BREAST LUMP

Issah J. kiswagala

(M.B.B.S)

INTRODUCTION

• Breast is a modified sweat gland occupies the pectoral region from the 2nd to the 6th rib vertically, and from the lateral border of sternum to the midaxillary line, horizontally.
• It is hemispherical, and lies in the superficial fascia planes.
• It is composed of fatty tissue and does the function of secreting milk.
• The entire breast is a subcutaneous structure.

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SURGICAL ANATOMY

• The human breast is a modified sweat gland located on the anterior aspect of the chest wall
• It is rudimentary in males but develops to variable proportions in the female
• The human breasts are usually two in number on either side of the sternum
• Blood Supply
• Arterial supply - is by the thoracic branches of the axillary arteries and from the internal mammary and intercostals arteries.
• Venous drain - is through the axillary and mammary veins.

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• Nerve supply of breast is by anterior and lateral cutaneous branches of 4th to 6th intercostal nerves and Supraclavicular nerves
• Lymphatic drainage of the breast
• The axillary lymph nodes usually receive >75% of the lymph drainage from the breast.
• The rest is derived primarily from the medial aspect of the breast, flows through the lymph vessels that accompany the perforating branches of the internal mammary artery, and enters the parasternal (internal mammary) group of lymph nodes.
• Pectoral nodes: Anterior, located along the lower border of the pectoralis major inside the anterior axillaries fold. These nodes drain anterior chest wall and much of breast.

• Central group: It is the node most easily properly clinically palpable in axilla.
• Receive lymph drainage both from the axillary vein, external mammary, and scapular groups of lymph nodes, and directly from the breast
• Apical group also called as sub-clavicular. It lies most superior and deep to pectoralis minor
• Receive lymph drainage from all of the other groups of axillary lymph nodes
• Subscapular nodes: Posterior, located along the lateral border of the scapula; palpated deep in the posterior axillary fold.
• Drain the posterior chest wall and a portion of the arm.

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• Lateral nodes: Located along the upper humerus.
• Drain most of the arm.
• Interpectoral node :- It lies between pectoralis major and minor.
• Receive lymph drainage directly from the breast.

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• The breast is divided into four quadrants by drawing imaginary longitudinal and transversal lines which cross at the nipple
• Upper outer
• Upper inner
• Lower outer
• Lower inner
• The region around the nipple is known as the peri-areola.

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BREAST LUMP

• A breast lump is a mass that develops in the breast. 
• Breast lumps vary in size and texture and may cause pain. Some are not found until a physical or imaging exam.
• Most breast lumps are benign (non-cancerous)
• Fibroadenoma
• Breast cysts
• Phyllodes
• Papilloma

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FIBROADENOMA

INTRODUCTION

• It is a benign encapsulated tumour occurring commonly in young females of 15–25 years age group.
• It is considered as hyperplasia of a single lobule of the breast
• It is the most common benign tumour of the breast below 30 years of age in females.

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Fig. shows Large fibroadenoma of left breast in a 14-year-old female.

• Incidence is 15% of palpable breast lumps. It is common in blacks and Negroes.
• Fibroadenoma may grow to a larger size usually grow to 1 or 2 cm in diameter and then are stable but may grow to a larger size.
• Small fibroadenomas (≤1 cm in size) are considered normal, whereas larger fibroadenomas (≤3 cm) are disorders, and giant fibroadenomas (>3 cm) are disease.
• It is bilateral in 20% of cases. 20% are multiple.
• 30% of fibroadenomas may disappear or reduce in size in 2–4 years. 10–15% will increase in size progressively.

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TYPES

• Juvenile fibroadenoma occurs in adolescent girls.
• It may clinically mimic phyllodes tumour.
• It does not turn into phyllodes tumour or carcinoma.

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• Complex fibroadenoma (Dupon et al) is a condition (variant) having typical fibroadenoma with fibrocystic changes like apocrine metaplasia, cyst formation, sclerosing adenosis.
• It occurs in older age group
• Occasionally it may turn into malignancy unlike usual fibroadenomas.

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CLINICAL FEATURES

• It presents as a painless swelling in one of the quadrants which is;
• Smooth
• Firm
• Nontender
• Well-localised and moves freely within the breast tissue (mouse in the breast).
• Axillary lymph nodes are not enlarged.

