EQB – BREAST

Q1) Enlist various types of nipple discharge. Describe condition causing greenish nipple
discharge. Illustrate various investigations modalities. Analyze role of treatment of duct
ectasia.

le discharge
The condition causing greenish nipple discharge is duct ectasia.
- It is dilatation of lactiferous ducts due to muscular relaxation (myoepithelial relaxation) of
duct wall with periductal mastitis.
- It is also called ‘plasma cell mastitis’ as periductal inflammation contains plasma cells.
- Hormonally induced myoepithelial relaxation with poor ductal absorption of secretions and
desquamated cells causing obstruction are the probable other causes and features.

Clinical Features:
- Greenish discharge or creamy/paste like from the nipple.
- Indurated mass under the areola which is often tender.
- Retraction of nipple which occurs at later stage of the disease. Slit like retraction of nipple
due to fibrosis occurs.
- Eventually it forms an abscess and fistula.
- Often they are bilateral and multifocal.
- More common in smokers—in relation to arterial pathology.
- Common in multiple pregnancies, perimenopausal age, hyperprolactin status.
- May present as mastalgia.
- Axillary nodes may be palpable as non-specific.
- Secondary bacterial infection (anaerobic) is common.

Investigations:
- Discharge study,
- FNAC.
- Mammography.

Treatment:
- It is important to stop smoking.
- Cone excision of involved major ducts (Adair-
Hadfield operation).
- Antibiotics.
- Melhem Novel modified breast ductal system excision.
Q2) Enlist conditions under acute and sub-acute inflammations of breast. Describe
clinical features of acute mastitis. Illustrate various non operative techniques of
management. Analyze role of surgery in acute mastitis due to various causes.

Acute and Sub-acute inflammations of the breast are:

- Mastitis
- Breast abscess
- Tuberculosis of Breast
- Actinomycosis
- Mondor’s Disease

Types of Mastitis:
1. Subareolar.
2. Intramammary (chronic).
3. Retromammary (submammary).

Clinical features:
- Red, inflamed, edematous areola with a tender swelling
underneath.
- Nipple retraction may develop.
- Continuous throbbing pain in the breast and high grade fever.
- Diffuse redness, tenderness, warmness and brawny induration in the breast.
- Purulent discharge from the nipple.
- Entire breast may get involved eventually.
- Occasionally tender fluctuant swelling (10%) may be felt; ulceration and discharge can occur
at a later period. Tender axillary lymph nodes may be palpable.
- It is difficult to differentiate initial stage of mastitis (stage of cellulitis) from stage of breast
abscess formation. When it is treated with antibiotics without incision and drainage eventually
it may get organised to form a nontender, hard breast lump with sterile pus inside—stage of
antibioma formation.

Non-operative Management of Mastitis:

- During the cellulitic stage, the patient should be treated with an appropriate antibiotic, such
as flucloxacillin or amoxiclav or cephalosporins.
- Feeding from the affected side may continue if the patient can manage.
- Support of the breast, local heat and analgesia will help to relieve pain.
- If an antibiotic is used in the presence of undrained pus, an ‘antibioma’ may form.
- This is a large, sterile, brawny oedematous swelling that takes many weeks to resolve.
It used to be recommended that the breast should be incised and drained if the infection did
not resolve within 48 hours or if after being emptied of milk there was an area of tense
induration or other evidence of an underlying abscess.
- This advice has been replaced with the recommendation that repeated aspirations under
antibiotic cover (if necessary using ultrasound for localisation) be performed. This often
allows resolution without the need for an incision and will also allow the patient to continue
breast-feeding.
- The presence of pus can be confirmed with needle aspiration, and the pus should be sent for
bacteriological culture. In contrast to the majority of localised infections, fluctuation is a late
sign.
- Usually, the area of induration is sector shaped and, in early cases, about one-quarter of the
breast is involved; in many late cases the area is more extensive. When in doubt, an ultrasound
scan may clearly define an area suitable for drainage.
- Repeated US guided aspirations (using 18 gauge needle with saline lavage) can be tried
which avoids surgery and scar—ideal and standard now.

