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The breast:

      is an apocrine gland containing the mammary gland that produces milk to feed an infant child.

•Both men and women develop breasts from the same embryological tissues.

•However, at puberty, female sex hormones, mainly estrogen, promote breast development, which does not occur in men, due to the higher amount of testosterone.

• the breast is a cone with the base at the chest wall, and the apex at the nipple.

• nipple: is a small projection of skin containing the outlets for 15–20 lactiferous ducts arranged cylindrically around the tip.

• Areola: the pigmented area on the human breast around the nipple.

• Each breast contains 15–20 lobes. The subcutaneous adipose tissue covering the lobes gives the breast its size and shape.

• Each lobe is composed of many lobules, at the end of which are sacs where milk is produced in response to hormonal signals.

• the weight of the breast 500–1,000 grams.

•Sensation in the breast is provided by the peripheral nervous system innervation, by cutaneous branches of the fourth-, the fifth-, and the sixth intercostal nerves.

• vascularisation:

• Lymphatic drainage: 75% of the lymph from the breast travels to the ipsilateral axillary lymph nodes, whilst 25% of the lymph travels to the parasternal nodes.

 

Types of Breast Lumps

A)-    Cysts and Abscess Lumps:

• breast cyst is a non-cancerous, fluid-filled sac in the breast. They generally feel smooth or rubbery under the skin and can be quite painful or cause no pain at all. Cysts are caused by the hormones that control the menstrual cycle and are rare in women older than 50.

• sebaceous cyst is a non-cancerous, closed sac or cyst below the skin that is caused by plugged ducts at the site of a hair follicle. Hormone stimulation or injury may cause them to enlarge but if no symptoms are present, medical treatment is not required.

• Abscesses are non-cancerous pockets of infection within the breast. They can be quite painful and cause the skin over the breast to turn red or feel hot or solid. Abscesses of the breast are most common in women who are breast-feeding.
B)-  Growths:

• Adenomas are non-cancerous abnormal growths of the glandular tissue in the breast. The most common form of these growths, fibroadenomas, occur most frequently in women between the ages of 15 and 30 and in women of African descent. They usually feel round and firm and have smooth borders. Adenomas are not related to breast cancer.

• Intraductal papillomas are wart-like growths in the ducts of the breast. These lumps are usually felt just under the nipple and can cause a bloody discharge from the nipple. Women close to menopause may have only one growth, while younger women are more likely to have multiple growths in one or both breasts.

• Breast cancer usually feels like a hard or firm lump that is generally irregular in shape and may feel like it is attached to skin or tissue deep inside the breast. Breast cancer is rarely painful and can occur anywhere in the breast or nipple

C)-   Fatty Lumps:

    • Fat necrosis is a condition in which the normal fat cells of the breast become round lumps. Symptoms can include pain, firmness, redness, and/or bruising. Fat necrosis usually goes away without treatment but can form permanent scar tissue that may show up as an abnormality on a mammogram.

      • lipoma is a non-cancerous lump of fatty tissue that is soft to the touch, usually movable, and is generally painless.

-:Caution :-

• When women feel a lump     36 of 100 are real
• Women with true lump
• Not dangerous or “benign”      85 out of 100
• Cancer                                          15 out of 100
• 
  

Evaluation of breast mass

History:

• Change in general appearance of breast (size, symmetry)
• New or persistent skin changes
• New nipple inversion
• Breast pain (cyclic vs. noncyclic, duration, location in breast)
• Breast mass (how it was discovered, duration, change in size, location)
• Relationship of mass to menstrual cycles
• Nipple discharge (unilateral vs. bilateral, color)
• Medications (e.g. hormones)
• Risk factors for breast cancer
• 
  

Clinic exam

Inspect (relaxed, arms raised, hands on hips)

            Breast symmetry

            Skin changes (dimpling, retraction, edema, ulceration)

            Nipples (symmetry, inversion/retraction, discharge)

Palapation (breasts, axillae, entire chest wall)

             Pain

             Masses

             Regional lymph nodes (Axillary and Supraclavicular)

Documentation“Clock” systemLocation of concern and abnormalityDistance from areolaSize of mass

Workup

•Imaging

•Bilateral diagnostic mammogram  (>30)

•U/S – solid vs cystic (<30)

•Biopsy

–Palpable – FNA or CNB

–Non-palpable - stereotactic or ultrasound-guided percutaneous core biopsy

–Incisional biopsy

–Exicional biopsy

self-exam of breast , auto-examination of breast

Nipple discharge

Etiology

Lactation

Physiologic nipple discharge

• Hyperprolactinemia
• Hypothyroidism
• Medication related
• Neurogenic stimulation

Pathologic

• Intraductal papilloma
• Ductal ectasia (common cause)
• DCIS

•Investigation:

1-cytology of discharge for exfoliated cancer cells.

