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Breast
(You have to know the breast disease from A to Z ) Anatomy of breast :Blood supply medial mammary branches of perforating branches and anterior intercostals branches of the internal thoracic artery, originating .from subclavian artery lateral thoracic and thoracoacromial arteries, branches of the .axillary artery posterior intercostals arteries, branches of the thoracic artery in .the second, third and 4th intercostals space Venous drainage Mainly to the axillary vein but there is some drainage to internal .thoracic vein Lymphatic drainage Lymph passes from the nipple, areola and lobule to the subareolar . lymphatic plexus :Then from subareolar plexus Most lymph (>75%) especially from the lateral quadrant of the breast, drain to the axillary lymph node, initially to the pectoral .( anterior) node Most of the remaining lymph especially from the medial quadrant, .drain to the parasternal node Lymph from the axillary node drain into infraclavicular and supraclavicular node and from them into subclavian lymphatic .trunk Lymph from parasternal nodes drain into bronchomediastinal .trunk These 2 trunks + jugular lymphatic trunk form right lymphatic duct on the right side, or entering the termination of the thoracic duct on the left. Then open into the junction of the internal jugular and .subclavian vein

N.B. skin of the breast ( exept the nipple and areola which drained by subareolar node ) drain into the axillary, inferior deep .cervical, infraclavicular and also parasternal nodes of both sides : in sagittal suction .the breast composed of glandular tissue and fat Its secretions draining on to the surface of the nipple through 5.7 main duct orifice The primary secreting unit is a group of secular alveoli draining .into a ductile .The alveoli and ducts are lined by single layer of epithelial cells The shape of the female breast is due to fat containing within .fibrous septa, and not to the glandular tissue :Presentation of breast disease :Breast disease present in 3 main ways lump, which may or may not be painfulpain.Nipple discharge or change in appearance Lump-1

Painful lump ;d.dx (fibroadenosis ( common ( matitis ( redness absecess ( usually (postpartum or lactational cyst and rarely carcinoma :questions to ask Q1: is it associated with ?menstrual period or not Q2: is the female ?lactating

Painless lump :d.dx (fibroadenoma ( breast mouse beast cancer cyst and some times adenosis :questions to ask ?Q1; Is it mobile or fixed Q2: is there any nipple ?changes Q3: dose the patient have back ?pain or headache (carcinoma )

;pain and tendrness without lump-2 ;d.dx cyclical breast pain non cyclical breast pain very rarely carcinoma

;nipple discharges -3 a- red, pink or clear pale yellow >>> duct papilloma or .carcinoma or duct ectasia b- brown, green or black >>>> duct ectasia or cyst c- creamy white yellow >>>> duct ectasia or lactation ;questions to ask ?Q1; is it come spontaneously ? Q2; is it unilateral ?Is it persistence ?Is the female lactating or not

:nipple changes -4 Duct ectasia Carcinoma Paget disease Eczema

change in breast size -5 Pregnancy Carcinoma Benign hypertrophy Rare large tumor

If you have breast case, you have .to cover all these symptoms

Examination of breast The patient must be fully undressed to the waist, resting comfortably on an examination couch with her body raised at 45 degree to the leg. This position is the best compromise between lying flat , which makes the breasts full sideways, and sitting .upright, which makes the breasts pendulous Ask the patient to slowly raise her arms above her head>>>> skin change may then become more apparent, particularly tethering to .the skin Ask the patient to press her hand against her hip to tense pectoral .muscle inspection Inspect area from clavicle upward to the 6th intercostals space .downward, and from midline to anterior axillary line Do not forget, inspect the axillae, arm and supraclavicular area for .dilated vein or LN enlargement :You have to inspect breast size-1 Symmetry-2 :skin-3 .the skin may be fixed by underlying cancer Peau, d orange, ( there may be edema caused by obstruction of skin lymphatics by cancer cells, which mark the opening of hair follicle and sweat .(glands result in orange- peel appearance Nipples and areola-4 The color of the nipple change with age, and there is darkening during .pregnancy .Nipple inversion or eczematous changes Duplication: accessory nipple :Palpation .Palpate with flat of the fingers and not with the palm of the hands If you find a lump, ascertain its site, size, shapeetc For example: there is a lump in left upper outer quadrant, 2*3cm, spherical, smooth not Fixed to skin, not tender..etc