Operative drainage of a breast abscess:

- This is less commonly needed as prompt commencement of antibiotics and repeated
aspiration is usually successful.
- Incision of a lactational abscess is necessary if there is marked skin thinning and can usually
be performed under local anaesthesia if an analgesic cream such as EMLA (lidocaine) is
applied 30 minutes before surgery.
- The usual incision is sited in a radial direction over the affected segment, although if a
circumareolar incision will allow adequate access to the affected area this is preferred
because it gives a better cosmetic result. The incision passes through the skin and the
superficial fascia. A long artery forceps is then inserted into the abscess cavity. Every part of
the abscess is palpated against the point of the artery forceps and its jaws are opened. All
loculi that can be felt are entered. Finally, the artery forceps having been withdrawn, a finger
is introduced and any remaining septa are disrupted. The wound may then be lightly packed
with ribbon gauze or a drain inserted to allow dependent drainage.
- Drainage under general anaesthesia, a counter incision may be needed. It is not advisable to
wait till the formation of abscess. Often takes very long time to heal after surgery causing
distress to patient and surgeon as well.
Q3) Enlist conditions included in ANDI. Describe etiology and pathology of ANDI.
Illustrate clinical features of ANDI. Analyze the role of treatment in breast pain.

- ANDI includes variety of benign breast disorders occurring at different periods of

reproductive periods in females—early, matured and involution phase of reproductive age
group.
- It is based on change in normal three phases of physiology of breast—(1) Lobular
development; (2) Cyclical hormonal modifications; (3) Involution.
- In early reproductive age group (15–25 years):
* Normal lobule formation may cause aberration as fibroadenoma. If it is more than 5
cm it is called as giant fibroadenoma as a diseasedstatus. 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 also called as fibrocystadenosis.
- Involution age group (40–55 years):
* Lobular involution with microcysts, fibrosis, adenosis, apocrine metaplasia and
eventual aberrations as macrocysts and 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, non-
lactational breast abscess and mammary duct fistula. Periductal fibrosis may cause
partial nipple retraction.
* Epithelial changes leads into epithelial hyperplasia and atypia.

Types of Mastalgia:
- Cyclical—65%.
- Noncyclical—30%.
- Chest wall pain—5%.

Causes of Cyclic Mastalgia:

- Pain related to menstrual cycles.
- Usually seen in ANDI like fibrocystadenosis.
- Present in women of menstruating age group.
- Pain is more during menstruation.
- It is bilateral, diffuse with “heavy feeling”.

Treatment of Cyclic Mastalgia:

- Evening primrose oil 325 mg BD.
- Gamolenic acid 120 mg BD.
- Danazol (100–200 mg BD)—antigonadotrophin agent.
- Bromocriptine (2.5 mg BD)—prolactin inhibitor.
- Tamoxifen (20 mg daily).
- GnRH analogue 3.6 mg injection depot-monthly.
- Testosterone undecanoate 40 mg BD.
- Vitamin B6, B12.
- Analgesics.

Causes of Non-cyclical Mastalgia:

- Other causes of breast pain are periductal mastitis, malignancy cervical root pain,
musculoskeletal pain, previous surgery, Tietze’s syndrome, idiopathic, Mondor’s syndrome.
- It is unilateral, chronic, burning or dragging in nature, occurs both in pre- and
postmenopausal age group.
- 5% of breast cancers present as pain during first presentation.

Treatment of Non-cyclic Mastalgia:

- Cause has to be identified.
- Malignancy has to be ruled out.
- Avoid coffee and stress.
- Proper support to breasts.
Q4) Enumerate the benign breast disorders classification. Describe clinical presentation of
phylloides tumour. Illustrate treatment options for various benign breast conditions. Analyze
the situation when the diagnosis of carcinoma is in doubt.

Benign breast disorder classification:

- Congenital disorders
1. Inverted nipple
2. Supernumerary breasts/nipples
3. Non-breast disorders including Tietze’s disease (costochondritis)
4. Sebaceous cysts and other skin conditions
- Inflammation/infection
1. ANDI (aberations of normal differentiation and involution):
2. Cyclical nodularity and mastalgia
3. Cysts
4. Fibroadenoma
5. Duct ectasia/periductal mastitis
- Pregnancy-related:
1. Galactocele
2. Lactational abscess

Phylloides tumour
- They are not simply giant fibroadenoma.
- They show a wide spectrum of activity, varying from almost a benign condition.
- Depending on mitotic index and degree of pleomorphism they are graded as low grade to
high grade tumours.
- Phylloides tumour is the most commonly occurring nonepithelial neoplasm of the breast,
although it represents only about 1% of tumors in the breast. It can also often be
fibroepithelial.

Histology of Phylloides tumour:

- 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 (Phylloides
—Greek—leaf-like). Cells show hypercellularity and pleomorphism. It may be a variant of
intra-canalicular fibroadenoma of breast (Giant type).

