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Examination of Breast
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Spread of carcinoma breast: To lymph nodes by
lymphatic permeation upto axillary nodes; through
lymphatic embolization from axillary nodes further.
Opposite breast and axillary nodes may be involved
through internal mammary nodes and dermal lymphatics. Spread through blood can occur to bone (lumbar
vertebra, pelvis, and femur), liver, lungs, and brain.
Causes of lymphatic block in carcinoma breast
• Involvement and fixation of the axillary nodes level
I,II and III
• After levels I, II and III dissection
• After radiotherapy to axilla
• Inoperable fixed nodes in axilla
• Recurrent axillary disease
• May be associated with cancer en cuirasse
• Secondary infection
Effects of lymphatic obstruction
• Peau d’ orange
• Brawny oedema of arm – indurated, painful, nonpitting
– occurs in fixed nodes in axilla
• Elephantiasis chirurgens – after radical mastectomy
or radiotherapy to axilla
• Cancer en cuirasse – seen in locally advanced
carcinoma of breast. Skin of chest wall is studded with
hard fixed nodules like armour coat (of soldiers)
• Lymphangiosarcoma after radical mastectomy or MRM
(Stewart-Treve’s)
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Fig. 16.46: Advanced carcinoma left breast involving
entire breast with nodularity.
Clinical features: A palpable lump which is painless
initially , irregular surface, stony hard in consistency ,
fixity to breast tissue - are typical of carcinoma breast.
Nipple retraction, dimpling, puckering of skin, tethering on palpation, skin fixation, ulceration, fungation,
fixity to pectoralis major, latissimus dorsi and serratus
anterior muscle; fixity to chest wall; palpable axillary
nodes which are mobile initially but later gets fixed;
palpable supraclavicular lymph nodes; palpable opposite axillary node; blood spread to bone, lungs, liver
and brain—are different clinical features (Figs 16.46
to 16.48).
Staging of Carcinoma Breast
Manchester Staging:
1. Tumour in the breast, not involving pectoral or
deeper plane. Skin involvement if present, it is
lesser than the size of tumour. Lymph nodes are
not palpable.
2. Same as stage I but with mobile, discrete lymph
nodes palpable in the ipsilateral axilla.
Fig. 16.47: Recurrent carcinoma of breast with
fungation. Note the scar of previous surgery.
Fig. 16.48: Carcinoma right breast with retraction of
nipple and areolar changes.
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SRB’s Clinical Surgery
3. Tumour fixed to pectoral muscle or skin involvement more than the tumour size or ipsilateral
axillary lymph nodes adherent to each other.
4. Tumour fixed to the chest wall, ‘cancer en
cuirasse’, skin involvement wider than that of the
breast or ipsilateral or contralateral side
supraclavicular lymph nodes or opposite breast or
opposite axillary lymph nodes or spread to bone,
lung, liver or inflammatory carcinoma of breast.
TNM Staging (AJCC Cancer staging manual 2002
sixth edition):
Tumour:
T0 No evidence of primary
Tis Carcinoma in situ (DCIS or LCIS)
Tis Paget’ s – Paget’s disease of nipple with no tumour
(with tumour underneath is staged according
to size)
T
Tumour size <2 cm in greatest diameter (T1a-
1
0.1-0.5 cm, T1b-0.5-1.0 cm, T1c-1-2 cm)
T
T
T
Size 2-5 cm.
2
Size >5 cm
3
Tumour fixed to chest wall or skin (T4a-fixed
4
to chest wall, T4b-fixed to skin, T4c-T4a+T4b,
T4d—inflammatory carcinoma breast).
Node:
N
N
N
N
No nodes.
0
Axillary nodes – ipsilateral, mobile, discrete.
1
2 -
Axillary nodes – ipsilateral fixed to one
2 a
another and other structures.
N
Clinically apparent ipsilateral internal
2 b
mammary nodes in the absence of clinically
palpable axillary nodes.
N3 –
N
Spread to ipsilateral infraclavicular lymph
3a
nodes with or without axillary nodes.
N
Spread to ipsilateral internal mammary nodes
3b
and axillary nodes.
N
Spread to ipsilateral supraclavicular lymph
3c
nodes with or without axillary or internal
mammary nodes.
Metastasis:
M
M
No metastasis.
0
Distant metastases.
