Breast anatomy

Breast development
Mammary gland is a modified sweat gland as it develops from skin epidermis. It
arises from the milk line (=mammary ridge) which extends from axilla to
the groin on each side.
Breast structure
Female breast consists of:
Tail of breast
Overlying skin

Mammary gland
Nipple & Areola

(1) Mammary gland

Mammary gland contains parenchyma & stroma.
Parenchyma of the gland is composed of 15-20 lobes. Each
lobe is composed of several lobules (from 10 to 100 lobules).
These lobules empty via ductules into a lactiferous duct (15-20
lactiferous ducts). Each lactiferous duct is lined by a spiral
arrangement of contractile myoepithelial cells and is provided
with a terminal ampulla (lactiferous sinus; a reservoir for milk
or abnormal discharges). Then ducts narrow to open separately
on the summit of nipple.
Stroma of the gland is formed fibrous strands, which extend
from the skin to deep fascia, between the lobes & lobules of
the gland. The ligaments of Cooper are hollow conical
projections of fibrous tissue filled with breast tissue, the apices
of the cones being attached firmly to the superficial fascia and
thereby to the skin overlying the breast.
(2) Nipple & Areola
Nipple is covered by thick skin with corrugations. Near its
apex lie the orifices of the lactiferous ducts. The nipple
contains smooth muscle fibres arranged concentrically and
longitudinally; thus it is an erectile structure, which points
outwards.
Areola surrounds the nipple. The areola contains
involuntary muscle arranged in concentric rings. Areolar
epithelium contains numerous sweat glands and sebaceous
glands.
N.B.: Sebaceous glands enlarge during pregnancy and serve to
lubricate the nipple during lactation.
(3) Tail of breast

It is a process from the gland extends laterally along the

lower border of pectoralis major to the axilla, so called
axillary tail.

Breast position
Breast base lies on the front of the thorax. It extends from the
sternum to the mid-axillary line, and from 2nd to 6th ribs Breast lies
on pectoralis major (2/3) & serratus anterior (1/3) muscles. Nipple
lies below the centre of the gland and lies opposite the 4th
intercostal space.
Blood supply of breast
Arterial supply
1. Perforating branches of internal mammary artery 60%
2. Lateral thoracic artery 30% (from axillary artery 2nd part)
3. Lateral branches of 2nd , 3rd & 4th intercostal arteries 10%
Venous drainage
1. Axillary vein
2. Internal mammary veins
3. Intercostal veins
Lymphatic drainage of breast
Lymphatics of the breast drain predominantly into:
Axillary lymph nodes 75%
Internal mammary lymph nodes medial part
(parasternal L.N.s)
Lymphatics of falciform ligament lower medial part
The axillary lymph nodes are arranged in the following groups:
Lateral along the distal part of axillary vein (humoral)
Subscapular along the subscapular vessels
Central embedded in fat in the centre of the axilla
Pectoral along the inferior border of pectoralis minor
muscle
Apical lies between the clavicle & pectoralis minor
tendon

Presentation of breast disease

Breast disease presents in 8 common ways:

8.Axillary mass.

7.Nipple retraction.

The likely diagnoses when the patient presents with 1 of the above
symptoms are:
A painless lump
4. Nodularity
(fibroadenosis)
A painful lump
4.Periductal (plasma-cell)
mastitis
5.Carcinoma (rare)

1. Carcinoma
2. Cyst
3. Fibroadenoma
1.Cyclical nodularity
(fibroadenosis)
2.Cyst
3.Abscess (usually lactational)

Pain & tenderness but no lump

1. Cyclical mastalgia (including premenstrual tension)
2. Non-cyclical mastalgia
3. Pregnancy mastitis
Nipple discharge
1. Discharge from the surface:
1. Pagets disease
2. Skin diseases (eczema. psoriasis)
3. Rare causes(e.g chancre)
2. Discharge from a single duct:
Serostis any colour
Blood-stained
- BROCYST C
- Intra-ductal
DISEASE
carcinoma
- Duct ectasia
- Intra-ductal
- Carcinoma
papilloma
- Duct ectasia
3. Discharge from more than one duct:
Serous
Blood-stained
- Fibrocystic disease
- Carcinoma
- Duct ectasia
- Duct Ectasia
- Carcinoma
- Fibrocystic disease
Milk
- Lactation
- Rare causes (hypothyroidism, pituitary tumour)
Purulent
- Infection

 Nipple retraction
2. Congenital since birth

1. Carcinoma
(commonest)
3. Chronic inflammation, abscess, T.B., syphilis, antibioma

Axillary mass
1. Contents:
1) L.N. enlargement carcinoma, inflammation, T.B.,
fibroadenosis
2) Axillary artery aneurysm & vein thrombosis
3) Enlarged breast tail
4) Cystic hygroma & nerve tumours
2. Skin & subcutaneous tissue:
6) Epithelioma
3) Lipoma
1) Extra-breast
4) Melanoma
2) Sebaceous
5) Papilloma
cyst
3. Axillary walls:
1) Ribs cold abcess, metastasis, chondrosarcoma
2) Humerus osteoma, osteoclastoma, bone sarcoma
3) Scapula chondrosarcoma
4) Shoulder joint dislocation, effusion
5) Muscles fibroma or fibrosarcoma
Changes in the nipple and/or areolar
4. Carcinoma
1. Nipple retraction
5. Pagets disease
2. Congenital inversion
6. Eczema
3. Duct ectasia with
7. Mammary duct fistula
periductal fibrosis
Changes in breast size
1. Pregnancy
3. Giant fibroadenoma
4. Phylloides tumour
2. Sarcoma

