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464
Manipal Manual of Surgery
• Clinical examination of the breast reveals a coarse,
nodular, tender, lumpiness which is better felt with
the finger and the thumb. Often, there are multiple,
irregular, firm, nodularities palpable bilaterally,
especially in the upper outer quadrants. Nipple
discharge which is serous or green coloured may
occur.
Treatment
It can be discussed on the following headings:
• Reassurance
• Lifestyle modifications
• Evening primrose oil
• Bromcryptine
• Antioxidants
• Topical NSAID
• Danazol
• Tamoxifen
• Non-steroidal SERM
• Goserelin
1. Reassurance is the most effective treatment for
mastalgia: Breast pain may be cyclical (worse before
a period) or non-cyclical, originating from the breast
or the chest wall, and occurs at some time in 70% of
women. Cyclical breast pain resolves spontaneously
in 20 to 30% of women, but tends to recur in 60% of
women. Non-cyclical pain responds poorly to
treatment but tends to resolve spontaneously in half
of women. Sometimes so serious disturbs routine
activities. Support to the breast, reassurance, a few
drugs. Surgeon should have good communication
skills in these cases. Just to assure the lady that this is
not a cancer, this is not a serious disease, it is just an
aberration of normal physiology, related to hormonal
changes and it may disappear. Vast majority of
patients can be managed by reassurance only.
However, in a few patients, it will not work. They
require pharmacotherapy.
2. Lifestyle modifications: Decrease use of coffee,
cigarettes, calories, chocolates. Caffeine restriction is
an effective means of management of breast pain
associated with fibrocystic disease. Smoking might
increase breast pain by increasing epinephrine
levels.
3. Evening primrose oil (EPO): Basis: Cyclical mastalgia
patients have abnormal fatty acid profiles and
decreased levels of essential fatty acids. EPO contains
7% linolenic acid and 72% linoleic acid. 1000 mg 3 to
Section II • General Surgery
6 times per day. 3 to 4 months period. No side effects.
Key Box 39.5
Evening Primrose Oil
First choice of treatment of cyclical mastalgia is
evening primrose oil (EPO)
Useful to treat mild to moderate cyclical mastalgia
EPO contains 7% linolenic acid and 72% linoleic acid
Dose is 1000 mg capsule—6 per day
EPO can be taken with oral contraceptive pills
No side effects
Initially proved to have a role in treating cyclical mastalgia,
but no trials have been able to prove the benefit over
and above the control oils, placebo oils and antioxidants
(Key Box 39.5).
4. Bromocriptine which decreases the prolactin levels,
1.25 mg, twice a day, may reduce the pain and may
be increased to 2.5 mg twice a day. It is useful for
cyclical mastalgia.
5. Danazol is a gonadotrophin releasing hormone
inhibitor. 200–400 mg/day, thrice a day is given. It
acts by reducing FSH and LH levels.
6. Tamoxifen 10 mg, twice a day, is a better alternative
to danazol.
7. Other drugs: Antioxidants, non-steroidal SERM and
Goserelin also have been used rarely.
Treatment may have to be continued for some months
(Table 39.4).
• Diuretics have no role. Topical NSAID application may
help.
• Danazol is the best drug in cases of noncyclical mastalgia
but it is teratogenic. Hence, the patient should take
precautions against pregnancy.
Surgery
Indications for surgery:
• FNAC suggests epitheliosis
• A very painful lump
• A hard lump about which the patient is worried and
anxious.
1. Excision of the lump. Surgery for fibroadenosis ends
up in removing some breast tissue and the lump.
As it has no capsule of its own, it is a messy surgery
unlike fibroadenoma surgery (Figs 39.14 to 39.16).
2. Is there a role for subcutaneous mastectomy? In
patients with family history of breast carcinoma, if
they have lumps in the breast with severe degree
of epitheliosis, it may be worthwhile doing subcutaneous mastectomy.
Breast
Table 39.4 Drug treatment of cyclical mastalgia
Drug Mechanism of action Dose Maintenance dose Side effects
1. Evening primrose • Contains essential fatty • 1000 mg/day • Can be reduced to No side effects
oil acids which correct 6 capsules 3 capsules/day
abnormal prostaglandin • First choice in • Mild to moderate
synthesis
• Natural form of gamolenic • 4 months treatment
acid
Danazol Interfere with FSH and LH • 50 mg/day—increased • 50 mg/day for
2.
