Affections of the skin of the breast are essentially the same as those involving the skin of any other area of the body. Rashes, moles, furuncles, lacerations, and contusions may be seen.
Fissure of the nipple is an ulceration of the nipple and areola which develops most often from the constant irritation of nursing. There develops a longitudinal cracking and ulceration on the surface. Fissure may be slight or severe, singular or multiple, involve one nipple or both. Cracking and fissure of the nipple occurring at times other than while nursing is rare, so that other diseases (such as a skin cancer) should be suspected. Biopsy may be needed. Prevention of fissure should be by cleanliness and proper hygiene in nursing mothers. Treatment of fissure of the nipple is by local medications; nursing may have to be modified or discontinued.
Inflammations of the breast may take a variety of forms: acute mastitis is most often seen in lactating women, especially at the beginning of lactation or when breast feeding is to be terminated. The onset may be rather sudden and the course of the disease is usually short with proper medical treatment. Germs gain entrance through the nipples and ascend up the ducts to infect any part of the mammary gland. A small portion of one breast, or an entire breast, or both breasts, may be involved. The breast becomes more swollen, reddened, and painful. The milk is infected; nursing must be discontinued. Treatment is by medical measures.
Mammary abscess may develop when an infectious process proceeds unhalted in its course. An area of inflammation becomes localized with pus formation, constantly enlarging as the disease progresses. The abscess may rupture spontaneously, but more often incision into the abscess for drainage is necessary. An abscess may occur in any portion of the breast, or behind it (retromammary abscess). Most often breast abscess follows acute mastitis, but some occur seemingly without preceding cause. Medical measures are needed as an adjunct to surgical incision for drainage, as well as local medications and applications.
Chronic cystic mastitis is, as the name implies, a chronic disease of the breast in which many small cysts are formed. These occur as a result of excessive fibrous and scar tissue around the drainage ducts. The ducts are somewhat narrowed and the glandular secretions are blocked and accumulate within the glands; these become distended into small cysts. There results a nodular lumpy consistency of the breasts. When many of these glands become distended into cysts and are matted together, there may result a discrete irregular lump in the region. Such a lump may be confused with tumor. Physical examination evaluation may not yield specific differentiation, so biopsy may be necessary.
Chronic cystic mastitis is known by several synonyms: fibrocystic disease of breast, fibrocystic mastitis, chronic cystic fibrosis of breast, fibromastitis, cystic mastitis, cystic disease of breast, and several other terms. The disease and the disease process are the same.
When this form of chronic mastitis exists, the normal cyclic changes in the breasts are exaggerated. Premenstrual engorgement may be pronounced and accompanied by pain and tenderness. The term mastitis implies an inflammatory process, but actually little evidence of inflammatory reaction is apparent. The role of hormonal action is more evident, as all parts of both breasts are to some extent involved. The disease is most common between the ages of 30 and 50.
Usually the symptoms associated with chronic cystic mastitis are minimal. The usual premenstrual discomfort can generally be controlled by the simple measures of aspirin, ice packs, supporting brassieres, or rest. Hormonal treatment may be instigated only in severe cases, as it so often complicates the general health with menstrual and psychic disturbances. The major problem with this disease is that it presents a most complicated diagnostic problem. Lumps in the breast from this disease are most difficult to distinguish from tumors. At the onset of fibrocystic disease a mass in the breast may present certain physical characteristics suggestive of the disease, but definite diagnosis can be ascertained only by study of the tissue under the microscope. So biopsy is most frequently necessitated.
Severe and prolonged chronic fibrocystic mastitis is in some cases a serious premalignant disease. Repeated biopsy may be necessary to assure that malignant change in the breast has not occurred. In advanced cases where malignancy is pending (by biopsy study), sacrifice of the breast may be necessary.
Other forms of chronic mastitis, such as tuberculosis and syphilis, are indeed rare. Almost all chronic involvement of the breast follows the course of chronic fibrocystic mastitis.
Biopsy is a minor operative procedure performed for exact diagnosis. This has been mentioned in several portions of this book, but warrants repetition in the study of the breast. The importance of determining the exact nature of a swelling or lump in the breast, early in the course of the disease, cannot be overemphasized. The procedure involves incision into the lump and removal of a small portion of it for study under the microscope. When the entire lump is excised, it is called excision biopsy. When the disease is suspected as such that further surgery may be anticipated, frozen section biopsy may be planned. In this a piece of tissue is taken at the operating table, frozen, sliced, stained, and studied by the pathologist immediately; according to its nature, the necessary operative procedures may be accomplished at the time.
Tumors of the breast may be benign or malignant, the latter unfortunately predisposing in frequency. The most common benign lump is that seen in chronic fibrocystic disease, wherein several of the dilated cystic structures become matted together to form a discrete irregular mass. This usually involves both breasts and frequently several regions of the breasts. Such a lump may be tender. There is often menstrual cyclic change in the size and tenderness of the lump. The greatest problem with the lump of fibrocystic disease is its differentiation from a malignant lump. Other benign neoplasms are less common, but they demand early accurate diagnosis.
