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Examination of Breast
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Fig. 16.33: Surgical levels of lymph nodes in the axilla draining from breast. a: Lateral group,
b: Central group, c: Pectoral group, d: Apical group, e: Supraclavicular group.
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Note
• Spread restricted to Level I nodes carries better
prognosis
• Spread to Level II has poor prognosis
• Spread to Level III indicates worst prognosis
Axillary tail of the Spence: It is the extension of the
upper outer quadrant of breast across foramen Langer
deep to deep fascia. Foramen Langer is an opening
in deep fascia over outer aspect of the breast which
allows part of breast tissue to extend under deep fascia,
otherwise rest all breast tissue is in subcutaneous plane.
Axillary tail is located adjacent to outer border of the
pectoralis major muscle. When it is involved by
carcinoma it should be differentiated by pectoral node
enlargement. Axillary tail will move along with main
breast tissue whereas pectoral node will not move when
breast is moved as it has got independent mobility.
Axillary tail often extends over the lateral edge of
the pectoralis major muscle up to axilla (Figs 16.34A
and B).
A
Figs 16.34A and B: Axillary tail of Spence. It is actually part of upper outer quadrant.
B
Tumour in the axillary tail of Spence which is fungating.
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SRB’s Clinical Surgery
Fixed enlarged axillary nodes can cause lymphoedema due to lymphatic block; venous thrombosis
and venous oedema due to venous block; and severe
excruciating pain along the distribution of the median
and ulnar nerves (rare in radial nerve) with often
significant sensory and motor deficits due to tumour
infiltration of the cords of brachial plexus (usually
medial cord occasionally lateral cord).
Examination of arms for venous oedema or
lymphoedema: V enous oedema may be due to axillary
vein compression by nodal mass. Lymphoedema may
be due to lymphatic block following nodal involvement. Lymphoedema is mainly distal. It is gradual in
onset and progressive. Venous oedema is sudden in
onset, with bluish discolouration over the skin, uniform
in both distal and proximal aspect of the upper limb
(forearm and arm).
Examination for mediastinal node involvement: It
is done by percussion. Initially percus for liver dullness.
Percussion is done one space above from lateral to
medial, to look for widened mediastinal border . Mediastinal nodes are common in middle mediastinum.
Examination of respiratory system: It is done for
secondaries—altered breath sounds, features of
consolidation or pleural effusion are looked for (Fig.
16.35).
Fig. 16.36: Always examine abdomen for liver enlargement,
ascites or Krukenberg tumour (in premenopausal age).
Examination of abdomen: To look for palpable
nodular liver, Krukenberg tumours in ovaries in
menstruating age group, and ascites. It is completed
with digital examination of rectum (P/R), and per
vaginal examination (Fig. 16.36).
Examination of pelvis, spine, long bones for any
swelling/tenderness/pathological fracture/restricted
movements of spine, hips, etc.
Examination of central nervous system to look for
any neurological deficits following metastatic disease
in the brain.
Fig. 16.35: Look for pleural effusion and altered
breath sounds for secondaries in lungs.
Breast self examination (BSE) has got a major role
in early detection of the carcinoma breast.
Ideally done once a month, just after the menstruation,
as during this time breasts are less engorged. In
postmenopausal age group it is done regularly at monthly
intervals (fixed day of the month).
• Examine both breasts
• American cancer society recommends monthly BSE
after 20 years of age
• Remind the patient that 90% of breast lumps are not
cancer
• Better way is in lying down position with arm raised
with a mattress support behind (Fig. 16.37)
• Palpation is done over all quadrants of the breast using
the fingers
• If any doubtful swelling is palpable, consult the surgeon
• Nursing mother should perform BSE just after feeding
the baby.
Assessment of nipple deviation: Nipple changes are
assessed by inspection, palpation and measurement.
Displacement of nipple is assessed by measuring
Examination of Breast
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Fig. 16.37: Self-examination of breast is
done in lying down position.
distance between mid-clavicular point to the nipple.
