A normal breast is slightly and uniformly nodular; most of its diseases make it lumpy. Sorting out these lumps can be difficult. The important decision is whether or not a patient has carcinoma.
Consider all lumps in the breast as malignant, unless you are sure they are benign. No woman should be left with a lump in her breast, if she can have it removed by aspirating a cyst, or by excision. After the menopause lumps in the breast are more likely to be malignant.
Fig. 21-3 TWO FUNGATING TUMOURS OF THE BREAST. Unfortunately, many patients in the developing world present late when their tumours are already fungating like this. A, a fibroadenoma (uncommon). B, a fungating carcinoma (very common); note the ''peau d'orange' (''orange skin') appearance of the skin over the breast, and the malignant ulcer.
BREAST LUMPS [s8]AND OTHER BREAST DISEASES EXAMINATION HISTORY. How long has the patient had her symptoms? Has she any pain? Is it associated with her periods? If she has pain, is it in one breast or both? Is there any discharge from her nipple? Is it watery, bloody, or like thin pus?
EXAMINATION. First examine her sitting up undressed to the waist, then lying down. Examine both her breasts, her liver, and her skeleton.
. Inspect: (1) Her nipples for position, retraction, and cracking. (2) Her areolae for pigmentation, swelling of Montgomery's tubercles, and a rash. (3) Her skin for prominent veins, sinuses, ulcers, and ''peau d'orange'.
Palpate her breasts: (1) Start with the breast she considers normal, feel each of its 4 quadrants with the flat of your hand, and then its subareolar area. (2) Feel for lumps, note their size and site, and whether they are single or multiple; also their consistency, warmth, tenderness, mobility, and surface. (3) If you find a lump, feel if it is tethered to the skin, or to pectoralis major. Test for the latter by asking her to place her open hand on her waist, and then ask her to press downwards to tense this muscle, while you try to move the lump. (4) Feel with your finger and thumb behind each nipple, and look for any discharge. (4) Feel her axillary nodes[md]medial (pectoral), lateral, anterior and posterior. Note their number and size, and if they are fixed to her skin, or to deep structures.
A normal breast is slightly and uniformly nodular, especially before the menopause; this nodularity is maximal before the periods. At the menopause the nodularity becomes less, and more fat is deposited.
The classical signs of malignancy are: (1) adherence of the lump to the skin or to pectoralis major, (2) enlarged nodes in the axilla, and (3) ''peau d'orange'. The absence of these signs does NOT exclude carcinoma. Their presence increases the chances of it, but they are not confirmatory, because they can also be caused by tuberculosis, or fat necrosis, etc.
If you are not sure if she has a lump or not, examine her in 2 weeks time, at the opposite phase of her menstrual cycle. Lumpiness of the breast varies with the menstrual cycle.
DIAGNOSING CYSTS [s7]IN THE BREAST If a lump is deep and spherical in all directions, it is probably a cyst; it may or may not be fluctuant, and it can be benign or malignant. Cysts and solid lumps can be difficult to distinguish. You may see any of the following cysts, but only the first two are common.
A mature breast abscess (very common, 21.2) has obvious signs of inflammation, and usually occurs in one breast only, commonly during lactation.
Fibroadenosis (also called fibrocystic disease, common) makes both breasts abnormally granular, usually with premenstrual pain and some tenderness. One or more of these granular areas may be sufficiently obvious to be palpable as a cyst. She is between 25 and 60, there is occasionally an association with malignancy, and there may be a clear discharge from her nipple; rarely, this is blood-stained.
An intracystic papilliferous carcinoma (rare) presents as a cyst. Aspiration yields blood-stained fluid, and does not make the cyst disappear entirely.
Carcinoma of the breast with colloid degeneration (rare), feels cystic. Aspiration yields only a little thick fluid, and does not make the cyst disappear.
Serocystic disease (cystadenoma phylloides, rare) is a rapidly growing benign giant fibroadenoma, which becomes partly necrotic and fluctuant. The skin over it may ulcerate, but is not inflitrated.
A galactocele (uncommon) is a residual milk- containing cyst, the contents of which may solidify.
Hydatid disease (not uncommon in endemic areas, 31.13). Look for cysts elsewhere, especially in the liver.
DIAGNOSING SOLID LUMPS [s7]IN THE BREAST A developing breast abscess (common, see above).
