Breast Dis

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    Breast)You have to know the breast disease from A to Z(

    Anatomy of breast

    Blood supply:-medial mammary branches of perforating branches and anterior

    intercostals branches of the internal thoracic artery, originatingfrom subclavian artery.

    -lateral thoracic and thoracoacromial arteries, branches of theaxillary artery.

    -posterior intercostals arteries, branches of the thoracic artery in

    the second, third and 4th

    intercostals space.Venous drainage

    Mainly to the axillary vein but there is some drainage to internalthoracic vein.

    Lymphatic drainageLymph passes from the nipple, areola and lobule to the subareolar

    lymphatic plexus.

    Then from subareolar plexus:Most lymph (>75%) especially from the lateral quadrant of thebreast, drain to the axillary lymph node, initially to the pectoral( anterior) node.

    Most of the remaining lymph especially from the medial quadrant,drain to the parasternal node.

    Lymph from the axillary node drain into infraclavicular andsupraclavicular node and from them into subclavian lymphatictrunk.

    Lymph from parasternal nodes drain into bronchomediastinaltrunk.

    These 2 trunks + jugular lymphatic trunk form right lymphatic ducton the right side, or entering the termination of the thoracic ducton the left. Then open into the junction of the internal jugular andsubclavian vein.

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    N.B. skin of the breast ( exept the nipple and areola whichdrained by subareolar node ) drain into the axillary, inferior deep

    cervical, infraclavicular and also parasternal nodes of both sides.

    in sagittal suction:-the breast composed of glandular tissue and fat.

    Its secretions draining on to the surface of the nipple through 5-7 main duct orifice.

    The primary secreting unit is a group of secular alveoli draininginto a ductile.The alveoli and ducts are lined by single layer of epithelial cells.

    The shape of the female breast is due to fat containing within

    fibrous septa, and not to the glandular tissue.

    Presentation of breast disease:Breast disease present in 3 main ways:

    -lump, which may or may not be painful-pain

    -Nipple discharge or change in appearance.

    1-Lump

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    ainful lump.dxbroadenosis ( commonmatitis ( rednessbsecess ( usuallyostpartum or lactationalst and rarely carcinoma

    uestions to ask1: is it associated withmenstrual period or not2: is the femaleactatin

    Painless lumpd.dx:fibroadenoma ( breast mouse(

    beast cancercyst and some times adenosis

    questions to ask:

    Q1; Is it mobile or fixed?Q2: is there any nipple

    changes?Q3: dose the patient have back

    pain or headache?carcinoma

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    2-ain and tendrness without lump.dxclical breast pain

    on cyclical breast pain

    ry rarely carcinoma

    3-nipple dischargesa- red, pink or clear pale yellow >>> duct papilloma orcarcinoma or duct ectasiab- brown, green or black >>>> duct ectasia or cystc- creamy white yellow >>>> duct ectasia or lactation

    questions to askQ1; is it come spontaneously?Q2; is it unilateral?Is it persistence?Is the female lactating or not?

    4-pple changesuct ectasiaarcinomaaget diseaseczema

    5-change in breast sizePregnancyCarcinoma

    Benign hypertrophyRare large tumor

    If you have breast case, you haveto cover all these symptoms.

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    Examination of breast

    The patient must be fully undressed to the waist, restingcomfortably on an examination couch with her body raised at 45degree to the leg. This position is the best compromise betweenlying flat , which makes the breasts full sideways, and sittingupright, which makes the breasts pendulous.

    Ask the patient to slowly raise her arms above her head>>>> skinchange may then become more apparent, particularly tethering to

    the skin.

    Ask the patient to press her hand against her hip to tense pectoralmuscle.

    -inspectionInspect area from clavicle upward to the 6th intercostals spacedownward, and from midline to anterior axillary line.

    Do not forget, inspect the axillae, arm and supraclavicular area fordilated vein or LN enlargement.You have to inspect:

    1-breast size2-Symmetry

    3-skin:-the skin may be fixed by underlying cancer.

    -Peau, d orange, ( there may be edema caused by obstruction of skinlymphatics by cancer cells, which mark the opening of hair follicle and sweat

    glands result in orange- peel appearance.(4-Nipples and areola

    The color of the nipple change with age, and there is darkening duringpregnancy.

    Nipple inversion or eczematous changes.Duplication: accessory nipple

    Palpation:Palpate with flat of the fingers and not with the palm of the hands.