Bromocriptine It lowers prolactin by blocking • 2.5 mg/day—slowly • 2.5 mg/day Nausea, vomiting,
3.
it
s release from pituitary increased to 2.5 mg • Inferior to danazol dizziness
Tamoxifen Antioestrogen • 10 mg/day for • Only for 3 months Minimal when used
4.
5.
Goserelin Luteinising hormone • 98% success in • Reserved for ref-
Releasing hormone cyclical mastalgia ractory cases postmenopausal
analogue symptoms
cyclical mastalgia mastalgia
Amenorrhoea
to 100 mg/day 3 months Weight gain
• Severe breast pain Acne, hirsutism
with nodularity
twice/daily
3 months • Start if relapses occur for short period.
Reversible
465
Fig. 39.14: Submammary incision is given to ex-
cise a large lump in the breast
Fig. 39.15: Observe the nodularity of
the lump
SU25.3: Describe the etiopathogenesis, clinical features,
investigations and principles of treatment of benign and
malignant tumours of breast.
Benign tumour of the breast is fibroadenoma—given here.
Malignant tumours are: Phylloides and carcinoma breast
are given in page …
FIBROADENOMA
It is a benign tumour in which the epithelial cells are
arranged in a fibrous stroma. It is an AND (Aberration
of Normal Development) of a single lobule.
Types
1. Pericanalicular type in which fibrosis is more.
. Intracanalicular type in which fibrosis is less.
2
Fig. 39.16: Excised specimen having
nodularity and cystic changes
• Small fibroadenomas (1 cm in size or less) are considered normal.
• Larger fibroadenomas (up to 3 cm) are disorders.
• Giant fibroadenomas (more than 3 cm) are a disease.
Clinical Features
• Peak age of incidence is at 20 years.
• Patients present with painless lump in the breast.
• It is smooth, round bordered, firm to hard in
consistency, and freely mobile within the breast.
• Due to its free movement within breast tissue, it is
known as breast mouse.
• However, when fibroadenoma occurs in elderly
patients, it may not have characteristic features
because of fibrosis.
Section II • General Surgery
466
Manipal Manual of Surgery
Treatment
• Excision of the lump
. In intracanalicular type, the lump is deeper and
1
peripheral. It is removed by submammary incision.
2. In pericanalicular type (Figs 39.17 and 39.18), the
lump is superficial. It is removed by periareolar
incision.
Fig. 39.17: Fibroadenoma
excised—external view
Fig. 39.18: Fibroadenoma—
excised specimen
Complications
Fibroadenoma and malignancy: Patients with simple
fibroadenoma and no family history of breast cancer
have no risk of cancer. Complex fibroadenomas which
show cysts, sclerosing adenosis, calcification have
increased risk (3 to 4 times) of cancer.
Fibroadenoma and fibroadenosis are compared in
Table 39.5.
treatment. Hence women under 40 years of age,
conservative treatment of reassurance, surveillance
and observation. Automated breast volume scans are
available to detect even a minute increase in fibroadenomas—useful specially in multiple fibroadenomas.
2. High Intensity Focused Ultrasound
Non-invasive treatment which ablates the tissues. It
uses the piezoelectric transducer inside a ultrasound
machine and generates a high frequency high intensity
ultrasound beam. This beam is directed towards the
specific target area of fibroadenoma. It results in
increase in local temperature, denaturation of protein,
cell death and results in tissue necrosis due to
temperature. A few reports say about 50% reduction of
maximum diameter of the fibroadenoma and also with
significant reduction in the discomfort or pain. However,
takes about more than 2 hours.
yotherapy
3. Cr
Localized destruction of the target tissue happens
i
n cryotherapy. Ultrasound-guided cryoprobe is
introduced into the fibroadenoma after making a small
skin incision. Cooling temperature is –170°C.
Different varieties of systems are available such as
argon-gas-based system, using liquid nitrogen as
cryogen. Irreversible damage to fibroadenoma occurs
due to intracellular ice formation at the tip of the
cryoprobe. Complications include ecchymosis and
swelling.
Recent Advances
Minimally invasive techniques are becoming popular.