This reveals any upward/downward displacement of
nipple. Outward/inward displacement is assessed by
measuring the distance of nipple from midline.
383
A
Cystic swellings of the breast
• Bloodgood cyst
• Breast abscess
• Hydatid cyst
• Galactocele
• Serocystic disease of Brodie
• Cystic necrosis in carcinoma breast
• Lymph cyst
• Haematoma in breast.
Causes of massive enlargement of breast
• Benign hypertrophy usually bilateral
• Giant fibroadenoma (> 5 cm)
• Serocystic disease of Brodie
• Sarcoma
• Carcinoma often when extensively involved
• Filariasis of breast.
Causes of hard swellings in the breast
• Carcinoma breast
• Antibioma breast
• Traumatic fat necrosis
• Calcified haematoma
• Fibroadenoma—hard variety.
Investigations in Carcinoma Breast/
Breast Lump
Mammography
It is plain X-ray of soft tissue of breast using low voltage
and high amperage X-rays (300 MV and 40 KV). T wo
B
Fig. 16.38: Mediolateral and craniocaudal mammographic
pictures showing microcalcification, spiculations and irregularity.
films are taken—Craniocaudal from above downward;
mediolateral from side-to-side. Dose of radiation is
0.1 cGy, a low dose. So it is a safe and effective
procedure (Figs 16.38A and B).
Findings
• Microcalcifications/branching calcification signify
malignancy
• Soft tissue shadow may be smooth and regular in
benign conditions or irregular in carcinomas
• Size and location of mass lesion is assessed with nipple
and skin change (thickness)
• Spiculations; mammary duct distortion; loss of
symmetry; clustering; architectural distortion suggests
carcinoma.
Breast Imaging Reporting and Data System (BI-RADS)
has got its own categories (0-5), assessment and
recommendations. Digital mammography is computerised electronic image of the breast with enhanced
magnified pictures. Digital spot-view mammography
allows faster and more accurate stereotactic biopsy.
Indications for mammography: For screening purpose
it is done after 40 years. Early screening is indicated
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when there is family H/o carcinoma breast or
histological risk factor. Mammography before 25 years
of age is usually not done unless there is a lump or
a strong family history or suspicious lump; in obese
patients; to find out spread or de novo tumour in the
opposite breast; mastalgias; mammography guided
biopsy can be done; evaluation and follow up in benign
breast disease with malignant potential; follow up
mammography after conservative breast surgery.
Grading of lesions in mammography: Grade I:
Negative; Grade II: Benign lesion; Grade III: Probably
benign lesion: Grade IV: Suspicious of malignancy;
Grade V : Highly suggestive of carcinoma; Grade VI:
Known carcinoma.
Digital mammography is better to analyse and store
the pictures.
Xeromammography is same as above, but here a
photoconductor is used to produce a final image on
a Selenium paper (on aluminium plate) rather than
on X-ray film. Such charged plate is placed behind
the breast and X-ray exposure is done. Selenium
positive charges are released, which depends on
X-ray traversing the plate and the tissue. Electrostatic
image of the breast produced is made blue by spraying
negatively charged blue toner on the plate which
attracts image of positive charges. This blue image
of breast in a special coated plastic paper is fused
permanently using heat. Advantages: Edge enhancement effect, therefore useful in dense breasts.
Disadvantage: Exposure to high radiation dose and
selenium plate is needed. Mammography of excised
specimen may be useful in identifying the exact site
of small lesion for histological assessment.
Contrast mammography often can be done by injecting
water soluble iodine dye into the major lactiferous
duct. Duct papilloma may show smooth filling defect;
duct carcinoma shows irregular filling defect.
The condition when lump is clinically not palpable
but mammogram shows identifiable carcinoma is ideal
for breast conservative surgery like quadrantectomy/
QUART therapy.
Ultrasound of Breast
It is done to look for lesion whether solid or cystic,
margin of the lesion, internal echoes, retrotumour
acoustic shadowing, compressibility, dimensions.
