Treatment of benign breast diseases

treatmentof benign breast diseases

1. Treatment of benign diseases of breast. DR INDUMATHI B

2. BENIGN DISORDERS OF BREAST - FIBROADENOMA -FIBROCYSTADENOSIS -SCLEROSING ADENOSIS -MASTITIS -PHYLLOIDES TUMOR -TRAUMATIC FAT NECROSIS -GALACTOCELE -DUCT ECTASIA -ANTIBIOMA -MANDOR’S DISEASE -TUBERCULOSIS OF BREAST -GYNECOMASTIA -DUCT PAPPILOMA

3. FIBROADENOMA TREATMENT: Excision through a circumareolar incision ( Webster's ) or submammary incision (Gaillard Thomas incision ) is done. Fibroadenoma which is small ( <3 cm)/single/age <30 years )can be left alone with regular follow-up with USG at 6 monthly interval.

4. FIBROADENOMA Indications for surgery Size >3 cm . Recurrence . Multiple. Cosmesis . Giant type. Complex type.

5. FIBROADENOMA

6. FIBROCYSTADENOSIS Conservative management: 1.Reassurance,avoid caffeine,chocolate,salt 2. Drugs: To stop progression. To relieve pain. To reverse changes. To soften breast tissue.

7. FIBROCYSTADENOSIS Oil of evening primrose used in moderate pain-drug of choice . It contains gamolenic acid which reverses saturated to unsaturated fatty acids. 1000-3000 mg/day for 4-6 months. It also contains 7% of linolenic acid and 72% of linoleic acid.

8. FIBROCYSTADENOSIS Gamolenic acid- 120 mg/day. Danazol -most effective drug; but second drug of choice-severe cases; 200 mg/day ; 3-6 months. very effective but causes acne, hirsutism , weight gain and amenorrhoea . It is teratogenic and so cannot be used if patient is planning for pregnancy.

9. FIBROCYSTADENOSIS Bromocriptine -lowers prolactin-2.5 mg/ day for 3 months. Tamoxifen-10 mg Bd is an antiestrogenic drug. G HRH agonist ( Goserelin ) is reserved for refractory cases . It shows 96-99% success. But it causes reversible postmenopausal symptoms .

10. FIBROCYSTADENOSIS Vitamin E and B6 are tried. NSAIDs-oral and topical . INDICATIONS FOR SURGERY: Intractable pain Florid epitheliosis on FNAC Persistent bloody discharge Psychological reason.

11. SURGICAL MANAGEMENT Excision of the cyst or localized excision of the diseased tissue. Subcutaneous mastectomy with prosthesis placement-severe & persistent. Its removal of entire breast with retaining skin over the breast,nipple&areola . Submammary gillard thomas incision. Adequate skin flap containing subcutaneous fat is raised which maintains the blood supply of the flap and prevents flap necrosis.

12. SCLEROSING ADENOSIS The clinical significance of sclerosing adenosis lies in its imitation of cancer . On physical examination, it may be confused with cancer, by mammography, and at gross pathologic examination . Excisional biopsy and histologic examination are frequently necessary to exclude the diagnosis of cancer.

13. Phylloides tumor

14. CONTINUED. TREATMENT: Wide excision with 1cm margin or subcutaneous mastectomy(avoid recurrence) Malignant-total mastectomy with adjuvant chemotheraphy .

15. Phylloides tumor WIDE LOCAL EXCISION: Synonym terms include- lumpectomy,tumourectomy and tylectomy . Simple removal of tumour with margins of normal tissue sufficient to obtain macroscopic clearance. Quadrantectomy is the most certain means of obtaining microscopically clear margins.

16. Phylloides tumor

17. Phylloides tumor SURGICAL TECHNIQUE skin incision is made T he skin and subcutaneous fat are dissected off the breast tissue . When elevating skin - subcutaneous fat should not be disrupted as thin skin flaps give a poor cosmetic result . The skin flaps should be elevated 1 to 2 cm beyond the edge of the cancer.

18. The fingers of the nondominant hand are then placed over the palpable tumour & the breast tissue divided beyond the fingertips. T he line of incision should be 1 cm beyond the limit of the palpable mass B reast tissue is divided beyond the edge and, the deep aspect of the tumor can be palpated .

19. D issection through the breast tissue is continued down to the pectoral fascia. T he breast tissue containing the tumour is lifted off the pectoral fascia. Having lifted the tumor and surrounding breast tissue off the chest wall muscles, the tumour are grasped between the finger and the thumb of the nondominant hand and excision is completed at the other margins .

20. After excision of the tumour mobilization of the breast tissue should be done. S uturing the defect in the breast without mobilization of the breast tissue - distortion of the breast contour . skin wound should be closed in layers with absorbable sutures ,.

