1. The document discusses the evaluation, diagnosis and management of breast masses. It covers the anatomy, epidemiology, clinical presentation, investigations and treatment of common benign and malignant breast conditions. 2. Investigations discussed include mammography, ultrasound, MRI and pathology tests. Malignant features on imaging include irregular masses and microcalcifications. Biopsy is needed to confirm malignancy. 3. Treatment depends on the diagnosis but includes aspiration for cysts, excision for fibroadenomas and tumors, and antibiotics for infections. Surgery is recommended for confirmed malignancies along with hormone therapy and chemotherapy.

1. EVALUATION OF BREAST
MASSES
DR YUSUF DIKKO

2. • INTRODUCTION
ANATOMY AND PHYSIOLOGY
OF THE BREAST
EPIDEMIOLOGY
ETIOLOGIES AND
DIFFERENTIALS
CLINICAL PICTURE
INVESTIGATION
TREATMENT
CONCLUSION
OUTLINE

3. INTRODUCTION
A breast lump/mass is a localized swelling, knot, bump, bulge or
protuberance in the breast tissue.
Breast masses may appear in both sexes at all ages.
In women, it may be due to a variety of etiologies with multiple risk
factors.
The commonest cause of a breast lump in males is gynecomastia.
Careful clinical examination and investigations are necessary to manage
breast lump.
No breast lump should be excused as benign until it has been checked by
a physician.

4. ANATOMY AND PHYSIOLOGY OF THE
BREAST
The breast (mammary gland)is a modified apocrine sweat gland.
Embryologically, the mammary glands develop from two ectodermal
thickenings, right and left (mammary ridges) which extend from the
axillae to the groins ( 4 weeks of gestation).
In humans, only the middle part of the upper third of the ridge persists
to form the breast while the rest of the line disappears.
The breasts lie between the skin and the pectoral fascia to which they
are loosely attached.
The human breast is grossly divided into 6 quadrants. UO, UI, LO, LI,
Retro-areolar and Axillary tail.

5. The adult female breast lies in an area between the 2nd and 6th
ribs and from the lateral border of the sternum to the anterior
axillary line.
The axillary tail of Spence is a prolongation of the parenchyma
which passes deeply through opening in the deep fascia to
blend with the axillary fat.
The breast tissue is supported by fibrous tissue ligaments which
run from the skin to the pectoral fascia. They are responsible for
division of the breasts parenchyma into lobes. They are called
the Cooper’s ligaments.

6. ANATOMY
The breast consists of 15-20 radially arranged
lobes and each lobe is drained by a lactiferous
duct.
The ducts converge at the nipple.
Each lobe is made up of 20-40 lobules, each of
which consists of 10-100 alveoli. It is of clinical
importance to recognize that the main ducts lie
behind the areola while the lobules lie more
peripherally.
Arterial supply: Internal mammary artery (of
axillary artery), Lateral thoracic artery, pectoral
branch of the thoraco-acromial artery.
Venous: internal thoracic, axillary and posterior
intercostal veins.
Lymphatic drainage: >75% to the axillary
nodes, <25% to the internal mammary nodes.

7. EPIDEMIOLOGY
After skin cancer, breast cancer is the most common
malignancy in women accounting for approximately 1 in 4
cancers diagnosed in women.
Breast infections occur in 10-33% of all lactating women
A study done in Enugu state Nigeria revealed 1 in 28
women(3.6%) die due to breast cancer.
Before the age of 40 years, African women have a higher
incidence, after the age of 40, Caucasian women have a
higher incidence.

8. ETIOLOGY
BENIGN:
A. FIBROADENOMA
B. FIBROADENOSIS
C. BREAST CYST
D. BREAST ABSCESS
E. MASTITIS
F. TB OF THE BREAST
G. FAT NECROSIS
H. GALACTOCELE
I. LIPOMA
J. INTRADUCTAL PAPILLOMA

9. ETIOLOGY
MALIGNANT
A. Infiltrating duct carcinoma
B. Infiltrating lobular carcinoma
C. In-situ ductal carcinoma
D. In-situ lobular carcinoma
E. Inflammatory carcinoma

10. RISK FACTORS OF BREAST CANCER:

11. TRIPLE ASSESSMENT APPROACH

12. HISTORY
Important biodata:
A.Sex
B.Age
C.Tribe/Race
D.Marital Status
PRESENTING COMPLAINTS:
1.When and how lump was first noticed
2.Associated pain, tenderness, change in size over time, changes with menstruation
3.Associated symptoms : discharge (nature of discharge), other swellings, skin changes and
body aches, Nipple changes,
4.Possible etiology: History of previous trauma, history of tuberculosis, history of similar familial
condition, Hx of drug use, Breast and skin care.
5.Complications: Weight loss, anorexia, bone pains and fractures, Cough with hemoptysis,
Jaundice, Seizures, Headaches

