GENERAL EXAMINATION In carcinoma of the breast, the liver should be examined for secondary deposits (Figs. 30.26A and B). Lungs and bones particularly the ribs, spine, sternum, pelvis, upper ends of femur and humerus should also be examined as they may be involved by metastasis. Rectal and vaginal examinations are also necessary to detect Krukenberg's tumor of the ovary, which occurs by transcoelomic implantation or lymphatic permeation. In gynecomazia firstly a careful history should be taken (Fig. 30.27). Patients having stilbestrol as treatment of prostatic cancer may present with this condition (Fig. 30.28). The testis should be examined for anorchism, cryptorchism, teratoma or chorionepithelioma. Liver should be examined for cirrhosis. Asso Certain drugs like digitalis, spironola course, certain amount of breast e considered normal. SPECIAL INVESTIGATIONS These are mainly used firstly to breast, secondly to detect an early and staging. 1. Aspiration: This is performe thought to be benign. But if the disappear on aspiration and if th be should be examined for cirrhosis. Associated leprosy may cause enlargement of breast in males. Certain drugs like digitalis, spironolactone, isoniazide may initiate enlargement of breast. Of course, certain amount of breast enlargement in male is noticed during puberty, which is considered normal. 3 fem pu SPECIAL INVESTIGATIONS These are mainly used firstly to differentiate cancer breast from other benign lesions of the breast, secondly to detect an early cancer and finally to know the extent of the cancer, its spread and staging. ents 30.38 Hioma 1. Aspiration: This is performed in case of cystic lumps of the breast which were preliminarily thought to be benign. But if the aspirated fluid is blood-stained, if the mass does not completely disappear on aspiration and if the cyst recurs rapidly after two aspirations, excision biopsy should be called for. Fluid should be sent for cytology. Though negative results is of little importance, yet the positive result means excision of the lump or even mastectomy. 2. Mammography: Roentgenography to identify breast disease was first used in 1913 at the University of Berlin. Since then, mammography has been widely accepted as a routine examination in the evaluation of breast diseases. There has been many technical improvements and modifications of equipment design in mammography. Most significant has been xeroradiography. This is not a different process but rather a different method of recording X-ray images. Xeroradiography utilizes an aluminum plate thinly coated on one surface with vitreous selenium. Selenium is a photoconductor. The charged xeroradiographic plate is placed beneath the breast and a conventional exposure is made. The positive charges on the selenium are discharged in proportion to the varying intensities of the X-rays reaching the plate, modified by the tissues traversed. This leaves an electrostatic image of the breast on the plate. A finely divided negatively charged blue powder or toner is sprayed on the surface of the plate and is attracted to the latent image of positive charges. This produces a blue image of the breast which is transferred to a special plastic-coated paper and permanently fused by heat. Malignant lesions reveal themselves as localized fine or punctate calcification and small areas of increased stromal density and architectural distortion (Fig. 30.29). Benign tumorske fibroadenoma present as denser calcification with smooth outline (Fig. 30.30). Accuracy d mammography is 95% or more in atrophic and postmenopausal breasts. Accuracy is significantly lower in younger patients whose dense glandular breasts can obscure even clinically obvious masses. If mammography suggests that there is an impalpable carcinoma in a particular quadrant of the breast, difficulties may be experienced in attempting to localize the area for biopsy. It is of great importance that the excised specimen should be sent for radiology to ensure that the area of microcalcification is within the biopsy. Contrast mammography: In this technique contrast medium is injected in one of the major mammary duct and then soft tissue X-ray is taken. Intraductal tumor (duct papilloma is demonstrated by smooth filling defect; whereas duct carcinoma is demonstrated by irregular filling defect) can be detected by this technique. Fig. 30.29: Mammography showing carcinoma of the breast. See the text. Fig. 30.30: Mammography showing a fibroadenoma Note the smooth outline of the tumor. 