Clinical Features
- They occur in premenopausal women (30–50 years).
- It is usually unilateral, grows rapidly to attain a large size with bosselated surface.
- Swelling is smooth, non-tender, soft, fluctuant with necrosis of skin over the summit due to
pressure.
- Skin over the breast is stretched, red and with dilated veins over it. Tumour is warmer, not
fixed to skin or deeper muscles or chest wall. Nipple retraction is absent. Lymph nodes are
usually not involved. These are the differentiating features from carcinoma.
- Tumour grows rapidly; undergoes necrosis at various places; causes cystic areas.
- Recurrence is common.

Treatment of Phylloides Tumour:

- Excision or subcutaneous mastectomy is done.
- If malignant (sarcoma), total mastectomy is indicated.

Treatment of Galactocoele:
- Aspiration of the content.
- Excision (submammary incision).
- Abscess when formed should be drained under general anaesthesia under cover of
antibiotics.

Treatment of Fibroadenoma:
- Excision through a circumareolar incision (Webster’s) or submammary incision (Gaillard
Thomas incision) is done under general anaesthesia.
- Fibroadenoma which is small (<3 cm)/single/age <30 years can be left alone with regular
follow-up with USG at 6 monthly interval. But anxiousness of patient and parents find
difficult for this conservative approach.

Treatment of Breast Cyst:

- Aspiration for two times.
- Surgical excision is done if cyst recurs after two aspirations or if there is bloody discharge or
residual mass if felt after aspiration.

Treatment of Cyclic Mastalgia:

- Evening primrose oil 325 mg BD.
- Gamolenic acid 120 mg BD.
- Danazol (100–200 mg BD)—antigonadotrophin agent.
- Bromocriptine (2.5 mg BD)—prolactin inhibitor.
- Tamoxifen (20 mg daily).
- GnRH analogue 3.6 mg injection depot-monthly.
- Testosterone undecanoate 40 mg BD.
- Vitamin B6, B12.
- Analgesics.

Treatment:
- It is important to stop smoking.
- Cone excision of involved major ducts (Adair-Hadfield operation).
- Antibiotics.
- Melhem Novel modified breast ductal system excision.
Suspicion of Carcinoma:
- If there is doubt on clinical, cytological or radiological examination, it is essential to obtain a
tissue diagnosis. This is often possible by needle biopsy.
- In the event of a negative result, open biopsy of the mass or large guage vacuum biopsy is
necessary. Because of the possibility of reporting errors and because the histology is likely to
be more difficult (if a diagnosis has not already been made), the author suggests that frozen-
section reporting should be used rarely and certainly should not form the basis for a decision
to undertake a mastectomy.

Risk of malignancy developing in association with benign breast pathology:

Q5) Recall the gross surgical anatomy of breast. Describe the blood supply and venous
drainage of breast. Illustrate the various axillary lymph node groups and lymphatic
drainage of breast. Analyze the role of sentinel node biopsy in carcinoma breast.

Introduction:
- The breast, or mammary gland (Latin breast) is
the most important structure present in the pectoral
region. Its anatomy is of great practical importance
and has to be studied in detail. The breast is found
in both sexes, but is rudimentary in the male. It is
well developed in the female after puberty. The
breast is a modified sweat gland. It forms in
important accessory organ in the female
reproductive system, and provides nutrition to the
newborn in the form of milk.
- The breast lies in the superficial fascia of the
pectoral region.
- The breast has 4 quadrants, upper medial and
lateral, lower medial and lateral.
- A small extension of the upper lateral quadrant called the axillary tail of Spence, passes
through an opening in the deep fascia and lies in the axilla. The opening is called foramen of
Langer.

Gross Anatomy of Breast:

The structure of the breast may be conveniently studied by dividing it into the skin, the
parenchyma, and the stroma.
- Skin : It covers the gland and presents the following features.
1. A conical projection, called the nipple, is present just below the centre of the breast
at the level of the fourth intercostal space 10 cm from the midline. The nipple is pierced
by 15 to 20 lactiferous ducts. It contains circular and longitudinal smooth muscle fibres
which can make the nipple stiff or flatten it, respectively. It has a few modified sweat
and sebaceous glands. It is rich in nerve supply and has many sensory end organs at the
termination of nerve fibres.
2. The skin surrounding the base of the
nipple is pigmented and forms a circular
area called the areola. This region is
rich in modified sebaceous glands,
particularly at its outer margin. These
become enlarged during pregnancy and
lactation to form raised tubercles of
Montgomery. Oily secretions of these
glands lubricate the nipple and areola,
and prevent them from cracking during
lactation. Apart from sebaceous glands,
 the areola also contains some sweat glands, and accessory mammary glands. The skin
of the areola and nipple is devoid of hair, and there is no fat subjacent to it. Below the
areola lie lactiferous sinus where stored milk is seen.
- Parenchyma :
1. It is a compound tubulo-alveolar gland which secretes milk. The gland consists of 15
to 20 lobes. Each lobe is a cluster of alveoli, and is drained by a lactiferous duct.
The lactiferous ducts converge towards the nipple and open on it. Near its termination
each duct has a dilatation called a lactiferous sinus.
2. Alveolar epithelium is cuboidal in the resting phase, and columnar during lactation.
In distended alveoli, the cells may appear cuboidal due to stretching, but they are much
larger than those in the resting phase.
3. The smaller ducts are lined by columnar epithelium, the larger ducts by two or more
layers of cells, and the terminal parts of the lactiferous ducts by stratified squamous
keratinised epithelium.
4. The passage of the milk from the alveoli into and along the ducts is facilitated by
contraction of myoepitheliocytes, which are found around the alveoli and around the
ducts, lying between the epithelium and the basement membrane.
- Stroma:
1. It forms the supporting framework of the gland. It is partly fibrous and partly fatty.
The fibrous stroma forms septa, known as the suspensory ligaments of Cooper, which
anchor the skin and gland to the pectoral fascia. The fatty stroma forms the main bulk of
the gland. It is distributed all over the breast, except beneath the areola and nipple.

Blood Supply:
The mammary gland is extremely vascular. It is
supplied by branches of the following arteries
1. Internal thoracic artery, a branch of the
subclavian artery, through its perforating
branches.
2. The lateral thoracic, superior thoracic and
acromiothoracic (thoracoacromial) branches of
the axillary artery.
3. Lateral branches of the posterior intercostal
arteries. The arteries converge on the breast and
are distributed from the anterior surface. The
posterior surface is relatively avascular.

Venous Drainage:
The veins follow the arteries. They first converge towards the base of the nipple where they
form an anastomotic venous circle, from where veins run insuperficial and deep sets.
1. The superficial veins drain into the internal thoracic vein and into the superficial
veins of the lower part of the neck.
2. The deep veins drain into the axillary and posterior intercostal veins.
Lymph Nodes:
Lymph from the breast drains into the following lymph nodes
- The axillary lymph nodes, chiefly the anterior (or pectoral) group. The posterior, lateral,
central and apical groups of nodes also receive lymph from the breast either directly or
indirectly.
- The internal mammary (parasternal) nodes which lie along the internal thoracic vessels.
- Some lymph from the breast also
reaches the supraclavicular nodes, the
cephalic (deltopectoral) node, the
posterior intercostal nodes (lying in
front of the heads of the ribs), the
subdiaphragmatic and subperitoneal
lymph plexuses.

Lymphatic vessels:
- The superficial lymphatics drain the
skin over the breast except for the
nipple and areola. The lymphatics pass
radially to the surrounding lymph nodes
(axillary, internal mammary,
supraclavicular and cephalic).
- The deep lymphatics drain the
parenchyma of the breast. They also drain the nipple and areola.

Sentinel Lymph node Biopsy in carcinoma:

- The first axillary node draining the breast
(by direct drainage) is designated as the
sentinel lymph node (SLN). 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.
- The incidence of 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 places of breast, and chances of false-
negative is high.
- Sentinel node is localised by preoperative (within 12 hours prior) or perioperative injection
of patent blue (Isosulfan vital blue dye 2.5–7.5 ml) or 99m TC radioisotope labelled albumin
(one mCi on previous day)/sulphur colloid (6 hours before) near the tumour (peritumour area)
or into subdermal plexus around the nipple.
- Marker will pass through the sentinel node which can be visually detected as blue staining or
with a hand held gamma camera; and is biopsied with a small incision made directly over it.
Frozen section biopsy or touch imprint cytology is done for presence of malignant cells.
- 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.
- Detection rate of sentinel node for blue dye and radioisotope is 90% and 98%, respectively.
Subdermal/subareolar injection of radioisotope has got better sentinel node localisation than
peritumour injection. But better imaging is obtained by peritumour injection and so
peritumour injection is usually practiced. Radioisotope tracer injection done in the early
morning of the day of surgery into peritumour area and perioperative injection
of patent blue dye in subareolar region—as a combined method is often used in many centres.
- After injection of patent blue, breast is massaged continuously to enhance the uptake.
Incision is made after 5–7 minutes between pectoralis major and latissimus dorsi to identify
blue stained lymphatics which are traced to 2–3 blue lymph nodes.
- Hand-held radio-probe is used to identify the sentinel node which is later excised. Often 2–3
nodes are removed.
Q6) Enlist types of carcinoma breast on basis of operability. Discuss Blood supply,
venous drainage, lymphatic drainage of breast. Illustrate Clinical features, pathology
and management of locally advanced carcinoma breast. Correlate operability stage with
plan of management.

