1

DISEASES OF THE BREAST

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BREAST CANCER
Introduction
1:871, 4:240

• The only life-threatening disease of the breast 2:444

• Commonest cancer in Sri Lankan women8
• Most common cause of death in middle-aged women in Western countries
• 1 in 12 lifetime risk for women in the UK
• 60% present as symptomatic disease
• 40% detected during screening

Incidence of Breast Cancer

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You are the new house officer at the Kantale Base Hospital. On a routine clinic day, a 45 year old female presents with a lump in the upper outer quadrant of her
right breast for the past 6 months. It’s progressively increasing in size. She presents to the surgical clinic because she is Concerned.

What diagnosis must be ruled out? How are you going to diagnose this condition?

Clinical Features
4:240, 2:440-447, 3: 409-410

Patient Profile • Fixity

• Geographical o Skin: Cannot move the lump separately
o Western world o Muscle: Lump becomes less mobile on palpation during
• Gender contraction2:442
o < 0.5% occur in men § Pectoralis major
o Female : Male = 200:1 o Chest wall
• Age Nipple/Areola
o Rare below the age of 20 years • Destruction 1:864

o Incidence steadily rises with age o Paget’s disease

o At age of 90 years nearly 20% • Depression (retraction or inversion) 2:443
o Not easily everted by gentle squeezing of the areola edge Vs.
Symptoms and Signs Easily everted
Lump o Unilateral Vs. Bilateral
2:444,445,447 o Recent onset Vs. Long standing
• Commonest presenting symptom • Displacement2:445
o Incidental finding Vs. Self breast examination o Elevated
• Painless • Deviation4:240
• Progressive o Normally points downward and outwards
• 60% in the upper outer quadrant 1:874 • Discharge 1:864
o Uni-ductal Vs. Multi-ductal
• Variable size
o Blood stained/serous
• Irregular shape
• Non-tender Skin5:171, 2:446,447
• No increase in temperature • Colour changes: Redness
o Only the very rare inflammatory breast cancer feels warm
• Puckering/ dimpling: Infiltration of ligaments of Astley Cooper
• Irregular surface4:240
• Peaud’orange appearance: Infiltration of lymphatics
• Ill-defined edge4:240
• Multiple hard nodules
• Most lumps are hard in consistency
• Ulceration/ fungation of the carcinoma
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Late Features
• Loss of appetite (anorexia)
o Anaemia
o Features of nutritional deficiency
§ Angular stomatitis
§ Glossitis
§ Ankle oedema
• Loss of weight (late stages)
Etilogical/ Risk Factors 1:871
• Endocrine: Increased oestrogen exposure 3: 409-410 • Previous radiation
o Nulliparity o Mantle/ supra-diaphragmatic radiotherapy for Hodgkin’s disease
o Age at first pregnancy > 35 years 9 • Smoking
o Early menarche: < 12 years
o Late menopause: > 55 years6:708 Table 1.1
o Oral contraceptive pill (OCP) Risk of Developing Breast Cancer In Benign Breast Diseases 1:871
§ Increased risk during taking the pill and during the 10 (A positive family history significantly increases the risks shown below)
years after stopping its usage
o Hormone replacement therapy (HRT) for 5 – 10 years Benign Breast Disease Risk
§ Risk is more with combined oestrogen-progesteron • Adenosis, sclerosing or florid
preparation Vs. Oestrogen only • Apocrine metaplasia
o Obesity: Risk factor in post-menopausal women • Cysts, macro (>3mm) and/or
§ Adipocytes metabolizes androstenedione (from the micro (<3mm)
adrenal gland) into oestrogen • Duct ectasia
• Fibroadenoma
• Family history: Genetic 1:880 No increased risk
• Fibrosis
o 5% related to a specific mutation
• Hyperplasia (mild) 11
o BRCA 1
§ Breast cancer: 50 – 80% risk, predominantly while pre- • Mastitis (inflammation)
menopausal • Periductal mastitis
§ Ovarian cancer: 50% risk • Squamous metaplasia
§ Colo-Rectal cancer • Fibro-cystic disease 3: 409
§ Prostate cancer • Hyperplasia, moderate or florid,
o BRCA 2 solid or papillary Slightly increased risk
§ Familial male breast cancer • Papilloma with a fibrovascular (1.5 – 2 times)
o p53 core
o Ataxia-Telangectasia genes 4:240 • Atypical hyperplasia (ductal or
Moderately increased risk (5 times)
• Benign breast diseases: Table 1.1 lobular)
• Diet • Solitary papilloma of lactiferous
o Low phyto-oestrogens (plant oestrogens) sinus Insufficient data to assign a risk
o Alcohol • Radial scar
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Complications/ Metastasis1: 873, 4:240

