Breast Anatomy and Quadrants

• Serum VIP (vasoactive intestinal peptide) test checks a blood sample to measure the amount of VIP
• VIPoma involves a lower than normal amount of potassium
• Stool analysis checks for a higher than normal sodium and potassium levels
• Treatment for a tumor mass is surgical excision after localization

Breast Surgery: Anatomical Landmarks

• The breast is a modified sweat gland developed from mammary ridges
• Breast tissue lies in the subcutaneous tissue above the 2nd rib, down to the 6th rib
• The tissue reaches the lateral border of the sternum medially, and the posterior axillary line laterally
• The breast lies on the pectoralis major muscle and pectoral fascia, and the serratus anterior muscle laterally

Breast Quadrants

• The breast is divided into upper medial, lower medial, upper lateral, and lower lateral quadrants
• It also includes the central (retro-areolar) area and the axillary tail
• The axillary tail is a prolongation of breast tissue in the upper outer quadrant
• The tail blends with axillary fat

Interior Structure

• The breast internally is formed of 15–20 lobes
• Each lobe has a single separate major lactiferous duct behind the areola
• Each lobe is divided into 20-40 lobules
• Each lobule contains several alveoli and is drained by a ductule
• Breast tissue is supported by fibrous tissue ligaments (suspensory ligaments) from the pectoral fascia
• These are arranged radially and attached to the skin of the breast
• These ligaments are called Cooper’s ligaments

Blood Supply

• Arteries:
• Internal mammary artery arises inside the chest and gives branches
• Branches perforate the intercostal spaces and pectoralis major to supply the breast
• This causes troublesome bleeding during mastectomy
• Lateral thoracic artery branches from the axillary artery
• Pectoral branch of the thoraco-acromial artery
• Intercostal arteries
• Veins offer venous drainage through the axillary vein and internal mammary vein
• Also through intercostal veins
• There is an important communication exists between them and vertebral venous plexus
• This explains metastases of breast cancer that tends to occur in axial bones

Lymphatic Drainage

• Involves intra-mammary and extra-mammary lymphatics
• Intramammary
• Lymph passes from the skin and breast tissue to the lymph vessels inside the breast
• It's collected in the sub-areolar lymphatic plexus of Sappey
• Lymph then passes deeper inside the breast to reach the sub-mammary (pectoral) lymphatic plexus
• Surgical importance related to infiltration of intramammary lymphatics by malignancy presented by Peau d'orange
• Extramammary:
• Lymph emerges from the breast to the axillary lymph nodes (75% of lymph drainage)
• Also to internal mammary lymph nodes along internal mammary vessels (intra-thoracic)
• Posterior intercostal lymph nodes at necks of the ribs, and inter-pectoral lymph nodes (Rotter's L.N.) which is a single L.N. between pectoralis major and minor muscles

Axillary Lymph Nodes

• Axillary Lymph Nodes receive 75% of breast lymph (medial and lateral parts)
• They average 35 nodes
• Axillary Lymph Nodes are arranged in anterior, posterior, medial, lateral, and central groups
• The apical L.N. group receives lymphatics from all other groups
• Surgically, axillary L.N. are arranged by the pectoralis minor muscle into 3 levels
• Level I: L.N. below the lower border of pectoralis minor, including medial, lateral, anterior, and posterior groups
• Level II: L.N. behind the pectoralis minor involves central L.N
• Level III: L.N. above the upper border of pectoralis minor (Apical L.N.)
• Lymph passes inside the axilla from level I → level II → level III
• This classification is of prognostic value in cancer breast
• Negative axillary L.N. is better prognosis than positive L.N
• Level I is better prognosis than Level II, better than Level III
• Involvement of the axillary L.N. by cancer breast necessitates treatment with chemotherapy after surgery

Breast Diseases - Inflammations

• Includes acute lactational mastitis and breast abscess, and chronic mastitis (duct ectasia)
• Acute Lactational Mastitis is an acute inflammation of the breast tissue occurring during lactation and late pregnancy
• The causative organism is mainly staph aureus
• The source of infection comes from the mouth of suckling baby that passes through nipple duct orifices
• Then it passes through the ducts with milk clotting inside, leading to stasis and infection
• It may also be blood borne from distant focus
• Predisposing factors include nipple cracks, milk engorgement, and poor breast hygiene

Stages of Acute Mastitis

• Involve milk engorgement, acute mastitis, acute breast abscess, and chronic breast abscess
• Patients may present with one of the stages, requiring clinical and investigational differentiation
• Breast engorgement general symptoms include lactating female and mild fever'
• Local Symptoms include pain in part or whole breast and heaviness in the breast
• Common general signs include low grade fever
• Common Local signs include diffuse breast enlargement and mild tenderness
• Acute mastitis general symptoms includes lactating female and high FAHM
• Local symptoms include marked pain in part or whole breast, redness in the skin, and nipple discharge
• Common general signs include high fever
• Common local signs include diffuse breast enlargement, severe tenderness/redness/hotness, and enlarged tender axillary L.N.
• Ultrasound will show engorgement