3. Thermography: This is nothing but pictorial representation of the infrared emission of the breast. This shows malignant lesions as areas of increased heat production and increase in vascularity. But thermography has proved to be somewhat disappointing in the diagnosis of carcinoma of breast. At present 50-75% of cancers are recorded as not being detected by thermographic scan. But when used in conjunction with physical examination and mammography, thermography can be expected to increase the number of cancers detected by 3-5%. 4. Ultrasound: This is an important diagnostic tool in many organ systems, but its application in breast cancer detection remains in the developmental stage. At present, ultrasonic examination of the breast is useful only in differentiation of solid from cystic swellings greater than 2.5 cm in diameter. Recently improvement in instrumentation has helped to detect 0.5 cm solid breast masses. Fluid-filled lesions lack an internal echo pattern, whereas solid lesions are filled with internal echoes. If the solid lesions are homogeneous, the echo pattern is evenly distributed throughout the mass. Echoes from the boundaries of a benign lesion are smooth and well-defined. Infiltrating lesions such as scirrhous carcinoma have jagged borders. Breast ultrasonograms are of limited usefulness in the detection and diagnosis of breast cancer. If however sophisticated instruments become commercially available, gray scale echography may become a valuable adjunctive procedure. 5. Biopsy: It is customary when presented with a palpable mass in the breast to remove the lump for accurate diagnosis. Whatever the degree of suspicion of cancer, most surgeons still prefer to be quite certain before committing a woman to mastectomy or radiotherapy. The frozen section histology technique has probably been put to use more often in the management of mammary lesions than in any other situation. There has been considerable interest recently in needle biopsy as an alternative to excision procedures. There were a few false-negative results, but greater problem was due to false positive results received with cytodiagnosis of aspirated material. Drill biopsy has been claimed to avoid this problem. 95% accuracy has been claimed. No false positive result has been recorded but the cancers less than 1 cm. in diameter may be missed by drill biopsy. Needle can be introduced to the center of the suspicious area under X-ray control. With this technique it has been claimed that as small as 3 mm in diameter tumors have been successfully identified and biopsied. Search for distant metastases: 6. Chest X-ray: This is the simplest method of looking for potential site of visceral metastasis. This should be a routine investigation for all women with early carcinoma of the breast (Fig. 30.31). 7. Bone X-ray: A skeletal survey is often asked for particularly X-ray of the spine, pelvis and upper ends of humerus and femur. Fig. 30.31: Chest X-ray showing metastasis in the lungs in a case of breast cancer. sion of crease gross tected nand tected stion in natio man 25 n sold event mooth Breast ancer. Il why may ove the ons still 8. Bone scan: Development of skeletal scintigraphy has undoubtedly improved our accuracy for detecting bony metastases (Fig. 30.32). Radioactive fluorine was one of the first few bone-seeking isotopes that had successfully demonstrated skeletal metastases earlier than would be detectable by conventional X-ray. Since then enormous improvement in the sensitivity of the scanning devices and availability of newer radioactive bone-seeking isotopes have made skeletal scintigraphy an attractive method to detect bone metastases. So for routine skeletal survey a whole body skeletal scan followed by specific radiology of the areas of abnormal uptake should be the method of choice. Healing fractures, Paget's disease and osteoarthritis also show hot spots as bone metastases. Obviously presence of bone metastases detected by bone scan will put the patient into stage IV category. False positive and false negative results are disturbing. In suspicious cases shown by the scan, open bone biopsy is the last court of appeal. 9. Liver scan: Isotope scintigraphy of the liver using radioactively labeled colloid may demonstrate metastases, but the secondary deposits less than 1 or 2 cm in diameter may be missed. Recent promising reports using gray scale ultrasonography, which appears to have a Fig. 30.32: Skull metastasis in breast cancer is being revealed by bone scan. peater accuracy, are encouraging in this field. 