PATHOPHYSIOLOGY, CLINICAL PATHOPHYSIOLOGY, CLINICAL MANIFESTATIONS, PHYSICAL MANIFESTATIONS, PHYSICAL

SIGNS AND DIAGNOSTIC SIGNS AND DIAGNOSTIC FEATURES OF BREAST DISEASESFEATURES OF BREAST DISEASES

PROFESSOR TURGUT IPEKPROFESSOR TURGUT IPEK

BREAST DEVELOPMENT AND BREAST DEVELOPMENT AND PHYSIOLOGYPHYSIOLOGY

PubertyPuberty beginsbegins at at aboutabout 12 12 yearsyears of of ageage. . ThisThis processprocess of of growthgrowth entailsentails cellcell divisiondivisionandand is is underunder thethe controlcontrol of of estrogenestrogen, , progesteroneprogesterone, adrenal , adrenal hormoneshormones, , pituitarypituitaryhormoneshormones, , andand trophictrophic effectseffects of of insulininsulinandand thyroidthyroid hormonehormone..

TheThe termterm prepubertalprepubertal gynecomastiagynecomastiarefersrefers toto thethe symmetricalsymmetrical enlargementenlargement andandprojectionprojection of of thethe breastbreast budbud in a in a youngyoung girlgirlbeforebefore thethe averageaverage ageage of 12, of 12, unaccompaniedunaccompanied byby thethe otherother changeschanges of of pubertypuberty. . TheThe maturemature oror restingresting breastbreast containscontains fatfat, , stromastroma, , lactiferouslactiferous ductsducts, , andand lobular lobular unitsunits..

WithWith pregnancypregnancy, , therethere is is diminutiondiminution of of thethefibrousfibrous stromastroma toto accommodateaccommodate thethehyperplasiahyperplasia of lobular of lobular unitsunits. . AfterAfter birthbirth, , therethere is is suddensudden lossloss of of thethe placentalplacentalhormoneshormones andand thethe continuedcontinued highhigh levellevel of of prolactinprolactin. .

WhenWhen breastbreast--feedingfeeding ceasesceases, , therethere is a is a fallfallin in prolactinprolactin andand no no stimulusstimulus forfor releaserelease of of oxytocinoxytocin. . TheThe breastbreast thenthen returnsreturns toto a a restingresting statestate andand toto thethe cycliccyclic changeschangesinducedinduced whenwhen menstruationmenstruation beginsbegins againagain. .

ForFor thethe breastbreast, , menapausemenapause resultsresults in in involutioninvolution andand a general a general decreasedecrease in in thetheepithelialepithelial elementselements of of thethe restingresting breastbreast. . TheseThese changeschanges includeinclude increasedincreased fatfatdepositiondeposition, , diminisheddiminished connectiveconnective tissuetissue, , andand thethe disappearancedisappearance of lobular of lobular unitsunits. .

ABNORMAL PHYSIOLOGY AND ABNORMAL PHYSIOLOGY AND DEVELOPMENTDEVELOPMENT

GynecomastiaGynecomastiaHypertrophyHypertrophy of of breastbreast tissuetissue in men isin men is a a common clinical entity.common clinical entity.The enlargement in teenage boys is common The enlargement in teenage boys is common and is frequently bilateral, although it may be and is frequently bilateral, although it may be unilateral .Unless it is unilateral or painful, it unilateral .Unless it is unilateral or painful, it passes unnoticed and regresses with adulthood. passes unnoticed and regresses with adulthood. Pubertal hypertrophy is general treated by Pubertal hypertrophy is general treated by reassurance and without operationreassurance and without operation

Hypertrophy in older men is also common Hypertrophy in older men is also common and may regress spontaneously. It is and may regress spontaneously. It is frequently frequently unilateral.Aunilateral.A number of number of commonly used medications, such as commonly used medications, such as digoxindigoxin, , thiazidesthiazides, estrogens, , estrogens, phenothiazinesphenothiazines and and theophyllinetheophylline may may exacerbate senescent exacerbate senescent gynecomastygynecomasty

Nipple DischargeNipple DischargeTheThe appearanceappearance of a of a dischargedischarge fromfrom thethenipplenipple of a of a nonlactatingnonlactating womanwoman is is frequentlyfrequently frighteningfrightening toto thethe patientpatient. . NippleNippledischargedischarge is is commoncommon andand is is rarelyrarelyassociatedassociated withwith an an underlyingunderlying carcinomacarcinoma..