Treatment plan for Carcinoma Breast.

Blood Supply:
The mammary gland is extremely vascular. It is
supplied by branches of the following arteries
1. Internal thoracic artery, a branch of the
subclavian artery, through its perforating
branches.
2. The lateral thoracic, superior thoracic and
acromiothoracic (thoracoacromial) branches of
the axillary artery.
3. Lateral branches of the posterior intercostal
arteries. The arteries converge on the breast and
are distributed from the anterior surface. The
posterior surface is relatively avascular.
Venous Drainage:
The veins follow the arteries. They first converge towards the base of the nipple where they
form an anastomotic venous circle, from where veins run insuperficial and deep sets.
1. The superficial veins drain into the internal thoracic vein and into the superficial
veins of the lower part of the
neck.
2. The deep veins drain into the
axillary and posterior intercostal
veins.

Lymph Nodes:
Lymph from the breast drains into the
following lymph nodes
- The axillary lymph nodes, chiefly the
anterior (or pectoral) group. The
posterior, lateral, central and apical
groups of nodes also receive lymph from
the breast either directly or indirectly.
- The internal mammary (parasternal)
nodes which lie along the internal thoracic vessels.
- Some lymph from the breast also reaches the supraclavicular nodes, the cephalic
(deltopectoral) node, the posterior intercostal nodes (lying in front of the heads of the ribs), the
subdiaphragmatic and subperitoneal lymph plexuses.

Lymphatic vessels:
- The superficial lymphatics drain the skin over the breast except for the nipple and areola.
The lymphatics pass radially to the surrounding lymph nodes (axillary, internal mammary,
supraclavicular and cephalic).
- The deep lymphatics drain the parenchyma of the breast. They also drain the nipple and
areola.

Clinical Presentation: carcinoma breast

- Lump in the breast which is hard, painless (most common). At least tumour should become 1
cm to clinically palpable
- Nipple discharge is the second common presentation
- Ulceration and fungation
- Axillary lymph node enlargement; supraclavicular lymph node enlargement
- Chest pain and haemoptysis
- Bone pain, tenderness, and pathological fracture
- Pleural effusion, ascites
- Liver secondaries, secondary ovarian tumour
- Pain in the lump in 10% cases
Cutaneous Manifestations of Carcinoma Breast:
- Peau d’orange: Due to obstruction of dermal lymphatics, openings of the sebaceous glands
and hair follicles get buried in the oedema giving rise to orange peel appearance.
- Dimpling of skin due to infiltration of ligament of Cooper.
- Retraction of nipple due to infiltration of lactiferous duct.
- Ulceration, discharge from the nipple and areola.
- Skin ulceration and fungation.
- Cancer-en-cuirasse: Skin over the chest wall and breast is studded with cancer nodules
appearing like an armour coat.
- Tethering to skin.

Spread into the Deeper Plane:

- Into pectoralis major muscle (is confirmed by observing the restricted mobility of the
swelling while contracting the PM muscle).
- Into latissimus dorsi muscle (extending the shoulder against resistance).
- Into serratus anterior (by pushing the wall with hands without flexing the elbow).
- Into the chest wall (breast will not fall forward when leaning forward, and while raising the
arm above the shoulder, breast will not move upwards as it is fixed to the chest wall).

Haematogenous Spread:
- Bone (most common) (70%) Lumbar vertebrae, femur, ends of long bones, thoracic
vertebrae, ribs, skull, in order. They are osteolytic lesion often with pathological fracture.
Presents with painful, tender, hard, non-mobile swelling, with disability. 70% of secondaries
in bone in a women is due to carcinoma breast. Spine secondaries can cause paraplegia.
- Liver—either through blood, occasionally through transcoelomic spread.
- Lung—causes malignant pleural effusion and ‘cannon ball’ secondaries.
- Brain—causes increased intracranial pressure, coning.
- Adrenals and ovaries.