Summary of Spread

Direct/Local Lymphatic Haematogenous

• Nipple changes • Axillary lymph nodes • Liver
o Described above o Anterior, posterior, central, apical, lateral o Jaundice, RHC pain, hepatomegaly, ascites5:171
• Skin changes • Internal mammary nodes • Lung
o Puckering/ dimpling o Posterior 1/3 of the breast o Haemoptysis, pleural effusion, dyspnoea5:171
o Ulceration/fungation • Supra-clavicular (represents advance disease) 1:873 • Bone
• Deep infiltration1:873 • Infra-clavicular 12 o Backache
o Pectoral muscles • Contralateral nodes § Even at rest
o Chest wall • Subdiaphragmatic nodes § Nocturnal pain
• Opposite breast o Reduced spinal movements
o Pathological fractures
§ Lower limb weakness/ paraplegia due to
vertebral collapse and cord compression
o Lumbar vertebra, femur, thoracic vertebra, ribs, skull
o Osteolytic1:873
• Brain
o Headache, vomiting, seizures
o Neurological symptoms and signs5:171
• Others
o Adrenal gland, ovaries, pericardial effusion1:873

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As a house officer, how would you investigate this patient with suspected breast malignancy?
INVESTIGATIONS
1:861-863, 3:396-399

• Confirm the diagnosis

• Assess spread (stage)
• Assess fitness for Surgery
Confirm the Diagnosis

Radiology/Imaging Histopathology
Mammography Fine Needle Aspiration Cytology (FNAC)
• > 35 years4:241 • Score
• X-ray o C1: Inadequate sample
o Cranio-caudal view o C2: Benign
o Medio-lateral oblique view o C3: Atypical cells (Probably benign)
• Sensitivity increase with age as the breasts become less dense o C4: Highly suspicious of cancer (Probably malignant)
• Features of malignancy o C5: Malignant cells
o Poorly defined irregular opacity • Least invasive technique of obtaining a cell diagnosis1:863
o Isolated density • Cannot differentiate CIS from invasive carcinoma1:800
o Tissue asymmetry • Stereotactic FNAC: If clinically not palpable
o Spiculated margins o Mammogram guided
o Linear, branching micro-calcifications: < 0.5mm o USS guided
o Skin tethering
o Dermal oedema Tru-Cut Biopsy
o Nipple inversion • If FNAC is inconclusive (C3 / C4)
o LNs with absent fatty hilum • Done under LA1:862
• Reported using BIRADS (Breast Imaging Reporting And Database System) • Can check receptor status1:863
• Used in screening: A normal mammogram does not exclude cancer1:861 • Can differentiate CIS from invasive carcinoma1:863
• Grading
Ultrasound Scan o B1: Inadequate sample
• All patients o B2: Benign
• Young women with dense breast o B3: Uncertain malignant potential
o Mammogram is difficult to interpret due to dense breast tissue o B4: Probably malignant
• Distinguish cyst Vs. solid (More likely to be malignant) o B5a: In-situ maligancy
• Axilary LNs o B5b: Invasive malignancy
• Not used in screening Operative Biopsy
• Types
o Incisional biopsy
o Excisional biopsy
• Usually not needed
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What are the advantages of Tru-cut biopsy over FNAC?

FNAC Vs. Tru-Cut Biopsy

FNAC Tru-Cut Biopsy

• Least invasive technique of obtaining a cell diagnosis • Histological diagnosis
Advantages • OPD procedure • Receptor status can be identified
• No anesthesia is needed • Can differentiate CIS from invasive carcinoma
• Only a cytological diagnosis • Need higher level of training
Disadvantages • Receptor status cannot be identified • Need LA
• Cannot differentiate CIS from invasive carcinoma

What will you see in a Tru-cut biopsy of a malignant breast lump? How is spread assessed in this patient?

