Surgical diseases of the breast

The Skin

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.

The Nipple

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.

Breast Inflammations

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.

Breast Biopsy

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.

Breast Tumors

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.

Breast Cysts

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.

Breast Injuries

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.