2. Welcome
to
One
Centre
for
Gynaecological
Excellence
3.
4.
Dr.
Kawita
Bapat
Chairperson female breast diseases committee FOGSI
– MS.FICOG
– DIRECTOR OF ONE CENTRE FOR
GYNAECOLOGICAL EXCELLENCE
– Senior practicing OBGYN at Indore
– ONE DAY HYSTERECTOMY SPECIALIST
– FOGSI Affiliated colposcopy center
– Past president OBGYN Society INDORE
– GOVRNING COUNCIL MEMBER ICOG
– Past President LIONS Club INDORE
– TREASURER IMS INDORE Chapter
– Award winner of Nayika Indore and captain of industry
5. BREAST COMMITTEE ROADMAP
• Establishing Awareness in Public & OBGY domains
• Detailing a module about breast health
• Communication Collaterals like:
– PowerPoint presentation
– Handbills
– Pamphlets
– Books
• Monthly magazine or newsletter
• Encouraging sharing of stories about breast cancer
survivors
• Adolescent breast health checkup, counseling &
knowledge enrichment
• Educational Seminars
6. BREAST COMMITTEE ROADMAP
– Collaborations with NGOs, Clubs & other social & community organizations
– Celebrity endorsements by those celebrities who are already working for breast
health
– Spreading knowledge about Mammography Screening, Breast checkups in all
corporate and social units
– Frequent awareness rallies
– Grand Marathon Events with mass participation where people will Run for Breast
Health Awareness
– Participation & support from in international agencies and organization
– Collaboration with government & related units that can help the cause
7. Infectious and Inflammatory Disorders of the Breast
• Except during the postpartum period,
infections of the breast are rare and are
classified
• Intrinsic (secondary to abnormalities in
the breast)
• Extrinsic (secondary to an infection in an
adjacent structure, e.g., skin, thoracic
cavity).
8.
9. Inflammatory and Related Lesions
• Mastitis
• A variety of inflammatory and reactive changes can be seen in the
breast.
– some of these are a result of infectious agents
– Some do not have a well-understood etiology
– Some may represent local reaction to a systemic disease
– Some localized antigen-antibody reaction
– Some are classified as idiopathic
10. • Inflammatory breast cancer, as the name suggests, mimics an
infectious or inflammatory etiology.
• often develops without a palpable mass lesion
• often initially misdiagnosed
• In fact, most patients are diagnosed after an initial treatment
with antibiotics or anti-inflammatory therapies failed to show
clinical improvement.
– Mammographic and sonographic evaluation are helpful in
establishing the diagnosis.
– Image-guided biopsy of the abnormal breast parenchyma or skin
biopsy confirms the diagnosis.
– A negative skin biopsy should not be used to exclude the
diagnosis.
11. • A
22-‐year-‐old
• presents
with
a
2-‐week
history
of
swelling
and
pain
in
the
right
breast.
• She
is
currently
breast
feeding
her
3-‐week-‐old
• On
examinaJon,
her
leL
breast
is
engorged
with
milk
• On
the
right
side
swelling
near
the
nipple
with
associated
redness,
warmth,
and
pain.
12. • In this patient, an
ultrasound study
revealed an
• Irregular hypo
echoic mass lesion
with internal
debris
13. – What is incidence
– About 0.4-11% (perhaps up to 20%) of all lactating mothers
– What is main cause of abscess
– Inadequately treated infectious mastitis
– What is the most common causative organism
– Staphylococcus aureus.
– What are other symptoms
– In addition to pain, warmth, and erythema,
symptoms may include fever, chills, and
malaise.
14. Acute Mastitis
• Usually occurs during the first 3
months postpartum as a result of
breast feeding.
• Also known as puerperal or
lactation mastitis
• Disorder is a cellulitis of the
interlobular connective tissue
within the mammary gland
• Which can result in abscess
formation and septicemia.
• It is diagnosed based on clinical
symptoms and signs indicating
inflammation.
15. Acute Mastitis
• Risk factors fall into two general categories:
• 1.Improper nursing technique
– leading to milk stasis and cracks or fissures of
the nipple, which may facilitate entrance of
microorganisms through the skin
• 2. Stress and Sleep deprivation
– which both lower the mother’s immune status
and inhibit milk flow, thus causing engorgement
Because the duration of symptoms before starting treatment is found to be the only
independent risk factor for abscess development, early diagnosis and early management of
mastitis is of value
16. • How to manage
• Smaller abscesses can be managed by
aspiration under ultrasound guidance
and oral antibiotics, as well as
symptomatic care.
• Larger abscesses may need formal
incision and drainage.
17. Granulomatous Mastitis
• Granulomatous reactions resulting from an
– Infectious etiology
– foreign material
• Systemic autoimmune diseases such as
1. Sarcoidosis
2. Wegener’s granulomatosis
• Identification of the etiology requires
1. Microbiologic and
2. Immunologic testing
3. In addition to histopathologic evaluation
• Many different types of organisms can cause Granulomatous mastitis
18. “Idiopathic granulomatous mastitis”
– without an identifiable cause
– excluding other possible causes
• An autoimmune localized response
– To retained and extravasated fat
– protein-rich secretions in the
duct
– Etiology unknown
– Histologically, chronic
noncaseating granulomatous
inflammation
– limited to lobuli
19. Granulomatous Mastitis
• The recommended therapy
– complete surgical excision whenever possible
• plus steroid therapy.
• Even when idiopathic granulomatous
mastitis is treated appropriately, in about
50% of the cases
– Persistence
– Recurrence
– Complications such as abscess formation
– Fistulae
– Chronic suppuration are encountered
• so long-term follow-up is necessary in these patients
20. Granulomatous Mastitis
• Tuberculosis of the breast
– Very rare disease.