21. COMPLICATIONS: B leeding with hematoma formation, Infection & Incomplete excision-Poor cosmetic results.

22. Phylloides tumor D oxorubicin plus I fosfamide is the most common regimen used . Liposomal doxorubicin in combination with bevacizumab has been tried in one case . In an Indian report, epirubicin with ifosfamide was administered to four patients. When disease progression happens, trabectedin and pazopanib is used.

23. Phylloides tumor Olaratumab is an IgG1 monoclonal antibody targeting platelet-derived growth factor receptor alpha (PDGFRα) thus blocking PDGF-AA , PDGF-BB and PDGF-CC binding and receptor activation . combination of doxorubicin with olaratumab is tried recently.

24. CYCLICAL MASTALGIA Treatment: Diclofenac gel-is very useful as local application. Evening primrose oil 325 mg B D . Gamolenic acid 120 mg BD. Danazol (100-200 mg BD)- antigonadotrophin agent. Bromocriptine (2.5 mg BD)-prolactin inhibitor. Tamoxifen (20 mg daily). GnRH analogue 3.6 mg injection depot-monthly . Vitamin B6 , B12 . Analgesics.

25. NONCYCLICAL MASTALGIA Treatment : Cause has to be identified. Malignancy has to be ruled out. Avoid coffee and stress. Proper support to breasts.

26. TRAUMATIC FAT NECROSIS Capillary ooze Trigycerides in fat to dissociate calcium from blood Saponification inflammatory reaction swelling of the breast

27. TRAUMATIC FAT NECROSIS Painless Nonprogressive Nonregressive FNAC-chalky fluid with fat globules Treatment is excision.

28. GALACTOCELE Cessation of lactation Blockage of lactiferous duct - dilation of lactiferous sinus. Retention cyst in subareolar region. Lower quadrant,nontender . FNAC- thick,creamy,greenish /brown fluid.

29. GALACTOCELE TREATMENT: Resolve spontaneously after hormonal change associated with pregnancy and lactation is ceased. Aspiration of the content . Excision Abscess when formed should be drained under cover of antibiotics.

30. MASTITIS 3 TYPES SUBAREOLAR INTRMAMMARY RETROMAMMARY

31. SUBAREOLAR MASTITIS Treatment –under antibiotic coverage pus is drained by subareolar incision.. Fluid obtained is submitted for culture for the detection of anaerobic organisms. Antibiotics are then continued based on sensitivity tests. When considerable purulent material is present, repeated ultrasound guided aspiration is performed.

32. SUBAREOLAR MASTITIS Subareolar abscess is usually unilocular & associated with a single duct system . Ultrasound will accurately delineate its extent. In a woman of childbearing age, simple drainage is preferred. B ut if there is an anaerobic infection, recurrent infection frequently develops.

33. SUBAREOLAR MASTITIS Recurrent abscess with fistula may occur. Treatment of periductal fistula was initially recommended to be opening up of the fistulous track and allowing it to granulate. The preferred initial surgical treatment is by fistulectomy and primary closure with antibiotic coverage.

34. SUBAREOLAR MASTITIS Radial incision for subareolar abscess with fistula. A. Excise island of skin around fistula and involved central nipple dermis, with connecting radial incision through areola . B . Completely excise abscess cavity and fistula tract.

35. SUBAREOLAR MASTITIS Simple radial closure, leaving gauze wick at lateral aspect to allow packing into subareolar space.

36. A.Infra -areolar incision for chronic subareolar abscess with fistula. B. Appearance after resection of fistula tract and central nipple ducts via small ellipse of nipple skin.

37. C. Gauze wick is exteriorized for packing. D. Postoperative result .

38. SUBAREOLAR MASTITIS

39. LACTATIONAL ABSCESS OF THE BREAST TREATMENT: Antibiotics- cephalosporins,flucloxacillin & amoxycillin . Feeding from the affected side may continue. Support of the breast, local heat and analgesia will help to relieve pain.

40. LACTATIONAL ABSCESS OF THE BREAST Use of antibiotic in the presence of undrained pus ‘ antibioma ’ This is a large, sterile, brawny oedematous swelling that takes many weeks to resolve . Incision and drainage- if the infection did not resolve within 48 hours. R epeated aspirations under antibiotic cover (if necessary using ultrasound for localisation ) be performed.

41. LACTATIONAL ABSCESS OF THE BREAST Operative drainage of a breast abscess: Incision of a lactational abscess - marked skin thinning & usually done under local anaesthesia . I ncision is sited in a radial direction over the affected segment. The incision passes through the skin and the superficial fascia.

42. LACTATIONAL ABSCESS OF THE BREAST A long artery forceps is then inserted into the abscess cavity. Every part of the abscess is palpated against the point of the artery forceps and its jaws are opened. All loculi that can be felt are entered.