SRB’s Clinical Surgery
Irregular mar gin, irregular internal echoes, irr egular
posterior shadowing, non-compressibility, ratio
between anteroposterior to width (lateral/horizontal)
dimensions more than 1 ar e the features of carcinoma.
Doppler will show high frequency signals with
continuous flow . Benign lesions are smooth, rounded
with well defined margins with weak internal echoes
and compressibility . Disadvantage is lesions less than
1 cm may not be identified. FNAC can be done under
US guidance. It is cheaper, easily available and there
is no risk of radiation. It is preferred method of
screening in pregnancy and early lactation (Fig. 16.39).
Fig. 16.39: US left breast showing fibroadenoma.
FNAC (Fine-Needle Aspiration Cytology)
FNAC is very useful in diagnosing the carcinoma
breast. FNAC is also done under US guidance. But
negative results are difficult to interpret because it
may be due to sampling errors and so requires further
diagnostic methods. FNAC of opposite breast, lymph
nodes, opposite axillary lymph nodes are also often
required. It is done with 23 gauge needle using FNAC
aspiration special syringe. With the lump held firmly ,
the needle is passed into the lump and with negative
pressure continuous aspiration is done until adequate
material comes through the needle. Needle with syringe
is removed without negative pressure. Material is
collected on a slide; a smear is made using 100%
alcohol. Cytology is studied after staining it under
microscopy. After FNAC, cystic swelling often
disappears completely . Excision may be indicated, if
it recurs rapidly after two aspirations, and if FNAC
is inconclusive (Fig. 16.40).
Examination of Breast
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Fig. 16.40: FNAC of breast lump.
Advantages of FNAC: FNAC is least painful, can be
done on OP basis, reliable and cheaper. Malignant
deposits will not occur along FNAC track (only
contraindication for FNAC is testicular tumour).
FNNAC is Fine Needle Non-Aspirating Cytology.
FNAC scoring: C0 – no epithelial cells; C1 – scanty
epithelial cells; C2 – benign cells; C3 – atypical cells;
C4 – suspicious cells; C5 – malignant cells.
Reliability of FNAC and mammography
Sensitivity (true positivity) FNAC Mammography
Specificity (without false 90-98% 90%
positive) 98-100% 90%
False negative 2-10% 10%
False positive Near 1-5% 10%
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Frozen Section Biopsy
If FNAC fails even after two trials or in cases of
negative FNAC, then on table frozen section biopsy
is done for diagnosis. It has got 20% false negative
results. It is often difficult to differentiate between
severe atypia and carcinoma by frozen section and
so its validity and use is under debate. In such situation
excision biopsy is better . While doing excision biopsy
incision is placed in such a way that it can be included
in eventual mastectomy. Trucut/core biopsy is also
used nowadays in many centres.
Chest X-ray: T o look for pleural effusion, cannon ball
secondaries in lungs, mediastinal lymph nodes,
secondaries in rib. CT chest is mor e r eliable method
to see lung secondaries.
Ultrasound abdomen: T o look for liver secondaries,
ascites, and ‘Krukenberg’ tumour.
X-ray spine or MRI spine/pelvis shows osteolytic
secondaries in the bone like vertebra and pelvic bones.
Radioisotope bone scan is done to look for secondaries
in bone in advanced cases. It is not done routinely
Fig. 16.41: Radioisotope bone scan is done to see
bone metastasis.
in early carcinoma of breast. Healed fractures; Paget’s
bone disease, osteoarthritis may show hot spots –
accounting for false positive pictures. Bone biopsy
in suspected area may be confirmative even though
it is not advocated commonly (Fig. 16.41).
