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Breast Disease

In order to properly discuss breast diseases, some definitions of the breast anatomy should be understood:

  • Lobules are the mammary glands which produce milk during pregnancy and breastfeeding.
  • Ducts carry milk from the lobules during breastfeeding.
  • Areola is the dark circle of skin surrounding the nipple.
  • Nipple is where milk is released during breast feeding.
  • Fatty tissue fills the space between the lobules and ducts.
  • Axillary lymph nodes are found behind the breast and under the arm pit and filter lymph fluid from the breast and arm.

Your breast tissue will go through many changes throughout your lifetime. Although the breast anatomy is the same for all women, each woman's breasts are unique. Knowing your breast features and being able to notice any changes in size, tenderness, firmness, or smoothness can help you understand breast changes when they occur. The monthly breast self-examination is the best way to know what is normal for you. In fact women find more than 90% of breast lumps themselves. If you notice a change, no matter how insignificant it may seem, you should see your doctor for further analysis. Breast pain or nipple discharge, if persistent, are also reasons to contact your physician.

The doctor will gather information about your family history and your personal history to help determine what testing might be appropriate for you. The doctor should perform a clinical breast examination and may schedule a mammogram or breast ultrasound to provide a detailed view of your breast tissue. The mammogram is used to establish a historical record and assess changes in the density of your breast tissue. It can show abnormalities too small to feel. The ultrasound can help determine whether a lump is solid or filled with fluid. The majority of breast abnormalities are not cancerous, however, it is important to have any change checked by a doctor.

American Cancer Society guidelines for breast care are:

  • Monthly breast self examination beginning at age 20.
  • Baseline mammogram between the ages of 35 and 40, then yearly after the age 40.
  • Clinical breast exams every three years between the ages of 20 and 39, then yearly after the age of 40.

Increased risk of breast cancer has been linked to those with family members who have had breast, ovarian, prostate or colon cancer. In those cases you may need to have examinations more often. You should consult a physician if you would like more information regarding your specific risk.

Breast Disease - Benign Conditions

After you have been seen by your doctor and have had a mammogram or breast ultrasound, imaging and physical exam, your doctor will determine if a biopsy is necessary. Depending on what the examination, and other diagnostic tests reveal, the doctor will determine which type of biopsy is appropriate for you.

Needle biopsy
A needle biopsy provides a quick diagnosis with little discomfort, and it can often be performed in the doctor's office. A fine needle aspiration will drain the fluid if the lump is a cyst or remove cells if the lump is solid. A core needle biopsy produces a larger cell sample and is often used to remove lumps that cannot be felt. When the lump cannot be felt, ultrasound guidance is used to locate the lump. A vacuum-assisted probe, which also uses ultrasound guidance, is used sometimes as an alternative to the core needle biopsy. Whichever type of needle biopsy is used, the cell samples are sent to the pathologist for analysis.

Open excisional biopsy
The open excisional biopsy is the most accurate method of determining if a lump is cancerous. Your surgeon will remove part or all of your breast lump in an open biopsy. The tissue will be sent to the pathologist for analysis. An open biopsy will leave a small scar on your breast.

If the mammogram detects an abnormality that our surgeon feels necessary to biopsy, a needle localization biopsy technique may be necessary. Your mammogram will be used as a guide for placing a thin wire near the abnormality. A blue dye will be injected into the wire to mark the abnormal tissue. The surgeon will make a small incision on the breast and use the wire and blue dye as a guide to remove the abnormal tissue. In 4 out of 5 cases the lump or mammographic abnormality removed is benign. Common lumps include fibroadenomas and papillomas. After these non-cancerous lumps are removed, usually no additional treatment is required.

The risks and complications associated with surgical biopsy include:

  • Excessive bleeding or bruising
  • Infection
  • Problems from general anesthesia
  • Poor wound healing
  • Small change in breast contour

Nipple discharge
Most women have some amount of nipple discharge when their nipples are squeezed. This is normal. Most nipple discharges are benign, but some types of discharges can indicate a more serious problem. There are several possibilities for the cause of nipple discharge. The most common cause of bloody nipple discharge is an intraductal papliioma, which is a benign condition. This most commonly occurs in women 30-50 years of age. Fibrocystic disease, another benign condition, may also cause nipple discharge; however, this is usually green or yellow/brown in color. It is not bloody. Galactorrhea is a milky discharge, usually from both nipples and is not associated with pregnancy or lactation. Numerous drugs can cause milky nipple discharge, including psychotropic agents.

Some forms of nipple discharge can indicate a cancerous condition. Malignant nipple discharge is usually spontaneous or occurs only in one breast. Therefore, it is important to consult your physician if you experience any type of nipple discharge.

Breast Disease - Malignant Conditions

Although breast cancer is not preventable, monthly self-breast exams, combined with yearly physician exams and mammography can lead to early detection and increased survivability.

Breast cancer is the abnormal growth of cells that start in the lining of the ducts or lobules of the breast. Breast cancer is classified by type where it starts (duct or lobule), and whether it has grown through the lining of the duct or lobule (invasive or noninvasive). The following definitions are presented in order to give you a better understanding of what it is and what treatments can be offered.