10. Computerized tomography (CT scan) can be used to detect mediastinal or retroperitoneal masses of malignantly involved lymph nodes. A Manual on Clinical Surgery 11. Biochemical studies: Elevated alkaline phosphatase and gamma glutamyl transaminase are crude estimates of liver metastasis. Similarly increase in urinary hydroxyproline indicates collagen break down from metastasis. So far as the diagnosis of early cases and determination of prognosis are concerned urinary steroids have got some value. An abnormally low level of etiocholanolone (a metabolite of the adrenal androgen dehydroepiandrosterone) in relation to the total amounts of 17-hydroxycorticosteroids in the urine is detected in patients with breast cancer. It also indicates bad prognosis. This is called "negative discriminants". They show poor response to adrenalectomy and hypophysectomy CONGENITAL ABNORMALITIES Amazia (congenital absence of breast) may very rarely affect one or both sides. It may be associated with absence of sternal portion of the pectoralis major. Polymazia (accessory breasts) (Fig. 30.33) may be seen occasionally in the axilla, groin and thigh-along the line of development of milk ridge. This is due to failure of disappearance of the milk ridge in that area. Accessory breast may lactate during the period of lactation. Diffuse hyperplasia, pendulous breast or underdevelopment of the breast on one side or both sides may be seen. TRAUMATIC FAT NECROSIS An injury or subcutaneous injection to the breast may lead to this condition. This is due to death of some fat cells and saponification of their fat. These are presented as painless lumps very much similar to those of carcinomata of the breasts. On examination, hard, irregular lump will be felt which will be fixed or tethered to the skin. The findings are also akin to carcinoma. History of injury, discoloration of the skin, bruising (if present), no enlargement of lymph nodes, mammographic finding,s etc., are the distinguishing features from carcinoma. On incision white chalky area of fat necrosis becomes evident which is similar to fat necrosis following acute pancreatitis. Fig. 30.33: Showing accessory breast in the axilla. ACUTE MASTITIS (FIG. 30.34) This is commonly seen in the child-bearing age particularly during lactation. Bacteria enter the breast either through the bloodstream or through the lactiferous ducts. The latter is due to trauma during lactation. Pain is the first semptom which is dull in the beginning and gradually becomes a continuous throbbing pain. place. Axillary lymph nodes are enlarged and tender. This condition leads to suppuration and On examination, the breast becomes swollen, red, hot and tender. Gradually localization takes formation of intramammary abscess. This should be diagnosed by throbbing pain, brawny. wollen, edematous and tender swelling. Fluctuation is a late sign and should not be waited for Subareolar mastitis occurs from infected glands of Montgomery or from a furuncle on or near the areola. Retromammary abscess has nothing to do with the breast. It arises from a tuberculous rib of spine and from empyema necessitatis. CHRONIC ABSCESS il atempts are made to control acute mastitis by injudicious antibiotic treatment, a chronic abscess develops. It becomes encapsulated by a thick fibrous wall. A painless firm mass (antibioma) develops which may or may not be fixed to the skin. At this time this condition becomes indistinguishable from carcinoma. A previous history of pain is very suggestive of this condition. Moreover this lump will be quite soft at the center while a carcinoma is harder at the center. Aspiration is the final court of appeal in doubtful cases. mal MAMMARY FISTULA This is a chronic discharging fistula. The usual sufferers are women of 3rd decade. It occurs unilaterally or bilaterally. The fistula communicates with one of the major ducts. This condition may be a frequent complication of long-standing retraction of the nipple and infection being restricted to a single obstructed duct. The abscess ruptures and subsides only to repeat the cycle till it forms the mammary fistula. This condition may also result from periductal mastitis, which has affected all the major ducts. MAMMARY DUCT ECTASIA (PLASMA CELL MASTITIS) teal will be fued r This is generalized dilatation of the major duct system of the breast with retrograde dilatation of the lobular ducts. The lining epithelium is atrophic and the ducts are filled with secretion. This secretion is made up of amorphous debris and lipoid-containing macrophages. The fluid within the ducts which causes the nipple discharge, varies and may be colored green, brown, viscous or even