An abscess modified by antibiotics (an ''antibioma', common) is the result of treating an abscess with antibiotics, and not draining it. The lump is usually tender, but not always so. She may have tender axillary nodes and ''peau d'orange'.
A fibroadenoma, (common) is a smooth, well-defined, solitary, and usually painless lump 2 to 5 cm in diameter (but which may be much larger), that moves freely in the breast (a ''breast mouse'). From its hardness such a lump could equally well be a carcinoma; mobility is the important sign, so is lobulation. There are two histological types, a common pericanalicular type, and a less common intracanalicular one. Be careful to distinguish a fibroadenoma, which is an isolated lump, from an area of nodularity due to fibroadenosis, which is a different disease. She is between 15 and 40, and usually between 18 and 25.
Tuberculosis of the breast, (uncommon) is less often seen than tuberculosis of the axillary lymph nodes (31.4), and closely resembles carcinoma. Suspect tuberculosis if a lump is tender or there is a sinus. The mass is painless, and may be attached to her skin or the muscles of her chest wall. Look for signs of tuberculosis elsewhere. Biopsy the mass or her axillary nodes. If you cut across a tuberculous node, you will see areas of caseation. Give the standard tuberculosis treatment. If she has a discharging sinus, you may have to admit her. There is no need for a mastectomy.
CAUTION ! In areas where tuberculosis is common, don't forget the possibility that it it may infect the breast or the axillary nodes.
A giant fibroadenoma (uncommon), presents as a large breast filled with a large, deeply lying, hard, smooth, lumpy, mass (21.5D). It it is untreated it may fungate as in Fig. 21-3. She is usually between 35 and 45.
A neurofibroma (rare) feels hard, like a fibroadenoma, but may be soft, and may be one of many similar tumours elsewhere.
A lipoma (uncommon) feels like breast tissue, but has an indistinct outline separating it from the surrounding normal breast.
An intraduct adenoma (fairly common), or an intraduct carcinoma (less common). A carcinoma is more often palpable than an an adenoma. Both present as a discharge from the nipple, which is usually serous, but may be dark or blood- stained. The prognosis after limited removal is good.
A carcinoma, may be schirrhous or medullary (both common). She has a hard, fixed mass with the criteria of malignancy listed above. Mastitis carcinomatosa (rare) is a highly malignant form of carcinoma seen during pregnancy. It is more generalized, and more like inflammation, or Burkitt's lymphoma, than the hard, fixed mass of a typical carcinoma.
Burkitt's tumour (only seen in endemic areas, and uncommon even there) is usually bilateral. She is between the ages of 14 and 25. It may simulate mastitis carcinomatosa, but is not particularly associated with pregnancy. Her skin is stretched, and may ulcerate; she usually has other tumours elsewhere.
Other possibilities include an organizing haematoma (fairly common), and fat necrosis (uncommon).
MANAGING CYSTS [s7]IN THE BREAST If you think a mass is a cyst, proceed as follows. First, exclude hydatid cysts (if yours is an endemic area), by looking for lumps that might be hydatid cysts elsewhere in her body. Aspirate the cyst with a wide bore needle.
If the fluid you aspirate is blood-stained, explore and biopsy the lump.
If the lump remains after you have aspirated it, operate to remove the lump completely, unless it is very large, and send tissue for histology.
If the fluid is clear and the lump disappears, as is usual in fibroadenosis (the commonest cause), no further treatment is necessary. Try to see her regularly. If the cyst appears again, or other cysts appear, aspirate again. If at any time lumps do not disappear, remove them as immediately above.
Fig. 21-4 THE PATHOLOGY OF A FIBROADENOMA. A, the tumour is attached to the capsule by a stalk carrying its blood supply. Sometimes the tumour extends into the capsule near the stalk. B, remove a superficial fibroadenoma by incising directly over it. If it is deeper, a submammary incision may be best. After Rob C and Smith R, (Operative Surgery'', Vol. 1 (2nd edn), (Butterworth), with the kind permission of Hugh Dudley.
MANAGING SOLID LUMPS [s7]IN THE BREAST Consider all lumps as malignant, until you are sure they are benign. Biopsy or excise solid lumps and send tissue for histology. The future management of the patient depends on the result.
CAUTION ! Excision of the entire lump for histological examination should be the general rule.
