Monday, October 12, 2009

1908 View of Solid Tumors of the Breast

I continue to be fascinated by the 1908 textbook, A Text-Book of Minor Surgery by Edward Milton Foote, MD.  As October is Breast Cancer Awareness Month, I’m going to share the section from the book on that topic.
Solid Tumors of the Breast
Sometimes during adolescence one of the breasts will become abnormally firm and larger than its fellow and rather more sensitive to pressure, but without acute pain.  The enlargement is diffuse and uniform, and there is no adhesion of the breast to the structures either beneath or superficial to it.  Such a condition has a tendency to resolve in the course of time.  This return to the normal state may be hastened by an application of ichthyol ointment.
An adenoma or an adenofibroma of the breast is a tumor which is composed of a localized increased growth of glandular and fibrous tissue.  There are several types of such tumors distinguishable microscopically, but as no adenoma is composed only of glandular tissue and no fibroma is without a certain increase in glandular tissue, and as both of these often contain cysts, an exact differential diagnosis between them is not always possible, nor has it more than a pathological significance.  The tumor is generally painless and is first noticed by the patient during a bath or by accident.  In other cases there is a little pain in the tumor.
Treatment – Such tumors are essentially benign, but they may also change their type of growth into one which has a tendency to spread into the surrounding tissues.  Hence they should be removed, or at least carefully watched from month to month in order to be sure that they are not growing.  Puncture with a hypodermic needle, and aspiration, will differentiate between a cystic and a solid tumor if fluid is obtained.  A negative aspiration is not conclusive.  If the tumor is small and freely moveable, a local anesthetic will often suffice; but otherwise, and especially if the patient is more than thirty years of age, she should be told beforehand of the possibility of a major operation and should be given a general anesthetic.  If the growth is found to be malignant, the operation should be continued until it includes the removal of the breast and dissection of the axillary and clavicular regions, and the excision of one or both pectoral muscles, according to the judgment of the surgeon.  It is of great assistance at such times to have a pathologist present, who, by making frozen sections of even a small, freely movable tumor which has been growing but a few months and is painful.  This is especially the case if the patient is a woman more than thirty years of age.

The Early Diagnosis of Malignant Tumors of the Breast
The treatment of malignant tumors of the breast is quite out of the range of minor surgery, but the importance of a correct diagnosis in the early stages is so great and these tumors are so often first seen in ambulatory practice, that the diagnostic points should be emphasized. 
In examining a patient’s breast these points should be observed:
Palpation – The patient should lie flat on the back with both breast exposed for the sake of comparison.  Some examiners prefer to have the patient sit upright, but the recumbent position is better for a thorough examination.  Each breast should then be thoroughly examined by rolling its substance between the palmar surface of the fingers and the wall of the thorax.  The aim of the examination is to determine the presence of any nodules or other irregularities.  If there are multiple nodules in both breasts, the case is probably one of chronic mastitis.   The same is probably true of multiple nodules in one breast, for if these are cancerous, the disease will of necessity be far advanced, and some of the other symptoms will be present.  A single nodule in one breast, or in each breast, may or may not be cancer.  It should be further examined.
Retraction of the Skin – This is best shown by pushing the breast, but not the tumor, toward the suspected part of the skin.  Retraction of the skin, under these circumstances, is one of the most reliable signs of cancer.
A Flattening of the Normal Curve of the Breast Over the Tumor --  This is determined by sighting across it with the eye on the same level.  If present it is an indication of malignancy.
The Presence of One or More Enlarged Glands in the Axilla or Between the Breast and Axilla – This is not one of the earliest signs.  Both Axillae should be palpated.  If the glands in each are equally enlarged, and only one breast contains a nodule, the axillary glands are presumably non-cancerous.
Retraction of the Nipple – This is an early sign of cancer only when the disease begins under or near the nipple.  In other cases the growth may be well advanced before retracting the nipple.
Hemorrhage from the nipple, either spontaneous or occurring when the nipple is gently squeezed, is a symptom of value if there is no inflammation or other obvious explanation of its occurrence.
Failure to Withdraw Fluid through a Fine Aspirating Needle  --  A long hypodermic needle is sufficiently large.  Fluid indicates cystadenoma in most cases, though some cancers contain fluid. 
The importance of carcinoma of the breast is so great that, unless the examiner can be sure that the tumor is of a benign character, he had better assume it to be malignant.  In doubtful cases a section should be removed for microscopical examination.  This may be successfully done with cocaine, unless the patient is of a nervous disposition.  If the tumor is malignant, an extensive removal of breast and axillary gland and pectoral muscles and fascia is indicated.
Carcinoma beginning in the nipple, so-called Paget’s disease may be mistaken for eczema.  There is redness and scaliness, followed by a shallow ulceration with a slightly indurated base and narrow indurated margin.  It is inexcusable to neglect such a condition, since the microscopic examination of a small section of the affected skin will reveal the true nature of the disease.
Sarcoma – Sarcoma of the breast differs somewhat from carcinoma in its gross characteristics inasmuch as it usually develops at a greater distance from the nipple and forms a diffuse swelling deeply situated beneath the skin, and often extending beyond the margin of the breast in one or more broad lobules before the surgeons’ advice is sought in regard to it.  It grows rapidly, without pain, and forms new nodules by continuity rather than through the lymphatic system; hence the axilla may be entirely free although the tumor has grown to a diameter of two inches or more.  Such a freedom of the axilla is never seen in carcinoma of the breast of a similar size.  Sarcoma grows more rapidly than carcinoma, and a thorough and early removal is, therefore, not less important. 
Tuberculosis may be mistaken for a malignant tumor (see p 180).  -- From p 180: 
Tuberculosis of the Mammary Gland – One of the less common situations for tuberculosis is the mammary gland.  Because of its rarity, and because of the similarity of the lesion in its general outline to carcinoma of the breast, this mistaken diagnosis is often made.  There will generally be a history of tuberculosis in the patient, or examination of the corresponding lung may show that the primary trouble was located within the chest and has worked outward.  If an ulcer or sinus exists its appearance will keep an observant  man from making a wrong diagnosis.  There will be in the edges of the tubercular ulcer none of the active growth which is always seen in the edges of a carcinomatous ulcer.  The axillary glands are usually enlarged if an ulcer exists.
Treatment – In tuberculosis of the breast it is quite unnecessary to remove more than the affected part.  Usually the whole gland is diseased at the time of operation, but unless the axillary glands are plainly diseased it is wrong to subject the patient to the extra shock of an axillary dissection.  On account of the possible involvement of an underlying rib, a general anesthetic is preferable.  If the disease is plainly limited to the freely moveable breast=gland, a complete removal can be satisfactorily effected under local anesthesia if the patient’s temperament warrants it.

Related posts:
Breast Self-Exam (October 10, 2009)
October – Breast Cancer Awareness Month (October 2, 2008)
Mammograms  (October 13, 2008)
ARM Technique (October 15, 2008)
Breast Reconstruction—Part I (October 2007)
Breast Reconstruction – Part II (October 2007)

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