Chapter 58 – The Breast

Bailey & Love 28th edition

Dr. Mahdi Aljamal, MD
General and Laproscopic Surgeon
Surgical Anatomy
• In adult female, extends from 2nd
– 6th ribs (inframmary crease),
medially from Lateral border of
sternum to AAL*

• Adult male rudimentary, 2 cm in

diameter, below the areaola

• Axillary tail (of spence) not well

developed in all women, mostly
seen in premenstrual period or
during lacation.
Surgical Anatomy
• Ducto-lobular and supportive tissue
• Terminal ductal tubular unit (TDLU) =
terminal ductule with lobule
- most active part of breast
-responds to number of hormones
(estrogen, progesterone, prolactin, GH)
- most breast disease from it
• 5-9 major lactiferous (milk) ducts
carrying milk from lobes
- each lined with spiral myoepithelium
• 10-100 lobules empty via ductules
into lactiferous duct
Surgical Anatomy
• 50% of breast ducto-tubular
tissue in upper outer quadrant
and 20% in central region
• Supportive tissue:
- cooper ligaments (suspensory
ligaments) = from dermis to
pectoral fascia deeply
- adipose tissue
- blood vessels, nerves and
lymphatic
Surgical Anatomy
• Areola and nipple
- contain involuntary muscle in form of
concentric rings (Sappy’s muscle = erection
of nipple) , and radially in subcutaneous
tissue. (Myerholtz muscle = retraction of
nipple)

• Areolar = numerous sweat glands and

sebaceous glands (enlarge during
pregnancy, to lubricate nipple during
lactation ( Montgomery's tubercle)
• Nipple
- thick skin
- apex contain opening of lactiferous ducts
 Lymphatic of breast
• 85% to axillary nodes (ALNG)
- lateral nodes = along lower border of axillary vein
- anterior \ pectoral = lateral border of pectoralis
maojor and minor, theses are sentinle LN in most
patients
- posterior\subscapular = anterior to lastissimus
dorsi muscle
- central\medial = center of axila
- interpectoral\ rotter’s node= between pectoralis
minor and major
- apical nodes = above and medial to pectoralis
minor tendon and lateral to fist rib, receive from all
of other ALNs – they in continuity with
supralcaviular LN to drain into subclavian Lymph
trunk  the to lymphatic duct

• 15-25% to meidal (internal mammary) and other

breast LNs groups
Lymphatic of breast
• Surgically ALNG classified into 3
levels:
level 1 below and lateral to
pectoralis minor (majority)

level 2 in front and behind

pectoralis minor (rotter’s)

level 3 above and medial to

medial border of Pectoralis
minor
Case scenario:
• A 37-year-old woman presents to her physician with concern about a
left breast nodule she recently discovered on self-examination.
• The patient states that the nodule is approximately 2 cm in size, close
to her left axilla, and feels firm.
• She is concerned because her mother, age 54, was recently diagnosed
with breast cancer.

Your approach to this case to diagnose this young lady?

History of breast complain
• Chief complain = pain (mastalgia), mass, discharge, abnormal shape
• for a mass  Site, when was the lump first noticed? has the lump changed in size?
In what time frame? does the lump feel soft or soft? Is it mobile or fixed? is the
lump painful or painless? Preceding injury ? are there any other masses present or
adjacent lumps? any change to surrounding skin? Any distortion of the breast
appearance?
• Hx of menarche (late menopause or early menarche increase risk for CA*), LMP,
and current status of menarche, other related gynecological diseases
• Gravidity vs parity , breast feeding status, 1st child \ at what age,
• Self history for breast CA or treatments
• Drug hx of HRT , oral contraceptive pills
• Family hx of breast CA or other gynecological CA **
Clinical examination
Ultrasonography
• Primary imaging modality in young female
(<30 years), as mamograms difficult to interpret (because of
their dense breast tissue)
• Distinguish cystic from solid
• Guide biopsy.
• Cystic lesion 
- simple cyst no need neither treatment nor follow up unless painful or comlex
cyst.

