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454
Manipal Manual of Surgery
15. Following are true for right adrenal gland except:
A. Right adrenal gland drains into renal vein
B.
Right adrenal gland is partly behind inferior vena
cava
C. Right adrenal gland is pyramidal in shape
D. Right adrenal gland is anterolateral to the right
crus
16. The majority of the sporadic primary hyperparathyroidism is due to:
A. Hyperplasia B. Adenoma
Carcinoma D. Cystic degeneration
C.
17. Severe bone disease due to primary hyperparathyroidism is called:
A. Sipple syndrome
Werner syndrome
B.
C. von Recklinghausen’s disease
D. Paget’s disease
18. Superior parathyroid gland can be found by:
A. Ligating the middle thyroid vein and dividing the
lobe
Ligating inferior thyroid artery and mobilising the
B.
gland
C. Ligating superior thyroid pedicle and mobilising
the gland anteriorly
D. Ligating inferior thyroid veins and diving isthmus
19. Following are locations of inferior parathyroid gland
except:
A. Upper horn of thymus
.
Within carotid sheath
B
C. Within thyroid lobe
D. Behind superior thyroid pedicle
20. Following are causes of secondary hyperparathyroidism except:
A. Malabsorption
Vitamin D-deficient rickets
B.
C. Pseudohypoparathyroidism
D. Acute renal failure
21. Parathyroids can be autotransplanted to:
A. Brachioradialis muscle
B
Biceps
.
C. Coracobrachialis
D. Flexor digitorum superficialis
22. Which of the following drugs is not used in treating
acute hypercalcaemic crisis due to primary hyperparathyroidism (benign)?
A. Mithramycin
.
Bisphosphonates
B
C. Furosemide
D. Normal saline
Answers
1. C 2. A 3. C 4. B 5. D 6. D 7. A 8. D 9. D 10. D
11. D 12. A 13. B 14. C 15. A 16. B 17. C 18. C 19. D 20. D
21. A 22. A
Section II • General Surgery
39
Breast
Congenital anomalies
Surgical anatomy
Cystic swellings of breast—
classification
Acute bacterial mastitis
Antibioma
Retromammary abscess
Aberrations of normal develop-
ment and involution
Fibroadenoma
Duct ectasia—plasma cell
Idiopathic granulomatous mastitis
Macrocysts
Galactocele
Galactorrhoea
Duct papilloma
Gynecomastia
Phyllodes tumours
Carcinoma breast
Effects of lymphatic obstruction
from carcinoma of breast
Breast reconstruction
mastitis
SU25.1: Describe applied anatomy and appropriate
investigations for breast disease.
EMBRYOLOGY
• The breast is a modified sweat gland and it is derived
from a downward growth of ectoderm into the
underlying mesenchyme.
• At 5th or 6th week of intrauterine life, two ventral
bands of thickened ectoderm,
called mammary
ridge/milk line or line of Schultz, appear. The line
extends from axilla to the groin. Thus, accessory
nipples can appear along the milk line from axilla
to groin (Fig. 39.1).
• Persistent part of mammary ridge is converted
into a pit.
Placental sex hormones enter fetal
circulation during 3rd trimester of pregnancy.
They induce canalizations of branched epithelial
tissues.
• Secondary buds develop, divide and form more lobes.
• The nipple is everted at the site of original position.
Male breast carcinoma
Mondor’s disease
Angiosarcoma of the breast
Disorders of augmented breast
Rare breast cancers
A case of carcinoma breast
Oncoplastic breast conservation
surgery
Fig. 39.1: Milk line with possible positions of accessory nipples
455
456
Manipal Manual of Surgery
• Oestrogens cause enlargement of mammary glands
at puberty and progesterone stimulates development
of secondary alveoli.
CONGENITAL ANOMALIES OF BREAST
I. Amazia: Congenital absence of breast is very rare.
It can be unilateral or bilateral.
