PATHOPHYSIOLOGY, CLINICAL

MANIFESTATIONS, PHYSICAL
SIGNS AND DIAGNOSTIC
FEATURES OF BREAST DISEASES

PROFESSOR TURGUT IPEK

 BREAST DEVELOPMENT AND
PHYSIOLOGY
¾ Puberty begins at about 12 years of age.
¾ This process of growth entails cell division
and is under the control of estrogen,
progesterone, adrenal hormones, pituitary
hormones, and trophic effects of insulin
and thyroid hormone.
¾ The term prepubertal gynecomastia
refers to the symmetrical enlargement and
projection of the breast bud in a young girl
before the average age of 12,
unaccompanied by the other changes of
puberty.
¾ The mature or resting breast contains fat,
stroma, lactiferous ducts, and lobular
units.
¾ With pregnancy, there is diminution of the
fibrous stroma to accommodate the
hyperplasia of lobular units. After birth,
there is sudden loss of the placental
hormones and the continued high level of
prolactin.
¾ When breast-feeding ceases, there is a fall
in prolactin and no stimulus for release of
oxytocin. The breast then returns to a
resting state and to the cyclic changes
induced when menstruation begins again.
¾ For the breast, menapause results in
involution and a general decrease in the
epithelial elements of the resting breast.
These changes include increased fat
deposition, diminished connective tissue,
and the disappearance of lobular units.
 ABNORMAL PHYSIOLOGY AND
DEVELOPMENT
Gynecomastia
¾ Hypertrophy of breast tissue in men is a
common clinical entity.
¾ The enlargement in teenage boys is common
and is frequently bilateral, although it may be
unilateral .Unless it is unilateral or painful, it
passes unnoticed and regresses with adulthood.
Pubertal hypertrophy is general treated by
reassurance and without operation
¾ Hypertrophy in older men is also common
and may regress spontaneously. It is
frequently unilateral.A number of
commonly used medications, such as
digoxin, thiazides, estrogens,
phenothiazines and theophylline may
exacerbate senescent gynecomasty
Nipple Discharge
¾ The appearance of a discharge from the
nipple of a nonlactating woman is
frequently frightening to the patient. Nipple
discharge is common and is rarely
associated with an underlying carcinoma.
¾ A milky discharge from both breasts is termed
galactorrhea may be associated with increased
production of prolactin.
¾ Unilateral nonmilky discharge coming from one duct
orifice is rare and is surgically significant and warrants
special attention.
¾ To conclude, nipple discharge that comes from a single
duct and contains blood must be investigated further.
¾ The most common cause of spontaneous nipple
discharge from a single duct is a solitary intraductal
papillom in one of the large subareolar ducts directly
under the nipple.
¾ In summary nipple discharge that is
bilateral and comes from multiple ducts is
usually not a surgical problem. Bloody
discharge from a single duct does require
surgical biopsy to establish a diagnosis.
Intraductal papilloma is found in most of
these cases. If an occult cancer is found. It
is usually an intraductal carcinoma.
Breast Pain
¾ Breast pain may occur in young women
associated with menstrual irregularity or as
a premenstruel symptom. In addition
fibrocystic change or ctstic mastopathy
may cause breast pain.
Fibrocystic Change (Cystic Mastopathy, Cystic Mastitis)
¾ Fibrocystic change popularly referred to as fibrocystic
disease, represents a spectrum of clinical and histologic
findings and describes a loose association of cystic
formation, breast nodularity, stromal proliferation and
epithelial hyperplasia.
¾ This condition is commonly painful and tender to touch
masrocysts, microcysts, stromal fibrosis, adenosis and a
variable amount of epithelial metaplasia and hyperplasia.
There is no consistent association between fibrocystic
complex and breast cancer.
Galactocele
¾ A galactocele is a milk-filled cyst that is
round well circumscribed and easily
movable within the breast. The
pathogenesis of galactocele is not known
but it is thought that inpissated milk within
duct is responsible
Absent or Accessory Breast Tissue
¾ Absence of breast tissue (amastia) and absence
of the nipple (athelia) are very rare anomalies.In
contrast accessory breast tissue (polymastia)
and accessory nipples (supernumerary nipples)
are both common. Supernumerary nipples are
usually rudimentary and occur along the milk
line from the axilla to the pubis in both males
and females.Accessory breast tissue is comonly
located above the breast in the axilla.
 DIAGNOSIS OF BREAST DISEASE