• Well circumscribed mobile, solid mass in young female with re-assuring

ultrasound  it only require re-assuring and imaging follow up.
Mammography
• 2 planes
• Can be used as initial screening tool for asymptomatic women in
population-based programs
• Taken by placing breast in direct contact wit ultrasensitive film and
exposing it to low voltage high amperage xrays.
• Dose 1mGy \ film
• In older patient it is the first imaging modality (> 40 years )
• Mamographic cancer features include = irregularity, spiculation,
pleomorphic calcification, architectural distorstion
MLO cc
BI-RADS = Breast Imaging Reporting and
Database System
• Mammoraphic and ultrasonographic features NOT diagnostic of cancer,
- Biopsy is required for definitive diagnosis in lesions with BI-RADS 4
or more
• BI-RADS 0 to BI-RADS 6
Breast Imaging Reporting and Database System BI-RADS
 Breast MRI

• Adjunctive diagnostic tool , high sensitivity for breast pathology

Scenarios where breast MRI is needed:

• women with dense breasts or discordant or equivocal findings on
mammogram/ultrasonography;
• to distinguish scar from recurrence in women who have had previous
breast conservation therapy for cancer;
• to assess multifocality and multicentricity and, in lobular cancer, high-
grade ductal carcinoma in situ (DCIS);
• women with breast cancer (BRCA) gene or other genetic mutations or a
strong family history
• Women with breast implants
Positron Emission Tomography (PET)
• Used as staging investigation in pressence of symptoms \ signs
suggestive of metastasis.
• Very expensive and insurance policies may not cover its cost.
Biopsy
• Needle biopsy
- local anesthisa, large diameter core needle biopsy device (NOT FNA)
- 14 G for breast and 18G for axillary nodes
- under image guidance (always) (US, Mammogram or MRI)
• Vaccum-assisted biopsy
- sampling error decrese as bx volume incresae using 8G or 11G allows
more extensive biosp;y
Benign Breast Disease
Nomeclature
• Confusion in the past was due to:
- benign breast conditions are practically universal among women but Variety of terms
USED to describe them all  fibrosis, adenosis, epitheliosis, fibroadenosis and
fibrocystic disease
- clinical patterns  pain, nodularity, benign lumps and nipple discharge
but this term (fibrocystic disease) when applied to a biopsy or a palpable breast
mass, nonspecific and often includes normal physiologic and morphologic
changes in breast along with specific benign disease process

• Most benign derived from minor aberration of normal process of development

(lobular development), cyclical hormone-related change and involution.
- so ANDI developed (abberations of normal development and involution) =
purposeof ANDI is to refrain from calling normal changes a disease and to eliminate
confusion
Etiology of benign breast Disorders
• Benign breast pathologies = 90% of clinical presentations related to breast
• Common 30-50 years, thus it is hormonal in nature

• Breast dynamic structure = alteration duet o cyclical changes in estrogen \ progesterone in every
menstrual cycle
- act as growth factors on epithelial and stroma cells of TDLU

• Pathogenesis of ANDI involves disturbances in breast physiology extending from perturbation of

normality to well defined disease

• Pathology is divided to 3 phases (lobule development 15-25 yr, hormonal cyclical changes 15-50
years, involution 35-55 years)
Lobular proliferation leads to formation of fibroadenoma
Involution leads to cystic formation
aberration in between can leak to number of benign conditions
 ANDI classification of benign breast
disorders
Disorder of development Disorder of involution
Disorder of cyclical
• Polymastia, polythelia • Fibrocystic breast disease\ chronic mastitis\
change
Mammary dysplasia
• Accessory axillary breast
• Mastalgia and - Include a variety of changes in glandular
tissue
and stomal tissue in response to estrogen\
nodularity
• Congenital inversion of progesterone level, and often present with
nipple cyclical pain (mastalgia)

• Macromastia • Fibrocystic changes:

• Fibroadenoma - cyst
- fibrosis
• Phylloides tumor
- sclerosing adenosis
•
pathology
• Hyperplasia of epithelium
- more than 2 layers of cell lining of duct and acini
- with or without atypia
- if atypia present  atypical ductal hyperplasia (ADH) and atypical
lobular hyperplasia (ALH)  if ADH involve >2 ducts or lesions >2
mm in diameter = Ductal carcinoma in Situ DCIS

• cyst formation:
- kinking or narrowing of ductules due to involution of stroma 
accumulation of secretion in lobules  microcyst  many microcysts
joint together  macrocyst
pathology
• Papilloma:
- localized hyperplasia to produce papilloma within the duct
- central fibrovascular core and papillary projection of epithelium and
myoepithelium