The only occasional exception to this rule, is the lump which is ''almost certain to be benign', for example, it has all the features which suggest a fibroadenoma. If the patient is highly reliable, and does not want her lump removed, you can measure it, and see her every two weeks at first and later monthly, measuring it each time. If it enlarges or changes its character, remove it. Leaving such a lump should be the exception. You can remove most fibroadenomata through a periareolar incision, with a good cosmetic result if the lump is small.
If it is an obvious fibroadenoma by the criteria above, shell it out without removing any normal breast tissue round it, and send part of the specimen for histology.
If she has carcinoma of her breast, see Section 21.4.
If she has a lump and a discharge from her nipple, her prognosis is better, because it is more likely to be a duct adenoma or carcinoma. Excise the duct involved (21.5) and her prognosis will be good.
If you suspect that she has Burkitt's lymphoma of her breast, take a needle biopsy, stain a slide preparation, and interpret it yourself as in Fig. 32-3. Or, less satisfactorily, send a biopsy. If you are not confident that you can interpret a slide preparation, do both; excise the lump, make a slide from it, and send the biopsy for histology. If the tumour is large and ulcerating, excise it, and graft her exposed pectoralis major. If Burkitt's lymphoma is likely and histology slow, start chemotherapy immediately.
MANAGING A DISCHARGE FROM THE NIPPLE This can be: (1) The normal active breasts of pregnancy (common). Colostrum can be discharged from the 16th week of pregnancy, and even earlier in multigravidae. (2) The normal usually milky discharge after lactation stops (fairly common). This may persist for months and occasionally years, especially if lactation is prolonged. (3) The discharge associated with fibroadenosis (uncommon). (4) The discharge associated with periductal mastitis (plasma cell mastitis, uncommon). (5) The clear, or less often blood-stained discharge, due to an intraduct adenoma (fairly common) or carcinoma (uncommon).
Discharge is more serious if it comes from one duct rather than from many, if it is bloody, or if it is associated with a lump. At the start of the examination, don't palpate the her breast in the normal way, because this may squeeze out any secretion which has accumulated, and you want to see exactly where it is coming from. Instead, ask her to lie back. Gently wipe her nipple clean. Then, press with one finger 3 cm distal to her areola, and move it towards her nipple. Start at ''one o'clock' and move progressively all round her breast to the ''12 o'clock' position. If there is any discharge, wipe it away and note its position. Then examine her breast in the usual way.
If she is pregnant, and the fluid is clear and comes from many ducts in both breasts, reassure her.
If both breasts continue to discharge milky fluid from many ducts, even years after lactation has stopped, reassure her.
If she has fibroadenosis, the retention cysts it causes may occasionally cause a disharge from one breast, seldom both. Aspirate the cyst if she has one. If it does not disappear, or if the fluid is blood-stained, do an excision biopsy.
If she has a watery, or bloody, or dark discharge from one duct, usually without a lump, she probably has an intraduct adenoma. If she has a lump, it is more likely to be a carcinoma; even so, her prognosis is good. Excise the lump with the duct (21.5).
If she has a recurrent discharge from several points on her nipple, watery or viscid, green, white, black or occasionally bloody, suspect periductal mastitis (plasma cell mastitis, rare). This can also present as a hard, tender swelling with redness of the overlying skin, which you can confuse with an acute breast abscess, or a rapidly growing carcinoma. It may regress spontaneously.
MANAGING A SINUS OR FISTULA [s7]IN THE BREAST A sinus or fistula may discharge milk, or a non-specific fluid. A milk fistula can follow a breast abscess (fairly common), or village surgery (fairly common in some communities), or tuberculosis of the breast (uncommon). Or it can complicate a carcinomatous ulcer. Other possibilities besides those below are a foreign body, and fungi.
If she has a milk fistula, and is or should be breast- feeding, try to improve or re-establish breast-feeding soon. Her fistula will probably heal. If it does not, it will probably do so when she stops breast-feeding at the normal time.
CAUTION ! A milk fistula is not an indication to stop breast-feeding. Rather, it is an indication to re-establish breast-feeding soon, if it has stopped.
NIPPLE DISEASES Chronic eczema, (uncommon) is bilateral. Clean her nipples frequently with soap and water. Apply Lassar's paste 1%, or hydrocortisone ointment 1%.
Paget's disease of the nipple, (uncommon) is unilateral, and is a sign that that there is an underlying intraduct carcinoma. ''Peau d'orange' may develop around it. Excise all the area affected, with the underlying lump, including a margin of at least 2 cm of normal tissue horizontally and vertically. Close the wound as for a ''lumpectomy' (21.5).
