explanation benign and malignant diseases, clinical presentation, investigations and treatment

1. Carcinoma of the breast: is the most
common cause of death in middle aged
women in western countries. In 2004
approximately one and half million new
cases were diagnosed worldwide. In
England and Wales one in 12 women
will develop the disease during their life
time.

4. • (1) Geographical: it occurs most commonly in
western world, accounting 3-5% of all death in
women. In developing countries it accounts for
1-3% of death.
• (2) Age: it is extremely rare below the age of 20
years but thereafter the incidence steadily rise
that by the age of 90 years nearly 20% of
women are affected.
• (3) Gender: it is less than 0.5% of patients with
breast cancer are male.

5. • (4) Genetics: it occurs more commonly in
women with a family history of breast cancer
than in general population. Breast cancer
related to specific mutation account for about
5% of breast cancer.
• (5) Diet: there is some evidence that there is a
link with diets low in phytoestreogen, a high
intake of alcohol is associated with increase risk.
Diets are recommended are walnut, broccoli,
peach and curcuma.

7. • (6) Endocrine: it is more common in
nulliparous women and breast feeding in
particular approved to be protective. Also
protective in having a first child at an early
age, especially if associated with late
menarche and early menopause. It is known
that in postmenopausal, breast cancer is
more in obese. This is thought to be because
of increased conversion of steroid hormone
to oestrodiol in the body fat.

8. • (7) previous radiation; this was considered to be
historical interest, with the majority of women
exposed to the atomic bombs at Hiroshima and
Nagasaki having dead, again using of utilized
uranium in Iraq war play a role in this disease. It
is, however a real problem in women who have
been treated with mantle radiotherapy as a part of
the management of Hodgkin lymphoma disease, in
which significant dose of radiation is received.
The risk appears about decade after treatment and
is higher if radiotherapy occurred during breast
development.

10. • Pathology: breast cancer may arise from the
epithelium of the duct system anywhere from the
nipple end of major lactiferous ducts to the
terminal duct unit, which is in breast lobule. The
disease may be entirely in situ, an increasingly
common finding with the advent of breast cancer
screening or may be invasive cancer. The degree of
differentiation of the tumor is usually described
using three grades as well differentiation,
moderately differentiation or poorly differentiation.
Commonly numerical grading system based on the
scoring of the three individual factors (nuclear
pleomorphism, tubular formation, and mitotic rate)
is used in grade 111 cancers roughly equating the
poorly differentiated group.

12. • Previously, descriptive terms were used to
classify breast cancer scirrhous meaning woody
or medullary meaning brain like. More recently
histological descriptions have been used.
however with the increasing application of
molecular markers there will be a change in the
way that the breast cancers are classified, and it
is likely that much more information about
individual tumor will be routinely reported, such
as its likelihood of metastases, and to which
therapeutic agents it will be susptible. Gene
array analysis of breast cancer has identified five
subtypes. Some of these correlate with known
markers such as estrogen receptor status.

13. • Current nomenclature: ductal carcinoma: is
the most variant with lobular carcinoma
occurring about 15% of cases, there are
subtypes of lobular carcinoma including the
classical type which carries a better prognosis
than the pleomorphic type, occasionally
pictures may be mixed with both ductal and
lobular features. There are different pattern
of spread depending on histological type.

14. • If there is doubt whether as tumor is
predominantly lobular in type,
immunohistochemical analysis using the e-
cadherin antibody which reacts positively in
lobular carcinoma will help in diagnosis. Rare
histological variants, usually carrying a better
prognosis, include colloid carcinoma whose
cells produce a abundant mucin.

15. • . Medullary carcinoma with solid sheets of
large cells usually associated with a marked
lymphocytic reaction. Invasive lobular
carcinoma is commonly multifocal and or
bilateral. Cases detected via screening
program are often smaller and better
differentiation than those presenting to
symptomatic and are of a special type.

17. • Cases detected via screening program are
often smaller and better differentiation than
those presenting to symptomatic and are of a
special type. Inflammatory carcinoma is a
fortunately rare, highly aggressive that
present as painful swollen breast which is
warm with cutanous edema; this is result of
blockage of the subdermal lymphatics with
cancer cells. Inflammatory carcinoma usually
involves at least 1l3 of the breast and may
mimic breast abscess.

