Brief overview of Breast anatomy and clinical assessment of benign as well as malignant breast disease. This information is perfect for the level of Final Year medical students.

1. Dr. Izza Abid
BREAST DISEASE

2. • Modified sweat gland, apocrine in nature
• Enclosed within the Superficial Pectoralis Fascia
• Located vertically from 2nd rib to 6th rib; horizontally from the lateral
sternal margin (medially) to the mid axillary line
• Superolaterally extends into the deep fascia of axilla – called Axillary Tail
of Spence
• Acini, ducts and fibrofatty stroma
BASIC ANATOMY

6. Q. 30 yr old female felt a lump in her left breast while showering. She doesn’t complain of
pain but is quite anxious that this may be cancer.
Q. 28 yr old lady presents to the A&E with pain in her right breast. She seems distressed as
this makes breastfeeding her 3 month old quite cumbersome and painful.
Q. 65 yr old lady presents to the outpatient clinic with a lump in her breast and bloody
discharge from her nipple. You notice that the overlying skin seems hard and rough and
nipple is inverted.
Q. 40 yr old male comes to your clinic with a hard mass just below his nipple.
HOW WOULD YOU ASSESS THESE PATIENTS
AND REACH A DIAGNOSIS?

7. TRIPLE
ASSESSMENT
CLINICAL
ASSESSMENT
History + Examination
IMAGING
Ultrasound+ Xray + MRI
HISTOPATHOLOGY
FNA + Core biopsy +
Open/ Excisional biopsy
DIAGNOSING ANY BREAST
DISEASE

8. • Pain – cyclical/ non cyclical
• Discharge – milky/ bloody/ yellow green/ brown/ creamy
• Lump – smooth/ lobular, mobile/ immobile, soft/ firm/ hard
• Change in appearance of skin
• Change in appearance of nipple
COMMON SYMPTOMS

10. BREAST DISEASE
BENIGN
Non-Proliferative
1. Breast Cyst
1. Fibrocystic disease
2. Duct ectasia
3. Mastitis +/- Abscess
4. Injury – Fat necrosis
5. Paget’s
Proliferative without atypia
1. Fibroadenoma
2. Intraductal papilloma
MALIGNANT
Non-invasive
1. Ductal Carcinoma in situ
2. Lobular Carcinoma in situ
Invasive
1. Invasive Ductal carcinoma
2. Invasive Lobular carcinoma
3. Medullary carcinoma
4. Inflammatory
5. Phylloides tumour

11.  Pathophysiology: Exact oetiology unknown. May be due to
hyperoestrogenemia as in menstrual cycle or pathological. The acini and
surrounding stroma grow incredibly leading to blockade of the ducts. Can
be a simple cyst or a multiloculated one.
 History: Presents as a solitary, unilateral breast lump. Small cysts are
painless but larger ( >5 cm) ones can cause discomfort. Can happen in all
age groups but common in young women <40 yrs. Can grow in size just
before her period.
 Examination: Well circumscribed, round/ oval, smooth, firm, mobile,
slightly tender.
BREAST CYST

12.  Same pathophysiology but occurs throughout the breast.
 History: Presents as multiple lumps spread across the breast with cyclical
pain. Young women.
 Examination: Lumpy Bumpy breast. Multiple cysts and nodules. Can be
unilateral or bilateral. Tenderness.
FIBROCYSTIC DISEASE

13. Complex cyst Fibrocystic disease
Normal mammogram Cyst Fibrocystic disease

14. MANAGEMENT:
1. Reassurance. Physiological breast changes. NOT CANCER.
2. Analgesia – Paracetamol, Evening primrose oil, firm bra support during
day
3. Cyst aspiration (if single, simple cyst) – can be both diagnostic AND
therapeutic. Aspirate should be serous or milky. If bloody, request
pathology.