DIFFICULTIES [s7]WITH BREAST DISEASES If she has evidence of ACUTE INFLAMMATION [md]a recent history, throbbing pain, and tenderness, don't wait for fluctuation. Treat her for a breast abscess, as in Section 21.2. Acute infection may be difficult to differentiate from mastitis carcinomatosa.
If she is over 70 and has a SOFT FATTY LUMP, which feels as if it might be a lipoma, suspect that it is in fact a carcinoma, which can be as soft as a lipoma at this age.
If BOTH HER BREASTS ARE ENLARGED, with pitting oedema, suspect some generalized disease, such as cirrhosis, the nephrotic syndrome, or heart failure.
If she has ONE SWOLLEN PAINLESS BREAST, with PITTING OEDEMA and NO PALPABLE MASS, she may have:(1) Tuberculosis of her axillary nodes causing lymphoedema of her breast, or (2) non-specific inflammation of them. If she has tuberculosis, her affected breast is larger than the opposite one, is not tender or only slightly so, and almost always shows ''peau d'orange'. Her axillary nodes (usually the lateral pectoral group) are commonly matted together, and may be attached to underlying structures and her skin. She may also have a discharging sinus. Look for signs of tuberculosis elsewhere, especially enlarged nodes in her other axilla, her groins, and her abdomen. X-ray her chest, and do an ESR and a tuberculin test. See also Sections 31.4 and 31.6 and Chapter 29. This manifestation of tuberculosis affecting the breast via the axillary nodes is more common than tuberculosis of the breast itself.
If she has SMALL FIBROTIC NODES IN HER AXILLA, not the typical enlarged matted tuberculous ones, and no signs of tuberculosis elsewhere, she may have chronic non-specific infection following repeated infection of her hand and arm, usually from wounds. Filariasis affecting her axillary nodes is another possibility (31.6).
If a nipple is CHRONICALLY ULCERATED, suspect that this is associated with an underlying duct carcinoma, unless she has a clear history of trauma. Biopsy it: there are also some rare causes such as syphilis and tuberculosis, etc.
If anyone but a female over 10 years has a firm tender discoid SWELLING DEEP TO THE NIPPLE just larger than the areola, and concentric with it, the condition is one of gynaecomastia. This is normal in infants of either sex, in boys near puberty, and in young men. In infants it is nearly always bilateral, and is sometimes complicated by mastitis. In young men it may be uni- or bilateral. Reassure all these patients.
If both an adult MAN'S BREASTS ENLARGE, this is still gynaecomastia. If the clinical findings are not those of physiological gynaecomastia (see above), he probably needs investigation. He may have disease of his liver, testes, adrenals, or pituitary, or he may have leprosy, or have been treated with stilboestrol. Investigate him as best you can. Often, no cause can be found. If you decide to remove such breasts, do so as in Fig. 30-9.
If one of A MAN'S BREASTS ENLARGES, he may have CARCINOMA OF THE MALE BREAST, or gynaecomastia; you can usually distinguish them clinically. If he has carcinoma treat him as if he were female. Excise it, together with some of the skin and the muscle underneath it. Because he has so little fatty tissue, the tumour infiltrates his skin and deeper tissues at an earlier stage, and his prognosis is worse. Orchidectomy usually produces a temporary remission. If he agrees, do the subcapsular operation. This leaves a small palpable ''testis', but even so it is not popular! (23.25).
If ONE BREAST IS VERY MUCH LARGER THAN THE OTHER, but is otherwise normal, the patient may have GIANT HYPERTROPHY (uncommon). This is probably congenital, and may affect both breasts. Such breasts may enlarge more in the third decade, especially following pregnancy.
Fig. 21-5 INCISIONS FOR REMOVING LUMPS FROM THE BREAST. A, if the lump is within 5 cm of the the nipple, make a periareolar incision, not larger than half the circumference of the areola. Some scratches across the site of the incision before you make it will help you to align its edges. B, if the lump is further away make a curved circumferential incision over it, parallel to the areola. C, if the lump is deep in the breast, you may be able to use a submammary incision. D, slant a mastectomy incision obliquely towards the axilla. E, if your histology services are good enough to justify taking a biopsy, make a radial incision within the area of a possible later mastectomy, so that you can excise the scar. If either your histological services or the patient are unreliable, don't take a biopsy and then hope to do another operation later.