Advantages being breast preservation, no scarring a
nd
cosmesis is better. Four types of treatment is followed.
acuum-Assisted Excision
4. V
Small incision is made in the breast and 8 or 11 gauge
probe is inserted through the lesion. Small amount of
tissue is aspirated. Probe is inserted into different parts
of the tissue and aspirated again. Procedure will take
1. Surveillance and no Treatment
Basis: 40% of fibroadenoma remain stable at the end of
2 years and 20% of fibroadenoma resolve without
Table 39.5 Differences between fibroadenoma and fibroadenosis
Fibroadenoma Fibroadenosis
• Incidence Less common More common
• Nature Benign tumour of one lobule Aberration of normal changes in the breast
• Pain in the breast Not a feature Very common, premenstrual
• Location Unilateral Usually bilateral
• Lump Well-defined,
• Capsule Well-defined No capsule
• Discharge No Serous or green coloured
• Malignancy Rarely–sarcoma Carcinoma (if epitheliosis is present)
• Treatment Excision Excision or drugs
Section II • General Surgery
firm, mobile Irregular, ill-defined, tender lump
about 30 to 60 minutes. Compression is applied at the
site of puncture. Haematoma, recurrence and postprocedure pain are complications.
Breast
467
DUCT ECTASIA/PERIDUCTAL MASTITIS—
PLASMA CELL MASTITIS
• Common in middle-aged women.
• There is primary dilatation in one of the lactiferous
ducts.
Aetiology
• Actual cause is not known. Mild low-grade infection
(anaerobic bacteria) has been considered as one of
the factors. Enterococci, staphylococci, bacteroids are
also found.
• The toxic substances in cigarette smoke may damage
ducts directly or cause local hypoxia.
• Increased in smokers: Smoking increases the
virulence of commensal bacteria.
Pathology
• There is dilatation of one of the lactiferous ducts.
• Due to dilatation, the contents tend to undergo stasis.
The epithelial debris, and serous fluid collectively
form a thick paste-like material rich in lipid.
• It may cause discharge per nipple
• There is intense periductal inflammation with
lymphocytes and plasma cells (Fig. 39.19). Hence, it
is called plasma cell mastitis (Key Box 39.6).
• Fibrosis causes nipple retraction.
Fig. 39.19: Excised specimen. Observe the fibrosis due to
periductal inflammation
Key Box 39.6
Summary of the Treatment of Periductal Mastitis
Periductal infiltration of plasma cells, lymphocytes
Excision of all major ducts (Hadfield’s operation)
Retraction of nipple (partial)
Infection by anaerobes/irritation by smoking
Dilatation of breast /ducts
Untreated—abscess/fistula/lump
Creamy/paste-like discharge
Treated by co-amoxiclav and metronidazole
Remember as PERIDUCT
Clinical Features
• Middle-aged woman
• Paste-like material discharge per nipple.
• After some time, because of fibrosis, a lump can be
felt, which can be confused for carcinoma of breast.
• Bilateral slit-like retraction of nipple of long duration.
• Recurrent abscess and recurrent fistula are other
complications.
• Routine mammogram—microcalcification
• Palpable subareolar mass
Management
• FNAC to confirm diagnosis.
• Antibiotics, drainage, excision of all major ducts.
IDIOPATHIC GRANULOMATOUS MASTITIS (IGM)
• IGM is a rare, inflammatory noncaseating chronic
granulomatous benign disease occurs within 5 years
of parturition. It is an autoimmune localised response.
• Often patients present with features of mastitis (non-
lactating) with pain, nipple retraction, lump in the
breast.
• Some of them are treated with antituberculous
treatment with FNAC, tru-cut or even biopsy findings
of granuloma but they are nontuberculous.
• When tuberculosis, sarcoidosis, diabetes and
Wegener’s granulomatosis are excluded, the diagnosis of idiopathic granulomatous mastitis is made.
• Aetiology is not known. However, a few factors
responsible can be autoimmune disease, undetected
organisms, reaction to childbirth, use of oral contraceptives, hyperprolactinaemia?
• To begin with damage to ductular epithelium by
infection, trauma or chemically induced inflammation. As a result of which, luminal secretion to
escape into the lobular connective tissue. It stimulates
a granulomatous response. Further damages the
lobular structures. Hence, it is also called idiopathic
lobular granulomatous mastitis.
