Benign breast disease

transcript

PROF. Amer Eltwati IRHUMA FRCSPROF. Amer Eltwati IRHUMA FRCS

'failure' is not falling down but in staying down ..!

anonymousanonymous

Definition

The word “breast” refers to the mammary glands, plus the additional connective tissue elements and fat that surround and support the gland.

INTRODUCTION

The breast has always been the symbol of womanhood The breast has always been the symbol of womanhood and Ultimate fertility. As result both, disease and surgery and Ultimate fertility. As result both, disease and surgery of the breast evoke of the breast evoke a fear of mutilationa fear of mutilation & & loss of femininity . loss of femininity .

Benign breast diseases account for about 80 % of the Benign breast diseases account for about 80 % of the breast pathologybreast pathology

Very few benign breast disease have an ability to become Very few benign breast disease have an ability to become malignant , but the majority are treated easily with out malignant , but the majority are treated easily with out adverse consequencesadverse consequences

However management of some benign breast diseases However management of some benign breast diseases proven to be troublesome and associated with high proven to be troublesome and associated with high psychological morbidity psychological morbidity

ANATOMY

The breast is an appendage of skin & is modified The breast is an appendage of skin & is modified sweat gland, the shape of the female breast is due to sweat gland, the shape of the female breast is due to the fat contained within fibrous septa. the fat contained within fibrous septa.

In the adolescent & young adults the breast is firm & In the adolescent & young adults the breast is firm & prominent , with the age the glandular & fibrous prominent , with the age the glandular & fibrous element atrophies, the skin stretch & breast sags. element atrophies, the skin stretch & breast sags.

The breast lies between the skin & pectoral fascia to The breast lies between the skin & pectoral fascia to which it is loosely attached. It extends from the 2nd which it is loosely attached. It extends from the 2nd to the 6th ribs & from the lateral border of the to the 6th ribs & from the lateral border of the sternum to the mid-axially line.sternum to the mid-axially line.

A prolongation of paranchymatus tissue, A prolongation of paranchymatus tissue, the axillary the axillary tailtail, runs up-ward between the pectorals major and , runs up-ward between the pectorals major and latissmus dorsi muscles to blend with the fat of the latissmus dorsi muscles to blend with the fat of the axilla .axilla .

Anatomy of the Breast

ANATOMY

The breast glandular tissue consists of 15 to 20 lobules (clusters of milk forming glands, or acini) that enter into branching and interconnected ducts. The ducts widen beneath the nipple as lactiferous sinuses and then empty via nipple openings.. .

The primary secretory unit is group of saccular alveoli draining into ductless (the terminal duct- lobular Unit ). In the resting state this secret watery fluid which is believed to be reabsorbed through the walls of large ducts.

The alveoli ducts are lined by single layer of epithelial cells. Myoepithelial surround the ducts, but not the lobules, they are contractile & move secretion along the duct system

Anatomy of the Breast

BLOOD SUPPLY

ARTERIAL: - laterally:- this comes from

branches of lateral thoracic artery and perforating branches of the intercostal arteries.

Medially from perforating branches of internal mammary artery.

B- VEINS:-it follows the same course of arterial supply.

Lymphatic drainage of the breast

The understanding of the lymph drainage of the breast are of great importance for the surgeon. The lymphatic is profuse &run within the substance of the breast

Medially:- to the intrenal mammary nodes

Laterally:- to the nodes along the lateral thoracic vesseles ( pectoral group) & subscapular vesseles (subscapular group), from these nodes lymph passes-up through the central & apical axillary nodes to the subclavin trunk.

Few lymphatic pierce the pectoral fascia & enter the chest

Levels of axillary nodes

Supraclavicular nodes

Interpectoral nodes

Internal mammary

Abdominal nodes

Latissimus dorsi

muscle

Axillary vein

Pectoralis major

muscle

Pectoralis minor muscle

Pectoralis major muscle

Hormones Affecting the Breast

Benign breast diseasesBenign breast diseases

INTRODUCTION

Host to a spectrum of benign and malignant diseases.

Benign breast conditions are practically a universal phenomena among women.

It accounts for 80% of clinical presentation related to the breast.

CONGENITAL & DEVELOPMENTAL

ABNORMALITIES Although the normal location of the breast is the

anterior thorax, breast tissue with or without a nipple or just nipple and areola alone can occur any where along the milk line

The milk line is an ectodermal thickening appearing at 6 weeks of gestation running from axilla to the midportion of inguinal ligament

The milk line (ectoderm) extends from the axilla to groin.