1
Stage I: T1N0M
Stage IIa:T0N1M0; T1N1M0; T2N0M0.
Stage IIb:T
Stage IIIa:T0N2M0; T1N2M0; T2N2M0; T3N1M0;
Stage IIIb:T4N0M0; T4N1M0; T4N2M
Stage IIIc: Any TN3M
Stage IV: Any T, any N, M
2N1M0
T
3N2M0
0
; T3N0M
0
0
0
Early invasive breast cancer – Stage I, IIa, IIb. Locally
advanced breast cancer – Stage IIIa/b/c. Distant spread
– Stage IV.
The Columbia Classification (Haagsen, Cooley, and
Stout)
Grave signs:
Oedema of skin Stage A—Only tumour.
Skin ulceration Stage B—tumour +
Fixity to chest wall Stage C—tumour +
Axillary lymph nodes Stage D—two or more
>2.5 cm Grave signs
Fixed axillary lymph nodes Supraclavicular lymph
No Grave signs
axillary lymph nodes
< 2.5 cm
any one of five Grave
signs
node involvement
Distant metastasis
Stage A—No skin oedema, ulceration, or fixation to
chest wall. Axillary nodes are not clinically involved.
Stage B—Clinically involved axillary nodes less than
2.5 cm in diameter; Not fixed.
Stage C—Grave signs of comparatively advanced
carcinoma; oedema of skin, skin ulceration, fixation
to chest wall; Massive axillary involvement with nodes
>2.5 cm in diameter; Axillary fixation.
Stage D—Advanced carcinoma including two or more
signs in stage C; in addition satellite nodules; supraclavicular nodes; inflammatory cancer, arm oedema
or distant metastasis.
Locally advanced carcinoma of breast (LACB: It
means locally advanced tumour with muscle/chest wall
involvement, extensive skin involvement or fixed
axillary nodes. It will be T
, T4a, T4b, T4c or T4d or
3
N2 or N3. It is investigated by FNAC of tumour,
mammography of opposite breast, chest CT, CT
Examination of Breast
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abdomen or whole body bone scan. Treatment of LACB
is always palliative by simple mastectomy, chemotherapy and hormone therapy using tamoxifen.
Palliation is to control pain, to prevent fungation or
bleeding. 5 year survival is 40% and 10 year survival
is less than 25%. Inflammatory carcinoma is T4d LACB.
It is also called as mastitis carcinomatosis or lactating
carcinoma of br east. It is 2% common. It is observed
in younger age group usually in pregnancy or lactating
period. There will be extensive skin involvement with
pain. It often mimics mastitis of lactation. FNAC or
incision biopsy concludes diagnosis. It is treated by
initial chemotherapy or radiotherapy; later if tumour
reduces in size then total mastectomy with axillary
clearance can be done. But most often it is inoperable.
After surgery , chemotherapy and tamoxifen is given.
5 year survival for inflammatory carcinoma of breast
is 25-30%.
Metastatic carcinoma of breast: It is blood spread
into different places like bone, lungs and pleura, liver,
soft tissues, brain and adrenals. It is evaluated by
FNAC/incision biopsy , chest CT , LFT , US abdomen,
CT abdomen, whole body bone scanning, CT brain,
tissue study for ER /PR/ HER-2 neu receptor status.
Common sites of distant spread in carcinoma breast
• Bones— 70% —(lumbar vertebrae, pelvic bones, long
bones)
• Lungs and pleura—20-30%
• Soft tissues—5-15%
• Liver—10-12%
• Brain—2-5%
• Adrenals—2-5%
Bone secondaries in carcinoma breast (Fig. 16.49)
• Commonest site of blood spread (70%)
• Common in lumbar vertebrae, femur, pelvis
• Pathological fracture can occur
• Can present with spinal compression and paraplegia
• Radiotherapy, internal fixation, spinal decompression
is required
• Biphosphonates 1600 mg/day is beneficial
Malignant pleural effusion as secondaries from
carcinoma breast (Fig. 16.49)
• It signifies terminal event
• It has got poor prognosis
• HRCT is ideal diagnostic tool.
• Respiratory distress and failure is the main feature
Treated by: Intercostal tube drainage; pleurodesis using
talc/ tetracycline; Chemotherapy
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Fig. 16.49: X-ray showing typical osteolytic bone
secondaries in pelvis in carcinoma breast.