white. Due to leakage of lipoid through the thin duct wall, there is periductal mastitis, the cellular element of which is predominantly plasma cells. The associated periductal fibrosis often leads to nipple retraction. This inflammatory process regresses within a few days, but recurs again with more severe form. Ultimately, an abscess develops at the edge of the areola. Patients are usually in 40-55 years age group. Younger women with congenitally inverted nipples may be affected with this condition early. The disease may remain asymptomatic, but a persistent nipple discharge or a lump in the breast in the para-areolar region is the usual complaint. The problem is that if the abscess is drained, it leads to a fistula into the affected duct, which is known as mammary duct fistula. In chronic cases the characteristic appearance is a mammary duct fistula, with inverted nipple and distortion of the areola. Sometimes a chronic abscess may be formed which presents as a tender mass with skin fixity, nipple retraction and enlarged axillary lymph nodes-almost simulating a carcinoma. Diagnosis is established by needle biopsy. BENIGN BREAST DISEASE It is a very common condition occurring in women between the ages of 20 and 40 years women or multiparous women who have not suckled their children. The incidence strictly falls mostly seen in them who have denied its intended function, e.g., spinsters, childless married after menopause, in contrast to malignant breast disease. Various names were given over the past few years, e.g., fibroadenosis, chronic mastitis, fibrocystic disease, cystic hyperplasia, benign mammary dysplasia, cystic mastopathy, etc. None of these nomenclatures is now acceptable These actually described the histological features of breast biopsies of this disease, such as fibrosis, epithelial hyperplasia, adenosis, microcyst formation and lymphocytic infiltration These changes are quite nonspecific and have been noticed even in breasts without any complaint. These aberrations are believed to be caused by very minor hormonal imbalances during the multiple menstrual cycles of the reproductive period. The best nomenclature which is now accepted for this condition is: ABERRATIONS OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI). The etiology is poorly understood but it seems to involve the action of cyclical circulating hormone levels on breast tissue. This is influenced by cyclical changes in the hormonal environment, oral contraceptives, hormone replacement therapy and probably some factors such as diet and smoking. Microscopic changes include adenosis, cyst formation, papillomatosis, epithelial hyperplasia, fibrosis and lymphatic infiltration. The most common MANIFESTATIONS of ANDI are cyclical pain and nodularity. When pain is a dominant symptom, it needs to be assessed apart from nodularity. Such pain can be divided into cyclical (premenstrual) and noncyclical (irregular or continuous) mastalgia. Cyclical mastalgia is often related with ANDI. But noncyclical mastalgia is usually not associated with ANDI, but may be associated with musculoskeletal origin of the chest wall or may be associated with inflammatory episodes caused by duct ectasia or periductal mastitis. It must be remembered that a persistent, localized pain or discomfort may be a symptom of cancer. Nodularity or lump in the breast is a very common symptom. It may be associated with certain amount of pain (mastalgia), which has been described in the previous paragraph. Though lump is present for sometime, yet it is often the pain which draws the patient's attention towards the lump. These nodules are often in the upper and outer quadrant of the breast and it must be remembered that lump in this region is noticed earlier than lump in the center and inner half of the breast. The lumps usually become larger and more tender premenstrually. Though it is difficult for the patient to judge whether the lump is progressively becoming larger or not, yet if the patient suggests that the lump fluctuates in size is typical of this condition and it almost excludes the diagnosis of carcinoma. Lumps can be single or multiple and characteristically sudden in onset. Lumps are often cysts, as changes in the secretory activity of breast tissue commonly give rise to such a cyst. Cysts may be single or multiple and vary from barely palpable to very large size. The cysts are usually smooth, round and of variable consistence. Fluctuation of the cyst can be elicited if the lump is relatively superficial and is often best elicited from behind (Fig. 30.13). It must be