The breast is one of the most frequent sites of malignancy or cancer in a woman. Every tumor or lump of the breast should be viewed with suspicion and receive prompt medical evaluation. Whenever doubt exists as to the exact nature of a lump, it should be biopsicd or removed. Cancer of the breast is slightly more common in women who have never been pregnant or nursed. The symptoms of malignancy of the breast unfortunately are slight and slow in onset. There is no pain during the early stages of the disease. The usual story is a nontender lump usually found by the patient. This is when immediate and thorough medical investigation should be sought, for the earlier the diagnosis is confirmed and proper treatment instigated, the greater the chances for a cure.
When cancer of the breast proceeds untreated, it continues to grow and invade the surrounding tissues. It may become attached to the chest wall or to the overlying skin. Elevation of the involved breast may be noted, and it becomes hard and not so mobile as the uninvolved breast. Distortion of the nipple or bleeding may be evident. The involved skin may become inflamed and may even ulcerate. As the cancerous tumor progresses untreated, there is spread of the malignant cells to the lymph glands of the armpit. These nodules may be apparent but not painful. Later in the course of the disease there may be spread (metastasis) to the lungs, bones, brain, and liver. Only late in the disease does pain become a symptom, but in the advanced stages it may be excruciating.
Cancer beginning in the nipple may occur (Paget’s disease), but more commonly cancer develops deep in the substance of the breast.
Treatment of cancer of the breast rests with removal or destruction of the entire tumor. It is apparent that complete removal can be accomplished more surely when the growth is still confined to the breast. Surgical removal of the breast for cancer must be directed at removing all the possible lymphatic pathways that the malignancy may take in its spread. Radical mastectomy (radical amputation) includes the complete removal of the breast with a large area of skin overlying the primary growth, removal of the underlying muscles through which the lymph channels pass, and removal of all the lymph glands from the armpit. There obviously results some disfigurement of the chest, but artificial appliances and special garments may mask the deformity. The breast is usually func- tionlcss in patients with cancer, and loss of the breast as against loss of life is a small price to pay.
X-ray therapy may be employed before or after operation. Usually combination of surgery and x-ray treatments is indicated.
In more recent years the role of ovarian hormonal influence on the growth of cancer has been apparent. Therefore in some cases, especially in women still menstruating, surgical removal of the ovaries may be advisable; or destruction of the ovaries by x-ray treatments may accomplish such a castration. Male sex hormone may be given to counteract the influence of hormones of the ovary. Usually these latter methods are employed late in the course of cancer to slow its growth and spread.
In cases of far-advanced cancer of the breast when the disease has obviously spread so far that the cancer is “inoperable,” palliative measures to ameliorate suffering may be used. When the breast is ulcerated, painful, or with offensive aroma, removal of just the breast itself may be undertaken; this is the operation simple mastectomy (or simple amputation).
Since early detection of cancer is imperative if a cure is to be accomplished, routine regular self-examination of the breast is advisable for all women. The method of examination should be specific and thorough and performed at regular intervals, perferably every month. The exact method should best be inaugurated by your own doctor, but one method is presented on pages 220-221 through the courtesy of the American Cancer Society, Inc., and the National Cancer Institute.
Cysts of the breast are relatively common. They are often found in association with chronic fibrocystic mastitis, but larger solitary cysts can occur. Cysts may be confused with tumors on examination. Withdrawal of the fluid from a cyst is an ineffective means of treatment as it usually re-collects. Removal of cysts surgically is the treatment of choice.
Injuries of the breasts are not infrequent. All varieties and degrees of injury may occur. Contusions and lacerations may result from vehicular accidents. Surgical repair of many such injuries may be necessary.
Plastic surgery of the breast is most often employed for the disease breast hypertrophy. In this condition the breasts become tremendously enlarged and producc symptoms merely by their massive weight. Ordinary garments are not sufficient to support such pendulous breasts. The shoulders become severely irritated or lacerated from the straps of garments used in attempts to relieve the weight. Poor posture with stooped shoulders eventually develops. The woman is incapacitated, with easy fatigability and pain. Even weight reduction does not reduce the size of the breasts. Physical incapacity is accompanied by psychological changes, with great concern over the symptoms and disfigurement. Occasionally just one breast is hypertrophied, but most often both are involved. Plastic operations have been devised in which a breast of normal size is produced by removal of much of the excessive tissue. The nipples are usually not sacrificed, but function may be impaired.
Breast Congenital Defects
Congenital defects of the breast are not common. But of surgical concern is the patient with a supernumerary breast (accessory breast). Such an extra breast occurs by some error during embryological development of the individual. In the embryo there is a line of tissues along the entire front of the trunk called the “milk- line,” which has the components for breast development. (In some mammals, such as the canine family, all the breasts develop.) Normally in man only the two breasts develop from the milk-line, but an extra breast may develop any place along this line from the armpit to the groin. They are most common in the armpit. A supernumerary breast may be an entire breast, one without a nipple, or just a supernumerary nipple. In women the same physiological changes take place as in a normal breast, with engorgement during pregnancy and cyclic changes. Treatment of this displaced extra breast tissue is by surgical removal.