Lecture of Breast

Property of Prof. Dr. Mohamed Ahmed Yehia, Department of General Surgery, Faculty of Medicine, University of Zagazig, Egypt

2. THE THE
BREASTBREAST
ByBy
Prof. Dr. Mohamad YahiaProf. Dr. Mohamad Yahia
Professor of General SurgeryProfessor of General Surgery
Zagazig Faculty of MedicineZagazig Faculty of Medicine

3. SURGICAL ANATOMYSURGICAL ANATOMY
The breast consists of following The breast consists of following
parts: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.

4. 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`sCooper`s LigLig". ".

5. 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`sCooper`s LigLig". ".

6. 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.

7. Blood supply of the breast:Blood supply of the breast:
A.A.Arterial supplyArterial supply
1)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 the breast.These two vessels supply the lateral aspect of 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 the breast.These two vessels supply the medial aspect of the breast.

8. MedialLateral

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

10. 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 umbilical nodule which can be occur also
from lymphatics though the posterior rectus from lymphatics though the posterior rectus
sheath.sheath.

11. 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 notesAxillary lymph notes

12. 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 pointsSome surgical clinical important points
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.

13. 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.

14. Indications of mammographyIndications of mammography
1.1.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.

15. 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.

16. 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.

17. 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.

18. Biopsy and cytology Biopsy and cytology
A-A-Trucut or Trucut or corecut 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 "FNACFNAC" "
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).

19. 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

20. THE NIPPLETHE NIPPLE
1.1.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 “
milklinemilkline”.”.
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.

21. 4.4. RetractionRetraction::
Congenital retraction.Congenital retraction.
Remote simple retractionRemote simple retraction occurs at occurs at
puberty, it is simple inversion, puberty, it is simple inversion,
unknown etiology, bilateral in 25% of unknown etiology, bilateral in 25% of
cases. cases. Treatment:Treatment: drawing out the drawing out the
nipple between finger and thumb nipple between finger and thumb
daily for three weeks during and daily for three weeks during and
sonly often puberty.sonly often puberty.
Recent retraction:Recent retraction: Usually Usually
accompanied with scirrhous accompanied with scirrhous
carcinoma occurs at womanhood.carcinoma occurs at womanhood.

22. 5- Nipple discharge5- Nipple discharge
a- Clear, serous discharge a- Clear, serous discharge
Physiological "early pregnancy".Physiological "early pregnancy".
Mammary dysplasia.Mammary dysplasia.
b-b-Blood stained discharge Blood stained discharge
Intra ductal papilloma.Intra ductal papilloma.
Intra ductal carcinoma. Intra ductal carcinoma.
Duct ectasia.Duct ectasia.

23. c-c-Black or brownish greenBlack or brownish green
Mammary dysplasia with cyst.Mammary dysplasia with cyst.
Duct ectasia.Duct ectasia.
d-d-MilkMilk
Following lactation.Following lactation.
Galactocele.Galactocele.
Increase in secretion of pituitary prolactin.Increase in secretion of pituitary prolactin.
Contraceptive pills.Contraceptive pills.
e-e-PurulentPurulent
Breast abscess.Breast abscess.
Fistula.Fistula.

24. The most common cases are:The most common cases 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.

25. 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

26. HB +veHB +ve
Over 40Over 40
HB –veHB –ve
under 40under 40
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 disappears
2.2.Localized to one duct: Localized to one duct:
Microdochectomy.Microdochectomy.
3.3.Lump appears: lumpectomy.Lump appears: lumpectomy.

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

28. 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 carcinoma of the breast, accepted theory is
that the disease started as intraductal that the disease started as intraductal
carcinoma which spread in two directions: one carcinoma which spread in two directions: one
to the skin of nipple → eczema and other to the to the skin of nipple → eczema and other to the
breast tissue → mass.breast 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

29. 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

30. 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.

31. 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 or followed by supra mammary type or
due to congenital abnormality with due to congenital abnormality with
abscess formation abscess formation
Treatment:Treatment: The track is laid open and The track is laid open and
saucerized or excision of the fistula saucerized or excision of the fistula
with its related duct.with its related duct.