• Proliferating ductal cells with cellular anaplasia Assess Spread/Stage the Disease4:241, 5:171
• Loss of double layering of ducts
• Invasion through the basement membrane • Liver
o LFT
What is BIRADS classification? o If LFT are abnormal: USS/ CECT abdomen

BIRADS Classification • Lung

• Breast Imaging Reporting and Data System. It classifies mammographically o Chest X-ray
breast pathology into 0 – 6 o If Chest X-ray is abnormal: CECT thorax
o 0 – Incomplete
o 1 – Negative • Bone
o 2 – Benign o Bone scan: If symptoms or signs present
o 3 – Probable benign o Serum calcium
o 4 – Probably malignant (suspicious)
o 5 – Probably malignant (highly suspicious) • Brain
o 6 – Known biopsy with proven malignancy o CECT scan: If symptoms or signs present
MRI1:862
• If USS and Mammogram are equivocal
• Imaging a breast with scar tissue due to previous surgery
o Scar Vs. Recurrence
• Assessment of multi-focality and multi-centricity in lobular carcinoma
• Assess extent of high-grade DCIS (less useful in low-grade DCIS)
• Best imaging modality if there are breast implants
• Screening in high risk women (family history)

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Give me a quick over view of TNM classification. UICC and TNM Staging
(Union for International Cancer Control)
TNM Staging
(AJCC-American Joint Committee on Cancer) NCCN
(National Comprehensive UICC TNM
T: Primary Tumour Cancer Network)
• Tx: Primary tumour cannot be assessed 0 Tis N0
• T0: No evidence of primary tumour
• Tis: Carcinoma in-situ I T1 N0
o Tis (DCIS) T1 N1
o Tis (LCIS) Early/ Local T2 N0
o Tis (Paget’s) II
T2 N1
• T1: < 2cm in greatest dimension T3 N0
• T2: 2-5cm in greatest dimension T3 N1
• T3: > 5cm in greatest dimension IIIA Operable LABC
• T4: Any tumour size with direct extension to the chest wall or skin: Skin Locally Advanced N2
nodules, peau d’ orange appearance, ulceration or inflammatory carcinoma (LABC) IIIB T4
N: Nodes IIIC N3
• Nx: Regional LN can not be assessed
• N0: No regional LN metastasis Metastatic/ Advanced IV M1
• N1: Ipsilateral axillary LN involved, but mobile
• N2: Ipsilateral axillary LN involved, but fixed What are the stages of Breast Cancer?
• N3: Ipsilateral internal mammary, infra-clavicular and supra-clavicular LN Stages of Breast Cancer (For Treatment Options)
involved
• Early/ Local
M: Metastasis o T1 N0 / N1
• Mx: Presence of distant metastasis cannot be assessed o T2 N0 / N1
• M0: No clinical or radiographic evidence of distant metastasis o T3 N0 / N1
• M1: Distant metastasis present
• Locally Advanced
o T4
o Any T with N2 / N3

• Metastatic/ Advanced
o M1

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Fitness for Treatment
• Blood
o FBC
o FBS
o Coagulation profile
• Heart
o ECG
o 2D Echo
• Lungs
o Chest X-ray
• Kidneys
o Blood urea
o Serum creatinine

What are the main components in the treament of breast cancer? How do you decide the best treatment plan?
TREATMENT
1:875-879, 3: 416-421

• Multi-disciplinary team management (MDT)

o Surgeon
o Anaesthesiologist
o Pathologist
o Radiologist
o Oncologist
o Counsellor
o Breast care nurse
• Depends on the stage
• Goals
o Achieve local disease control and reduce the chance of local recurrence
o Achieve regional disease control in the tumour draining LNs
o Reduce the risk of metastatic spread

Treatment Options Based on Stage Of The Disease

Local Locally Advanced5:174 Metastatic5:174

• Surgery +/- radiotherapy
• Adjuvant chemotherapy (and other systemic
treatment) 5:174
• Neoadjuvant chemotherapy (and other systemic
treatment)
• Surgery +/- radiotherapy
• Adjuvant chemotherapy (and other systemic
treatment)
• Chemotherapy (and other systemic treatment)
• Surgery is only done for local disease control
• Radiotherapy for painful bony deposits and
internal fixation of pathological fractures1:881

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Local Treatment
Breast
• Breast conserving surgery + Radiotherapy • Mastectomy + / - Radiotherapy
o Wide local excision (1cm margin) o Simple: No axillary node clearance
o Quadrantectomy/ lumpectomy o Modified radical (Patey): Includes level II axillary node
clearance
§
The whole breast, skin with the nipple and all of the fat,
fascia and lymph nodes of the axilla are removed.1:876

