Lump in Breast

A 55-years old female complained to her family physician of a hard painless lump in the upper and outer portion o her right breast. The examination of the breast revealed the peau d’orange appearance of the skin, loss of mobility of the beast, and retraction of the nipple. The examination of axilla revealed the enlargement of axillary lymph nodes. The x-ray of the vertebral column revealed an irregular shadow in the vertebral bodies of T6 and T7 vertebrae. She was diagnosed as a case of breast cancer.

Questions

1. What do you understand of a lump in the breast? What are its common causes?
2. Mention the anatomical basis of the peau d’ orange appearance of the skin, retraction of the nipple, and loss of mobility of the breast.
3. Name the three muscles lying deep to the base of the breast.
4. What is the venous route of the spread of breast cancer?
5. What is the most common site of breast cancer?

Answers:

1. Any abnormal mass or thickening of the breast tissue is called a breast lump. Lump in the breast may occur due to fibroadenoma (a benign tumor of the breast, which is usually a firm solitary mass that is mobile beneath the skin), breast cysts, fibrocystic changes, fat necrosis, or breast cancer (a malignant tumor of the breast, which is adherent to underlying tissue and immobile).
2. Peau d’orange (orange-peel appearance) results from obstruction of the cutaneous lymphatic drainage by malignant cells, causing skin edema. The skin remains tethered at hair follicles and by Cooper’s suspensory ligaments, producing the characteristic dimpled appearance.

Retraction of the nipple occurs due to the infiltration of lactiferous ducts by the cancer cells and their subsequent fibrosis.

Loss of mobility of the breast occurs when cancer cells invade the retromammary space, pectoral fascia, or underlying muscles, causing fixation of the breast to the chest wall.

3. The bed of the breast is formed mainly by:
   • Pectoralis major
   • Serratus anterior
   • External oblique aponeurosis (inferiorly)
4. Enlargement of axillary lymph nodes occurs because lymph from most parts of the breast drains into the axillary lymph nodes. Their involvement is an important sign of regional spread of breast cancer.
5. Breast cancer may spread through the posterior intercostal veins to the vertebral venous (Batson’s) plexus, allowing metastasis to the vertebral column, ribs, skull, and other bones.
6. The upper outer quadrant of the breast, including the axillary tail (Tail of Spence), is the most common site of breast carcinoma.

Common warning signs of breast cancer include a painless breast lump, nipple retraction, skin dimpling, peau d’orange appearance, abnormal nipple discharge, and enlarged axillary lymph nodes.