Peau d' orange
◼️It is a clinical manifestation of advanced breast cancer.
◼️Peau d orange is a french term, which means skin of the orange (resembling peel of orange fruit).
◼️It is a lymphatic cutaneous edema due to lymphatic vessel permeation and obstruction by malignant cells.
◼️The above image shows typical peau d orange, with circumferenial nipple retraction, the pits in the skin are due to tethered sweat gland ducts which cannot swell.
◼️This condition may also occur in chronic breast abscess (always remember that the closest mimicer of a breast cancer is a chronic breast abscess which too can cause nipple retraction)
#Breast
◼️It is a clinical manifestation of advanced breast cancer.
◼️Peau d orange is a french term, which means skin of the orange (resembling peel of orange fruit).
◼️It is a lymphatic cutaneous edema due to lymphatic vessel permeation and obstruction by malignant cells.
◼️The above image shows typical peau d orange, with circumferenial nipple retraction, the pits in the skin are due to tethered sweat gland ducts which cannot swell.
◼️This condition may also occur in chronic breast abscess (always remember that the closest mimicer of a breast cancer is a chronic breast abscess which too can cause nipple retraction)
#Breast
Causes of nipple retraction
◼️ Carcinoma (must exclude first).
◼️ Duct ectasia (slit like retraction).
◼️ Chronic abscess
◼️Idiopathic simple nipple inversion of puberty.
◼️ Advanced ANDI.
#Breast
◼️ Carcinoma (must exclude first).
◼️ Duct ectasia (slit like retraction).
◼️ Chronic abscess
◼️Idiopathic simple nipple inversion of puberty.
◼️ Advanced ANDI.
#Breast
How does eczema differ from paget disease clinically?
◼️Paget disease is associated with nipple destruction, whereas the nipple is intact in eczema.
◼️Paget disease do not respond to treatment whereas eczema does.
◼️Paget disease is usually unilateral whereas eczema is usually bilateral.
◼️Eczema is itchy whereas paget disease usually is not
#Breast
◼️Paget disease is associated with nipple destruction, whereas the nipple is intact in eczema.
◼️Paget disease do not respond to treatment whereas eczema does.
◼️Paget disease is usually unilateral whereas eczema is usually bilateral.
◼️Eczema is itchy whereas paget disease usually is not
#Breast
Operative note
When performing a circumareolar incision, do not cut beyond half of the circumference of the areola, in hopes that the attached part will provide enough blood supply to the remainder,, if extensive incision is done, necrosis of the areolar tissue follows.
#Breast
When performing a circumareolar incision, do not cut beyond half of the circumference of the areola, in hopes that the attached part will provide enough blood supply to the remainder,, if extensive incision is done, necrosis of the areolar tissue follows.
#Breast
Note
Athelia means abscent nipple (usually with amazia = abscent breast)
Polythelia = multiple nipples (supernumerary nipple)
#Breast
Athelia means abscent nipple (usually with amazia = abscent breast)
Polythelia = multiple nipples (supernumerary nipple)
#Breast
Examples of tumors presenting with signs and symptoms of acute inflammation
◼️Inflammatory breast carcinoma.
◼️Testicular neoplasm.
◼️Hepatocellular carcinoma.
◼️Ewing sarcoma.
#Surgery
◼️Inflammatory breast carcinoma.
◼️Testicular neoplasm.
◼️Hepatocellular carcinoma.
◼️Ewing sarcoma.
#Surgery
Interesting rare case of a male inflammatory breast carcinoma, these are highly malignant tumors with undifferentiated histology, they appear as redness, warmth, and cutaneous edema of the breast, BECAREFUL, it mimics breast abscess,, histology is required for diagnosis.
#Breast
#Breast
Paget disease of the nipple
◼️This is an eczema like condition of the nipple and areola.
◼️It is indicative of an underlying breast carcinoma.
◼️The nipple becomes slowly eroded until its completely obsecured (see image above black arrow) , if left, the underlying carcinoma will sooner or later become clinically evident.