Breast Conserving Surgery Vs. Mastectomy

Breast Conserving Surgery Mastectomy

• Small tumours in a large breast • Large tumours in a small breast
• Peripheral location • Central location
• Not for retro-areolar/multi-focal/multi-centric tumours • Retro-areolar/multi-focal/multi-centric tumours
• Ensure clear margins • Late presentation with complications such as ulceration4:242
• Local radiotherapy is invariably given to the remaining breast • Recurrent cancer following wide local excision
• Diffuse in-situ carcinoma4:242
• Carcinoma in Pregnancy1:881
• Radiotherapy is not essential
o Indications for radiotherapy-
§ Large tumours
§ Large number of positive LNs
§ Extensive lympho-vascular invasion
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Axilla
How is the axilla managed in breast cancer? What is a sentinal LN and what is the principal of sampling it? How is it
• Options 1:876 identified?
o FNAC/USS-guided FNAC along with the ultrasound scanning • Sentinel node 1:877

of the breast o Is the FIRST node that drains the diseased part of the breast
o Axillary clearance o Is localized peroperatively by the injection of patent blue dye
o Axillary node sampling and radioisotope-labelled albumin
o Sentinel node biopsy o The principle of doing this is that, if the sentinel node is
unaffected, then the rest of the nodes should also be unaffected

Management of the Axilla

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What are the options available for systaemic control in this patient?

Systaemic Treatment

Chemotherapy: Adjuvant/Neo-Adjuvant1:878 Hormone Therapy

• Cyclophosphamide • Anti-oestrogens: Selective oestrogen receptor modulator (SERM)
• Methotrexate o Tamoxifen for 5 years post-operatively1:878
• 5-Fluorouracil o Pre-menopausal women
§ Oestrogen from the ovaries
(CMF is no longer considered an adequate adjuvant chemotherapy and modern o Contraindicated in pregnancy: Potentially teratogenic1:881
regimens include an anthracycline(doxorubicin or epirubicin) and newer agents o Antagonist for breast cancer cells
such as the taxanes) o Agonist for
§ Bones: Protection against osteoporosis
• Side effects: Affects all rapidly proliferating cells § Endometrium: Risk of endometrial cancer
o Nausea/ vomiting/ diarrhoea o Risk of DVT
o Hair loss o Can be used as the primary mode of treatment in elderly unfit
o Cytopenia patients5:174
o Some cause neuropathy
• Reduce production of oestrogen1:878
o LHRH agonists (Medical oophoretomy) for premenopausal women
o B/L Oophorectomy (Surgical oophorectomy)
o Aromatase inhibitors: Anastrazole, Letrozole
§ Reduce peripheral conversion androgens to oestrogen
§ Post-menopausal women
o Oestrogen from peripheral conversion of
androgens
• Risk of osteoporosis
o Add calcium and Vit D

Immunotherapy1:878
• Her 2 receptor blockers
o Trastuzumab (Herceptin) – Monoclonal antibody
o Risk of cardiac dysfunction

Radiotherapy (Also used in local)

• Bone and brain metastasis5:174

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What are the options available for breast reconstruction and when is it done?

Breast Reconstruction1:879, 880

• During same time or later stage
• Latissimus dorsi flap
• TRAM flap (Transverse Rectus Abdominis Myocutaneous)
• Prosthesis

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The patient gave consent for surgery and a right-sided mastectomy + level II axillary clearance was done in the next available surgical list under general
anaesthesia. The post-operative period was uneventful. She recovered well. She was discharged on the 3rd post-operative day and was advised to return to the clinic
in 2 weeks to trace the histology report.