Acute Breast Abscess

• Sites within the breast consist of a skin associated abscess, lactational abscess, central or subareolar abscess, and peripheral parenchymal abscess
• Clinical presentations involve commonly lactating females
• Patients present with history of lactation or late pregnancy with marked or severe throbbing pain, increasing in severity
• It’s associated with high or hectic fever
• Breast examination shows localized redness of the overlying skin, pitting edema, hotness, and severe tenderness, where fluctuation might be elicited although difficult
• Sometimes nipple discharge is evident
• Enlarged tender axillary lymph nodes in homoaxilla
• Diagnostic needle aspiration by syringe reveals pus
• Investigations for breast ultrasound reveal pus
• Lines of treatment: conservative in breast engorgement and acute mastitis
• Broad spectrum antibiotic analgesic & antipyretic followed by hot fomentation
• Breast feeding involves to encourage weaning if the infant is over 9 months, or use the healthy breast by gradually emptying the diseased one
• Needle aspiration is better under ultrasound guidance in small abscess
• Surgical incision & drainage in breast abscess where one doesn't wait for fluctuation (early drainage) once suspected, as it is difficult to be elicited (fatty tissue)
• Under general anesthesia, with coverage of broad spectrum antibiotics
• Site of incision is radial or circumferential over the most pointing point to release pus from inside the abscess cavity
• Sinus forceps are introduced to break down the internal septa and aids drainage
• A drain is put inside the cavity to drain the remaining pus

Chronic Breast Abscess

• This results from improper treatment of acute breast abscess, such as improper antibiotic use or inadequate drainage
• Pathology: improper treatment of acute abscess leads to sterile pus inside, called antibioma
• Antiboma leads to excessive fibrous tissue formation, causing thickening of the breast tissue that is firm to hard in consistency
• Clinical: history of acute abscess in the breast along with low-grade fever
• Local mild painful breast mass
• Low grade fevers are common
• Local signs include skin or nipple retraction due to fibrosis
• Breast firmness and fixity to the breast or the skin (D.D. cancer breast)
• Enlarged, mild tender and firm axillary lymph nodes
• Leukocytosis via a CBC
• Breast ultrasound reveals a chronic abscess
• Needle aspiration shows little pus
• Treatment: Excision of the abscess within its fibrous wall is sent for histopathology
• Also called plasma cell mastitis where ectasia means dilatation
• Cause is unknown
• Pathology: Chronic inflammation with dense infiltration by plasma cells and fibrous tissue mainly around the ducts
• This causes their dilatation, stasis, and recurrent infection and discharge

Clinical features of Duct Ectasia

• May be asymptomatic
• Nipple discharge: Is unilateral or bilateral, and has discharge that is serous, yellowish, or brownish
• Nipple retraction (due to shortening of the ducts by fibrosis)
• Breast mass (firm due to fibrosis)
• Recurrent inflammation or chronic abscess
• Nipple discharge upon squeezing; common and may be bilateral
• Nipple retraction & a retro-areolar firm mass with restricted mobility and ill-defined edges (D.D. malignancy)
• Investigations include C/S from nipple discharge, and U/S and mammography to exclude malignancy
• Treatment involves conservative care, mostly in young females (antibiotics)
• Major ductal excision can happen in females not expecting to be lactating
• Major duct excision happens with failure of conservative treatments to control discharge or a mass
• Circum-areolar incision
• Elevation of areolar skin flaps
• Dissection of the major ducts deep to the areola
• Clamping the whole ducts and division with proximal ligation
• Closure with drain

Fibrocystic Disease/Fibroadenosis

• Thought to be due to the exaggeration of normal physiological changes in the breast
• These occur at puberty, pregnancy, lactation, and menopause along with abnormal development and involution
• Unilateral or bilateral - mainly in the upper lateral quadrant of the breast
• Number of breast alveoli increases (adenosis)
• Lining increases in epithelial cells in the small ducts (epitheliosis/hyperplasia)
• Fibrous tissue deposition increases around the ducts and alveoli (fibrosis)
• Duct obstruction occurs by fibrous tissue causing their dilatation (cyst formation) from small to large
• Commonly bilateral -It may be asymptomatic and discovered accidentally
• Commonest symptom: Painful nodularity of the breasts
• Frequent symptom of breast pain (more during menstruation)
• Nipple discharge (serous or brownish) unilateral or bilateral
• Breast examination reveals nothing, fine nodularity of the breast (commonly bilateral), and/or cystic swelling may be felt