A A milkymilky dischargedischarge fromfrom bothboth breastsbreasts is is termedtermedgalactorrheagalactorrhea maymay be be associatedassociated withwith increasedincreasedproductionproduction of of prolactinprolactin..UnilateralUnilateral nonmilkynonmilky dischargedischarge comingcoming fromfrom oneone ductductorificeorifice is is rarerare andand is is surgicallysurgically significantsignificant andand warrantswarrantsspecialspecial attentionattention. . ToTo concludeconclude, , nipplenipple dischargedischarge thatthat comescomes fromfrom a a singlesingleductduct andand containscontains bloodblood mustmust be be investigatedinvestigated furtherfurther. . TheThe mostmost commoncommon causecause of of spontaneousspontaneous nipplenippledischargedischarge fromfrom a a singlesingle ductduct is a is a solitarysolitary intraductalintraductalpapillompapillom in in oneone of of thethe largelarge subareolarsubareolar ductsducts directlydirectlyunderunder thethe nipplenipple. .

InIn summarysummary nipplenipple dischargedischarge thatthat is is bilateralbilateral andand comescomes fromfrom multiplemultiple ductsducts is is usuallyusually not a not a surgicalsurgical problem. problem. BloodyBloodydischargedischarge fromfrom a a singlesingle ductduct doesdoes requirerequiresurgicalsurgical biopsybiopsy toto establishestablish a a diagnosisdiagnosis. . IntraductalIntraductal papillomapapilloma is is foundfound in in mostmost of of thesethese casescases. . IfIf an an occultoccult cancercancer is is foundfound. . ItItis is usuallyusually an an intraductalintraductal carcinomacarcinoma..

BreastBreast PainPainBreastBreast painpain maymay occuroccur in in youngyoung womenwomenassociatedassociated withwith menstrualmenstrual irregularityirregularity oror as as a a premenstruelpremenstruel symptomsymptom. . InIn additionadditionfibrocysticfibrocystic changechange oror ctsticctstic mastopathymastopathymaymay causecause breastbreast painpain. .

FibrocysticFibrocystic ChangeChange ((CysticCystic MastopathyMastopathy, , CysticCystic MastitisMastitis))FibrocysticFibrocystic changechange popularlypopularly referredreferred toto as as fibrocysticfibrocysticdiseasedisease, , representsrepresents a a spectrumspectrum of of clinicalclinical andand histologichistologicfindingsfindings andand describesdescribes a a looseloose associationassociation of of cysticcysticformationformation, , breastbreast nodularitynodularity, , stromalstromal proliferationproliferation andandepithelialepithelial hyperplasiahyperplasia..ThisThis conditioncondition is is commonlycommonly painfulpainful andand tender tender toto touchtouchmasrocystsmasrocysts, , microcystsmicrocysts, , stromalstromal fibrosisfibrosis, , adenosisadenosis andand a a variablevariable amountamount of of epithelialepithelial metaplasiametaplasia andand hyperplasiahyperplasia. . ThereThere is no is no consistentconsistent associationassociation betweenbetween fibrocysticfibrocysticcomplexcomplex andand breastbreast cancercancer..

GalactoceleGalactoceleA A galactocelegalactocele is a is a milkmilk--filledfilled cystcyst thatthat is is roundround wellwell circumscribedcircumscribed andand easilyeasilymovablemovable withinwithin thethe breastbreast. . TheThepathogenesispathogenesis of of galactocelegalactocele is not is not knownknownbut it is but it is thoughtthought thatthat inpissatedinpissated milkmilk withinwithinductduct is is responsibleresponsible

AbsentAbsent oror AccessoryAccessory BreastBreast TissueTissueAbsenceAbsence of of breastbreast tissuetissue ((amastiaamastia) ) andand absenceabsenceof of thethe nipplenipple ((atheliaathelia) ) areare veryvery rarerare anomaliesanomalies..InIncontrastcontrast accessoryaccessory breastbreast tissuetissue ((polymastiapolymastia) ) andand accessoryaccessory nipplesnipples ((supernumerarysupernumerary nipplesnipples) ) areare bothboth commoncommon. . SupernumerarySupernumerary nipplesnipples areareusuallyusually rudimentaryrudimentary andand occuroccur alongalong thethe milkmilklineline fromfrom thethe axillaaxilla toto thethe pubispubis in in bothboth malesmalesandand femalesfemales..AccessoryAccessory breastbreast tissuetissue is is comonlycomonlylocatedlocated aboveabove thethe breastbreast in in thethe axillaaxilla. .