13. EXAMINATION
INSPECTION: Done in a sitting position, inspect for:
A. BREAST: Positioning, symmetry, size and shape compared to the other breast, visible
masses and their location
B. Skin over breast: Color, previous bruises, dilated veins, peau d’orange, dimpling, nodules,
ulceration, fungating masses
C. Nipple: Number, size and shape, Retracted, symmetry (elevated or deviated), cracks or
fissures, ulcers.
D. Areola: Color, size, surface, textures, scaliness, ulceration
E. Arms: Edema
F. Axilla and Supraclavicular regions: Fullness, swellings
G. Anterior chest wall: Nodules

14. Normal breast should be palpated first
Breast lump: Site in relation to breast quadrants (Ca breast
favors the UO quadrant), Number(multiple in case of
fibroadenosis), Shape(Irregular in Ca breast) , Size,
Surface, Consistency, Flunctuancy, Fixity to the skin, Fixity
to underlying pectoral fascia and pectoralis major, Fixity to
chest wall.
Nipple and Areola: Check for nipple retraction, any mass
deep to the nipple, press the breast segments and areola
and observe for any discharge.
Axilla and Supraclavivular fossa: Enlarged lymph nodes,
Number, size, tenderness, consistency, fixity and matting.
PALPATION

16. SYSTEMIC EXAMINATION
General examination: Pallor, Jaundice, Alopecia, Cachexia,
Lymphadenopathy.
Abdominal examination: Hepatomegaly, usually nodular and
tender in malignancy
Chest examination: Dyspnea, Added sounds, signs of pleural
effusion.
Lumbar spine: Tenderness, swelling, kyphosis.
Bones: Tenderness in the ribs, sternum, pelvis and long bones.
Rectal and vaginal examination: Krukenberg tumor.

17. INTERPRETATION:
MALIGNANT BENIGN
HARD FIRM/RUBBERY
PAINLESS PAINFUL
IRREGULAR SHAPE REGULAR
FIXATION TO SKIN/CHEST WALL MOBILE/NOT FIXED
SKIN DIMPLING NO SKIN DIMPLING
DISCHARGE IS BLOODY DISCHARGE MOSTLY YELLOW/GREEN
NIPPLE RETRACTION NO NIPPLE RETRACTION

18. Fibroadenoma: It is the most common benign condition of the
breast. Found in females less than 35 years, firm, rubbery, well
circumscribed, painless swelling that increases gradually in size.Not
fixed to the skin and characteristically very mobile (breast mouse).
Fibroadenosis: Found in females 30-50 years, multiple, sometimes
painful small lumps. Mastalgia is the commonest presentation,
which is typically premenstrual and accompanied by enlargement
and increased nodularity of the breast.
Breast cysts: fluctuant swellings that gradually increase in size.
Mastitis and breast abscess: May be lactational or non-lactational.
Most common organism responsible is S.aureus. Markedly painful
breast swelling with increased redness of skin, and edema.
Differential warmth could also be elicited.
FEATURES OF COMMON BREAST MASSES

19. Breast abscess: Usually may follow mastitis, fever is hectic and pain is
throbbing. An intense course of broad spectrum antibiotics is needed followed
by incision and drainage. A breast abscess is one of the masses where a
surgeon should not wait for flunctuancy before drainage.
Duct papilloma: Usually in young women, commonly presents as bloody nipple
discharge from a single duct. Accumulated blood may be felt as a swelling
usually deep to or just lateral to the areola. Pressure on the swelling produces
discharge. Breast contour is usually preserved.
Ductile or lobular carcinoma: Usually in women older than 40. Skin changes
such as peau d’orange, skin puckering are present. Breast lump fixed to the
skin. Nipple changes as ulceration and retraction, bloody nipple discharge.
Axillary lymph nodes may be enlarged in advanced cases.
Phyllodes tumor: Rapidly growing, occurs at around the age of 40, but can
appear in younger women. Tumor is usually large, stretches the skin, may
ulcerate because of pressure necrosis and show dilated veins.

20. Tuberculosis of the breast: this is rare condition always associated with
active pulmonary tuberculosis or secondary to tuberculous cervical
lymphadenitis. The disease either presents as multiple cold abscesses
and sinuses or multiple nodules in the breast substance. The axillary
nodes are enlarged and matted and manifestations of tuberculous
toxemia are present.

21. Gynecomastia: a benign enlargement
of male breast tissue resulting from
proliferation of glandular component of
the breast tissue. Clinically presents
as firm/rubbery mass extending
concentrically from the nipples. It
should be differentiated from pseudo-
gynecomastia (lipomastia), which is
chsracterized by fat deposition without
glandular proliferation. Usually caused
by estrogen-androgen imbalance in
favor of estrogen or an increased
sensitivity of breast tissue to normal
circulating estrogen.