18. • A biopsy will confirm the diagnosis and show
undifferentiated cells, it used to be rapidly
fatal but with aggressive chemotherapy and
radiotherapy and with salvage surgery the
prognosis has improved considerably. In situ
carcinoma is a preinvasive cancer that has
not breached the epithelium basement
membrane.

20. • This was previously a rare usually asymptomatic,
finding in breast biopsy specimens but is becoming
increasingly common because of the advent of
mammographic screening. In situ carcinoma may be
ductal (DCIS) or lobular (LCIS). The latter is often
being multifocal and bilateral. Both are markers for
later development of invasive cancers which will
develop in at least 20% of patients. Although
mastectomy is curative, this constitutes
overtreatment in many cases. The best treatment for
carcinoma in situ is depend if it is a high grade tumor
treated by excision and radiotherapy, whereas those
of low grade whose tumor completely excised need
no further treatment.

21. • Staining for estrogen and progesterone receptors is
now considered routine, as their presence will
indicate the use of adjuvant hormone therapy with
tamoxifin or the newer aromatase inhibitors as
anastrazole. Tumors also stained foe c- erb2( a growth
factor receptor)as patients who are positive can be
treated with monoclonal antibody as trastuzumab
(herciptin) either in the adjuvant or relapse sitting.
The pathologist is an important member of breast
cancer team (MDT) and will increasingly help decide
which adjuvant therapies will be appropriate.

22. • Paget's disease of the nipple: is a superficial
manifestation of underlying disease of the breast
carcinoma. It presents as eczema- like condition of
the nipple and areola which persists despite local
treatment. The nipple is eroded slowly and eventually
disappears. If it left the underlying carcinoma will
sooner or later become clinically evident. Nipple
eczema should biopsied if there any doubt of its
cause. Microscopically Paget's disease characterized
by the presence of a large ovoid cells with abundant,
clear, pale staining cytoplasm in malpighian layer of
the epithelium.

26. • Spread of the breast cancer:
• (1) Local spread: the tumor increases in size
and invade other portion of the breast. It
tends to involve the skin and to penetrate the
pectorals muscles and even the chest wall if
diagnosed later.

27. • (2) Lymphatic metastasis: it occurs primarily to
axillary and internal mammary lymph nodes. A
tumor in the posterior one third tends to spread
to internal mammary lymph nodes. The
involvements of lymph nodes have both
biological and chronological event in the spread
of carcinoma and it also a marker of metastases
potential of that tumor. Involvement of the
supraclavicular lymph nodes and of any of the
contra lateral breast represents advanced
disease.

31. • (3) Blood streams: it is by this route skeletal
metastases occur. In order of the frequency
the lumbar vertebrae, femur, thoracic
vertebrae, rib and skull are affected and
these deposits are generally osteolytic.
Metastases may also commonly occur in the
liver, lung, brain, and occasionally adrenal
glands and ovaries.

35. • Clinical presentation: although any portion of
the breast including axillary tail may be
involved breast cancer is found most
frequently in the upper outer quadrant most
carcinoma will present as a hard lump which
may be associated with indrawing of the
nipple, as the disease advances locally there
may be skin involvement with peau d orange
or frank ulceration and fixation to the chest
wall.

38. • This is described as cancer en-cuirasses when
disease progress around chest wall. About 5%
carcinoma in UK presented as locally
advanced or symptoms of metastatic disease
this figure is much higher in developing
countries. These patients under goes staging
evaluation so this will include a careful
clinical examination, chest x-ray, CT scan
chest and abdomen and isotope scan, bone
scan.

39. • This will be important for both prognosis and treatment. A
patient with wide spread visceral metastases may obtain
an increased length and quality of survival from systemic
hormone therapy or chemotherapy but is unlikely to
benefit from surgery as she will die from her metastases
before local disease becomes a problem. In contrast,
patients with relatively small tumors less than 5 mm in
diameter confined to the breast and ipsilateral lymph
nodes, rarely need staging beyond a good clinical
examination as puck up rate for distant metastases is so
low. Currently, a chest x-ray, full blood count , liver
function test are all that recommended for screening of
the patient with early breast cancer.