Pathology:
- Breast carcinoma arising from lactiferous ducts is called as ductal carcinoma.
- Breast carcinoma arising from lobules is called as lobular carcinoma. It is 10% common.
- In situ carcinoma is pre-invasive carcinoma which has not breached the epithelial basement
membrane.
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 T3, T4a, T4b, T4c or T4d or N2 LACB is
stage II B and III disease.
- It is investigated by FNAC of tumour/core needle biopsy/incision biopsy/mammography of
opposite breast, chest CT, CT abdomen or whole body bone scan. Biopsy is needed to
assess receptor status (ER/PR/HER2Neu).
- Bilateral mammography is done to assess tumour size and multicentricity which is needed to
check the chemotherapy response at a later period. FNAC of axillary node is required.
- If bone scan is positive it becomes metastatic carcinoma of breast not LACB. Only when
60% of bone is dimeneralised in metastatic bone disease, plain X-ray bone will detect
the lesion. Even though X-ray may be normal in stage III disease, in 30% of these patients
bone scan will be positive making the disease stage IV metastatic.

Treatment of LACB:
- Neoadjuvant chemotherapy, mastectomy either total or modified radical mastectomy (MRM
—usually after 3 cycles of initial chemotherapy), further chemotherapy, radiotherapy
[local breast field and axilla (concurrent)], hormone therapy (as sequential—trastuzumab for
HER2 Neu positive/tamoxifen/ letrozole) is becoming more popular. Evaluation with
bone scan and HRCT chest is a must to rule out metastatic type. Survival rate will be
increased to 50% by these modalities. Targeted therapy like trastuzumab in HER2 Neu
positive patient with neoadjuvant chemotherapy can be safely administered prior to
mastectomy.
- This anterior (neoadjuvant) chemotherapy helps in downstaging the diseases by
cytoreduction; controls the micrometastases first which will be present mostly in LACB; it
allows the chemosensitivity; also provides systemic chemotherapy.
- Remaining chemotherapy should be started within 6 weeks of surgery. If BCS is done RT
should be given first then chemotherapy. After completion of chemotherapy hormone
therapy is started.
- LACB with entirely fixed fungating masses, chemotherapy, palliative total mastectomy
(often with skin graft to cover the defect), hormone therapy using tamoxifen or letrozole or
trastuzumab. Axillary dissection is not necessary in this type.
- Only chemotherapy and radiotherapy (to breast and axilla) is also advocated in few; later
with hormone therapy.
- Treatment for LACB is targeted at present as curative; but it is achieved only in 50% of
patients. So in 50% of patients therapy becomes palliative.
- During treatment period for LACB, disease may become metastatic (systemic) and so
evaluation at regular intervals with CT chest, bone scan, MRI spine, liver function tests,
CT abdomen is needed.
- Breast conservative surgery (BCS) has got limited role as it will effect on the survival rate
(even though many proponents practice, this may not be ideal).
- 5-year survival is 50% with proper therapy and 10-year survival is 25% or less.
Q7) Enlist the etiological factors for carcinoma abreast. Describe pathology and various
types of carcinoma breast. Illustrate the modes of spread of breast cancer. Analyze the
algorithm for management of operable breast cancer.