1. Carcinoma
2. Benign hypertrophy

Breast Investigations
Although an accurate history and clinical examination are still the
most important methods of detecting breast disease, there are a
number of investigations that can assist in the diagnosis:
Breast Self-Examination A number of recent studies have
confirmed an improved prognosis of breast cancers found in

women who regularly practice breast self-examination (BSE),

because the lesion discovered at an earlier clinical stage. The
method should be taught in the physicians office and encouraged
uniformly.
Mammography: Soft-tissue radiagraph, dose of radiation is
approximately 0.1 Gy, and therefore mammography is a very safe
investigation.
Indications:
1. Screening for high-risk group.
2. Detect impalpable cancer breast.
3. Evaluate both breasts, the normal or involved areas.
4. Unusual localized breast pain.
Findings suggestive of malignancy:
1. Clustered pleomorphic micro-calcifications (> 4 mm )
2. Irregular masses.
3. Ill defined edge of the mass.
4. Enlarged L.N. in axilla.
5. Skin thickening.
6. Assymmetry.
Ultrasonography
Indications:
1. Useful in young women with dense breasts in whom
mammograms are difficult
2. Differentiation of solid or cystic breast masses
3. Localise impalpable breast lumps.
Biopsy: several types of biopsy are available.
1.Fine-needle aspiration: if the lesion is cystic, the mass usually
resolves when the fluid is completely aspirated.
2.Needle biopsy/cytology: Fine-needle aspiration cytology
(FNAC) is the least invasive technique for obtaining a cell
diagnosis for solid mass.
3.Core-Needle biopsy for large locally advanced lesions
4.Excisonal biopsy for palpable lesions.
5.Needle guided biopsy with mammography is performed by
excising the lesion after the radiologist places a localizing wire
in the breast to identify the site.
6.Stereotaxic biopsy uses computed mammographic equipment to
employ a core needle accurately to non-palpable lesions.

Benign cyst criteria:

1.Smooth wall
2.Clear fluid
3.No rapid filling
4.No residual mass after aspiration
5.No malignant cells in aspirate
Ductography demonstrates duct anatomy and pathology by
injection of radio-opaque contrast medium into a major lacteal
duct and taking a radiograph. It is a painful technique, rarely of
value except in certain obscure cases of discharge.

Abnormalities of Breast
Congenital abnormalities
Amazia Congenital absence of breast on one or both sides,
may be associated with pectoralis major sternal portion
absence (Polands syndrome).
Polymazia Accessory breasts and nipples have been
recorded in the axilla (the most frequent site), groin, buttock,
and thigh, i.e. at the milk line.
Physiological abnormalities
Mastitis of infants: On the third or fourth day of life, if the
breast of an infant is pressed lightly, a drop of colourless fluid
can be expressed; a few days later there is often a slight milky
secretion, which disappears during the third week. It is due to
stimulation of the fetal breast by maternal prolactin.
Diffuse hypertrophy of the breasts occurs in healthy girls at
puberty and, much less often, during the first pregnancy. The
breasts attain enormous dimensions, and may reach the knees
when the patient is sitting due to alteration in the normal
sensitivity of the breast to oestrogenic hormones. Treatment is
anti-oestrogens or by reduction mammoplasty.
Injuries of the breast
Haematoma particularly a resolving haematoma, gives rise to
a lump, it may lead to acute breast abscess. Treatment:
antibiotics & hot fomentation.
Traumatic fat necrosis may be acute or chronic, and usually
occurs in middle-aged women. Following a blow, painless
lump appears. Trauma fat necrosis liberate fatty acid +

calcium soap which invites foreign body reaction. This may

mimic a carcinoma. Treatment: excisional biopsy.

Abnormalities of Nipple
-

Athelia Absence of the nipple (rare) and usually

associated with amazia.
Supernumerary nipples occasionally occur along a line
extending from the anterior fold of the axilla to the fold of the
groin (the milk line).
Nipple retraction or inversion this may occur at puberty
or later in life. Retraction occurring at puberty is of unknown
aetiology, if is bilateral it may cause problems with breastfeeding, and infection can occur, especially during Lactation,
due to retention of secretions. Treatment is bimanual eversion,
and retraction may spontaneously resolve during pregnancy or
lactation. Mechanical suction devices may be used to evert the
nipple.
N.B.: A slit-like retraction of the nipple may be due to duct
ectasia and chronic periductal mastitis but circumferential
retraction (with or without an underlying lump) may indicate
an underlying carcinoma.
Cracked nipple may occur during lactation leading to
acute mastitis. To prevent this, the nipples and areolae should
be carefully washed, dried and lubricated with a little lanolin
during the last two months of pregnancy and lactation. If the
nipple becomes cracked during lactation, it should be rested
for 24-48 hours and the breast emptied with a breast pump.
Papilloma of the nipple has the same features of any
cutaneous papilloma and should be excised with a tiny disc of
skin.
Retention cyst of a gland of Montgomery these glands,
situated in the areola, secrete sebum and, if they are blocked,
sebaceous cyst forms.
Chancre of the nipple very rare condition, usually occurs
by infection from a syphilitic buccal ulcer in the mouth of the
partner, although it can be seen in a wet-nurse of a syphilitic
baby. The mother of such an infant is immune to reinfection
from her own child.
Eczema of the nipples is a rare condition and is bilateral.

