TUMORS OF THE BREAST.
The mammary gland is a frequent site for tumors, although neoplasms of embryonic origin are not as frequent here as might perhaps be expected. Nearly one-fifth of all tumors occurring in the body will be found in this location, while the larger proportion of breast tumors are malignant.
Cysts abound in this locality, occurring in one or both breasts, and singly or in exceedingly multiple form, the latter being small and containing but a few drops of fluid. Their cystic contents are colorless and of a serous consistency, sometimes thick and mucous, occasionally discolored, and in rare instances almost like unchanged milk. In the latter case the condition is known as galactocele.
In an organ so thoroughly provided with ducts it is easy to understand how retention cysts may readily occur from plugging of some duct and the accumulation of secretion behind it. Should it occur at a time when milk is forming galactocele may be readily explained. At other times it is in every respect an abnormal development. This occlusion of the ducts may be the result of disease or of injury, and is not always complete, for it often happens that from a distended duct more or less accumulated material may be expressed by gentle pressure. In this case it will be found thick and loaded with the epithelial cells which line the passages. These retention cysts are spoken of as serous, mucous, or sanguinolent (blood cysts), according to their contents, while the lacteal contain material more or less resembling butter. True galactocele seems to be rare. While the original contents are milky it is claimed that through changes taking place in the neighborhood induration and proliferation in the surrounding membrane may result, or that mammary tissue may soften and break down into pulpy detritus.
Cystic tumors in the breast may be of innocent character, or may assume all degrees of malignancy. A cyst whose lining membrane is smooth, without reduplications or irregularities, may be regarded as innocent, while the complete extirpation of its walls will be all that is required. This may be made more complete after injecting it and staining it with methyl blue, or filling it with melted paraffin in order to occupy the place of the fluid, which should have been drawn off. On the other hand, every cyst whose interior is roughened, or presents the slightest papillomatous appearance, or which is unduly adherent, or has about it any mark of infiltration, calls not only for its own eradication, but for practically the complete removal of the breast.
The signs of cystic tumor in the breast are essentially those of any other neoplasm, except that it is frequently possible to recognize its cystic character by fluctuation. A cyst ordinarily presents as a distinct tumor, and when innocent is circumscribed and non-adherent, lacking the clinical evidences of malignancy. Pain is an uncertain feature. Most cysts develop slowly, but a cyst developing suddenly after parturition or during lactation, without previous local inflammatory changes, is probably a galactocele. The small multiple form of cyst, with which one or both breasts may be studded, is frequently confused with chronic mastitis, from which it is difficult to separate it. The escape of sebaceous material or of milky fluid from the nipple, or the possibility of making it appear by gentle pressure, will probably afford the best indication. If along with this possibility the nipple be found ulcerated, or if the extruded fluid be bloody, complete extirpation of the breast would be the only suitable measure.
Treatment.
—The general treatment of cyst has been indicated. It is a question simply of how extensively the eradication should be made. The advice of the older text-books is misleading, and it is the studies of very recent years which have shown how early the lining membrane of apparently innocent cysts may undergo malignant changes, by which the breast is soon compromised and which necessitate its entire removal.[52]
[52] It will be a safe rule to follow if it be assumed that every cyst whose contents are bloody, unless this can be traced to recent accident, and especially every cyst whose interior is papillomatous, is on the border-land of malignancy, if not malignant in character. All such tumors then should be extirpated. If they occur in the breast a complete operation, as for cancer, should be done.
Of the benign tumors lipomas in the substance of the gland are rare, while they may frequently develop in its fatty surroundings. Adenoma and fibroma, with their various combinations, are the most common of the innocent tumors, and they constitute single or multiple nodules, located in the substance of the gland, or in evident communication with it, constituting masses of well-marked density, slow growth, nearly always mobile and non-adherent to the skin, causing neither retraction of the nipple nor lymphatic involvement, and being frequently accompanied by a very disproportionate amount of pain and tenderness, some of them being, in fact, exquisitely sensitive. While these growths are rare previous to puberty they are frequently met in girls and young women, and, occurring in these neurotic subjects, they cause considerable mental as well as physical trouble. In these patients there may be found coincident pelvic disorder. The removal of these sensitive masses, which seems to be plainly indicated, is often disappointing, as the remaining scar may retain the original hypersensitiveness, and patients often suffer as much as before the operation.