40. • Investigations: ( 1) mammaography: soft
tissue radiographs are taken by placing the
breast in direct contact with ultrasensitive
film and exposing it to low-voltage, high
amperage x-rays. The dose of radiation is
very low so it is a safe investigation. The
sensitivity of this investigation increases with
age as the breast becomes less dense. In
total, 5% of breast cancers are missed by
population –based mammographic screening
programme , even in retrospect , such
carcinoma are not apparent.

43. • . Thus, a normal mammogram does not
exclude the presence of carcinoma. Digital
mammography is being introduced, which
allow manipulation of the images and
computer aided diagnosis. Tomo-
mammography is also being assessed as a
more sensitive diagnostic modality.

44. • (2)ultrasound: ultrasound is particularly
useful in young women with dense breasts in
whom mammograms are difficult to
interprets, and in distinguishing cysts from
solid lesions. It also can be used to localize
impalpable areas of breast pathology. It is
useful as screening tool and remains operator
dependent. Increasingly, ultrasound of the
axillary tissue is performed when cancer is
diagnosed and guided percutaneous biopsy
of any suspicious glands may be performed.

47. • (3)magnetic resonance imaging (MRI); MRI is
of increasing interest to breast surgeons in a
number of setting: it can distinguish scar
from recurrence in women who have had
previous breast conservation therapy for
cancer. It is the best imaging modality for the
breast of women with implants. It has proven
to be a useful as screening tool in a high risk
women because of a family history. It is less
useful than ultrasound in the management of
the axilla in both primary breast cancer and
recurrent diseases.

50. • (4) needle biopsy/ cytology: histology can be
obtained under local anesthesia using a spring
loaded core needle biopsy device. Cytology is
obtained using a 21 G or 23G needle and 10 ml
syringe with multiple passes through the lump
with negative pressure in the syringe. The
aspirate is then smeared on to a slide which is
air dried or fixed. Fine needle aspiration
cytology (FNAC) is the least invasive technique
of obtaining a cell diagnosis and is a rapid and
very accurate if both operator and cytologist are
experienced.

52. • However, false negative do occurs, mainly
through sampling error, and invasive cancer
cannot distinguished from in situ disease. A
histological specimen taken by a core biopsy
allows a definitive preoperative diagnosis,
differentiates between duct carcinoma in situ
and invasive disease and also allows the
tumor to be stained for receptor status.

53. • This is important before commencing
neoadjuvant therapy. (5)large needle biopsy
with vacuum systems: the sampling error
decreases as the biopsy volume increases and
using 8G or 11G needles allows more
extensive biopsies to be taken this is useful in
management of micro calcifications or in
complete excision of benign lesions such as
fibroadenomas.

54. • Triple assessment: the diagnosis should be
made by a combination of clinical
assessment, radiological imaging and a tissue
sample taken for either cytological or
histological analysis, the so called triple
assessment. The positive predictive value of
this combination should exceed 99.9%.

55. • Staging of breast cancer: classical staging
of breast cancer by means of TNM ( tumor,
nodes, metastasis) criteria is used less often
as we gain more knowledge of the biological
variable that affect prognosis. It is becoming
increasingly clear that it is these factors
rather than anatomical mapping that
influence the outcome of the disease and
treatment. As shown below

56. group Approximate 5 year
survival
example treatment
Very low risk  90% Screen detected DCIS Local
Low risk prim tumor 70-90% Node negative with
favorite histology
Locoregional with or
without systemic
High risk prim tumor <70% Node positive or
unfavorite histology
Locoregional with
systemic
Loca
lly advanced
<30% Large prim or
inflammatory type
Primary systemic
metastatic ------------ ------------------- Primary systemic

57. • Prognosis of breast cancer: the best
indicator of likely prognosis in breast cancer
remains tumor size and lymph node status. It
is realized that some large tumors remain
confined to the breast for decades whereas
some very small tumors are incurable at time
of diagnosis. Hence the prognosis of a cancer
depends not on chronological age but on its
invasive and metastatic potential.