Along this line accessory breast or nipples may be found

Development of the breast

CONGENITAL & DEVELOPMENTAL ABNORMALITIES

total lack of breast tissue ( amastia) or of nipple (athlelia) is un unusual

supernumerary nipples polythelia & breast polymasita are quite common.

when polymastia is present in women, the additional breast tissue can secret milk when nipple is present.

Amastia

Amastia: A rare condition wherein the normal growth of the breast or nipple does not occur.

Unilateral amastia (just on one side) is often associated with absence of the pectoral muscles.

Bilateral amastia (with absence of both breasts) is associated in 40% of cases with multiple congenital anomalies involving other parts of the body as well.

Amastia is distinguished from amazia wherein the breast tissue is absent, but the nipple is present. Amazia typically is a result of radiation or surgery.

amastia

Mastalgia

Mastalgia is breast pain and is generally classified as either cyclical (associated with menstrual periods) or noncyclic

Breast pain of any type is a rare symptom of breast cancer , only 7% of breast cancer have mastalgia as the only symptom.

Most mastalgia is of minor to moderate severity and accepted as part of the normal changes that occur in relation to menstrual cycle.

Mastalgia

Cyclic mastalgia: begin since average 34 y/o, relieved by menopause, physical activity can increase the pain, e.g. lifting and prolonged use of arm.

Non-cyclic mastalgia: affects older women (mean age 43), arises from chest wall. Breast itself or outside the breast.

Mastalgia - treatment

Danazol: (200-300 mg daily, slowly reduced to 100 mg daily or on alternative day, given on days 14-28 of menstrual cycle, after pain relief.

Responses are usually seen within 3 months Weight gain, acne and hirsutism.

Gynecomastia

Gynecomastia is the growth of glandular tissue in male breasts.

The name comes from the Greek term (gyne + mastos) meaning "female-like breasts." It is a benign condition that accounts for more than 65% of male breast abnormalities.

Gynecomastia is clearly differentiated from pseudogynecomastia, which is an accumulation of excess fat in a male breast.

it is usually unilateral & occur in young man. there is no hormonal dysfunction in unilateral Gynecomastia.

Bilateral Gynecomastia is due to systemic causes. Causes of Gynecomastia may be regarded as:

Primary Gynecomastia physiological causes

Neonatal gynaecomastia is due to the trans-placental passage of maternal

oestrogen and may be associated with a nipple discharge known as 'witch's milk'. It usually resolves during the first few weeks of life.

Pubertal gynaecomastia is the commonest male breast lesion. It can be either

unilateral or bilateral. Reassurance is often the only treatment that is required. The lesion will generally settle spontaneously but may persist for months or years.

Senile gynaecomastia can be difficult to differentiate from the pseudo-

gynaecomastia due to general adiposity increasingly seen in old age.

Secondary Gynecomastia – pathological causes

Primary testicular failure Anorchia Klinefelter's syndrome or bilateral cryptorchidism.

Acquired testicular failure Mumps irradiation.

Secondary testicular failure hypopituitarism. Isolated gonadotrophin deficiency.

Endocrine tumours Testicular adrenal pituitary.

Gynecomastia – pathological causes Non-endocrine tumours

bronchial carcinoma Lymphoma hypernephroma.

Hepatic disease alcoholic cirrhosis haemochromotosis.

Drugs oestrogen agonists (spironolactone), hyperprolactinaemia (phenothiazines), Testosterone target cell inhibitors (cimetidine, cyproterone

acetate)

Pathophysiology of breast gynecomastia

Pathophysiology of breast gynecomastia. Estradiol is the growth hormone of the

breast, and an excess of estradiol leads to the proliferation of breast tissue.

Under normal circumstances, most estradiol in men is derived from the peripheral conversion of testosterone and adrenal estrone.

The basic mechanisms of gynecomastia are a decrease in androgen production, an absolute increase in estrogen

production, and an increased availability of

estrogen precursors for peripheral conversion to estradiol.

Gynecomastia – clinical features

The cause is often self evident from a full history and examination.