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INVESTIGATION�

• Up to the age of 25 years clinical diagnosis enough.
• Mammography is routine diagnosis with increase in age
• Fine Needle Aspiration Cytology (FNAC) - Performed to exclude malignancy.
• Ultrasonography - used to exclude differential diagnosis palpable breast lump.

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TREATMENT�

• Excisional biopsy is the treatment of choice

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BREAST CYSTS

INTRODUCTION

• They are cavities lined by epithelium in the breast containing fluid.
• It arises from destruction and dilatation of breast lobule and terminal ductules. It is due to nonintegrated stromal and epithelial involution.
• It is common after the age of 35 years up to menopause. It is uncommon after menopause.
• Hormone replacement can cause cyst formation in old women.
• Cyst size varies with menstruation due to influence of ovarian hormones.
• Cysts can be multiple (50%). Often bilateral and can be recurrent (50%).

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CLINICAL FEATURES

• Smooth, soft and well-localized swelling.
• Fluctuant often trans-illuminant.

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DIFFERENTIAL DIAGNOSES�

• Bloodgood cyst, haematoma,
• cystic necrosis in a carcinoma,
• Brodie’s disease,
• Galactocele,
• Lymph cyst,
• hydatid cyst.

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INVESTIGATION�

• Ultrasound of breast
• FNAC
• Mammography to rule out associated carcinoma.

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TREATMENT

• Aspiration for two times.
• Surgical excision is done if cyst recurs after two aspirations or if there is bloody discharge or residual mass if felt after aspiration.

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PHYLLODES TUMOUR

INTRODUCTION

• They are fibroepithelial tumours composed of an epithelial and cellular stromal component.
• Phyllodes tumour show wide spectrum varying from benign to a local aggressive and sometime metastatic tumour.
• When diffuse small, multiple cysts are the main component, it is called as Schimmelbusch’s disease.
• It is the most common breast disease, common in upper and outer quadrant.
• It is an exaggerated response of breast stroma and epithelium to hormones and growth factors.

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• It is rare in nulliparous/ovulating/OCP taking women.
• They can be benign, borderline or malignant tumours
• As the tumour grows very fast, it undergoes necrosis in various places resulting in cystic areas within the breast.

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CLINICAL FEATURES

• Rapid growth
• Stretched, shiny skin, Red, dilated veins over surface, warm to touch
• Bosselated surface (big nodules), a few cystic areas.
• It is not fixity to the skin or pectoralis muscle-mobile on the chest wall
• Lymph nodes will not be involved
• No nipple retraction.

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INVESTIGATIONS

• Mammography is routine diagnosis with increase in age
• Fine Needle Aspiration Cytology (FNAC)-Performed to exclude malignancy.
• Ultrasonography-used to exclude differential diagnosis palpable breast lump.
• Chest X-ray, CT chest when you suspect malignancy to see secondaries

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TREATMENT

• Simple enucleation is recommended. Older patient require wider excision with 1cm margin of normal breast tissue
• Large tumour may require wider excision in the form quadrantectomy or even simple mastectomy.

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DUCT PAPILLOMA

INTRODUCTION

• Duct Papilloma is a benign tumour ,which arise from the lining epithelium of principal lactiferous duct.
• It is usually single, from a single lactiferous duct
• They are epithelium lined true polyps of breast lactiferous ducts.
• Usually, it is <1 cm in size often with a small lump under areola.
• But can attain large size.
• Vascular stalk is present usually.
• Majority of the patients are between the age of 30 and 50 year

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• Rarely a cystic soft swelling may be present underneath which is probably due to obstruction of the duct by papilloma.

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• Papilloma breast which is large. Usually it is small intraductal.

CLINICAL FEATURES

• Papilliferous swelling (projection), usually seen near the nipple orifice.
• Blood stained discharge from the nipple is common.
• But serous or serosanguinous discharge can also occur.
• Single papilloma is not premalignant.
• But multiple papilloma in many ducts can be premalignant.
• Peripheral papilloma should be differentiated from invasive papillary carcinoma.
• The regional axillary lymph node are usually not affected

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INVESTIGATIONS�

• Injection of contrast into the duct (Ductogram).
• Mammography may show dense lesion under the areola.

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TREATMENT

• Complete excision of duct involved along with the tumour should be performed. This operation called Microdochectomy.

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