II. Poland’s syndrome
• Amazia
• Absence of sternal portion of pectoralis major
• Occurs commonly in males
III. Supernumerary nipples: Accessory nipples,
polythelia (Fig. 39.2)
Fig. 39.2: Accessory nipple
IV. Athelia: Absence of nipple.
V. Polymastia: Accessory breasts occur along the milk
line—axilla (most common), groin, thigh or buttock
(Figs 39.3 and 39.4).
VI. Micromastia: Due to congenital defects of ovary,
lack of hormonal stimulation occurs which results
in small breast.
the lateral border of sternum to the midaxillary line,
horizontally. It is hemispherical, and lies in the
superficial fascial planes.
• It is composed of fatty tissue and does the function
of secreting milk. The axillary tail of Spence is the
part of the breast which is in the axilla and is deeper
to the deep fascia, whereas the entire breast is a sub-
cutaneous structure.
• The opening in the axillary fascia, through which
outer quadrant breast tissue enters into axilla is called
foramen of Langer.
Structure of the Breast (Fig. 39.5)
1. Nipple and areola complex: The nipple is located in
he 4th intercostal space, in the midclavicular line.
t
It is the erectile structure of the breast, and is
directed forwards and laterally for the convenience
of feeding the child. Areola has modified sweat
glands and sebaceous glands. These enlarge during
pregnancy and are called glands of Montgomery.
Both nipple and areola are pigmented due to melanin
deposition which increases during pregnancy. Hair
is absent in the areola of women (present in males).
2. Parenchyma of breast.
3. Stroma gives support to the glandular structure.
Therein lie ligaments of Cooper which are cone-
shaped fibrous bands. Their apex is attached to
overlying skin, and base to the fascia over pectoralis
major. Puckering of the skin is due to infiltration
of the ligaments of Cooper.
Figs 39.3 and 39.4: Accessory breasts
SURGICAL ANATOMY OF BREAST
• Breast, a modified sweat gland, occupies the pectoral
Section II • General Surgery
region from the 2nd to the 6th rib vertically, and from
Fig. 39.5: Structure of the breast
Breast
457
4. Lobule is the chief functional and structural unit of
breast. Many lobules join to form a lobe. There are
15–20 lobes and each lobe is drained by a lactiferous
duct. They are 15–20 in number arranged radially,
lined by myoepithelial cells, which converge into the
nipple. Diameter of a lactiferous duct is 2–4 mm.
5. Skin: The skin of the breast is thin and contains hair
follicles, sebaceous glands and eccrine sweat glands.
Lymphatic Drainage
They can be divided into lymph nodes and lymphatics
(Fig. 39.6).
ymph Nodes
I. L
1. Anterior or pectoral: They are under the pectoralis
major which forms anterior fold of axilla.
. Central group: These lymph nodes are present in the
2
centre of axilla (armpit). One has to dip the examining
fingers slightly deeper into axilla to detect the
enlargement.
• Anterior and central group of nodes are commonly
involved in carcinoma breast.
. Lateral group are felt against humerus. They are also
3
called brachial group.
4. Apical: They are found at apex of the axilla. It is the
space between pectoralis minor and clavicle. They
are also called infraclavicular nodes, situated very
high in the axilla. They are difficult to feel clinically.
5. Posterior: They are also called subscapular group of
lymph nodes. They are felt along the posterior fold
of the axilla. These five groups together form the
axillary group of lymph nodes.
6. Internal mammary lymph nodes: Also called
parasternal nodes. They lie along internal mammary
vessels. They are located in the 2nd, 3rd and 4th space.
7. Supraclavicular lymph nodes: Spread to supraclavicular lymph nodes indicates advanced stage of
the disease. It indicates poor prognosis.
Miscellaneous lymph nodes/plexus
1. Cephalic nodes—deltopectoral nodes
2. Interpectoral nodes—Rotter’s nodes
3. Posterior intercostal nodes—in front of heads of ribs
4. Intra-abdominal—subdiaphragmatic/retroperitoneal.
II. Lymphatic Vessels
1. Superficial lymphatics: Drain skin over the breast
except nipple and areola. Superficial lymphatics of
one breast communicate with the contralateral breast
across midline.
