1. The Breast Dr. Naser El-Hammuri Head of the Department of Surgery
A. Professor & Consultant of GIT Surgery

2. The Breast Anatomy Modified sweat gland
Pigmented skin covers the areola and the nipple
Opening of the lactiferous ducts are seen near the apex of the nipple
The nipple is in the 4th intercostal space
Accessory breast / nipple tissue may develop anywhere down the nipple line (axilla to groin)

3. The Breast
Anatomy
The adult breast is divided into nipple, the areola and four quadrants, upper and lower, inner and outer, with an axillary tail projecting from upper outer quadrant
The size of the breasts are influenced by age, hereditary factors, sexual maturity, phase of the menstrual cycle, parity, lactation and general state of nutrition

4. The Breast

5. The Breast
Anatomy
Fat and stroma surrounding the glandular tissue determine the size of the breast, except during lactation , when enlargement is mostly glandular

6. The Breast Symptoms / Breast Lump Breast cancer 1 in 9 women
Solid mass with irregular outline
Usually, but not always, painless firm and hard
Fibrocystic changes
Irregular nodularity of the breast
Common especially in the upper outer quadrant in young women
Rubbery in texture
Prominent premenstrually
Usually bilateral and B9

7. The Breast Symptoms / Breast Lump Fibroadenoma
B9 lumps are an overgrowth of parts of the terminal duct lobules
Smooth, mobile, discrete and rubbery
2nd most common cause of breast mass in women under 35 years old

8. The Breast Symptoms / Breast Lump Breast Cyst Smooth fluid-filled sacs
Most common in women age 35 – 50 yr
Soft and fluctuant when the pressure in the sac is low, but hard and painful if the pressure is high
May occur in multiple clusters
Most are B9, but any cyst in which aspirate is blood stained or there is a residual mass following aspiration or which recurs after aspiration, should be investigated

9. The Breast Symptoms / Breast Lump Breast Abscesses
Lactational, usually peripheral
None Lactational, occur as extension of peri-ductal mastitis, usually found under the areola and usually associate with nipple inversion

10. The Breast Symptoms / Breast Pain Mastalgia
Could be cyclical, related to menstrual cycle, worse in the latter half of the cycle and relieved by the period
None cyclical, no variation

11. The Breast Symptoms / Skin Changes
Skin dimpling, the skin remains mobile over cancer
Indrawing of the skin, skin fixed to cancer
Lymphedema of the breast, the skin is swollen between the hair follicles and looks like peel of an orange (Peau d’orange)
Eczema of the nipple and areola, may be part of generalized skin disorder or may be due Paget’s disease or invasion of the epidermis by an intraductal cancer

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13. The Breast

14. The Breast

15. The Breast Symptoms / Nipple Changes Nipple Inversion
Retraction of the nipple
B9, symmetrical, slit like
Malignant, asymmetrical, distorted nipple, nipple pulled to one side

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17. The Breast Symptoms / Nipple Changes Nipple Discharge
Can be expressed from multiple ducts or single duct
Clear yellow, white or green
Investigate if persistent single duct discharge or bloodstained (macroscopic or microscopic) discharge to exclude duct ectasia, periductal mastitis, intraduct papilloma or intraduct cancer

18. The Breast Symptoms / Nipple Changes Galactorrhea
Milky discharge from multiple ducts in both breasts due to hyperprolactinemia

19. The Breast Symptoms / Gynecomastia Enlargement of the male breast
Often occurs in pubertal boys
In chronic liver disease it occurs due to high levels of circulating estrogens

20. The Breast

21. The Breast Symptoms / Gynecomastia 10.3 Causes of gynaecomastia
Drugs, including
Cannabis
Oestrogens used in treatment of prostate cancer
Spironolactone
Cimetidine
Digoxin
Decreased androgen production
Klinefelter's syndrome
Increased oestrogen levels Chronic liver disease
Thyrotoxicosis
Some adrenal tumours

22. The Breast The History Not all patients have symptoms
Abnormality on screening mammography
Concern about family history
Explore the patient’s FIFE
Presenting complaints
- How long have symptoms been present?
- What changes have occurred?
- Is there any relationship to menstrual cycle?
- Does any thing make it better or worse?
Breast cancer may present with symptoms of metastatic disease