Investigations for Fibrocystic Changes

• Ultrasound and mammography
• Excludes malignancy in old age patients
• Shows cyst and can be aspirated
• Fine needle aspiration cytology and/or Tru-cut needle biopsy for solid suspicious nodules

Treatment for Fibrocystic Changes

• Re-assurance as it is a benign condition
• Cysts are aspirated under ultrasound guidance
• Large masses receive excision under general anesthesia especially in old females
• Analgesics for cyclic pain
• Prolactin inhibitor offers good results
• Benign & malignant tumors are classified as breast neoplasms
• Duct papilloma & fibroadenoma are benign tumors
• Duct carcinoma, lobular carcinoma, & Paget's disease are malignant tumours
• Duct Papilloma is a benign tumour arising from epithelium of the major ducts near the nipple
• Duct Papilloma is a commonest cause of bleeding by/per nipple

Pathology of Duct Papilloma

• Young females
• Microscopic: hyperplasia of duct epithelium with highly vascular connective tissue core
• Macroscopic: small red nodule inside the affected duct that may ulcerate and bleed

Clinical Presentation of Duct Papilloma

• May be asymptomatic.
• Most common presentation is unilateral bleeding per nipple.
• Palpable mass (less common).Signs:
• Normal breast contour, skin & areola.
• Squeezing of the nipple reveals blood from on or more duct orifice
• Swelling may be felt retro-areolar (accumulated blood or mass but less common)
• No palpable axillary L.N. (lymph node)

Investigations for Duct Papilloma

• Blood sample from the nipple for C/S and cytology shows benign cells
• Radiology needs breast U/S and mammography in old females
• Ductography can be done

Treatment for Duct Papilloma

• Micro-doch-ectomy: -Squeezing the nipple to reveal the affected duct to bleed -Insert fine cannula (the plastic part) in the duct orifice of the affected duct -Excision of the affected duct from the nipple and areola while the plastic cannula is inside
• Close the nipple and areola
• Send the specimen for histo-pathology for cancer

Fibroadenoma Description

It is the commonest tumour affecting young females and is mixed Arises from both fibrous and glandular breast tissue

Types of Fibroadenoma

• Hard Fibroadenoma (peri-canalicular) is the commonest type
• Soft Fibroadenoma (intra-canalicular)

Fibroadenoma Pathology

• Young and middle age females
• Microscopic: -Hard Fibro-Adenoma has Excess Fibrous tissue + a little glandular tissue with. -Soft Fibro-Adenoma has Excess Glandular tissue +little fibrous tissue, Macroscopic

Signs & Symptoms of Fibroadenoma

Has a solitary or multiple swellings and is very firm

• Breast normal contoured, skin, nipple and areola
• No palpable axillary L.N
• There is well circumscribed, firm, not tender and freely mobile mass (Breast mouse). Patients are usually don't feel pain

Investigations for Fibroadenoma

• No need for investigation as it’s clinical/physical diagnosis
• Ultrasound detects others & evaluates mass and, mammography is needed in old age females for cancer screening as patients usually don't feel painful Criteria of benign mass: well capsulated with no signs of malignancy Treatment: Excision and histopathology

Cysto-sarcoma Phylloides

• They are leaf masses and are tumors
• It is a benign Tumor but not Sarcoma, and a soft Fibroadenoma Tumor that is very and gross
• Resembles a large malignant Sarcoma
• Takes on a leaf-like appearance when sectioned and displays epithelial cyst-like spaces and is viewed microscopically
• Patient will have small but rapidly increase in mass the rapid increase in size with well circumscribed and consistency & mobil mass
• The huge mass may ulcerate through the skin with
• Patients also does not have lymph node so that investigation is done to find out this diagnosis similar diagnosis And we treat patients but
• Need to be complete accurate of exam patient and if patients still has rapid mass increased after cutting away this mass

Breast Cancer

• Most common cancer in women and causes death, and happens cause of genetic
• Incidence increases cancer as age increases as median also goes up as age is 60 so less chances
• Family member have this diagnosis and as the cancer get aggressive and inherited to child

Cancer Etiology

Genetic- Cancer cells increase from 5 to 10% and family has cancer

• Endocrine factors and risk increases as age is above menopause or pregnancy Pre-cancer lesions may get aggressive after cancer and the lesion cells keep multiplying Cancer starts to metastasize Types/Microscopic picture is Invasive =Non -Invasive

• Cancer Types

  • Arises from the epithelium to malignant

• The Tumor is muti centered

  • Patient/Type of Epithelial Alveolar of cancer

• Paget cell= clear vacuolated cells with multiple number of tumors

• The common type as the site to find it in outer side of breast as hard tumor with 75 percent chance