2. Deep lymphatics: Drain parenchyma of the breast.
They also drain nipple and areola.
Important key points about lymphatics and spread
• The first lymph nodes draining the tumour-bearing area
is called sentinel node.
• 75% of the lymph from the breast drains into axillary nodes.
• 20% drains into the internal mammary nodes.
• 5% of lymph drains into posterior intercostal lymph nodes.
• Most of the lymphatics eventually drains into central
to apical and then to supraclavicular lymph nodes.
• Internal mammary nodes receive lymphatics not only
from inner quadrant but also from outer quadrant.
• Lymphatics from inner quadrant of the breast penetrate
rectus sheath and thus spread into coelomic cavity. It
results in ascites, rectovesical deposits and Krukenberg
tumours.
• Krukenberg tumours are bilateral bulky ovarian meta-
stasis in premenopausal women. During ovulation, raw
surface develops over the ovary into which malignant
cells drop and develop into large tumours (transcoelomic spread).
Fig. 39.6: Lymph nodes and lymphatic spread from breast
Blood Supply of the Breast
(Branches of Axillary Artery)
Arterial Supply
1. Lateral thoracic artery gives many branches which
penetrate through the pectoralis major and supply
the breast.
. Internal mammary artery gives branches which
2
perforate intercostal spaces.
3. Pectoral branches of thoracoacromial artery supply
upper part of the breast.
4. Lateral branches of posterior intercostal arteries.
Section II • General Surgery
458
Manipal Manual of Surgery
Venous Return
Breast is drained by perforating branches of internal
mammary veins, tributaries of axillary veins and
perforating branches of posterior intercostal veins.
Venous return follows the arteries but drain into large
veins that also receive blood from vertebrae and thoracic
cage, e.g. posterior intercostal veins joining paravertebral
plexus of veins (Batson’s venous plexus). This explains
the occurrence of metastasis in the vertebrae and pelvic
bones from carcinoma of the breast.
Physiology (Key Box 39.1)
Key Box 39.1
Physiology of the Breast
Oestrogen: Initiates ductal development.
Progesterone: Differentiation of epithelium and lobular
development (glandular development)
Prolactin: Lactogenesis in late pregnancy and post-
partum period. It also upregulates hormone receptors
and stimulates epithelial development.
SU25.2: Describe the etiopathogenesis, clinical features
and principles of management of benign breast disease
including infections of the breast.
CYSTIC SWELLINGS OF BREAST
Classification
1. Inflammatory: Acute bacterial mastitis with abscess*
2. Neoplastic:
a. Benign: Phyllodes tumour*
b. Malignant: Intracystic carcinoma*
3. Non-neoplastic cyst
a. Fibroadenosis—cyclical mastalgia
b
. Simple cysts of the breast
c. Cyst of Bloodgood—blue domed cyst
4. Retention cyst of the breast: Galactocele
5. Other rare causes of cysts of the breast
a. Tuberculous mastitis with cold abscess*
b
. Lymphatic cyst of the breast (congenital)
c. Hydatid cyst of the breast
d. Haematoma of the breast
ACUTE BACTERIAL MASTITIS
(BREAST ABSCESS—PYOGENIC MASTITIS)
Aetiopathogenesis
1. Lactational mastitis: It is most commonly encoun-
tered during lactation. Hence, it is called lactational
mastitis.
Precipitating factors
• Crack/fissure in the nipple
• Retracted nipple. Hence, cleaning of the breast is a
problem.
• Oral cavity infection in the child
2. Haematoma
• Infection in a haematoma can result in an abscess—
rare cause.