.You have to palpate the axillae, and axillary lymph node .Normal breast is firm, fibrous and easily palpable nodule *** There is different between skin fixed and tethering ** .If a lump can not be moved without moving the skin, it is fixed .If a lump can move independently, it is skin tethering .A tethering lesion is one which is more deeply situated :Triple assessment history and examination-1 diagnostic imaging ( US <30 and mammogram >30 ) >>> -2 .important for screening cytology or histology ( fine needle aspiration FNA) >>> Most -3 .reliable :Breast disease breast carcinoma cancer of the breast is an adenocarcinoma and the commonest .cancer in women The cut surface of a carcinoma is classically concave, gritty .and pale grey with prominent yellow and white flecks :Etiology ;genetic factors-1 Family history >>>>> premenopausal first-degree relative ** with breast cancer confers a lifetime risk of 25%, which reduce .to 14% if the same relative is postmenopausal If both mother and sister develop premenopausal BC, the risk .is 33% Gene carriage >>> BRCA1 AND BRCA2 ( AUTOSOMAL ** .DOMINENT) present in 80-90% of the cases An individual whose mother carries a mutation in one of these genes has a 50% chance of inheriting that mutation, which will .confer a lifetime risk of 80-90% The presence of mutation in BRCA1 also increase risk of .ovarian cancer :hormonal factors -2 Gender>>>> women are 100 times more likely to have BC than .men
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Menarche and menopause>>>> early menarche and late .menopause are associated with high risk Parity >>> nulliparous and late age at first pregnancy (35yr) .have high risk .Hormonal replacement therapy also slightly increase the risk benign breast disease ( lobular or ductular hyperplasia) -3 .increase the risk of 4-5 times radiation exposure in adolescences or early childhood -4 .increase the risk The commonest type of BC (85%) is invasive ductal carcinoma .(or (no special type NST :SPREAD direct extension to skin >>>> skin dimpling and nipple -1 retraction <<< by lymphatic >>> blockage of lymphatic >>> edema -2 .pea, d orange The main lymph channels pass directly to the axillary and internal thoracic LN. later spread to the supraclavicular, .abdominal, mediastinal, groin and opposite axillary node .blood >>>> to lung, liver, brain and bone -3 :Prognostic factors axillary node status >>>> the greater the number of -1 .ipsilateral node>>> the worse the prognosis (tumor grade ( histology -2 .(Well differentiated(1), poor differentiated(2) or plemorphic (3 .tumor size >>>> large size more prone to metasis -3 :(NPI (Nottingham prognostic index The above 3 prognostic factors combined to form a prognostic index which allocate patient to 5 different groups with variable .10 yr survival rate :The NPI is calculated as follows .DIAMETER+ GRADE+ NODAL STATUS *0.2 (see table 35-1 lecture note)
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:TNM classification T >>>> TUMOR T IS >>> CARCINOMA IN SITU T0 >>>> no primary tumor located T 1 >>>> tumor less than 2 cm >>>> 80% 5 year survival T2 >>>> tumor 2-5 cm >>>> 50% 5 year survival T3 >>>> tumor more than 5 cm >>>> 15% 5 year survival T4 >>>> extension to chest wall >>>> 5% 5year survival N >>>> NODE N1 >>>>> no palpable axillary node N2 >>>> MOBILE palpable axillary node .N3 >>>>> palpable supraclavicular nodes M >>>> metasis M0>>>> no metasis M1 >>>> distance metasis ;History of breast carcinoma .Age>>> rare in teenager and 20 from 30 onward there is progressively increase incidence to .which peak in late 50 :Clinical pictures .Majority of patients with invasive BC have painless lump -1 Other features are nipple changes, blood stained nipple -2 .(discharge and unilateral nipple eczema (paget disease .The nipple may become retracted, or even destroyed -3 Swelling of the arm, caused by lymphatic or venous -4 .obstruction in the axilla Backache, caused by secondary infiltration and collapse of -5 lumbar vertebrae, with nerve root pain radiating down the back of legs, is a common symptoms of advanced disseminated .disease .Cerebral metaplasia may cause a fit -6 Pathological fracture may be the first indication of the -7 .presence of the disease The general symptoms commonly associated with cancer, such as malaise, weight loss and cachexia, are rare in patient with

breast cancer. Even those with disseminated fatal disease .usually feel well in themselves until the final stages

;Examination Site; half of carcinomata of the breast occur in upper outer .quadrant, which include the axillary tail :Colour If the tumor is close to the surface, the overlying skin may be .discolored Tumor fixed to the skin first give the skin a smooth, redness appearance, but as the process advance and ulceration is .imminent, the skin becomes paler Tenderness: most carcinomata are not tender, but palbation .may produce mild discomfort Temperature: only the very rare ' inflammatory type' of breast .carcinoma feel warm .Shape; in early stages, it is roughly spherical Surface: the surface is usually indistinict, which makes it difficult to define the shape. Few cancer are encapsulated and .have smmoth surface, mimicking cysts and fibroadenoma Composition: carcinomas are solid, so they do not fluctuate, .transilluminte or have a fluid thrill .Their consistency is normally quit firm .Some are soft as a lipoma Fixation of a lump to the skin is almost diagnostic of a carcinoma. The only other condition producing fixation is .traumatic fat necrosis or pointing abscess (Peau d, orange ( already mentioned Lymph gland containing metastases are usually hard and .discrete. Ulceration in the axilla is rare

