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
Extensions of the breast
◼️It is generally considered that the protruding part of the breast extend from the 2nd rib to the 6th rib, and from the lateral border of the sternum to the anterior axillary line.
◼️Infact, there is a thin layer of mammary tissue which extends considerably furthur, from the clavicle above to the 7th or even 8th rib below, and from the midline to the Latissimus Dorsi posteriorly, this fact is important surgically during mastectomy, the aim of which is remove the whole breast.
◼️The axillary tail of the breast is of surgical importance, sometimes it can be normally palpable, and may be seen premenstrually or during lactation, a well developed axillary tail may be mistaken for enlarged lymph nodes or lipoma.
#Breast
◼️It is generally considered that the protruding part of the breast extend from the 2nd rib to the 6th rib, and from the lateral border of the sternum to the anterior axillary line.
◼️Infact, there is a thin layer of mammary tissue which extends considerably furthur, from the clavicle above to the 7th or even 8th rib below, and from the midline to the Latissimus Dorsi posteriorly, this fact is important surgically during mastectomy, the aim of which is remove the whole breast.
◼️The axillary tail of the breast is of surgical importance, sometimes it can be normally palpable, and may be seen premenstrually or during lactation, a well developed axillary tail may be mistaken for enlarged lymph nodes or lipoma.
#Breast
Plummer vinson syndrome
◼️ Also called Brown kelly paterson syndrome or simply sidropenic dysphagia.
◼️This condition is described in women who have iron defeciency anemia and a dysphagia referred high in the neck.
◼️Certainly there is a fibrotic thin web in the upper esophagus, which attributes to dysphagia.
◼️The pathophysiology of this condition is uncertain, some patients had developed postcricoid carcinoma, ulceration and strictures, some patients shows heterotropic gastric mucosa, which may explain for those patients who developed adenocarcinoma in the upper esophagus.
◼️These webs can be easily dilated.
◼️ Also called Brown kelly paterson syndrome or simply sidropenic dysphagia.
◼️This condition is described in women who have iron defeciency anemia and a dysphagia referred high in the neck.
◼️Certainly there is a fibrotic thin web in the upper esophagus, which attributes to dysphagia.
◼️The pathophysiology of this condition is uncertain, some patients had developed postcricoid carcinoma, ulceration and strictures, some patients shows heterotropic gastric mucosa, which may explain for those patients who developed adenocarcinoma in the upper esophagus.
◼️These webs can be easily dilated.
Note
Crohn's disease of the esophagus responds poorly to medical treatment, and resection may be required, remember that the esophagus is an unusual site for Crohn's disease, but surprisingly in some patients the esophagus is the only site for Crohn's disease in which a diagnostic challenge arise.
Crohn's disease of the esophagus responds poorly to medical treatment, and resection may be required, remember that the esophagus is an unusual site for Crohn's disease, but surprisingly in some patients the esophagus is the only site for Crohn's disease in which a diagnostic challenge arise.