– Both clinical and radiological features of
tuberculous mastitis are not diagnostic
– Easily can be confused
• with breast cancer
• pyogenic breast abscess
– Prognosis for complete cure with appropriate
antituberculous drug therapy is excellent
– Definitive diagnosis of the disease is based on
• identification of typical histological
features under microscopy or
• detection of the tubercle bacilli with
mycobacterial culture
21.
22.
23. Foreign Body Reactions
• Foreign materials
• Silicone and Paraffin
• For breast augmentation
and reconstruction
• Cause a granulomatous
reaction
• (“siliconomas”) Silicone
granulomas occur
– after direct injection of
silicone into the breast
tissue
– after extracapsular
rupture of an implant
24. Foreign Body Reactions
• Foreign body
granulomatous
• response associated
with multinucleated
giant cells surround
silicone.
• Fibrosis and
contractions
• clinically apparent
firm nodules
• that may be tender.
25. Recurring Subareolar Abscess
• (Zuska’s disease)
• Rare bacterial infection
• Characterized by a triad
» Draining
cutaneous
fistula from the
subareolar
tissue
» Chronic thick,
pasty
discharge from
the nipple
» History of
multiple,
recurrent
mammary
abscesses
26. Recurring Subareolar
Abscess
• (Zuska’s disease)
• Caused by
– Squamous metaplasia of one or
more lactiferous ducts
– Passage through the nipple
– Probably induced by smoking
– Keratin plugs obstruct and dilate
the proximal duct
– Becomes infected and ruptures
– The inflammation eventuates in
abscess formation beneath the
nipple
– which typically drains at the
margin of the areola
• Therapy
– Abscess drainage
– Complete excision of the
affected duct and sinus
– But abscesses may recur
27. Mammary Duct Ectasia
• Periductal mastitis is a distinctive
clinical entity that can mimic invasive
carcinoma clinically.
• primarily middle-aged to elderly
parous women, who usually present
with
– Nipple discharge,
– Palpable subareolar mass
– Noncyclical mastalgia
– Nipple inversion or retraction
• The pathogenesis and the etiology of
the disease are still being debated.
28. Mammary Duct Ectasia
• Smoking has been
implicated as an
etiologic factor in
mammary duct
ectasia
• Usually an
asymptomatic lesion
• Detected
mammographically
because of
microcalcifications.
29. Fat Necrosis
• Benign non-suppurative
• Inflammatory process adipose tissue.
• It can occur secondary to accidental or
surgical trauma,
• May be associated with carcinoma
• Any lesion that provokes suppurative or
necrotic degeneration,
– such as mammary duct ectasia
– to a lesser extent, fibrocystic disease with large cyst formation
30. Fat Necrosis
• Clinically, fat necrosis may mimic breast
cancer
– appears as an ill-defined
– spiculated dense mass,
– associated with skin retraction,
– ecchymosis
– erythema
– skin thickness
31. Fat Necrosis
• May not always distinguish fat necrosis from a malignant lesion.
– Mammography
– Sonography
– Magnetic resonance imaging
– Even the macroscopic appearance of the benign lesion can suggest a
malignant tumor.
• Histologically, however, the diagnosis of fat necrosis presents no problem,
as it is characterized by
– anuclear fat cells
– often surrounded by histiocytic giant cells and
– foamy phagocytichistiocytes
• Excisional biopsy is required if carcinoma cannot be excluded
preoperatively
32. Mycotic Infections
n Rare
n Intraoral fungi inoculated into the breast tissue by the
suckling
n Present as mammary abscesses
n Pus mixed with blood may be expressed from sinus tracts.
n
33. Mycotic Infections
n Antifungal agents
n Occasionally drainage of an abscess
n Persistent fungal infection partial mastectomy
n Candida albicans presents as
n Erythematous
n Scaly lesions of the axillary folds.
n Scrapings from the lesions
n Removal of predisposing factors
n Topical application of nystatin
34. Hidradenitis Suppurativa
n Chronic inflammatory condition
n Originates within the
n Accessory areolar glands of Montgomery
n Axillary sebaceous glands.
n Nipple-areola complex
n Axilla
n Chronic acne predisposes
n DIFFERENTIAL DIAGNOSIS
Paget's disease of the nipple
Invasive breast cancer
n Involvement of the axillary skin is often multifocal and
contiguous.
35. Hidradenitis Suppurativa
n Antibiotic therapy
n Incision and drainage of fluctuant areas
n Excision of the involved areas may be required
n Large areas of skin loss may necessitate coverage
with advancement flaps or split-thickness skin
grafts
36. Mondor's Disease
n Variant of thrombophlebitis
n Involves the superficial veins of the anterior
chest wall and breast
n In 1939, Mondor described the condition as
"string phlebitis,"
n A thrombosed vein presenting as a tender, cord-
like structure.
n Frequently involved veins include
n the lateral thoracic vein
n the thoracoepigastric vein
n less commonly, the superficial epigastric
vein.
37. Mondor's Disease
n Typically, presents
n Acute pain in the lateral aspect
n A tender, firm cord
n follow the distribution the
major superficial veins
n Rarely, the presentation is
bilateral
n No evidence of
thrombophlebitis in other
anatomic sites.
38. Therapy for Mondor's disease
• Restriction of motion
– Ipsilateral extremity
– Shoulders
• Brassiere support
• Resolves within 4 to 6
weeks.
• When symptoms persist or
are refractory to therapy
• Excision of the involved
vein segment is
appropriate.
n Self-limited disorder
n Not indicative of a cancer
n Biopsy is indicated
n When the diagnosis is
uncertain
n When a mass is present
near the tender cord
n Liberal use of anti-
inflammatory
n Application of warm
compresses