Abnormal Discharge from the Nipple

Discharge can occur from one or more lactiferous ducts.
Pathological nipple discharge is persistent, spontaneous, and
unassociated with nursing.
Types & Aetiology
Clear, serous discharge may be physiological in a
parous woman or may be associated with a duct
papilloma or mammary dysplasia.
Bloodstained discharge may be caused by duct ectasia
or less commonly a duct papilloma or carcinoma.
Black or green discharge is usually due to duct ectasia
and its complications.
Pus discharge due to breast abscess.
Milk discharge due to Galactorrhea (bilateral).
N.B.: A duct papilloma is usually single and situated in one of the
larger lactiferous ducts and is sometimes associated with a cystic
swelling beneath the areola
Investigation:
Localization by zonal pressure.
Mammography to exclude an underlying impalpable mass.
Cytology may reveal malignant cells but -ve result doesnt
exclude carcinoma.
Management depends on the presence of a lump and on the
presence of blood in the discharge.
If a lump is present lumpectomy & histopathology.
If no lump from one duct Microdochectomy
from many ducts Cone excision of the major
ducts
Microdochectomy: Lacrimal probe is inserted into the duct from
which the discharge is emerging. Using a pair of fine-pointed
scissors, a triangular area is cut 1 mm away from the point of
entry of the probe. The whole specimen including the probe and
triangular area of skin is removed intact.
Cone excision of the major ducts: in case of unknown origin of
bleeding duct, or bleeding or discharge from multiple ducts. A
circumareolar incision is made and a cone of tissue is removed
with its apex just deep to the surface of the nipple and its base
on the pectoral fascia. The resulting defect is obliterated by a
series of pursestring sutures.

Infections & Inflammation

Acute and subacute infections
Bacterial mastitis is the commonest variety of mastitis. It is:
1. Associated with lactation in the majority of cases.
2. Associated with an Infected haematoma
3. Associated with periductal mastitis.
4. More commonly seen in smokers.
Aetiology: Mostly Staphylococcus aureus in the baby
nasopharynx.
Pathogenesis: ascending infection from cracked nipple may
initiate the mastitis, in many cases the lactiferous ducts will first
become blocked by epithelial debris leading to stasis, then
staphylococci cause clotting of milk and multiply in duct ampulla.
This theory is supported by the relatively high incidence of
mastitis + a retracted nipple in women.
Clinical features: The affected breast, or more usually a segment
of it, presents the classic signs of acute inflammation. Early on,
this is a generalised cellulitis but later an abscess will form.
Treatment:
During the cellulitic stage the patient should be treated with an
appropriate antibiotic, e.g. flucloxacillin, and the breast rested,
with feeding on the opposite side only. The infected breast should
be emptied of milk using a breast pump. Support of the breast,
local heat and analgesia will help relieve pain.
The breast should be incised and drained if the infection does not
resolve within 48 hours or if, after being emptied of milk, there is
an area of tense Induration or other evidence of an underlying
abscess.
N.B.: If an antibiotic without drainage of pus, an antibioma may
form. This is a large, sterile, brawny, oedematous swelling which
takes many weeks to resolve.
Types of Breast Abscess
Premammary Abscess: (Subareolar mastitis)
It is not a true mastitis but results from an infected sebaceous
gland or follicle of Montgomery, or from a furuncle on or near the
areola. Spontaneous discharge of pus is usual, but incision of a

subcutaneous abscess may be necessary. Incision of a premammary abscess may rarely be followed by a persistent purulent
discharge from a maimmilliferous fistula. Such a fistula
communicates with a lactiferous duct, and hence with the nipple.
Histology of the nipple shows squamous metaplasia of the
epithelium of all or of several of the ducts. Treatment is laying
open of all the tracks into the nipple and allowing healing by
granulation.
Intramammary Abscess (commonest)
It is a common complication of puerperium, in nullipara is a
complication of inverted nipples. The infection is due to
Staphylococcus aureus, affecting depressed, malformed and
cracked nipples.
It produces cellulitis in areolar tissue around the ducts with Fever
& malaise suppuration. The breast is first engorged & tender
then become firm tender area.
Treatment is not delayed until fluctuation. Engorged breasts
should be emptied by gentle manual expression, breast-feeding is
abandoned. Lactation can be suppressed with oral bromocriptine
though this can be avoided if antibiotics are administered in the
early stages of inflammation. If pus forms, large radial incision
over the affected segment should be performed under general
anaesthesia. Because the abscess is usually loculated, it is
essential to break down any septa with finger then drain should be
inserted.
Retromammary Abscess
A rare complication of osteotismyelitis of a rib, or tuberculous
infection of a rib, cartilage or extra-pleural glands may present as
an acute abscess near a costo-chondral junction under pectoralis
major muscle. Treatment entails drainage of the abscess by
Thomas incision and treatment of the primary focus.
Mastitis from milk engorgement
It is liable to occur at weaning time, and sometimes at early days
of lactation when one of the lactiferous ducts becomes blocked
with epithelial debris indurated & tender breast sector.
Mastitis of mumps is usually unilateral, and more common in
females.
Mondors disease
It is thrombophlebitis of the superficial (thoraco-epigastric) veins

of breast & anterior chest wall although it has also be encountered

in the arm.
The pathognomonic feature is a thrombosed subcutaneous cord,
usually attached to skin. When the skin over the breast is stretched
by raising the arm, a narrow, shallow subcutaneous groove
alongside the cord becomes apparent.
Differential diagnosis: lymphatic permeation from an occult breast
carcinoma. The only treatment required is restricted arm
movements then entire condition subsides within a few months
without recurrence, complications, or deformity.