◼️The pathophysiology is uncertain, according to the migratory theory, malignant cells travel along the duct system and eventually reach the nipple and areola, the motility of these cells being induced by motility factors acting through HER2/NEU receptors.
◼️Microscopic picture include presence of large ovoid malignant cells with abundant pale cytoplasm in the malpighian layer of epidermis.
◼️It should be suspected strongly when a presumed eczema of the nipple fails to respond to local treatment, whenever in doubt, biopsy of the nipple should be obtained to confirm the diagnosis.
#Breast
◼️This is an eczema like condition of the nipple and areola.
◼️It is indicative of an underlying breast carcinoma.
◼️The nipple becomes slowly eroded until its completely obsecured (see image above black arrow) , if left, the underlying carcinoma will sooner or later become clinically evident.
◼️The pathophysiology is uncertain, according to the migratory theory, malignant cells travel along the duct system and eventually reach the nipple and areola, the motility of these cells being induced by motility factors acting through HER2/NEU receptors.
◼️Microscopic picture include presence of large ovoid malignant cells with abundant pale cytoplasm in the malpighian layer of epidermis.
◼️It should be suspected strongly when a presumed eczema of the nipple fails to respond to local treatment, whenever in doubt, biopsy of the nipple should be obtained to confirm the diagnosis.
#Breast
Ductal carcinoma
◼️This is the commonest histologic variant of breast cancer.
◼️The malignant cells arise from the epithelial lining of the duct system, which can occur anywhere in these ducts.
◼️Ductal carcinoma in situ (malignant cells did not invade the basement membrane), previously was a rare finding, but now with the advent of screening programs, it became increasingly recognized (above is a histologic section showing ductal carcinoma in situ DCIS).
#Breast
◼️This is the commonest histologic variant of breast cancer.
◼️The malignant cells arise from the epithelial lining of the duct system, which can occur anywhere in these ducts.
◼️Ductal carcinoma in situ (malignant cells did not invade the basement membrane), previously was a rare finding, but now with the advent of screening programs, it became increasingly recognized (above is a histologic section showing ductal carcinoma in situ DCIS).
#Breast
Note
Obestiy = more adipose tissue = more conversion of steroids to estradiol = more risk of breast cancer.
#Breast
Obestiy = more adipose tissue = more conversion of steroids to estradiol = more risk of breast cancer.
#Breast
Aetiologic factors in breast cancer
◼️Geographic
Breast cancer is more common in developed western counteries, it account for 3-5% of all deaths, whereas in developing counteries the incidence is lower and account for 1-3% of all deaths. It was found to be rare in japan.
◼️Age
Breast cancer is extremely rare below the age of 20 years, but thereafter, the risk steadily increasea until it becomes 20% at 90 years.
◼️Gender
Males represent less than 0.5% of all cases of breast cancer.
◼️Genetic
Breast cancer is more common in women with a family history of breast cancer,, breast cancers that are due to a specific mutation represent about 5% of all cases, and they will be discussed later in details.
◼️Diet
It was found that there is a link to diets with low phytoestrogens, also high alcohol consumption increase the risk.
◼️Endocrine
Estrogenic drive seems to increase the risk of breast cancer, it was found that nulliparous women are more likely to have breast cancer, also having the first child at an early age is protective, breastfeeding in protective, also late menarche and early menopause seem to be protective.
The role of oral contraceptive pills and hormonal replacement therapy is controversial, it seems that the benefits from these treatments outweight the small putative risk.
#Breast
◼️Geographic
Breast cancer is more common in developed western counteries, it account for 3-5% of all deaths, whereas in developing counteries the incidence is lower and account for 1-3% of all deaths. It was found to be rare in japan.
◼️Age
Breast cancer is extremely rare below the age of 20 years, but thereafter, the risk steadily increasea until it becomes 20% at 90 years.
◼️Gender
Males represent less than 0.5% of all cases of breast cancer.
◼️Genetic
Breast cancer is more common in women with a family history of breast cancer,, breast cancers that are due to a specific mutation represent about 5% of all cases, and they will be discussed later in details.
◼️Diet
It was found that there is a link to diets with low phytoestrogens, also high alcohol consumption increase the risk.