Aetiology:
- Carcinoma breast is more common in developed, Western countries.
- In African-American women, it is more aggressive. It is less common in Japan, Taiwan.
- It is second most common carcinoma in females. Incidence is 19–34%. Median age is 47
years.
- Carcinoma in one breast increases the risk of developing carcinoma on opposite breast by 3–
4 times. Incidence of bilateral carcinoma is 2%.
- It is more common after middle age, but can occur at any age group, after 20 years.
- It can be familial in 2–5% cases. Vast majority of cases are sporadic without family history.
- Mutation of tumour suppressor genes BRCA1/BRCA2 is thought to be involved with high-
risk of breast carcinoma. (BRCA means BReast CArcinoma). BRCA1 mutation is
having more risk (35–45%) than BRCA2 mutation. It is located in long arm of chromosome
17, whereas BRCA2 is located in long arm of chromosome 13. BRCA1 more commonly
shows ER negative status, high grade, aneuploidy with raised S fraction than BRCA2 which
shows ER positive status. BRCA1 is associated with increased risk in males. Lifelong risk of
breast cancer in BRCA1 and BRCA2 mutations is 50–70%. Both are associated with high-risk
for ovarian cancer.
- Occasionally mutation of BRCA3 and p53 suppressor gene is also involved.
- Li-Fraumen’s syndrome (LFS) is autosomal dominant condition with breast cancer
inheritance (90%) along with sarcoma, leukemia, brain tumours, adrenocortical tumours.
- Diet low with phytoestrogens and high alcohol intake have high-risk of breast cancer.
Vitamin C reduces the risk.
- It is more common in nulliparous woman.
- Attaining early menarche and late menopause have high-risk of breast malignancy.
- Early child-bearing and breastfeeding reduces the chances of malignancy. Early 1st child
birth reduces the risk; late first child birth after 35 years increases the risk.
- It is more common in obese individuals.
- Breast cancer relative risk is qualified as relative risk (RR). If RR is 2.0 means, risk is twice
the normal population. If RR is 0.5 means, risk is 50% less than normal population.
- Risk is 3–5 times more if 1st degree relative is having breast cancer. Risk is more if 1st
degree relative is younger or premenopausal or having bilateral breast cancers.
- In males, occasionally gynaecomastia turns into carcinoma—not proved.
- Benign breast diseases with atypia, hyperplasia and epitheliosis has got higher risk in a
patient with family history. RR in nonproliferative fibrocystic disease is 1.0; proliferative
without atypia is 1.5; proliferative with atypia is 4.0 (with family history 6.5, premenopausal
6.0).
- Cowden’s syndrome—it is an autosomal dominant condition, with cutaneous facial lesion
(100%), bilateral breast lesion (50%), GI polyps, brain, thyroid tumours.
- It is often associated with ataxia telangiectasia.
- Previous therapeutic radiation (thoracic) may predispose carcinoma breast especially when
RT is given at younger age mainly for Hodgkin’s lymphoma.
- Radial scar may predispose the carcinoma. It is a complex sclerotic condition of breast with
microcyst, epithelial hyperplasia, adenosis, central sclerosis with lesions less than 1 cm in
size. It mimics carcinoma clinically and mammographically.
- It is more common in individuals who are on oral contraceptive pills (not proved) and
hormone replacement therapy (HRT) for more than 5 years.
- Presently carcinoma breast is considered as a systemic disease. Halsted concept of spread is
sequential spread. Breast—axillary lymph node—systemic spread. Fischer concept is early to
begin with itself, there is distant blood spread because of micrometastasis without nodal
disease. Only tumour lesser than 1 cm size can be sequential. Helman spectrum concept is
new one where disease spreads loco-regionally as well as systemically which makes it to
aim at both loco-regional disease control as well as systemic disease control.
- Prior diagnosis of uterine/ovarian/colonic cancers.

Classification of breast carcinoma:

Types of breast carcinoma:

1. Scirrhous carcinoma: It is 60% common.
a. It is hard, whitish, or whitish yellow, noncapsulated, irregular, with cartilaginous
consistency.
b. It contains malignant cells with fibrous stroma.
2. Medullary carcinoma (5%): Also called as ‘encephaloid type’ because of its brain like
consistency.
a. It contains malignant cells with dispersed lymphocytes.
 b. Medullary variant with some features of pure form shows uniformly high grade
aggressive tumour cells with negative ER, PR, HER2 NEU cell surface receptors
(triple negative).
c. They express molecular markers of basal/myoepithelial cells and so now termed
as basal-like breast cancers.
3. Inflammatory carcinoma/Lactating carcinoma/Mastitis carcinomatosis:
a. Most aggressive type of carcinoma breast. It is 2% common. It is common in
lactating women or pregnancy.
b. It mimics acute mastitis because of its short duration, pain, warmth and
tenderness.
c. Clinically, it is a rapidly progressive tumour of short duration, diffuse, painful,
warm often involving whole of breast tissue with occurrence of peau d’ orange,
often extending to the skin of chest wall also.
d. More than 1/3rd of skin over the breast is involved; diffuse lymphoedema is due
to tumour emboli within dermal lymphatics. Underlying localised palpable mass
need not be evident clinically.
e. It should be differentiated from other LACB with skin involvement where
underlying palpable mass is well evident.
f. Mammography may not show any finding except skin thickening. Inflammatory
carcinoma of breast is a clinical diagnosis.
g. Ductal or lobular invasive type with cancer cells in dermal lymphatics is the
histology.
h. It rapidly metastasises to chest wall, bone and lungs. It is always stage IIIB
carcinoma (T4d).
i. FNAC confirms the diagnosis—it contains undifferentiated cells.
j. Punch biopsy is ideal and better which shows undifferentiated cells.
k. Total count is normal.
l. Treatment: External radiotherapy and chemotherapy.
m. Salvage surgery whenever possible. It has got worst prognosis.
n. Differential diagnosis : Acute mastitis—total count is increased here.
4. Colloid carcinoma: It produces abundant mucin, both intra and extracellularly carrying
better prognosis.
5. Paget’s disease of the nipple: It is superficial manifestation of an intra-ductal carcinoma.
a. 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.
b. In Paget’s disease, there is a hard nodule just underneath the areola, which later
ulcerates and causes destruction of nipple.
c. Histologically, it contains large, ovoid, clear Paget’s cells with malignant features.
Paget’s hyperchromatic cells are located in rete pegs of epidermis containing
intracellular mucopolysaccharides as clear halo in cytosol.
d. It is 2% common. 90% is invasive ductal carcinoma. 70% shows mass underneath
nipple and areola.
e. Breast conservation surgery (BCS) is difficult here; hence, MRM is needed.
6. Tubular, papillary, cribriform are other types of duct carcinomas.
7. Atrophic scirrhous carcinoma: Seen in elderly females. It is a slow growing tumour which
has got better prognosis. FNAC is diagnostic. Mastectomy or curative brachytherapy (using
breast moulds) is the treatment of choice. It is curable.
8. Lobular carcinoma in situ: It originates in terminal duct lobular unit only of female breast
showing its distension and distortion.
a. It is 12 times more common in white females. Predominantly perimenopausal. It is
3–5% common. High chance to predispose to invasive cancer.
b. 35% of LCIS may develop invasive lobular carcinoma either in same or contralateral
breast; 65% may develop invasive ductal cancer (same side/opposite side/both
sides).
c. LCIS is a marker/predictor of increased risk of invasive breast cancer; not an
anatomical precursor unlike DCIS.
d. It is now advocated as a risk factor for developing breast cancer.
e. It is multifocal, bilateral (50%). It is an incidental pathological entity.
f. Classical type carries better prognosis; pleomorphic type does not so; occasionally
mixed ductal and lobular in situ may be seen.
g. Clinically it does not form a lump. Need not be detected by mammography, as it
does not provoke calcification.
h. 50% cancers can develop in the contralateral breast.
i. Immunohistochemistry using e-cadherin antibody shows positive reaction in lobular
carcinoma.
j. It has poor prognosis due to bilateral, multifocal nature and difficulty in identifying
it.
k. Tamoxifen (risk reduction in premenopausal) or raloxifen (postmenopausal) often
with bilateral total mastectomy is the treatment.
9. Disease of Reclus: It is a rare intracystic papilliferous carcinoma of breast presenting as a
cystic swelling with bloody discharge from the nipple.

