The Breast Dr. Naser El-Hammuri Head of the Department of Surgery A. Professor & Consultant of GIT Surgery

The Breast Anatomy Modified sweat gland Pigmented skin covers the areola and the nipple Opening of the lactiferous ducts are seen near the apex of the nipple The nipple is in the 4th intercostal space Accessory breast / nipple tissue may develop anywhere down the nipple line (axilla to groin)

The Breast Anatomy The adult breast is divided into nipple, the areola and four quadrants, upper and lower, inner and outer, with an axillary tail projecting from upper outer quadrant The size of the breasts are influenced by age, hereditary factors, sexual maturity, phase of the menstrual cycle, parity, lactation and general state of nutrition

The Breast

The Breast Anatomy Fat and stroma surrounding the glandular tissue determine the size of the breast, except during lactation , when enlargement is mostly glandular

The Breast Symptoms / Breast Lump Breast cancer 1 in 9 women Solid mass with irregular outline Usually, but not always, painless firm and hard Fibrocystic changes Irregular nodularity of the breast Common especially in the upper outer quadrant in young women Rubbery in texture Prominent premenstrually Usually bilateral and B9

The Breast Symptoms / Breast Lump Fibroadenoma B9 lumps are an overgrowth of parts of the terminal duct lobules Smooth, mobile, discrete and rubbery 2nd most common cause of breast mass in women under 35 years old

The Breast Symptoms / Breast Lump Breast Cyst Smooth fluid-filled sacs Most common in women age 35 – 50 yr Soft and fluctuant when the pressure in the sac is low, but hard and painful if the pressure is high May occur in multiple clusters Most are B9, but any cyst in which aspirate is blood stained or there is a residual mass following aspiration or which recurs after aspiration, should be investigated

The Breast Symptoms / Breast Lump Breast Abscesses Lactational, usually peripheral None Lactational, occur as extension of peri-ductal mastitis, usually found under the areola and usually associate with nipple inversion

The Breast Symptoms / Breast Pain Mastalgia Could be cyclical, related to menstrual cycle, worse in the latter half of the cycle and relieved by the period None cyclical, no variation

The Breast Symptoms / Skin Changes Skin dimpling, the skin remains mobile over cancer Indrawing of the skin, skin fixed to cancer Lymphedema of the breast, the skin is swollen between the hair follicles and looks like peel of an orange (Peau d’orange) Eczema of the nipple and areola, may be part of generalized skin disorder or may be due Paget’s disease or invasion of the epidermis by an intraductal cancer

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The Breast

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The Breast Symptoms / Nipple Changes Nipple Inversion Retraction of the nipple B9, symmetrical, slit like Malignant, asymmetrical, distorted nipple, nipple pulled to one side

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The Breast Symptoms / Nipple Changes Nipple Discharge Can be expressed from multiple ducts or single duct Clear yellow, white or green Investigate if persistent single duct discharge or bloodstained (macroscopic or microscopic) discharge to exclude duct ectasia, periductal mastitis, intraduct papilloma or intraduct cancer

The Breast Symptoms / Nipple Changes Galactorrhea Milky discharge from multiple ducts in both breasts due to hyperprolactinemia

The Breast Symptoms / Gynecomastia Enlargement of the male breast Often occurs in pubertal boys In chronic liver disease it occurs due to high levels of circulating estrogens

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The Breast Symptoms / Gynecomastia 10.3 Causes of gynaecomastia Drugs, including Cannabis Oestrogens used in treatment of prostate cancer Spironolactone Cimetidine Digoxin Decreased androgen production Klinefelter's syndrome Increased oestrogen levels Chronic liver disease Thyrotoxicosis Some adrenal tumours

The Breast The History Not all patients have symptoms Abnormality on screening mammography Concern about family history Explore the patient’s FIFE Presenting complaints - How long have symptoms been present? - What changes have occurred? - Is there any relationship to menstrual cycle? - Does any thing make it better or worse? Breast cancer may present with symptoms of metastatic disease

The Breast The History Evaluate patient’s risk factors 10.4 Indicators of breast cancer risk* Female gender Increasing age Family history, esp. if associated with: Early age of onset Multiple cases of breast cancer Ovarian cancer Male breast cancer Early menarche Nulliparity or late age of first child Late menopause Prolonged HRT use Postmenopausal obesity Mantle irradiation for Hodgkin's disease, esp. at young age (<30 years)

The Breast Physical Examination Male doctor should always have a chaperone Examination sequence Ask the patient to undress to the waist and sit upright on a well-illuminated chair or the side of a bed. Ask her to rest her hands on the thighs to relax the pectoral muscles (Fig. 10.10A).

The Breast Physical Examination Face the patient and look at the breasts for: asymmetry local swelling skin changes nipple changes. Ask the patient to press her hands firmly on the hips to contract the pectoral muscles and repeat the inspection (Fig. 10.10B). Ask her to raise her arms above the head and then to lean forward to expose the whole breast and exacerbate skin dimpling (Figs. 10.10C and D).

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The Breast Ask the patient to lie with her head on one pillow and her hand under the head on the side to be examined. Ask her to do this on both sides at the same time (Fig. 10.11). Hold your hand flat to the skin and palpate the breast tissue, using the palmar surface of your middle three fingers. Compress the breast tissue firmly against the chest wall. View the breast as a clock face. Examine each 'hour of the clock' from the outside towards the nipple, including under the nipple (Fig. 10.12). Compare the texture of one breast with the other. Examine all the breast tissue. The breast extends from the clavicle to the upper abdomen, and from the midline to the anterior border of latissimus dorsi (posterior axillary fold). Define the characteristics of any mass (Box 3.10, p. 58).

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The Breast

The Breast Elevate the breast with your hand to uncover dimpling overlying a tumour which may not be obvious on inspection. Is the mass fixed underneath? With the patient's hands on her hips, hold the mass between your thumb and forefinger. Ask her to contract and relax the pectoral muscles alternately by pushing into her hips. As the pectoral muscle contracts, note whether the mass moves with it and if it is separate when the muscle is relaxed. Infiltration suggests malignancy. Examine the axillary tail between your finger and thumb as it extends towards the axilla.

The Breast Palpate the nipple by holding it gently between your index finger and thumb. Try to express any discharge. Massage the breast towards the nipple to uncover any discharge. Note the colour and consistency of any discharge, along with the number and position of the affected ducts. Test any nipple discharge for blood using urine-testing sticks. Palpate the regional lymph nodes, including the supraclavicular group. Ask the patient to sit facing you, and support the full weight of her arm at the wrist with your opposite hand. Move the flat of your other hand high into the axilla and upwards over the chest to the apex. This can be uncomfortable for patients, so warn them beforehand and check for any discomfort. Compress the contents of the axilla against the chest wall. Assess any palpable masses for: size consistency fixation.

Examine the supraclavicular fossa, looking for any visual abnormality Examine the supraclavicular fossa, looking for any visual abnormality. Palpate the neck from behind and systematically review all cervical lymphatic chains (Boxes 10.5 and 10.6).

The Breast Investigation Accurate diagnosis of breast lesions depends on clinical assessment, backed up by mammography and/or breast ultrasound and pathological diagnosis, either by fine needle aspiration cytology or core biopsy ('triple assessment'

The Breast Investigations of Breast Lump Investigation Indication / Comment Ultrasound Lump Mammography Not in women under 35 unless there is a strong suspicion of cancer MRI Dense breast / ruptured implant Fine needle aspiration Aspirate lesion using a 21 or 23 G needle Core biopsy To differentiate invasive or in situ cancer Large core vacuum assisted core biopsy Open surgical biopsy

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The Breast

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