◼️Endocrine
Estrogenic drive seems to increase the risk of breast cancer, it was found that nulliparous women are more likely to have breast cancer, also having the first child at an early age is protective, breastfeeding in protective, also late menarche and early menopause seem to be protective.
The role of oral contraceptive pills and hormonal replacement therapy is controversial, it seems that the benefits from these treatments outweight the small putative risk.
#Breast
Phyllodes tumor
◼️Previously known as serocystic disease of Brodie, but also known as cystosarcoma phyllodes.
◼️They may reach massive size (see picture above), and may cause pressure necrosis and ulceration of the overlying skin (note the ulcerations in the picture above), despite all this they remain mobile on the chest wall, and you can insert a probe between the tumor and the skin (usually not fixed).
◼️Phyllodes tumors are usually of the benign type,, only very rarely they are malignant.
◼️Histology is variable, some tumors show low malignant potential, resembling a fibroadenoma, some show high mitotic index which is worrying.
◼️The name cystosarcoma phyllodes, is really out of character, because these tumors are rarely cystic, and very rarely act like a malignant sarcoma.
◼️Treatment can be done by enucleation or wide local excision, but if the tumor is massive, recurrent or of the malignant type, mastectomy is indicated.
#Breast
◼️Previously known as serocystic disease of Brodie, but also known as cystosarcoma phyllodes.
◼️They may reach massive size (see picture above), and may cause pressure necrosis and ulceration of the overlying skin (note the ulcerations in the picture above), despite all this they remain mobile on the chest wall, and you can insert a probe between the tumor and the skin (usually not fixed).
◼️Phyllodes tumors are usually of the benign type,, only very rarely they are malignant.
◼️Histology is variable, some tumors show low malignant potential, resembling a fibroadenoma, some show high mitotic index which is worrying.
◼️The name cystosarcoma phyllodes, is really out of character, because these tumors are rarely cystic, and very rarely act like a malignant sarcoma.
◼️Treatment can be done by enucleation or wide local excision, but if the tumor is massive, recurrent or of the malignant type, mastectomy is indicated.
#Breast
Note
Another theory to suggest the pathogenesis of duct ectasia, is that periductal mastitis is the initial event, supported by the presence of anaerobic bacteria in some patients.
#Breast
Another theory to suggest the pathogenesis of duct ectasia, is that periductal mastitis is the initial event, supported by the presence of anaerobic bacteria in some patients.
#Breast
Duct ectasia/Periductal mastitis
◼️The pathology, is a dilated duct with surrounding periductal inflammation.
◼️The pathogenesis is unclear, the classic event is that dilatation of a large lactiferous duct takes place, then a green or brown secretion fills up the dilated duct, and becomes stagnant, it may discharge from the nipple.
◼️This stagnation initiate irritation of surrounding tissues, and lead to periductal mastitis, abscess formation (see figure yellow arrow), this abscess may open into the skin leading to a fistula (black arrow).
◼️Sometimes these inflammatory changes causes an indurated subareolar mass, which mimics carcinoma.
◼️Eventually, fibrosis takes place and causes a slit like nipple retraction (white arrow).
◼️Smoking clearly increases the risk, some say because it causes an arteriopathy which is an aetiologic factor, others say that it increase virulence of commencal bacteria, either ways, cessation of smoking clearly increase chance of long term cure.
#Breast
◼️The pathology, is a dilated duct with surrounding periductal inflammation.
◼️The pathogenesis is unclear, the classic event is that dilatation of a large lactiferous duct takes place, then a green or brown secretion fills up the dilated duct, and becomes stagnant, it may discharge from the nipple.
◼️This stagnation initiate irritation of surrounding tissues, and lead to periductal mastitis, abscess formation (see figure yellow arrow), this abscess may open into the skin leading to a fistula (black arrow).
◼️Sometimes these inflammatory changes causes an indurated subareolar mass, which mimics carcinoma.
◼️Eventually, fibrosis takes place and causes a slit like nipple retraction (white arrow).