Types of papilloma:
1- solitary papilloma relative risk (RR) x1.5-2
2- papillomatosis: 5 or more papilloma in many ducts with peripheral and
often bilateral distribution RR x3
3- juvenile papillomatosis = Swiss cheese disease: young women, multiple
firm nodules, with multiple papilloma with\without atypia, apocrine cysts,
ductal hyperplasia and sclerosing adenosis.
Family hx of breast CA increase lifetime CA risk
Clinical features of ANDI
• Most common breast pain and benign nodularity (localized or spread)
• Usually follow menstrual cycle, appear day 14 and continue till day
28= becomes sever (cyclical pronounced mastalgia with premenstrual
exacerbation)
• Often bilateral, mostly in UOQ
• Nodularity may be cyclical, 1-2 weeks prior to menstruation, and
regress with onset of menses.
• Discrete lump in breast commonly fibroadenoma in young and cyst
in middle-aged
Mastalgia = mastodynia = mazodynia
• 50-70% of presenting complain to clinic
• True mastalgia = from breast tissue
• Classified cyclical and non cyclical
• Cyclical mastalgia
- pain starts mid of cycle and increases, can be very sever
- usually both breasts
- relieved with onset of menses
-may radiate to upper arm and mistaken for angina
- cause unclear (low dietary fatty acid, water retention , psychoneurosis, high caffeine
intake, hormone in balance not supported by research)
- progesterone, estrogen, prolactin in normal level mostly
• BUT most patient respond to txt with antiestrogen drugs (tamoxifen), LH analogues
or danazol (this suggest excessive responsiveness of breast tissue to circulating
estrogen)
Mastalgia = mastodynia = mazodynia
• Non-cyclical mastalgia
- at any time, at any location, before and after menopause
- often localized
- palpation shows very tender spot = trigger spot\point
- can be due local duct ectasia, periductal ectasia, musculoskeletal (Tietz’s
syndrome), trauma, cancer, sclerosing adenosis
- Vitamin D and calcium deficiencies  bony aches and may present as a on-
cyclical mastalgia

• 5% of breast CA exhibit breast pain, but usually not as sole presenting

complain
Treatment of
breast pain
Nodular or Lumpy breasts
• Painful tender nodularity with
mastalgia  treat as mastalgia
• Nodularity without pain 
TRIPLE assessment
• In the absence of a discrete lesion
on breast imaging, reassurance
may be given.
• If necessary, treatment with an
antiestrogen such as tamoxifen or
ormeloxifene has been found to
control nodularity within a few
week
Discrete breast lump
Discrete lumps in the breast
• Evanescent lump = a lump appears in breast then disappear within few
days
- due to inflammatory mass of periductal mastitis
- pain, mass, tenderness all disappear together.

• If a cyst or galactocele ruptured  mass disappear but pain\

tenderness appear (due to milk\ fluid leaking into stoma 
inflammation)
Breast Cysts
• Common 35-55 years old, usually painless mass, present suddenly
• Causative factors contribute as part of ANDI – lobular involution, increased
secretion, ductile obstruction, loss of stroma, hyperestrogenemia, HRT
• Often multiple, can mimic malignancy
• Dx by ultrasound,
• Simple cyst = Smooth-walled cyst without solid component  BI-RAD2 
only observation no bx , aspiration only in case of pain\inflammation
• Complex cyst = presence of solid component in wall and need biopsy
• Complicated cyst = contain intracystic floating debris moves within cyst
with change of posture
Galactocele
• Rare
• Solitary subareolar milk-
filled cyst during \ just after
lactation
• Disappear completely and
cured with single aspiration
• If recurs  open duct with
nylon strand or re-aspirated
• Surgery rarely needed.
• If lactating women, encourage
to continue breast feeding
Fiboadenoma
• Most common cause of breast lump 15-25 years.
• Hyperplasia of lobule, surrounded by well defined capsule
• Can reach 2-3 cm
• Typical fibroadenoma, approved on US  observation without bx
• Bx if patient > 25 or atypical feature on US
• May regress with anti-estrogen medications
• Giant fibroadenoma: occasionally during puberty, > 5 cm, rapidly
growing and can be enucleated by sub-mammary incision
• RR x 1.5-1.7 , in case of hyperplasia x3.5
• Complex fibroadenoma +family hx  RR x 3-4 specially lobular CA
Fiboadenoma
• Indications for surgical removal:
- > 30 years
- suspicious feature e.g. microlobulation
- atypia on bx
- > 5 cm
- family hx of breast CA
- patient preference
• Excision of fibroadenoma in elderly
need excision with rim of normal tissue
due to possibility of malignancy or
phyllodes.
 Phyllodes tumor
• Old name = cystosarcoma phyllodes
• Benign lesion , usually > 30 years
• Large, massive sometimes BUT remains
mobile on chest wall
• Occasionally ulceration of skin due to
pressure necrosis
• Both epithelial and mesenchymal elements
• Resembling fibroadenoma even on bx
 Phyllodes tumor
• Classified to:
- benign
- borderline
- malignant
based on mitotic rate (<4, 4-9, >10) respectively

