Foote and Stewart originally proposed the following classification for invasive breast cancer130:

1. Paget’s disease of the nipple 2. Invasive ductal carcinoma—Adenocarcinoma with productive

fibrosis (scirrhous, simplex, NST), 80% 3. Medullary carcinoma, 4% 4. Mucinous (colloid)
carcinoma, 2% 5. Papillary carcinoma, 2% 6. Tubular carcinoma, 2% 7. Invasive lobular
carcinoma, 10% 8. Rare cancers (adenoid cystic, squamous cell, apocrine)

Diagnosis:
In ∼30% of cases, the woman discovers a lump in her breast. Other less frequent presenting
signs and symptoms of breast cancer include: (a) breast enlargement or asymmetry; (b) nipple
changes, retraction, or discharge; (c) ulceration or erythema of the skin of the breast; (d) an
axillary mass; and (e) musculoskeletal discomfort. However, up to 50% of women presenting
with breast complaints have no physical signs of breast pathology. Breast pain usually is
associated with benign disease

Examination
Inspection. The clinician inspects the woman’s breast with her arms by her side (Fig. 17-18A),
with her arms straight up in the air (Fig. 17-18B), and with her hands on her hips (with and
without pectoral muscle contraction).135,136 Symmetry, size, and shape of the breast are
recorded, as well as any evidence of edema (peau d’orange), nipple or skin retraction, or
erythema. With the arms extended forward and in a sitting position, the woman leans forward to
accentuate any skin retraction.

Imaging techniques

Mammography: Screening mammography is used to detect unexpected breast cancer in

asymptomatic women.gard, it supplements history taking and physical examination. With
screening mammography, two views of the breast are obtained: the craniocaudal (CC) view
(Fig. 17-20A,B) and the mediolateral oblique (MLO) view (Fig. 17-20C,D). The MLO view
images the greatest volume of breast tissue, including the upper outer quadrant and the axillary
tail of Spence. Compared with the MLO view, the CC view provides better visualization of the
medial aspect of the breast and permits greater breast compression.

Ultrasonography: Second only to mammography in frequency of use for breast imaging,

ultrasonography is an important method of resolving equivocal mammographic findings, defining
cystic masses, and demonstrating the echogenic qualities of specific solid abnormalities.. On
ultrasound examination, breast cysts are well circumscribed, with smooth margins and an
echo-free center (Fig. 17-23). Benign breast masses usually show smooth contours, round or
oval shapes, weak internal echoes, and well-defined anterior and posterior margins (Fig. 17-24).
Breast cancer characteristically has irregular walls (Fig. 17-25) but may have smooth margins
with acoustic enhancement. but it does not reliably detect lesions that are ≤1 cm in diameter.
utilized to image the regional lymph nodes in patients with breast cancer. . The features of a
lymph node involved with cancer include cortical thickening, change in shape of the node to
more circular appearance, size larger than 10 mm, absence of a fatty hilum and hypoechoic
internal echoes.

MRM
e. A modified radical mastectomy permits preservation of the medial (anterior thoracic) pectoral
nerve, which courses in the lateral neurovascular bundle of the axilla and usually penetrates the
pectoralis minor to supply the lateral border of the pectoralis major. Anatomic boundaries of the
modified radical mastectomy are the anterior margin of the latissimus dorsi muscle laterally, the
midline of the sternum medially, the subclavius muscle superiorly, and the caudal extension of
the breast 2 to 3 cm inferior to the inframammary fold inferiorly. Skin-flap thickness varies with
body habitus but ideally is 7 to 8 mm inclusive of skin and telasubcutanea (Fig. 17-35). Once the
skin flaps are fully developed, the fascia of the pectoralis major muscle and the overlying breast
tissue are elevated off the underlying musculature, which allows for the complete removal of the
breast (Fig. 17-36)