• Histology report
• Post-Operative complications of surgery

Histology1:872,873 What are the types of breast cancer that you know of?
• Confirm that it’s malignant Pathological Types
• Pathological type: Ductal or lobular
• Invasive or non-invasive Ductal Carcinoma Lobular Carcinoma
•85% • 15%
How are breast malignancies graded? •Unifocal • Commonly multifocal1:872
•Unilateral • Commonly bilateral1:872
• Tumour grading •Elderly women • Pre-menopausal women
o Nuclear pleomorphism: Variations in, •Reacts positively with the e-cadherin
§ Nuclear size antibody1:872
§ Nuclear shape • Non-invasive: 5% • Non-invasive: 1%
§ Nuclear staining (especially with hyperchromasia) o Confined within the duct system o Confined within the
o Tubular formation (DCIS) lobular system
o Number of mitoses • Invasive: 85% (LCIS)
• Nottingham grading 13:20 o Not otherwise specified: 65%
o Low: Grade 1 • Invasive: 9%
§ Bad prognosis6:713
o Intermediate: Grade 2 o With specific features: 20%
o High: Grade 3 § Medullary, Tubular,
• Hormone receptor status Mucinous, Papillary,
o Oestrogen Cribriform, Others
o Progesterone § Good prognosis6:713
o Her-2 receptor

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A few weeks after surgery, your patient presents with pain and swelling of the On what factors does prognosis depend on?
ipsilateral upper limb. What is the most likely diagnosis? Prognosis1:875
• Lymphoedema of upper limb • Axillary LN status
o Single best determinant of prognosis1:877
• Histological grade
What could have been done post-operatively to prevent shoulder stiffness?
• Stage of the tumour
• Physiotherapy • Hormone receptor status
o ER/PR: Good prognosis6:713
What other complications can the patient present with or could have
o Her 2 (Human epithelial receptors): Bad prognosis6:713
presented with ?
o Triple negative: Worst prognosis
Post-Operative Complications of Surgery
• Nottingham prognostic index
o 0.2 X Diameter(cm) + Nodal status + Grade5:168
Mastectomy Axillary Clearance
• 5 year survival
• Immediate (Within 6 hours of • Immediate
o Local: > 70%
Surgery) o Bleeding
o Bleeding o Long thoracic nerve injury: o Locally advanced: <30%
• Early (6-72 hours) Winging of scapula o Metastatic: ---
o Wound seromas o Intercostobrachial nerve:
o Haematoma Paraesthesia over the axilla
o Wound infection o Thoracodorsal nerve:
o Flap/skin necrosis Weakness of arm extension
• Late (>72 hours) • Early
o Wound infection o Axillary vein thrombosis
o Keloid/hypertrophic scar • Late
formation o Lymphoedema of
ipsilateral upper limb
o Shoulder stiffness

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What is Paget’s disease? INFLAMMATORY CARCINOMA / MASTITIS
1:873
PAGET’S DISEASE CARCINOMATOSA5:176
• Rare superficial manifestation of an underlying carcinoma, which maybe in- • Occur in pregnancy and lactation
situ or invasive • Painful, swollen breast, which is warm with cutaneous oedema1:872
• An eczema-like condition of the nipple and areola, which persists despite
• Locally advanced inoperable breast carcinoma1:881
local treatment
• Characterized by ‘Paget cells’ in epidermis • Most aggressive breast cancer
• Wedge or punch biopsy is diagnostic • Metastasize widely and rapidly
• Same principals of treatment: Mastectomy5:176 • Treatment
o Palliative
What are the differences between Paget’s disease and Eczema? § Chemotherapy
Paget’s Disease Vs. Eczema 2: 452 § Radiotherapy
§ Tamoxifen: If ER +
Paget’s Disease Eczema
o Prognosis
• Unilateral • Bilateral
§ 5 year survival: < 5%
• At menopause • Common at lactation
• No itching • Itching
• No vesicles • Vesicles
• Nipple destroyed • Nipple intact
• May have an underlying lump • No lumps

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BENIGN BREAST DISEASES
Classification1:870 ANDI (Aberration of Normal Development and Involution)
• Congenital disorders Aberration of Normal Development
o Inverted nipple • Early reproductive period (15-25y)
o Supernumerary breasts/nipples o Fibroadenoma
• Non-breast disorders including Tietze's disease(costochondritis) • Mature reproductive period (25-40y)
• Sebaceous cysts and other skin conditions o Fibroadenosis (cyclical nodularity and mastalgia)
• Injury
• Inflammation/Infection Aberration of Normal Involution (40-55y)
o ANDI (Aberrations of Normal Differentiation and Involution): • Breast cysts
§ Fibroadenoma • Duct ectasia
§ Cyclical nodularity and mastalgia
§ Cysts Benign Neoplasm
§ Duct ectasia/periductal mastitis • Fibroadenoma
o Pregnancy-related: • Phylloidstumour
§ Galactocoele • Intraductal
§ Lactational abscess • Papilloma
• Lipoma

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A 20 year old female presents with a mobile lump in the inner lower quadrant
of her right breast for the past 6 months. It’s painless, but she is concerned
because she has recently attended an educational programme at her
workplace regarding breast cancer.
What is the most likely diagnosis?
A 35 year old female complains of a lumpy area in the lower inner quadrant
of her right breast for the past 6 months. It’s painful and disturbs her day to
day activities. On examination you find it difficult to palpate and define a
lump.
What is the most likely diagnosis?