• Characteristic histological features include multi-
nucleated giant cells, epithelioid histiocytes—
noncaseating.
• Recurrent bouts of mastitis and or chronic dis-
charging sinuses. Core biopsy is done to rule out
malignancies and tuberculosis or sarcoidosis.
Organisms, if any, to be treated—Corynebacterium
kroppenstedtii infection. The diagnosis of IGM is
established via core needle biopsy of a solid mass.
The biopsy should be sent for Gram stain, bacterial
culture, acid-fast bacilli stain and culture, fungal stain
and culture, and histopathology.
Section II • General Surgery
468
Manipal Manual of Surgery
• Many diseases may cause granulomatous response in
the breast including cryptococcosis, actinomycosis,
filariasis, autoimmune diseases, plasma cell mastitis, etc.
• IGM is a self-limiting inflammatory condition that
resolves slowly; complete resolution may take 9 to
12 months. Steroids, oral and topical, can be used.
Steroids with methotrexate—10 to 15 mg/week
found to be successful. 80% success rates.
• Corynebacterium infection—amoxicillin-clavulanate
(875 mg orally every 12 hours); for penicillin-allergic
patients, doxycycline (100 mg orally twice daily) may
be used.
MACROCYSTS
• They occur due to excessive secretion of thin fluid
within the lobules which enlarge to produce a cyst.
Clinically, they present as firm swelling in the breast.
It is an ANDI of a single lobule (firm because it is tense).
• They can be single or multiple. One of them can have
huge dimension having a thin bluish capsule—blue-
domed cyst of Bloodgood (Figs 39.20 to 39.21 and Key
Box 39.11).
Treatment
Excision of cyst in the following situations:
. Recurrence after 2 aspirations
1
2. Blood-stained aspirate
3. Residual lump after aspiration.
GALACTOCELE (Fig. 39.22)
• It is a solitary, subareolar retention cyst filled with
milk. It occurs and dates back to the lactational
period.
• It occurs due to inadequate drainage of the milk
added by epithelial debris which blocks the lactiferous duct. Once the duct is blocked, proximally,
the milky fluid accumulates resulting in a huge
enlargement of breast.
Fig. 39.20: Submammary incision—
cyst delivered
Section II • General Surgery
Fig. 39.21: Fibrocystic
disease—nature of fluid
Fig. 39.22: Galactocele
• Rarely, they undergo calcification.
• It is treated by repeated aspirations. Duct patency
can be restored by using 4-0 nylon.
• Excision is the last choice.
DISCHARGE PER NIPPLE
Nipple Discharge
• It is a common problem encountered in the outpatient
department. It can be physiological, such as lactational
and/or pathological from various causes.
• The clinical evaluation of the case of nipple discharge
consists of the following history examination.
1. Nature of the discharge:
• Serous Fibrocystic disease
Duct ectasia
• Bloody Duct papilloma
Duct ectasia
Duct carcinoma
• Greenish Duct ectasia
• Milk Lactational
Non-lactational—
Hyperprolactinaemia
Oestrogen replacement therapy
• Yellow Breast abscess
(purulent)
2. Unilateral or bilateral: Duct papilloma is unilateral;
fibrocystic disease and hyperprolactinaemia are
bilateral.
3. Single or multiple ducts: Duct carcinoma/duct
papilloma involves single duct, but fibrocystic disease
affects multiple ducts.
4. Spontaneous discharge is typical of duct papilloma.
Blood-stained discharge on pressing the mass may
be seen in carcinoma breast.
Breast
469
5. Related to menstruation: This is seen in fibrocystic
disease and patients who are taking oestrogen
replacement therapy.
6. Discharge with mass:
• Tender mass—fibrocystic disease breast abscess
• Nontender mass—carcinoma
Localisation
• Mammogram and ultrasound to detect any mass,
any cystic lesions. Very often they do not help in the
diagnosis.
• Prolactin levels, thyroid hormone profile (rarely
hypothyroidism can cause discharge per nipple)
• Cytological examination of bloody discharge for
malignancy.
• Ductoscopy has been done but not very successful.