The testes should always be examined. Useful investigations may include

a chest x-ray, full blood count and liver function test. If there is suspicion of a testicular tumour then

ultrasound should be requested. Hormonal assays may confirm endocrinopathies

Gynecomastia

Treatment of gynecomastia• for physiological causes reassurance is all what

is needed• stop drugs causing gynecomastia• subcutaneous mastectomy in troublesome

cases• Liposuction - assisted mastectomy

FAT NECROSIS

This is traumatic in nature & is met with women with This is traumatic in nature & is met with women with large fatty breast large fatty breast

Results from injury to breast fat by Trauma, surgery, biopsy….

Causes to focal fibrosis and cicatrix formation.

Early: edema of the fat lobules,increased echogenicity.

Post surgical scar, hematoma, seroma

FAT NECROSIS

Clinically:

The patient develop sever bruising after moderately sever trauma, When the bruise settles the woman notice swelling which is clinically Impossible to distinguish from carcinoma of the breast because the Irregular mass is often attached to the skin.

Microscopically a central area of necrotic fat cells are surrounded by a granulomatous reaction consisting of macrophage cells.

FAT NECROSIS

Treatment:by surgical excision, the excised mass is an infiltrative yellowish white mass.

Duct Ectasia

This condition has several stages of involvement & vanity of names include (plasma- cell mastitis, comedo mastitis, & chronic abscess simulating carcinoma).

It is benign lesion may be virtually impossible to differentiate from carcinoma by it is gross appearance

Duct Ectasia is a widening of the ducts of the breast, a condition

that occurs most frequently in women in their 40s and 50s. A thick and sticky discharge, usually gray to green in color, is the most common symptom.

Tenderness and redness of the nipple and surrounding breast tissue may also be present. Sometimes, scar tissue forms around the abnormal duct, leading to a lump that may be initially mistaken for cancer.

Duct Ectasia

MicroscopicallyMicroscopically-The periductal elastic -The periductal elastic

tissue is destroyed & the tissue is destroyed & the surrounding tissue are surrounding tissue are infiltrated with infiltrated with lymphocytes & plamsa lymphocytes & plamsa cellcell

Duct EctasiaClinically:-

this condition present as solitary or multiple tender swelling in the sub or Peri-areolar region of the breast.

- Nipple retraction, skin adherence, edema & axillary adenopathy may accompany a hard, diffuse mass within the breast - palpation reveals a number of cord like swelling which

radiate from the areola. - the ducts are dilated & contain an inspissated yellow

cheesy material that can be expressed like toothpaste from the cut end of a duct.

- occasionally, the inflammatory response are so acute that skin changes occur & the condition may be mistaken for a breast abscess.

Duct Ectasia Treatment :

Small volume discharge is managed conservatively

Socially embarrassing discharge is treated by Major duct excision

Galactocele

Cystically dilated terminal ductules that are filled with milk and lined by double layer of breast epithelium and myoepithelium.

Classically appears as a painless lump weeks – months after cessation of breast feeding.

GALACTOCELE

It is probably formed by obstruction to a duct in the puerperium . the milk retained proximal to the obstruction eventually becomes cheese-like.

The common complication of this type of swelling is infection.

The treatment is by surgical excision.

INTRA-DUCTAL PAPILLOMA

This benign lesions of the lactiferous duct wall occur centrally beneath the areola In 75% of cases.

They most commonly produce a bloody nipple discharge, some times associated with Pain

They are solitary proliferation of ductal epithelium

Intraductal papillomas should be treated by excision of a duct as a wedge resection.

FIBROADENOMA

Fibroadenomas are benign tumors composed of stromal and epithelial elements. The tumors are commonly seen in young women.

Fibroadenoma is a common well - circumscribed lesion of the breast & develop in the breast prior to menopause.

Pericanalicular tumors usually being found below the age of 30 & intracanalicular tumors there after.

Either breast may be affected and multiple & successive tumors may develop in the same or contra-Lateral breast.

FIBROADENOMA

The preicanalicular tumor forms a firm discrete mass, which is freely mobile in the breast tissue, hence the name (BREAST MOUSE )

The intracanalicular tumors tends to be softer & may grow to such size that there is necrosis of the overlying skin. To such a condition the terms serocystic disease of bordie OR cystisarcoma phylloides OR Giant fibroadenoma have been given. However despite the implication of malignancy in the later term, the tumor is benign.

FIBROADENOMA

Pathophysiology: Fibroadenomas are benign tumors that represent a

hyperplastic or proliferative process in a single terminal ductal unit; their development is considered to be an aberration of normal development. The cause is unknown. Approximately 10% of fibroadenomas disappear each year, and most stop growing after they are 2-3 cm in size.

