THE THE BREASTBREAST

ByByProf. Dr. Mohamad Prof. Dr. Mohamad

YahiaYahiaProfessor of General SurgeryProfessor of General SurgeryZagazig Faculty of MedicineZagazig Faculty of Medicine

SURGICAL ANATOMYSURGICAL ANATOMY The breast consists of following parts:The breast consists of following parts:1- The mammary gland.1- The mammary gland.2- The superficial fascia.2- The superficial fascia.3- The overlying skin with areola and 3- The overlying skin with areola and

nipple.nipple.

The mammary glandThe mammary gland lies in the superficial lies in the superficial fascia, it is modified skin gland differ from fascia, it is modified skin gland differ from other glands in the body being it doesn't have other glands in the body being it doesn't have a capsule and not enclosed in a sheath of a capsule and not enclosed in a sheath of fascia. It is formed of 16-20 lobes each lobe is fascia. It is formed of 16-20 lobes each lobe is divided into lobules, the lobules are separated divided into lobules, the lobules are separated by septa of fibrous tissue attached from the by septa of fibrous tissue attached from the fascia of the chest wall to the subcutaneous fascia of the chest wall to the subcutaneous tissue "tissue "Cooper`s Lig". ".

The mammary glandThe mammary gland lies in the superficial lies in the superficial fascia, it is modified skin gland differ from fascia, it is modified skin gland differ from other glands in the body being it doesn't have other glands in the body being it doesn't have a capsule and not enclosed in a sheath of a capsule and not enclosed in a sheath of fascia. It is formed of 16-20 lobes each lobe is fascia. It is formed of 16-20 lobes each lobe is divided into lobules, the lobules are separated divided into lobules, the lobules are separated by septa of fibrous tissue attached from the by septa of fibrous tissue attached from the fascia of the chest wall to the subcutaneous fascia of the chest wall to the subcutaneous tissue "tissue "Cooper`s Lig". ".

Thus, the breast is divided into number of Thus, the breast is divided into number of fascial compartment; each lobe pours its secretion fascial compartment; each lobe pours its secretion into lactiferous duct. All the lactiferous ducts into lactiferous duct. All the lactiferous ducts converge upon the nipple and under the areola, converge upon the nipple and under the areola, every lactiferous duct enlarges to form lactiferous every lactiferous duct enlarges to form lactiferous sinus and then becomes narrow again to open on sinus and then becomes narrow again to open on summit of the nipple. The whole gland extends summit of the nipple. The whole gland extends upwards to 2ry rib, downwards to six costal upwards to 2ry rib, downwards to six costal cartilage medially to edge of the sternum, laterally cartilage medially to edge of the sternum, laterally to mid-axillary line. The nipple is a conical to mid-axillary line. The nipple is a conical projection placed usually over 4th intercostal space. projection placed usually over 4th intercostal space. It is surrounded by areola which is circular area of It is surrounded by areola which is circular area of pigmented skin. pigmented skin.

Blood supply of the Blood supply of the breast:breast:

A.A. Arterial Arterial supplysupply1)1) Superior thoracic artery "from the first part Superior thoracic artery "from the first part

of axillary artery".of axillary artery".2)2) Lateral and acromiothoracic arteries "from Lateral and acromiothoracic arteries "from

the second part of axillary artery". the second part of axillary artery". These two vessels supply the lateral aspect of These two vessels supply the lateral aspect of

the breast.the breast.3)3) Perforating branches of intercostal arteries.Perforating branches of intercostal arteries.4)4) Perforating branch of internal mammary Perforating branch of internal mammary

artery.artery.These two vessels supply the medial aspect of These two vessels supply the medial aspect of

the breast.the breast.

MedialLateral

B.B. Venous supply: Venous supply: Venous return Venous return simply follow the arteries.simply follow the arteries.

The lymph drainage of the breast, as with any The lymph drainage of the breast, as with any other organ follows pathway of its blood supply other organ follows pathway of its blood supply and therefore it travels:and therefore it travels:

C.C. Lymphatic drainageLymphatic drainage

1-Along tributaries of the axillary vessels to 1-Along tributaries of the axillary vessels to axillary L.N.S.axillary L.N.S.

2-Along tributaries of internal thoracic vessels 2-Along tributaries of internal thoracic vessels piercing pectoralis major to traverse each piercing pectoralis major to traverse each intercostal space to L.N.S. along the internal intercostal space to L.N.S. along the internal mammary chain.mammary chain.

There are two main lymphatic plexuses:There are two main lymphatic plexuses:Lymphatic plexusLymphatic plexus

Sub-areolar plexus of Sappy, for superficial Sub-areolar plexus of Sappy, for superficial parts of the breast.parts of the breast.

Pectoral plexus on the pectoral fascia for Pectoral plexus on the pectoral fascia for deep parts of the breast. deep parts of the breast.

Lymphatics of the breast do not cross the Lymphatics of the breast do not cross the midline but cross the diaphragm, so lymphatic midline but cross the diaphragm, so lymphatic spread from the lower medial part of the spread from the lower medial part of the breast can spread through lymphatics of the breast can spread through lymphatics of the liver into falciform ligament forming 2ry liver into falciform ligament forming 2ry umbilical nodule which can be occur also from umbilical nodule which can be occur also from lymphatics though the posterior rectus sheath.lymphatics though the posterior rectus sheath.

1.1. Anterior group" Pectoral": along the lower border of Anterior group" Pectoral": along the lower border of pectoralis M. It drains the whole chest wall, upper pectoralis M. It drains the whole chest wall, upper abdomen down to umbilicus.abdomen down to umbilicus.

2.2. Posterior group" Subscapular": closely related to Posterior group" Subscapular": closely related to subscapular V. It drains the back to iliac crest. subscapular V. It drains the back to iliac crest.

3.3. Lateral group" humeral": along side the axillary Lateral group" humeral": along side the axillary vein. It drains the upper limb.vein. It drains the upper limb.

4.4. Central group: In floor of the axilla. It drains the Central group: In floor of the axilla. It drains the three upper groupsthree upper groups

5.5. Apical group" infraclavicular": immediately behind Apical group" infraclavicular": immediately behind the clavicle.the clavicle.

6.6. It drains the center group.It drains the center group.

Axillary lymph Axillary lymph notesnotes

1.1. Abscess of the breast should be open by a radial Abscess of the breast should be open by a radial incision to avoid cutting across the lactiferous ducts.incision to avoid cutting across the lactiferous ducts.

2.2. Retraction in relation to cancer of the breast:Retraction in relation to cancer of the breast:

Some surgical clinical important Some surgical clinical important pointspoints

Retraction of the skin "dimpling" due to invasion of Retraction of the skin "dimpling" due to invasion of Cooper’s ligaments.Cooper’s ligaments.

Retraction of the nipple due to extension of the Retraction of the nipple due to extension of the growth along the main milk ducts with fibrosis growth along the main milk ducts with fibrosis leading to indrawing of the nipple.leading to indrawing of the nipple.

Peau d`orange: The pits of hair follicles appear to be Peau d`orange: The pits of hair follicles appear to be retracted beneath the level of the surrounding skin. retracted beneath the level of the surrounding skin. It is due to blockage of lymphatics draining the skin It is due to blockage of lymphatics draining the skin leading to edema of the skin.leading to edema of the skin.

1.1. MammographyMammography::Investigation of the breastInvestigation of the breast

Soft tissue mammography.Soft tissue mammography. Xero mammography.Xero mammography.

Mammography is the only reliable means Mammography is the only reliable means of detecting breast cancer before a mass of detecting breast cancer before a mass can be palpated.can be palpated.

The principle of soft tissue mammography is The principle of soft tissue mammography is based on detecting a difference in radiographic based on detecting a difference in radiographic densities between the normal beast and cancer densities between the normal beast and cancer containing area. Carcinoma tends to be denser containing area. Carcinoma tends to be denser than normal tissues and show irregular outlines than normal tissues and show irregular outlines with fine calcified spots. with fine calcified spots.

Indications of mammographyIndications of mammography1.1. To evaluate the opposite breast if carcinoma To evaluate the opposite breast if carcinoma

is diagnosed in one breast.is diagnosed in one breast.2.2. To evaluate doubtful masses in fatty breast.To evaluate doubtful masses in fatty breast.3.3. To screen a selected group of women with To screen a selected group of women with

high risk factor for developing cancer breast.high risk factor for developing cancer breast.BUTBUT mammography is inappropriate for mammography is inappropriate for

patient under the age of 35 years old for two patient under the age of 35 years old for two reasons: reasons: 1.1. Incidence of breast cancer is low.Incidence of breast cancer is low.2.2. The normal breast is too dense in young The normal breast is too dense in young

female to permit sufficient diagnostic details.female to permit sufficient diagnostic details.

UltrasonographyUltrasonography It is useful in young women with dense It is useful in young women with dense

breasts in whom mammograms are difficult to breasts in whom mammograms are difficult to interpret. It is helpful in differentiating solid interpret. It is helpful in differentiating solid from cystic swelling. It can also used to locate from cystic swelling. It can also used to locate impalpable breast lumps.impalpable breast lumps.

Galactography Galactography Soft tissue X-rays combined with injection Soft tissue X-rays combined with injection

of radio-opaque material into a major duct, of radio-opaque material into a major duct, specially used in demonstration of duct tumor.specially used in demonstration of duct tumor.

ThermographyThermography A technique by which the heat emission A technique by which the heat emission

from the surface of the breast in form of infra-from the surface of the breast in form of infra-red radiation can be recorded, as the skin over red radiation can be recorded, as the skin over malignant tumor of breast is usually warmer malignant tumor of breast is usually warmer than surrounding, but infection may give false than surrounding, but infection may give false +ve.+ve.

Magnetic resonance imaging Magnetic resonance imaging

It can be useful to distinguish scar from It can be useful to distinguish scar from

recurrence in women who have had recurrence in women who have had

previous breast conservation therapy for previous breast conservation therapy for

cancer. It is gold standard for imaging the cancer. It is gold standard for imaging the

breasts of women with implants.breasts of women with implants.

Biopsy and Biopsy and cytology cytology A-A- Trucut or Trucut or corecut biopsy may be used biopsy may be used

under local anesthesia. under local anesthesia.

B-B- Fine needle aspiration cytology "Fine needle aspiration cytology "FNAC" " is the least invasive and more accurate if is the least invasive and more accurate if both operator and cytologist are both operator and cytologist are experienced.experienced.

C-C- Open biopsy (excisional or incisional).Open biopsy (excisional or incisional).

Triple assessment Triple assessment It is combination of clinical assessment, radiological It is combination of clinical assessment, radiological imaging and a tissue sample taken for either imaging and a tissue sample taken for either cytological or histological analysiscytological or histological analysis

Clinical Clinical Imaging Imaging PathologyPathology

Age Age

Examination Examination US US Mammography Mammography

FNAC FNAC CorecutCorecut

Triple assessment Triple assessment

THE NIPPLETHE NIPPLE1.1. Athelia:Athelia: absence of nipple "rare". absence of nipple "rare".2.2. Polythelia:Polythelia: multiple nipples along line multiple nipples along line

extended from ant. fold of axilla to groin “extended from ant. fold of axilla to groin “milkline”.”.

3.3. Fissure:Fissure: it is cracked nipple, occurs during it is cracked nipple, occurs during lactation must probably due to lack of lactation must probably due to lack of cleanliness which lead to maceration and cleanliness which lead to maceration and falling the superficial layers epithelium and falling the superficial layers epithelium and sucking becomes painful.sucking becomes painful.

Treatment: Cleaning with boric acid lotion keeping it dry. Evacuate the milk with breast pump.