FIBROADENOMA FIBROADENOSIS/ FIBROCYSTIC DISEASE4:246

Introduction1:870 Introduction
• Overgrowth/ hyperplasia of a single lobule • Combination of localized fibrosis, inflammation, cyst formation
• Fibrous + glandular components2:448 • No well-formed capsule/ No discrete mass5:168
• Well-formed capsule: Therefore enucleated easily • Not pre-malignant, but proliferative type of fibroadenosis has an increased risk
• Not pre-malignant
Clinical Features2:448,449 Clinical Features
• Commonest age: < 35 years (15-25 years) 1:870 • Almost exclusively between menarche and menopause (15-55y)
• Oestrogen-dependant • Oestrogendependant
o Increases in size with menstruation o Cyclical pain
o Involutes after menopause5:168 o Worse before a period1:868
• Painless • Multiple breast cysts
• May be multiple or giant ( > 5cm )1:870 • Bilateral
• Unilateral • May have a nipple discharge1:864
• No nipple discharge o Serous
• Freely mobile (Breast mouse), smooth, firm/rubbery, discrete lump o Blood stained
• ‘Lumpy’ breasts
• If suspected, examination should be repeated at different stages of the menstrual
cycle5:168

Investigations5:168 Investigations
• Ultrasound scan • Ultrasound scan
• FNAC • FNAC

Treatment Treatment
• Reassurance • Reassurance1:869
o 1/3 regress spontaneously • Anti-inflammatories: NSAIDs
• Surgical excision1:870 • Analgesics
o Doubtful diagnosis/Lump increasing in size • Adequate support1:869
o Cosmesis/Patient preference o Firm bra during the day and a softer bra at night
o Pain/ symptoms4:246 • Vit E
• Alternatives to surgery1:870 • Hormone or ‘cellular’ manipulation
o Cryoablation o Evening primrose oil (gamma-linoleic acid)
o Heating with high-frequency ultrasound (echotherapy) o Danazol (Androgen)1:869
o Removal with a large core biopsy vacuum system o COC pill
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A 30 year old breast feeding mother presents with severe pain in her right A 50 year old mother of 5 children presents with a greenish nipple discharge.
breast. On examination, the breast is swollen, red, warm and tender. She’s a smoker.
What is the most likely diagnosis? What is the most likely diagnosis?

ACUTE BACTERIAL MASTITIS/ BREAST ABSCESS1:866 DUCT ECTASIA/ PERIDUCTAL MASTITIS1:867,868

Introduction Introduction
• Acute Staphylococcus auerus infection of mammary ducts4:246 • Dilated, scarred, chronically inflamed subareolar mammary ducts4:246
• From the baby’s mouth
• Enters through cracks and fissures in the nipple Clinical Features
• Chiefly in the fifth decade5:169, Multiparous women
Clinical Features2:453 • Associated with smoking
• First few weeks after delivery • Breast
• Common in smokers o Nipple discharge: Any colour
• Fever § Recurrent yellow-green discharge, blood, serous
• Breast o Pain5:169
o Pain o Recurrent abscesses4:246
o Swelling o Mass beneath the nipple
o Redness o Nipple retraction: Highly characteristic transverse slit appearance
o Tenderness due to fibrosis2:452
o Lactating breast
Investigations
Investigations • To exclude carcinoma in the case of a mass or nipple retraction
• No investigations: Clinical diagnosis o USS
o Mammogram
Treatment o Cytology or histology
• Antibiotics • Ductography
o Flucloxacillin or co-amoxiclav • Ductoscopy: Technically feasible but generally disappointing1:864
• Repeated aspirations if an abscess has formed
• Incision and drainage if aspirations fail and if there is marked skin thinning Treatment
• Analgesics • Antibiotics if associated infection
• If the nipple was cracked, it should be rested for 24-48 hours and the breast • I and D if abscess
should be emptied with a breast pump1:863 • Duct excision
• No need to stop lactation: If the inflamed area communicated with the duct o If severe discharge, recurrent sepsis
system, the infection would have discharged this way and the abscess • Surgery
would not have formed2:453 o Hadfield's operation: Excision of all the major ducts1:868
o Microdochectomy: Removal of a single affected duct