Duct ectasia

(periductal mastitis =Plasma cell mastitis)

Pathology: This is a dilatation of the breast large ducts, associated

with periductal inflammation in the form of plasma cells
lymphocytes, and foamy histiocytes, epithelial cells & giant cells
(occur in middle aged women).
Pathogenesis theories: as pathogenesis is unclear
The first stage in the disorder is a dilatation in one or more
of the larger lactiferous ducts, which fill with a stagnant
brown or green secretion, it may discharge. These secretion
set up an irritant reaction in surrounding tissue periductal
mastitis or even abscess and fistula formation.. Fibrosis
eventually develops which may cause nipple retraction.
An alternative theory suggests that periductal Inflammation
is the primary condition, and anaerobic bacterial infection is
found in some cases.
Clinical features:
Nipple discharge (of any colour, but almost always watery)
Mastalgia may be associated with this condition.
Subareolar mass or abscess
Mammary duct fistula and/or nipple retractionthe
commonest symptoms.
Treatment: excision of all major ducts (Had-fields operation).

Benign Breast Disease

30 % of women will suffer from a benign breast disorder requiring
treatment at some time in their lives. The most common
symptoms are pain (47 %) and lump (35 %). The aim of treatment

is to exclude cancer and to treat any symptoms.

Classification:
Fibrocystic disease or ANDI (Aberrations of normal
development & involution) lumpy breasts, tenderness or
smooth lump
-Fibroadenoma
-Fibroadenomatosis
-Cysts
-Cyclical nodularity
Duct ectasia/periductal mastitis
-Abscesses
-Nipple discharge &
-Mammillary fistula
inversion
Epithelial hyperplasia
Pregnancy related
-Puerperal abscess
-Galactocoele
Congenital disorders
-Supernumary breasts/nipples
-Inverted nipple
Non-breast disorders
-Tietzes disease
-Sebaceous cysts and other skin conditions

Fibrocystic disease = Chronic cystic mastitis =

Fibroadenosis
=Aberrations of normal development and
involution (ANDI)
This term is used for a broad spectrum of benign breast changes.
The terminology is inadequate because the correlation between
clinical symptoms and histologic changes is poor.
Incidence: The breast undergoes changes throughout a womans
reproductive life (25-45). It can be unilateral or bilateral
Aetiology: Disturbances in breast physiology as:
1. Estrogen unopposed by progesterone
2. Prolactin
3. Abnormal response of breast to estrogen
Pathology:
Macroscopically, the affected areas of sectioned breast are white
or yellow and of rubbery consistency, but they never present the
gray stones and hard, gritty texture of a carcinoma.
Microscopically the disease consists essentially of four features:

 Cyst formation: Obstruction of ducts & lobules leads to

dilatation of ducts & acini. The lining epithelium may show
apocrine metaplasia.
Fibrosis: Fat & elastic tissue disappears and is replaced by
dense white fibrous trabeculae + in collagen tissue.
Papillomatosis & Sclerosing adenosis: Papillomatosis is a
proliferation of ductal cells in papillary pattern. Sclerosing
adenosis is a proliferation of acini in the lobules, which may
appear to have invaded the surrounding breast stroma
Epithelial Hyperplasia of epithelium lining the ducts and
acini may occur, with or without atypia.
Clinical presentations
Mastalgia (breast pain) occurs in two patterns:
1. Cyclic mastalgia correlates with the menstrual cycle and is
usually worst just prior to the menses.
2. Noncyclic mastalgia is commoner in peri- & postmenopausal women.
Breast lump is commonly a cyst or a fibroadenoma. Lumpiness
may be bilateral, commonly in the upper outer quadrant, or less
commonly confined to one quadrant of one breast.
Nipple discharge: clear serous, greenish or dark in colour.
Diagnosis by needle aspiration, mammography or
ultrasonography. No further therapy is necessary if the cyst disappears completely after aspiration and the fluid obtained is not
bloody.
Treatment
Treatment of lumpy breasts
If the clinician is confident that he not dealing with cancer, then
initially the woman can be offered firm reassurance. In most
cases supportive treatment, including local heat, a firm brassiere,
and occasionally diuretic tablets, may be of value.
Treatment of mastalgia:
For cyclical mastalgia initially, firm reassurance that the
symptoms are not associated with cancer will help most
women. Then planned treatments advised:
1. Exclude cancer
2. Reassure
3. Pain chart
4. Evening primrose oil s Danazol a Tamoxifen.

Oil of evening primrose, in adequate doses given over 3

months, will help more than half of these women. For those
with intractable symptoms, a prolactin inhibitor (danazol) may
be given. Very rarely an antioestrogen, e.g. tamoxifen or a
luteinizing hormone releasing hormone (LHRH) agonist, to
deprive the breast epithelium of oestrogenic drive.
For noncycical mastalgia it is important to exclude
extramammary causes such as chest wall pain. Treatment may
be with non-steroidal analgesics or by injection with local
anaesthetic of a trigger spot.

Cysts
These occur most commonly in the last decade of reproductive life
due to a nonintegrated involution of stroma & epithelium. They
are often multiple, may be bilateral, and can mimic malignancy.
Diagnosis Cysts cannot be clinically differentiated from
fibroadenomas unless aspiration is done and/or ultrasonography.
Treatment: A solitary cyst or small collection of cysts can be
aspirated. If they resolve completely, and if the fluid is not bloodstained, no further treatment is required. However 30 % will recur
and require further aspiration. If there is a residual lump, or if the
fluid is blood-stained, a local excision for histological diagnosis is
advisable.
Lymphatic cyst of the breast is a curiosity, and is akin to the more
common lymphatic cyst of the neck (cf. cystic lymphoma).
Hydatid cysts are found in the breasts in areas where this disease
is common.