Noninvasive Breast Cancer
Carcinoma In Situ
Carcinoma In Situ means that the cancer is confined to the ducts or lobules in the breast. The cancer cells have not grown into the surrounding breast tissue or spread to other parts of the body. There are two types of carcinoma of the breast.

  • Ductal Carcinoma In Situ (DCIS) DCIS starts in the duct and does not grow through the lining and spread to other parts of the breast or body. DCIS is the most common type of noninvasive breast cancer.
  • Lobular Carcinoma In Situ (LCIS) LCIS begins in the lobule and does not grow through the lobule wall. Many breast cancer specialists do not think that LCIS is actually a cancer but is a marker for developing a future invasive breast cancer. Women with LCIS have a 25% risk for developing an invasive breast cancer in either breast within 30 years.

Invasive Breast Cancer
An invasive breast cancer means that the cancer cells have grown through the lining of either the duct or lobule and have spread to the surrounding breast tissue. The cells potentially could spread to the lymph nodes and other parts of the body. The two most common invasive breast cancers are defined as follows:

  • Invasive Ductal Carcinoma (IDC) IDC originates in the breast ducts and cancer cells have grown through the wall and spread into the surrounding tissue. Over time IDC cells will continue to grow and could spread to the lymph nodes and other parts of the body.
  • Invasive Lobular Carcinoma (LDC) LDC originates in the breast lobules and has spread into the surrounding tissue. Over time LDC cells will continue to grow and could spread to the lymph nodes and other parts of the body.

Treatment for Breast Cancer
Treating breast cancer, whether noninvasive or invasive, is dependent on many factors. Your doctor will discuss with you which options will be the best for you and offer the highest cure rate. Breast cancer treatments may include surgery and radiation to the breast, drug therapy or possibly chemotherapy. Most women will be offered the option of either a partial mastectomy or total mastectomy to initially treat the cancer. Your surgeon will discuss which surgery will offer the best results for your specific situation. We perform the following surgical options and have defined them as follows:

  • Partial Mastectomy (Lumpectomy) A partial mastectomy removes the cancer cells and a rim of healthy surrounding tissues, known as the margin. After the tissue is removed, a pathologist will study the tissue margins to make sure there are no cancer cells present. If some caner cells are found in the margin, a re-excision will be necessary to remove the remaining cancer cells. In almost every case where invasive cancer is treated by a lumpectomy, radiation treatments are needed. Whole breast radiation treatments are given 5 days a week for approximately 5-6 weeks. In certain situations partial breast radiation may become an option, and you should discuss with your doctor if this may be an appropriate option for you.

It is important to know that lumpectomy offers equal overall survival rates with a total mastectomy, but has an increased risk of cancer recurrence over a total mastectomy.

  • Total Mastectomy A total mastectomy removes the entire breast and not any of the lymph nodes under the arm.
  • Modified Radical Mastectomy A modified radical mastectomy removes the entire breast as well as some of the axillary lymph nodes under the arm. The chest wall muscles are left intact.
  • Lymph Node Surgery Whether a lumpectomy or mastectomy is performed for an invasive cancer, the lymph nodes will need to be tested to determine if the cancer has spread to that area. The surgeon may perform a sentinel lymph node biopsy which removes the sentinel or "guardian " lymph node under the arm. The sentinel lymph node is identified after a blue dye is injected into the breast to determine which is the primary axillary lymph node that the dye drains toward in flushing the dye from the system. The pathologist will immediately examine the sentinel node during surgery using a method called frozen section to determine if cancer cells are present. If no cancer cells are present, the surgeon will not remove any additional lymph nodes. If cancer cells are detected the surgeon will remove additional lymph nodes. The lymph nodes may also require removal if the sentinal lymph node can not be localized. This happens 1-3% of the time. Some patients may not be a candidate for sentinel node biopsy, but need a complete axillary node dissection. Your surgeon will discuss your options with you.

Reconstructive Surgery
If you have a mastectomy, you may choose to have breast reconstruction. We will refer you to a plastic surgeon to discuss the options available to you depending on your specific situation. The plastic surgeon will assist you in deciding what is best for you. For most women the breast can be reconstructed at the same time as the mastectomy.

Risks and complications The most common risks and complications associated with breast surgery and lymph node surgery include:

  • Infection
  • Bleeding
  • Fluid collection (seroma)
  • Pain or numbness
  • Lymphedema (swelling) of the affected arm
  • Sentinel lymph node may not be located (occurs 5-10% of the time and would necessitate a complete axillary lymph node dissection)
  • There is a very small chance of a false positive reading in which the axillary nodes are removed based on the frozen section results of the sentinel node. Frozen section is normally 95% accurate.
  • Also, there is a 5% chance of a false negative frozen section reading. Additional testing performed after the surgery may indicate cancer cells that the frozen section did not reveal. This would require a complete axillary lymph node dissection at a later date.
  • Allergic reaction to the dye.
  • Dye may discolor the skin which will resolve on its own but can take up to a year to resolve.
  • Dye may discolor urine but this will resolve on its own after a few days.
  • Slight chance of nerve injury
  • Stiffness of the shoulder

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