4.4. RetractionRetraction:: Congenital retraction.Congenital retraction. Remote simple retractionRemote simple retraction occurs occurs

at puberty, it is simple inversion, at puberty, it is simple inversion, unknown etiology, bilateral in 25% unknown etiology, bilateral in 25% of cases. of cases. Treatment:Treatment: drawing out drawing out the nipple between finger and the nipple between finger and thumb daily for three weeks thumb daily for three weeks during and sonly often puberty.during and sonly often puberty.

Recent retraction:Recent retraction: Usually Usually accompanied with scirrhous accompanied with scirrhous carcinoma occurs at womanhood.carcinoma occurs at womanhood.

5- Nipple discharge5- Nipple discharge

a- Clear, serous a- Clear, serous discharge discharge Physiological "early pregnancy".Physiological "early pregnancy".Mammary dysplasia.Mammary dysplasia.

b-b- Blood stained Blood stained discharge discharge Intra ductal papilloma.Intra ductal papilloma.Intra ductal carcinoma. Intra ductal carcinoma. Duct ectasia.Duct ectasia.

c-c- Black or brownish greenBlack or brownish greenMammary dysplasia with cyst.Mammary dysplasia with cyst.Duct ectasia.Duct ectasia.

d-d- MilkMilkFollowing lactation.Following lactation.Galactocele.Galactocele.Increase in secretion of pituitary prolactin.Increase in secretion of pituitary prolactin.Contraceptive pills.Contraceptive pills.

e-e- PurulentPurulentBreast abscess.Breast abscess.Fistula.Fistula.

The most common cases The most common cases are:are:

1.1. Duct papilloma.Duct papilloma.2.2. Mammary fistula.Mammary fistula.3.3. Duct ectasia.Duct ectasia.4.4. Mammary dysplasia.Mammary dysplasia.5.5. Paget’s disease.Paget’s disease.

Associated Associated with lump with lump

LumpectomyLumpectomy++

biopsy biopsy

No lumpNo lump

Treatment of abnormal dischargeTreatment of abnormal discharge

From one From one ductduct

MicrodochectomyMicrodochectomy

From many From many ductsducts

HB +veHB +ve

Over Over 4040

HB –veHB –ve

under under 4040

More than one ductMore than one duct

Observe and repeat Observe and repeat occult blood test occult blood test

periodically periodically

Simple mastectomy Simple mastectomy + biopsy+ biopsy

1.1. Discharge disappearsDischarge disappears2.2. Localized to one duct: Localized to one duct:

Microdochectomy.Microdochectomy.3.3. Lump appears: lumpectomy.Lump appears: lumpectomy.

PAGET'S DISEASEPAGET'S DISEASE It is persistent eczema like It is persistent eczema like

condition usually occurs in patient condition usually occurs in patient over 50 years and, doesn't respond over 50 years and, doesn't respond to treatment. The disease started to treatment. The disease started as eczema of nipple which is as eczema of nipple which is followed by mass in underlying followed by mass in underlying tissue, the eczematous area looks tissue, the eczematous area looks bright red, it may moist or dry and bright red, it may moist or dry and scaly.scaly.

The mass develops 2-10 years after The mass develops 2-10 years after appearance of eczema and it proves to be appearance of eczema and it proves to be carcinoma of the breast, accepted theory is that carcinoma of the breast, accepted theory is that the disease started as intraductal carcinoma the disease started as intraductal carcinoma which spread in two directions: one to the skin which spread in two directions: one to the skin of nipple → eczema and other to the breast of nipple → eczema and other to the breast tissue → mass.tissue → mass.

Microscopic features includes: hypertrophy Microscopic features includes: hypertrophy of epidermis which becomes thick Paget cells of epidermis which becomes thick Paget cells which are large, clear and vacuolated and which are large, clear and vacuolated and round, plasma cells in sub epidermis round, plasma cells in sub epidermis

TreatmentTreatment radical mastectomy. radical mastectomy.PrognosisPrognosis extremely good. extremely good.Paget’s disease of nipple is radio-resistant.Paget’s disease of nipple is radio-resistant.

EczemaEczema Paget’sPaget’s

Duct Ectesia Duct Ectesia "plasma cell mastitis""plasma cell mastitis"

It is primary dilatation of major ducts of the breast It is primary dilatation of major ducts of the breast which possible may be due to relaxant effects of which possible may be due to relaxant effects of progesterone or an auto-immune reaction. It is progesterone or an auto-immune reaction. It is commonly associated with discharging nipple in commonly associated with discharging nipple in middle aged woman. The initial manifestation is middle aged woman. The initial manifestation is worm-like swelling accompanied with local pain, worm-like swelling accompanied with local pain, tenderness, hardness of the mass with nipple tenderness, hardness of the mass with nipple retraction.retraction.

It is benign lesion, but may be mistaken for either It is benign lesion, but may be mistaken for either cancer or abscess, so it is also called "Plasma cell cancer or abscess, so it is also called "Plasma cell mastitis".mastitis".

Treatment:Treatment: Total excision is performed. Total excision is performed.

Mammary fistulaMammary fistula It is due to subacute recurrent It is due to subacute recurrent abscess which ruptures usually abscess which ruptures usually followed by supra mammary type followed by supra mammary type or due to congenital abnormality or due to congenital abnormality with abscess formation with abscess formation

Treatment:Treatment: The track is laid open The track is laid open and saucerized or excision of the and saucerized or excision of the fistula with its related duct.fistula with its related duct.

Duct Papilloma Duct Papilloma It arises from epithelium of one or more of It arises from epithelium of one or more of

main lactiferous duct. It may be single or main lactiferous duct. It may be single or multiple and usually pedunculated with multiple and usually pedunculated with narrow basenarrow base

ClinicallyClinically::Female patient of 40 years old with bloody, painless, Female patient of 40 years old with bloody, painless,

profuse discharge from nipple. Cystic swelling may profuse discharge from nipple. Cystic swelling may felt under areola due to obstruction of the duct with felt under areola due to obstruction of the duct with cystic formation. It shows tendency to malignant cystic formation. It shows tendency to malignant change so it should be removed early. change so it should be removed early.

The bleeding nipple is more than in duct carcinoma The bleeding nipple is more than in duct carcinoma due to less fibrous tissue.due to less fibrous tissue.

Localization of the papilloma by: Localization of the papilloma by: Investigation:Investigation:

1-1- Differential pressure.Differential pressure.2-2- Duct mammography.Duct mammography.3-3- Soft tissue mammography.Soft tissue mammography.4-4- Cytology.Cytology.

Treatment:Treatment:Discharging from the duct: Discharging from the duct: microdochectomy is performed.microdochectomy is performed.Multiple masses: simple Multiple masses: simple mastectomy. mastectomy.

Congenital Congenital abnormalities of the abnormalities of the

breastbreast1-1-

AmaziAmazia a

Absence of breast (Absence of breast (unilateral or or bilateral).bilateral).

May associate with absence of May associate with absence of the sternal portion of the the sternal portion of the pectoralis major "Poland’s pectoralis major "Poland’s syndrome"syndrome"

Common in male.Common in male.

2- Polymazia2- PolymaziaPresence of Presence of one or more..May be found in axilla "most common site" May be found in axilla "most common site"

groin or lateral side of the thigh. groin or lateral side of the thigh. Usually functionless but it may be Usually functionless but it may be

functionally during lactation.functionally during lactation.

3- Diffuse hypertrophy of the 3- Diffuse hypertrophy of the breastsbreastsUsually in healthy girls at puberty and less Usually in healthy girls at puberty and less often during the first pregnancy due to often during the first pregnancy due to hypertrophy of stroma and fat of stroma and fat

Treatment:Treatment: Reduction Reduction mammoplasty.mammoplasty.

Injuries of the BreastInjuries of the BreastHaematomaHaematomaIt is cystic lump with past history of trauma and It is cystic lump with past history of trauma and

aspiration is diagnostic.aspiration is diagnostic.

Traumatic fat necrosisTraumatic fat necrosisIt is due to trauma (a blow or indirect violence) It is due to trauma (a blow or indirect violence)

prolonged pressure or needle. prolonged pressure or needle. Biopsies of benign conditions. An area of fat becomes Biopsies of benign conditions. An area of fat becomes

devitalized and liberates fatty acids which react with devitalized and liberates fatty acids which react with calcium to form calcium soaps which become calcium to form calcium soaps which become surrounded by fibrosis forming an irregular hard surrounded by fibrosis forming an irregular hard painless lump which may be mistaken for carcinoma, painless lump which may be mistaken for carcinoma, so excision and frozen section are needed for so excision and frozen section are needed for differentiation. History of trauma is not diagnostic.differentiation. History of trauma is not diagnostic.

Acute mastitis and Acute mastitis and acute breast abscessacute breast abscess

1.1. Mastitis of infants. Mastitis of infants. 2.2. Mastitis of puberty.Mastitis of puberty.3.3. Mastitis of Mumps.Mastitis of Mumps.4.4. Mastitis of local irritation. Mastitis of local irritation. 5.5. Mastitis during lactation.Mastitis during lactation.6.6. Mastitis due to bacterial Mastitis due to bacterial

invasion.invasion.

1- Mastitis of infants1- Mastitis of infants It is the effect of female hormonal It is the effect of female hormonal

stimulation through placenta. The stimulation through placenta. The breast becomes swollen and breast becomes swollen and tender on the 3rd or 4th day of tender on the 3rd or 4th day of life. If the breast of the infant is life. If the breast of the infant is pressed lightly drop of colourless pressed lightly drop of colourless fluid can be expressed, few days fluid can be expressed, few days later, milky secretion from nipple, later, milky secretion from nipple, that is will disappear during 3rd that is will disappear during 3rd week and known as "witch’s week and known as "witch’s milk". milk".

Rarely suppuration occur.Rarely suppuration occur.

2- Mastitis of puberty2- Mastitis of puberty Male breast may become Male breast may become

enlarged, firm tender during enlarged, firm tender during puberty, the condition puberty, the condition subsides spontaneously and subsides spontaneously and needs no special therapy. needs no special therapy. Suppuration never occur.Suppuration never occur. 3- Mastitis of mumps3- Mastitis of mumps

Unilateral in femaleUnilateral in female

4- Mastitis due to local 4- Mastitis due to local irritationirritation

It is due to too tight elastic It is due to too tight elastic brassiere, rare in male rare in brassiere, rare in male rare in suppuration.suppuration.

5- Mastitis due to 5- Mastitis due to lactationlactation

It is due to milk engorgement, It is due to milk engorgement, when one of the duct becomes when one of the duct becomes blocked with epithelial debris. blocked with epithelial debris. The breast becomes painful and The breast becomes painful and tender.tender.

6- Mastitis due to bacterial 6- Mastitis due to bacterial invasion with abscess invasion with abscess formationformation

It is the most common variety It is the most common variety of mastitis. 32% of mastitis in of mastitis. 32% of mastitis in female is due to bacterial mastitis female is due to bacterial mastitis without lactation probably may without lactation probably may due to infected haematoma. the due to infected haematoma. the common infected organism is common infected organism is ""Staph aureusStaph aureus" which is penicillin " which is penicillin resistant.resistant.

Pathology:Pathology:The organism reaches the breast through The organism reaches the breast through

milk ducts or through fissures in nipples but milk ducts or through fissures in nipples but blood borne infection is rare. The breast at blood borne infection is rare. The breast at first congested and later suppurated.first congested and later suppurated.

Clinical features:Clinical features:General features of Toxemia are usually General features of Toxemia are usually

marked especially in common marked especially in common intramammary abscess, it may be masked by intramammary abscess, it may be masked by ill-advise use of antibiotics leading to ill-advise use of antibiotics leading to "antibioma". In case of supramammary "antibioma". In case of supramammary abscess it usually has subacute course.abscess it usually has subacute course.

Local features:Local features:Suppuration: Suppuration: A- Intramammary abscess.A- Intramammary abscess.

B- Supramammary abscess.B- Supramammary abscess.C- Submammary abscess. C- Submammary abscess.