Galactocele
It is rare, usually presents as a solitary, sub-areolar cyst, and
always dates from lactation. It contains milk, and in long-standing
cases its walls tend to calcify.

Benign Breast neoplasms

Classification of Benign neoplasms

 Connective tissue
Epithelial
-Neurofibroma
-Duct papilloma
-Lipoma
-Pure adenoma (very rare)
Mixed
-Fibroadenoma (including giant fibroadenoma)

Fibroadenoma

-Usually occurs in women during the 1835 year age period.

-They are usually single but may be multiple in the same breast.
Pathology:
Grossly, it is firm, rounded or oval, smooth, and freely
movable mass, no > 3 cm in diameter, well encapsulaed
tumour (not true neoplasm). The cut surface is solid, greywhite, bulging with a whorl-like pattern and slit-like spaces.
Microscopically: composed of 2 components glandular
epithelial units and fibrous tissue.
Types:
Pericanalicular fibroadenoma when the regular round or
oval glandular configuration is maintained, and surrounded
by fibrous tissue.
Intracanalicular fibroadenoma (a misnomer) when the
fibrous tissue invaginates into the glandular spaces appearing
within them.
Clinical picture:
It gives the sensation of a marble in the breast and rarely demonstrates retraction of the skin or dimpling.
Treatment:
Is excision or enucleation through a cosmetically appropriate
incision. However in a patient under 25 years with risk of
malignancy, they do FNAC/cytology before excision.
N.B.: Giant fibroadenomas (Benign Cystosarcoma) occur
occasionally during puberty. They are rapidly growing over 5 cm
in diameter, but are similar to smaller fibroadenomas and can be
enucleated through a submammary incision + breast
reconstruction. Metastases do not occur.

Duct papilloma

-Usually occurs in women between 35 and 50.

-It may be unilateral or bilateral.

-It can arise in large or small ducts, in two or more ducts of the
same breast.
-It is a pre cancerous condition papillary carcinoma.
Pathology:
The duct of origin is distended by papilloma, which has a stalk,
and is sessile or pedunculated. There is bloody nipple discharge on
touch and papilloma may be palpable in a sub-areolar location but
its diameter rarely exceeds 3 cm.
Microscopically: arborescent intracystic papillae composed of
connective tissue cores surrounded by epithelium & myoepithelial
cells.
Clinical features.
Dark bloody nipple discharge.
On examination: a cystic swelling can be felt beneath the
areola, pressure upon it will cause a discharge from the
affected duct on the nipple.
Investigation:
Mammography.

Benzidine test.

Treatment:
Microdochectomy: removal of affected duct with safe margin (2.5
cm).
Adenoma
True mamary adenomas do occur, but are rare. They are usually
small (<0.5 cm in diameter), and are discovered by
mammography.

Cystosarcoma Phylloides

Serocystic disease of

Brodie
Occur in women over the age of 40. Commonly a unilateral mass
Pathology:
Present as a solid fleshy large mass, with ulceration of the
overlying skin occurs due to pressure necrosis. They are freely
mobile on the chest wall.
Histologically there is a resemblance to a fibroadenoma but,
despite the name of cystosarcoma phyllodes, they are rarely cystic
and even more rarely develop features of a sarcomatous tumour.

Metastasis via the blood stream.

Treatment for the benign type is enucleation in very young women
or wide local excision. Massive tumours, recurrent tumours and
those of the malignant type will require total mastectomy
combined with axillary node sample.
Clinical, cytological or radiological examination, needle
biopsy,frozen section histology for diagnosis of malignancy.

Breast Carcinoma
Etiology: unknown but Genetic linkage studies revealed
abnormality in chromosome 17 short arm, or mutations in p53
tumour suppressor gene in women with cancer family history.
N.B.: Breast-feeding & having the 1st child at early age is
protective especially if associated with late menarche and early
menopause.
Incidence: Cancer of the breast represents 27% of all female
cancers. The most common occurrence is between 40 and 60
years of age. It occurs commonly in the Western world,
accounting for 3-5 % of deaths, yet is a rare tumour in Japan. In
developing countries it accounts for 1-3 % of deaths. Only 1% of
patients with breast cancer are male.
Predisposing factors:
degree
1. Nullipara & non-lactating.
5. Early menarche & late
2. Contraceptive pills
menopause
3. Contralateral breast cancer
6. Irradiation
4. Family history of First7. Family history positive for breast carcinoma.
Risk factors:
- First-degree relative with premenopausal breast carcinoma has 3
times higher risk
- First-degree relative with bilateral breast carcinoma has 5 times
higher risk.
- First-degree relative with bilateral premenopausal breast carcinoma
has 8 times higher risk.
- History of chronic cystic mastitis with atypical hyperplasia is 3-6
times high risk.
- Contralateral breast cancer: adenocarcinoma2 times, lobular
carcinoma25-50%

- High socioeconomic status carries a high risk.