Fibroadenomas may involute in postmenopausal women, and coarse calcifications may develop. Conversely, the tumors may grow rapidly during pregnancy, during hormone replacement therapy, or during immunosuppression, in which case they can simulate malignancy.

Fibroadenoma variants include juvenile fibroadenoma, which occurs in female adolescents.

FIBROADENOMA - Pathology This swelling has been

variously regarded as a simple hyperplasia of epithelial and / or connective tissue elements or as a composite neoplasm of the breast in which the epithelial & mesnchymal components grow simultaneously

FIBROADENOMA Clinical Features:

On clinical examination, fibroadenomas may be nonpalpable or palpable, oval, freely mobile, rubbery masses. Their size varies from smaller than 1 cm in diameter to as large as 15 cm in diameter in the giant forms.

Most commonly, the tumors are removed surgically when they are 2-4 cm in diameter. In young women, the tumors are usually palpable. In older women, the tumors typically appear as a mass on mammograms, and the tumor may be palpable or nonpalpable.

The size of fibroadenomas also can vary during the menstrual cycle and during pregnancy.

In the postmenopausal period, tumors regress and often develop calcifications

Fibroadenoma Types Solitary Few (< 5 / breast )Multiple (> 5 / breast )Giant (> 4 / 5 cms) & Juvenile

Natural history

Majority remain small & static 50% involute spontaneously No future risk of malignancy

DIAGNOSIS : Triple assessmentTriple Assessment

pathologyHx and clinical exam Imaging

UltrasoundMammography

FNACCore biopsyOpen biopsy

FIBROADENOMA - investigation

Breast, fibroadenoma Sonogram. demonstrates a hypoechoic mass with smooth partially lobulated margins that are typical of a fibroadenoma.

FIBROADENOMA - investigation

Breast, fibroadenoma. Craniocaudal mammograms obtained 1 year apart demonstrate a newly developing mass in the outer part of the breast.

FIBROADENOMA

Treatment Reassurance of the patient Excisional biopsy

Treatment The natural history of these lesions has recently been

elucidated and has resulted in a change in management policy.

Over a 2 year period approximately 20% slowly increase in size, 10% reduce in size, 20% completely resolve and 50% remain static.

With knowledge of this natural history a conservative management policy can often be adopted. In those <35 years and with a triple assessment

supporting the diagnosis then observation with regular review is acceptable.

In those > 35 years and in younger patients requesting it, excision biopsy should be considered.

Discharge with advice on BSE

No change/ shrinkage / disappearence

Extra capsular Excision

Increase in size/A t patient request

C linical observation for 2 years

A ll results concurrAge < 30 years

Excisionwith rim of normal tissue

Results do not concurrAge > 30 years

Excision of largestC linical observation of rest

Multiple fibroadenomas(Selective triple assessment)

Extracapsular Excision

Giant fibroadenoma/Juvenile fibroadenoma

Triple assessment

Fibroadenoma(clinical diagnosis)

Management algorithm for Fibroadenomas

Cystosarcoma phyllodes (CSP)

Cystosarcoma phyllodes (CSP) is a rare, predominantly benign tumor that occurs almost exclusively in the female breast. Its name is derived from the Greek words sarcoma, meaning fleshy tumor, and phyllo, meaning leaf.

Grossly, the tumor displays characteristics of a large, malignant sarcoma, takes on a leaflike appearance when sectioned, and displays epithelial cystlike spaces when viewed histologically (hence the name).

Because most tumors are benign, the name may be misleading. Thus, the favored terminology is now phyllodes tumor.

Pathophysiology of CSP

Pathophysiology: Phyllodes tumor is the most commonly

occurring nonepithelial neoplasm of the breast, and it occurs only in the female breast.

It has a sharply demarcated, smooth texture and is typically freely movable. It is a relatively large tumor, and the average size is 5 cm. However, lesions more than 30 cm in size have been reported.

TREATMENT of CSP Surgical Care:

In most cases, perform wide local excision with a rim of normal tissue

If the tumor/breast ratio is sufficiently high to preclude a satisfactory cosmetic result by segmental excision

total mastectomy, with or without reconstruction, is an alternative.