Indications for whole body bone scan in carcinoma
breast
, T4 advanced disease
•T
3
• Advanced nodal disease
• Bone pain, bone swelling, pathological fracture
• Chest/liver secondaries
Oestrogen Receptor Study
They are oestrogen sensitive receptors, which are
cytosolic glycoprotein present in the breast and tumour
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tissue. It is an important indicator of prognosis of
carcinoma breast. Tissue for receptor study is sent
in low temperature in ice flasks. It is assessed by
quantitative analysis (Frozen –70°). If value is more
than 10 units (Femtomoles) per ng gram tissue it is
called as ER +ve status. If value is 5-9 it is borderline
and if it is less than 5 femtomoles per nanogram tissue
it is called as ER –ve status. In ER +ve status—
Prognosis is good; Hormone therapy including
Tamoxifen is very beneficial; Response to treatment
is better. In ER –ve status—Prognosis is poor;
Hormone therapy is not very beneficial (but used) as
compared to ER +ve patients; Response to treatment
is not good. ER positivity is common in postmenopausal women (60%) compared to premenopausal
women (30%). Progesterone r eceptor (P R staus) study
and Her 2 Neu receptor status are other studies done
at present to plan the therapy and assess the prognosis.
Study of Discharge from the Nipple
Nipple discharge is usually unilateral in carcinoma
breast. Ductal lavage may be useful in some patients.
Microcatheter of 1 cm length is introduced gently into
the ductal opening. 10 ml saline is infused through
the catheter. Fluid is withdrawn into the syringe and
cytological analysis is done.
MRI of Breast and MRI of Spine
(in case of suspected spine secondaries)
It is done—to differentiate scar from recurrence; to
image breasts of women with implants; to evaluate
the axilla and recurrent disease. Both precontrast and
postcontrast MRI are done. T
and T2-weighed images
1
are taken. Irregular mass with spiculations, changes
in skin and nipple, lymphoedema are the findings in
carcinoma breast (Fig. 16.42).
Edge Biopsy
Edge biopsy is done only when there is skin involvement—ulceration and fungation. Diathermy should
be avoided in incision biopsy as it may distort the
histology of tumour and study of hormone receptor
status may not be possible.
Tumour Markers
They are used mainly during follow up period.
CA 15/3 is commonly done when needed.
Fig. 16.42: MRI spine showing secondaries primary
Sentinel Lymph Node Biopsy (SLNB)
being carcinoma breast.
The first axillary (SLN) node draining the breast (by
direct drainage) is designated as the sentinel node.
SLN is first node involved by tumour cells and presence
or absence of its histological involvement, when
assessed will give a predictive idea about the further
spread of tumour to other nodes. Involvement of other
nodes without SLN is less than 3% and so if SLNB
is negative nodal dissection can be avoided but regular
follow up is needed. SLNB is done in all cases of
early breast cancers, T1 and T2 without clinically
palpable node. It is not done in clinically palpable
axillary node as there is already distortion of lymphatic
flow due to tumour. It is also not done in multifocal
and multicentric tumours, as there is involvement of
many lymphatic trunks from different quadrants of
breast, chances of false negative is high. Sentinel node
is localised by preoperative (within 12 hours) or peroperative injection of patent blue (Isosulfan vital blue
dye) or
99m
TC radioisotope labeled colloid albumin
near the tumour (peritumour area). Marker will pass
through the sentinel node which can be detected
Examination of Breast
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Fig. 16.43: Sentinel Lymph Node Biopsy (SLNB) of breast.
Note: Spread by skipping the sentinel node is less than
3%.
visually as blue staining or with a hand held gamma
camera; and is biopsied with a small incision directly
over it. If there is no involvement of sentinel node
by tumour then further axillary dissection is not
required as skip lesions (skipping sentinel node) occur
only in less than 3% cases. Note: Facility for SLNB
is not available in many centres (Fig. 16.43).
SLNB is done in—
• Carcinoma breast
• Carcinoma penis
• Malignant melanoma.
Axillary sampling is often done with an adequate
axillary incision. 10-15 nodes are removed for
sampling. It is not commonly practiced now (Minimum
10 nodes should be removed—level I nodes).
CT scan of chest, abdomen and brain whenever
needed. CT is said to be more useful to detect
secondaries in these regions.
Triple assessment—It includes (1) Clinical
assessment; (2) Radiological imaging (US in young,
mammography in adult; (3) Cytological (FNAC) or
histological analysis (core biopsy).