32. 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
Clinically:Clinically:
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.

33. 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 mastectomy. Multiple masses: simple mastectomy.

34. Congenital abnormalities Congenital abnormalities
of the breastof the breast
1-1-Amazia Amazia
Absence of breast (Absence of breast (unilateralunilateral or or
bilateral).bilateral).
May associate with absence of the May associate with absence of the
sternal portion of the pectoralis sternal portion of the pectoralis
major "Poland’s syndrome"major "Poland’s syndrome"
Common in male.Common in male.

35. 2- Polymazia2- Polymazia
Presence of Presence of one or moreone 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 breasts3- Diffuse hypertrophy of the breasts
Usually 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
hypertrophyhypertrophy of stroma and fat of stroma and fat
Treatment:Treatment: Reduction mammoplasty. Reduction mammoplasty.

36. Injuries of the BreastInjuries of the Breast
HaematomaHaematoma
It 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 necrosis
It 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.

37. Acute mastitis and acute Acute mastitis and acute
breast abscessbreast 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.

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

39. 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 subsides puberty, the condition subsides
spontaneously and needs no spontaneously and needs no
special therapy. Suppuration special therapy. Suppuration
never occur.never occur.
3- Mastitis of mumps3- Mastitis of mumps
Unilateral in femaleUnilateral in female

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

41. 6- Mastitis due to bacterial 6- Mastitis due to bacterial
invasion with abscess invasion with abscess
formationformation
It is the most common variety of It is the most common variety of
mastitis. 32% of mastitis in female is mastitis. 32% of mastitis in female is
due to bacterial mastitis without due to bacterial mastitis without
lactation probably may due to lactation probably may due to
infected haematoma. the common infected haematoma. the common
infected organism is "infected organism is "Staph aureusStaph aureus" "
which is penicillin resistant.which is penicillin resistant.

42. 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.

43. 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.

44. 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..

45. 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

46. In intramammary abscessIn intramammary abscess
The 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 abscess
It 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.

47. Chronic specific inflammationChronic specific inflammation
1- 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 form of tender mass or
masses which may be masses which may be
mistaken for tumors. It may mistaken for tumors. It may
be adherent to the skin with be adherent to the skin with
multiple caseous discharging multiple caseous discharging
sinus.sinus.
Treatment:Treatment:
Anti-T.B. drugs with excision of the affected Anti-T.B. drugs with excision of the affected
part.part.

48. 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.

49. 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 periphery
3- No nipple retraction3- No nipple retraction
4- 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.

50. Mondors Mondors
disease:disease:It is thrombophlebitis of superficial It is thrombophlebitis of superficial
veins of the breast and anterior chest veins of the breast and anterior chest
wall in absence of injury or wall in absence of injury or
inflammation due to unknown causes.inflammation due to unknown causes.
Clinically:Clinically: presented with indurated presented with indurated
subcutaneous cord like structure. It subcutaneous cord like structure. It
may be diagnosed as lymphatic may be diagnosed as lymphatic
permeation of an occult carcinoma. permeation of an occult carcinoma.
Treatment:Treatment: restriction of arm restriction of arm
movements.movements.

51. 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 disease7. Monder’s disease
8. 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)

52. Fibroadenosis/Cystic hyperplasiaFibroadenosis/Cystic hyperplasia
“Aberrations of normal development “Aberrations of normal development
and involution” (ANDI)and involution” (ANDI)
““Mammary Mammary dysplesiadysplesia””
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.

53. 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

54. 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.

55. 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.

56. The relationship of mammary dysplasia The relationship of mammary dysplasia
to carcinoma: 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.

57. 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.

58. CYSTS OF THE BREAST CYSTS OF THE BREAST
1) Cysts connected to big ducts (1) Cysts connected to big ducts (galactocelegalactocele
& & Simple retention cystSimple retention cyst).).
2) Cysts connected to small ducts (Cysts of 2) Cysts connected to small ducts (Cysts of
mammary dysplasia).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).