Treatment
• Rule out carcinoma—first
• Watery/serous discharge needs reassurance after
ruling out fibrocystic disease
• A duct papilloma requires microdochectomy
• Discharge from multiple ducts or origin of the
discharge is not clear—‘core excision’ of major ducts
should be done (Hadfield’s operation).
Treatment
• If the cause is identified, such as drugs mentioned
above, stop them.
• If any other reason is detected, then treat the cause.
• Often no cause is identified, reassure the patient.
DUCT PAPILLOMA
• It is a benign lesion of the breast, usually single and,
unilateral, rarely multiple.
• Middle-aged women are affected and present with
bleeding per nipple (Fig. 39.23).
• The tumour is situated in one of the larger lactiferous
ducts.
• It presents as a small swelling just beneath the areola,
palpation of which results in discharge of blood.
• Since, it is a premalignant condition, it is treated by
microdochectomy.
• Microdochectomy: The opening of the lactiferous
duct discharging blood is identified. It is probed with
lacrimal probe or a straight needle. A small triangular
piece of skin, along with the needle, and a wedge of
breast tissue to a depth of about 4–5 cm is removed
(Figs 39.24 and 39.25).
• Hadfield’s operation: Cone excision of the lactiferous
ducts is done when duct of origin of nipple bleeding
GALACTORRHOEA
Secretion of milk unrelated to breastfeeding.
Causes
Physiological
• Stimulation during sexual activity.
• Extremes of reproductive age (puberty and meno-
pause)
Drugs
• Oral contraceptive agents and oestrogen
• Antihypertensive agents, such as methyldopa,
atenelol, clonidine
• Dopamine receptor blocking agents, such as
chlorpromazine, haloperidol, metoclopramide.
receptor antagonists, such as ranitidine
• H
2
Pathological
• Pituitary adenoma/microadenoma
Miscellaneous
• Ectopic prolactin secretion
• Hypothyroidism
• Chronic renal failure
Fig. 39.23: Bleeding per nipple
Fig. 39.24: Papilloma excision
Fig. 39.25: Specimen of
papilloma
Section II • General Surgery
470
Manipal Manual of Surgery
is uncertain. A circumareolar incision confined to onethird of the circumference is given and deepened. The
flap is better not raised to avoid necrosis of areola. A
core or cone of breast tissue from nipple to pectoral
fascia or about 5 cm length is removed. Most of the
ductal papilloma will be located within 5 cm from
the nipple.
• Nipple ductoscopy: Fibreoptic—less than 1 cm
diameter with 0.2 mm secondary channel attachment.
Ductoscopy—dilatations can be done—sterile saline
is used for distension. Minimally invasive, scarless.
According to the findings, it can be classified as
polypoidal, epithelial, suspicious, normal. Excision of
papilloma/lesions can be done. It is not possible to
remove lesions that are more than 10 mm.
AXILLARY TAIL HYPERTROPHY
• More commonly it is the enlargement of axillary tail
of Spence.
• It is usually bilateral and feels like fatty tissue, lobular,
soft to firm. This is how it is differentiated from lymph
nodes in the axilla.
• Causes can be physiological at puberty or during
premenstrual/menstruation period or can be a part
of ‘ANDI’.
• Pregnancy is also one of the causes of enlargement.
• Rarely ‘ectopic’ axillary breast tissue other than tail
of the breast may be present along the milk line.
• Usually reassurance is all that is required.
• Pain and cosmesis are the indications for removal.
TRAUMATIC FAT NECROSIS
T: Trauma either by a direct blow or by a seat belt or
trivial contraction of pectoralis major. Sometimes
no history of trauma.
R: Retraction of nipple, palpable hard lump, tethering
of skin mimic carcinoma.
A: Acids—fatty acids and glycerol released due to
injury to the fat causes saponification.
U: Unusually large, pendulous breasts are affected
more often.
M: Middle-aged women with microcalcification in
mammography—mimics carcinoma.
A: Age around 40 to 50 years
T: Treatment—biopsy/excision of the lumps
I: Immediate reconstruction is possible
C: Can develop after tamoxifen therapy and, after any
type of breast surgery
Section II • General Surgery
You can remember as TRAUMATIC
GYNAECOMASTIA
This is an unphysiological enlargement of the male breast.