23. • MAMMOGRAPHY
ULTRASONOGRAPHY
MRI
OTHERS: CHEST XRAY,
NUCLEAR IMAGING AND
PET SCAN,
DUCTOSCOPY
INVESTIGATIONS:
RADIOLOGICAL

24. MAMMOGRAPHY
It is a soft tissue imaging of the breast. In expert
hands, it is 95% accurate in diagnosing breast
cancer.
Women aged 45 to 54 years should get a
mammogram every year. Women 55 years and
older should get mammograms every 2 years.
It is of less diagnostic value in young women in
whom the density of lesions differs little from that
of surrounding tissue.
Nipple retraction may be detected.
It can detect enlarged axillary L.N
Sensitivity is 90%

25. FEATURES OF MALIGNANCY ON MAMMOGRAM
1. Solid mass with/without stellate features
2. Asymmetric thickening of the breast mass
3. Clustered micro-calcifications
4. Spiculations
5. Duct extension

27. BI-RADS CLASSIFICATION FOR MANAGEMENT OF ABNORMAL
MAMMOGRAMS
The Breast Imaging
Reporting and Data System
(BI-RADS), developed by the
American College of
Radiology, provides a
standardized classification
for mammographic studies.
This system demonstrates
good correlation with the
likelihood of breast
malignancy. The BI-RADS
system can inform family
physicians about key
findings, identify appropriate
follow-up and management
and encourage the provision
of educational and emotional
support to patients.

28. It can differentiate cystic from solid masses
Best initial treatment for women less than 35 years of age with
breast lump.
Malignant lesions appear as Elongated, hypoechoic masses with
irregular margins.
Duplex ultrasound may detect the vascularity of the gland.
Malignant lesions receive blood from all around with turbulent
speed, whereas benign lesions receive blood flow from one side
with low speed.
It is useful in young people in whom mammography is not very
helpful
BREAST ULTRASOUND

30. MAGNETIC RESONANCE IMAGING
It is indicated in certain
situations such as
A. Postoperative scarring to
differentiate between fibrosis
and local recurrence of
malignancy
B. In presence of breast implants

31. INVESTIGATIONS: PATHOLOGY
A pathological evidence of malignancy is the corner stone of diagnosis. The different types of
biopsies include:
A. FNAC: Depends on examination of cells to detect the criteria of malignancy is them. It can
differentiate between benign and malignant lesions but cannot differentiate between ductal
carcinoma in situ and invasive malignancy.
B. Tru-cut biopsy: Done under local anesthesia, with a special needle that cuts a core of tissue out
of the mass. The obtained specimen allows for histological examination and for assessment of
receptors. Preferably done under US guidance.
C. Excision biopsy: It is the Gold standard technique. The whole mass is excised through a
circumareolar or transverse incision. It is the most reliable and provides big enough tissue
specimen to allow hormone receptor estimation.
D. Frozen section biopsy: The mass is either excised or incised and a diagnosis is obtained within
30mins. If it is negative for malignancy, the patient is awakened, if positive for malignancy,
surgeon proceeds for radical surgery.

33. OTHERS
Baseline investigations:
A. FBC
B. RFT
C. LFT
D. ECG
E. URINALYSIS
F. SERUM Ca
Investigations for Suspected
Malignancgy:
A. Chest X-ray
B. US of Abdomen and Pelvis
C. Xray spine
D. Bone scan
E. PET Scan
F. Tumor markers: CA-15-3, CEA
G. Estrogen and progesterone receptor study
H. Sentinel LN Biopsy

35. TREATMENT
Treatment is curated towards the cause of the breast mass.
Benign solid lesions may be managed expectantly, provided
regular follow up is undertaken.
Malignant solid lesions require a multidisciplinary approach
for efficient management.

36. BREAST CYST
A solitary cyst or small collection of cyst can be aspirated.
Surgical excision is done if: cyst recurs after two
aspirations, there is a bloody aspirate or residual mass is
felt after aspiration.
FNAC of any residual mass should be done after any
aspiration.
Patient should be examined for refilling of the cyst in 6
weeks.

37. Fibroadenoma: Fibroadenomas
usually do not require excision
unless associated with suspicious
pathology. Alternative therapies
include Cryoablation, heating with
high frequency ultrasound or
removal with a large core vacuum
biopsy.
Indications for surgery include:
>3cm, recurrence, multiple, giant
type.
Excision is done through a 4cm
circumareolar incision (Webster’s)
or Submammary incision (Gaillard
Thomas) to avoid ductal system.