• Staphylococcus produces many enzymes/toxins such
as catalase, coagulase, hyaluronidase which result in
an abscess. It also inhibits phagocytosis because of
type ‘A’ protein on its surface. Staphylococcus aureus,
which enters through the nipple, proliferates
intraductally and produces clotting of the milk. Within
the clot, the organisms multiply, which results in a
cellulitic stage of the breast (mastitis) and in
untreated cases, it may give rise to a breast abscess.
Initially, only one lobule and duct get affected. Later
other lobules get infected, giving rise to an intramammary abscess.
3. Nonlactational breast abscess: It occurs in patients
with duct ectasia and periductal mastitis. When such
an abscess ruptures, it results in a mammary duct
fistula. It classically drains at the junction between
the areola and breasts skin. Anaerobic bacteria are
the cause in majority of cases.
4. Other factors: Diabetes, AIDS and chronic illness also
can give rise to breast abscess (Key Boxes
39.2 and 39.3).
5. MRSA and breast abscess
Clinical Features
• Severe pain in the breast due to spreading inflamma-
tory exudate. Breast is swollen, tense, tender and
warm to touch. These are the signs of cellulitic stage.
Key Box 39.2
MRSA and Breast Abscess
Methicillin resistant Staphylococcus aureus (MRSA) or
community acquired MRSA or CA-MRSA can cause
breast abscess in patients who have no traditional risk
factors
Hospitals, nursing homes (patients with open wounds)
are the risk areas
Co-amoxyclav 1000 mg 2 times/day—7–10 days
Erythromycin 500 mg 3 times/day—7–10 days
Vancomycin 1.5 g vial 12th hourly × 7–10 days
Suspect MRSA infection when abscesses recur, abscess
persists and is nonlactational.
Section II • General Surgery
*These swellings may give rise to fluctuation in a ‘small’ part of the swelling. Truly, they are not cystic swellings.
Breast
459
Fig. 39.7: Large breast abscess presented late to the hospital.
Managed by incision and drainage (I and D), not aspiration
• Once breast abscess develops, there is high grade fever
with chills and rigors and a soft, cystic fluctuant
swelling can be felt in the breast. In untreated cases,
abscess may rupture through the skin resulting in
necrosis of the skin of the breast, ulceration and discharge
(Figs 39.7 and 39.8).
• In deep-seated abscess, it is difficult to elicit
fluctuation and often fluctuation is a late sign. Hence,
if throbbing pain and fever with chills and rigors
are present, immediate drainage is mandatory. If not
done, significant amount of breast tissue will be
destroyed.
Treatment
. Stage of cellulitis
1
– Not to feed the child on the affected side.
– Cloxacillin 500 mg, 6th hourly, orally for 7–10 days.
– Anti-inflammatory drugs, such as ibuprofen 400 mg,
three times a day.
Key Box 39.3
Breast Abscess
Common organism—Staphylococcus aureus
Retracted nipple is one of the causes
Commonly seen during lactational period
Very painful condition
Do not wait for fluctuation
Ultrasound-guided aspiration should be done (Fig. 39.9)
Cloxacillin is the drug of choice
Nonlactational abscess—Metronidazole is drug of choice
Abscess confined to one sector—aspiration is the treat-
ment of choice. It can also be repeated.
Fig. 39.8: Extensive necrosis of skin due to severe mastitis
(Courtesy: Dr CG Narasimhan, Surgeon, Mysore, Karnataka)
Fig. 39.9: Breast abscess aspirated. Current thinking is that
repeated aspiration of the breast abscess can also be an
alternative treatment to incision and drainage
– Good support to the breast.
– For nonlactational breast abscess, add metr-
onidazole 400 mg, 3 times a day for 5–7 days.
Advice given to mothers in cases of breast abscess:
• Pus is frequently expressed from nipple.
• Breast feeding is stopped.
• Antibiotics are started.
• Milk is expressed and is boiled and can be given to
baby in cases of absolute requirement.
• Never feed the baby when there is active breast
abscess.
2. Stage of abscess
– The abscess should be drained—incision and
drainage (I and D) under antibiotic cover.
