CASE SCENERIO
A 35 years old female reported to her doctor with the complaint that for the last 3 months she
was having difficulty in doing household work because of swelling of her right arm.
She also felt difficulty during changing her clothes particularly while wearing right sleeve.
On examination, the physician noted an apparent difference in the size of both arms, swelling
of whole right arm with a lump in right axilla 4 x 4 cms. in size.
On further examination, he noticed another lump in upper and outer quadrant of her right
breast.
LEARNING OBJECTIVES:
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The student should know the:
Anatomy of the axilla.
Anatomy of the breast and relationship to the axilla.
Clinical importance of axilla in relation to breast diseases?
QUESTIONS:
 What do you think what is the cause of the swelling of the arm?
 Relation of this swelling with axillary lump?
 What is the relation of breast lump and axillary lump?
 What are the important structures that pass through the axilla?
 What are the different groups of axillary lymph nodes and the area of drainage of these
lymph nodes?
 What are the causes of the axillary Lymph node enlargement?
 What are the causes of Breast Lump?
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Facilitator’s guide
Lymph edema of the arm
With enlarge lymph nodes in Axilla probably secondary to metastasis from malignant lump in
same breast.
Lymph edema
Collection of fluid (Lymph) in interstitial spaces due to impairment of lymph flow
Causes of Lymph edema
A. Primary
B. Secondary
Primary Lymph edema
Caused by abnormal lymphatic development either hypo plastic resulting in sever reduction in
numbers of lymphatic vessels and the lymphatic diameter
Secondary Lymph edema
Results from wide variety of disease processes that cause obstruction to lymphatic system.
Most important and common among these is surgical excision of lymph nodes from breast
cancer or radiation of axilla. Other causes of secondary lymph edema are bacterial and fungal
infections, trauma and lympho-proliferative disease.
Edema of the arm
It occurs in about 10-30% of patients. After axillary dissection with or without mastectomy. It
occurs more commonly if radiotherapy has been given or if there was postoperative infection.
Late or secondary edema of the arm may develop years after primary of the breast cancer as a
result of axillary recurrence or infection in the hand or arm with obliteration of lymphatic
channels
Clinical manifestations
History of disease process will usually define the cause.
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Early Signs and symptoms of arm Lymphedema
1.) Unexplained aching, hurting or pain in the arm
2.) Experiencing “fleeting lymphedema.” This is where the limb may swell, even slightly, then
return to normal. This may be a precursor to full blown arm lymphedema.
3.) Localized swelling of any area. Sometimes lymphedema may start as swelling in one area, for
example the hand, or between the elbow and hand. This is an indication of early lymphatic
malfunction.
4.) Any arm inflammation, redness or infection.
5.) You may experience a feeling of tightness, heaviness or weakness of the arm.
Stages of arm lymphedema
There are three basic stages active of lymphedema. The earlier lymphedema is recognized and
diagnosed, the easier it is to successful treat it and to avoid many of the complications.
It is important as well to be aware that when you have lymphedema, even in one limb there is
always the possibility of another limb being affected at some later time. This “inactive” period
referred to as the latency stage. It is associated with hereditary forms of lymphedema.
LATENCY STAGE
Lymphatic transport capacity is reduced No visible/palpable edema Subjective complaints are
possible
STAGE I
(Reversible Lymphedema) Accumulation of protein rich edema fluid Pitting edema Reduces
with elevation (no fibrosis)
STAGE II
(Spontaneously Irreversible Lymphedema) Accumulation of protein rich edema fluid Pitting
becomes progressively more difficult Connective tissue proliferation (fibrosis)
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CAUSE OF LUMP IN AXILLA
ENLARGED AXILLARY LYMPH NODES
 Infection,
 Local: abscess in primary areas
 Breast
 Upper limb
 Generalized
 Syphilis
 Tumor
 Primary: Lymphoma, CLL
 Secondary: Ca Breast, Skin Cancer
CAUSES OF BREAST LUMPS
BENIGN
FIBROADENOMA ,FIBROCYSTIC DISEASE,GALACTOCELE
MALIGNANT
BREAST CARCINOMA
Breast carcinoma is the 2nd commonest malignancy in female. Rare before the age of 20 but by
the age of 90years nearly 20% females are affected.
According to studies it is reported that 1 in every 9 females is affected.
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AETIOLOGY
Genetic factors, Dietary factors, Hromones, Previous radiation are important aetiological
factors in causation of Ca breast.
PATHOLOGY
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80-85% cases are ductal carcinoma while 15% are lobular. Rare types include colloid carcinoma,
medullary carcinoma, mucinous carcinoma, inflammatory carcinoma.
CLINICAL PRESENTATION
Appear as hard lump with indrawing of nipple
commonly in upper and outer quadrant of
breast. As disease advances locally
involvemenet of dermal lynphatics leads to
peau d orange appearance. Ulceration and
fixation to chest wall occurs.
SPREAD
1. Breast cancer spreads primarily to regional axillary lymph nodes by lymphatics
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2. Local spread
3. Spread by blood stream to distant viscera and bones.
DIAGNOSTIC TOOLS FOR BREAST CANCER (Tripple assesment)
1. Clinical assesment
2. Radiological assesment
3. Tissue diagnosis
INFLAMMATORY CONDI TIONS
BREAST ABSCESS
WORKUP PLAN
HISTORY
CLINICAL EXAMINATION.
LAB INVESTIGATIONS
KEY TO QUESTIONS.
1.Lymphedema of the arm secondary to carcinoma of breast.
2Enlargement of lymphnodes due to tumor infilteration resultsin blockage of lymphatic
channels causing swelling of arm.
3This breast lump is probably a malignant lump which has metastasized to regional lymph
nodes in axilla
4. Important structure passing through the axilla areaxillary artery, vein, brachial plexus
5.Different groups of axillary lymph nodes include ,anterior orpectoral group,central
group,lateral group,posterior group,and apical group.Thir area of drainage includes arm breast
claical.
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