Carcinoma breast in pregnancy
• Incidence is 3%
• Treatment is modified radical mastectomy (MRM)
• Chemotherapy can be given in 2nd trimester with care;
Radiotherapy has no role
• As commonly ER negative, hormone therapy is not
used. When distressing secondaries are present
termination of pregnancy may be required
• Women with breast cancer can become pregnant
2 years after the completion of therapy, as recurrence
is more common within 2 years.
Carcinoma of male breast (Fig. 16.50)
• It is less than 1% of cases of breast cancers. Commonly
associated with BRCA 2 gene mutation
• Gynaecomastia and excess oestrogen are said to be
the aetiological factors
• Commonly it is infiltrating duct carcinoma. Commonly
ER positive (80%)
• Presentation, spread, behaviour are same as
carcinoma of female breast. Investigations and
treatment are same as carcinoma female breast. It
is more aggressive than in females
• Tamoxifen is very useful in carcinoma male breast.
LHRH agonists are next option. Earlier bilateral
orchidectomy was the preferred choice. Now not
commonly done.
Complications after mastectomy with axillary clearance are lymphoedema and eventual lymphangio-
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Fibroadenoma
It is a benign encapsulated tumour occurring commonly
in young females of 15-25 years age group. Presently
it is considered as hyperplasia of a single lobule of
the breast (may be classified under ANDI).
Types: Gross: Soft; Hard; Giant (> 5 cm in size).
Microscopy: Pericanalicular—small and hard-mainly
fibrous; Intracanalicular— large and soft—mainly
cellular.
Clinical features: It presents as a painless swelling
in one of the quadrants, which is smooth, firm, non-
tender , well localised and moves freely within the breast
tissue—‘mouse in the breast’. It is common in lower
quadrant but can occur in any quadrant. Axillary lymph
nodes are not enlarged (Fig. 16.52).
Fig. 16.50: Carcinoma male breast showing mass,
puckering and retraction.
sarcoma (after 3 to many years later) of the limb
(Stewart-Treves syndrome). After chemotherapy
alopecia is seen (Fig. 16.51).
Fig. 16.51: Alopecia after chemotherapy
to carcinoma breast.
Fig. 16.52: Fibroadenoma left breast.
Investigations: Mammography (well localised smooth
regular shadow); FNAC; Ultrasound (to confirm solid
nature).
Points to be remembered:
• Size of giant duodenal ulcer is > 2 cm
• Size of giant gastric ulcer is > 3 cm
• Size of giant fibroadenoma is > 5 cm
• Diameter of transverse colon in toxic megacolon is
> 6 cm
• Giant naevus is > 20 cm
Fibrocystadenosis (Fibrocystic Disease of the
Breast/Mammary Dysplasia)
It is due to Aberration of Normal Development and
Involution (ANDI) of breast causing—Fibrosis; Cyst
formation; Glandular proliferation (Adenosis); Hyperplasia (Epitheliosis); Papillomatosis. It is an oestrogen
dependent condition. One of the cysts may get enlarged
Examination of Breast
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to become a clinically palpable well localized swelling
- bluedome cyst of Bloodgood. Diffuse, small, multiple
cysts in fibrocystadenosis is called as Schimmelbusch’s
disease. Disease is common in upper outer quadrant.
Clinical features: Presentation is during menstruating
age group as a bilateral, painful, diffuse, granular,
tender, swelling which is better felt with palpating
fingers (poorly felt with palm). It is not fixed to skin,
muscle or chest wall. Pain and tenderness are more
during menstruation (Cyclical mastalgia). It subsides
during pregnancy, lactation and after menopause.
Discharge from the nipple when present will be serous
or greenish. Greenish discharge is due to mixture of
serous exudates and ductal epithelial cell debris.
Investigations: FNAC (Epitheliosis, when florid is
undoubtedly premalignant); Ultrasound, mammography.
Aberration of Normal Development and
Involution (ANDI) of the Breast
ANDI includes variety of benign breast disorders
occurring at different periods of reproductive life in
females—early, matured and involution phase of
reproductive age group. It was first coined at Cardiff
Breast Clinic in 1987 by LE Hughes. All conditions
under ANDI should be carefully clinically examined
and often mammography and FNAC/core cut biopsy
should be done to rule out malignancy . ANDI includes
different aberrations and diseases.