Section II • General Surgery
460
–
If the abscess is situated in any quadrant of breast,
other than lower quadrant, it is drained by radial
incision.
– Abscess in lower quadrant is drained by infra-
mammary incision placed in the inferior aspect of
breast (refer to breast abscess drainage under
operative surgery section).
– When both the breasts have an abscess, the breasts
should be emptied and the milk that is expressed
can be boiled and given to the child.
Currently, the initial treatment policy is USG-guided drainage.
Complications of Acute Mastitis
• Abscess
• Toxaemia
• Skin
• Antibioma (Fig. 39.10)
MRSA and Breast Abscess
• Postpartum MRSA infections among young, immuno-
competent women lacking risk factors for MRSA have
surfaced in the past few years. CA-MRSA are susceptible to multiple non-beta-lactam antibiotics. Although
they are sensitive to vancomycin, it should be given
to patients with signs of systemic septicaemia, hence
routine admission for intravenous vancomycin is not
necessary. Patients with MRSA infections should be
evaluated based on their culture sensitivity results and
treated accordingly. Many may respond to betalactam antibiotics, such as penams, cephalosporins
and even many other drugs, such as cotrimoxazole and
erythromycin.
• All patients should be tested for swabs from nostril,
axilla and groin for MRSA.
• Unilocular abscess or even multilocular abscess
without toxicity can be managed with ultrasoundguided aspiration followed by drugs according to the
culture sensitivity.
• However, when patients have toxicity, tachycardia,
immunocompromised status, they need to be admitted
and aspirations can be done. However, if tachycardia
does not subside, better to do open drainage.
• Recent trails have shown superior results to open
drainage than aspiration.
• Abscess: Patients with severe infections with sepsis
should be admitted and are treated with injectable
antibiotics.
Section II • General Surgery
Manipal Manual of Surgery
Fig. 39.10: Nipple retraction—she also had a lump-antibioma.
Observe previous drainage incision
ANTIBIOMA
• It means an antibiotic-induced swelling. [Oma =
Tumour (swelling)].
• When an abscess occurs in the breast and antibiotics
are given, without draining the abscess, the abscess
cavity may become fibrous and it results in firm to
hard lump in the breast. It gives rise to vague ill
health of the patient.
• This hard lump can be confused for malignancy.
• It is treated by excision.
OTHER TYPES OF BREAST ABSCESSES
RETROMAMMARY ABSCESS
It is collection of pus behind the pectoralis major
(Fig. 39.11).
Fig. 39.11: Different types of breast abscesses
Common Causes
1. Haematoma with secondary infection
. Tuberculosis of ribs with cold abscess
2
3. Cold abscess arising from lymph node
4. Empyema necessitans: Empyema of lung, if left
untreated, tracks out and the pus collects in the
subcutaneous plane posteriorly and retromammary
region anteriorly, thereby forming retromammary
abscess. There may be a tense, tender and cystic
lump
palpable which can be confused with breast
abscess.
Breast
461
Management
• Chest X-ray to rule out pulmonary tuberculosis.
• It is treated by draining the abscess by means of sub-
mammary (Galliard-Thomas) incision.
SUBAREOLAR ABSCESS
• It is common in nonlactating women.
• It communicates with lactiferous duct resulting in
mammary fistula.
• In chronic cases, retraction of the nipple can occur
which is partial or slit-like.
• It can also be due to an infected sebaceous cyst.
TUBERCULOUS MASTITIS
• Incidence is 1 to 4% in India.
• Poor socioeconomic conditions
• Presents as a lump, which can be hard and mimics
carcinoma.
• More common in the reproductive age group—
mainly in lactating women.
• Clinical features may include multiple tender
abscesses, sinuses and matted nodes in the axilla
(need not always be present).
• Involvement of nipple and areola is very rare.
• It is almost secondary to a pulmonary lesion—
retrograde lymphatic spread via paratracheal and
internal mammary lymph nodes.