58. • In attempt to define which tumor will behave
aggressively and thus require early systemic
treatment, a host of prognostic factors have
been described. These include histological
grade of tumor, hormone receptors status,
measure of tumor proliferation such as S-
phase fraction, growth factor analysis and
oncogene or oncogene product
measurement.

59. • Prognostic indices as Nottingham prognostic
index have combined these factors to allow
subdivision of patients in to discrete
prognostic group. Others put gene profile
with other group indicator to give recurrence
score but still unproven at moment. Others
develop gene signatures said able to detect
cancers of good or poor prognosis but still
again unproven

60. • Nottingham prognostic index: it depends on
pathological size of the tumor in cms and
node status as score 1 if no node is involved,
score 2 if 1-3 nodes are involved score 3 if
four or more nodes are involved. And also
depend on grade of the tumor as score 1 if
grade 1 and score 2 if grade 2 and score3 if
grade 3.

61. • Nottingham prognostic index= (0.2×size cm)+score node+ score
grade
• Prognostic group value 10 year
survival %
• Excellent <2.4 94
• Good 2.4- <3.4 83
• Moderate 1 3.4-<4.4 70
• Moderate2 4.4-< 5.4 51
• Poor >5.4 19

64. • Treatment of breast cancer: the two basic principles of
treatment are to reduce the chance of local recurrence
and the risk of metastatic spread. The treatment of early
breast cancer will usually involve surgery with or without
radiotherapy. Systemic therapy such as chemotherapy or
hormone therapy is added if there are adverse prognostic
factors such as lymph nodes involvement, indicating a
high likelihood of metastases relapse. At other end of
spectrum locally advanced or metastatic disease is usually
treated by systemic therapy to palliate symptoms with
surgery playing a much smaller role. Algorithm for
management of breast cancer is shown in summary as

66. • (1) Achieve local control
• (2) Appropriate surgery include (a) wide local
excision (clear margin)+radiotherapy (b)
mastectomy+- radiotherapy immediate or
delayed. Combined with axillary procedure.
• (3) Treat risk of systemic disease by
chemotherapy if prognostic factors are poor
and hormone therapy if estrogen and
progesterone receptor are positive.

67. • Details of local treatment or early breast
cancer: local control is achieved through
surgery and or radiotherapy. The aim of
treatment is to (1) cure: likely in some cases
but late recurrence is possible. (2)Control
local disease in breast and axilla. (3)
Conservation of local form and function.
(4)Prevention or delay of occurrence of
distant metastases.

68. • Surgery: still has central role to play in the
management of breast cancer but have been
gradual shifts toward more conservative
techniques, that might show equal efficacy
between mastectomy and local excision
followed by radiotherapy. It was initially hoped
that avoiding mastectomy would help to
alleviate the considerable psychological
morbidity associated with breast cancer but
recent studies as has shown that over 30% of
women develop significant anxiety and
depression following both radical and
conservative surgery .

69. • After mastectomy women tend to worry the
effect of operation on their appearance and
their relationship whereas after conservative
surgery they may remain fearful of
recurrence. Mastectomy indicated for(1) a
large tumor in relation to size of 5he breast
(2) central tumor beneath or involving g the
nipple(3) multifocal disease(4) local
recurrence (5) patient preference.

70. • Types of operation: the radical Halsted mastectomy
including excision of breast axillary lymph nodes +
pectorals major and minor, this operation is no longer
preformed it cause excessive morbidity with no
survival benefits. The modified radical (Patey)
mastectomy is more commonly performed by
preservation of pectorals major and division of
pectorals minor. Simple mastectomy, wide local
excision. Conservative breast surgery is aimed at
removing the tumor plus a rim of at least 1 cm of
normal breast tissue this called wide local excision.
Lumpectomy is removal of benign lump.
Quadrantectony involve removing f entire segment of
the breast that contains the tumor.

73. • Radiotherapy: it performs to the chest wall
after mastectomy in selected patient in whom
the risk of local recurrence is high. This includes
patient with large tumor and those with large
numbers of nodes or extensive lymph vascular
invasion. it improve survival in women with
node positive breast cancer. It is conventional to
combine conservative surgery with radiotherapy
to remaining breast tissue. Recently
radiotherapy can be given intraoperatively at
one sitting or as accelerated postoperative
course.

