. Most breast lumps are benign (non-cancerous) Fibroadenoma Breast cysts Phyllodes Papilloma

10. Fibroadenoma

11. Introduction It is a benign encapsulated tumour occurring commonly in young females of 15–25 years age group. I t is considered as hyperplasia of a single lobule of the breast It is the most common benign tumour of the breast below 30 years of age in females. Fig. shows Large fibroadenoma of left breast in a 14-year-old female.

12. Introduction cont… Incidence is 15% of palpable breast lumps. It is common in blacks and Negroes. Fibroadenoma may grow to a larger size usually grow to 1 or 2 cm in diameter and then are stable but may grow to a larger size. Small fibroadenomas (≤1 cm in size) are considered normal, whereas larger fibroadenomas (≤3 cm) are disorders, and giant fibroadenomas (>3 cm) are disease.

13. Introduction cont… It is bilateral in 20% of cases. 20% are multiple. 30% of fibroadenomas may disappear or reduce in size in 2–4 years. 10–15% will increase in size progressively. Juvenile fibroadenoma occurs in adolescent girls. It may clinically mimic phyllodes tumour. It does not turn into phyllodes tumour or carcinoma.

14. Introduction cont… Complex fibroadenoma ( Dupon et al) is a condition (variant) having typical fibroadenoma with fibrocystic changes like apocrine metaplasia, cyst formation, sclerosing adenosis. It occurs in older age group Occasionally it may turn into malignancy unlike usual fibroadenomas.

15. Clinical features of fibroadenoma It presents as a p ainless swelling in one of the quadrants which is; S mooth F irm N ontender W ell-localised and moves freely within the breast tissue (mouse in the breast). Axillary lymph nodes are not enlarged.

16. Management Investigation Up to the age of 25 years clinical diagnosis enough. Mammography is routine diagnosis with increase in age Fine Needle Aspiration Cytology (FNAC)-Performed to exclude malignancy. Ultrasonography-used to exclude differential diagnosis palpable breast lump. Treatment Excisional biopsy is the treatment of choice

17. Breast Cysts

18. Introduction They are cavities lined by epithelium in the breast containing fluid. It arises from destruction and dilatation of breast lobule and terminal ductules . It is due to nonintegrated stromal and epithelial involution. It is common after the age of 35 years up to menopause. It is uncommon after menopause. Hormone replacement can cause cyst formation in old women. Cyst size varies with menstruation due to influence of ovarian hormones. Cysts can be multiple (50%). Often bilateral and can be recurrent (50%).

19. Clinical features and differential diagnosis S mooth, soft and well-localized swelling. F luctuant often trans-illuminant. Differential diagnoses Bloodgood cyst, haematoma , cystic necrosis in a carcinoma, Brodie’s disease, galactocele, lymph cyst, hydatid cyst.

20. Management Investigation Ultrasound of breast FNAC Mammography to rule out associated carcinoma. Treatment Aspiration for two times. Surgical excision is done if cyst recurs after two aspirations or if there is bloody discharge or residual mass if felt after aspiration.

21. Phyllodes tumour

22. Introduction They are fibroepithelial tumours composed of an epithelial and cellular stromal component. Phyllodes tumour show wide spectrum varying from benign to a local aggressive and sometime metastatic tumour. When diffuse small, multiple cysts are the main component, it is called as Schimmelbusch’s disease.

23. Introduction cont… It is the most common breast disease, common in upper and outer quadrant. It is an exaggerated response of breast stroma and epithelium to hormones and growth factors. It is rare in nulliparous/ovulating/OCP taking women. They can be benign, borderline or malignant tumours As the tumour grows very fast, it undergoes necrosis in various places resulting in cystic areas within the breast.

24. Clinical features Rapid growth Stretched, shiny skin, Red, dilated veins over surface, warm to touch Bosselated surface (big nodules), a few cystic areas. It is not fixity to the skin or pectoralis muscle - mobile on the chest wall Lymph nodes will not be involved No nipple retraction. Phylloides tumour of the left breast

25. Investigations Mammography is routine diagnosis with increase in age Fine Needle Aspiration Cytology (FNAC)-Performed to exclude malignancy. Ultrasonography-used to exclude differential diagnosis palpable breast lump. Chest X-ray, CT chest when you suspect malignancy to see secondaries

26. Treatment Simple enucleation is recommended. Older patient require wider excision with 1cm margin of normal breast tissue Large tumour may require wider excision in the form quadrantectomy or even simple mastectomy.

27. Duct papilloma

28. Introduction Duct Papilloma is a benign tumour ,which arise from the lining epithelium of principal lactiferous duct. It is usually single, from a single lactiferous duct They are epithelium lined true polyps of breast lactiferous ducts. Usually, it is <1 cm in size often with a small lump under areola. But can attain large size.

29. Introduction cont… Vascular stalk is present usually. Rarely a cystic soft swelling may be present underneath which is probably due to obstruction of the duct by papilloma. Majority of the victim are between the age of 30 and 50 year Papilloma breast which is large. Usually it is small intraductal.

30. Clinical Features Papilliferous swelling (projection), usually seen near the nipple orifice. Blood stained discharge from the nipple is common. But serous or serosanguinous discharge can also occur. Single papilloma is not premalignant. But multiple papilloma in many ducts can be premalignant. Peripheral papilloma should be differentiated from invasive papillary carcinoma. The regional axillary lymph node are usually not affected

31. Treatment Investigations Injection of contrast into the duct (Ductogram). Mammography may show dense lesion under the areola. Treatment Complete excision of duct involved along with the tumour should be performed. This operation called Microdochectomy.

32. Reference Siram Bhat M (2015) SRB’s Manual of surgery( 5 th edition). Prakash Rao Thangam venghese Joshua. F.Charles Brunkardi (2019) Schwartz’s principles of surgery (11 th edition). McGraw-Hill Education K.Rajgopal Shenoy, Anitha shenoy (2016) Manipal Manual of surgery (4 th edition). CBS New Delhi.