Ductography
It is contrast study of ducts of breast in case of unilateral
nipple discharge. Fine cannula is passed under vision
carefully through the duct opening into the duct and
0.2 ml of dilute water-soluble contrast media is injected
387
into the duct. Craniocaudal and mediolateral X-ray
films are taken. Contrast irregular filling defect may
be observed.
Thermography is not very sensitive test (50%).
Malignant tumours are hypervascular and so
transmitted temperature is detected through different
thermographic methods. It is the pictorial representation of infrared emission of breast.
Biochemical analysis: Increased serum alkaline
phosphatase, γ glutamyl transaminase suggests liver
secondaries. Raise in urinary hydroxyproline means
collagen breakdown suggesting secondaries. A low
value of urinary aetiocholanolone, a metabolite of
adrenal dehydroepiandrosterone in relation to total
17 hydroxycorticosteroids (in urine) is specific of
breast carcinoma suggesting poor prognosis and poor
response to adrenalectomy and hypophysectomy (Poor
discriminants).
Newer modalities of investigations: Stereotactic core
biopsy using computer mammography; vacuum
assisted biopsy using 11 gauge biopsy probe; needle
localised biopsy under mammographic guidance; I
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localisation biopsy.
Differential Diagnosis
Carcinoma Breast
How carcinoma breast is suspected?
Any lump in the breast can be malignant unless proved
otherwise. But one has to remember that every breast
lump need not be always malignant. Short duration,
rapid progression, nodal status, hard consistency, with
often irregular surface and late features like fixity to
chest wall, ulceration/fungation and distant spread are
the features to consider for carcinoma breast. Painless
lump with irregular surface and stony har d consistency
are typical features of carcinoma breast.
One has to remember that differential diagnosis
for carcinoma breast is same as all conditions which
are benign diseases of the breast (Table 16.1).
Table 16.1: Differential diagnosis for carcinoma
• Fibroadenosis • Mastitis
• Traumatic fat necrosis • Antibioma
• Tuberculosis of breast • Galactocele
• Bloodgood cyst • Mondor’s disease
• Filariasis breast • Cystosarcoma phylloides
breast/benign diseases of breast
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SRB’s Clinical Surgery
Aetiology: Carcinoma breast is more common in
developed western countries. In African-American
women, it is more aggressive. It is less common in
Japan. It is second most common carcinoma in females.
Incidence is 19-34%. Median age is 47 years. It is
more common after middle age, but do can occur at
any age group after 20. It is familial in 2-5% cases.
Carcinoma in one breast increases the risk of
developing carcinoma on opposite breast by 3-4 times.
Incidence of bilateral carcinoma is 2 %. Diet low with
phytoestrogens and high alcohol intake may predispose
carcinoma. It is common in nulliparous women. Early
child bearing and breastfeeding reduces the incidence
of malignancy. Breast carcinoma is directly related
to oestrogen level increase. Early menarche and late
menopause has got higher risk probably due to
increased oestrogen level. It is more common in obese
patient. Breast cancer relative risk is qualified as
Relative Risk (RR). RR 2.0 means risk is twice the
normal population. If RR is 0.5 means risk is 50%
less than normal population. In males, occasionally
gynaecomastia turns into carcinoma. Benign breast
diseases with atypia, hyperplasia and epitheliosis have
got higher risk in a patient with family history of
carcinoma breast; mutation of tumour suppressor genes
BRCA 1 and BRCA 2 has also shown high risk of
carcinoma breast. BRCA 1 has got more risk (35-45%).
It is located in long arm of chromosome 17. It is also
associated with ovarian carcinoma. It is poorly differentiated, ductal invasive, hormone receptor negative
type carcinoma BRCA2 is located in long arm of
chromosome 13. It is well-differentiated, invasive,
positive hormone receptor type carcinoma. It is also
associated with carcinoma male breast. Occasionally
mutation of BRCA3 and p53 suppressor gene is also
involved. Cowden’s syndrome and Li-Fraumen’s
syndrome are associated with carcinoma breast.
