breast

• Breast


  Overlying the second to the sixth ribs and extending from the lateral border of the sternum to the anterior axillary line

  
• Axillary tail of the breast


  • Of surgical importance
  • Palpable in some normal subjects
  • Can be seen premenstrually or during lactation
  • Sometimes mistaken for a mass of enlarged lymph nodes or a lipoma

  
• Ligaments of Cooper


  • Hollow conical projections of fibrous tissue filled with breast tissue
  • Apices of the cones are attached firmly to the superficial fascia and thereby to the skin overlying the breast
  • Account for the dimpling of the skin overlying a carcinoma

  
• Areola


  Contains involuntary muscle arranged in concentric rings as well as radially in the subcutaneous tissue
• Nipple


  Covered by thick skin with corrugations
• Estrogen


  Ductal proliferation
• Progesterone


  Glandular proliferation
• Prolactin


  Milk secretion
• Lymphatic drainage of the breast


  • Axillary lymph nodes
  • Internal mammary lymph nodes

  
• Axillary lymph node groups


  • Lateral
  • Anterior
  • Posterior
  • Central
  • Interpectoral
  • Apical
• Levels of the axillary nodes (Berg's levels)


  • Level I: Below and lateral to the pectoralis minor muscle
  • Level II: Behind the pectoralis minor muscle
  • Level III: Above and medial to pectoralis minor muscle

  
• • Spread restricted to level I nodes carries better prognosis
  • Spread to level II has poor prognosis
  • Spread to level III indicates worst prognosis
• Investigations


  • History and clinical examination
  • Ultrasound
  • Mammography
  • Magnetic resonance imaging (MRI)
  • Needle biopsy/cytology

  
• Ultrasound


  • Particularly useful in young women with dense breasts
  • Can distinguish cysts from solid lesions
  • Can localise impalpable areas of breast pathology

  
• Mammography


  • Soft tissue radiographs
  • A very safe investigation
  • A normal mammogram does not exclude the presence of carcinoma

  
• Magnetic resonance imaging (MRI)


  • Can distinguish scar from recurrence in women who have had previous breast conservation therapy
  • Best imaging modality for breasts with implants
  • Useful as a screening tool in high-risk women
  • Less useful than ultrasound in managing the axilla

  
• Fine-needle aspiration cytology (FNAC)


  • Least invasive technique of obtaining a cell diagnosis
  • Rapid and very accurate if both operator and cytologist are experienced
• Large-needle biopsy with vacuum systems


  • Allows more extensive biopsies to be taken
  • Useful in managing microcalcifications or complete excision of benign lesions
• Painful conditions of the breast


  • Acute mastitis
  • Breast abscess
  • Fibroadenosis
  • Musculoskeletal pain

  
• Causes of loss of weight in breast disease


  • Carcinoma breast
  • Tuberculosis breast
  • TB chest wall causing retromammary abscess
• Factors predisposing to carcinoma


  • Early menarche
  • Late menopause
  • Late childbirth
  • Absent breastfeeding
  • Hormone replacement therapy
  • Unopposed estrogen without progesterone
• Oral contraceptive pills are not a risk factor for breast cancer, only progesterone-only (mini-pills) pills have the risk
• Causes of prominent veins over the breast


  • Rapidly growing sarcoma
  • Cystosarcoma phyllodes
  • Huge breast abscess

  
• Mondor's disease


  Thrombophlebitis of the superficial veins of the breast and anterior chest wall

  
• Tethering (dimpling)


  • Infiltration of Astley Cooper's ligament, pulls the skin inwards creating a dimple or puckering over the breast
  • Tumor moves independent of skin
  • Not considered as skin involvement in staging
• Fixity


  • Infiltration of skin itself by the tumor
  • Tumor cannot be moved, i.e. skin cannot be pinched
  • TNM staging: T4b
• Indications for mammography


  • Age greater than 50 years
  • Age greater than 40 with risk factors
  • Already operated for one side
  • To rule out multifocal involvement in the same breast
  • To screen the opposite breast routinely
  • Mammography guided biopsy

  
• Features suggestive of cancer on mammography


  • Mass effect
  • Architectural distortion
  • Symmetry lost
  • Spiculation
  • Branching calcification
  • Clustering
  • Microcalcification

  
• Types of nipple discharge


  • Blood - Duct papilloma/carcinoma breast
  • Pus - Breast abscess
  • Milk - Lactation/galactocele/mammary fistula
  • Serous/Greenish - Fibroadenosis duct ectasia

  
• Retraction of nipple


  • Circumferential - Carcinoma breast
  • Slit-like - Mammary duct ectasia with periductal mastitis

  
• Magnetic resonance imaging (MRI)


  Indicated to distinguish scar from recurrence, assess multifocality and extent of DCIS, evaluate breasts with implants, screen high-risk women, less useful than ultrasound in managing the axilla
• Triple assessment of breast


  • Clinical examination
  • Radiological imaging (USG, mammography)
  • Pathological examination (FNAC, core biopsy)

  
• The positive predictive value of the triple assessment combination should exceed 99.9%
• Amazia


  Congenital absence of the breast
• Supernumerary nipples


  Commonly occur along a line extending from the anterior fold of the axilla to the fold of the groin
• Nipple retraction


  • May occur at puberty (simple nipple inversion) or later in life
  • Unknown aetiology
  • May cause problems with breastfeeding and infection
  • Recent retraction may indicate underlying carcinoma

  
• Treatment of nipple retraction


  • Usually unnecessary, may resolve spontaneously
  • Simple cosmetic surgery can produce correction but divides underlying ducts
  • Mechanical suction devices can be used to evert the nipple
• Cracked nipple


  • May occur during lactation and be the forerunner of acute infective mastitis
  • Should be rested for 24-48 hours and the breast emptied with a pump, then resume feeding
• Papilloma of the nipple

  Has the same features as any cutaneous papilloma, should be excised with a tiny disc of skin
• Retention cyst of a gland of Montgomery


  Sebaceous cysts forming from blocked glands in the areola