• Few types: Nodular, sclerosing, disseminated type,
TB mastitis obliterans and miliary form.
• FNAC, care biopsy will help in the diagnosis—
caseating granuloma with Langhan type of giant
cells.
• Aspiration of pus, lumpectomy, excision/even
mastectomy may be required along with concurrent
antitubercular treatment (Fig. 39.12).
Fig. 39.12: Tuberculous mastitis (Courtesy: Dr Maruthu Pandyan,
Government Medical College, Madurai)
ABERRATIONS OF NORMAL DEVELOPMENT AND
INVOLUTION OF THE BREAST
The concept of aberrations of normal development and
involution (ANDI) of the breast was first published by
LE Hughes, et al. of Cardiff Breast Clinic in 1987. The
ANDI classification is based on pathogenesis, and
recognises that a spectrum exists from normal, through
mild abnormality to disease. This has resulted in a
radical change in attitude to the understanding and
management of breast disorders. Changes previously
regarded as disease are so common that they must be
regarded as lying within the spectrum of normality
(Fig. 39.13).
This concept is of value in dispelling the supposed
association between the benign conditions and cancer.
Most patients with lumps and mastalgia are concerned
that they may be harbouring cancer (the result of a
successful information campaign!!), and once a definite
opinion of the benign nature of the lump is conveyed
and the patient is informed that no further treatment is
required, most would be reassured.
Having noted the above, a word of caution is due
here—it is preferable to overtreat a benign breast disease
rather than miss or delay treatment of an early
carcinoma of the breast (Fig. 39.13). So following the
clinical dictum “in a patient who is above the age of 40,
with a recently detected lump in the breast, it should be
considered to be carcinoma breast until proved
otherwise” may prove to be a wrong answer in many
but the correct management in most.
From the above, it follows that, in case of doubt
(where there is a high-risk patient or doubtful signs of
malignancy), it would be prudent on the part of the
treating surgeon to rule out malignancy by triple
assessment (physical examination, mammography and
cytology).
Section II • General Surgery
462
Fig. 39.13: Benign breast disorders and diseases (Courtesy: Dr Stanley Mathew, Professor, Department of Surgery, KMC, Manipal)
Note:1 Fibroadenoma is an AND (Aberration of Normal Development) of a lobule.
2
Cyst (macrocyst) is an ANI (Aberration of Normal Involution) of a lobule.
Manipal Manual of Surgery
If it is not possible to conclusively rule out the
possibility of malignancy, then the patient would be best
advised a lumpectomy.
The term ANDI should not be confined to imply
fibroadenosis (now termed mastalgia with nodularity).
ANDI includes several aberrations and disorders
(Table 39.1). Table 39.1 includes all the aberrations,
disorders and disease entities originally included under
the ANDI classification as proposed by LE Hughes,
et al.
Table 39.1 Aberration of the Normal Development and Involution (ANDI) of the breast
Stage Normal process Aberration Disease state
(Peak age in years) Underlying condition Clinical presentation
Early reproductive Lobule formation Fibroadenoma Discrete lump Giant fibroadenoma
period (15–25 years) (more than 5 cm).
Stroma formation Juvenile hypertrophy Excessive breast Multiple fibroadenomas
Nipple eversion Nipple development Submammary abscess/
mammary fistula
Mature reproductive Cyclical hormonal Exaggerated cyclical Generalised or Cyclical mastalgia and
period (25–40 years) effects on glandular effects. Bloody discrete lump nodularity (incapacitating)
tissue and stroma discharge per nipple
Involution Lobular involution Macrocysts Discrete lumps Cystic diseases
(25–55 years) (including microcysts, Sclerosing lesions
apocrine changes, Adenosis X-ray abnormalities
fibrosis, adenosis)
Ductal involution Duct dilatation Nipple discharge Periductal mastitis with
(including periductal Periductal fibrosis Nipple retraction bacterial infection and
round cell infiltrates), nonlactational breast
dilate with scleroma mammary duct fistula
Epithelial turnover Mild epithelial Histological report Epithelial hyperplasia with
hyperplasia atypia
Terms to be avoided: Fibroadenosis—replace with mastalgia and nodularity.