Presently carcinoma breast is considered as systemic
disease. Her 2 neu mutation (transmembrane growth
factor) is seen in 80% invasive ductal carcinoma;
carries poor prognosis. Halsted concept of spread is
sequential spread. Breast—axillary lymph node—
systemic spread. Fischer concept is early to begin with
itself, there is possibility of distant blood spread
because of micro metastasis without nodal disease.
Only tumour lesser than 1 cm size can be sequential.
Spectrum concept is new one where disease spreads
locoregionally as well as systemically which makes
it to have both locoregional as well as systemic disease
control. Prior diagnosis of uterine/ovarian/colonic
cancers increases the risk of breast cancer. Endocrine
cause is considered as ‘Koreman’s hypothesis’. It
means, anovulatory cycle which is more common in
early menarche and late menopause with unopposed
estrogen without progesterone; hyperprolactinaemia
due to late child birth (which is inhibited in early child
birth); oral contraceptives; absent breastfeeding;
hormone replacement therapy; all predisposes carcinoma breast. Carcinoma breast shows geographical
variation with very less incidence in Japan.
Incidences in carcinoma breast
• 30% of all female cancers
• 20% of cancer related deaths in females
• 2-4% bilateral
• 2-5% hereditary
• Familial breast cancer – 25%
• Sporadic breast cancer 70%
• Lump in the breast-commonest presentation (75%)
• 10% presents with pain
• 35-45% with mutation of BRCA1 gene
• 70% blood spread occurs to bones
Classification of Carcinoma Breast
Classifications
I. Ductal carcinoma – 90%.
Lobular carcinoma – 10%
II. a. In situ carcinoma – no invasion through
baesement membrane.
• DCIS (Ductal carcinoma in situ) – 5-20% papilary, cribriform, solid, comedo types.
• LCIS (Lobular carcinoma in situ)– 2%.
Li-Fraumen syndrome Cowden’s syndrome Ataxia telangiectasia
• P53 gene mutation • Autosomal dominant • Haemangioma
• Autosomal dominant • Multiple hamartoma syndrome • Breast cancer
• Breast cancer • Facial trichilemmoma
• Osetosarcoma, leukaemia, • Papilloma, GI polyps,
soft tissue sarcoma, adreno- thyroid tumours
cortical tumours • Breast cancer
Examination of Breast
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Van Nuy‘s prognostic index for DCIS
Score 1 2 3
Size in mm < 15 mm 15-40 mm > 40 mm
Clearance in mm > 10 mm 1-10 mm < 1 mm
Grade and necrosis Not high grade Not high grade High grade
No necrosis Necrosis present Necrosis present
Total score is 9
Score 3-4 Conservative breast surgery (wide local excision)
Score 5-7 Conservative surgery + Radiotherapy
Score 8-9 Total mastectomy
Nottingham Prognostic Index (NPI) – (0.2 × Tumour size in cm) + Lymph node stage
+ Tumour grade
For nodes—1 – nodes; 2 is 1 to 3 nodes; 3 is 4 or more nodes
For grading 1,2,3
NPI score < 3.4 Good prognosis with 80% survival (15 years)
NPI score 3.4-5.4 Moderate prognosis with 40% survival
NPI score > 5.4 Poor prognosis with 15% survival
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b. Invasive—invasion through basement
membrane—80%.
• Invasive ductal carcinoma—70%.
• Invasive lobular carcinoma. It is commonly
multifocal and often bilateral. It is 10-15%.
III. Unilateral.
Bilateral: 2-5% common.
IV. Unifocal.
Multifocal.
Multifocal—tumour tissues within the same quadrant.
Multicentric—tumour tissues within the breast but in
different quadrant.
