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11-29-2009, 09:27 AM
Clinical Picture of Breast CA.:
Depends on the pathological type:
(I) Duct carcinoma:
1- Bleeding / nipple which is usually painless "pathognomonic" .
2- When the duct become occluded by the growth a subareolar mass may be felt due to dilatation of its proximal part .
3- All cases of duct papilloma or duct carcinoma gives drak bloody discharge, but cystic disease of the breast is considered as more common cause because of its high incidence.
4- The prognosis is good. WHY?
a- It is well diff. columnar cell CA. ® late lymph > spread.
b- Early presentation with bl. / nipple.
(II) Atrophic scirrhous carcinoma:
1- Very slow course.
2- Old aged women with atrophic breast .
3- It gives hard lump with other criteria of malignancy in the breast.
4- The patient usually die from inter current lesion not from CA. breast.
(III) Scirrhous carcinoma: "The commonest type" .
1- History: 93% of cases presents with painless lump discovered accidentally during bathing.







Compare size while setting






Protrusion on leaning forward




Abnormal ascent on raising arms


Positions of breast inspection

2- Breast:
A- Breast as a whole in comparison with healthy side :
a- Small size due to fibrosis .
b- Higher level due to attachment to underlying muscle .
c- Less protrusion in leaning forward due to fixation .
d- Ascends to higher level than other breast during raising the arms above the head .
B- Skin changes with CA:
a- Blockage of lymphatics ® Peau- d'orange due to oedema of skin except sites of hair follicles & sweat glands.
b- Infiltration of Cooper's ligaments ® dimpling or even puckering which becomes more evident in stretching the skin.
c- Malignant ulcer may be noticed.
d- Skin nodules due to lymphatic permeation to skin ®when the skin infiltration become marked it becomes thick and hard ® cancer en cuirasse .
C- Nipple & areola:
a- Nipple retraction "recent retraction".
b- Changed direction " Normally downward, forward & laterally ".
c- Fixation to the lump "Limited mobility when fixing Lump".
d- Disharge per nipple ® crystal straw coloured or blood discharge.
D- The mass:
a- Felt easily by flat of hand & tips of the fingers.
b- With flat under surface.
c- Fixed to breast tissue ."Does not move freely inside the breast".


d- Fixation to skin "by pinching" and underlying muscles should be tested ® Pectoralis major muscle.
® Serratus anterior muscle.
3- Arm: Brawny oedema may occur with :
a- Advanced cases with infiltration of axillary nodes .
b- Late postoperative complication due to recurrence in the axilla.
4- Axilla : For palpable axillary nodes and test its mobility.
(IV) Encephaloid carcinoma: "Medullary carcinoma"
Although it is more anaplastic than scirrhous CA. it carry better prognosis WHY?
1- Rapid growth giving big soft tumors ® Early presentation .
2- Occurs in younger age group "25-35 ys" can stand radical op .
3- Lymphocytic infiltration around the tumour = good resistance.
(V) Mastitis carcinomatosa: "the most malignant"® Rapid growth with hotness, tenderness, redness and palpable axillary lymph nodes.
D.D. from breast abscess "Acute mastitis"
1- Oedema is more extensive than in abscess with dusky red coloration of skin due to venous invasion occlusion.
2- Pyrexia and leucocytosis are usually absent.
3- No response to antibiotics as in acute mastitis.
4- Lymph nodes are hard and fixed but in abscess are firm & tender.
(VI) Paget 's disease: see before
SOURCE: Prof. AYMAN SALEM'S BOOK
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