74. • Adjuvant systemic therapy: it was targeted at
these putative micrometastases that might
expect to delay relapse and prolong survival for
about 30% relapse free. So women with
hormone receptors positive tumors will obtain
worthwhile benefit from about 5 years of
endocrine therapy, either 20mg daily of
tamoxifin if she s premenopausal or newer
aromatase inhibitors as anastrazole (femara) or
letrozole and exemstane if she is
postmenopausal. No need to give these drugs in
hormone negative receptors tumors.

75. • Hormone therapy: tamoxifin (antiestrogen) is most
widely used treatment in breast cancer. It reduces the
annual rate of recurrence by 25% with 17% reduction
in annual rate of death. It is also useful in reduce the
tumor in contralateral breast. Other hormone
includes LHRH agonist which induces reversible
ovarian suppression and has beneficial effect as
surgical or radiation induced ovarian ablation in
premenopausal receptor positive tumor. It also used
in recurrent tumor as it is superior on tamoxifin. The
third drug is aromatase inhibitor has benefit on
relapse free and less side effect.

76. • Chemotherapy: first generation regime such
as a six monthly cycle as cyclophosamide,
methotraxate and 5flurouracil all is called
(CMF) it reduces relapse by 25% over 10-15
years period. Modern regime include
anthrocycline (doxorubicin) and newer agent
such as taxanes suitable for premenopausal
with poor prognosis. Recently it also given to
postmenopausal patients.

77. • Primary chemotherapy (neoadjuvant): it is
being used in many centers for a large tumor but
operable that requires mastectomy. The idea is
to shrink the tumor before surgery to enable
breast conserving surgery to be performed.
Newer biological agent used frequently as
molecular targets as trastuzumab (herciptin) it is
active against tumor containing growth receptor
c-erb2. Others as bevacizumab a vascular
growth receptor inhibitor, still is not widely
used.

78. • Follow up of breast cancer: she is followed for life
to detect recurrence and dissemination, so yearly or 2
yearly mammography of treated and contra lateral
breast. Ultrasound of breast and abdomen can also
be used; tumor marker is not routine checking for the
patients.
• Multidisciplinary team approach (MDT): this team
including surgeon, medical oncologist , radiotherapist,
and histopathologist also physiotherapist and
psychologist working together for treatment decisions
in breast cancer. This has been shown good for the
patient to achieve good treatment

79. • Phenomena resulting from lymphatic
obstruction in advanced and breast cancer:
• peau d'orange :- caused by coetaneous
lymphatic edema when the infiltrated skin is
tethered by the sweat ducts .it cannot swell
leading to appearance like orange skin. it also
seen in chronic abscess . late edema of the
arm in troublesome complication of breast
cancer threats .fortunately seen less often
now that radical axillary dissection and radio
therapy are rarely combined .

81. • it might appears at any time from months to
years after treatment .there is usually no
precipitating cause but recurrent tumors
should be excluded because infiltratation
block both lymphatic and venous
.edematous limb is susceptible for bacterial
infection following quite minor trauma and
this requite vigorous antibiotics .treatment
of limb edema is difficult but limb elevation,
elastic arm stocking and pneumatic
compressive devices can be useful.

82. • cancer-en-cuirasses:- the skin of the chest is
infiltrated with carcinoma and has been likened to
coat ,it may be associated with grossly swollen arm .it
usually occurred with local recurrence of the
mastectomy and following irradiation to the chest
wall .it has poor prognosis.
• lymphangiosarcoma:- is rare complication of
lymphadema with an onset many years after the
original treatment it take form of multiple
subcutaneous nodule in the upper limb and must be
distinguish from recurrent tumor .it has poor
prognosis.

84. • Familial breast cancer: - recent development
in molecular genetics and the identification
of number of breast cancer predisposition
gene (BRCA, BRCA2, P53) have done much to
stimulation interest in this area .yet women
whose breast cancer is due to inherited
genetic change actually account for less than
5% of all cases of breast cancer . These
women have a risk of developing breast
cancer that in 2-10 times above baseline .