59. 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.
Treatment:Treatment:
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

60. FibroadenomaFibroadenoma
Two types: Two types: hard pericanalicular typehard pericanalicular type where where
the ducts are surrounded by dense C.T. the ducts are surrounded by dense C.T. soft soft
intracanalicular typeintracanalicular 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.

61. 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.
Treatment:Treatment:
If small: decisional biopsy.If small: decisional biopsy.
If larger: simple mastectomy + biopsy.If larger: simple mastectomy + biopsy.

62. Cystosarcoma PhyllodesCystosarcoma Phyllodes
(Serocystic Disease of Brodie)(Serocystic Disease of Brodie)
““PhylloidsPhylloids Tumors 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.

63. 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

64. 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:

65. 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 from In general, the rates reported from
developing countries are low, where as developing countries are low, where as
rates are high in developed countries rates are high in developed countries
except in Japan.except in Japan.
Etiology and PathogenesisEtiology and Pathogenesis
Family history:Family history: Women whose mother or Women whose mother or
sisters had breast cancer are 2 or 3 sisters had breast cancer are 2 or 3
times more likely to develop the disease times more likely to develop the disease
than controls.than controls.

66. 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:

67. There is some evidence that continuous There is some evidence that continuous
administration of estrogens to administration of estrogens to
postmenopausal women may result in an postmenopausal women may result in an
increased risk of breast cancer after 10 – increased risk of breast cancer after 10 –
12 years.12 years.
It should be noted that the adrenal gland It should be noted that the adrenal gland
is a major source of estrogen and is a major source of estrogen and
androgen in postmenopausal women.androgen in postmenopausal women.
There is no correlation between thyroid There is no correlation between thyroid
mass and breast cancer, but some mass and breast cancer, but some
reported higher incidence of breast cancer reported higher incidence of breast cancer
in patient with hypothyroidism.in patient with hypothyroidism.
Hormonal Factor: Hormonal Factor:

68. 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 Breast: Risk Factors for Female Breast:

69. 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 rats.human body although it is effective in rats.
Milk Factor: Milk Factor:
It has a role in animal but, no evidence in It has a role in animal but, no evidence in
human.human.
Role of Virus: Role of Virus:

70. 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 ClassificationStaging and Classification

71. 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).

72. 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:

73. 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

74. 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 features
Symptoms: Symptoms:

75. 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.

76. 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:

77. 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.

78. 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.

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

80. 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

81. 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
carcinomacarcinoma
1)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.

82. Pathology of Carcinoma Pathology of Carcinoma
of the Breast:of the Breast:
All types of carcinoma of the breast All types of carcinoma of the breast
arise in epithelium of the duct, with arise in epithelium of the duct, with
variation in the power of infiltration of variation in the power of infiltration of
the breast tissue.the breast tissue.
1)1)Site of affection.Site of affection.
2)2)Pathological classification.Pathological classification.

83. 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 infiltration
and invasion of breast tissue and invasion of breast tissue
resulting in variable degree of resulting in variable degree of
cellular and fibrous tissues.cellular and fibrous tissues.
2.2.Spheroidal cell carcinomaSpheroidal cell carcinoma

84. 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.

85. 3.3.Paget’s disease.Paget’s disease.
The cells are distended with colloid The cells are distended with colloid
material and the nucleus is pushed to material and the nucleus is pushed to
one side "signet ring”. It is bulky one side "signet ring”. It is bulky
tumor not highly malignant as in tumor not highly malignant as in
colloid type of carcinoma of stomach colloid type of carcinoma of stomach
or colon.or colon.
4.4.Colloid carcinomaColloid carcinoma
1. Local: 1. Local: into breast tissue and later to into breast tissue and later to
pectoral M. and chest wall.pectoral M. and chest wall.
3)3)SpreadSpread

86. 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:

87. 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

88. Special Clinical from of Special Clinical from of
Carcinoma of BreastCarcinoma of Breast
1) Mastitis carcinoma 1) Mastitis carcinoma most most
malignant.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 carcinoma
most big.most big.
5) Duct carcinoma5) Duct carcinoma most bloody.most bloody.