A- Intramammary abscessA- Intramammary abscess It may reach big size with lactation the breast It may reach big size with lactation the breast

is swollen, tender with marked pain and is swollen, tender with marked pain and dilated veins on the surface. When pus is dilated veins on the surface. When pus is formed the pain becomes throbbing and formed the pain becomes throbbing and temperature becomes hectic edema increases. temperature becomes hectic edema increases. The fluctuation is not dependable sign so don't The fluctuation is not dependable sign so don't wait for fluctuation.wait for fluctuation.

B- Supramammary abscess B- Supramammary abscess It is formed under the skin, follows subacute It is formed under the skin, follows subacute

course, pain attendance are not so marked, so course, pain attendance are not so marked, so the patient comes late. If it is neglected it may the patient comes late. If it is neglected it may burst through skin forming milk fistula.burst through skin forming milk fistula.

C- Submammary abscess C- Submammary abscess Abscess here may form as result of extension Abscess here may form as result of extension

of infection from deeper parts of breast, but of infection from deeper parts of breast, but more frequently it is due to extension of more frequently it is due to extension of infection from other tissue, e.g. Osteomyelitis infection from other tissue, e.g. Osteomyelitis of ribs or pointing empyema. The abscess of ribs or pointing empyema. The abscess usually points at lower outer parts of the usually points at lower outer parts of the breastbreast..

Treatment of cellulitic stage: Treatment of cellulitic stage:

Including antibiotic "Tetracycline" with hot Including antibiotic "Tetracycline" with hot fomentation and rest of the pectoralis muscle fomentation and rest of the pectoralis muscle by support the breast and arm. If the by support the breast and arm. If the resolution fails to occur, the breast should be resolution fails to occur, the breast should be evacuated by milk pump. evacuated by milk pump.

Treatment of suppuration: Treatment of suppuration:

Drainage Drainage

In intramammary abscessIn intramammary abscessThe incision must be radiating from nipple to The incision must be radiating from nipple to

avoid injury of the milk ducts. Circumareolar avoid injury of the milk ducts. Circumareolar incision is done at margin of areola and it incision is done at margin of areola and it divides the skin only then long haemostate is divides the skin only then long haemostate is pushed into abscess cavity to break any fibrous pushed into abscess cavity to break any fibrous bands or adhesion inside it. And drain is left bands or adhesion inside it. And drain is left inside it. inside it.

In supramammary abscessIn supramammary abscessIt is incised where it points as no fear of It is incised where it points as no fear of

cutting through milk ducts as the abscess is cutting through milk ducts as the abscess is subcutaneous. subcutaneous.

In submammary abscess In submammary abscess It is incised in retromammary fold.It is incised in retromammary fold.

Chronic specific Chronic specific inflammationinflammation1- T.B. of the breast:1- T.B. of the breast:

It is rare, usually 2ry to T.B. It is rare, usually 2ry to T.B. lymph node in axilla with lymph node in axilla with pulmonary T.B. It takes the pulmonary T.B. It takes the form of tender mass or masses form of tender mass or masses which may be mistaken for which may be mistaken for tumors. It may be adherent to tumors. It may be adherent to the skin with multiple caseous the skin with multiple caseous discharging sinus.discharging sinus.

Treatment:Treatment: Anti-T.B. drugs with excision of the affected Anti-T.B. drugs with excision of the affected

part.part.

2- Syphilis of the breast:2- Syphilis of the breast:It occurs from nursing of syphilic child. It occurs from nursing of syphilic child.

It extremely rare.It extremely rare.Treatment:Treatment: Anti-syphilitic drugs Anti-syphilitic drugs

3- Actinomycosis of the breast:3- Actinomycosis of the breast:Extremely rare, 2ry to involved lung, Extremely rare, 2ry to involved lung,

presented with indurated mass with sulphur presented with indurated mass with sulphur discharging sinus.discharging sinus.

Treatment:Treatment: Penicillin "large doses" with Penicillin "large doses" with excision of the affected part. excision of the affected part.

Chronic non-specific Chronic non-specific inflammationinflammation

Chronic abscess:Chronic abscess:It is usually from in adequate use of antibiotics for It is usually from in adequate use of antibiotics for

acute mastitis and it is very difficult to differentiate acute mastitis and it is very difficult to differentiate between it and “scirrhous carcinoma” of the breast.between it and “scirrhous carcinoma” of the breast.

For differentiation: For differentiation: 1- History of acute mastitis. 1- History of acute mastitis. 2- It is less resistant in center than at periphery2- It is less resistant in center than at periphery3- No nipple retraction3- No nipple retraction4- Rounded posterior surface.4- Rounded posterior surface.5- Lymph node is small, firm, tender and mobile.5- Lymph node is small, firm, tender and mobile.

In doubtful cases, frozen biopsy is recommended to In doubtful cases, frozen biopsy is recommended to confirm or exclude malignancy. confirm or exclude malignancy.

Mondors Mondors disease:disease: It is thrombophlebitis of superficial It is thrombophlebitis of superficial veins of the breast and anterior veins of the breast and anterior chest wall in absence of injury or chest wall in absence of injury or inflammation due to unknown inflammation due to unknown causes.causes.

Clinically:Clinically: presented with presented with indurated subcutaneous cord like indurated subcutaneous cord like structure. It may be diagnosed as structure. It may be diagnosed as lymphatic permeation of an occult lymphatic permeation of an occult carcinoma. carcinoma.

Treatment:Treatment: restriction of arm restriction of arm movements.movements.

Benign Breast DiseasesBenign Breast Diseases 1. ANDI “fibroadenosis / cystic hyperplasia”1. ANDI “fibroadenosis / cystic hyperplasia”2. Fibroadenoma (hard & soft)2. Fibroadenoma (hard & soft)3. Cysts 3. Cysts 4. Duct papilloma 4. Duct papilloma 5. Duct ectasia 5. Duct ectasia 6. Fat necrosis 6. Fat necrosis 7. Monder’s 7. Monder’s

diseasedisease8. Pregnancy related disease (galactocele & puerperal 8. Pregnancy related disease (galactocele & puerperal

abscess)abscess)9. Congenital disorders (inverted nipple and 9. Congenital disorders (inverted nipple and

supramammary breast)supramammary breast)10. Non breast disorders (Tietze’s disease, sebaceous 10. Non breast disorders (Tietze’s disease, sebaceous

cysts, other skin lesions)cysts, other skin lesions)

Fibroadenosis/Cystic Fibroadenosis/Cystic hyperplasiahyperplasia

“Aberrations of normal development “Aberrations of normal development and involution” (ANDI)and involution” (ANDI)

““Mammary dysplesia””Aetiology:Aetiology:It is an aberration of normal physiological changes It is an aberration of normal physiological changes

related to ovarian activity. The blood hormone related to ovarian activity. The blood hormone levels are usually within normal limits and it may levels are usually within normal limits and it may

be that the disease is caused by an abnormal be that the disease is caused by an abnormal breast tissue response rather than an abnormal breast tissue response rather than an abnormal

stimulus.stimulus.

Pathology:Pathology:Site:Site: Bilateral common but may be unilateral.Bilateral common but may be unilateral.

Diffuse or localized type.Diffuse or localized type.Macroscopic:Macroscopic: When sectioned with knife, the affected When sectioned with knife, the affected

area in the breast are white or yellow and of India-rubber area in the breast are white or yellow and of India-rubber consistency but never present gritty sensation of consistency but never present gritty sensation of

carcinoma.carcinoma.

Microscopically:Microscopically:1) Cystic formation: solitary or multiple.1) Cystic formation: solitary or multiple.2) Adenosis 2) Adenosis 3) Fibrosis: the fat and elastic tissue replaced by dense 3) Fibrosis: the fat and elastic tissue replaced by dense

white fibrous tissue. white fibrous tissue. 4) Epitheliosis: hyperplasia of epithelium.4) Epitheliosis: hyperplasia of epithelium.5) Papillomatosis: Epithelial hyperplasia may be so 5) Papillomatosis: Epithelial hyperplasia may be so

extensive that it results in papillomatous formation. extensive that it results in papillomatous formation.

Five features with variationFive features with variation

Clinical Features:Clinical Features: Mild degree of the condition are very common being Mild degree of the condition are very common being

usually a tender or painful area of breast tissue of usually a tender or painful area of breast tissue of increased density.increased density.

The pain and swelling may be mainly premenstrual The pain and swelling may be mainly premenstrual and caused by vascular engorgement.and caused by vascular engorgement.

By for it is the commonest disease of female breast By for it is the commonest disease of female breast (25 – 45 years).(25 – 45 years).

The main complain is painful or tender mass or The main complain is painful or tender mass or masses in the breast.masses in the breast.

The pain increases during or before the menstruation The pain increases during or before the menstruation and relieved by pregnancy and lactation.and relieved by pregnancy and lactation.

The pain may mistake for angina as it is shooting to The pain may mistake for angina as it is shooting to the arm.the arm.

The nodules felt between the thumb and fingers and The nodules felt between the thumb and fingers and vaguely by flat the of the hand. It is not adherent to vaguely by flat the of the hand. It is not adherent to the skin of the skin of Pectoralis fasciaPectoralis fascia. . N.B: The mass which is N.B: The mass which is felt by flat of the hand inside the breast:felt by flat of the hand inside the breast:

* Cyst formation* Cyst formation * Chronic abscess* Chronic abscess * Malignancy* Malignancy

There may be discharge from nipple (serous, green-There may be discharge from nipple (serous, green-brown).brown).

L.N. in axilla may be tender but never hard.L.N. in axilla may be tender but never hard. The localized type “sector type” of the disease may The localized type “sector type” of the disease may

simulate carcinoma.simulate carcinoma.

The relationship of mammary The relationship of mammary dysplasia to carcinoma: dysplasia to carcinoma: The mater is not yet settled.The mater is not yet settled. It is considered as not precancerous but, the It is considered as not precancerous but, the

incidence of carcinoma in female within cystic incidence of carcinoma in female within cystic disease has been reported to be about 3 or 5 disease has been reported to be about 3 or 5 times that of general female population.times that of general female population.

Others report prominent epithelium hyperplasia as Others report prominent epithelium hyperplasia as finding that has a significant frequency relationship to finding that has a significant frequency relationship to subsequent carcinoma of the breast.subsequent carcinoma of the breast.

Treatment:Treatment:1)1)Reassurance is very important.Reassurance is very important.2)2)Support the breast.Support the breast.3)3)Testosterone 5 mg/3 times daily for 2 months Testosterone 5 mg/3 times daily for 2 months

but not recommended in young female.but not recommended in young female.4)4)Multiple cysts: Surgical treatment.Multiple cysts: Surgical treatment.5)5)Localized mass: excisional biopsy.Localized mass: excisional biopsy.6)6)Iodine in milk may cause improvement of Iodine in milk may cause improvement of

fibrosis.fibrosis.7)7)For severe pain: Danazol synthetic androgen For severe pain: Danazol synthetic androgen

may be used.may be used.

CYSTS OF THE BREAST CYSTS OF THE BREAST 1) Cysts connected to big ducts (1) Cysts connected to big ducts (

galactocele & & Simple retention cyst).).2) Cysts connected to small ducts (Cysts 2) Cysts connected to small ducts (Cysts

of mammary dysplasia).of mammary dysplasia).3) Cysts connected to the tumors (Duct 3) Cysts connected to the tumors (Duct

papiloma, serocystic disease, papiloma, serocystic disease, cystadenoma, degenerated cyst in cystadenoma, degenerated cyst in malignancy).malignancy).

4) Cysts found in the stroma (Lymphatic 4) Cysts found in the stroma (Lymphatic cyst, blood cyst, hydatid cyst).cyst, blood cyst, hydatid cyst).