:General examination ;Essential to detect the metastasis The skeleton; especially the lumbar spine, causing back pain .and reduced spinal movements The lung: plural effusion, lung parenchyma, in the form of diffuse lymphatic involvement known as lymphangitis .carcinomatosa, may cause severe dyspnea .The liver; making it palpable and causing jaundice and ascities .The skin; producing multiple hard nodules within the skin ;Condition mimicking breast cancer Fat necrosis; fat necrosis occur in the elderly after an injury -1 or trauma. There may be focal necrosis of subcutaneous fat .with local scaring which causes skin tethering Mondor,s disease; it is thrombophlebitis of the lateral thoracic-2 vein which produce a cord like, linear skin puckering. It .rexsolve spontaneously ;Treatment :Early breast cancer wide local excision >>> removal of the lump with margin of -1 .normal breast simple mastectomy involve excising the breast tissue ( it -2 usually combined with reconstructive surgery) + axillary node clearance. By this combination we avoid the needs of .postoperative radiotherapy in most cases ;adjuvnt therapy -3 Pt. with early BC should be considered for chemotherapy with .(or without antiestrogen (tamoxifin Antiestrogen therapy should be given only in females who have .estrogen receptors are positive (In Stage 4 ( palittation local radiotherapy for fungation -1 .radiotherapy to bone metastasis -2 .aspiration of pleural effusion -3 tamoxifine -4 .chemotherapy -5 N.B. patients with bone metastasis>>> hormonal therapy is .better than chemotherapy While patients with liver metastasis>>> chemotherapy is .better
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:Complication of mastectomy wound seroma -1 stiffness of the shoulder -2 .lymphedema of the arm -3 .psychological -4

:the cardinal signs of a late cancer of breast .hard, non tender, irregular lump -1 tethering or fixation of lump -2 .palpable axillary lymph gland -3 Benign breast tumor :(fibroadenoma ( breast mouse -1 .The commonest breast tumor in young women A fibroadenoma is a benign neoplasm of the breast in which .fibromatous element is the dominant feature There are 2 histological varieties of fibroadenomata, pericanalicular, which mainly consist of fibrous tissue, and .intracanlicular, which contain more glands Most fibroadenomata present in young women, age between 15 .and late 20 :History .The patient present with painless lump, that it is highly mobile :Examination Will demarcated, spherical, painless, smooth, firm swelling that .can present anywhere in the breast .It is the most mobile of all breast lesions :Deferential diagnosis Breast cyst, but cysts are found in a different age group and are .not usually mobile .all fibroadenoma must be investigated by triple assessment .The largest lump should undergo core biopsy Surgery should be avoidable in the majority of cases but should ;be considered in the following circumstances lump increase in size -1 symptomatic lump- pain or tenderness -2
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.patient preference -3 :(Phylloides tumor ( cystsarcoma phyllodes or brodie tumor This is rare, large and massive, irregular, bosselated tumor that .dose not metastasis. LN enlargement is rare It present as a slow- growing, smooth swelling in the middle .age>40 .It can be big enough to cause skin necrosis :Treatment .Removal of the tumor with a wide margin of normal breast If massive tumor>>>> total mastectomy with axillary node .sampling :Intraduct papilloma .This due to hyperplasia of the duct epethelia lining .Predispose to malignant >>>> ductal carcinoma- in situ .It is the only benign breast disease that may lead to malignancy .The most common cause of Bleeding from nipple Papilloma can be felt as a small nodule at the areolar margin, .pressure at that point >>> discharge :Treatment .Surgical excision of the involved duct :Lipoma of the breast Lipoma may occur anywhere in the body where there is fat, which include the breast, both SC and more deeply seated between the .lobule :Lumps and nodularity The symptoms of lumps and nodularity occur during the years of ovarian activity, from early menarche to menopause, beginning in .the early 20 and reaching the peak in the 30 :Symptoms Pt. present with more than 1 lump in the breast which are commonly tender. The pain is Intermittent related to menstrual cycle, mostly in premenstrual phase and resolving when the .menses begin :On examination Benign breast lump vary from a diffuse nodularity to quite discrete .lesion
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Nodular lumps tend to be in the upper outer quadrants and have .moderate hardness, sometimes describe as rubbery .They are not fixed or tethered to skin or muscle ;Breast pain Cyclical breast pain Non- cyclical breast pain :cyclical breast pain -1 .Cyclical breast pain is very common .It comes on during the second half of the cycle It is quite commonly unilateral, it may be felt through out the .breast, or more in the upper outer quadrent .The pain is usually reduced by oral contraceptive On examination, there may be tenderness but no discrete lump. Diffuse nodularity is common particularly in upper outer quadrant .The pain is never a symptom of cancer :Treatment: If the pain is so severe .(bromcriptin ( dopamine antagonist .(danazol ( gonadotropin antagonist .tamoxifen .firm supporting brassiere may help :non- cyclical breast pain -2 .This is less common :It occur at these condition at puberty .(at menopause due to cessation of hormone ( usually unilateral tietze syndrome ( this is uncommon condition in which pain and tenderness arise from costochondral junction lateral to the .sternum). The pain is exacerbated by movement duct ectasia .mondors disease .inflammatory disease :Breast cyst Breast cyst is probably the commonest of the discrete breast .swelling Breast cyst is fluid filled cavity appears in the breast, without a .demonstrated endothelial lining or a capsule