In early reproductive age gr oup (15-25 years): Normal
lobule formation may cause aberration as fibroade-
noma. If it is more than 5 cm it is called as giant
fibroadenoma as a diseased status. It is AND of a lobule.
Normal stroma may develop juvenile hypertrophy as
aberration and multiple fibroadenoma as diseased
status.
In mature reproductive age group (25-40 years):
Normal cyclical hormonal effects on glands and stroma
get exaggerated by aberration causing generalised
enlargement. Its diseased status is cyclical mastalgia
with nodularity termed as fibrocystadenosis.
Involution age group (40-55 years): Lobular involution with microcysts, fibrosis, adenosis, apocrine
metaplasia and eventual aberrations as macrocysts and
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cystic disease of breast. Macrocyst is an aberration
of normal involution (ANI). Sclerosing adenosis is
also a type of aberration. Ductal involution may cause
ductal dilatation and nipple discharge as aberration.
Later disease status develops with periductal mastitis,
bacterial infection, nonlactational breast abscess and
mammary duct fistula. Periductal fibrosis may cause
partial nipple retraction. Epithelial changes leads into
epithelial hyperplasia and atypia.
Phylloides Tumour (Cystosarcoma Phylloides/
Serocystic Disease of Brodie)
They are not simply giant fibroadenoma. They show
a wide spectrum of activity, varying from almost a
benign condition to a locally aggressive and sometimes
with a metastatic potentiality to lungs through blood.
Benign phylloides is commonest type which needs
excision; borderline phylloides is intermediate in
nature which needs wide local excision with 1 cm
margin; malignant phylloides is rare but an aggressive
sarcoma spreading through blood commonly to lungs
and needs total mastectomy without axillary nodal
addressing but carries poor prognosis. Depending on
mitotic index and degree of pleomorphism they are
graded as low grade to high grade tumours. Gross:
Large capsulated area with cystic spaces and cut surface
shows soft, brownish, cystic areas. Microscopy: It
contains cystic spaces with leaf-like projections, hence
the name. Cells show hypercellularity and pleomorphism. It may be a variant of intracanalicular
fibroadenoma of breast.
Clinical features: They occur in premenopausal
women (30-50 years). It is usually unilateral, grows
rapidly to attain a large size. Swelling is smooth, non-
tender, soft, fluctuant with necrosis of skin over the
summit due to pressure. Probing can be done easily
between tumour and skin across the necrosed summit
(Figs 16.53 and 16.54). Recurrence is common.
Investigations: US; FNAC; Chest CT.
Traumatic Fat Necrosis
It may be due to either direct or indirect trauma (most
often trauma may not have been noticed or forgotten).
Pathogenesis: Capillary ooze causes triglyceride in
the fat to dissociate into fatty acids. It combines with
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Fig. 16.53: Cystosarcoma phylloides of left breast. Note
the dilated veins. Tumour occupies the entire breast.
SRB’s Clinical Surgery
due to the blockage of lactiferous duct resulting in
enormous dilatation of lactiferous sinus. It contains
milk within. It is a retention cyst due to blockage of
single duct which begins under the areola.
Features: Lump in the lower quadrant of the breast
which is usually unilateral, large, freely mobile, soft,
fluctuant, with smooth surface and nontender. It is
a retention cyst–subareolar type. It may get precipitated, inspissated, or get calcified. When it gets
calcified it mimics carcinoma breast. If it gets infected
it will form an abscess (Fig. 16.55). US and FNAC
are used to diagnose.
Fig. 16.54: Pressure necrosis of the skin over the summit
can occur in cystosarcoma but tumour is not adherent to
the skin. Probing can be done freely between tumour and
under the skin.
calcium from the blood resulting in saponification
which causes inflammatory reaction and later presents
as a nonprogressive swelling in the breast.
Features: Painless swelling in the breast which is
smooth, hard, nontender and adherent to breast
tissue (D/D-Carcinoma). It is nonprogressive. FNAC
shows chalky fluid with fat globules. Mammography
is done to rule out malignancy. It often mimics
carcinoma breast. Excision biopsy confirms the
diagnosis and cures the disease.
Galactocele
It is seen in lactating women (can develop even
6-10 months after caseation of breastfeeding). It is
Fig. 16.55: Galactocele. Note the block at the opening
of the duct.
Mastitis
It is infection and inflammation of breast tissue.