15.  Pathophysiology: Disease of lactation. Microbes on the skin may enter the
breast tissue through a cracked nipple and colonize the ducts. This leads to
localized inflammation and duct blockage. This in turn causes the milk to
accumulate and to subsequently become infected. Commonest culprit is
Staph. aureus.
 History: Breastfeeding lady with a painful, tender breast. Fever, sometimes
with rigors and chills. Symptoms of being unwell ie nausea, loss of
appetite, lethargy. Some ladies complain of inability to feed their child
either due to pain or low milk output.
 Examination: On inspection breast looks inflamed. Red, hot and tender
breast. Pyrexia.
MASTITIS

16.  Diagnosis is usually clinical. Raised
WCCs and CRP support diagnosis.
Remember to differentiate from
Breast Abscess! If in doubt, can do
ultrasound.
MANAGEMENT:
1. If septic, do blood culture PLUS
breast milk swab.
2. Antibiotics – Flucloxacillin; good
pain relief.
3. Breastfeed. Breastfeed. Breastfeed!

17.  Pathophysiology: Same as Mastitis. Sometimes the infection leads to
formation of an abscess within the blocked duct surrounded by fibrofatty
stroma.
 History: Same as Mastitis but this time your patient may also complain of a
painful lump in her breast and pus discharge from nipple.
 Examination: Hot, red, tender breast with a visible/ palpable lump. May
have mixture of pus and milk discharging from the nipple. Ipsilateral
axillary lymphadenopathy. Pyrexia.
BREAST ABSCESS

18. MANAGEMENT:
1. Incision & Drainage. If small
and superficial, can do under
local anaesthesia. Send a swab of
drained pus to pathology.
2. Antibiotics and painkillers
3. DO. NOT. BREASTFEED.

19.  Pathophysiology: Unknown etiology. May be a normal variant of breast
involution in women >50 yrs of age. Around menopause, the lactiferous
ducts shorten and widen causing thick fluid build up. This fluid, in turn
oozes out of the nipple. Commonly one duct is affected but may involve
multiple ducts causing Severe duct ectasia. Smoking is a major risk factor.
 History: Middle aged lady complains of nipple discharge. May vary from
serous to thick yellow-green to creamy. No pain. No lump.
 Examination: Nipple may appear inverted. Normal palpation.
DUCT ECTASIA

20. MANAGEMENT:
1. Reassurance
2. Keep breast and nipple clean
and dry.
3. Painkillers. Evening primrose oil.
4. If complicated by infection –
antibiotics
5. Mild to moderate –
Microdochectomy
Multiple ducts or Severe – Total
duct excision
6. Smoking cessation
MRI

21.  Pathophysiology: 12% of all breast lumps. Unknown etiology but risk
factors constitute Oestrogen replacement (HRT), pregnancy, lactation
or immunosuppresion. Proliferation of glandular as well as stromal cells.
No cellular atypia. Usually small, upto 4cm but may grow larger. Age group
18 – 25 yrs.
30% of these regress with age. No increased risk of malignancy.
 History: Presents as a painless, palpable lump. May be multiple or bilateral.
No nipple discharge. No change in nipple/ skin.
 Examination: Well-circumscribed, discrete, smooth or nodular, firm,
mobile, non-tender lump. No lymphadenopathy.
Breast Mouse.
FIBROADENOMA

22. FNAC shows sheets or clusters of bland
epithelial + mesenchymal cells. No atypia
of nuclei. Rare mitotic activity. Strands
of stroma dispersed between and around
the epithelial cells.
If lump is small (up to 4 cm), FNAC is
enough to make a diagnosis of
Fibroadenoma. If bigger, it will need a
core biopsy to rule out Phylloides tumour
and cancer.

23. MANAGEMENT:
1. Young females with small
adenomas – wait and watch
policy as many lesions regress
eventually. Follow-up exam and
imaging every 6 to 12 months.
2. Women aged 40 yrs and above or
those with bigger fibroadenomas
– excision biopsy. Diagnostic as
well as therapeutic. Send excised
sample to histopathology.
3. Follow-up is vital to detect
recurrence
Infra
mammary

24.  Pathophysiology: Exact cause unknown. Benign proliferation of
epithelium and stroma into a single duct beneath the areola. No clear risk
of malignancy for a solitary papilloma. Relatively common in middle aged
women.
 History: Presents with blood stained discharge. Sometimes discomfort and
a small lump. No nipple or skin changes.
 Examination: Usually unremarkable findings. Sometimes small, soft, sub-
areolar lump may be palpated. Blood stained serous discharge can be
expressed from nipple.
INTRADUCTAL PAPILLOMA