Galactocele:Galactocele:Rare lesion, due to obstruction of main milk duct Rare lesion, due to obstruction of main milk duct by inspirated milk or fibrosis. It is painless cystic by inspirated milk or fibrosis. It is painless cystic swelling behind nipple and areola since lactation swelling behind nipple and areola since lactation and milk expressed from areola by pressure over and milk expressed from areola by pressure over the cyst. the cyst. TreatmentTreatment

::Excision or repeated aspiration. Excision or repeated aspiration. Aspiration of any cyst is not safe if: Aspiration of any cyst is not safe if: 4R4R RRefilling of the cyst.efilling of the cyst. RRed aspirated fluid.ed aspirated fluid. RResidual lump after aspiration.esidual lump after aspiration. RRevealing malignant cells by cystological examinationevealing malignant cells by cystological examination

FibroadenomaFibroadenoma

Two types: Two types: hard pericanalicular typehard pericanalicular type where the ducts are surrounded by dense C.T. where the ducts are surrounded by dense C.T. soft intracanalicular typesoft intracanalicular type where the ducts are where the ducts are surrounded by loose C.T.surrounded by loose C.T.

Pathology:Pathology:

Hard fibroadenoma: Hard fibroadenoma: 15 – 35 y, commoner, slow rate of growth small in size.15 – 35 y, commoner, slow rate of growth small in size. Cut section:Cut section: smooth, not gritty, bulges on cutting. smooth, not gritty, bulges on cutting. Clinically:Clinically: painless small, firm well defined freely painless small, firm well defined freely

mobile “breast mouse” mass no axillary L.N.mobile “breast mouse” mass no axillary L.N. Complication:Complication: rarely turns malignant. rarely turns malignant. Treatment:Treatment: Excisional biopsy. Excisional biopsy.

Soft fibroadenoma: Soft fibroadenoma: 30 – 50 y, less common, more rapid rate of 30 – 50 y, less common, more rapid rate of

growth, huge size, may burst through the skin.growth, huge size, may burst through the skin.Clinically:Clinically: painless, large, soft swelling with painless, large, soft swelling with

more rapid rate of growth.more rapid rate of growth.Complication:Complication: cystadenoma, cystosarcoma cystadenoma, cystosarcoma

phyllodes more liable to be malignant phyllodes more liable to be malignant transformation.transformation.

TreatmentTreatment:: If small: decisional biopsy.If small: decisional biopsy.

If larger: simple mastectomy + biopsy.If larger: simple mastectomy + biopsy.

Cystosarcoma PhyllodesCystosarcoma Phyllodes(Serocystic Disease of Brodie)(Serocystic Disease of Brodie)

““Phylloids Tumors”” It is a giant soft fibro adenoma.It is a giant soft fibro adenoma. Not sarcoma Not sarcoma Not cystic Not cystic It grows rapidly causing pressure necrosis of the It grows rapidly causing pressure necrosis of the

overlying skin without infiltrating it and the tumor overlying skin without infiltrating it and the tumor fungates from it “Probe Test” is used to differentiate it fungates from it “Probe Test” is used to differentiate it from fungating malignant tissue.from fungating malignant tissue.

The surface is bosselated with area of softening.The surface is bosselated with area of softening. Dilated veins may be seen in skin over it.Dilated veins may be seen in skin over it. Neither attached to the skin nor to deeper structures.Neither attached to the skin nor to deeper structures. No axillary L.N unless secondary infection occurs. No axillary L.N unless secondary infection occurs.

MastalgiaMastalgia

1) Cyclic mastalgia: It occurs in mammary dysplesia 1) Cyclic mastalgia: It occurs in mammary dysplesia tenderness and heaviness in the breast immediately tenderness and heaviness in the breast immediately before each period.before each period.

2) Non–cyclic mastalgia: as in duct ectasia, trauma or 2) Non–cyclic mastalgia: as in duct ectasia, trauma or idiopathic.idiopathic.

3) Acute inflammation: lactational mastitis, abscess.3) Acute inflammation: lactational mastitis, abscess.4) Cancer: only in"5 – 10"of cases.4) Cancer: only in"5 – 10"of cases.5) Extramammary cause: 5) Extramammary cause: Tietze’s disease: condritis of costal cartilage.Tietze’s disease: condritis of costal cartilage. Biliary diseases.Biliary diseases. PleurisyPleurisy

It is a pain in the breast It is a pain in the breast

1)1) Exclude cancer.Exclude cancer.2)2) Reassurance.Reassurance.3)3) Pain chart.Pain chart.4)4) Treatment the specific cause.Treatment the specific cause.

Treatment of mastalgia: Treatment of mastalgia:

Breast CancerBreast Cancer

Age:Age: It may occur at any age but the It may occur at any age but the commonest age is over fifty.commonest age is over fifty.

Race:Race: In general, the rates reported In general, the rates reported from developing countries are low, from developing countries are low, where as rates are high in where as rates are high in developed countries except in Japan.developed countries except in Japan.

Etiology and PathogenesisEtiology and Pathogenesis

Family history:Family history: Women whose mother Women whose mother or sisters had breast cancer are 2 or 3 or sisters had breast cancer are 2 or 3 times more likely to develop the times more likely to develop the disease than controls.disease than controls.

Mammary dysplasia complained by proliferative Mammary dysplasia complained by proliferative changes papillomatosis or solid hyperplasia is changes papillomatosis or solid hyperplasia is associated with an increased incidence of cancer.associated with an increased incidence of cancer.

A woman who has had cancer in one breast is at A woman who has had cancer in one breast is at increased risk of developing cancer in other breast.increased risk of developing cancer in other breast.

A woman with uterine cancer has a higher risk of A woman with uterine cancer has a higher risk of breast cancer.breast cancer.

Previous Medical History: Previous Medical History:

Early menarche (under age 12) and late menopause Early menarche (under age 12) and late menopause (of the age 50) are associated with increase in risk of (of the age 50) are associated with increase in risk of developing breast cancer.developing breast cancer.

Menstrual History: Menstrual History:

Unmarried woman or married woman with fever Unmarried woman or married woman with fever pregnancy or married woman with first children of pregnancy or married woman with first children of the age 30 has a higher incidence of breast cancer.the age 30 has a higher incidence of breast cancer.

Marital History: Marital History:

There is some evidence that There is some evidence that continuous administration of estrogens continuous administration of estrogens to postmenopausal women may result to postmenopausal women may result in an increased risk of breast cancer in an increased risk of breast cancer after 10 – 12 years.after 10 – 12 years.

It should be noted that the adrenal It should be noted that the adrenal gland is a major source of estrogen gland is a major source of estrogen and androgen in postmenopausal and androgen in postmenopausal women.women.

There is no correlation between There is no correlation between thyroid mass and breast cancer, but thyroid mass and breast cancer, but some reported higher incidence of some reported higher incidence of breast cancer in patient with breast cancer in patient with hypothyroidism.hypothyroidism.

Hormonal Factor: Hormonal Factor:

1)1) Old age.Old age.2)2) High socioeconomic factor.High socioeconomic factor.3)3) Early menarche.Early menarche.4)4) Late menopause.Late menopause.5)5) Never married.Never married.6)6) Fewer Pregnancies.Fewer Pregnancies.7)7) Female who has had 1st children of the 30 years old.Female who has had 1st children of the 30 years old.8)8) Female who is non-lactating.Female who is non-lactating.9)9) History of benign breast disease (BBD).History of benign breast disease (BBD).10) Continuous administration of estrogen to 10) Continuous administration of estrogen to

postmenopausal women.postmenopausal women.11) Family history of cancer breast.11) Family history of cancer breast.

Risk Factors for Female Risk Factors for Female Breast: Breast:

As an infective agent carried from the As an infective agent carried from the mother to baby in the milk "Bitter milk mother to baby in the milk "Bitter milk factor” but, no evidence to support it in factor” but, no evidence to support it in human body although it is effective in human body although it is effective in rats.rats.

Milk Factor: Milk Factor:

It has a role in animal but, no evidence It has a role in animal but, no evidence in human.in human.

Role of Virus: Role of Virus:

1)1) Broder’s classification.Broder’s classification.

2)2) TNM classification.TNM classification.

3)3) Clinical and histologic Clinical and histologic staging.staging.

4)4) Manchester classification.Manchester classification.

Staging and Staging and ClassificationClassification

Grad I:Grad I: Not more than 25% of cells are undifferentiated. Not more than 25% of cells are undifferentiated.Grad II:Grad II: From 25% to 50% of cells are undifferentiated. From 25% to 50% of cells are undifferentiated.Grad III:Grad III: From 50% to 75% of cells are undifferentiated. From 50% to 75% of cells are undifferentiated.Grad IV:Grad IV: Over 75% of cells are undifferentiated. Over 75% of cells are undifferentiated.

Broder’s Classification: Broder’s Classification:

This grading must not be taken in estimating the This grading must not be taken in estimating the treatment or prognosis.treatment or prognosis.

As grad I may have disseminated wildly while grad IV As grad I may have disseminated wildly while grad IV may still be localized.may still be localized.

The undifferentiated tissue are usually radio sensitive, The undifferentiated tissue are usually radio sensitive, but, commonly recur, while high differentiated tissue but, commonly recur, while high differentiated tissue tend to be (radio resistant).tend to be (radio resistant).

TisTis = no palpable tumor. = no palpable tumor. T1T1 = 2 cm or less. = 2 cm or less.T2T2 = 2 cm – 5 cm. = 2 cm – 5 cm.T3T3 = More than 5com or pectoral fixation. = More than 5com or pectoral fixation.T4 T4 = more than 10 cm: Skin involved, not beyond the = more than 10 cm: Skin involved, not beyond the

breast chest wall fixation Peau d’orange ulcer.breast chest wall fixation Peau d’orange ulcer.

N0N0 = No palpable axillary L.N. = No palpable axillary L.N.N1 N1 = axillary mobile L.N.= axillary mobile L.N.N2N2 = axillary fixed L.N. = axillary fixed L.N.N3N3 = Supra clavicular L.N or edema of Arm. = Supra clavicular L.N or edema of Arm.

M0M0 = No distant metastases. = No distant metastases.M1M1 = Metastases beyond breast. = Metastases beyond breast.

T.N.M. Classification: T.N.M. Classification:

Stage Tis: Stage Tis: Tis, N0, M0 Tis, N0, M0 Stage I: Stage I: T1, N1, M0 T1, N1, M0 Stage II: Stage II: T2, N1, M0 T2, N1, M0 Stage III: Stage III: T3, N2 or N3, M0 T3, N2 or N3, M0 Stage IV: Stage IV: Any T, any N with M1Any T, any N with M1

Clinical Staging "American Clinical Staging "American Committee"Committee"

Negative axillary L.N.Negative axillary L.N. Positive axillary L.N.Positive axillary L.N. 1 – 3 Positive axillary L.N.1 – 3 Positive axillary L.N. > 5 Positive axillary L.N.> 5 Positive axillary L.N.

Histologic Staging Histologic Staging

Stage I:Stage I: Mobile lump without axillary L.N. Mobile lump without axillary L.N. Stage II:Stage II: Mobile Lump with mobile L.N. Mobile Lump with mobile L.N. Stage III:Stage III: Fixed lump with fixed L.N. Fixed lump with fixed L.N. Stage IV:Stage IV: Distant metastases. Distant metastases.

Manchester Staging Manchester Staging

In about 70% of cases the presenting complaint is In about 70% of cases the presenting complaint is painless lump.painless lump.

Less frequent symptoms are breast pain, nipple Less frequent symptoms are breast pain, nipple discharge, erosion, retraction and redness with discharge, erosion, retraction and redness with hardness.hardness.

Rarely, an axillary mass or bone pain may be 1st Rarely, an axillary mass or bone pain may be 1st symptom.symptom.