More radical procedures generally are not warranted Perform axillary lymph node dissection only for

clinically suspicious nodes. However, virtually all of these nodes are reactive and do not contain malignant cells.

FIBROCYSTIC DISEASE

This is the most common lesion of the female breast.

Cystic lobular hyperplasia & fibrocystic disease of the breast are the two common acceptable description.

Cystic hyperplasia is a variant of normal cyclic changes in the breast that occur with menstruation.

This hyperplasia usually presents bilaterally in the upper outer quadrant of the breast & is most painful in the premenstrual period

Fibrocystic Breast Disease

Most benign breast condition Incidence-varying, related to age

Menstruating years-20% 30-50% in premenopausal years

Synonyms- Mammary dysplasia, Cystic disease, Cyclic Mastopathy, Cystic Hyperplasia

Pathophysiology of fibrocystic disease

The exact cause of fibrocystic disease is unkwon Hormonal basis

Oestrogen & Progesterone Prolactin Thyroid

Methylexanthiones Trauma- NOT A CAUSE

Oestrogen & Progesterone Oestrogen predominance over progesterone is considered

causative Serum levels of Oestrogen high Luteal phase is shortened

Progesterone level decreased to 1/3 normal, and women with progesterone deficiency carry a five fold risk of premenopausal breast cancer

Corp. Lut. Deficiency / Anovulation in 70% Patients with Pre Menstrual Tension syndrome more likely to

develop FDB

Prolactin- levels are increased in 1/3 of women with FDB Probably due to Oestrogen dominance on pituitary

Thyroid – Suboptimal levels sensitize mammary epithelium to

Prolactin stimulation

Methylexanthiones- Increased intake of coffee, tea, cold drinks chocolate

is associated with development of FDB

Pathomorphology Oestrogens stimulate proliferation of

connective and epithelial tissues. The polymorphism of fibrocystic disease

is documented by : fibrosis, cyst formation, epithelial proliferation, and lobular-alveolar atrophy

Clinical Course of fibrocystic disease

FDB represents a clinical problem in approximately 30% of patients.

Predominantly afflicted are women with menstrual abnormalities nulliparous women patients with a history of spontaneous abortions nonusers of oral contraceptives and women with early menarche and late menopause.

Early fibrocystic manifestations may occur between the age of 20 and 25 years, but most patients (70% to 75%) are in their mid 30s and 40s.

Incidence of FBD

10%20%

Under 21 Years Menstrual years Pre-menopausal

Clinical Course of fibrocystic disease

Clinically, three phases of fibrocystic disease can be recognized- Phase I - Moderate stromal fibrosis, beginning

hardness of breast tissue and premenstrual breast tenderness

Phase II - Progressive fibrosis leading to increased hardening and tenderness, cyst formation, moderate modularity

Phase III - Pronounced fibrosis and tenderness, macrocyst formation

Diagnosis of fibrocystic diseasetriple assessment

Symptoms and Signs - Fibrocystic disease has a history of many months to

several years. Fibrocystic disease is rare in ovulating women,

multiparous women, and patients using oral contraceptives.

Breast pain (mastodynia) and/or tenderness is observed in the majority of patients.

In 40% to 60% of patients these are associated with irregular menses, dysmenorrhea, menometrorrhagia, or ovarian cysts.

Diagnosis of fibrocystic disease

Nipple secretion- In one third of patients with FDB, discharge is

spontaneous or secretion can be expelled from the nipple. The cytological features may include amorphous material (fat, proteins), ductal cells, erythrocytes, and / or foam cells. the fluid is straw yellow, greenish, or bluish. In 2-3% carcinoma is diagnosed

Bloody Nipple secretion- when present 50-60% due to intra ductal proliferation (Papilloma) 30-40% due to carcinoma ( 64% after age 50).

Patients with early fibrocystic change show small areas of increased density on the mammographic film.These are irregular and scattered, with varying degrees of density. As disease progresses, dark areas may occur along with the whitish grey areas, and microcalcifications may also become prominent. These calcifications can be single or multiple small flecks located in intraductal or periductal stroma or in entire lobules.

Mammography –

Ultrasonography - Particularly useful in delineating solid from cystic

breast masses. Ultrasound of cystic masses characteristically defines a

mass with a uniform outer margin demonstrating no asymmetry or unusual thickness of the wall. The central part of the mass shows no echoes, and there is posterior wall enhancement.