25. MRI
US guided Core needle biopsy:
fibrovascular core and intraluminal
myoepithelial cells, lined by single layer
of epithelial cells

26. MANAGEMENT:
1. Solitary papilloma – Microdochectomy ie excision of the lactiferous duct
Multiple papillomas – Total Duct Excision ie excision of all the ducts
2. Always submit excised sample to histology to rule out malignancy. An
excision biopsy is more diagnostic than a core biopsy.
3. Follow-up.
Recurrence is higher with Microdochectomy.
Slight risk of malignant transformation of large papillomas

27. Risk Factors:
• Age >40 yrs; F> M
• Family history. BRCA genes.
• Oestrogen replacement (HRT)
• Oral contraceptives
• Early menarche
• Late menopause
• Virgin uterus ie no history of
pregnancy
• 1st pregnancy over 35 yrs of age
• Not breastfeeding
• Radiation exposure
• Smoking
• Excessive alcohol intake
• Obesity
• Lack of exercise
BREAST CANCER
Commonest cancer in all women of the world.
In UK: 1 in 8 women.

28.  Pathophysiology:
BRCA 1 / BRCA 2 or
combined mutation
Inactivation of
tumour suppressor
genes eg p53
Decreased apoptosis
of faulty DNA
Activation of growth
promoting oncogenes
eg Her 2 neu
Proliferation of
breast tissue
(Hyperplasia)

29. DUCTAL
Arises from the
terminal duct
Dysplasia with intact basement
membrane – DCIS
Dysplastic cells cross the
basement membrane – Invasive
Ductal Carcinoma
LOBULAR
Arises from the
lobule
Dysplasia with intact
basement membrane – LCIS
Dysplastic cells cross the
basement membrane –
Invasive Lobular Carcinoma

30.  History: Presents as a hard lump or
lumps in the breast. May have lumps in
the ipsilateral axilla. Overlying skin may
become inflamed or harden (peau d’
orange). Nipple inversion with blood
discharging from the nipple.
Cancer symptoms ie anorexia, weight
loss, lethargy
 Examination: Discrete, nodular, hard,
immobile, non tender lump in the breast.
Blood can be expressed from the nipple.
In advanced cases, the overlying skin
appears rough like an orange peel. Hard
lymph nodes can be appreciated in the
axilla.

31. Core needle biopsy should always be taken to assess whether lesion is In situ or
invasive.

33. MANAGEMENT:
1. All information from the triple assessment is discussed in MDT and a
management plan is formed.
2. Downstaging of lesion with chemotherapy and hormonal therapy
3. Ultimately surgery:
• Simple Mastectomy – Excision of breast only
• Radical Mastectomy – Excision of breast + Axillary dissection + Pectoral
dissection
• Modified Radical Mastectomy – Excision of breast + Axillary Dissection
• Breast Conservation Surgery – Wide local excision ie excision of breast
lump with at least 3 cm of surrounding tissue
• Sentinel lymph node biopsy vs Axillary dissection

34. Mastectomy Wide Local Excision
Multifocal tumour Solitary lesion
Central tumour Peripheral tumour
Large lesion in small breast Small lesion in large breast
In situ disease >4 cm In situ disease <4 cm
Sentinel LN Biopsy Axillary Dissection
Clinically normal axilla Clinical lymphadenopathy
4. Adjuvant Radiotherapy (post-op radiotherapy) to prevent recurrence
5. Follow up

36.  BREAST CANCER SCREENING:
All women aged from 50 to their 71st birthday who are registered with a
GP are automatically invited for breast cancer screening every 3 years.
Screening involves Mammogram.
 ONE STOP BREAST CLINIC:
This is an outpatient clinic specifically for patients with any breast related
symptom whether this be a worrisome lump, nipple discharge, breast pain
or skin changes. It involves a triple assessment as well as imaging.
Therefore, it offers a thorough breast assessment all on one day.

38. QUESTIONS?