85. • pregnancy and breast cancers :- breast cancer
presenting during pregnancy or lactation tends to be
at late stage ,presumably because the symptoms are
masked by the pregnancy ,however in other respect
it behaves in similar way to the breast cancer in non
pregnancy women .treatment is similar with some
modification ,radiotherapy should be avoided
,chemotherapy is not used in first trimester but
appears safe subsequently ,most tumors are hormone
receptor negative and so hormonal treatment .which
is potentially teratogenic is not required . For women
they have breast cancer, they should wait for 2 years
before be pregnant as it is within this time that
recurrence most often occurs.

86. • Benign breast disorder:-
• fibroadenoma :- this is usually arise in the fully developed
breast between the age of 15-25 years although occasionally they
occur in much older women .they arise from hyperplasia of single
lobule and usually grow up to 2-3 cm in this case ,they surrounded
by well marked capsule and can thus be enucleated through
cosmetically appropriate incision. fibroadenoma does not require
excision unless associated with suspicious cytology ,it becomes
very large or the patient expressly desire the lump to be removed
.Giant fibroadenoma occasionally occur during puberty they are
over 5cm in diameters and are often rapidly growing but in other
respects are similar to smaller fibroadenoma and can be
enucleated through submammary incision .

88. • Phyllodes Tumors: these benign Tumors
previously sometimes known as serocystic
disease of Brodie or cystosacroma phyllodes,
usually occur in women over the age of 40
years ,but can appear in younger women.
They present as large, sometimes massive,
tumor with unevenly bosselated surface,
occasionally ulceration of over lying skin
occurs because of pressure necrosis, despite
their size they remain mobile on the chest
wall.

91. • Histologically there is a wide variation in their
appearance with some of low malignant
potential resembling a fibroadenoma and others
having mitotic index which histologically
worrying, the latter may recur locally but
despite the name of cystosaroma phyllodes,
they are rarely cystic and only very rarely
develop features of sarcomatous Tumor . These
may metastases via blood stream. Treatment for
benign type is enucleation in young women or
wide local excision. Massive Tumor, recurrent
tumors and those of the malignant type will
require mastectomy.

92. • Galactocele: is rare, usually present as a
solitary, subareolar cyst and always dates from
lactation , it contain milk and in longstanding
cases its wall tend to calcify .
• Aberration of normal development and
involution (ANDI)
• Nomenclature: - the names are confusing. The
name (ANDI) has been applied to this condition
including fibrocystic disease, fibroadenosis,
chronic mastitis and mastopathy.

95. • Etiology: - the breast is a dynamic structure that
undergoes changes throughout a women's
reproductive life and superimposed up on this ,
cyclical changes throughout the menstrual cycle,
the pathogenesis of ANDI involve the
disturbance in the breast physiology extending
from perturbation of normality to well defined
disease process. There is little correlation
between the histological appearance of the
breast and symptoms. Pathology of the breast
consists essentially of four features that may
vary in extent and degree in any one breast.

96. • (1)Cyst formation (variable in size), (2) fibrosis: -
fat and elastic tissue disappear and replaced
with dense white fibrous trabeculae, the
interstitial tissue is infiltrated with chronic
inflammatory cell. (3) Hyperplasia of epithelium
in the lining of the ducts and acini may occur
with or without atypia. (4) Papillomatosis: - the
epithelium hyperplasia may be so extensive that
it results in papillomatous overgrowth within
the ducts.

97. • Clinical features:-the symptoms of ANDI are
may as the term is used to encompass a wide
range of benign conditions, but often include
an area of lumpiness (seldom of discrete)
and/or breast pain ( mastalgia )A benign
discrete lump in the breast is commonly a
cyst or fibroadenoma . The true lipoma
occurs rarely. Lumpiness may be bilateral
commonly in the upper outer quadrant or
less commonly confined to one quadrant of
the breast.