Clinical featuresClinical featuresSymptoms: Symptoms:

The frequency of breast The frequency of breast carcinoma at various carcinoma at various anatomical sites as anatomical sites as shown in the diagram.shown in the diagram.

Signs: Signs:

About ½ of breast cancer About ½ of breast cancer begin in upper last quarter, begin in upper last quarter, probably because it probably because it contains the largest volume contains the largest volume of breast tissue. The tumor of breast tissue. The tumor in that quadrant is of best in that quadrant is of best prognosis.prognosis.

Single, non tender, firm to hard mass Single, non tender, firm to hard mass with defined margins.with defined margins.

Nipple erosion with or without a mass.Nipple erosion with or without a mass. Mammography may detect cancer before Mammography may detect cancer before

development of palpable masses.development of palpable masses.

Early Findings: Early Findings:

Skin or nipple retraction.Skin or nipple retraction. Axillary L.N.Axillary L.N. Redness, edema, pain.Redness, edema, pain. Fixation of mass to skin Fixation of mass to skin

or chest wall.or chest wall.

Late Findings: Late Findings: Ulceration.Ulceration. Supra clavicular L.N.Supra clavicular L.N. Edema of arm.Edema of arm. Bone or lung Bone or lung

metastases.metastases.

Very late Very late findings: findings:

Skin Manifestation of Breast Skin Manifestation of Breast CancerCancer

Peau d’orange: Peau d’orange: Intradermal lymphatic Intradermal lymphatic obstruction by lymphatic obstruction by lymphatic permeation resulting in permeation resulting in tough in compressible tough in compressible edema with pits at sites of edema with pits at sites of sebaceous gland.sebaceous gland.

Puckering of Skin: due to fibrosis leading to Puckering of Skin: due to fibrosis leading to contraction of cooper’s ligament.contraction of cooper’s ligament.

Cancer en Cuirass: with progressive lymphatic Cancer en Cuirass: with progressive lymphatic obstruction the entire skin of the breast and obstruction the entire skin of the breast and sometimes the chest wall becomes deeply pigmented sometimes the chest wall becomes deeply pigmented hard, thick and rigid tethering.hard, thick and rigid tethering.

Skin Nodule: due to lymphatic permeation Skin Nodule: due to lymphatic permeation occurring at skin of the breast or around umbilicus.occurring at skin of the breast or around umbilicus.

Ulceration and fungation.Ulceration and fungation. Edema of the arm.Edema of the arm.

1)1) Peau d’orange.Peau d’orange.2)2) Cancer en cuirasse.Cancer en cuirasse.3)3) Edema of the arm.Edema of the arm.4)4) Lymphangio sarcoma.Lymphangio sarcoma.5)5) Serous effusion into peritoneal or pleural cavities.Serous effusion into peritoneal or pleural cavities.

Phenomena resulting four Phenomena resulting four lymphatic obstruction in cases of lymphatic obstruction in cases of cancer breast cancer breast

Lymphangiosarcoma Lymphangiosarcoma It is post mastectomy lymphadema it may be It is post mastectomy lymphadema it may be confused with recurrent carcinoma of the breast.confused with recurrent carcinoma of the breast.

A.A. Early post operative:Early post operative: within matter of days the within matter of days the radical mastectomy may be related to axillary vein radical mastectomy may be related to axillary vein thrombosis but, it is wise to regard it as infective in thrombosis but, it is wise to regard it as infective in origin and treatment with full course of antibiotics.origin and treatment with full course of antibiotics.

B.B. Late edema:Late edema: from several months to many years from several months to many years after operation it may be associated with local after operation it may be associated with local infection, so it is treated vigorously with antibiotics infection, so it is treated vigorously with antibiotics while the only treatment of value is elevation with while the only treatment of value is elevation with elastic bandage from wrist to the axillary.elastic bandage from wrist to the axillary.

C.C. Brawny Arm:Brawny Arm: can result from advanced neoplastic can result from advanced neoplastic infiltration of unarmored or in completely removed infiltration of unarmored or in completely removed axillary or supra clavicular L.N. edema is persistent axillary or supra clavicular L.N. edema is persistent brawny (does not pit).brawny (does not pit).

Edema of the ArmEdema of the Arm

1)1) Duct papilloma.Duct papilloma.2)2) Huge soft fibro adenoma.Huge soft fibro adenoma.3)3) Epithelial type of ANDI.Epithelial type of ANDI.

Precancerous Breast Lesions Precancerous Breast Lesions

Easley Detection of Breast Easley Detection of Breast carcinomacarcinoma1)1) Mass Examination:Mass Examination: clinical examination of women clinical examination of women

in the cancer age in special clinics annually in in the cancer age in special clinics annually in certain area.certain area.

2)2) Self Examination: all women above 30 years ago Self Examination: all women above 30 years ago should be palpate and examine her breast by herself should be palpate and examine her breast by herself monthly in front of a mirror.monthly in front of a mirror.

3)3) Mammography, Ultrasonography:Mammography, Ultrasonography: as a screening as a screening program. program.

Pathology of Pathology of Carcinoma of the Carcinoma of the

Breast:Breast:

All types of carcinoma of the All types of carcinoma of the breast arise in epithelium of the breast arise in epithelium of the

duct, with variation in the power of duct, with variation in the power of infiltration of the breast tissue.infiltration of the breast tissue.

1)1) Site of affection.Site of affection.2)2) Pathological classification.Pathological classification.

It is a duct carcinoma with slow It is a duct carcinoma with slow progress an good prognosis.progress an good prognosis.

1.1.Columnar cell carcinomaColumnar cell carcinoma

It is a duct carcinoma with It is a duct carcinoma with infiltration and invasion of breast infiltration and invasion of breast tissue resulting in variable degree tissue resulting in variable degree of cellular and fibrous tissues.of cellular and fibrous tissues.

2.2.Spheroidal cell carcinomaSpheroidal cell carcinoma

A.A. Atrophic scirrhous carcinoma:Atrophic scirrhous carcinoma: there is marked there is marked fibrous with minimal cellular tissue. The progress is fibrous with minimal cellular tissue. The progress is slow with small rounded nodule of dense whitish slow with small rounded nodule of dense whitish tissue with central yellowish area.tissue with central yellowish area.

B.B. Scirrhous carcinoma:Scirrhous carcinoma: there is marked fibrous with there is marked fibrous with more cellular tissue, presented with hard mass, which more cellular tissue, presented with hard mass, which on cutting with knife the cut surface is concave, gray on cutting with knife the cut surface is concave, gray in color with small granular whitish streaks radiating in color with small granular whitish streaks radiating into surrounding tissues with no capsule.into surrounding tissues with no capsule.

C.C. Encephaloid carcinoma:Encephaloid carcinoma: the cells are more active, the cells are more active, spread rapidly, with minimal fibrous tissue. The mass spread rapidly, with minimal fibrous tissue. The mass is soft, gray and homogeneous with early presentation.is soft, gray and homogeneous with early presentation.

D.D. Mastitis carcinoma:Mastitis carcinoma: highly malignant, occurs during highly malignant, occurs during pregnancy and lactation. The cellular activity is pregnancy and lactation. The cellular activity is higher than the fibrous reaction.higher than the fibrous reaction.

3.3.Paget’s disease.Paget’s disease.

The cells are distended with The cells are distended with colloid material and the nucleus is colloid material and the nucleus is pushed to one side "signet ring”. It pushed to one side "signet ring”. It is bulky tumor not highly is bulky tumor not highly malignant as in colloid type of malignant as in colloid type of carcinoma of stomach or colon.carcinoma of stomach or colon.

4.4.Colloid carcinomaColloid carcinoma

1. Local: 1. Local: into breast tissue and into breast tissue and later to pectoral M. and chest later to pectoral M. and chest

wall.wall.

3)3) SpreadSpread

Axillary and internal mammary lymph nodes Axillary and internal mammary lymph nodes may be affected early.may be affected early.

Other breast, supra circular lymph nodes and Other breast, supra circular lymph nodes and mediastinum may be affected later.mediastinum may be affected later.

2ry carcinoma in umbilicus via lymphatic of 2ry carcinoma in umbilicus via lymphatic of falciform ligament.falciform ligament.

Pathway of lymphatic spread are either Pathway of lymphatic spread are either embolization or permeation.embolization or permeation.

In embolization, the malignant cells are carried In embolization, the malignant cells are carried as emboli in lymph stream to the lymph node.as emboli in lymph stream to the lymph node.

2.2.Lymphatic: Lymphatic:

In permeation, the malignant cells grow as In permeation, the malignant cells grow as malignant column in the lymphatic vessel. This malignant column in the lymphatic vessel. This may reach the lymph nodes or may be arrested at may reach the lymph nodes or may be arrested at some point giving rise to nodules away from the some point giving rise to nodules away from the primary growth in the breast tissue, in the skin, in primary growth in the breast tissue, in the skin, in the other breast.the other breast.

To the bones, liver or brain. It usually affect the To the bones, liver or brain. It usually affect the ribs and vertebrae with osteolytic activity leading ribs and vertebrae with osteolytic activity leading to pathological fractures due to these secondaries.to pathological fractures due to these secondaries.

3. Blood3. Blood

Special Clinical from Special Clinical from of Carcinoma of of Carcinoma of

BreastBreast1) Mastitis carcinoma 1) Mastitis carcinoma most malignant.most malignant.

2) Scirrhous carcinoma2) Scirrhous carcinoma most common.most common.

3) Atrophic scirrhous carcinoma.3) Atrophic scirrhous carcinoma.

4) Encephaloid or medullary carcinoma4) Encephaloid or medullary carcinomamost big.most big.

5) Duct carcinoma5) Duct carcinoma most bloody.most bloody.

1. Mastitis 1. Mastitis carcinomatosacarcinomatosa This is the most of carcinoma and This is the most of carcinoma and

the most difficult to diagnose as it the most difficult to diagnose as it easily mistaken for acute mastitis easily mistaken for acute mastitis

or breast abscess for the following or breast abscess for the following reasons:reasons:

i.i. The course is rapid, and the tumor is painful (in The course is rapid, and the tumor is painful (in contrast to common carcinoma of the breast which contrast to common carcinoma of the breast which is usually painless).is usually painless).

ii.ii. Redness, hotness and edema are marked features.Redness, hotness and edema are marked features.iii.iii. The axillary lymph nodes are usually enlarged. The axillary lymph nodes are usually enlarged.

Retraction of nipple may he found. Diagnosis may Retraction of nipple may he found. Diagnosis may be helped by noticing that:be helped by noticing that:

1.1. The edema is marked and more extensive.The edema is marked and more extensive.2.2. Pyrexia and leucocytosis are usually absent.Pyrexia and leucocytosis are usually absent.3.3. No response to antibiotics. The Prognosis is always No response to antibiotics. The Prognosis is always

bad and patients usually die within few months of bad and patients usually die within few months of onset. Hormonal therapy, termination of pregnancy onset. Hormonal therapy, termination of pregnancy and ovariectomy may give some improvement. and ovariectomy may give some improvement. Radical mastectomy Radical mastectomy contraindicated. contraindicated. Fortunately this is a rare type of carcinoma.Fortunately this is a rare type of carcinoma.

2. Scirrhous carcinoma 2. Scirrhous carcinoma (65%) (65%) This is a commonest carcinoma of This is a commonest carcinoma of

the breast the breast 95 % of cases the patients 95 % of cases the patients

present with a painless lump present with a painless lump discovered accidentally during discovered accidentally during washing washing

The breast may be smaller than The breast may be smaller than the other breast with higher level.the other breast with higher level.

The nipple is retracted with The nipple is retracted with evidence of malignant skin evidence of malignant skin features.features.

The mass is hard and may be The mass is hard and may be fixed to the muscle or to the skin.fixed to the muscle or to the skin.