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PHYLLODES TUMOUR1:870 BREAST CYSTS4:246

• Usually > 40 years • Almost always benign

• Rare: < 1% of all breast lumps • Filled with green-yellow fluid, even black2:451
• Large • Often associated with fibrocystic disease1:869
• Rapidly growing5:176 • Spherical2:451
• Variant of fibroadenoma • Symmetrical lump/s
• Potentially malignant • May be discrete or multiple
o Lung metsastasis via bloodstream • Occasionally painful2:451
• Need triple assessment • Diagnosis: Triple assessment
• Treatment o USS
o Wide local excision o Mammography
o Mastectomy o FNAC/Aspiration: Typical fluid aspirated
§ Massive tumours o Core biopsy/ local excision: If,1:869
§ Recurrent tumours § Residual mass
§ Malignant type § Recurrent cysts
§ Bloody aspirate
• Treatment
o Repeated aspiration
§ 30% of breast cysts will require reaspiration1:869
o Hormone manipulation

FAT NECROSIS4:247, 1:866

• Causes
o Trauma
o Surgery
o Radiotherapy
• Common in obese women
• Organized local haematoma
• Occasional calcification
• Mimics carcinoma
o New, painless or painful breast lump
o Poorly defined
o Nipple retraction and skin tethering
• History of trauma is often absent2:447
• Diagnosis
o Triple assessment: Need to exclude malignancy

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1:864
NIPPLE DISCHARGE
Causes Sinister Features of a Discharge1:864
• Discharge from surface • Presence of a lump
o Paget’s disease • Presence of blood in the discharge
o Skin diseases • Discharge from a single duct
§ Eczema
§ Psoriasis Features of a Physiological Discharge1:864
o Chancre of syphilis • Non-bloody
• Multi-ductal
• Discharge from a single duct • Clear/ serous/ multi-coloured
o Blood stained • Usually need manipulation to produce
§ Intraduct papilloma (Bloody or purulent discharge are NEVER physiological)
§ Intraduct carcinoma
§ Duct ectasia
o Serous (any colour)
§ Fibrocystic disease MASTALGIA
§ Duct ectasia • Cyclical: 80%
§ Carcinoma o Co-relates with the menstrual cycle1:868
§ Early pregnancy5:167 o Fibrocystic disease
• Non-cyclical
• Discharge from multiple ducts o Periductal mastitis1:869
o Blood-stained 
 o Breast abscess1:866
§ Carcinoma 
 • Mondor's disease : Superficial thrombophlebitis
• Referred pain
§ Ectasia 

o From the neck, chest wall, back in postmenopausal women1:869
§ Fibrocystic disease
o Breast pain in the elderly is often skeletal in origin, referred from
o Black or green
conditions such as frozen shoulder and osteoporosis of the spine2:450
§ Duct ectasia
o Purulent
§ Infection
o Serous
§ Fibrocystic disease 

§ Duct ectasia
§ Carcinoma
o Milk
§ Late pregnancy5:167/Lactation
§ Hypothyroidism
§ Pituitary tumour: Hyperprolactinaemia

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Reference:

1. Bailey And Love’s Short Practice Of Surgery – 27th Edition

2. Browse’s Introduction To The Symptoms And Signs Of Surgical Disease – 5th Edition
3. Fundamentals Of Surgical Practice – 3rd Edition
4. Oxford Hand Book Of Clinical Surgery – 4th Edition
5. Churchill's Pocketbooks – Surgery – 4th Edition
6. Robbin's Basic Pathology – 9th Edition
7. Surgery At A Glance – 5th Edition
8. National Cancer Control Programme, Ministry of Health & Indigenous Medicine, Sri Lanka
9. Surgery (Journal): Management of Breast Cancer - Basic Principles
10. Up To Date 2018
11. American Cancer Society
12. AJCC: American Joint Committee on Cancer
13. Clinical Surgery Made Easy – 2nd Edition

Clinical Surgery