89. 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 or easily mistaken for acute mastitis or
breast abscess for the following breast abscess for the following
reasons:reasons:

90. 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.

91. 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 present 95 % of cases the patients present
with a painless lump discovered with a painless lump discovered
accidentally during washing accidentally during washing
The breast may be smaller than the The breast may be smaller than the
other breast with higher level.other breast with higher level.
The nipple is retracted with evidence The nipple is retracted with evidence
of malignant skin features.of malignant skin features.
The mass is hard and may be fixed The mass is hard and may be fixed
to the muscle or to the skin.to the muscle or to the skin.

92. 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

93. Treatment of Breast CancerTreatment of Breast Cancer
A.A. Early breast cancer: Early breast cancer:
No evidence of disease beyond No evidence of disease beyond T2 T2
N1.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.

94. A- Treatment of early breast cancerA- Treatment of early breast cancer
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 of affected breast and either removal of
axillary nodes or their treatment by axillary nodes or their treatment by
irradiation constitute effective local irradiation constitute effective local
treatment.treatment.

95. 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.

96. 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.

97. Some surgical points in mastectomy Some surgical points in mastectomy
Structures must be protected during Structures must be protected during
mastectomy: 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 thrombosed.axillary vein ligated or thrombosed.

98. Dissection begins from axilla for Dissection begins from axilla for
the following reasons: the following reasons:
To allow early exploration of axilla.To allow early exploration of axilla.
To avoid lymphatic dissemination if To avoid lymphatic dissemination if
the tumor is mobilized first.the tumor is mobilized first.
The chest wall remains covered by The chest wall remains covered by
the breast most of the time of the breast most of the time of
operation. This will minimizes operation. This will minimizes
shock and pulmonary complication.shock and pulmonary complication.

99. Radical mastectomy may be required Radical mastectomy may be required
for some cases of advanced local for some cases of advanced local
disease of the tumor invade the disease of the tumor invade the
muscle.muscle.
Extended radical mastectomy could Extended radical mastectomy could
be only for patients with medical be only for patients with medical
lesions, axillary L.N. involvement but lesions, axillary L.N. involvement but
no signs of distant metastases.no signs of distant metastases.

100. 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: failure Injury to nerve to latissimus dorsi: failure
of adduction.of adduction.
Early postoperative edema: due to Early postoperative edema: due to
axillary vein thrombosis or infection, also axillary vein thrombosis or infection, also
it may indicate complete clearance of it may indicate complete clearance of
axilla.axilla.
Wound complications.Wound complications.
ShockShock
PneumothoraxPneumothorax

101. 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 been When a simple mastectomy policy has been
adopted.adopted.

102. Indications of preoperative irradiation:Indications of preoperative 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 grafting In these two cases, the skin grafting
after radical mastectomy is usually after radical mastectomy is usually
needed and if post operative needed and if post operative
irradiation is given the graft will irradiation is given the graft will
slough.slough.

103. 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 vascular.It renders the tissue more vascular.
The patient may refuse the operation The patient may refuse the operation
if irradiation causes some reduction if irradiation causes some reduction
in size of tumor.in size of tumor.
However:However: recent studies show that pre recent studies show that pre
operative irradiation is better in operative irradiation is better in
preventing post operative local preventing post operative local
recurrence than post operative.recurrence than post operative.

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

105. 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:

106. A- Treatment of advanced breast cancerA- Treatment of advanced breast cancer
A. Local therapy:A. Local therapy:
1) Surgery.1) Surgery.
2) Radio therapy.2) Radio therapy.
3) Cytotoxic.3) Cytotoxic.
B. Systemic therapy:B. Systemic therapy:
1) Hormonal 1) Hormonal
therapy.therapy.
2) Cytotoxic therapy.2) Cytotoxic therapy.
3) Management of 3) Management of
hypercalcemia. hypercalcemia.
4) Immune therapy.4) Immune therapy.