• Treatment = WLE = wide local excision with 2 cm margin along with

overlying skin and underlying major muscle due to high incidence of local
recurrence

• Massive tumor, recurrent tumor and malignant type  mastectomy

 Pathological terms
• Nipple inversion = failure to
elongation of major milk duct, not
predispose to CA

• Nipple retraction = acquired,

fibrosis around major milk ducts, if
recent need to R\O CA, most cause is
periductal mastitis.
• If slit like  periductal mastitis , if
circumferential  may CA
 Pathological terms
• Cracked nipple = small ulceration on the
nipple due to strong negative force of
sucking.
• Papilloma of nipple = as any skin
papilloma, excised with tiny disc of skin
• Retention cyst of gland of Montgomery
(mentioned earlier)
• Eczema = if failed to heal with
betamethasone cream and moisturizing
soap, baget's disease need to be ruled out
 Pathological terms
• Paget’s disease
- unique type of DCIS in nipple
- erosion of nipple slowly destroy nipple and
areola
- may become invasive and mts to ALNG
- triple assessment is needed to R\o
underlying malignancy.
- Paget’s without malignancy central core
excision down to pectoralis major then
radiotherapy
- Paget's with malignancy treated with
mastectomy and evaluation of axillary nodal
status
 Patholgoical conditions
• Amazia = congenital absence of breast may occur
on one or both sides. = Poland’s syndrome
• Polymazia = accessory breast, most frequent site
is axilla
• Macromastia = benign, massive enlargement of
one or both breasts
• Gynecomastia = enlargement of male breast tissue
• Fat necrosis = acute\ chronic, following a blow to
breast, causes a lump, painless
• Galactorrhoea = spontaneous milk discharge from
several ducts of both nipples unassociated with
childbirth or breastfeeding.
 Patholgoical conditions
• Duct ectasia =
- dilated major milk ducts, disorder of involution, part of ANDI , can lead to periductal
mastitis and fibrosis and n. retraction
- Toothpaste like or colored brown\green\mud colored nipple discharge
- US  dilated major milk ducts > 3 mm in diameter
- Txt = triple assessment then Abs 2-3 weeks
- in case of profuse discharge or subareolar abscess major mammary duct excision
is performed

• Mondor’s disease
- thrombophlebitis of superficial veins of breast and anterior chest wall
- tender thrombosed subcutaneous cord attached to skin
- txt = only restrict arm movement, subsides within few months without recurrence or
consequences
 Patholgoical conditions
• Lactational mastitis = in lactating mothers, mostly S.aureus, can be bacterial
or non-bacterial, specially in 1st month of lactation and at weaning
- txt – Antibiotics (14 days) , encourage \ 2 hours breastfeeding, breast support
garment, cold compression and analgesia
- if not treated  suppuration and abscess  txt currently aspiration and
culture and Abs (14days)
- if abscess > 3 cm , or more >30 cc pus need vacuum suction drain

• Other types of mastitis – non-lactational mastitis

- periductal mastitis (chronic), may autoimmune
- granulomatous mastitis = self-limiting inflammatory of unknown etiology
-
Discharge from the nipple
 Discharge form nipple:
• Most nipple discharge caused by physiological aberrations as part of
ANDI
• Single or many ducts, one side or both
• Single, serous, sanguineous, spontaneous  pathological , need to rule
out Malignancy
- Multi-duct, multicolored = physiological
• Bloody discharge during pregnancy considered physiological, and abate
spontaneously after birth.
Discharge from the nipple
 Discharge form nipple- treatment
• Triple assessment
• Ultrasound, 85% diagnostic accuracy for duct papilloma
• Ductoscopy currently not practiced, poor diagnostic yield
• Cytological examination of nipple discharge abandoned due to poor
yield
• <40 yrs + blood discharge and normal triple assessment  reassured and
followed up annual imaging
• >40 + bloody discharge  microdocheectomy for single duct discharge ,
or Hadfield’s major mammary duct excision for multi-duct discharge
Thank You 