remembered that very tense cyst is often hard and not fluctuant. One must consider during examination whether the nodularity is focal or diffuse. When it is focal, one must take it seriously. Diffuse nodularity is often bilateral and found mainly in the upper and outer quadrant. If the patient is seen first in premenstrual period, it is useful to examine her again in the first half of the cycle. Fecal nodularity should be examined very carefully to exclude malignant condition. One must differentiate between a benign lump and a cyst. It is advisable to apply further diagnostic aspirate should be sent for cytological examination to exclude presence of malignant cells ests to obtain a definite diagnosis. One of the easiest method is fine-needle aspiration. The Following successful aspiration, there should not be residual mass and the breast should be e-examined several weeks later to ensure that it has not reaccumulated A benign lump or a cyst from this condition is neither fixed nor tethered to the skin or the underlying muscle and is usually moderately mobile within the breast. The axillary nodes are usually not enlarged. It must be remembered that the other breast may be affected with the similar condition. TION AND Patient usually complains of pain in one breast, which becomes worse just before menstruation. Pain is also felt after over-using the arm. There may be greenish or serous discharge through the nipple. On examination, simultaneous palpation of both the breasts in standing posture from behind Simplified

TUMORS OF THE BREAST BENIGN TUMORS 1. Fibroadenoma: Two histological varieties of fibroadenoma are seen-(a) Pericanalicular fibroadenoma which consists of fibrous tissue surrounding a few small tubular glands. This type of fibroadenoma is smaller in size and hard. (b) Intracanalicular fibroadenoma contains more glands which become stretched into elongated spidery shapes and become indented by fibrous tissue. This type of fibroadenoma is larger in size and comparatively soft. The pericanalicular fibroadenoma (hard) occurs in young girls between 15 and 30 years, whereas the intracanalicular (soft) variety is seen in middle-aged women between 35 and 50 years. The main symptom is a painless lump in the breast. It is a slow growing tumor and remains more or less same size for quite a long time. This may occur anywhere within the breast substance, though more often seen in the lower half than in the upper half. On examination, the swelling is not tender and without any rise in temperature. It is smooth, firm and possesses a well-defined margin. This tumor is not fixed to the skin or deeper structure.often called a "breast mouse" or a "floating tumor. There is no enlargement of the axillary lymph nodes, Sometimes a soft fibroadenoma undergoes cystic degeneration leading to cystadenoma which is ultimately transformed into cystosarcoma phyllodes. Cystosarcoma Phyllodes (serocystic disease of Brodie): This is a real giant fibroadenoma the patients may complain of serous discharge through the nipple. This is not a malignant seen in women of over 40 years of age. Main complaint is huge swelling, though occasionally condition. The tumor does not infiltrate the skin though the overlying skin becomes thin and tense. The subcutaneous veins become prominent. This tumor is not fixed to deeper structures. The axillary lymph nodes become rarely enlarged only secondary to infections. 2. Duct papilloma: This tumor occurs in one of the major ducts. Occasionally two or more ducts of the same breast may be affected. Majority of the patients are above 30 years of age. Bloody discharge from the nipple is the main symptom. Generally it is bright red blood and less often dark blood. A cystic swelling may sometimes be felt just deep or lateral to the areola. If this swelling be pressed bloody discharge will come out from the affected duct. This should be considered as premalignant condition and the axillary lymph nodes are only enlarged when the growth has become malignant. found in the breast. Other benign tumors like neurofibroma, lipoma, papillary cystadenoma, etc., are rarely MALIGNANT TUMORS are: atrophic scirrhous carcinoma the least malignant, scirrhous carcinoma the commonest type, encephaloid (medullary) carcinoma, comedocarcinoma, colloid carcinoma and mastitis carcinomatosa-the most malignant, duct carcinoma, Paget's disease of the nipple and sarcoma. 