Causes
Physiologic causes
• Neonatal period, adolescence, senescence
• Idiopathic is the most common wherein no cause can
be identified. However, there are many other causes
of gynaecomastia which can be summarised as
“MASTIA” (Key Box 39.7).
Key Box 39.7
MASTIA
Malignant tumour: Teratoma, bronchogenic carcinoma.
Anorchism: Absent testis
Sex chromosome anomaly: Klinefelter’s syndrome (XXY).
Tablets: Cimetidine, stilboesterol, digitalis, spironolactone
Idiopathic: No cause is found
Atrophy of the testis: Liver cell failure, leprosy, etc.
Clinical Classification of Gynaecomastia
Grade I Mild grade enlargement
Grade
IIa Moderate grade enlargement
Grade IIb Moderate grade enlargement with skin
redundancy
Grade III Marked grade enlargement with skin redun-
dancy and ptosis (simulates a female breast)
Clinical Features
• In idiopathic variety, gynaecomastia is bilateral. In
other cases, it may be unilateral.
• A ‘disk’ like tender lump is palpable, with smooth
surface.
• Examination should also include palpation of testis
and to look for liver cell failure.
Treatment
Lumpectomy or mastectomy with preservation of
nipple and areola (subcutaneous mastectomy).
Complications
Rarely, gynaecomastia can predispose to male breast
carcinoma (Fig. 39.26).
• However, innocent looking the breast lump may be, it can
be malignant unless proved otherwise.
• Multicentricity refers to occurrence of a second in situ breast
cancer outside the breast quadrant of primary in situ
carcinoma.
Fig. 39.26: Gynaecomastia (Courtesy: Dr Satish Deshmukh and
Dr Murtaza Akhthar, NKP Salve Institute of Medical Sciences, Nagpur)
Breast
Types of Phyllodes
• Benign: More than 60% younger women
• Borderline Depends upon mitotic activity, cellularity
• Malignant and infiltration at the edge of the tumour
Clinical Features (Key Box 39.8)
• Age group—30 to 40 years—premenopausal
• Rapid growth
• Stretched, shiny skin
• Red, dilated veins over surface, warm to touch
• Bosselated surface (big nodules), a few cystic areas.
471
SU25.3: Describe the etiopathogenesis, clinical features,
investigations and principles of treatment of malignant
tumours of breast.
PHYLLODES TUMOURS
• They are fibroepithelial tumours composed of an
epithelial and cellular stromal component.
• Earlier known as cystosarcoma phyllodes and
mistakenly labelled as a giant intracanalicular
fibroadenoma. They are tumours of the breast, with
a predilection to attain massive size and recur locally
after lumpectomy (Figs 39.27 and 39.28).
• It is considered as potentially malignant tumour of
the breast.
• Account for less than 1% of all breast neoplasms.
Fig. 39.27: Phyllodes tumour of the left breast at surgery
(Courtesy: Dr Hartimath B, Associate Professor, KMC, Manipal)
It is differentiated from carcinoma by:
• No fixity to the skin
• No fixity to the pectoralis—mobile on the chest wall
• Lymph nodes will not be involved.
• No nipple retraction.
As the tumour grows very fast, it undergoes
–
necrosis in various places resulting in cystic areas
within the breast. It discharges serous fluid. Hence,
the name serocystic disease of Brodie. However, it rarely
feels cystic.
– Histologically, the tumour cells have a branching
pattern, penetrating the cystic cavity (phyllus means
leaf-like pattern). Fibrous stromal proliferation is
a feature.
Diagnosis
• Very often, it is a clinical diagnosis.
• Ultrasound will help to detect the size of the tumour,
solid and cystic areas.
• Tru-cut biopsy may reveal mitotic figures suggestive
of malignancy.
Treatment of Phyllodes
. Report after FNAC/excision:
I
A. Those who undergo, excision and report is
fibroadenoma, just wait and watch.
. If after excision report is phyllodes—benign and
B
borderline—if 1 cm margin is adequate, just
watch. If margin is not adequate—re-excise with
1 cm margin.
C. If it is invasive carcinoma or in situ carcinoma—
treat accordingly.