- Western hemisphere have greater risk than those of eastern
hemisphere.
- Nulliparous women have 2-3 times higher risk.
- Breast cancer risk Women with wet cerumen > women with dry
cerumen.
- Estrogen compounds have an association with endometrial carcinoma.
- Postmenopausal breast cancer is more common in obese, due to
increased conversion of steroid hormones to oestradiol in body fat.
Spread
Local spread invades other portions of breast, skin,
penetrate pectoral muscles, and chest wall.
Lymphatic spread metastasis occurs primarily to axillary
and internal mammary L.N.s .
Blood spread skeletal metastases to lumbar vertebrae,
femurs, thoracic vertebrae, ribs and skull; they are generally
osteolytic. Metastases may also occur in liver, lung and brain,
adrenal glands and ovaries.
Classification: according to the ability of a cell type to
metastasize

Noninvasive breast cancer

situ
1. Ductal carcinoma in
3. Pagets disease
situ
2. Lobular carcinoma in

Invasive breast cancer

(1) Favorable histologic types (associated with an 85% 5-year
survival rate)
(2) Papillary carcinoma
(1) Tubular carcinoma
(3) Colloid or mucinous carcinoma
(2) Less favorable lesions
(2) Invasive lobular cancer
(1) Medullary cancer
(3) Invasive ductal cancer is the most common histologic type
and constitutes over half of breast cancers.
(3) Least favorable histologic types
(2) Invasive ductal lesions
(1) Inflammatory breast
cancer
Another Classification: according to origin of cancer
Pagets disease of the Nipple
Ductal origin carcinoma

1.Non-infiltrating
(3) Comedo

id
(2) Cribriform

(1) S
ol

2.Infiltrating
(3) Papillary carcinoma
(1) Medullary cancer
(4) Tubular carcinoma
(2) Comedo carcinoma
(5) Colloid or mucinous carcinoma
Lobular origin carcinoma
1. Non-infiltrating
2. Infiltrating
Pathology
Noninvasive breast cancer (10% of all breast cancer)
good Prognosis
Ductal carcinoma in situ (DCIS) is confined to ductal cells,
without invasion of the basement membrane, usually preceded by
intraductal papilloma.
Microscopically: It is differentiated into 3 morphological types:
1. Solid carcinoma: the ducts show a solid growth of large
pleomorphic cells with abundant mitotic activity.
2. Comedo carcinoma: as solid type but with necrosis at duct
center.
3. Cribiform carcinoma
Lobular carcinoma in situ (LCIS) is most commonly found
incidentally. The risk of invasive cancer is in both breasts.
Microscopically, the acini in the lobules are distended and filled
by relatively uniform, round, small to medium-sized cells with
round and normochromatic nuclei. In general, atypia,
pleomorphism, mitotic activity and necrosis are minimal or
absent.
Pagets disease is an uncommon lesion involving the nipple.
Histologically vacuolated cells (Pagets cells) are seen in the
nipple epidermis, round cell infilteration, hypertrophy of all layers
of epthelium, and result in an eczematous dermatitis of the nipple.
The nipple is eroded slowly and eventually disappears. It is
associated with an invasive component in the underlying ducts.
Invasive breast cancer
Medullary carcinoma is characterized by lymphocytic infiltration.
It presents as a relatively large, soft, well-circumscribed tumour
up to 10 cm in diameter. Microscpically, it is composed of large,
pleomorphic cells growing in so1id, syncytium-like anastomosing
masses separated by a delicate stroma showing a dense lymphoplasma cell infiltrate.

Invasive duct (schirrhous) carcinoma Grossly: firm to hard mass,

that is poorly circumscribed, cuts with a gritty sensation and
shows trabeculae radiating through the surrounding fat. Nipple is
retracted. Microscopically, the tumour can grow in diffuse sheets,
rests or cords, with or without glandular differentiation. The
tumour cells are large, pleomorphic with increased mitotic activity
in dense vascular stroma.
Invasive lobular carcinoma it tends to be multifocal and bilateral.
It appears as a rubbery, poorly circumscribed mass.
Microscopically, it is characterized by presence of small uniform
tumour cells growing singly separated by abundant dense stroma.
Tubular carcinoma (rare) it is characterized by a haphazard
proliferation of angulated or elongated tubules within a reactiveappearing, fibroblastic stroma. It resembles well-differentiated
adenocarcinoma. It carries a better prognosis compared to an
ordinary infiltrating duct carcinoma.
Mucinous (colloid) carcinoma is a carcinoma that contains large
amounts of extracellular mucous lakes, populated by clusters of
tumour cells, and displaying a gelatinous gross appearance. It is
regarded as a low-grade variant of mammary carcinoma.
Inflammatory carcinoma (mastitis carcinomatosa) (rare) it carries
the worst prognosis among breast carcinomas, it occurs during
pregnancy or lactation. There is pain, tenderness, firmness and
enlargement of the breast. Breast skin is red, warm, oedematous
and thickened. The oedema is accompanied by peau dorange.
These symptoms are due to lymph stasis accompanying diffuse
dermal lymphatic involvement.
Clinical presentation
Occult presentation
Patient C/o S & S of metastasis, eg. cachexia, bone pain,
pathological fractures, cough, haemoptysis, jaundice, ascitis.
Early Frank presentation
General ve.
Local
- Swelling lump: painless or painful (mastitis
carcinomatosa), slowly (schirrhous) or rapidly (medullary)
progressive
- Pain-ve
- Disturbance of function in the form of bleeding per nipple
Late Frank presentation
General
Cachexia, jaundice, enlarged supra-clavicular L.N., bone