Duct carcinoma in situ (DCIS): It is intraductal
carcinoma without any invasion into the basement
membrane. It is 5-20% common. It can be—Solid;
Comedo with necrosis is high grade with increased
chances of microinvasion; Cribriform; Papillary,
Micropapillary. It is associated with high expression
of C – erb2 gene (80%). Nipple discharge and oftensmall swelling are main presentations. US assisted
FNAC and mammography are the needed investigations.
Risk of lymph node spread in DCIS is less than
4%. So axillary dissection is not necessary.
Sentinel Lymph Node Biopsy and later required
surgical procedure is the preferred method (if facility
is available).
Pathological Types
Scirrhous carcinoma: It is 60% common. It is hard,
whitish, or whitish yellow, noncapsulated, irregular,
with gritty, cartilaginous consistency. It contains
malignant cells with fibrous stroma.
Medullary carcinoma: It is also called as ‘encephaloid
type’ because of its brain-like consistency. It contains
malignant cells with dispersed lymphocytes. It is
4-10% common; occurs in younger age group;
associated with BRCA 1 hereditary cancers; it is soft
and often haemorrhagic; it carries better prognosis
than scirrhous type.
Inflammatory carcinoma/lactating carcinoma/
Mastitis carcinomatosis: It is 2% common; it is
common in lactating women or pregnancy; it mimics
acute mastitis because of its short duration, pain,
warmth and tenderness. Clinically, it is rapidly
progressive tumour of short duration, often involving
whole of breast tissue with occurrence of Peau`d
orange, often extending to the skin of chest wall also.
It rapidly metastasizes to chest wall, bone and lungs.
It is always stage IV carcinoma. FNAC confirms the
diagnosis—It contains undifferentiated cells. It mimics
acute mastitis but total count is normal in inflammatory
carcinoma of breast.
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Differences between Paget’s disease and eczema of nipple
Paget’s Disease (Jame‘s Paget-1874) Eczema
1 Unilateral Bilateral
2 Edges are distinct Edges are indistinct
3 Itching absent Itching present
4 Seen in menopausal women / elderly Occurs during the time of lactation
5 Vesicles absent Vesicles present
6 Nipple is usually destroyed Nipple is usually intact
7 Underlying lump is usually present No underlying lump
SRB’s Clinical Surgery
Colloid carcinoma (2%): It produces abundant mucin;
common in elderly; presents as bulky tumour; positive
for oestrogen receptors.
Paget’s disease of the nipple: It is superficial
manifestation of an intraductal carcinoma. The
malignancy spreads within the duct up to the skin of
the nipple and down into the substance of the breast.
It mimics eczema of nipple and areola. In Paget’s
disease, there will be a hard nodule just underneath
the areola, which later ulcerates and also causes
destruction of nipple. Histologically it contains large,
ovoid, clear Paget’ s cells with malignant features (Figs
16.44 and 16.45).
Tubular (2%), Papillar y (2%), Cribriform are the other
types of duct carcinomas. Papillary carcinoma occurs
Fig. 16.44: Paget’s disease of the breast.
Fig. 16.45: Subareolar carcinoma with destruction of
nipple-areolar complex.
in late age group – 7th decade; small tumour of less
than 3 cm; carries good prognosis. Tubular also carries
very good prognosis.
Atrophic scirrhous carcinoma: It is seen in elderly
females. It is a slow growing tumour which has got
better prognosis.
Lobular carcinoma in situ: It is predominantly premenopausal; need not be detected by mammography;
it is an incidental pathological entity; multifocal and
bilateral; clinically, it does not form a lump; does
predispose to invasive cancer; 50% cancers can
develop in the contralateral breast; immunohistochemistry using cadherin antibody shows positive
reaction; it carries poor prognosis.
Disease of Reclus: It is rare intracystic papilliferous
carcinoma of breast presenting as a cystic swelling
with bloody discharge from the nipple.
Presently invasive breast cancer is classified as
ductal and lobular. 70% are invasive breast cancers.
It can be infiltrating ductal carcinoma not otherwise
specified (NOS); tubular (2%); colloid (2%); medullary (basal like, triple negative means ER/PR/Her
2 neu negative, aggressive, 5%).
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