Fig. 39.28: Phyllodes tumour with dilated veins (Courtesy:
Dr Sreejayan, Professor, Department of Surgery, Calicut Medical
College, Kerala)
Key Box 39.8
Bosselated Surface—Conditions
Phyllodes tumour
Polycystic kidney
Polycystic liver
Large nodular goitre
Section II • General Surgery
472
Manipal Manual of Surgery
II. Report after core needle biopsy:
A. Excision if it is fibroadenoma, or indeterminate.
. Phyllodes—benign and borderline and malignant
B
wide local excision with 1 cm margin. Enlarged
nodes should be subjected for biopsy (like
carcinoma-sentinal node) and treat accordingly.
C. If it is invasive carcinoma or in situ carcinoma—
treat accordingly.
D. When whole breast is involved as in advanced
cases, simple mastectomy and re-construction.
Summary of Phyllodes Tumour
• Median age of presentation is 45 years.
• Rapid growth and large size can also be a feature of
benign phyllodes tumour.
• Large lump with dilated veins, shiny skin is typical of
phyllodes tumour.
• No nipple retraction, no skin fixation, no axillary nodes.
• High resolution ultrasound will reveal well-circum-
scribed lesion with smooth walls. Intramural septations
can be defined better with MRI.
• Core biopsy can give more details about cellular
pleomorphism, hypercellularity and nuclear hyperchromatism (Refer below).
• Distant metastasis rare—sites are lungs, bone, heart, liver.
• Adjuvant radiotherapy for phyllodes with recurrence with
invasion to chest wall or inadequate margin, can be given.
• Chemotherapy, hormonal manipulations have proven
no role.
Azzopardi and Salvadori criteria for diagnosis of nature of
phyllodes tumour
Histological type
Criteria Benign Borderline Malignant
Tumour margins Pushing
Stromal cellularity Low Moderate High
Mitotic rate <5 5–9 >10
(per 10 hpf)
Pleomorphism Mild Moderate Severe
— Infiltrative
Complications
• Pressure necrosis—secondary infection
• Distant spread—lungs and long bones
Intracystic Carcinoma of Breast: Reeclin’s Disease
Rapidly growing carcinoma of the breast can undergo
cystic degeneration resulting in a cyst, called intracystic
carcinoma of the breast. Aspiration reveals haemorrhagic fluid, containing malignant cells and which
refills after aspiration. Other features of carcinoma of
the breast may be present.
Section II • General Surgery
SU25.3: Describe the etiopathogenesis, clinical features,
investigations and principles of treatment of benign and
malignant tumours of breast.
CARCINOMA BREAST
Incidence
Breast cancer is a major global public health concern
for women in the 21st century. Worldwide it is leading
cause of cancer in women and the leading cause of
cancer-related mortality. In India as of 2018 ICMR
statistics obtained from Indian Cancer Registries, it is
the number one cancer afflicting women, also the
leading cause of cancer-related mortality. In the United
States, breast cancer remains the most frequent cancer
in women and the second most frequent cause of cancer
death. Better understanding of tumour biology, genetics
and availability of advanced multimodality treatment
options is gradually increasing survival.
RISK FACTORS FOR BREAST CANCER
The aetiology of breast cancer is multifactorial. A
combination of risk factors appears to have a role in its
causation. Majority of these factors carry a small to
moderate increase in risk for any individual woman.
We cannot identify risk factors in least half of women
who develop breast cancer. These factors can be divided
into two broad categories:
Non-modifiable
A.
B. Modifiable
A. Non-Modifiable Risk Factors
Female sex: Women are 100 times more likely to have
breast cancer as compared to men.
Age: Increasing age is a strong risk factor. Carcinoma
breast is very rare below 20 years of age. More common
in 35 to 75 years of age. Indian women tend to get
carcinoma breast a decade earlier than western women.
Race: Highest in whites, rare in Japanese and Taiwanese
population.
Breast Cancer and Hereditary Factors
• A family history of breast cancer has long been
recognized as a risk factor for the disease, but only 5
to 10% of women who develop breast cancer have a
true hereditary predisposition. Overall, the risk of
developing breast cancer is increased 1.5- to 3-fold,
if a woman has a mother or sister with breast cancer.
• BRCA I and BRCA II genes have been found in long
arm of chromosome 17 and 13 respectively in women
Breast
473
with a family history of carcinoma of the breast.