Needle aspiration biopsy – Indicated in patients with breast mass, a lump like

structure,, a hard dense area or any abnormal tissue areas, as defined by clinical examination, mammography or USG.

In patients at high risk of breast cancer, needle aspiration should be performed when the slightest suspicion arises.

In women with fibrocystic disease, ductal epithelium consists of cohesive cells with a scant rim of cytoplasm and round or oval small, slightly hyper chromatic nuclei. Connective (fibrous) tissue is usually predominant.

Treatment of fibrocystic disease

Goal-Goal- To stop progressionTo stop progression To relieve painTo relieve pain To reverse changesTo reverse changes Soften breast tissueSoften breast tissue

Indicated when-Indicated when- FDB not increasing in FDB not increasing in

sizesize No nipple dischargeNo nipple discharge No psychological No psychological

effecteffect

Intervention indicated Intervention indicated when-when- FBD is increasing in FBD is increasing in

sizesize Serous / Serous /

Serosanguineous / Serosanguineous / bloody discharge bloody discharge occursoccurs

Patients are Patients are pshychologicaly pshychologicaly disturbeddisturbed

Medical- Surgical-

OC pills- Users are protected from

FBD Progestogen potency

should be high Progestogens -

To be given in the luteal phase for 9-12 months

About 80% get relief but 40% require restart of of therapytherapy

Danazol Remains the most

effective therapy Basis- ovarian supression Dose-200-600mg/day

Hormones

Treatment of fibrocystic disease Medical-

Ineffective modalitiesIneffective modalities Diet therapy-Caffeine Diet therapy-Caffeine

restrictionrestriction DiureticsDiuretics Iodine containing Iodine containing

agentsagents Thyroid hormoneThyroid hormone Evening Primrose oilEvening Primrose oil Vitamin E & B6Vitamin E & B6 Dihydroergotamine Dihydroergotamine Antiprolactin drugsAntiprolactin drugs

Hormones-Hormones- Low Oestrogen Low Oestrogen

Combined OC pillsCombined OC pills Progestogens in the Progestogens in the

luteal phaseluteal phase Antioestrogens- Antioestrogens-

TamoxifenTamoxifen Androgens-DanazolAndrogens-Danazol

TreatmentTreatment Medical-

Efficacy of Danazol

75%81.40%

0%10%20%30%40%50%60%70%80%90%

200mg 400mg 100-800mg 200-400mg

Treatment of fibrocystic disease

- Danazol Medical- Hormones

surgical removal of lumps, in most severe cases of benign fibrocystic breast disease

Surgical treatment

MASTITIS

Breast mastitis Breast mastitis is an infection that commonly is an infection that commonly affects women who are breast-feeding affects women who are breast-feeding (especially (especially during the first two months after childbirth) but during the first two months after childbirth) but can occur in all women at any time. can occur in all women at any time.

Mastitis is a benign condition that can usually Mastitis is a benign condition that can usually be treated successfully with antibiotics. be treated successfully with antibiotics.

Inflammation can be caused by many types of Inflammation can be caused by many types of injury including :injury including : infectious agents and their toxins,infectious agents and their toxins, physical trauma physical trauma or chemical irritantsor chemical irritants

SIGNS AND SYMPTOMS OF MASTITIS

Part or all of the breast is intensely: painful, hot, tender, red, and swollen.

Some patients can pinpoint a definite area of inflammation, while at other times the entire breast is tender. - feel tired, run down, achy, have chills .feel like flu .

A breastfeeding mother who thinks she has the flu probably has mastitis.

chills or feel feverish, or temperature 38c or higher. These symptoms suggest an infection.

Feeling progressively worse, the breasts are growing more tender, and the fever is becoming more pronounced.

Other signs of mastitis: cracked or bleeding nipples, stress or getting run down, missed feedings or longer intervals between

feedings.

TREATMENT OF MASTITIS Mastitis usually requires treatment.Treatment for mastitis

may require the following: Antibiotics are usually prescribed by a physician to

help clear up the infection. Use warm water on the infected area of the breast

before breast-feeding to help stimulate let-down (the milk ejection reflex).

Breast-feed or pump frequently, using both breasts. Lactation consultants recommend first breast-feeding from the unaffected breast until let-down (milk ejection reflex) occurs and then switch to the breast with mastitis.

Breast-feed only until the breast is soft. Apply icy compresses to the breasts after breast-

feeding to relieve pain and swelling. Drink fluids and get enough rest. Analgesia to control the pain.

