BREAST LUMPS-part1

Dr Pasha

Development of
Mammary Glands
1. Ectoderm thickens along the line from axilla to inguinal region forming
Mammary ridges
2. Mammary glands develop from a part overlying pectoral region
3. Thickened mass forms from epidermal cells then projects into the dermis
4. 16- 20 solid outgrowths arise and grow further into dermis
5. The mass and its outgrowths canalize
6. Secretory elements develop from the terminal parts of the outgrowths.
7. Proximal ends forms lactiferous ducts opening into a pit formed by
cavitation.
8. Growth of underlying mesoderm pushes out of the cavity, passing the
epidermis forming the nipple
9. In females the breasts continue to grow through puberty and pregnancy
10.In males remain rudimentary.

Development of breast
prepuberty, puberty, pregnancy
At birth,after the mother's hormones dissipate, a small amount
of breast tissue lies dormant under the infant's nipple & areola.
At puberty,estrogen(duct) and progesterone(alveoli) causes the
breasts to enlarge. However, only Type 1 and 2 lobules are formed,
which are where ductal and lobular cancers start respectively. Most
of the breast tissue is stroma (tissue surrounding the lobules). The
lobules account for about 10% of the breast tissue.
After puberty,there is a reduction in stroma and lobules account
for 30% of the breast tissue: 75% are Type 1 and 25% are Type 2
lobules with a few Type 3.

ANATOMY OF BREAST
Specialized gland of the skin capable of
secreting milk
Lie anterior to the deep fascia of the
pectorialis major with retromammary
space in between
Thus, gland is NOT firmly attached to
deep fascia.
Extends from 2nd to 6th rib, lateral margin
of the sternum to midaxillary line.
Axillary extends upwards laterally and
pierces the deep fascia, lower border of

STRUCTURE
Basic unit is a lobule
A lobule is formed by 10-100 acini
Acini consist of layers of epithelial and myoepithelial cells
that surround a lumen
20-40 lobules form a lobe
A breast has 15-20 lobes embedded in fats
Lobes drain into branching and interconnected ducts
Lactiferous Ducts widen beneath the nipple as lactiferous
sinus
Then empty into 5-9 nipple openings
Main ducts of each lobe opens into a dilated ampulla prior
to termination in the nipple.

Suspensory ligaments
of cooper
Anchors deep layer of skin to deep
fascia of pectorialis major muscle.
Thus, glands are firmly attached to
the skin
Compartmentalizes the fat lobules
of the gland

Blood supply of the

breast
1. Perforating branches 2nd,3rd ,4th
branch of Internal mammary
artery
2. Posterior intercostal arteries from
2nd, 3rd, 4th spaces supply base of
the breasts
3. Axillary artery supplies via lateral
thoracic artery
4. Pectoral branch of
thoracoacromial artery

Axilla

Axillary nodes
1. Anterior( pectoral) group
2. Posterior (subscapular) group
3. Lateral (brachial) group
4. Central group
5. Apical group

Lymphatic Drainage

Drain lymph from breast to series of

nodes
Lat. drainage is via 5 groups of axillary
nodes
Supr. drainage is via 1 group of
interpectoral nodes
Med. drainage is via 1 group of
parasternal nodes
Inf. Drainage is via inferior phrenic nodes
75% of lypmh mainly from lateral lobes
passes into axillary nodes

Nipple
Small
Surrounded by pigmented area
called areola
Lubricated by glands of
Montgomery.

Quadrants of breast
1. Superolateral (upper
outer) quadrant
2. Superomedial (upper
inner) quadrant
3. Inferolateral (lower
outer) quadrant
4. Inferomedial( lower
inner) quadrant
Majority of breast
carcinoma develops
in the upper outer
quadrant, large
amount of glandular

tissue and axillary tail extends

into axilla

pathophysiology
After conception,the baby secretes hCG, stimulating the ovaries to produce
estrogen and progesterone, which cause the breast to start to enlarge by
making greater numbers of lobules. T
By the end of the 1st trimester,during the maturation of Type 1 lobules into
Type 2, the actual numbers of these lobules will increase while the surrounding
tissue (stroma) decreases. The breast now has more places for cancers to start.
By mid 2nd trimester,the breast has doubled in volume and has continued to
mature rapidly under the influence of placental lactogen. The breast is now 70%
Type 4 cancer resistant lobules and 30% immature cancer susceptible lobules.