    If you find a lump, ascertain its site, size, shapeetcFor example: there is a lump in left upper outer quadrant, 2*3cm, spherical,smooth not Fixed to skin, not tender..etc

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    You have to palpate the axillae, and axillary lymph node.***Normal breast is firm, fibrous and easily palpable nodule.

    **There is different between skin fixed and tethering

    If a lump can not be moved without moving the skin, it is fixed.If a lump can move independently, it is skin tethering.

    A tethering lesion is one which is more deeply situated.

    Triple assessment:1-history and examination

    2-diagnostic imaging ( US 30 ) >>>important for screening.

    3-cytology or histology ( fine needle aspiration FNA) >>> Most

    reliable.

    Breast disease:breast carcinomacancer of the breast is an adenocarcinoma and the commonestcancer in women.

    The cut surface of a carcinoma is classically concave, grittyand pale grey with prominent yellow and white flecks.

    Etiology:1-genetic factors;

    **Family history >>>>> premenopausal first-degree relativewith breast cancer confers a lifetime risk of 25%, which reduceto 14% if the same relative is postmenopausal.

    If both mother and sister develop premenopausal BC, the riskis 33%.

    **Gene carriage >>> BRCA1 AND BRCA2 ( AUTOSOMAL

    DOMINENT) present in 80-90% of the cases.An individual whose mother carries a mutation in one of thesegenes has a 50% chance of inheriting that mutation, which willconfer a lifetime risk of 80-90%.

    The presence of mutation in BRCA1 also increase risk ofovarian cancer.

    2-hormonal factors:Gender>>>> women are 100 times more likely to have BC than

    men.

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    Menarche and menopause>>>> early menarche and latemenopause are associated with high risk.

    Parity >>> nulliparous and late age at first pregnancy (35yr)have high risk.

    Hormonal replacement therapy also slightly increase the risk.

    3-benign breast disease ( lobular or ductular hyperplasia)increase the risk of 4-5 times.

    4-radiation exposure in adolescences or early childhood

    increase the risk.

    The commonest type of BC (85%) is invasive ductal carcinomaor (no special type NST.(

    SPREAD:1-direct extension to skin >>>> skin dimpling and nipple

    retraction2-by lymphatic >>> blockage of lymphatic >>> edema>> to lung, liver, brain and bone.Prognostic factors:

    1-axillary node status >>>> the greater the number ofipsilateral node>>> the worse the prognosis.

    2-tumor grade ( histology(

    Well differentiated(1), poor differentiated(2) or plemorphic (3.(3-tumor size >>>> large size more prone to metasis.

    NPI (Nottingham prognostic index:(The above 3 prognostic factors combined to form a prognosticindex which allocate patient to 5 different groups with variable10 yr survival rate.The NPI is calculated as follows:

    0.2*DIAMETER+ GRADE+ NODAL STATUS.

    )see table 35-1 lecture note(

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    TNM classification:T >>>> TUMORT IS >>> CARCINOMA IN SITU

    T0 >>>> no primary tumor locatedT 1 >>>> tumor less than 2 cm >>>> 80% 5 year survivalT2 >>>> tumor 2-5 cm >>>> 50% 5 year survivalT3 >>>> tumor more than 5 cm >>>> 15% 5 year survivalT4 >>>> extension to chest wall >>>> 5% 5year survival

    N >>>> NODEN1 >>>>> no palpable axillary nodeN2 >>>> MOBILE palpable axillary node

    N3 >>>>> palpable supraclavicular nodes.

    M >>>> metasisM0>>>> no metasisM1 >>>> distance metasis

    History of breast carcinoma;Age>>> rare in teenager and 20.

    from 30 onward there is progressively increase incidence towhich peak in late 50.Clinical pictures:

    1-Majority of patients with invasive BC have painless lump.2-Other features are nipple changes, blood stained nipple

    discharge and unilateral nipple eczema (paget disease.(3-The nipple may become retracted, or even destroyed.

    4-Swelling of the arm, caused by lymphatic or venousobstruction in the axilla.

    5-Backache, caused by secondary infiltration and collapse of

    lumbar vertebrae, with nerve root pain radiating down the backof legs, is a common symptoms of advanced disseminateddisease.

    6-Cerebral metaplasia may cause a fit.7-Pathological fracture may be the first indication of the

    presence of the disease.

    The general symptoms commonly associated with cancer, suchas malaise, w