1. Carcinoma (scirrhous) (Figs. 30.35 to 30.37): Since there is great hope of curing this disease only when it is still localized to the breast tissue, a diagnosis of carcinoma should be made in the early stage. A lump, as discovered by palpation with the flat of the hand, is painless, stony hard and irregular in surface and outline, is a carcinoma. Carcinoma should not be excluded if the patient is young or the lump is free from the skin or deeper structure or if the lymph des are no des deterra may be dim (resulti Cooper follo pple (due ctiferous d Lorange ( eto obs cells and p cles ang sue). Lat scia, pec stant sui induration blood) an Clinic adherenc invol muscle, than the mobile; away fro Inte Union Amph TI retrac Fig. 30.35: Fungated carcinoma. Note the everted edge. Fig. 30.36: Fungated recurrence after mastectomy. betet nodes are not involved. Involvement of lymph nodes determines the prognosis of the case. There may be dimpling, retraction or puckering of the skin (resulting from invasion of the ligaments of Cooper followed by contraction), retraction of the nipple (due to extension of the growth along the lactiferous ducts with subsequent fibrosis) or peau dorange (i.e.. edema with pitting; edema being due to obstruction of the lymphatics by cancer cells and pitting being due to fixation of the hair follicles and sebaceous glands to the subcutaneous tissue). Late features include adhesion to the deep fascia, pectoral muscle and chest wall, presence of distant subcutaneous nodules, fungation, brawny induration of the arm, cancer en cuirasse and distant blood) and ovary (by transcoelomic implantation). Fig. 30.37: Demonstration of extreme retraction of nipple due to carcinoma on the left side. metastases in the liver, lungs, bones (by Clinical stages: Stage I-The growth is limited to the breast. There may be a small area of adherence to the skin. Stage II-In addition to the growth in the breast, the axillary lymph nodes are involved but they are still mobile. There may be just tethering of the growth to the pectoral muscle. Stage III-The growth is fixed to the pectoral muscle or the skin involvement is larger than the tumor. Stage IV-The growth is fixed to the chest wall; axillary nodes are no longer mobile; supraclavicular nodes are affected; and there is metastasis in the opposite breast, skin away from the tumor, liver, lungs, bones or other distant organs such as the ovary. International Classification and TNM Classification: This is advocated by International Union against cancer. T denotes the characteristic of the tumor, N-the characteristic of the lymph nodes (particularly the axillary group) and M-the presence or absence of metastasis. TI-means the size of the tumor is same as or less than 2 cm diameter. No fixation or nipple retraction. T2-more than 2 cm but less than 5 cm diameter. No pectoral fixation but skin may be tethered. T3-more than 5 cm but less than 10 cm diameter. There may be pectoral fixation. Skin infiltrated or ulcerated. T4-more than 10 cm diameter. Chest wall fixation. Skin involved, but not beyond breast. No-No palpable lymph nodes. NI-Axillary lymph nodes are palpabie and mobile. N2-Axillary nodes are palpable and fixed. N3-Supraclavicular nodes are involved. MO-No Metastasis. M1-Metastases are present including involvement of the skin beyond the breast and contralateral nodes. This TNM classification can be applied in clinical staging-Stage 1-T1, T2 and NO, Stage II-T1, T2 and NI; Stage III-T3, T4 and MO; Stage IV-T4, N3 and M1. Prognosis. In assessing prognosis in a case of carcinoma of the breast, the following points should be taken into consideration: (1) Age: The younger the patient, the worse becomes the prognosis. Prognosis is better when the growth occurs within 5 years of menopause. (2) Sex: Carcinoma of the male breast carries a bad prognosis owing to early fixation to the chest wall. (3) Site: Growths occurring at the inner and lower quadrant convey a bad prognosis owing to early metastasis into the mediastinum and abdomen. (4) Nature of the growth: The prognosis is the worst with the mastitis carcinomatosa whereas it is much better with the atrophic scirrhous as the spread is limited by extensive fibrosis. Contradictory to the common belief the prognosis is better with medullary carcinoma than with scirrhous. (5) Metastasis: It must be remembered that there is 75% chance of cure if the carcinoma is operated upon before the involvement of lymph nodes; whereas the percentage comes down to 25 as soon as the axillary nodes are invaded-so the importance of diagnosing carcinoma before the involvement of lymph nodes cannot be too strongly impressed. Involvement of distant lymph nodes, lung, liver, bones, etc. 2. Atrophic scirrhous: The patient is very old and the tumor grows slowly for years. Due to excessive fibrosis, the spread and metastasis are limited. 