39. Conservative management including: Reassurance, avoid
caffeine, chocolate, salt
Drugs: Primrose oil( drug of choice), Gamolenic acid
120mg/day, Danazol (most effective but has drawback of
multiple side effects hirsutism, weight gain, amenorrhea),
Bromocryptine 2.5mg/day
Indications for surgery include Intractable pain, persistent
discharge and psychological reasons
Incision of choice is submammary Gillard Thomas incision.
Excision of cyst or localized excision of the diseased tissue
is done.
FIBROADENOSIS:

40. MAMMARY DUCT ECTASIA
Stop smoking
Antibiotic therapy: co-amoksiclav or flucloxacillin and
metronidazole
Cone excision of involved major ducts (Adair-Hadfield
operation)
It is important to shave the back of the nipple to ensure that all
terminal ducts are removed.
Incision of choice is infra-areola incision and should not
exceed 1/3 of the circumference of the areola.

41. DUCT PAPILLOMA
Microdochectomy: A lacrimal probe or length of stiff nylon
suture is inserted into the duct from which the discharge is
emerging.
Cone excision of the major ducts: a periareolar incision is
made and a cone of tissue is removed with its apex. The
resulting defect may be obliterated by a series of purse
string sutures
A temporary suction drain will reduce the chance of long
term deformity.

42. MASTITIS AND BREAST ABSCESS
Before the development of an abscess,
the condition is medically treated with
Broad spectrum antibiotics as Amoxicillin
clavulanic acid.
Warm fomentation
Non lactational mastitis is most commonly
due to Anerobic organisms, so it
customary to use metronidazole in
addition to amoxyclav.
Abscess is managed by Incision and
drainage. Best done under GA, a
circumferential incision is made over the
most tender area to release the pus which
is sent for C/S.

43. Tuberculosis of the breast: The treatment of breast
tuberculosis consists of anti-tubercular chemotherapy and
surgery by specific indications
Anti-tubercular chemotherapy is done for 6 months.
Excision biopsy of residual sinus tracts or lumps is done
mainly after poor response to chemotherapy.

44. Gynecomastia: initially managed medically with Androgens,
Anti-estrogens and Aromatase inhibitors.
Indications for surgical management include Ineffective
medical therapy, long standing gynecomastia and suspicion
of malignancy.
Surgical management includes excision of glandular tissue
coupled with liposuction.
Incision of choice is Gaillard Thomas sub-mammary
incision.

45. BREAST CANCER:
Management of diagnosed cases of breast cancer depends
appropriate staging of cancer
Staging can be done using the TNM system or Manchester
staging system
TNM Staging is the most commonly used .

46. TNM STAGING SYSTEM

47. MANCHESTER STAGING

48. Early breast cancer: Classified as TNM T1, T2, T2N1M0, and
Manchester Stage 1 and 2.
Principles of treatment include Surgery and Adjuvant therapy.
Surgery: Conservative breast surgery is indicated for tumors 5cm or
less, not centrally located, adequately sized breast and availability of
radiotherapy facilities. It entails Wide local excision of the tumor with
safety margin + removal of axillary LN and post operative radiotherapy.
(TART or QUART)
Modified radical mastectomy is indicated for patients not suitable for
CBS, large tumors, extensive calcification on mammography and poorly
differentiated tumors.It entails excision of the whole breast, axillary
clearance with sparing of the axillary vessels, nerve to latissimus dorsi
and nerve to serratus anterior.
Adjuvant therapy includes radiotherapy, chemotherapy (5-fluorouracil,
cyclophosphamide and methotrexate) and Anti-estrogen tamoxifen in
patients +ve for estrogen receptors.

49. Advanced breast cancer: T4, N2, M1 and stage 3 and
stage 4.
Very poor prognosis
Management includes Simple mastectomy +/-
Radiotherapy, Chemotherapy, Hormonal therapy and
Immunotherapy.
Hypercalcemia secondary to tumor lysis syndrome is
managed using IV Inorganic phosphate, Large doses of
furosemide and adequate hydration.

50. CONCLUSION
Although fortunately most breast masses turn out to be
benign, a thorough assessment is necessary to diagnose
very serious condition especially carcinoma
Early detection of breast cancer is the key to cure, hence
females are advised for self examination of their breast at
least once a month after their menses to catch early
disease.
A thorough history and physical examination is sufficient to
determine most probable cause of a breast mass.

51. REFERENCES
1. Kasr-el-Ainy Textbook of Surgery by Cairo University
Surgical Dept.
2. Baileys and Love’s Short Practice of Surgery 27th Edition
3. Approach to Breast Lump by Salami Ernest Osemudiamen;
Dept of Family Medicine I.S.T.H IRRUA
4. Principles and Practice of Surgery, 4th Edition; EA Badoe.
5. https://emedicine.medscape.com/article/1697353-overview