pathophysiology
By the end of the 3rd trimester,85% of the breast is fully matured
to Type 4 lobules and only 15% remain immature cancer susceptible
lobules, leaving fewer places for cancer to start.At delivery,the
mother's breasts are now predominantly Type 4 lobules. They are fully
mature and resistant to carcinogens, resulting in lower long-term risk of
breast cancer for the mother.
While breastfeeding,the mother's menstrual cycles may stop or
become anovulatory, further reducing her risk.
After weaning,Type 4 lobules regress to Type 3 and the breasts get
smaller again. However, there is evidence of permanent changes in the
genes of these Type 3 lobules which confer life-long cancer resistance
even after menopause when they further regress to Type 1.

hormones
Prolactin:
initiate and
sustainlactation

hormones
feedingOxytocin:
1) Letdown reflex breast
2) Uterine
contraction

SYSTEMIC REVIEW
1.
.
2.
.
3.
.
4.
.
5.
.

Constitutional symptoms
Weight loss, lethargy
Respiratory symptoms
Cough, hemoptysis, dyspnoea, chests pain due to
metastasis
Abdominal symptoms
Acites, jaundice due to liver metastasis
Bone symptoms
Bone pain, pathological fracture due to metastasis
CNS symptoms
Headache, vomitting, diplopia,focal fits, twitching,
paresis,paralysis

Specific risk factors

1. Patient profile Female, >40yrs, caucasian(but in Malaysia,
Chinese)
2. Menstrual history- early menarche(<11yrs), regularity,
duration, use of oral contraception, changes of breast lumps
with the cycle, late menopause(>55yrs), Hormone
replacement therapy.
3. Obstetric history. Nulliparity(high risk)/multiparity,
. Age of first childbirth- lesser the age below 30, lower the
risk.
. Breast feeding- Better immunity if breastfeed for 1 yr.
4. Past medical history- Fibroadenosis has risk of developing
into carcinoma, Ca of Uterus, Ca of ovary.

Risk factors
4. Personal- Diet rich in saturated fats increases
peripheral fatty tissue which converts
circulating androgens to oestrogens
5. Social history. High socioeconomic status, higher the risk.
. High alcohol consumption increases risk
6. Family History. first degree maternal relatives having breast
cancer (sister,mother,grandmother,aunt)
. Inherited BRCA1 and BRCA2

BENIGN BREASE
DISEASES

Breast Disease
manifests as lumps
Inflammatory: Mastitis, breasts abcess,
duct ectasia
Trauma: hematoma, fat necrosis,
fibrosis, calcification
Neoplastic Benign: Fibroadenoma,
phylloids tumor, intraductal papilloma,
sclerosingadenosis
Sclerosing adenosis: Fibroadenosis,
cystsm galactocoel, mastalgia.

Benign breast lumps

Fibroadenomas (15-30yrs)
Fibroadenosis (25-40yrs)
Cysts (40-50yrs)
Galactocoel (lactating women)
Phylloids tumor (40-50yrs)
Fat necrosis

Congenital
1. Amazia- Congenital absence of breast
unilaterally or bilaterally.
2. Polymazia- accessory breast in
axilla/groin/buttock/thigh, may lactate
3. Mastitis of infants- slight mil secretion by
infants, boys/girls, due to stimlation of foetal
breasts by prolactin.
4. Diffuse hypertrophy- Tremendous
overgrowth of breasts, may reach the knees
in sitting position, due to oversensitivity of
breasts to oestrogenic hormones.