107. 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 for Palliative simple mastectomy for
untreated fungating tissue.untreated fungating tissue.
d. Effects of distant metastases as: d. Effects of distant metastases 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.

108. (2) Radiotherapy: (2) Radiotherapy:
Radical irradiation of the breast, Radical irradiation of the breast,
chest wall and axillary lymph nodes chest wall and axillary lymph nodes
for locally advanced inoperable for locally advanced inoperable
lesions with no evidence of distant lesions with no evidence of distant
metastases.metastases.
Palliative radiotherapy may be used Palliative radiotherapy may be used
for locally advanced cases with for locally advanced cases with
distant metastases in order to control distant metastases in order to control
ulcer-ation, pain and other 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.

109. (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 and closed tube drainage of the chest and
intra-pleural instillations of sclerosing intra-pleural instillations of sclerosing
agent through inter costal tube.agent through inter 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 saline tetracycline dissolved in 30ml of saline
are then infected into the pleural cavity are then infected into the pleural cavity
through the tube, which is clamped for through the tube, which is clamped for
6 hours.6 hours.

110. The patient’s position is clamped The patient’s position is clamped
frequently to distribute the frequently to distribute the
tetracycline within the pleural cavity. tetracycline within the pleural cavity.
This procedure is repeated for 5-6 This procedure is repeated for 5-6
days, thus, if the sclerosing action of days, thus, if the sclerosing action of
tetracycline is effective adherence of tetracycline is effective adherence of
visceral to partial pleura is occurred.visceral to partial pleura is occurred.
Other chemo therapeutic agent as Other chemo therapeutic agent as
thiotepa may cause nausea, vomiting thiotepa may cause nausea, vomiting
or bone marrow depression. or bone marrow depression.

111. 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 primary It is the time from the primary
treatment to appearance of treatment to appearance of
metastases.metastases.
The chance of success The chance of success
increases as the free interval increases as the free interval
lengthens.lengthens.

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

113. 4) Pregnancy: 4) Pregnancy:
Tumors occur during pregnancy Tumors occur during pregnancy
or lactation diagnosed late or lactation diagnosed late
because physiologic changes in because physiologic changes in
the breast may obscure the true the 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.

114. (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 in factor and is of great importance in
managing patients with recurrent or managing patients with recurrent or
metastatic disease.metastatic disease.

115. (3) Forms of Hormonal treatment:(3) Forms of Hormonal treatment:
1) Estrogen:1) Estrogen:
Women more than 5 years post Women more than 5 years post
menopausal.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 H
22O 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.

116. 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.

117. 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.

118. 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.

119. 5) Endocrine ablation5) Endocrine ablation
A. 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.

120. B.B.Adrenalectomy or hypophysectomy:Adrenalectomy or 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.

121. 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.

122. C.C.2ry Endocrine Therapy:2ry Endocrine Therapy: may be indicated may be indicated
in women who had a good response to in women who had a good response to
primary endocrine manipulation and then primary endocrine manipulation and then
relapsed it includes: relapsed it 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).

123. 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.

124. 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.
Treatment Treatment

125. 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.

126. 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.

127. Management of Breast Cancer During Management of Breast Cancer During
Pregnancy and Lactation 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.

128. 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.

129. 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 with: The rate of local recurrence correlates 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:

130. Clinical Examination of Clinical Examination of
the Breastthe 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:

131. HistoryHistory
After birthAfter birth mastitis neonatorum. mastitis neonatorum.
At pubertyAt puberty puberal mastitis. puberal mastitis.
In adolescenceIn adolescence hard fibro adenoma. hard fibro adenoma.
In child – bearing periodIn child – bearing period soft fibro soft fibro
adenoma, ANDI and duct papilloma.adenoma, ANDI and duct papilloma.
At any age:At any age: carcinoma carcinoma
In male In male gynaecomastia and carcinoma gynaecomastia and carcinoma
are the two main affections of the are the two main affections of the
breast.breast.
Age and Sex: Age and Sex:

132. LumpLumpLumpLump
Complaint: Complaint:
DischarDischar
gege
DischarDischar
gege
PainPainPainPain

133. 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.