It occurs in old women with very slow progress.It occurs in old women with very slow progress.a.a.Atrophic scirrhous carcinoma (5 Atrophic scirrhous carcinoma (5

%)%)

It occurs in younger age (25-35 years), the mass is It occurs in younger age (25-35 years), the mass is bigger and softer, the prognosis is not so bad like bigger and softer, the prognosis is not so bad like

scirrhous carcinoma as the women usually scirrhous carcinoma as the women usually presented with an early big mass in the breast.presented with an early big mass in the breast.

b.b.Encephaloid or medullary Encephaloid or medullary carcinoma (15 %)carcinoma (15 %)

It is painless bloody charged tumor with mass It is painless bloody charged tumor with mass under the areola. The prognosis is good due to early under the areola. The prognosis is good due to early

bloody presentation and late lymphatic spread.bloody presentation and late lymphatic spread.

c.c. Duct carcinomaDuct carcinoma

Treatment of Breast Treatment of Breast CancerCancer

A.A. Early breast cancer: Early breast cancer: No evidence of disease beyond No evidence of disease beyond T2 N1.T2 N1. The aim of treatment: The aim of treatment: curative.curative.

B.B. Advanced breast cancer: Advanced breast cancer: Disease beyond Disease beyond T2 N1.T2 N1.The aim of the treatment: The aim of the treatment: palliative.palliative.

A- Treatment of early breast A- Treatment of early breast cancercancer

Although the spread of breast Although the spread of breast cancer is centrifugal (i.e. both to cancer is centrifugal (i.e. both to axillary and to internal mammary axillary and to internal mammary

nodes), removal of the growth, the nodes), removal of the growth, the affected breast and either removal affected breast and either removal of axillary nodes or their treatment of axillary nodes or their treatment

by irradiation constitute effective by irradiation constitute effective local treatment.local treatment.

SurgerySurgery 1)1) Radical mastectomyRadical mastectomy “ “Halsted operationHalsted operation”: removal ”: removal

of the primary lesion, whole breast axillary lymph of the primary lesion, whole breast axillary lymph nodes with wide softy margin of surrounding nodes with wide softy margin of surrounding tissue including the pectoralis muscles.tissue including the pectoralis muscles.

2)2) Modified radical mastectomyModified radical mastectomy “ “Patey operationPatey operation”: ”: total mastectomy with axillary dissection total mastectomy with axillary dissection preserving the pectoralis major M. It is the choice preserving the pectoralis major M. It is the choice for carcinoma of the breast.for carcinoma of the breast.

3)3) Extended radical mastectomyExtended radical mastectomy “ “Urban’s Urban’s operationoperation” radical mastectomy with removal of ” radical mastectomy with removal of internal mammary nodes with supraclavicular internal mammary nodes with supraclavicular L.N + lateral half of sternum and costal cartilages L.N + lateral half of sternum and costal cartilages from 2nd to 5th.from 2nd to 5th.

4)4) Simple mastectomy:Simple mastectomy: total mastectomy leaving the total mastectomy leaving the axillary nodes intact.axillary nodes intact.

5)5) Segmental mastectomy:Segmental mastectomy: removal of the affected removal of the affected segment for very early cases.segment for very early cases.

6)6) Subcutaneous mastectomy:Subcutaneous mastectomy: only for in sites lesion only for in sites lesion which is very small in size with micro invasion. The which is very small in size with micro invasion. The whole of mammary T. is removed but skin is whole of mammary T. is removed but skin is preserved and the contour of the breast is restored preserved and the contour of the breast is restored by inserting a silastic prosthesis into the resulting by inserting a silastic prosthesis into the resulting subcutaneous pocket.subcutaneous pocket.

Some surgical points in Some surgical points in mastectomy mastectomy Structures must be protected Structures must be protected

during mastectomy: during mastectomy: N. to serratus anterior. N. to serratus anterior. N. to latissimus dorsi.N. to latissimus dorsi. The brachial plexus.The brachial plexus. The brachial artery.The brachial artery. Cephalic vein: which carries the Cephalic vein: which carries the

blood back from the limb if the blood back from the limb if the axillary vein ligated or axillary vein ligated or thrombosed.thrombosed.

Dissection begins from axilla for Dissection begins from axilla for the following reasons: the following reasons:

To allow early exploration of To allow early exploration of axilla.axilla.

To avoid lymphatic To avoid lymphatic dissemination if the tumor is dissemination if the tumor is mobilized first.mobilized first.

The chest wall remains covered The chest wall remains covered by the breast most of the time of by the breast most of the time of operation. This will minimizes operation. This will minimizes shock and pulmonary shock and pulmonary complication.complication.

Radical mastectomy may be Radical mastectomy may be required for some cases of required for some cases of advanced local disease of the advanced local disease of the tumor invade the muscle.tumor invade the muscle.

Extended radical mastectomy Extended radical mastectomy could be only for patients with could be only for patients with medical lesions, axillary L.N. medical lesions, axillary L.N. involvement but no signs of involvement but no signs of distant metastases.distant metastases.

Complications of radical Complications of radical mastectomy mastectomy HaemorrhageHaemorrhage HaemothoraxHaemothorax Injury of nerve to serratus anterior: Injury of nerve to serratus anterior:

winging of scapula.winging of scapula. Injury to nerve to latissimus dorsi: Injury to nerve to latissimus dorsi:

failure of adduction.failure of adduction. Early postoperative edema: due to Early postoperative edema: due to

axillary vein thrombosis or infection, axillary vein thrombosis or infection, also it may indicate complete also it may indicate complete clearance of axilla.clearance of axilla.

Wound complications.Wound complications.

ShockShock PneumothoraxPneumothorax

IrradiationIrradiation 1.1. McWhirter’s methods “postoperative McWhirter’s methods “postoperative

irradiation”.irradiation”.2.2. Preoperative irradiation.Preoperative irradiation.3.3. QUART = Quadrantectomy + axillary QUART = Quadrantectomy + axillary

dissection + radiotherapy. dissection + radiotherapy. Indications of post operative Indications of post operative

radiotherapy: radiotherapy: When L.N.S are involved and have not When L.N.S are involved and have not

certainly been removed by mastectomy.certainly been removed by mastectomy. When a simple mastectomy policy has When a simple mastectomy policy has

been adopted.been adopted.

Indications of preoperative Indications of preoperative irradiation:irradiation:1.1. Carcinoma of male breast.Carcinoma of male breast.2.2. in small female breast with short in small female breast with short

skin.skin. In these two cases, the skin In these two cases, the skin

grafting after radical grafting after radical mastectomy is usually needed mastectomy is usually needed and if post operative irradiation and if post operative irradiation is given the graft will slough.is given the graft will slough.

Disadvantages of pre-operative Disadvantages of pre-operative irradiation: irradiation: It delays the time of operation.It delays the time of operation. It renders the tissue more It renders the tissue more

vascular.vascular.The patient may refuse the The patient may refuse the

operation if irradiation causes operation if irradiation causes some reduction in size of tumor.some reduction in size of tumor.However:However: recent studies show that recent studies show that pre operative irradiation is better pre operative irradiation is better in preventing post operative local in preventing post operative local

recurrence than post operative.recurrence than post operative.

It is now used as an adjuvant to It is now used as an adjuvant to primary therapy in stage I and stage primary therapy in stage I and stage II with positive axillary L.N. and II with positive axillary L.N. and have no evidence of distant have no evidence of distant metastases and treated for one by metastases and treated for one by surgery or irradiation or both. The surgery or irradiation or both. The aim of adjuvant therapy is to aim of adjuvant therapy is to eradicate occult distant metastases eradicate occult distant metastases and residual tumor in chest wall. and residual tumor in chest wall. CMF program 12 monthly cycles is CMF program 12 monthly cycles is used.used.

Adjuvant chemotherapy CMFAdjuvant chemotherapy CMF

A. Immediate care against wound complications: A. Immediate care against wound complications: 1)1) Fluid collection (seroma, hematoma) to avoid Fluid collection (seroma, hematoma) to avoid

that, meticulous hemostasis pressure dressing, that, meticulous hemostasis pressure dressing, suction drainage and immobility of arm for 3–4 suction drainage and immobility of arm for 3–4 days.days.

2)2) Skin flap necrosis to avoid that, cut flaps must Skin flap necrosis to avoid that, cut flaps must be thick, gentle handling and closure without be thick, gentle handling and closure without tension.tension.

B.B. Follow up care: Follow up care: to detect recurrences and to to detect recurrences and to observe other breast every 6 months till 5 years observe other breast every 6 months till 5 years then every 8 – 12 months.then every 8 – 12 months.

Postoperative care against Postoperative care against complication: complication:

A- Treatment of advanced breast A- Treatment of advanced breast cancercancer

A. Local therapy:A. Local therapy:1) Surgery.1) Surgery.

2) Radio 2) Radio therapy.therapy.

3) Cytotoxic.3) Cytotoxic.

B. Systemic B. Systemic therapy:therapy:

1) Hormonal 1) Hormonal therapy.therapy.

2) Cytotoxic 2) Cytotoxic therapy.therapy.

3) Management of 3) Management of hypercalcemia. hypercalcemia.

4) Immune 4) Immune therapy.therapy.

A) Local therapyA) Local therapy (1) Palliative surgery indications:(1) Palliative surgery indications:a. Solitary skin secondaries.a. Solitary skin secondaries.b. Local recurrence or chest wall.b. Local recurrence or chest wall.c.c. Palliative simple mastectomy Palliative simple mastectomy

for untreated fungating tissue.for untreated fungating tissue.d. Effects of distant metastases d. Effects of distant metastases

as: as: Paraplegia from vertebral column Paraplegia from vertebral column

involvement: laminectomy is indicated.involvement: laminectomy is indicated. Pathological fracture: internal fixation is Pathological fracture: internal fixation is

indicated.indicated.

(2) Radiotherapy: (2) Radiotherapy: Radical irradiation of the breast, Radical irradiation of the breast,

chest wall and axillary lymph chest wall and axillary lymph nodes for locally advanced nodes for locally advanced inoperable lesions with no inoperable lesions with no evidence of distant metastases.evidence of distant metastases.

Palliative radiotherapy may be Palliative radiotherapy may be used for locally advanced cases used for locally advanced cases with distant metastases in order to with distant metastases in order to control ulcer-ation, pain and other control ulcer-ation, pain and other manifestations of breast cancer.manifestations of breast cancer.

Palliative radio therapy is useful in Palliative radio therapy is useful in treatment of isolated bony treatment of isolated bony metastases.metastases.

(3)(3) Local cytotoxic drugs: Local cytotoxic drugs: It is indicated in cases of malignant It is indicated in cases of malignant

pleural effusion.pleural effusion. This effusion is best controlled by This effusion is best controlled by

closed tube drainage of the chest closed tube drainage of the chest and intra-pleural instillations of and intra-pleural instillations of sclerosing agent through inter sclerosing agent through inter costal tube.costal tube.

So after water seal drainage and So after water seal drainage and removal of the fluid: 500mg of removal of the fluid: 500mg of tetracycline dissolved in 30ml of tetracycline dissolved in 30ml of saline are then infected into the saline are then infected into the pleural cavity through the tube, pleural cavity through the tube, which is clamped for 6 hours.which is clamped for 6 hours.

The patient’s position is clamped The patient’s position is clamped frequently to distribute the frequently to distribute the tetracycline within the pleural tetracycline within the pleural cavity. This procedure is repeated cavity. This procedure is repeated for 5-6 days, thus, if the sclerosing for 5-6 days, thus, if the sclerosing action of tetracycline is effective action of tetracycline is effective adherence of visceral to partial adherence of visceral to partial pleura is occurred.pleura is occurred.

Other chemo therapeutic agent as Other chemo therapeutic agent as thiotepa may cause nausea, thiotepa may cause nausea, vomiting or bone marrow vomiting or bone marrow depression. depression.