Pathology:
- Breast carcinoma arising from lactiferous ducts is called as ductal carcinoma.
- Breast carcinoma arising from lobules is called as lobular carcinoma. It is 10% common.
- In situ carcinoma is pre-invasive carcinoma which has not breached the epithelial basement
membrane.
Lymphatic Spread:
- It occurs through Subareolar Sappey’s lymphatic plexus (presently its significance is
discounted). Cutaneous lymphatics. Intramammary lymphatics.
- Lymphatic drainage of the breast is predominantly through axillary (75%) and internal
mammary lymph nodes.
- Interpectoral, lies between pectoralis major and minor muscle (Rotter’s nodes). Presently
involvement of these lymph nodes are considered due to retrograde spread. These lymph
nodes are cleared during Patey’s mastectomy.
- From axillary lymph nodes spread occurs to supraclavicular lymph nodes by lymphatic
embolisation.
- Through dermal lymphatics, it may spread to opposite breast or to opposite axillary lymph
nodes.
- Spread may occur into internal mammary lymph nodes of same side and then to mediastinal
lymph nodes.
- Contralateral internal mammary lymph nodes can also get involved by retrograde spread.
- 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 (medial
cord often lateral cord).
Spread into the Deeper Plane:
- Into pectoralis major muscle (is confirmed by observing the restricted mobility of the
swelling while contracting the PM muscle).
- Into latissimus dorsi muscle (extending the shoulder against resistance).
- Into serratus anterior (by pushing the wall with hands without flexing the elbow).
- Into the chest wall (breast will not fall forward when leaning forward, and while raising the
arm above the shoulder, breast will not move upwards as it is fixed to the chest wall).

Haematogenous Spread:
- Bone (most common) (70%) Lumbar vertebrae, femur, ends of long bones, thoracic
vertebrae, ribs, skull, in order. They are osteolytic lesion often with pathological fracture.
Presents with painful, tender, hard, non-mobile swelling, with disability. 70% of secondaries
in bone in a women is due to carcinoma breast. Spine secondaries can cause paraplegia.
- Liver—either through blood, occasionally through transcoelomic spread.
- Lung—causes malignant pleural effusion and ‘cannon ball’ secondaries.
- Brain—causes increased intracranial pressure, coning.
- Adrenals and ovaries.

Treatment plan for Carcinoma Breast.