BREAST DISORDERS

Dr. Mohammed Niyaz MEM RESIDENTMIMS-K

Common breast complaints

Breast pain Breast mass Nipple discharge Infection Postoperative complications

Pathophysiology

Normal breast tissue – glandular tissue Anterior chest wall Sternocostal junction Midaxillary line 2nd to 6th ribs in midclavicular line Arterial supply – internal mammary, lateral thoracic,

thoracodorsal and subscapular arteries

History

Onset of mass or pain, location and duation Complaints varying with menses – benign Presence of symptoms on contralateral side – benign Colour and consistency of nipple discharge Family history 50 % breast cancers - age > 65 years

Physical examination

Supine position with ipsilateral hand behind the head.

Upper outer quadrant – origin of half of breast Ca Asymmetry in glandular consistency, nodules Nipple areolar complex, axilla , anterior and posterior

neck

PHYSIOLOGY AND DISORDERS OF LACTATING BREAST

ABNORMAL LACTATION Inappropriate secretion of milky discharge –

Galactorrhea Prolactinomas- galactorrhoea, amenorrhea,

hirsuitism, facial acne , visual defects , headache

Complications of Lactation

Breast engorgment – 3rd to 5th postpartum day Carbohydrate rich milk bacterial overgrowth

colonization of Candida in lactiferous ducts Obstruction of flow

Topical application - Nystatin

• Endemic mastitis , occurs few weeks to months postpartum

• Staphylococcus (40 %), E.coli and Streptococcus

INFLAMMATORY BREAST CONDITIONSDifferential Diagnosis

Infectious Mastitis Ruptured breast cyst Inflammatory neoplasm Metastatic cancer Tuberculosis Paget disease

MASTITISSigns and Symtoms Erythematous area on breast with well localized pain Fever, chills , myalgias, flu like symptoms Investigatiions : Ultrasound to r/o abscess

Treatment : Analgesia and antibiotics, Surgery follow up

BREAST ABSCESS

Signs and Symtoms Erythematous area on breast with well localized pain Fever, chills , myalgias, flu like symptoms

Treatment : US guided needle aspiration for abscesses < 3 cm Analgesia and antibiotics General anesthesia for larger periareolar or

retroareolar abscess.

PERIDUCTAL MASTITIS

Plasma cell mastitis or Mammary duct ectasia 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

HYDRADENTIS SUPPURATIVA Chronic inflammatory disease involving obstruction

of sweat glands Recurrent multiple abscesses, sinsus tracts and

scarring of breast folds Treatment : Incision and drainage

ANTIBIOTICS

Dicloxacillin 250 mg four times a day x 10-14 daysOr Cephalexin 500 mg four times a day x 10-14 daysOr Clindamycin 300 mg four times a day x 10-14 daysOr TMP-SMX , 80/160 mg twice a day

INFLAMMATORY BREAST CANCER Highest mortality and longest delay from initial

presentation Breast enlargement , warmth, tenderness, edema,

eythema and discolouration of overlying skin Erythema and edema – Peau d’ orange appearance Mammography and biopsy

NON INFLAMMATORY PAINFUL BREAST DISORDERSMASTODYNIA :

Discomfort- cyclic , waxing or waning with menstrual cycle Pain – bilateral and more in upper outer quadrant Examination – tender, nodular breasts

Treatment : Reassurance and supportive measures. Reduction in dosage of HRT Flaxseed oil and diclofenac 2 % topical gel Persistent pain – increased risk for breast cancer

Nipple Discharge

Purulent : Infection, Periductal mastitis Milky (Galactorrhea) : Pregnancy, Prolactinoma,

Pituitary adenoma, Drugs- hormones, Psychotropics phenothiazines), antiemetics, antihypertensives

Serous or serosanguinous : Intraduct papilloma, Ductal ectasia, cancer

Watery : Papilloma, Cancer Green, gray, black or tan : Duct ectasia

SKIN AND NIPPLE ABNORMALITIESMONDOR DISEASE : Thrombophlebitis of superficial thoracoepigastric

vein Cord like mass in the breast, common in lower

quadrant Breast pain, skin changes Treatment – NSAIDs

NIPPLE IRRITATION : Repeated friction from clothing or sun burn Indicative of atopic dermatitis , erosive adenomatosis

or Pagets disease Petroleum jelly or use of protective pads

FIBROCSTIC DISEASE : Breast nodularity and tenderness Mammography and follow up Recurrent symptoms, skin changes, solid masses,

nipple abnormalities- Possibility of cancer Family history, endogenous estrogens, nulliparity or

biopsy confirmed atypical hyperplasia- increase risk of cancer

PERIOPERATIVE AND POST OPERATIVE COMPLICATIONS

BREAST HEMATOMA : 1.5 L of blood can extravasate Expanding hematoma – evacuation or ligation of vessels Late presentation – conservative management

WOUND INFECTION : First generation cephalosporins