In females breast are hemispherical
eminences in the front of chest, each extends
from the second rib above to the sixth rib
below, and from the side of the sternum to
near the midaxillary line.
Mature breast is cushioned between
subcutaneous fat and superficial pectoral
fascia. Between breast and superficial fascia
there lies loose areolar tissue known as retro
Histologically breast consist of glandular tissue
connected by fibrous tissue, the space in
between is filled by fatty tissue.
Total 15 to 20 lobes further divisible in several
Breast of young girl contain dense stroma and
epithelium while that of old age women contain
more fat. Fat absorb less radiation thus
mammography more useful in older women.
Ductal system consist of acini that forms milk
and open into lactiferous ducts that dilate before
opening forming ampulla that act as resorvoir of
milk. Ducts open on nipple in 10-15 orifices. At
nipple cuboidal epithelium abruptly meets
In stroma there are fibrous bands that run
from superficial fascia to skin and give shape
and support to breast known as cooper’s
Blood supply is derived from
1. Perforating branches of internal mammary
2. Lateral branches of posterior intercoastal
3. Branches from axillary artery
About 75% of lymphatics drain in axillary nodes
while rest 25% drain in parasternal nodes.
Axillary nodes are classified as:
1. Lateral group along axillary vein
2. Pectoral group or anterior group
3. Scapular group or posterior group
4. Central group
5. Subclavicular group
Rotter’s nodes described later.
Surgically axillary nodes are assigned levels:
Level I : Lateral to pectoralis minor
Level II: Deep to pectoralis minor
Level III: Medial to pectoralis minor
Deep to pectoralis major muscle lies pectoralis
minor enclosed in clavipectoral fascia.
It further extends laterally to fuse with axillary
Breast is related posteriorly by pectoralis major,
serratus anterior and external oblique abdominis.
Interposed between pectoralis major and minor
one to four nodes know as rotter’s node. They
receive lymphatics directly from breast and drain
into central and supraclavicular nodes.
Breast development is influenced by several
hormones like estrogen, progesterone and
prolactin, oxytocin, thyroid hormone, cortisol
and growth hormone.
Estrogen initiates ductal development
Progesterone is responsible for differentiation
of epithelium and lobular development.
Prolactin is primary hormonal stimulus for
After birth, in a female there is fall in
steroidal hormone and breast remain under
In adolescence breast is mostly composed of
mainly dense fibrous stroma and scattered
duct lined by epithelium.
After beginning of nocturnal pulsatile
gonadotrophin release in puberty cause
deposition of fat in stroma. Local homones
like epidermal growth factors can replace
estrogen thus have a proposed role of
mediator of action.
During menstrual cycle hormones have cyclical
effects on breast. Dominant change is
hypertrophy rather than hyperplasia.
During late luteal (premenstrual) phase due to
accumulation of fluid and interlobular edema that
causes pain and heaviness in breast
During anovulatory cycles engorgement, pain and
nodularity get accentuated.
During pregnancy fibrous stroma diminish to
accommodate hypertrophied lobular tissues. This
formation of new lobules or acini is termed as
adenosis of pregnancy.
Expulsion of milk occur by contraction of
During menopause there is deposition of fats,
atrophy of glandular and connective tissue.
1. Absent (Amastia) or accessory breast tissue
(Polymastia) amastia is rare , during
adolsence hypertrophy of one breast compared to
other is common. There could be supernumerary
nipples anywhere along milk line but true
polythelia reffers to more than one nipple serving
single breast. Accessory breast tissue that
enlarge during preganancy.
Surgery indicated only for cosmetic reasons
2. Gynecomastia hypertrophy of breast in men.
Physiological in neonatal, pubertal and senescent age
group. Phases when circulating testosterone is less
Pathological in liver, renal disease, certain cancers and
In non obese person a breast tissue of 2 cm in diameter
should be there for diagnosis. Usually gynecomastia
doesn’t predispose to breast cancer except for those
having klinefelter’s syndrome(XXY).
Drugs causing gynecomastia are ketoconazole, estrogen,
cimetidine, spironolactone, digitalis.
Grades Clinical classification of gynecomastia
Grade I Mild breast enlargement without skin redundancy
Grade IIa Moderate breast enlargement without skin redundancy
Grade IIb Moderate breast enlargement with skin redundancy
Grade III Marked breast enlargement with skin redundancy and
ptosis, which simulates a female breast
Gynecomastia could present with tenderness or
discomfort and breast tissue is symmetrical around
areola. Carcinoma is non tender and asymmetric
tissue around areola, firm, irregular and at times fixed
to dermis or fascia.
and senescent age group require only reassurance only
indication for surgery is cosmetic
Is a milk filled cyst, round well circumscribed and easily
movable. Usually following cessation of lactation.