43. LACTATIONAL ABSCESS OF THE BREAST Finally, the artery forceps are withdrawn & a finger is introduced to disrupt remaining septa. The wound may then be lightly packed with ribbon gauze or a drain inserted to allow dependent drainage.

44. Nonlactational breast abscess Duct ectasia and periareolar infection Organisms- Bacteriodes,Anerobic streptococci Diabetic Recurrent swelling with tenderness under areola. TREATMENT: Antibiotics Repeated aspirations Drainage and later cone excision of the duct is done.

45. DUCT ECTASIA Treatment: stop smoking . Antibiotic therapy - co- amoxiclav or flucloxacillin and metronidazole. Cone excision of involved major ducts ( Adair-Hadfield operation). It is important to shave the back of the nipple to ensure that all terminal ducts are removed . Melhem Novel modified breast ductal system excision.

46. DUCT ECTASIA I nfra-areolar incision in made that should not exceed 1/3rd of the circumference of the areola . Dilated ducts containing secretions are identified and all ductal tissue is excised .

47. MONDOR’S DISEASE Self-limiting. The only treatment required is restricted arm movements. subsides within a few months without recurrence, complications or deformity . A nti inflammatory drugs may be needed. Refractory cases-excision of involved segment of vein.

48. TB BREAST The treatment of breast tuberculosis consists of anti-tubercular chemotherapy and surgery by specific indications . Anti-tubercular therapy with four drugs is the primary line of treatment .

49. TB BREAST The six-month regimen comprises of a two-month intensive phase. E thambutol 800 mg/day Pyrazinamide1500 mg/day , Rifampicin 450 mg/day I soniazid 300 mg/day F ollowed by a continuation phase of four months with two drugs I soniazid and Rifampicin.

50. TB BREAST E xcisional biopsy is necessary mainly for diagnostic purposes. Excision of residual sinus tracts or lumps after poor response to antituberculosis therapy.

51. BREAST CYSTS A solitary cyst or small collection of cysts can be aspirated . Surgical excision is done - if cyst recurs after two aspirations if there is bloody discharge residual mass if felt after aspiration.

52. BREAST CYSTS After aspiration one should examine for the residual lump. FNAC of this residual lump should be done. Cyst when recurs (30%) reaspiration should be done. Patient should be examined for refilling of the cyst in 6 weeks.

53. GYNECOMASTIA TREATMENT: Treat the cause MEDICAL TREATMENT: 3 classes of medical tretment : ANDROGENS ANTI-ESTROGENS AROMATASE INHIBITORS

54. GYNECOMASTIA ANDROGENS: Testosterone is used to treat hypogonadism,its use to specifically counteract gynecomastia is limited. Dihydrotestosterone ,is used in patients with prolonged pubertal gynecomastia . Danazol ,a weak androgen that inhibits gondotropin secretion ,200mg BD. Side effects – edema ,acne, and cramps.

55. GYNECOMASTIA ANTI ESTROGENS: Clomiphene citrate-100mg/day Tamoxifen –low side effect & high efficacy 10mg BD or 20mg OD daily for 3-6 months. Patients usually improve within one month. Raloxifene has also been used in the treatment of pubertal gynecomastia .

56. GYNECOMASTIA AROMATASE INHIBITORS: Newer aromatase inhibitors such as Anastrozole and letrozole is used. Testolactone is under trial.

57. GYNECOMASTIA Indications for surgical treatment: Ineffective medical therapy Long standing gynecomastia psychological or cosmetic problem. When gynecomastia interferes with the patients activities of daily living Suspicion of malignancy of breast

58. GYNECOMASTIA Treatment :surgical excision. Removal of glandular tissue coupled with liposuction. Gaillard thomas submammary incision Reduction mammoplasty Causative drugs should be stopped.

59. GYNECOMASTIA REDUCTION MAMMOPLASTY: HISTORY- Theodore Galliard –Thomas suggested a sub-mammary incision to rescue a part of the glandular disc . Vincenz Czerny transplanted the nipple following a simple mastectomy to preserve the natural breast.

60. REDUCTION MAMMOPLASTY: Axhausen pioneered his three step technique: Extensive subcutaneous undermining of the breast to reduce the glandular portion of the breast. Nipple transposition Fashioning of a skin brassiere.

61. REDUCTION MAMMOPLASTY: Biesenberger combined three elements: Separation of skin from gland. Resection of lateral half of the gland. Transposition of nipple on the retained gland

62. REDUCTION MAMMOPLASTY: Wise ,modified Biesenberger operation but his contribution was more in the form of excision patterns and mechanical aids to produce a safer reduction. McKissock described the popular vertical bipedicle dermal pedicle technique where the vascularity of the nipple areola depended on the intact dermal parenchymal pedicle

63. REDUCTION MAMMOPLASTY: Requirements of an ideal breast reduction: two breasts should be symmetrical The nipple and areola should be translocated to an appropriate location. The blood supply to nipple and areola should not be jeopardized. The function of the breast should be preserved. The scars should not be prominent.