134. 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:

135. 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 estrogen Continuous administration of estrogen
to post menopausal female.to post menopausal female.
Previous medical history: Previous medical history:
Early menarrache and late Early menarrache and late
menopause.menopause.
Menstrual history:Menstrual history:

136. 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:

137. GENERALGENERAL GENERALGENERAL
ExaminationExamination
LOCALLOCAL LOCALLOCAL
AbdomenAbdomen
ChestChest
Bones/spineBones/spine
ss
UmbilicusUmbilicus
P.V.P.V.
General General
considerationconsideration
InspectionInspection
PalpationPalpation

138. 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 bodyside of body..

139. 2.2.Sitting with raising Sitting with raising
the arms above the the arms above the
head.head.
For accentuation of For accentuation of
lumps or dimples in lumps or dimples in
lower surface of the lower surface of the
breast. breast.
3.3.Bending forward:Bending forward:
For detection the For detection the
degree of protrusion degree of protrusion
of the breast of the breast

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

141. 1. Breast as whole 1. Breast as whole 1. Breast as whole 1. Breast as whole
SizeSize
ShapeShape
Semetery/contourSemetery/contour
LumpsLumps
Superficial veinsSuperficial veins

142. 2. Skin of it 2. Skin of it 2. Skin of it 2. Skin of it
PuckeringPuckering
Peau d’orangePeau d’orange
Thickening/nodularityThickening/nodularity
DiscolourationDiscolouration
Ulceration/fungationUlceration/fungation
Cancer en cuirassCancer en cuirass

143. 3. Nipple 3. Nipple 3. Nipple 3. Nipple
Level Level
DirectionDirection
RetractionRetraction
FissuresFissures
EczemaEczema
DischargeDischarge
AnomaliesAnomalies

144. 4. Areola 4. Areola 4. Areola 4. Areola
Degree of pigmentationDegree of pigmentation
EczemaEczema
5. Axilla, arm, supraclavicualr5. Axilla, arm, supraclavicualr5. Axilla, arm, supraclavicualr5. Axilla, arm, supraclavicualr

145. PalpationPalpation
“ “3 positions”3 positions”
1.1. Lying down in semi-Lying down in semi-
recumbent 45recumbent 45
oo
C 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.

146. 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.

147. 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.

148. 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

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

151. FixationFixation
When a lump is fixed to the skin the When a lump is fixed to the skin the
two structures (lump and skin) can two structures (lump and skin) can
not be moved separately.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.

152. Relation to the muscle:Relation to the muscle: the same the same
definitions (tethering and fixation) definitions (tethering and fixation)
apply to the deep attachments of a apply to the deep attachments of a
lump in the breast. But, it is more lump in the breast. But, it is more
difficult to distinguish between difficult to distinguish between
them because you can not see them because you can not see
puckering or movement of the puckering or movement of the
muscle.muscle.
Examination of the lump while the Examination of the lump while the
hand of the pat pressing on her hip hand of the pat pressing on her hip
can detect the mobility of the lump.can detect the mobility of the lump.

153. Palpation of the nipplePalpation of the nipple
If there is If there is retractionretraction  tray to event it tray to event it
by gentle pressure on either side of it.by gentle pressure on either side of it.
If there is If there is discharge 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 try to detect its nature from
its color. its color.
Palpation of axilla: for 5 axillary L.N.Palpation of axilla: for 5 axillary L.N.
Examination of the arm.Examination of the arm.

154. AnteriorPosterior Lateral
Apical
Central
Examination Examination
of the armsof the arms

155. BREASTBREAST
BBreast Mass/breast as a wholereast Mass/breast as a whole
RRetraction etraction
EEdema, eczemadema, eczema
AAxillary involvedxillary involved
SSanguineous anguineous
TTendernessenderness

156. 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 abscess. Acute mastitis and breast 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.

157. 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.

158. 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.

159. 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.

160. 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.

161. El-Shamy