Instructions to the students: Carefully go through Tables 39.1, 39.2 and Fig. 39.1
References: British Medical Bulletin: Volume 47, Number 2, April 1991.
Section II • General Surgery
Cystosarcoma phyllodes—replace with phyllodes tumour.
Breast
Table 39.2 Classification of benign breast diseases
Nonproliferative disorders Proliferative breast disorders Atypical
• Cysts, apocrine metaplasia • Sclerosing adenosis • Atypical ductal
• Duct ectasia • Intraductal papilloma hypoplasia (ADH)
• Calcification • Ductal epithelial hyperplasia • Atypical lobular hypoplasia (ALH)
• Fibroadenoma and other related • Radial scar
lesions • Complex sclerosing lesions
463
Breast Pain
• It is for mastalgia that many women attend breast
clinic. It can be classified as given in Table 39.3.
• If painful nodularity is present for more than one
week, it is significant (more than normal discomfort).
• Cyclical mastalgia pain is bilateral, located in the
upper quadrant of the breast, poorly localised,
radiation to the axilla and patient also complains of
the heaviness of the breast.
CYCLICAL MASTALGIA WITH NODULARITY
Also called mammary dysplasia, fibrocystic disease,
Schimmelbusch disease, hormonal mastopathy, or fibroadenosis.
The term ANDI should not be confined to imply fibro-
adenosis (now termed mastalgia and nodularity). In
fact fibroadenoma is an AND of a lobule and cyst
(macrocyst) is an ANI of a lobule.
Definition
• It is an aberration of physiological changes that occur
in the breast from menarche till menopause. It is an
ANDI (aberration in normal development and
involution).
• Women around the age of 40 are the usual sufferers.
Table 39.3 Mastalgia
Cyclical Noncyclical
• Related to monthly cycles • Less common
• Associated with • Pain can be due to
premenstrual
and breast discomfort costochondritis (Tietz’s
• Excessive prolactin • Simple measures, such as
release from pituit
gland may be the cause
• Premenopausal women • Analgesics may be
fected (35 years age) beneficial
are af
• Reassurance • Injection with local
• Drugs anaesthetic on a trigger point
• Excision—last resort
nodularity periductal mastitis or
disease)
ary well supported brassieres
Pathology (Key Box 39.4)
1. Fibrosis results in increased connective tissue
growth. Fat and elastic tissue become less, and
chronic inflammatory cells, such as plasma cells, can
be present.
2. Cyst formation: Fibrosis compresses the ductules,
which is responsible for cyst formation. Hence, it is a
retention cyst. The cyst contains dark mucoid
material and it may discharge serous fluid or green
coloured fluid through the nipple. Hence, it is called
fibrocystic disease of the breast. Cyst may be single
or multiple confined to one lobe or many lobes. These
are microcysts.
3. Adenosis: Proliferation of the acini and gland is an
important feature of fibroadenosis.
4. Epitheliosis: Fibroadenosis is not a precancerous
condition but if the degree of epitheliosis is more,
it can be considered as premalignant condition.
Epithelial hyperplasia mainly occurs in the acini.
5. Papillomatosis and apocrine metaplasia of the
epithelium lining cystic spaces are the other features.
These changes are not considered premalignant.
Key Box 39.4
Pathology
Fibrosis
Cyst formation
Adenosis
Epitheliosis
Papillomatosis
Apocrine metaplasia
Clinical Features
• Females around the age of 30–40 are the victims—
spinsters, married childless women and women
who have not suckled their babies are the usual
sufferers.
• Severe pain in the breast in the premenstrual period
and during menstruation. It is called cyclical mastalgia.
Upper outer quadrant, bilaterally is affected.
Section II • General Surgery