◼️Smoking clearly increases the risk, some say because it causes an arteriopathy which is an aetiologic factor, others say that it increase virulence of commencal bacteria, either ways, cessation of smoking clearly increase chance of long term cure.
#Breast
Note
Another theory to suggest the pathogenesis of duct ectasia, is that periductal mastitis is the initial event, supported by the presence of anaerobic bacteria in some patients.
#Breast
Another theory to suggest the pathogenesis of duct ectasia, is that periductal mastitis is the initial event, supported by the presence of anaerobic bacteria in some patients.
#Breast
Mondor's Disease
◼️The above image is a mondor's disease under the right breast.
◼️It is a thrombophlebitis of the superficial veins of the breast and anterior chest, also reported to involve the arm.
◼️In absence of infection or injury, the cause of this disease is obsecure.
◼️The Pathognomonic feature, is a thrombosed subcutaneous cord of vein usually attached to the skin, when the skin overlying the breast is stretched, a narrow shallow groove appear along side the cord.
◼️Differential diagnosis include lymphatic permeation from an occult breast carcinoma.
◼️No treatment other than restricting arm movement is needed, it resolve on its own in few months without complication, recurrence or deformity.
◼️Some case reports suggested association of mondor's Disease with breast cancer, although this is probably a coincidental event.
#Breast
◼️The above image is a mondor's disease under the right breast.
◼️It is a thrombophlebitis of the superficial veins of the breast and anterior chest, also reported to involve the arm.
◼️In absence of infection or injury, the cause of this disease is obsecure.
◼️The Pathognomonic feature, is a thrombosed subcutaneous cord of vein usually attached to the skin, when the skin overlying the breast is stretched, a narrow shallow groove appear along side the cord.
◼️Differential diagnosis include lymphatic permeation from an occult breast carcinoma.
◼️No treatment other than restricting arm movement is needed, it resolve on its own in few months without complication, recurrence or deformity.
◼️Some case reports suggested association of mondor's Disease with breast cancer, although this is probably a coincidental event.
#Breast
Note
Sometimes one of the lactiferous ducts becomes blocked by epithelial debris, this causes a milk stasis in a particular sector of the breast which is drained by that duct, thus only a sector of the breast becomes indurated and tender
#Breast
Sometimes one of the lactiferous ducts becomes blocked by epithelial debris, this causes a milk stasis in a particular sector of the breast which is drained by that duct, thus only a sector of the breast becomes indurated and tender
#Breast
Note
Traumatic fat necrosis occurs following a blow to the breast, or indirect violence such as contraction of the pectoralis major muscle, it present with a lump which is often painless, this lump closely mimic a carcinoma, it can display skin tethering or even nipple retraction, a biopsy is needed to confirm the diagnosis, and a history of trauma is not diagnostic.
#Breast
Traumatic fat necrosis occurs following a blow to the breast, or indirect violence such as contraction of the pectoralis major muscle, it present with a lump which is often painless, this lump closely mimic a carcinoma, it can display skin tethering or even nipple retraction, a biopsy is needed to confirm the diagnosis, and a history of trauma is not diagnostic.
#Breast
Amazia is the congential absence of the breast (see figure above), it may be unilateral or bilateral, some cases are associated with congenital absence of the sternal head of pectoralis major muscle (poland syndrome), amazia is more common in males.
#Breast
#Breast
Side topic... Caroli disease
This can be inherited as autosomal dominant or recessive, the disease is rare and is charactarized by abnormal cystic dilatation of intrahepatic bile ducts, resulting in bile stasis with subsequent cholangitis, choledocholithiasis and jaundice,, additionally those with caroli disease are 100 times at risk for cholangiocarcinoma
#Hepatobiliary
This can be inherited as autosomal dominant or recessive, the disease is rare and is charactarized by abnormal cystic dilatation of intrahepatic bile ducts, resulting in bile stasis with subsequent cholangitis, choledocholithiasis and jaundice,, additionally those with caroli disease are 100 times at risk for cholangiocarcinoma
#Hepatobiliary
Slit like Recent nipple retraction is suggestive of duct ectasia and chronic periductal mastitis
#Breast
#Breast