Types: Subareolar; Intramammary; Retromammary
(Submammary).
Subareolar mastitis: It is the infection under the areola
due to cracks in the nipple or areola. Red, inflamed,
edematous areola with tender swelling underneath is
the presentation. Differential diagnosis is Paget’s
disease of the nipple.
Intramammary mastitis: Infection occurs within the
breast tissue.
Examination of Breast
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a. Lactational abscess of the breast— It is commonly
seen in lactating women.
Mode of infection: Bacteria (Staphylococcus aur eus)
enter the breast during sucking through the cracked
nipple. Occasionally it can be of haematogenous origin.
Gram negative and other bacterial infection can
supervene later.
Features: Pain in the breast and fever; diffuse redness,
tenderness, and induration in the breast; purulent
discharge from the nipple; entire breast may get involved eventually . Differential diagnosis is inflammatory
carcinoma of breast (Figs 16.56A and B).
A
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Complications: Antibioma formation; sinus formation;
recurrent infection.
b. Non-lactational abscess of the br east: It commonly
occurs in duct ectasia and periareolar infections.
Common organisms are Bacteroides, anaerobic strep-
tococci, enterococci and gram negative organisms. It
is commonly recurrent with tender swelling under the
areola.
Retromammary mastitis: It is due to tuberculosis
of the intercostal lymph nodes or ribs beneath or
suppuration in the intercostal lymph nodes. It could
be tuberculous disease of these tissues also. Here
breast is normal. Investigations: Chest X-ray , FNAC,
ESR, peripheral smear, CT chest.
Antibioma
If intramammary mastitis is not drained but only treated
by antibiotics, pus localizes and becomes sterile
(flaques) with a thick fibrous tissue cover, which is
called as antibioma.
Features: There is previous history of mastitis treated
with antibiotics. Presents with a painless swelling
which is, smooth, nontender, hard, fixed to breast tissue
without involving the pectorals and chest wall.
Differential diagnosis is carcinoma breast (Scirrhous
carcinoma breast). Investigations are FNAC, mammography and US breast.
Mastitis
Mastitis of infancy (Witches milk) is due to maternal
hormone in infant blood. It usually subsides but may cause
suppuration.
Mastitis of puberty is common in boys, is invariably
unilateral with tender, swollen and inflamed breast.
Mastitis of mumps is usually unilateral and can occur
in both sexes.
Bacterial mastitis is seen in adult women commonly
lactating and is due to staphylococci infection.
Subareolar mastitis is due to infection of gland of
Montgomery or due to areolar furuncle.
B
Figs 16.56A and B: Typical look of breast
abscess/mastitis.
Treatment: Antibiotics; Drainage under general
anaesthesia, a counter incision may be needed; It is
not advisable to wait till the formation of abscess.
Duct Ectasia
It is dilatation of lactiferous ducts due to muscular
relaxation of duct wall with periductal mastitis (plasma
cell mastitis). Many ducts are commonly involved.
It shows greenish discharge from the nipple; indurated
mass under the areola which is often tender; retraction
(slit-like) of nipple occurs at later stage of the disease;
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eventually it forms an abscess, and fistula; often they
are bilateral and multifocal; differential diagnosis is
carcinoma breast. Investigations are—discharge study
and mammography. Treatment is cone excision of
involved major ducts (Hadfield operation) with
antibiotics.
Mondor’s Disease
Mondor’s disease is thrombophlebitis of the superficial
veins of the breast and anterior chest wall; presents
as a thrombosed subcutaneous cord which is attached
to the skin; it is often a self limiting disease without
any recurrence, complication or deformity; it mimics
the lymphatic permeation of carcinoma breast.
Galactorrhoea
It is secretion of milk not related to pregnancy or
lactation (In true galactorrhoea milk should contain
lactose, fat and milk specific proteins).
Primary galactorrhoea is due to stress and other
factors. Reassurance is the treatment.
Secondary galactorrhoea is due to enhanced dopamine
activity by drugs (haloperidol, methyldopa, chlorpromazine, metoclorpramide), hyperprolactinaemia due
to tumours.
Witch milk is secretion of milk in both male and female
infants due to maternal hormonal effects in foetus which
lasts for 3 weeks after child birth.
Duct Papilloma
It is usually single, from a single lactiferous duct. It
is the commonest cause of nipple discharge; causes
ductal dilatation by blocking the duct.
