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CHAPTER 10 Breast

Whatever the presenting symptoms, the patient fears she may have cancer. A rapid, efficient and sympathetic approach, paying attention to psychological and emotional problems, is required in dealing with breast disease. The treatment of breast cancer is multidisciplinary involving surgeons, oncologists, breast care nurses, breast clinicians, specialist radiologists and pathologists.

Symptoms of breast disease

Patients with breast disease present with either a lump, discharge from the nipple, pain in the breast, abnormality of the nipple, or a change in size of the breast (→ Table 10.1).

TABLE 10.1 Presentation of breast disease

Breast lump Carcinoma, cyst, localized area of fibroadenosis, fibroadenoma, breast abscess, fat necrosis, duct ectasia, lipoma, galactocele, phyllodes tumour, cyst of Montgomery’s glands, sebaceous cyst
Pain in the breast Cyclical and non-cyclical breast pain
Carcinoma (85% are painless)
Duct ectasia (pain behind the nipple)

Fat necrosis
Costochondritis (Tietze’s disease)
Mondor’s disease (superficial thrombophlebitis of veins of the chest wall)

Nipple discharge Bloodstained (intraduct carcinoma, intraduct papilloma, Paget’s disease)
Serous (early pregnancy)
Yellowish, brown or dark green (benign nodularity)
Thick and creamy (duct ectasia)
Purulent (rarely in association with breast abscess)
Milky (late pregnancy, post-lactation, prolactinoma) Nipple abnormalities Retraction (congenital, duct ectasia, carcinoma)
Inflammation (eczema, Paget’s disease)
Destruction (Paget’s disease)
Mamillary fistula Breast enlargement Benign hyperplasia, pregnancy, cancer, giant fibroadenoma, phyllodes tumour, mammary lymphoedema

Benign nodularity/breast pain

This occurs between 20 and 45 years and settles after the menopause. It probably results from an abnormal response of the breast to changes in the hormonal environment. The terms fibroadenosis and cystic hyperplasia describe the pathological condition well. There is exaggeration of the fibrotic element (i.e. fibrosis), the epithelial element undergoes hyperplasia (i.e. adenosis), and there is a tendency to cyst formation. The condition may be extremely painful, especially premenstrually, hence the terms cyclical mastitis or cyclical mastalgia.