Treatment is needle aspiration. On aspiration thick
creamy material with dark green tinge.
Surgery indicated only if cyst cannot be aspirated or get
Bacterial infections most commonly
Staph. aureus and Streptococccus are involved. Staph
typically causes breast abcess which present with
point tenderness, erythema and hyperthermia. Abcess
are related with lactation and occur with in first few
weeks of breastfeeding.
Location could be subcutaneous, subareolar,
interlobular and retromammary. Preoperative
sonography can guide the extent of surgery. Circum
areolar or along langer’s line incision to be taken.
Staphylococcus causes more localized deep seated
abscess formation requiring surgery while
streptococcus in diffuse superficial involvement
managed by local wound care and IV antibiotics.
Epidemic puerperal mastitis is caused by MRSA spread due
to baby’s mouth and require stopping of breast feeding
as site of infection is intra ductal while non epidemic
purperal mastitis has inter lobular involvement and
breast feeding can be continued. Patient usually have
milk stasis and breast emptying with suction pumps
reduces symptoms and duration of disease.
Zuska’s disease refer to recurrent periductal masititis
characterized by recurrent retroareolar infection and
abcess. Symptomatic management with IV antibiotics
and incision drainage is done but for long term
prevention chronically inflammed tissue should be
Smoking has been implicated as an important risk
• Myocotic infections
Rare entity. Usually blastomycosis or sporotrichosis. Get
incoculated from mouth of suckling infant.
Treatment: Incision drainage and antifungals. Chronic
infection debridement of infected tissue.
Skin of breast if infected with Candida albican(intertrigo)
managed with topical antifungals
• Hiradenitis suppurativa
Chronic inflammatory disease of nipple areolar glands of
Montgomery or axillary sebaceous glands. Common in
women having acne. When in nipple areolar complex
mimic Paget’s disease or invasive carcinoma. Managed
by antibiotics and incision drainage. If recurrent
• Mondor’s disease
It is a variant of thrombo phlebitis that involve
superficial veins of anterior chest wall and
breast. Described by Mondor in 1939 as
“string phlebitis” . Commonly involved veins
are lateral thoracic vein and thoracoepigastric
C/F: acute pain in lateral part of breast. A hard
cord like structure palpable.
Treatment: anti inflammatory drugs. Resolves
on its own in 3-4 weeks. If not excision of
involved segment of vein done.
There are three basic principles underlying
1. Benign breast diseases and disorders are
related to the normal processes of
reproductive life and involution.
2. There are spectrum of breast condition that
ranges from normal to disorder.
3. The ANDI encompasses all aspects of breast
diseases including pathogenesis and degree
Normal Disorder Disease
years (age 15-25
Nipple eversion Nipple inversion Subareolar abcess
years (age 25- 40
Lobular involution Macrocysts
Dilatation Duct ectasia Periductal mastitis
Sclerosis Nipple retraction
Epithelial turnover Epithelial
Fluid filled cavity lined by epithelium.
Influenced by hormones.
Diagnosed by ultrasonography or needle aspiration.
Formed by destruction and dilatation of terminal
lobules and ductules.
Histololgically flattened epithelium having features
of apocrine metaplasia or pappillary epithelium.
During surgery sometimes seen as dark cyst known
as blue dome cyst.
Treatment is aspiration. Send for cytology if bloody.
If recur more than twice excision is justified.
Most common of all benign breast disease
Most common between ages 20- 50
Incidence-varying, related to age
Early fibrocystic manifestations may occur between the age of 20 and 25
years, but most patients (70% to 75%) are in their mid 30s and 40s.
Predominantly afflicted are
women with menstrual abnormalities
patients with a history of spontaneous abortions
nonusers of oral contraceptives and
women with early menarche and late menopause.
50% of women with Fibrocystic changes have clinical symptoms
53% have histologic changes
Believed to be associated the Imbalance of progesterone and
May present with bilateral cyclic pain, breast swelling, palpable
mass and heaviness
Simple: Second most common benign breast lesion
Benign solid tumors containing glandular as well as fibrous tissue . Usually
present as well defined, mobile mass. slips between palpating fingers
Commonly found in women between the ages of 15 and 35 years
Cause is unknown, thought to be due to hormonal influence
May increase in size during pregnancy or with estrogen therapy
Histologically presents with variable proportion of epithelial and stromal
proliferation. Stroma is either cellular or replaced with acellular swirls of
Has no malignant potential. Chances of malignancy in a women having
fibroadenoma is only modestly more than that in other women.