Features: Papilliferous swelling (projection), usually
near the nipple orifice (4-5 cm from orifice); blood
stained discharge from the nipple is common; but
serous or serosanguinous discharge can also occur.
Single papilloma is not premalignant. But multiple
papillomas in many ducts can be premalignant. Study
of discharge and ductogram may be needed (Fig.
16.57).
Gynaecomastia
It is hypertrophy of male breast more than normal, often
attaining features of female breast. Puberty hypertrophy occurs in adolescents; senescent hypertrophy
occurs in adult after 50 years. There is increase in ductal
and/or connective tissue components of breast. It can
be unilateral or bilateral (Figs 16.58A and B).
Presentations: Diffuse enlar gement of breast occurs
occupying all quadrants or as a well localised, small,
firm or hard nodule under the areola which is often
painful and tender.
Causes: Idiopathic; T eratoma testis; Ectopic hormonal
production in bronchial carcinoma; Anorchism, after
castration; Adrenal and pituitary disease; Leprosy,
because of bilateral testicular atrophy; Drugs: Stilboestrol, digitalis, cimetidine, spironolactone; Liver
diseases and liver failure; Klinefelter’s syndrome
(XXY T risomy). Rarely gynaecomastia may turn into
carcinoma.
Mastalgia
It is pain in the breast. Types: Cyclical; Noncyclical
(see Table 16.1).
Fig. 16.57: Papilloma of breast. It is the commonest
cause of bloody discharge from the nipple.
Tuberculosis of the Breast
It is relatively rare; usually associated with active
pulmonary tuberculosis; presents as a swelling in the
breast with cold abscess, sinuses and a typical bluish
appearance of surrounding skin with matted lymph
nodes in the ipsilateral axilla (Fig. 16.59).
Examination of Breast
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A
B
Figs 16.58A and B: Gynaecomastia – right side breast in
a young male. Compare to opposite side to note the difference
in size. Bilateral gynaecomastia in another old man is also
shown.
Differential diagnosis: Carcinoma breast.
Investigations: FNAC; Frozen section biopsy is useful
to differentiate from carcinoma. Excision biopsy is
often needed.
Tietze’s Syndrome
It is costochondritis of 2nd costal cartilage commonly
seen in females, mimics mastalgia.
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Fig. 16.59: Tuberculosis of breast. Mastectomy should not
be done in tuberculosis. Disease often clinically mimic
carcinoma breast.
Congenital Anomalies of Breast
Absence of breast is called as amazia/amastia. It may
be unilateral or bilateral. Absence of breast; absence
of sternal portion of pectoralis major muscle; usually
seen in males—called as Pendred’ s syndr ome. Accessory breasts (Polymazia) and nipple (polythelia,
supernumerary nipples) can develop in axilla, groin
and thigh (along the milk line). It may be unilateral
or bilateral. It is due to failure of the disappearance
of milk line which occurs during developmental period
in normal individual. These accessory breasts may
secrete milk during lactation. Accessory breast tissue
is common in the axilla above the normal breast tissue.
True polythelia is more than one nipple to one breast.
Accessory nipple may be rudimentary and often looks
like a mole. Diffuse hyperplasia; pendulous breasts;
underdeveloped breasts are other anomalies which
cause cosmetic challenge (Figs 16.60 and 16.61).
Cyclical mastalgia Noncyclical mastalgia
• Pain related to menstrual cycle • Pain due to causes other than ANDI like periductal mastitis,
• Seen in ANDI like fibrocystadenosis malignancy, cervical root pain, musculoskeletal pain, previous
• Treatment is like for fibrocystadenosis surgery, Tietze’s syndrome (costochondritis of 2nd costal cartilage,
Table 16.1: Types of mastalgia
commonly seen in females)
• It is unilateral, chronic, burning / dragging pain occurs in pre- and
postmenopausal age group
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Fig. 16.60: Accessory nipple.
Mammary Fistula of Atkins
It is a fistula from lactiferous duct to areolar skin.
Initially recurrent abscess forms underneath the areola
which points on the surface through areola causing
Fig. 16.61: Unilateral diffuse enlargement of breast.
Note the dilated veins on the breast.
discharging fistula. Condition should be differentiated
from carcinoma breast by discharge study , biopsy, and
mammography .
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