23. The Breast The History Evaluate patient’s risk factors
10.4 Indicators of breast cancer risk*
Female gender
Increasing age
Family history, esp. if associated with:
Early age of onset
Multiple cases of breast cancer
Ovarian cancer
Male breast cancer
Early menarche
Nulliparity or late age of first child
Late menopause
Prolonged HRT use
Postmenopausal obesity
Mantle irradiation for Hodgkin's disease, esp. at young age (<30 years)

24. The Breast Physical Examination
Male doctor should always have a chaperone
Examination sequence
Ask the patient to undress to the waist and sit upright on a well-illuminated chair or the side of a bed.
Ask her to rest her hands on the thighs to relax the pectoral muscles (Fig A).

25. The Breast Physical Examination
Face the patient and look at the breasts for:
asymmetry
local swelling
skin changes
nipple changes.
Ask the patient to press her hands firmly on the hips to contract the pectoral muscles and repeat the inspection (Fig B).
Ask her to raise her arms above the head and then to lean forward to expose the whole breast and exacerbate skin dimpling (Figs C and D).

26. The Breast

27. The Breast
Ask the patient to lie with her head on one pillow and her hand under the head on the side to be examined. Ask her to do this on both sides at the same time (Fig ).
Hold your hand flat to the skin and palpate the breast tissue, using the palmar surface of your middle three fingers. Compress the breast tissue firmly against the chest wall.
View the breast as a clock face. Examine each 'hour of the clock' from the outside towards the nipple, including under the nipple (Fig ). Compare the texture of one breast with the other. Examine all the breast tissue. The breast extends from the clavicle to the upper abdomen, and from the midline to the anterior border of latissimus dorsi (posterior axillary fold). Define the characteristics of any mass (Box 3.10, p. 58).

28. The Breast

29. The Breast

30. The Breast
Elevate the breast with your hand to uncover dimpling overlying a tumour which may not be obvious on inspection.
Is the mass fixed underneath? With the patient's hands on her hips, hold the mass between your thumb and forefinger. Ask her to contract and relax the pectoral muscles alternately by pushing into her hips. As the pectoral muscle contracts, note whether the mass moves with it and if it is separate when the muscle is relaxed. Infiltration suggests malignancy.
Examine the axillary tail between your finger and thumb as it extends towards the axilla.

31. The Breast
Palpate the nipple by holding it gently between your index finger and thumb. Try to express any discharge. Massage the breast towards the nipple to uncover any discharge. Note the colour and consistency of any discharge, along with the number and position of the affected ducts. Test any nipple discharge for blood using urine-testing sticks.
Palpate the regional lymph nodes, including the supraclavicular group. Ask the patient to sit facing you, and support the full weight of her arm at the wrist with your opposite hand. Move the flat of your other hand high into the axilla and upwards over the chest to the apex. This can be uncomfortable for patients, so warn them beforehand and check for any discomfort. Compress the contents of the axilla against the chest wall. Assess any palpable masses for:
size
consistency
fixation.

32. Examine the supraclavicular fossa, looking for any visual abnormality
Examine the supraclavicular fossa, looking for any visual abnormality. Palpate the neck from behind and systematically review all cervical lymphatic chains (Boxes 10.5 and 10.6).

33. The Breast Investigation
Accurate diagnosis of breast lesions depends on clinical assessment, backed up by mammography and/or breast ultrasound and pathological diagnosis, either by fine needle aspiration cytology or core biopsy ('triple assessment'

34. The Breast Investigations of Breast Lump Investigation
Indication / Comment
Ultrasound
Lump
Mammography
Not in women under 35 unless there is a strong suspicion of cancer
MRI
Dense breast / ruptured implant
Fine needle aspiration
Aspirate lesion using a 21 or 23 G needle
Core biopsy
To differentiate invasive or in situ cancer
Large core vacuum assisted core biopsy
Open surgical biopsy

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36. The Breast

37. Thank you All the Best