BRCA I and BRCA II are the genes associated with
increased risk. BRCA I and II mutations are more
common in Ashkenazi Jews. They are more prone to
ovarian cancer also. Hence all patients with BRCA I
and BRCA II mutations should consider a
prophylactic bilateral oophorectomy after childbearing is completed, with bilateral mastectomy.
• Cowden’s disease (multiple hamartoma syndrome):
It is associated with reduced tumour suppressor gene
PTEN. 30–50% of patients will develop breast cancer
by 50 years of age. The lesions found in this syndrome
are multiple facial trichilemmoma (pathognomonic),
oral papilloma, bilateral breast cancer, haemangiomas, lipomas, thyroid tumours, etc.
• Ataxia telangiectasia: It is associated with haeman-
gioma and carcinoma breast.
• Li-Fraumeni syndrome is a
rare disease with familial
breast cancer and is associated with inherited
mutation of tumour suppressor P53 gene. It is a rare
autosomal dominant disorder. 90% of carriers will
develop breast cancer by the age of 50. They also can
have other tumours in childhood, such as soft tissue
sarcoma, osteosarcoma, and leukaemia.
Patient which Requires Genetic Evaluation
Diagnosis of DCIS (ductal carcinoma in situ) or invasive
breast cancer + one or more of the following:
• Diagnosed at 50 years and younger
• Triple-negative breast cancer diagnosed at 60 years and
younger
• At any age:
– A known mutation in a cancer susceptibility gene
within the family
– An additional breast cancer primary
– ≥1 close blood relative (first to third degree) with breast
cancer 50 years and younger
– ≥1 close blood relative with ovarian cancer at any age
– ≥2 close blood relatives with breast cancer, pancreatic
cancer, or prostate cancer (Gleason score ≥7 or
metastatic) at any age
• An individual of Ashkenazi Jewish ancestry
• Male breast cancer
Patients without diagnosis of cancer should consider
further genetic risk evaluation, if they have:
• Close relative with a known mutation in a cancer
susceptibility gene; 2 or more breast primaries in a
single individual; 2 or more individuals with breast
cancer on the same side of the family with at least one
diagnosed at age of 50 years or younger; ovarian cancer
• Male breast cancer
• A first- or second-degree relative with cancer at age
of 45 years or younger.
• A family history of 3 or more of the following: Breast
cancer, pancreatic cancer, prostate cancer (Gleason 7
or higher or metastatic), melanoma, sarcoma, adrenal
cortical carcinoma, brain tumours, leukaemia, diffuse
gastric cancer, colon cancer, endometrial cancer,
thyroid cancer, kidney cancer, dermatologic
manifestations, and/or macrocephaly, or hamartomatous polyps of GI tract.
History of Breast Cancer
Risk of developing second breast cancer is about 0.5 to
0.7% in women with previous invasive breast cancers.
Breast cancer is 3 to 4 times more likely to develop in
women with a first degree relative who had breast cancer.
This risk is further increased, if they had premenopausal
and bilateral cancer. Women with ductal carcinoma in
situ (DCIS) are at an increased risk of developing ipsilateral
and contralateral breast cancers (4.1% after 5 years).
Hormonal Factors
The development of breast cancer in many women
appears to be related to female reproductive hormones,
particularly endogenous oestrogens. Early age at
menarche, nulliparity or late age at first full-term
pregnancy, and late age at menopause increase the risk
of developing breast cancer.
Benign Breast Disease
Benign breast lesions are classified as proliferative or
nonproliferative. Nonproliferative disease is not
associated with an increased risk of breast cancer.
Proliferative disease without atypia results in a small
increase in risk, whereas proliferative disease with
atypical hyperplasia is associated with a greater risk of
breast cancer.
B. Modifiable Risk Factors (Table 39.6)
• Breastfeeding, particularly for longer duration,
lowers the risk of breast cancer.
• Postmenopausal hormone replacement therapy
(HRT) particularly when a combination of oestrogen
and progesterone is used.
• Diet: Increased risk has been found in postmeno-
pausal obese women and is due to increased synthesis
of oestrogen (oestradiol) in the body fat. As a result
of aromatisation of androgens in adipose tissue,
circulatory oestrogen levels are increased. Increased
intake of saturated fats and reduced intake of phyto-
1
It means spread of individual cell proliferation in the upper level of dermis
Section II • General Surgery