3. Comedocarcinoma: Tumors arising in peripheral ducts confine within the ducts and the proliferation of cells leads to central plug of necrotic neoplastic cells. These extrude from the cut surface of the growth. 4. Colloid carcinoma-is cystic and occurs in older patients. Microscopically, the cells lie in pool of extracellular mucin. Prognosis is better than scirrhous carcinoma. Encephaloid type occurs in young women. The tumor grows rapidly to give rise to a soft swelling which becomes adherent to the surrounding structures. There may be no retraction of the nipple. The lymph nodes are soon involved. This type of cancer has a high degree of lymphocytic infiltration, a factor which in itself is associated with a favorable prognosis. 5. Acute lactation carcinoma or mastitis carcinomatosa or inflammatory carcinoma is extremely malignant. It occurs during pregnancy or lactation. This often produces obstruction of subepithelial lymphatics and veins resulting in redness and edema. This gives a false impression of inflammation. It has been mistaken for acute mastitis and incised to let out pus. Differentiation is made by the facts that pain and tenderness are comparatively slight and there may be fever but no rigor. 6. Duct carcinoma: The symptoms are very much similar to those of duct papilloma. On examination a solid swelling may be felt at the region just beneath or around the areola. The axillary lymph nodes are enlarged. Diagnosis is mainly established by mammography and finally by biopsy. 7. Paget's disease: This is a malignant condition characterized by gradual destruction of the nipple and development of a carcinoma within the breast usually close to the nipple. At first the nipple and areola become red and covered with scales. Subsequently, the scales are detached and the nipple is destroyed. Ultimately, the nipple disappears completely, leaving a flat bright red weeping surface. In the early stage this condition very much resembles eczema of the nipple. The differentiating features are: (i) Eczema is often bilateral, whereas Paget's disease is unilateral; (ii) Eczema is often seen during lactation, whereas Paget's disease is seen at menopause; (iii) Eczema itches, but Paget's disease does not itch; (iv) Vesicles are formed in eczema whereas vesicles are not found in Paget's disease; (v) In eczema the nipple remains intact, but in Paget's disease the nipple may be destroyed; (vi) In eczema no lump can be felt deep to the nipple, whereas in Paget's disease one may feel a lump deep to the nipple. 8. Carcinoma of the male breast is a more serious condition than that in the female since it affects the chest wall more readily, owing to much less amount of tissue between the carcinoma and the chest wall. It has all the characteristic features of carcinoma with a great tendency to fungate quite early (Fig. 30.38). Sarcoma: Sarcomatous changes in a soft fibroadenoma account for more than half the cases of sarcoma of the breast. A history of swelling, which is present for months or years and has recently enlarged rapidly, is frequently obtained. On examination, a large prominent swelling with dilated subcutaneous veins and without retraction of the nipple is observed. It is of inequal consistency, parts of it being hard, parts soft and parts fluctuating, due to cystic degeneration or phemorrhage. Only in the late stages does the skin become adherent (without being infiltrated) естостерor fungation occurs. Lymph nodes are not involved until very late. Gynecomastia: Increase in the ductal and connective tissue element of the male breast is called older gynecomastia. Though this condition may occur commonly at puberty idiopathically, yet one or other cause may be found out. It may occur in liver failure, in Klinefelter's syndrome, in leprosy, in chorioncarcinoma and Sertoli cell tumors of the testis, in bronchial carcinoma (ectopic hormonal production), in adrenal or pituitary diseases, after stilboestrol therapy for prostatic adcarcinoma and after ingestion of certain drugs like digitalis, isoniazide, spironolactone, certain tranquilizers, steroid and a few other diuretics. The common idiopathic variety found at puberty among school boys is a firm disc of breast tissue beneath the areola and is called the 'hard' type. It may be slightly tender and is called 'true gynecomastia. But the variety which develops following estrogen therapy is of soft consistency and is called 'soft' type of mammaplasia Simplified