98. • The changes may be cyclical with an increase
in both lumpiness and often tenderness
before menstrual period. Non cyclical
mastalgia is more common in peri
menopausal than post menopausal women.
it should be distinguish from referred pain
due to musculoskeletal disorder . Breast pain
in post menopausal women not taking
hormone replacement therapy is usually
derived from the chest wall. About 5% of
breast cancers exhibit pain at presentation.

99. • Treatment of lumpy breast: - if the clinician is
confident that she is not dealing with discrete
abnormality and clinical confidence is
supported by mammography and or
ultrasound scanning if appropriate, then
initially the women can be offered firm
reassurance. It is worth while reviewing the
patient at a different point in menstrual cycle
for example 6 weeks after initial visit and
often the clinical signs will have resolved by
that time.

100. • There is tendency for women with lumpy breasts to
be rendered un necessarily anxious and to be
submitted to multiple biopsies because the clinician
lacks courage of lies or conviction. treatment of
mastalgia :- Rx recommended of the pain interfere
with women's life ,disturb her sleep and impair
sexual activity ,initially firm reassurance that the
symptoms are not associated with cancer will help
the majority of the women . acknowledgement that
this is a real symptom , non dismissive attitude and
an explain of etiology are all helpful in managing the
conditions .in first instance , an appropriately fitting
and supportive bra should be worn throughout the
day and a soft bra ( such as sports bra ) worn at night .

101. • Avoiding caffeine drinks is said to be help. A patient
symptoms diary helps her to chart the pattern of pain
throughout the month and determine whether this is
cyclical mastalgia. If these measures are not enough in
treatment with evening primrose oil (it is Gammalinolenic
acid metabolized to anti inflammatory prostaglandin)
adequate dose given over 3 months will help more than
half of these women, it appears to achieve higher
response rates in those over 40 years of age rather than
younger age. For those of intractable pain,
antigonadotrophin drug such as danazol cap 200mg, or
prolactin inhibitor (parlodel tab promocriptin) may be
tried. Very rarely it is necessary to prescribe anti estrogen
for example tamoxifin or LHRH agonist to deprive the
breast epithelium of estrogenic derives. .

102. • Duct ectasia :-( periductal mastitis):
pathology. this is dilatation of the breast
ducts which is often associate with periductal
inflammation . the pathogenesis is obscure
and almost certainly not uniform in all cases.
Although the disease in much more common
in smokers. it is dilatation in one or more of
the larger lactiferous ducts which fill with a
stagnant brown or greenish secretion , this
may discharge .these fluids then set up an
irritant reaction in surrounding tissue leading
to periductal mastitis or even abscess and
fistula formation.

104. • In some cases a chronic indurations has forms
.beneath the areola, which is mimes as
carcinoma .fibrosis eventually develops
which cause may slit like nipple retraction.
Some believes it is anaerobic bacterial
infection and smoking causing arteriopathy.
Clinical features: nipple discharge of any
color, subareolar mass, abscess, mammary
duct fistula and nipple retraction are most
common symptoms.

105. • Treatment: in case of a mass or nipple retraction
carcinoma must be excluded by obtaining
mammography and negative cytology or
histology. Any suspicion should be excised.
Antibiotics should be tried co-amoxiclav or
flucloxacillin and metronidazole. Surgery is often
the only option likely to bring about cure of this
condition; this consists of excision of all major
ducts (Hadfield's operation). It is particularly
important to shave the back of the nipple to
ensure that all terminal ducts are removed,
failure to do so will lead to recurrence.

106. • Bacterial mastitis: it is the most common
variety of mastitis and is associated with
lactation in majority of the cases. Etiology:
lactational mastitis is seen less frequently than
previously. Most of the cases caused by staph,
infective from the hospital or from infants who
50% of them harbor staph in their nasopharynx.
Although ascending infection from a sore and
cracked nipple may initiate mastitis, in many
cases the lactiferous ducts will first become
blocked by epithelial debris leading to stasis,
this theory is supported by relatively high
incidence of mastitis in women with a retracted
nipple.

108. • Once within ampulla of the duct, staph.
cause clotting of the milk and with clot
bacteria multiply. Clinical features: classical
signs of acute inflammation (pain, fever,
rigor, edema, erythema, tender swelling) and
start as general cellulitis end by abscess
formation. Treatment: during cellulitis stage
patient should be treated by appropriate
antibiotics as flucloxacillin or amoxiclav.