64. PEDICLES Inferior pedicle- 4 th  and 5 th intercostal arteries  are responsible for the viability of the inferior pedicle.

65. PEDICLES Superior pedicle

66. PEDICLES Central pedicle- perforating branches of the intercostal arteries

67. PEDICLES Lateral pedicle- based on the lateral thoracic artery perforators.

68. SKIN RESECTION PATTERNS

69. skin resection pattern is marked The pedicle is then marked so that the base is 6 to 8 cms wide and centered on the breast it extends for about 2 cms above the nipple areola complex  .

70. The procedure begins by stretching the areola and its then incised to the dermis. The inferior pedicle is de- epithelialised  

71. With the breast centralized and supported on the chest, medial and lateral triangular excisions are carried out

72. The superior flaps are thinned to achieve coning of the breast  .

73. After thorough haemostasis , the medial and lateral flaps are approximated and closed along the inframammary crease

74. An adequate opening for the nipple areola complex is created by excision of skin and the suturing is done

75. DUCT PAPILLOMA Mammary ductoscopy (MD ) N ew endoscopic technique S ub-millimetre fiberoptic micro-endoscopes measure between 0.7 and 1.2 mm in external diameter. A llow direct visualization of the mammary ductal epithelium .

76. DUCT PAPILLOMA S copes also provide working channels for insufflation, irrigation , ductal lavage, and possible therapeutic intervention. ADVANTAGES: A ccurate localisation of pathology D uctal lavage under direct visualization. I ntra-operative guidance especially for lesions deep within the ductal system

77. DUCT PAPILLOMA C ytological analysis of endoscopically retrieved ductal lavage has been recently reported to be more accurate than simple discharge cytology.

78. DUCT PAPILLOMA D ischarge – localized to a single duct, microdochectomy gives satisfactory results in younger patients with a minimal interference with the breast . In older patients where breast-feeding is not required-major duct excision. When a specific duct cannot be identified then blind excision of the retro-areolar ductal system is usually performed.

79. DUCT PAPILLOMA MD can detect multiple lesions within the same duct . R educe the number of duct excision procedures & minimise the extent of surgical resection .

80. DUCT PAPILLOMA

81. DUCT PAPILLOMA

82. DUCT PAPILLOMA

83. DUCT PAPILLOMA Microdochectomy : It is important not to express the blood before the operation. A lacrimal probe or length of stiff nylon suture is inserted into the duct from which the discharge is emerging. A tennis racquet incision can be made to encompass the entire duct.

84. DUCT PAPILLOMA N ipple flap dissected to reach the duct. The duct is then excised. A papilloma is nearly always situated within 4–5 cm of the nipple orifice.

85. DUCT PAPILLOMA Cone excision of the major ducts ( after Hadfield )( subareolar resection) A periareolar incision is made and a cone of tissue is removed with its apex. J ust deep to the surface of the nipple and its base on the pectoral fascia.

86. DUCT PAPILLOMA The resulting defect may be obliterated by a series of purse-string sutures. A temporary suction drain will reduce the chance of long-term deformity .

87. DUCT PAPILLOMA

88. DUCT PAPILLOMA

89. references Bailey and love 27 th edition Sabiston text book of surgery,20 th edition Schwartzs principle of surgery 10 th edition Breast tuberculosis: Diagnosis, management and treatment by Spyridon Marinopoulosa ,∗, Dionysia Lourantoua , Thomas Gatzionisa , Constantine Dimitrakakisa , Irini Papaspyroub , Aris Antsaklisa

90. references Breast papillomas : current management with a focus on a new diagnostic and therapeutic modality by W Al Sarakbi1, D Worku1, PF Escobar2 and K Mokbel * Galactocele in the Axillary Accessory Breast Mimicking Suspicious Solid Mass on Ultrasound by Donya Farrokh, Ali Alamdaran, Farhad Yousefi, and Bita Abbasi

91. references Management of Mastitis in Breastfeeding Women JEANNE P. SPENCER, MD, Conemaugh Memorial Medical Center, Johnstown, Pennsylvania. The response of phyllodes tumor of the breast to anticancer therapy: An in vitro and ex vivo study. Olaratumab administered in two cases of phyllodes tumour of the breast: end of the beginning ? Current Trends in the Management of Phyllodes Tumors of the Breast Taiwo Adesoye Reduction mammoplasty Shrirang Purohit

92. Thank you