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
Above image shows a normal retracted nipple (white arrow) and an accessory nipple (black arrow),, nipple retraction may occur at puberty, and is known as simple nipple inversion, the cause is unknown, but it can present difficulty with breastfeeding and can predispose to infections especially during lactation due to retension of secretions, accessory nipples (supernumerary) are usually de novo without an underlying disease, but it can be associated with many syndromes and congential defects, such as renal, Cardiac, genital defects, and many others.
#Breast
#Breast
Triple assessment of breast symptoms include
◼️Clinical history and examination.
◼️Radiological investigations including mammography and ultrasound.
◼️Histologic and cytologic investigation including corecut biopsy and FNAC.
The positive predictive value exceed 99.9%.
#Breast
◼️Clinical history and examination.
◼️Radiological investigations including mammography and ultrasound.
◼️Histologic and cytologic investigation including corecut biopsy and FNAC.
The positive predictive value exceed 99.9%.
#Breast
Needle biopsy/Cytology
◼️Histology can be obtained under local anaesthesia using a trucut or corecut biopsy device.
◼️Biopsy can give definitive preoperative diagnosis and can differentiate between duct carcinoma in situ (DCIS) and invasive disease, and can provide staining of the tumor for receptor status which is important for planning on neoadjuvant therapy.
◼️Fine needle aspiration cytology (FNAC) is the least invasive cell based diagnostic tool, it is very accurate if both the operator and cytologist are experienced, however false negative can still occur mainly due to sampling error, also FNAC cannot differentiate between in situ disease and invasive disease.
◼️Above figure is fine needle aspiration cytology showing grade III ductal carcinoma cells.
#Breast
◼️Histology can be obtained under local anaesthesia using a trucut or corecut biopsy device.
◼️Biopsy can give definitive preoperative diagnosis and can differentiate between duct carcinoma in situ (DCIS) and invasive disease, and can provide staining of the tumor for receptor status which is important for planning on neoadjuvant therapy.
◼️Fine needle aspiration cytology (FNAC) is the least invasive cell based diagnostic tool, it is very accurate if both the operator and cytologist are experienced, however false negative can still occur mainly due to sampling error, also FNAC cannot differentiate between in situ disease and invasive disease.
◼️Above figure is fine needle aspiration cytology showing grade III ductal carcinoma cells.
#Breast
Breast MRI
◼️Useful for differentiating between a scar and recurrence in those who had previous breast conservation therapy (not useful within 9 months of radiotherapy due to abnormal enhancement).
◼️It is Gold standard for women with breast implants.
◼️Above image is contrast enhanced MRI showing a highly vascular breast carcinoma.
#Breast
◼️Useful for differentiating between a scar and recurrence in those who had previous breast conservation therapy (not useful within 9 months of radiotherapy due to abnormal enhancement).
◼️It is Gold standard for women with breast implants.
◼️Above image is contrast enhanced MRI showing a highly vascular breast carcinoma.
#Breast
Breast ultrasound
◼️Particularly useful in young women with dense breasts whose mammography is difficult to interpret.
◼️It is useful in differentiating a cystic from a solid breast lesion (figure above shows a breast cyst).
◼️Ultrasound is not useful as a screening tool and remains operator dependant.
#Breast
◼️Particularly useful in young women with dense breasts whose mammography is difficult to interpret.
◼️It is useful in differentiating a cystic from a solid breast lesion (figure above shows a breast cyst).
◼️Ultrasound is not useful as a screening tool and remains operator dependant.
#Breast
Mammography
◼️The breast is placed against an ultrasensitive film and exposed to low voltage high amperage X ray, the dose is 0.1 cGy (Gy = Gray unit which equal 1 joule in 1 kg of tissue).
◼️This dose is low and mammography is a very safe investigation.
◼️The accuracy of mammography increase with increasing age, because the breast becomes less dense.
◼️About 5% of carcinomas are missed on population bases mammography screenings.
#Breast
◼️The breast is placed against an ultrasensitive film and exposed to low voltage high amperage X ray, the dose is 0.1 cGy (Gy = Gray unit which equal 1 joule in 1 kg of tissue).
◼️This dose is low and mammography is a very safe investigation.
◼️The accuracy of mammography increase with increasing age, because the breast becomes less dense.
◼️About 5% of carcinomas are missed on population bases mammography screenings.
#Breast
Lymphatic drainage of the breast
◼️About 85% drains into the axillary lymph nodes which are arranged as
1- Lateral group along the axillary vein.
2- Posterior group along the subscapular vessels.
3- Central group embedded in that fat at the centre of axilla.
4- interpectoral group, which lies between pectoralis major and minor muscles.
5- Apical group which are in continuity with the lateral group and receive efferents from all other groups, the apical group is also continuous with supraclavicular lymph nodes which drain into the subclavian lymph trunk or jugular lymph trunk or thoracic duct (on the left) which directly drain into the venous system. (see next image)
◼️ The remaining drainage goes to the internal mammary nodes which are deep to the thoracic cage and along the internal thoracic artery, some lymph drainage goes to the inframammary nodes and the upper abdomen.
#Breast
◼️About 85% drains into the axillary lymph nodes which are arranged as
1- Lateral group along the axillary vein.
2- Posterior group along the subscapular vessels.
3- Central group embedded in that fat at the centre of axilla.
4- interpectoral group, which lies between pectoralis major and minor muscles.
5- Apical group which are in continuity with the lateral group and receive efferents from all other groups, the apical group is also continuous with supraclavicular lymph nodes which drain into the subclavian lymph trunk or jugular lymph trunk or thoracic duct (on the left) which directly drain into the venous system. (see next image)
◼️ The remaining drainage goes to the internal mammary nodes which are deep to the thoracic cage and along the internal thoracic artery, some lymph drainage goes to the inframammary nodes and the upper abdomen.
#Breast
The right and left subclavian lymph trunks recieve lymphatic drainage coming from the axilla also, the jugular lymph trunk may recieve some of that lymph drainage, on the left the thoracic duct can recieve drainage directly from the supraclavicular lymph nodes, all of these large lymphatic channels drains directly into the venous system, on the left side the left subclavian, jugular and bronchomediastinal lymph trunks drains into the thoracic duct, whereas on the right side the right subclavian, bronchomediastinal and jugular lymph trunks drains into the Right lymphatic duct
Note
The Thoracic duct starts at level T12 and drains into the angle between the left subclavian and left internal jugular veins at the commencement of the brachiocephalic vein
Note
The Thoracic duct starts at level T12 and drains into the angle between the left subclavian and left internal jugular veins at the commencement of the brachiocephalic vein
Note
The sentinel lymph node is the first lymph node which drains the tumor bearing area in the breast.
#Breast
The sentinel lymph node is the first lymph node which drains the tumor bearing area in the breast.
#Breast
Ligaments of cooper
◼️They are hollow strands of fibrous tissue filled with breast tissue.
◼️They firmly adhere to the superficial fascia and thereby to the skin (see figure).
◼️What is the clinical importance of cooper's ligaments?
#Breast
◼️They are hollow strands of fibrous tissue filled with breast tissue.
◼️They firmly adhere to the superficial fascia and thereby to the skin (see figure).
◼️What is the clinical importance of cooper's ligaments?
#Breast