BREAST ABSCESS

This condition is usually found during lactation . as role the infecting organism is : staphylococcus aureus, and less commonly

streptococcus pyogenes . the usual mode of infection is via the nipple,

the infection being carried by suckling infant in the nasopharynx.

The infection is at first limited to the segment drained by the lactiferous duct but it may subsequently spread to involve other areas of the breast.

BREAST ABSCESS

CAUSES : Staphylococcus aureus and streptococcal

species are the most common organisms isolated in puerperal breast abscesses.

Nonpuerperal abscesses typically contain mixed flora (S aureus, streptococcal species) and anaerobes.

BREAST ABSCESS

CLINICAL FEATURES SYMPTOM

Localized breast area edematous, erythematous, warm, and painful

History of previous breast abscess Associated symptoms of fever, vomiting, and

spontaneous drainage from the mass or nipple May be lactating

BREAST ABSCESS

CLINICAL FEATURES SIGNS

Localized breast area erythematous, hot, edematous, and extremely painful

Most commonly found in the areolar or periareolar area

Fluctuance of the mass May have associated fever or axillary

lymphadenopathy Discharge with palpation from nipple or mass Nipple inversion

Investigations

1-Ultrasound: used to localize the abscess

2. FNAC: used to exclude underlying carcinoma especially in chronic Breast abscess where the abscess become encapsulated with a thick fibrous capsule & the condition can’t be distinguished from a carcinoma without a biopsy.

3. Needle Aspiration: to confirm presence of pus.

4. Mammogram: to exclude underlying carcinoma. carcinoma.

BREAST ABSCESS MANAGEMENT 1- If the patient present in the cellulitis stage the patient should

be treated with an appropriate Antibiotic. 2- Breast rested with feeding on the opposite side only.3- The milk should be expressed from the healthy segments of

the affected breast.4- Support of the breast 5- Local heat & analgesia to relive the pain.6- If the infection doesn’t resolve within 48 h, the breast should

be incised & drained.

N.B. if antibiotics used in the presence of undrained pus, an Antibioma form. This is a large sterile brawny edematous swelling which takes many weeks to resolve..

BREAST ABSCESS

MANAGEMENT 7.If pus is present at the time of presentation, which can

be confirmed by Needle aspiration, Incision & Drainage is done which can be achieved by : Simple Needle Aspiration: using a wide pore needle under local

anesthesia. Guided drainage: under image control with radiological or

ultrasound techniques a tube drain can be inserted & left until the cavity has collapse.

Surgical drainage: it is the most certain method, not only can all loculi be reached, but also dead tissue can be removed. The cavity is then dressed regularly & left open to heal by 2ry intention.

Excision of all of the major ducts in case of Periductal Mastitis..

BREAST ABSCESS Prevention

Taking care of Breasts during pregnancy & Lactation

Stop lactating from cracked nipple. Treating Mastitis in its early stages with

appropriate medication & duration. Drainage of Post-traumatic Hematoma. Excision of Sebaceous Cyst. Self Examination for any masses or

tenderness. Control of concomitant disease that increase

the tendency to get infections such as DM

MANAGEMENT

Lactational breast abscess Usually due to Staph. aureus Usually peripherally situated Surgery may be pre-empted by early

diagnosis Attempt aspiration If no pus - antibiotics If pus present consider repeated

aspiration or incision and drainage Consider biopsy of cavity wall Continue breast feeding from

opposite breast No need to suppress lactation

Non-lactational breast abscess Occur in periareolar tissue Culture yield - Bacteroides, anaerobic strep,

enterococci Usually manifestation of duct ectasia / periductal

mastitis Occur 30- 60 years , More common in smokers Often give history of recurrent breast sepsis Repeated aspiration is the treatment of choice Metronidazole and flucloxacillin Drain through small incision if non-resolving Definitive treatment when quiescent with

antibiotic prophylaxis Usually a major duct excision = Adair's operation Spontaneous discharge or surgical excision can

result in mammary fistula

BREAST ABSCESS

CONCLUSION

Benign breast disorders & diseases are common The aetiopathogenesis is complex and not fully

understood Lump and pain are the most common complaints Evaluation is done by Triple assessment Histological risk factors for future malignancy are

relative and not absolute risk factors Treatment is based on the natural history of clinical

problems Treatment must be tailored to individual needs

Benign breast disease

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