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This condition occur at times when the pt. hormone environment is changing, usually around the menopause ( before the age of 40, .(the peak incidence is in the late in 40 and early 50 :Presentation They may develop sudden swelling, moderate pain and .tenderness are common ;Examination .Solitary cyst is smooth, spherical swelling If it is large cyst, it may be visible and even appear blue or green through the skin, but there will never be tethering or fixation to skin .or muscle It is rarely possible to elicit fluctuation or fluid thrill or to .transilluminate the lesion The clinical diagnosis of a cyst, will processed immediately to .needle aspiration, the appropriate treatment The fluid that emerges is variable in color and clarity, varying from .very dark green to clear yellow Galactocele It is milk containing cyst and occur during or after lactation. It .presents as above and the physical signs are similar Aspiration produces milk, but the cyst rapidly refills and resolution .must await cessation of breast feeding :Paget disease of then nipple Paget disease of the nipple is caused by cancer cells migrating or spreading along the duct system from a carcinoma situated deeply in the breast, which in the early stages is usually confined to the .(epithelium (DCIS THE presence of carcinoma cells in the skin of the nipple produce a clinical appearance similar to that of eczema. patches of skin first become red and then encrusted and oozy. The edges of .these lesions are distinict, unike eczema, and they do not itch .In time the nipple is destroyed, and replaced by a malignant ulcer Paget disease of the nipple always indicated underlying malignant .process in the breast itself ;The different between eczema and paget disease of the nipple

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eczema Bilateral Commonly occur at lactation Itches Vesicles Nipple intact No lump

Paget disease unlateral Occur at menopause Dose not itch No vesicles Nipple may be destroyed May be underlying lump

:Duct ectasia .This is common of unknown etiology It is dilatation of the mammary ducts, which are full of inspissated material containing macrophages and chronic inflammatory .debris :It has the following presenting features .nipple inversion, which is at first mild and readily everted There is characteristic transverse slit appearance. In many pt. this .is the only feature .difficulty in breast feeding nipple discharge chronic low grade infection of the peri- areolar area, with tender thickening around the nipple, going on abscess formation, known .as periductal mastitis periductal abscess that may rupture and stay in communication .with the duct system. This result in mammillary fistula ;Supernumary breast/ nipple Extra nipple or breast develope along the primitive milk line as a .congenital anamolies Breast absess .Acute breast abscess is often associated with lactation .S. aureous is the commonest organism Bacteria may gain access to the engorged breast lobules, an .excellent medium for bacterial culture The pt. develop malise and fever accompanied by an ache in the .breast which progresses to throbbing pain
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:On examination :Signs of inflammation which are .Pain, redness, swelling It is safe to continues breast feeding even from the breast .containing the abscess When a breast abscess occurs in a women who is not lactating there is often a predisposing risk factor such as diabetes mellitus .or immunocompromise ;Recurrent and chronic breast abcess .It is usually associated with duct ectasia .Tuberculosis remain common in some part of the world .Mycobacterial infection is rare cause :the breast changes of pregnancy ** fullness and pricking sensation .enlargement and distended subcutaneous vein increase nipple and areolar pigmentation with clear, expressed .(secretion( colostrums hypertrophy of subareolr sebaceous glands ( montogomery .(tubercle :The male breast .There are 2 causes of enlargement of the male breast (gynecomastia ( benign -1 ;The causes of gynecomastia are The pt. complain of painless, or slightly tender, enlargement of .one or both breast There is clearly palpable disk of firm breast tissue behind and .attached to the areolar General examination, especially of liver and scrotum (testes), may .yield information that indicate the likely cause ;carcinoma of the male breast -2 .It is uncommon, usually of elderly men Its symptoms and signs are identical to those of carcinoma of .female breast .There is little public awareness of the condition Because the male breast is small and not covered by a thick layer .of SC fat, the disease spread rapidly

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Physical signs such as skin and muscle fixation, ulceration and axillary lymphadenopathy are often present by the time of .presentation

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