History
¾ The age of menarche, menstruel irregularities
and the age at menapouse should be sought.
¾ In younger women the history of pregnancy and
location should be recorded. A drug history
should pay particular attention to HRT or the use
of hormones for contraception. The family
history should be directed to cancer of the breast
in primary relatives (mother,sisters,and
daughters).
Risk Factors for Breast Cancer
¾ Gender is an important risk factor. Males at risk
for breast cancer although the incidence in
males is less than %1 of the incidence in the
females.
¾ A history of mammary cancer in one breast
increases the likelihood of a second primary
cancer in the contralateral breast. In the relative
risk (ratio of observed cases over expected
cases) ranges between three and four. The
magnitude of relative risk depends on age at
diagnosis of the first primary cancer
¾ The relationship of family history and the risk of
breast cancer. 1)there is a twofold to threefold
excess risk of the disease in first degree
relatives (mothers, sisters, and daughters) of
patients with breast cancer. 2) risk decreases
quickly in women with distant relatives who are
affected with breast cancer (cousines, aunts,
grandmothers) and 3) the risk is much higher if
affected first degree relatives had
premenopausal onset or bilateral breast cancer.
¾ The relative risk of cancer in women with
atypical hyperplasia was 4.4 times the risk
of development of breast cancer in control
population of women. The coexistence of
a positive family history with atypia on
biopsy increased the risk to nearly nine
times the general population. The average
risk ratio for 5 years of HRT is 1.35 and
risk increases by about %2 to %3 with
each year of use.
Physical Examination
¾ Edema of the skin, frequently
accompanied by erythema, produces a
clinical sign known as peau d’aronge
¾ The second clinical feature of carcinoma
that directly involves the nipple was
described by Sir James Paget in 1874 and
named Paget’s disease.
Fine-Needle Aspiration
¾ Its main utility is the differentiation of solid
from cystic masses.
¾ Carcinoma will not be missed if surgical
biopsy is done when 1)needle aspiration
produces no cyst fluid and a solid mass is
diagnosed 2)the cyst fluid produced is
thick and blood tinged. 3)fluid is produced
but the mass fails to resolve completely.
 BREAST IMAGING
¾ The goal of radiographic imaging is to detect
small abnormalities in the breast which are not
palpable by physical examination .

Diagnostic Mammography
¾ The mammographic features of malignancy can
be broadly divided into density abnormalities
(including masses, asymmetries and
architectural distortions) and microcalcifications.
Nonpalpable Mammographic Abnormalities
¾ Mammographic abnormalities that cannot be
detected by physical examination are classified
in the broad categories. 1)lesions consisting of
microcalcifications only 2)density lesions
(masses, architectural distortions, and
asymmetries) and 3)those with both
calcifications and density abnormalities.
Screening Mammography
¾ At present screening mammography should be
offered to women older than 50 years and be
done either annually or at least biannually. For
women in their 40s recommendations for
standard practice are harder to make. Younger
women with a significant family history,
histologic risk factors or a history of prior breast
cancer should be offered routine screening.
¾ References
z Iglehart JD, Kaelin CM Disease of the Breast.
Sabiston Textbook of Surgery Ed. Townsend CM WB
Saunders Company Pennsylvania 2001, 555-601.
z Bland KI, Copeland EM Breast. Principles of Surgery
Ed. Schwartz JI McGraw Hill 1994, 531-593.
z Onat D Meme anatomisi ve fizyolojisi. Temel Cerrahi
Ed. Sayek İ Güneş Kitabevi Ankara 1991, 493-530.