Intraduct papilloma
Papillary neoplasm arising from
ductal epithelium
Presentation: blood stained
discharge from nipple, soft swelling
over areola

Injuries to breast
1. Hematoma- gives rise to lump
2. Traumatic fat necrosisacute/chronic, common in stout
middle aged women, presents
with painless lump, mimics
carcinoma due to skin tethering
and nipple retraction

Inflammation
1. Bacterial mastitis- acute inflammation, associated with
lactation or cracked nipple, infection by staph.aureus of
the lactiferous ducts, may form breasts abcess.
2. Tuberculosis infection- associated with pulmonary Tb, Tb
cervical adenitis, causes multiple abscess
3. Mondors disease- thrombophlenitis of the superficial veins
of breast, causes subcutaneus grooves which can mimic
carcinoma.
4. Duct ectasia/periductal mastitis- dilatation of the breasts
ducts, infection and filled with stagnant liquid, irritates
surrounding tissue producing abscess, inflammation,
fistula and fibrosis, presents slit like nipple retraction,
subareolar mass and abscess.

Phylloides Tumor
Biphasic tumor resembling fibroadenoma, but with
hypercellular mesenchymal component organized in leaflike pattern around benign epithelial / myoepithelial lined
spaces
The amount and appearance of stroma helps distinguish
between the two.Size larger than 4 cmand ahistory of
rapid growth favorsthe diagnosis ofphyllodes tumor.
Commonly >40yrs
Presentation: can be large, massive,uneven surface or slow
growing smooth swelling like fibroadenoma, both remains
mobile, can cause pressure necrosis and ulceration over
skin.

Breast Cysts
1. Simple cyst: Fluid filled cavity appearing in breast with
endothelial lining/capsule
Pathology: non integrated involution of stroma and
epithelium
Presentation: around menopause, spherical,smooth, soft to
hard(can mimic ca), variable in size but never fixed or
tethered to skin.
2. Galactocoel: milk containing cyst
Presentation: solitary subareolar cyst, similar to simple
cyst, happens shortly after lactation.

Fibroadenoma

Commonly in15-25yrs, maybe even in 40s

Oestrogen dependent and slow growing
Pathology: Duct like slit spaces surroumded by Fibroblastic
stroma, can be pericanalicular (fibrous)or
intracanalicular(more glands),
Clinical features: painless lump anywhere in breast,
spherical/oval/lobulated, smooth, well defined edge, rubbery
firm, very mobile (breast mouse)

Fibroadenosis
Commonly in 25-35yrs, reproductive age
Pathology: Fibrosis+ adenosis+ epitheliosis
+cysts formation under microscope
Pain before menstruation(cyclical) or non
cyclical
Lumpy or nodular

Abberations of normal
development and
involution(ANDI)
A group of benign disorders of
breast associated with normal
development and involution.
Pathology: formation of cysts,
fibrosis, hyperplasia of epithelial
linings, papillomatosis(extensive
epithelial hyperplasia)
Includes Fibroadenoma, Cysts,
Fibroadenosis

Breast Examination

Introduction
1. Introduce self
2. Expose: waist up, with exposure of
axilla
3. Position: Pt at sitting position or
propped up 45

History taking
1. Pain
. In the breast- mastodynia(cyclical or
non-cyclical)
. In the swelling mastitis, breast abscess
and duct ectasia
2. Lump in the breast- fibroadenoma,
fibroadenosis, cysts, phylloids tumour,
carcinoma breast
3. Fever- breast abscess

Lump in the breast

Side
Site
Onset
Initial size
Duration
Progress
Present size

Skin Changes
Dimpling- onset, duration, progress
Skin nodules and ulceration- onset,
duration , progress

Fever
1.
2.
3.
4.
5.
6.
7.
8.

Verify presence of fever and the grade

Duration- Acute or chronic
Mode of onset- Abrupt of gradual
Progression- Continuous, intermittent,
remittent
Severity
Relieving and aggravating factors
Treatment received and outcome
Associated symptoms- Localizing
symptoms may indicate source of fever
(eg. Nausea,vomitting, nipple discharge)

Nipple changes
1. Nipple Discharge
. Duration
. Colour(clear/milky/yellow/green/bl
oody) eg. Fibroadenosis, duct
ectasia, duct papilloma, prolactin
producing adenoma, medications
like antidepressants, cimetidine
2. Itching, redness, excoriation,
ulceration of nippleareolar
complex eg. Pagets disease,
Eczema

Lump in axilla
Onset , duration, progress

Inspection
1. Comparison of both breast
a) Asymmetry
b) Lump
c) Level of nipple compare both levels
a) Malignant lump pull nipple towards lump
b) Benign lump nipple away from mass
d) Raise both arms slowly
a) Tethering of skin
b) Nipple level change
e) Push hands against hips
a) may reveal lumps that were not visible before when
pectoralis muscle were relaxed.