109. • Feeding from the affected breast side may
continue if the patient can do, local heat and
analgesia will help to relieve pain. If an
antibiotic is used in presence of undrained
pus an antibioma may form. This is large,
sterile, brawny edematous swelling that take
many weeks to resolve.

110. • It is used to 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
indurations or other evidence of underlying
abscess, this advice has been replaced with
recommendation that repeated aspiration under
antibiotics cover and ultrasound guide be
performed. This often allows resolution without
need foe incision scar and also allows carrying
on breast feeding.pus should be sending for
culture and sensitivity.

111. • Breast abscess: if there is lactational abscess and
marked skin thinning drainage can be done under
local or general anesthesia. Drainage is done by
opening all loculi by removing septi between loculi to
make one room or loculi, with this procedure we
ensure we draining the entire abscess.
• Mondor's disease: it is superficial thrombophlibitis
of superficial veins of the breast and anterior chest
wall, it appears as subcutaneous cord. It should be
distinguish from cancer permeation.

114. • Congenital abnormalities of the breast: amazia:
congenital absence of the breast on one or both sides, it
might be associated with absence of pectorals major or
absence of the nipple. Polymazia: accessory breast has
been recorded in axilla most often, buttock and thigh.
• Mastitis in infant: equal in boys and girls and usually in
3rd or 4th day of life, if pressed lightly a drop of colorless
fluid can be expressed or milky secretion and usually
disappear at 3rd week , this called witch's milk. It caused
by stimulation of the fetal breast by prolactin in response
to drop in maternal estrogen and it essentially
physiological, mastitis usually due to staph. aurous.

115. • Diseases of the nipple: absence of the nipple is
rare and usually associated with amazia.
Supernumerary nipples not un commonly occurs
along a line extending from the anterior fold of the
axilla to the fold of the groin this is called milk line.
• Retraction of the nipple: this may be occurred at
puberty or later in life in puberty is called simple
nipple inversion and of unknown etiology. It might be
bilateral in 25%, usually it cause problems with breast
feeding and infection can occur specially during
lactation, recent retraction of nipple may be of
considerable pathological significance.

116. • Discharge of the nipple; it can occur from one or more
lactiferous ducts, management depends on the presence
of lump and presence of blood in discharge from single
duct. Mammography is done to exclude presence of
underlying mass. Cytology is useful to exclude malignancy.
a clear serous fluid means physiological in parous women,
or it might associated with duct papilloma or mammary
dysplasia.## blood stained discharge occurs in duct
papilloma, duct carcinoma and in duct ectasia. Black or
green secretion usually occurs in duct ectasia. Treatment:
carcinoma should be excluded by occult blood and
cytology. Surgical treatment of single duct is done by
excision of the duct by microdecotomy, or multiple duct
excision by core excision of major ducts.

118. • Discharge from the nipple
• ------------------------------------------------------------------
• associated with lump no lump present
• remove the lump localized to one duct from many ducts
• Microdecotomy Hb+ve Hb-ve
• over40 year under 40 years observe
and repeat
• core excision
• discharge disappear
• Locloised tone duct--
microdectomy
• Lump appears---lumpectomy

119. • Gynecomastia: hypertrophy of a male breast, may
be unilateral or bilateral. The breast enlarges at
puberty and sometimes present the characteristic
female breast causes
• (1) Hormonal cause as in patient with carcinoma of
prostate and treated by stilbestrol (now rarely used),
in teratoma of the testis, anarchism, after castration,
bronchial carcinoma, adrenal and pituitary disease
and using of steroids in young body builder.
• (2) associated with leprosy due to bilateral testicular
atrophy.

120. • (3) associated with liver failure as in cirrhosis
due to failure of metabolism of estrogen.
• (4) drugs as cemitidine, digoxine and
spirenolactone.
• (5) Klinefelter, s syndrome: sex chromosome
anomaly has 47 XXY trisomy.
• Treatment: reassurance, drugs as dostinix
(antiprolactin), parlodel, or surgery by
mastectomy with preservation of nipple and
areola.