2-mammography

3-duct galactography

4- serum prolactine

•Treatment:

1-palpable mass ==== excised for histology and treated accordingly.

2-single duct bloody discharge === microdochectomy

3-multiple ducts no mass ==initially conservative by observation.

     If persiste === excision of major ducts

self-exam of breast , auto-examination of breast

Breast cancer

Risk Factors vs. Protective Factors

Neoplasia and benign Tm

Duct papilloma

•Usually in the main ducts near the nipple.

•Young women.

•Before it become palpable may ulcerate and bloody discharge.

•Block may cause a retention cyst.

Clinic :

1-  bloody discharge (no pain).

2-  small mass fusiform behind areola. Pressur on it bloody discharge.

3-  if no mass the pressure on certain point behind the areola will reveal discharge from one duct

•Investigation:    Ductography

•Treatment: Excision of the affected duct (micro-dochectomy).

fibroadenoma

The commonest breast mass of young women (15-30)

Fibrous +++ and glandular tissues ++

clinical:

Hard mass (20-30) painless , soft mass (30-50) painfull , accident discover

•Usually small, non tender, spherical, firm, well circumscribed, high mobility.

•Investigation: 

Clinical exam enough for diagnosis

Soft tissue == mammography ==reveal a well circumscribed.

May U/S

Treatment: Excision and histological confirmation of diagnosis

CYSTOSACROMA phylloides

-A highly cellular type of fibroadenoma that tend to grow rapidly (brodie). Enlarge slowly and rich a large size (20-30 cm).

-Cystic formation with skin ulceration

-Rarely malignant.

-Phylloides tumour

 -wide local excision to prevent recurrence

-if infiltrate whole breast simple mastectomy.

Carcinoma of breast

•Most common cancer in women

•In USA     9:1

•Breast cancer is second only to lung cancer as a cause of cancer deaths in American women

•The mean age of affection 60 years.

•The commonest malignant neoplasm in Egyptian female 35%.

Histology:

•The carcinoma may arise from the lobule, ducts or nipples

•Arise from the ductal epithelium in the majority of cases.

Carcinoma of ducts:

-ductal carcinoma in situ

-Infiltrating ductal carcinoma

•Carcinoma of the lobules:

-Non infiltrating lobular carcinoma (lobular carcinoma in situ)

-Infiltrating lobular carcinoma. Bilateral in 25%.

        

•Paget’s disease of nipple:

An introduction of carcinoma which begins in the epithelium of a main collecting lactiferous duct and

spreads within epithelium up to the skin of the nipple and down into the breast substance.

A mass may appear after 2 years from the start of the disease.

•Spread:

Local spread: overlying (skin), underlying (pectoralis major,…..., chest wall).

Lymphatic spread: mostly to axillary node, next common is the internal mammary chain.

Blood stream spread: produces metastases in the lungs, bones, brain and liver.

Clinical features

•Symptoms:

1-  accidently notices a painless lump.

2-  mild breast pricking pain , nipple retraction or bloody nipple discharge.

3-  symptomatic metastases.(axillary lump ,pulmonary metastasis)

4-  by routine screening mammography in high risk women.

•Signs:

For breast examination , the top half of trunk exposed, both breast, axillae, arms and supraclavicular.

-Beast asymmetry                  - enlargement

-Skin dimpling                       - skin puckering

-Peau d’orange                       - skin ulceration or nodule

-Mass :   hard  ,  irregular  ,  immobile  ,  fixe  

Nipple : retraction ulce

STAGING OF cancer breast

•Manchester staging:

Stage 1:

Mobile mass ,   no LNs , no attachment of wall.

Stage 2:

Mobile mass , no attachment of wall , mobile ipsilateral axillary LNs.

Stage 3: (wide licale spread) any of theses

1-skin affection (more than tm but at breast)

2-fixed to pectoral muscles

3-ipsilateral axillary LN  matted together

4-ipsilateral supra clavicular  LNs

5-edema of the arm.

Stage 4:

1-skin affection wide of the breast.

2-fixed to chest wall.

3-controlateral axillary LNs.

4-distant metastasis.

v tmn:

self-exam of breast , auto-examination of breast