B) Systemic therapyB) Systemic therapy (1) Hormonal Therapy:(1) Hormonal Therapy:

A- Prediction of response to A- Prediction of response to hormone manipulation.hormone manipulation.

1. The free interval:1. The free interval: It is the time from the It is the time from the

primary treatment to primary treatment to appearance of metastases.appearance of metastases.

The chance of success The chance of success increases as the free increases as the free interval lengthens.interval lengthens.

2) The site of the first 2) The site of the first metastases:metastases: Visceral metastases e.g. brain, Visceral metastases e.g. brain, lung, liver are less regress than lung, liver are less regress than skeletal skin or L.N deposits.skeletal skin or L.N deposits.

3) The menopausal status of the 3) The menopausal status of the host: host: Pre-menopausal women are Pre-menopausal women are better than others. Women better than others. Women within 5 years post menopausal within 5 years post menopausal are with bad prognosis with are with bad prognosis with hormonal treatment.hormonal treatment.

4) Pregnancy: 4) Pregnancy: Tumors occur during Tumors occur during

pregnancy or lactation pregnancy or lactation diagnosed late because diagnosed late because physiologic changes in the physiologic changes in the breast may obscure the true breast may obscure the true nature of the lesion.nature of the lesion.5) Extent of the disease: 5) Extent of the disease:

Jaundice ascites and cachexia, Jaundice ascites and cachexia, indicates hopeless cases.indicates hopeless cases.

(2) Hormone Receptor Sites: (2) Hormone Receptor Sites:

The presence or absence of The presence or absence of estrogen receptor on tumor cells estrogen receptor on tumor cells appears to be a major prognostic appears to be a major prognostic factor and is of great importance factor and is of great importance in managing patients with in managing patients with recurrent or metastatic disease.recurrent or metastatic disease.

(3) Forms of Hormonal treatment:(3) Forms of Hormonal treatment:1) Estrogen:1) Estrogen: Women more than 5 years post menopausal.Women more than 5 years post menopausal. Diethyl stillbesterol 5 mg 13 times 1 daily.Diethyl stillbesterol 5 mg 13 times 1 daily. Side effect: anorexia, nausea, vomiting, Side effect: anorexia, nausea, vomiting,

pigmentation, enlarged breasts, Na and Hpigmentation, enlarged breasts, Na and H22O O retention.retention.

When estrogen therapy stopped:When estrogen therapy stopped: uterine bleeding occurs in majority of uterine bleeding occurs in majority of post menopausal women.post menopausal women.

2) Anti estrogens:2) Anti estrogens: These are group of compounds, capable of These are group of compounds, capable of

decreasing the specific uptake of estrogen by decreasing the specific uptake of estrogen by various target tissues.various target tissues.

Mode of action: either by competitive Mode of action: either by competitive binding to estrogen receptor sites or by binding to estrogen receptor sites or by failure of anti estrogen complex when Trans failure of anti estrogen complex when Trans located into nucleus to stimulate estrogen located into nucleus to stimulate estrogen receptors.receptors.

Dosage: tamoxifen citrate 10 mg/twice/daily/ Dosage: tamoxifen citrate 10 mg/twice/daily/ rolly. It is the best treatment for estrogen rolly. It is the best treatment for estrogen receptor +ve post menopausal women with receptor +ve post menopausal women with non visceral metastatic breast cancer. non visceral metastatic breast cancer.

3) Androgens:3) Androgens: For premenopausal women with advanced breast For premenopausal women with advanced breast

cancer.cancer. It may be usefully added to castration in patients It may be usefully added to castration in patients

under age 35.under age 35. Dosage: testosterone propionate 100 mg I.M/ 3 Dosage: testosterone propionate 100 mg I.M/ 3

times/weekly (Danazol) times/weekly (Danazol) Side effects: Increased libido and masculinization Side effects: Increased libido and masculinization

e.g e.g (Hisutism, Hoarseness of voice, loss of scalp (Hisutism, Hoarseness of voice, loss of scalp hair), fluid retention, anorexia, vomiting and hair), fluid retention, anorexia, vomiting and hepatotoxicity, virilization in prolonged treatment hepatotoxicity, virilization in prolonged treatment for 6 months.for 6 months.

Estrogen and androgen therapy are generally of Estrogen and androgen therapy are generally of limited value in patients with metastases to liver, limited value in patients with metastases to liver, lung or brain.lung or brain.

4) Corticosteroids4) Corticosteroids Indications:Indications:

a)a)Patient with acute serious Patient with acute serious symptoms.symptoms.b)b)Too ill patient unfit for major Too ill patient unfit for major endocrine ablation.endocrine ablation.c)c) To improve hypercalcemia, brain To improve hypercalcemia, brain and lung metastases symptoms.and lung metastases symptoms.

Dosage:Dosage: cortisone 150mg twice or 3 cortisone 150mg twice or 3 times daily.times daily.

5) Endocrine ablation5) Endocrine ablationA. Castration:A. Castration: Oophorectomy in pre menopausal women with Oophorectomy in pre menopausal women with

advanced metastatic or recurrent cancer breast advanced metastatic or recurrent cancer breast with 50% regression of estrogen – receptors +ve with 50% regression of estrogen – receptors +ve cases.cases.

No value in post menopausal women.No value in post menopausal women. Castration can be performed by bilateral Castration can be performed by bilateral

oophorectomy or irradiation but, oophorectomy oophorectomy or irradiation but, oophorectomy is preferable because it rules out the possibility is preferable because it rules out the possibility of residual ovarian function.of residual ovarian function.

B.B. Adrenalectomy or Adrenalectomy or hypophysectomy:hypophysectomy: Patients who respond to castration or to Patients who respond to castration or to hormonal therapy are most likely to benefit hormonal therapy are most likely to benefit from removal of adrenals or pituitary.from removal of adrenals or pituitary.

Adrenalectomy is better than hypophysectomy Adrenalectomy is better than hypophysectomy due to its wider availability and greater ease of due to its wider availability and greater ease of post operative endocrine management.post operative endocrine management.

Recently chemical method of adrenal Recently chemical method of adrenal suppression may be used amino glutethimide suppression may be used amino glutethimide 1g/daily in a combination with hydrocortisone 1g/daily in a combination with hydrocortisone 40 mg/daily it is simple, non toxic, effective.40 mg/daily it is simple, non toxic, effective.

Summery of Endocrine Summery of Endocrine TherapyTherapy

A.A. Pre menopausal women: Pre menopausal women: oophorectomy.oophorectomy.

B.B. Post menopausal women (5y): Post menopausal women (5y): Tamoxifen 10mg/twice/d.Tamoxifen 10mg/twice/d. Diethyl stiebesteral 15mg/d.Diethyl stiebesteral 15mg/d.

C.C. 2ry Endocrine Therapy:2ry Endocrine Therapy: may be may be indicated in women who had a good indicated in women who had a good response to primary endocrine response to primary endocrine manipulation and then relapsed it manipulation and then relapsed it includes: includes: 1)1) Hypophysectomy.Hypophysectomy.2)2) Adrenalectomy: surgically or with Adrenalectomy: surgically or with

aminoglutethmide 1g/daily.aminoglutethmide 1g/daily.3)3) Androgens testosterone 100mg Androgens testosterone 100mg

/I.M/3 times/weekly or recent drug /I.M/3 times/weekly or recent drug (Danazol). (Danazol).

Systemic Chemotherapy Systemic Chemotherapy It is commonly used as the 1st line of treatment It is commonly used as the 1st line of treatment

for advanced breast cancer because the response for advanced breast cancer because the response are more rapid and the rate of response is are more rapid and the rate of response is greater when drugs are used in combination greater when drugs are used in combination than when drugs are used alone.than when drugs are used alone.

The most useful single chemotherapeutic agent is The most useful single chemotherapeutic agent is "Adriamycin“ with rate of response 40 – 50%."Adriamycin“ with rate of response 40 – 50%.

CAF program every 4 weeks.CAF program every 4 weeks. CMFP program every 4 weeks.CMFP program every 4 weeks.

C: cyclophosphamide.C: cyclophosphamide.A: adriamycin.A: adriamycin.

F: fluorouracil.F: fluorouracil.M: methotrexate.M: methotrexate.

Hypercalcemia with Breast CancerHypercalcemia with Breast Cancer Hypercalcemia is may be due to osteolytic sterols Hypercalcemia is may be due to osteolytic sterols

secreted by breast tumors.secreted by breast tumors. The symptoms include confusion, nausea, vomit-The symptoms include confusion, nausea, vomit-

ing constipation, dehydration and polyuria.ing constipation, dehydration and polyuria.

1)1) Hydration with isotonic saline, in addition to Hydration with isotonic saline, in addition to rapid mobilization of bedridden institution of rapid mobilization of bedridden institution of low calcium diet devoid of daily products.low calcium diet devoid of daily products.

2)2) If the patient is under androgen or estrogens If the patient is under androgen or estrogens therapy for breast cancer, with drown therapy therapy for breast cancer, with drown therapy must be done.must be done.

TreatmenTreatment t

3)3) Chelating agents as Na Citrate promote renal Chelating agents as Na Citrate promote renal excreting of cancer.excreting of cancer.

4)4) Potent diuretics as frusamide inhibit Potent diuretics as frusamide inhibit readsorption of Ca by renal tubule.readsorption of Ca by renal tubule.

5)5) EDTA: but it’s effect is transient.EDTA: but it’s effect is transient. But these measures, may not benefit in patients But these measures, may not benefit in patients

with impaired renal function or congestive with impaired renal function or congestive failure, so other measures may used as: failure, so other measures may used as:

1) Predispose 60 – 100 mg/day to reduce 1) Predispose 60 – 100 mg/day to reduce resumption of cancer from bone.resumption of cancer from bone.

2)2) Oral phosphate.Oral phosphate.3)3) Mithramycin 25 mg/kg/I.V is effective, drug of Mithramycin 25 mg/kg/I.V is effective, drug of

choice if hydration is not possible.choice if hydration is not possible.

Other causes of hypercalcemia Other causes of hypercalcemia 1)1) Myeloma.Myeloma. 2) Lung carcinoma.2) Lung carcinoma.3)3) Prostatic carcinoma.Prostatic carcinoma. 4) Lymphomas.4) Lymphomas.5)5) LeukemiasLeukemias 6) Sarcoidosis.6) Sarcoidosis.7)7) Drugs: vitamin D intoxication, estrogen therapy Drugs: vitamin D intoxication, estrogen therapy

for breast cancer, excess Ca intake in combina-for breast cancer, excess Ca intake in combina-tion with antacids (milk alkali syndrome).tion with antacids (milk alkali syndrome).

8)8) Immobilization.Immobilization.9)9) Acute osteoporosis.Acute osteoporosis.10) Hyperthyroidism.10) Hyperthyroidism.11) Primary hyperparathyroidism.11) Primary hyperparathyroidism.

Management of Breast Cancer Management of Breast Cancer During Pregnancy and Lactation During Pregnancy and Lactation 1)1) Carcinoma during 1st half of pregnancy:Carcinoma during 1st half of pregnancy: radical radical

mastectomy without irradiation or interruption mastectomy without irradiation or interruption of pregnancy.of pregnancy.

2)2) Carcinoma during 2nd half of pregnancy:Carcinoma during 2nd half of pregnancy: require more individual consideration small require more individual consideration small lesion not treatment until after delivery if rapid lesion not treatment until after delivery if rapid growth occurs or the lesion is already stage III growth occurs or the lesion is already stage III pregnancy must be terminated lactation is pregnancy must be terminated lactation is suppressed by androgens and the lesion is suppressed by androgens and the lesion is treated.treated.

3)3)Breast cancer during lactationBreast cancer during lactation are treated are treated in conventional manner after suppression in conventional manner after suppression of lactation.of lactation.

