Suspensory ligament Areola-
B. Nipple secretion or discharge
1. Nipple secretion typically contains exfoliated duct cells, cx-lactalbumin, immunoglobulins, lactose, cholesterol, steroids, and fatty acids, along with ethanol, caffeine, nicotine, barbiturates, pesticides, and technetium.
2. Nipple discharge a. Nipple discharge from a benign cause typically is green, milky, yellow, or brown; is bilateral; is not spontaneous; and affects multiple ducts.
c. Nipple discharge from a malignant cause typically is bloody or clear (serous), is unilateral, is spontaneous, and affects a single duct.
1. Fibroadenoma is a benign proliferation of connective tissue in which the mammary glands are compressed into cords of epithelium. It presents clinically as a sharply circumscribed, spherical nodule that moves freely.
2. Infiltrating ductal carcinoma a. Infiltrating ductal carcinoma is a malignant proliferation of duct epithelium in which the tumor cells are arranged in cell nests, cords, anastomosing masses, or a mixture of all of these.
b. It is the most common type of breast cancer, accounting for 65%-80% of all cases.
c. It presents clinically as a jagged-edged mass that is fixed in position, with dimpled skin in the area of the lesion, an inverted nipple, and thick, leathery skin.
d. The presence of estrogen receptors or progesterone receptors within the carcinoma cells indicates a good prognosis for treatment. Tamoxifen is an estrogen-receptor blocker and is one of the preferred drugs for treatment.
e. The presence of the c-erb B2 oncoprotein (a protein similar to the epidermal growth factor receptor) on the surface of the carcinoma cells indicates a poor prognosis for treatment.
f. BRCA 1 (the breast cancer susceptibility gene) is an antioncogene (tumor suppressor gene) located on chromosome 17 (17q21). This gene encodes for BRCA protein (a zinc finger gene regulatory protein) that contains phosphotyrosine and suppresses the cell cycle. A mutation of the BRCA 1 gene is present in 5%— 10% of women with breast cancer. This mutation confers a very high lifetime risk of breast and ovarian cancer.
Figure 3-1. (A) Anatomy of the breast. (B) Ductogram. 1 = nipple; 2= lactiferous duct; 3= lactiferous sinus; 4 = major excretory duct; 5 = minor excretory duct; 6 = glandular tissue with contrast filling; 7 = glandular tissue without contrast filling. (C) Mediolateral oblique mammogram showing a benign mass. A benign mass has the following characteristics: the shape is round or oval; the margins are well circumscribed; the density is low to medium contrast; it becomes smaller over time; and calcifications are large, smooth, and uniform. (D) Craniocaudal mammogram showing a malignant mass. A malignant mass has the following characteristics: the shape Is irregular, with many lobulations; the margins are irregular or spiculated; the density is medium to high; the breast architecture may be distorted; it becomes larger over time; and calcifications (not shown) are small, irregular, variable, and found within the ducts (ductal casts). Arrows indicate a clear zone around the tumor, with spicules. (B reprinted with permission from Fleckenstein P, Tranum-Jensen J: Anatomy in Diagnostic Imaging. Philadelphia, WB Saunders, 1993, p 239; C reprinted and D adapted with permission from Le Treut A, Dilhuydy MH: Mammography: A Guide to Interpretation. St. Louis, Mosby-Year Book, 1991, pp 36, 103.)
3. Surgical procedures for breast cancer a. Lumpectomy is the removal of the primary lesion with clear gross margins around the tumor.
b. Axillary lymphadenectomy is the removal of level I lymph nodes (at the lateral border of the pectoralis minor muscle) and level II nodes (behind the pectoralis minor muscle). Level III nodes (at the medial border of the pectoralis minor muscle) usually are not removed.
c. Simple mastectomy is the removal of all breast tissue, including the nipple— areolar complex. Care is taken to preserve the long thoracic nerve. Damage to this nerve paralyzes the serratus anterior muscle, causing a "winged scapula."
d. Modified radical mastectomy (Patey operation) is the removal of the skin, entire breast, pectoralis minor muscle, and axillary contents.
e. Halsted radical mastectomy is the removal of the skin, entire breast, pectoralis minor muscle, pectoralis major muscle, and axillary contents.
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