pain and swelling, ascitis, nodules in liver, nodules in the

umbilicus, P.V nodules in douglus pouch.
Local
- Wide Direct spread
- L.N the axillary L.Ns. enlarged, hard, fixed &
supraclavicular L.N. might be enlarged.
- Skin manifestations of carcinoma.
Skin manifestations of cancer breast
Nipple Retracted due to infiltration of milk duct. Protruding
usually in medullary carcinoma. Ulcerated & cracked in Paget.
Areola Eczema, Florid red, raised, eroded in paget disease of the
breast
Skin proper
1. Dimpling & buckering due to infilteration of coopers
ligament. (earliest sign)
2. Peau de orange due to obstruction of deep, superficial
lymphatics so lymphoedema of the skin occurs except at the
site of the hair follicules & sweat glands.
3. Skin nodules due to retrograde lymphatic spread it becomes
thick pigmented.
4. Fungation, ulceration
5. Cancer en cuirasse due to obstruction of the deep lymphatics &
infilteration of the skin with malignant cells which becomes
thick leathery pigmented.
6. Brawny edema due to obstruction of lymph. vessels, removal
of lymphatics or obstruction of axillary vein.
To asses Pt. e cancer breast comment On:
1. Breast
2. Axilla.
3. Abdomen.
4. P.V.
Diagnosis
Self-examination: Monthly breast self-examination is
recommended, ideally just after the menses.
Physical examination by a physician is imperative to
supplement breast self-examination and radiographic studies.
Mammography reveals breast architecture.
Suspicious signs of malignancy are asymmetry, skin thickening,
irregular masses, or architectural distortions. Clustered
pleomorphic microcalcifications may also indicate breast cancer.

 Ultrasound is most useful in determining whether a mass

(palpable or non-palpable) is solid or cystic.
Biopsy Several types of biopsies are available:
Aspiration biopsy:
- If the lesion is cystic, the mass usually resolves when the
fluid is completely aspirated.
- If the lesion is solid, a fine-needle aspirate can be used to
extract cells, which can be examined cytologically.
Core needle biopsy for large, locally advanced lesions.
Excisional biopsy for palpable lesions, is most common.
For non-palpable mammographic abnormalities, two
approaches to biopsy are available.
- A needle-guided biopsy is performed by excising the lesion
after the radiologist places a localizing wire in the breast to
identify the site
- A stereotaxic biopsy: uses computed mammographic
equipment to employ a core needle accurately to sample
nonpalpable lesions.
Determination of distant metastasis
(1) Liver function tests, alkaline phosphatase and gammaglutamine transaminase (gamma GT) are sensitive in
detecting hepatic metastasis.
(2) A chest radiograph detects pulmonary parenchymal or
bone metastasis.
(3) Bone scan if nodes +ve or if nodes ve but the patient has
symptoms of bone pain (all stages II, Ill, and IV patients).
(4) Mammogram, radioisotope or CT scan.
(5) Pathologic examination. a pathological sample of the
suspected metastasis must be obtained to prove the
diagnosis.
Criteria for inoperability as defined by Haagensen
1. Extensive edema of the breast
2. Satellite nodules of carcinoma
3. Inflammatory carcinoma
4. Supraclavicular metastasis
5. Arm edema
6. Distant metastasis
7. A parasternal tumor, indicating spread to the internal
mammary nodes
Screening
Self-examination programs: Avoids expensive and toxic treatment

of advanced cancer.
Mammography: of women > age of 50. Breast screening depends
upon mammography. Features of carcinoma seen on
mammography are:
A solid lesion with ill-defined edges or stellate configuration
Asymmetry (of density, vascularity or stromal architecture)
True micro-calcification
Distortion of the skin or the outline of the breast
Increased skin thickness
A single, dilated duct
A large lesion of nodular outline
Changes on serial mammography
True micro-calcification is a particular feature of early tumours
which are undetected by clinical examination.

Treatment
Aim of treatment is cure & control of local disease, conservation
of local form and function, prevention or delay of the occurrence
of distant metastases.
Surgery
Lumpectomy is defined as removal of the primary lesion,
with clear gross margins around the tumor + histologically
free margins.
Contraindications to Lumpectomy
1.Large tumor size > 3-5 cm
2.Bilateral, multifocal disease or diffuse malignant
microcalcifications
3.Retroareolar or nipple lesions (Paget disease)
4.Inability to participate in needed follow-up
Radical mastectomy: Whole breast + nipple & areola + skin
overlying the tumour + Fat & fascia from clavicle to rectus
abdominis, and from sternum to latissimus dorsi + pectoralis
major + Pectoralis minor + Clavipectoral Fascia + LNs of
axilla + Costocoracoid membrane
Modified radical mastectomy (Pateys operation) as radical +
Preservation of pectoralis minor muscle
Halsted radical mastectomy excision of the breast plus
axillary lymph nodes, and both pectoralis major and
pectoralis minor muscles is no longer indicated as it causes
excessive morbidity with no survival benefit.
Simple mastectomy includes removal of all breast tissue,
including the nipple & areola for noninvasive breast cancer +

level I axillary node dissection.

Quadrantectomy (QUART) removing segment of breast
containing the tumour + axillary nodes dissection +
radiotherapy
Radiation therapy
Radiation therapy involves whole breast radiation (4500-6000
rads), with a boost to the tumor site (2000 rads). It is deep X-ray
(cobalt or linear accelerator).
Side effects: local burn, interstitial pulmonary fibroses.
Indications:
1. Irradiation with lumpectomy and axillary dissection with
stage I & II.
2. Radiation as a palliative therapy in bone or CNS metastases.
3. Radiation as adjuvant therapy after mastectomy in high-risk
patients.
4. Radiation to high-risk patients with extensive carcinoma in
Situ.
Chemotherapy or hormone therapy
Adjuvant therapy for occult distant disease in stage I
& II, patients with positive axillary node involvement, high-risk
node-negative patients.
Chemotherapy with a triple-drug regimen involves 6-month
cycles of cyclophosphamide, methotrexate, and fluorouracil
(or cyclophosphamide, adriamycin, and fluorouracil). Side
effects: Bone marrow suppression, Carcinogenesis
(cyclophosphamide cancer bladder and leukemia)
Hormone therapy uses tamoxifen (antiestrogen) for 2-5
years for postmenopausal patients.
Neo-adjuvant therapy (chemotherapy given before
surgery)
In stage III inoperable patients. Several cycles of chemotherapy
are given to decrease bulk of tumour. Then undergo surgery
followed by further chemotherapy and, sometimes, radiation
therapy.
Recurrent & metastatic disease treatment.
Hormone therapy is based on the estrogen receptor status
of the tumor.
(1) In estrogen receptor positive patients: Tamoxifen
(antiestrogen) drug is used in both pre- and
postmenopausal patients.
(2) Estrogen receptor positive patients with recurrent disease:

Premenopausal patients oophorectomy, antiestrogen

therapy, or both. Postmenopausal patients antiestrogen
therapy is used.
Chemotherapy is used in estrogen receptor negative
patients or who do not respond to hormone therapy. Cyclophosphamide, methotrexate, fluorouracil, and doxorubicin are
usually used in these cases.
Postoperative care
Immediate care includes both mobilization of the arm to prevent
limitation of motion and psychological support for the return to
normal living.
Follow-up (throughout life) to detect local and distant recurrences.
(1) Frequent physical examination (every 3 months in 1st year,
every 6 months thereafter)
(2) Monthly breast self-examination
(3) Annual mammography, chest radiograph, and liver function
studies

Treatment according to stages

STAGE 0 -Lumpectomy + axillary dissection + radiotherapy
Carcinoma -Or Total mastectomy + axillary dissection + Breast reconstruction
in situ
STAGE I
-Lumpectomy + axillary dissection + radiotherapy (5000 cGy)
-Or Modified radical mastectomy + radiotherapy
-Adjuvant Chemotherapy or Hormonal therapy.
STAGE II
-As stage I
-Or radical mastectomy
STAGE III -Radical mastectomy + Neo-adjuvant chemotherapy
-Premenopausal oophorectomy, antiestrogen or chemotherapy.
-Postmenopausal antiestrogen or chemotherapy.
STAGE IV -Palliative simple mastectomy
-Palliative radiation
-Hormonal therapy (+ve estrogen receptors) or Chemotherapy
Breast reconstruction
Techniques involve the use of tissue expanders to enlarge
the skin flap and space available for a prosthetic silicone gel
implant. Pedicled or free muscle and/or muscle and skin
(myocutaneous) flaps can be used to simulate breast tissue if
the skin at the mastectomy site is poor. Musculocutaneous is
either from latissimus dorsi muscle (an LD flap) or the
contralateral transversus abdominis muscle (a TRAM flap).

External breast prostheses which fit within the brazier may

also be recommended.
Nipple reconstruction: In a second (or third) procedure the
nipple and areolar complex can be reconstructed under a local
anaesthetic. To achieve symmetry, the opposite breast
occasionally requires a cosmetic procedure such as reduction
mammoplasty.
Edema of the arm
Occurs in approximately 10% of women who have had axillary
lymphadenectomy and mastectomy. This condition may be aggravated by
radiation therapy to axilla.
Treatment
Minor skin infections should receive early treatment with antibiotics.
Chronic edema can be treated with an elastic sleeve or pneumatic compression device.
Complications Chronic edema lasting >10 years can lead to lymphangiosarcoma in the affected arm.

Male Breast
Gynaecomastia is painless enlargement of male breast, due to
glandular tissue.
Etiology:
Idiopathic: Hypertrophy of the male breast may be
unilateral or bilateral. Breasts enlarge at puberty, and shows
the characteristics of female breasts.
Hormonal: Enlargement of breasts often accompany stilboestrol therapy for prostate cancer. Also occur as a result of
testis teratoma, in anorchism, and after castration. Rarely due
to ectopic hormonal production in bronchial carcinoma and in
adrenal and pituitary disease.
Associated with leprosy: This is possibly because of
bilateral testicular atrophy, which is a frequent accompaniment
of leprosy (Bowesman).
Associated with liver failure: Gynaecomastia sometimes
occurs in patients with cirrhosis due to failure of the liver to
metabolise oestrogens.
Klinefelters syndrome: a sex chromosome anomaly having
XXY trisomy.
Drugs such as dmetidine. digitalis and spironolactone.

Treatment. Provided the patient is healthy and comparatively

young, reassurance may be sufficient. If not mastectomy with
preservation of the areola and nipple can be performed.
Carcinoma of male breast
Accounts for 1 % of all cases.
Clinical picture: gynaecomastia and excess endogenous or
exogenous oestrogen, present as a lump.
Treatment: Stage for stage the treatment is the same as for
carcinoma in the female and prognosis depends upon stage at
presentation. Adequate local excision, because of the small size of
the breast, Halsted mastectomy is done. Castration is done for
endocrine control.
RARE BREAST TUMOURS
Lipoma is very rare.
Sarcoma is usually of the spindle-cell variety, it is 0.5 % of
malignant tumours of the breast. Sarcoma tends to occur in
younger women between the ages of 30 and 40. Some of these
growths arise in an intracanalicular flbroadenoma or may follow
previous radiotherapy, e.g. for Hodgkins lymphoma many years
previously. It may be Impossible to distinguish clinically a
sarcoma of the breast from a medullary carcinoma, but areas of
cystic degeneration suggest a sarcoma and, on incising the
neoplasm. it is characteristically pale and friable.
Treatment is by simple mastectomy followed by radiotherapy. The
prognosis depends on the stage and histological type.
Metastases rarely present.