Inspection
2.
a)
b)
c)
d)
e)
f)
g)

Nipple & Areola(7D)

Discolouration
Depression
Destruction
Deviation
Displacement
Duplication
Discharge
1.
2.
3.
4.

Fresh blood Ca, duct papilloma

Black
- Duct papilloma with obstruction
Clear/green - Fibroadenosis
Milky
- lactation, galactorrhea, mammary duct
ectasia, galactocoele
5. Purulent
- acute mastitis, chronic abcess

Inspection
3. Skin
a. redness, shininess,edema
-inflammation acute mastitis/abcess
b. Dimpling, retraction, puckering
c. Peau dorange appearance
a. Orange peel appearance due to malignancy block
superficial lymphatics of skin
edema except hair follicles(the holes)
d. Ulcer & skin nodule

*look at axillae, arms and supraclavicular fossa for enlarged l.

nodes, swelling or distended veins.

Palpation
6. Nipples
a)Palpate breast deep to nipple
b)Gently press on nipple to see if there is
discharge. If present note the appearance,
character and colour of discharge.
7. Axilla and cervical lymph nodes

. .
.

Axillary lymph nodes

-Must be palpated with patient sitting, back against you. You may wear
gloves.
-To examine the right: ask the patient to hold your elbow while you support
the weight of their right arm at their elbow with your right hand. Now left
hand into the axilla. Now palpate the apical (lift the arm up and scoop deep
inside and bring it down), central (go down slightly), anterior (move
towards front) and posterior (swoop backwards), then lateral lymph node
groups (change hand, palpate laterally) by pressing the soft tissues (hard)

Palpation
1.
2.
3.
4.

5.
6.
a.
b.

c.

Ask for any pain

Palpate normal breast first
Palpate in circular motion including axillary tail
Lump
1. site
6. tender
2. size
7. warmth
3. shape
8. Fluctuance
4. surface
9. Margins
5. consistency
Fixation to skin try to pick up skin on lump
Fixation of underlying muscle
Move lump in 2 perpendicular directions.
Ask patients to press her hands againts her hips to contract
pectoralis ms, then try to move it in 2 perpendicular directions
again
If on contraction the lump is non mobile indidcating mass is
fixxed to pectoralis ms

To complete examination
1. Examine lings for pleural effusion
2. Examine spine for bony tenderness
3. Examine the abdomen for hepatomegaly

Investigation

Investigation
Histology
1. Fine Needle Aspiration Cytology
.Less invasive
.Only cells obtained, cannot differentiate
between in-situ Ca and invasive Ca
2. Core Biopsy
.Obtains tissue specimen,
can stain for ER/PR status

Investigation
2. Ultrasound
<35 yo or pregnant, lactating patients
Abnormalities:
a) Markedly hypoechoic
b) Irregular edge
c) Microcalcification

Investigation
1. Mammography
Abnormal findings:
a) Asymmetric density
b) Microcalcifications
c) Spiculated mass
d) Architectural distortion

Investigation
1. Mammography
.
.
.
.

Gold standard
Performed in older women(>35 yo)
-uses compression plates, hence, good compression of breast
is one of the essentials of effective mammography
- in young female patients (>fibro-collageneous tissues) we do
ultrasound since mammogram is going to have false +ve result
-the same applies to male patient (little breast tissue)
2 views:

Craniocaudal
Mediolateral Oblique

CPG Recommendations:

full blood count

liver function tests
chest X-ray.
In patients with clinically Stage 3 and
4 breast cancer, a bone scan and
liver CT /ultrasound should be done.