Clinical Presentation of Cancer

Skin Dimpling/Infiltration

• The major ducts also cause retraction of Nipple with Ulceration of module skin
• The cells effect by cancer or through skin

Types of Cancer

• Inflammatory carcinoma (= mastitis carcinomatosa); is a deadly skin cancer and seems to look like it on the skin and is a mastiditis as if there something pregnancy
• Paget’s ; it is a Nipple alone when it erodes or erodes and spread in skin as a mass to
• Patient is consider at worse if they have positive prognosis if they have had it or are going to get it

Cancer Types of Metastasis (Spread)

• Extra mammary- It is also known if the cancer level has not spread upper body

Internal Mammary/Blood Cancer

• Clinical presentation usually presents breast lung but presents to the bones as vertebra -The cancer shows pain and presents to the Axillary and in the Lymphs/Nodules

Clinical Presentation on Signs, inspection or Palpation

• In palpitation the Tumor/Cancer is now at consistency , the upper chest and the Axillary that causes hard

Skin Changes Due to Cancer

• Skin D’ range/Ulceration (Nipple)

Pagets Disease

• Special for cancer and presents eczema with 1 percent to show eczema but is
• Special form of presentation:*
• The clinic show in skin
• Patients show eczema and don't is not a mess that the body does not present

Investigation of cancer or breast diagnosis

• Do female exam to exclude malignity
• The patient should be do Triple Assessment for test and assess to the patients
  • Lab Assessment/Diagnosis, ultrasound or radiological and pathological
• For mammography It’s Plain show-ray and if that mass is suspected you would see micro in the mass which raises that malignant (Density mass)

Clinical Findings that indicate cancer from a plain x-ray

• Thick skin and for lipodema, see nipple retraction is seen and other can be seen and is enlarged and is now at 90% sensitivity

Breast Assessment or Bi-rads

• The BIRADS test means if you are assess can tell how it looks if there any malignant (High) with or has any mass
• This detects all lump inside breast if the lump is solid or is not
  • For MRI- test is most recent to find and detect and malignancy and is accurate but high is cost , so patient has density
• This tells if cancerous If we are to look for metastasis/lumps for the Ab test

Additional tests for Metastasized Cancer

• Bone Scan/Lung for Chest that gives information as for cancer
• Special

1. Find needle from the cell as to what exactly tumor is/ has
2. Cut mass after to know and remove
3. Operate of the mass so that can remove and prevent so test

Hormone Assessment

Hormone Assessment is to see if they have had or express cancer , and estrogen hormone for women needs to tested before starting Sentinel- It see what causes and it the lymph nodes

• If Patient Has early breast cancer. A test to find (Biopsy can be done to also see ) can see what type of cancer,
• Labs for tests that if Cbc, liver, tumor or cancer

Early Breast Cancer Staging and Diagnosis

• We must Evaluate
• And Evaluation (The Systems)
• TNM – Most Comon

T= Size , location, Tumor - Nodes, Metasis and stage is 3 to 4 and consider late Breast for patient when they are N1, Mo or less (Cancer early stage)

• Then what happens when Cancer late (For Patients) Stage 1-Is mass mobile with free test with mass and cancer tumor - And can do a test is if cancer

Additional cancer assessments

• We evaluate mass and if tumor cell The Goal is to treat- To the local control area or metastasis Main cancer operation
• We want this and we -Therapy Conservative
• Chemo for stage and Breast Surgery
• If patients are early breast
• And if not go for breast surgery -The is breast (Radical) and patient is not doing to radiation therapy or mass
• For adjuvant you need to do therapy
• It depends what is not and for to test and see and if patient and to test and see If patients comes back due to cancer tumor or radiation - (To follow adequate what risk they need for to do)

The Requirements to avoid adjuvant for tumors

• What Size it is / How older is the patient also is
• You dont really give chemotherapy with tumors that is less than 1
• if patients has side opposite
• for test patients needs any treatment and to test or what to give

Advanced Testing with Patients

We the stage, Chemo, Surgery- Cancer patients for early stage +Testrogens- better than the other

Tests (Advanced) Tests

• Check C/P and has mammo to see if can and is for nipple to - Bleeding for nipple to see if pap or cancer or duct - Test: Can can patients for gynocosmtia
• What that gynecostomia is and if men has condition to what that is when enlarge and over
• We see hormone to get in balance with between and and and with estrogen for breast with is the
• It’s Test is for examination with radio tests for if suspects for diagnosis that
• We treat and is simple is to follow , is more that’s it is when test is for Lipo to get test
• Remove tissue for mass to get in test and in contour to what test is and to it so test for it