In young women should be biopsied by a core needle biopsy and if
excision needed cosmetic circumareolar incsion with modest tunneling to
Giant: Fibroadenomas over 5cm in size
Excision is recommended
Variant of fibroadenomas
Found in young women between the ages of 10 -18.
Vary in size from 5 - 20cm in diameter. Usually painless, solitary, unilateral
Histologically more cellular than normal fibroadenomas
Excision is treatment of choice
One in four malignant
One in Ten Metastasize
Create bulky tumors that distort the breast
May ulcerate through the skin due to pressure necrosis
Histologically its an fibroadenoma compressed by swirls of
fibroblastic growth, these whorls of stroma resembles clusters of
leaf like structure that gives it the name.
Treatment consists of wide excision unless metastasis has
Secondary to trauma- often not remembered
Tender, ill defined mass
Occasionally skin retraction
Usually sampled since it presents as a mass clinically and on
mammography it present as a density lesion that calcify.
On histology it shows lipid laden macrophages, scar tissue and
chronic inflammatory cells.
Not an epithelial lesion and no malignant potential.
Treat with excisional biopsy
Cellular neoplasm of ductules packed closely together forming
sheets of tiny glands without supporting storma.
Histologically shows secretory differentiation.
Non malignant condition.
Polyps of epithelium lining breast duct.
Present with bloody discharge, less frequently
Appear as density lesion on mammogram.
Treatment is excision via circumareolar
Associated with smoking
Pain and greenish discharge
Sometimes a palpable retroareolar mass
or retraction can be present.
Episode of sepsis
Tx : reassurance, stop smoking, antibiotic for sepsis, limited
excision ( microdochectomy ), partial mastectomy.
Marked proliferation and atypia of the epithelium,
either ductal or lobular.
Found in 3% of benign breast biopsies
Associated with a 13% subsequent development of
breast cancer (4x risk factor)
Some may be an under-diagnosed ductal carcinoma
Excisional Biopsy – do not need clear margins
• More common during reproductive years
• Association with cancer is uncommon
• Cyclic pain associated with Fibrocystic changes
• Noncyclic pain associated with infection or cancer
if associated with mass or bloody nipple discharge.
• Tx: NSAIDs, primrose oil, OCP, avoid caffeine .
Nonspontaneous: B/L, multiple ducts, greenish, milky
is likely benign.
Spontaneous: unilateral, bloody, serous is worrisome.
◦ Meds – TCAs, Verapamil, Reserpine
◦ Galactorrhea – r/o Prolactinoma
◦ Intraductal Papilloma – not premalignant
Most common cause of bloody nipple d/c
Diffuse papillomatosis has increased risk of cancer
◦ Mammo/sono/ Ductogram
◦ Ductal excision ( microdochectomy)
Skin / Nipple Change
Bulges / Retractions
The breast examination starts with inspection of both breast
Sitting up with arms in relaxed position,
Both arms raised over the head
Hands on the hips
Complete regional lymph node examination while
patient is in the sitting position.
Bimanual may be done while patient is still in the sitting
position, useful in patient with large pendulous breast
Complete with the patient in a supine position, with the
arms raised above the head, breast exam can be
accomplished with either concentric circles, radial
approach, or vertical strip approach
Areas examined should extend from the clavicle
superiorly to the rib cage inferiorly and from the
sternum medially to the mid axillary line laterally
uses low dose radiation
Includes magnification and
Features of malinancy are::
architerctural distortions or
• Need additional imaging
• Negative- routine in 1 yr
• Benign finding – routine
in 1 yr
• Probable benign, 6 m
• Suspicious abnormality,
• Highly suggestive of
action should be takin
Uses sound energy
to produce images.
Based on echo
interfaces of tissues
of different density.
Best to differentiate
a cyst from solid
Involved ductule is identified in nipple and
cannulated with a flexible small cannula with
the help of microscope.
Contrast is injected and adequacy of contrast
is checked with sonography.
Image is taken at various angles to ensure
cannula doesn’t obstruct the view.
Unable to differentiate
b/w in situ vs CA
Benign breast problems account for the majority of
breast problems seen in women
Breast complaints need careful assessment with
thorough history and physical as well as diagnostic
work up if indicated
Women with breast problems can present with a
mass, pain, nipple discharge or skin changes. They
can also be asymptomatic
It is important to rule out breast cancer
Last but not the least benign breast disorders are
more difficult for a surgeon to manage than
malignant breast conditions.
Micheal S Sabel. Initial approach to the woman with breast problems. http://uptodateonline.com 2008, November 6