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