4)4)Breast cancer under 35 yearsBreast cancer under 35 years are are encouraged to plan pregnancies after a encouraged to plan pregnancies after a minimum one year following mastectomy. minimum one year following mastectomy.

Local Recurrence Local Recurrence

1)1) Incomplete removal of tumor.Incomplete removal of tumor.2)2) Involved L.N.Involved L.N.3)3) Spillage of tumor cells into wound.Spillage of tumor cells into wound.

The rate of local recurrence correlates The rate of local recurrence correlates with: with:

Tumor size. Tumor size. Presence and No of L.N.Presence and No of L.N. Histological types of T.Histological types of T. Presence of skin edema.Presence of skin edema. Skin and fascia fixation.Skin and fascia fixation.

Causes:Causes:

Clinical Examination Clinical Examination of the Breastof the Breast

Complaint.Complaint.Past History.Past History.Family History.Family History.

History:History:

General examination.General examination.Local examination:Local examination:

Examination:Examination:

General consideration.General consideration. Inspection.Inspection. Palpation.Palpation.

Anatomical.Anatomical.Pathological.Pathological.

Diagnosis:Diagnosis:

HistoryHistory

After birthAfter birth mastitis neonatorum. mastitis neonatorum. At pubertyAt puberty puberal mastitis. puberal mastitis. In adolescenceIn adolescence hard fibro hard fibro

adenoma.adenoma. In child – bearing periodIn child – bearing period soft fibro soft fibro

adenoma, ANDI and duct adenoma, ANDI and duct papilloma.papilloma.

At any age:At any age: carcinoma carcinoma In male In male gynaecomastia and gynaecomastia and

carcinoma are the two main carcinoma are the two main affections of the breast.affections of the breast.

Age and Sex: Age and Sex:

LumpLump

Complaint: Complaint:

DischarDischargege

PainPain

A.A. Pain less lump:Pain less lump: carcinoma, fibro adenosis/cystic carcinoma, fibro adenosis/cystic hyperplasia, fibro adenoma, fat necrosis.hyperplasia, fibro adenoma, fat necrosis.

B.B. Painful lump:Painful lump: fibro adenosis hyperplasia, abscess fibro adenosis hyperplasia, abscess fat necrosis, carcinoma.fat necrosis, carcinoma.

C.C. Pain and tenderness but no lump:Pain and tenderness but no lump: pregnancy pregnancy mastitis, mild fibro adenosis/cystic hyperplasia.mastitis, mild fibro adenosis/cystic hyperplasia.

D.D. Discharge: Discharge:

Site.Site. Amount.Amount. Odour.Odour. Colour.Colour.

Duct papilloma.Duct papilloma. Mammary fistula.Mammary fistula. Duct ectasia.Duct ectasia. Mammary dysplasia.Mammary dysplasia. Duct carcinoma. Duct carcinoma. Pregnancy and lactation.Pregnancy and lactation. Abscess.Abscess. Paget’s diseasePaget’s disease

The common discharging breast The common discharging breast diseases: diseases:

Past historyPast history

Who has had cancer in one breast.Who has had cancer in one breast. With a cancer of uterus.With a cancer of uterus. Continuous administration of Continuous administration of

estrogen to post menopausal estrogen to post menopausal female.female.

Previous medical history: Previous medical history:

Early menarrache and late Early menarrache and late menopause.menopause.

Menstrual history:Menstrual history:

Unmarried.Unmarried. Married but non-lactating.Married but non-lactating. Married without children.Married without children. Married with 1st child after 30 years old.Married with 1st child after 30 years old. Married with single or multipurpose.Married with single or multipurpose.

Marital history: Marital history:

Abscess/inflammation.Abscess/inflammation. Fat necrosis.Fat necrosis.

Trauma: Trauma: Operation.Operation.T.B.T.B.

whose mothers or sisters had breast cancer.whose mothers or sisters had breast cancer.Family History: Family History:

GENERALGENERAL

ExaminationExamination

LOCALLOCAL AbdomenAbdomen ChestChest Bones/Bones/spinesspines

UmbilicusUmbilicus P.V.P.V.

General General consideratioconsiderationn

InspectionInspection PalpationPalpation

Any mass in the breast = carcinoma till Any mass in the breast = carcinoma till proved otherwise. It is a wrong statement, proved otherwise. It is a wrong statement, but a correct management.but a correct management.

InspectionInspection “ “3 positions”3 positions”

1.1. Standing or Standing or sitting with sitting with arm by the arm by the side of side of bodybody..

2.2.Sitting with Sitting with raising the arms raising the arms above the head.above the head.For accentuation For accentuation of lumps or of lumps or dimples in lower dimples in lower surface of the surface of the breast. breast. 3.3.Bending forward:Bending forward:

For detection the For detection the degree of degree of protrusion of the protrusion of the breast breast

The examiner must be stand in The examiner must be stand in front of the pat and look at both front of the pat and look at both breasts.breasts.

The two sides must be The two sides must be compared starting with the compared starting with the normal side first.normal side first.

1. Breast as whole 1. Breast as whole SizeSize

ShapeShape Semetery/contourSemetery/contour

LumpsLumps Superficial veinsSuperficial veins

2. Skin of it 2. Skin of it PuckeringPuckering

Peau d’orangePeau d’orange Thickening/Thickening/

nodularitynodularity DiscolourationDiscolouration

Ulceration/fungationUlceration/fungation Cancer en cuirassCancer en cuirass

3. Nipple 3. Nipple Level Level

DirectionDirection RetractionRetraction

FissuresFissures EczemaEczema

DischargeDischarge AnomaliesAnomalies

4. Areola 4. Areola Degree of pigmentationDegree of pigmentation

EczemaEczema

5. Axilla, arm, 5. Axilla, arm, supraclavicualrsupraclavicualr

PalpationPalpation “ “3 positions”3 positions”

1.1. Lying down in semi-Lying down in semi-recumbent 45recumbent 45ooC position C position with small pillow placed with small pillow placed beneath the scapula of beneath the scapula of the affected side (best the affected side (best position).position).

2.2. Lying down in flat position but, his position Lying down in flat position but, his position makes the breast flatten out & fall sideways.makes the breast flatten out & fall sideways.

3.3. Sitting but, this position Sitting but, this position makes the breasts makes the breasts pendulous and bulky.pendulous and bulky.

Feel the normal side first.Feel the normal side first.Examination is performedExamination is performed

in sequence:in sequence: 1) Normal breast.1) Normal breast.2) Axilla of same side.2) Axilla of same side.3) Neck and deep cervical L.N of same side.3) Neck and deep cervical L.N of same side.4) Opposite breast.4) Opposite breast.5) Opposite axilla.5) Opposite axilla.6) Opposite side of the neck.6) Opposite side of the neck.

Palpate the breast with hand flat not with Palpate the breast with hand flat not with the flat of the hand.the flat of the hand.

Palpation must done quadrant for Palpation must done quadrant for quadrant any lump felt in this way must quadrant any lump felt in this way must be considered highly suspicious of be considered highly suspicious of malignancy till prove other wise.malignancy till prove other wise.

Next:Next: Palpation with finger and thumb is Palpation with finger and thumb is performed.performed.

Any lump must be described for: Any lump must be described for:

Number Number SizeSize SensationSensation ConsistencyConsistency Relation to the muscleRelation to the muscle

SiteSite ShapeShape SurfaceSurface Relation to the skinRelation to the skin

Relation to the skin:Relation to the skin:

a) Tethering a) Tethering b) Fixationb) Fixation

TetheringTetheringWhen malignant disease in the When malignant disease in the breast begins to spread, it grows breast begins to spread, it grows along the cooper’s ligament along the cooper’s ligament infiltration of that ligament by infiltration of that ligament by tumor makes them shorter and tumor makes them shorter and inelastic. This pulls the skin in word inelastic. This pulls the skin in word puckering of skin surface, but the puckering of skin surface, but the under lying lump can still be moved under lying lump can still be moved independently of the skin for a independently of the skin for a limited distance so it is described limited distance so it is described as tethered to the skin.as tethered to the skin.

FixationFixationWhen a lump is fixed to the skin When a lump is fixed to the skin

the two structures (lump and skin) the two structures (lump and skin) can not be moved separately.can not be moved separately.

Fixity means that, there is direct Fixity means that, there is direct continuous and widespread continuous and widespread infiltration of skin by underlying infiltration of skin by underlying disease.disease.

Relation to the muscle: the same the same definitions (tethering and definitions (tethering and fixation) apply to the deep fixation) apply to the deep attachments of a lump in the attachments of a lump in the breast. But, it is more difficult to breast. But, it is more difficult to distinguish between them distinguish between them because you can not see because you can not see puckering or movement of the puckering or movement of the muscle.muscle.

Examination of the lump while Examination of the lump while the hand of the pat pressing on the hand of the pat pressing on her hip can detect the mobility her hip can detect the mobility of the lump.of the lump.

Palpation of the nipplePalpation of the nipple If there is If there is retraction tray to event it by tray to event it by

gentle pressure on either side of it.gentle pressure on either side of it. If there is If there is discharge try to find its try to find its

source by gentle pressure on each source by gentle pressure on each segment of the breast and areola. If it is segment of the breast and areola. If it is visible visible try to detect its nature from its try to detect its nature from its color. color.

Palpation of axilla: for 5 axillary Palpation of axilla: for 5 axillary L.N.L.N.

Examination of the arm.Examination of the arm.

AnteriorPosterior Lateral

Apical

Central

ExaminatioExamination of the n of the armsarms

BREASTBREASTBBreast Mass/breast as a wholereast Mass/breast as a wholeRRetraction etraction EEdema, eczemadema, eczemaAAxillary involvedxillary involvedSSanguineous anguineous TTendernessenderness

Questions of Examination Questions of Examination 1)1) Management of abnormal Management of abnormal

discharge from nipple.discharge from nipple.2)2) Acute mastitis and breast Acute mastitis and breast

abscess.abscess.3)3) Begin breast mass. Begin breast mass.4)4) Acute breast mass. Acute breast mass.5)5) Chronic breast mass. Chronic breast mass.6)6) Management of breast cancer Management of breast cancer

(early – advanced).(early – advanced).7)7) Cysts of the breast. Cysts of the breast.

D.D of acute breast D.D of acute breast masses: masses: 1)1) Acute mastitis.Acute mastitis.

2)2) Acute abscess.Acute abscess.

3)3) Acute mastitis carcinomatosis.Acute mastitis carcinomatosis.

4)4) Milk engorgement.Milk engorgement.

D.D of Ch. Breast masses: D.D of Ch. Breast masses:

1)1) Carcinoma.Carcinoma.2)2) Fibro adenoma.Fibro adenoma.3)3) Sector type of mammary Sector type of mammary

dysplasia.dysplasia.4)4) Ch. Breast abscess.Ch. Breast abscess.5)5) Traumatic fat necrosis.Traumatic fat necrosis.

D.D of cystic D.D of cystic swellings: swellings: 1)1) Cysts connected to big ducts.Cysts connected to big ducts.

2)2) Cysts connected to small ducts.Cysts connected to small ducts.

3)3) Cysts connected to Tumors.Cysts connected to Tumors.

4)4) Cysts found in the stroma.Cysts found in the stroma.

D.D of massive swelling in D.D of massive swelling in the breast (huge breast): the breast (huge breast):

1)1) Diffuse hypertrophy.Diffuse hypertrophy.2)2) Soft fibro adenoma.Soft fibro adenoma.3)3) Encephaloid carcinoma.Encephaloid carcinoma.4)4) Cystosarcoma phyllodes.Cystosarcoma phyllodes.5)5) Sarcoma.Sarcoma.6)6) Filiarial elephantiasis.Filiarial elephantiasis.7)7) Huge cystadenoma.Huge cystadenoma.

El-Shamy