DIAGNOSIS OF BREAST DISEASEDIAGNOSIS OF BREAST DISEASE

HistoryHistoryTheThe ageage of of menarchemenarche, , menstruelmenstruel irregularitiesirregularitiesandand thethe ageage at at menapousemenapouse shouldshould be be soughtsought..InIn youngeryounger womenwomen thethe historyhistory of of pregnancypregnancy andandlocationlocation shouldshould be be recordedrecorded. A . A drugdrug historyhistoryshouldshould pay pay particularparticular attentionattention toto HRT HRT oror thethe useuseof of hormoneshormones forfor contraceptioncontraception. . TheThe familyfamilyhistoryhistory shouldshould be be directeddirected toto cancercancer of of thethe breastbreastin in primaryprimary relativesrelatives ((mothermother,,sisterssisters,,andanddaughtersdaughters). ).

Risk Risk FactorsFactors forfor BreastBreast CancerCancerGenderGender is an is an importantimportant risk risk factorfactor. . MalesMales at risk at risk forfor breastbreast cancercancer althoughalthough thethe incidenceincidence in in malesmales is is lessless thanthan %1 of %1 of thethe incidenceincidence in in thethefemalesfemales..A A historyhistory of of mammarymammary cancercancer in in oneone breastbreastincreasesincreases thethe likelihoodlikelihood of a of a secondsecond primaryprimarycancercancer in in thethe contralateralcontralateral breastbreast. . InIn thethe relativerelativerisk (risk (ratioratio of of observedobserved casescases overover expectedexpectedcasescases) ) rangesranges betweenbetween threethree andand fourfour. . TheThemagnitudemagnitude of of relativerelative risk risk dependsdepends on on ageage at at diagnosisdiagnosis of of thethe firstfirst primaryprimary cancercancer

TheThe relationshiprelationship of of familyfamily historyhistory andand thethe risk of risk of breastbreast cancercancer. 1). 1)therethere is a is a twofoldtwofold toto threefoldthreefoldexcessexcess risk of risk of thethe diseasedisease in in firstfirst degreedegreerelativesrelatives ((mothersmothers, , sisterssisters, , andand daughtersdaughters) of ) of patientspatients withwith breastbreast cancercancer. 2) risk . 2) risk decreasesdecreasesquicklyquickly in in womenwomen withwith distantdistant relativesrelatives whowho areareaffectedaffected withwith breastbreast cancercancer ((cousinescousines, , auntsaunts, , grandmothersgrandmothers) ) andand 3) 3) thethe risk is risk is muchmuch higherhigher ififaffectedaffected firstfirst degreedegree relativesrelatives had had premenopausalpremenopausal onsetonset oror bilateralbilateral breastbreast cancercancer..

TheThe relativerelative risk of risk of cancercancer in in womenwomen withwithatypicalatypical hyperplasiahyperplasia waswas 4.4 4.4 timestimes thethe risk risk of of developmentdevelopment of of breastbreast cancercancer in in controlcontrolpopulationpopulation of of womenwomen. . TheThe coexistencecoexistence of of a a positivepositive familyfamily historyhistory withwith atypiaatypia on on biopsybiopsy increasedincreased thethe risk risk toto nearlynearly nine nine timestimes thethe general general populationpopulation. . TheThe averageaveragerisk risk ratioratio forfor 5 5 yearsyears of HRT is 1.35 of HRT is 1.35 andandrisk risk increasesincreases byby aboutabout %2 %2 toto %3 %3 withwitheacheach yearyear of of useuse..

PhysicalPhysical ExaminationExaminationEdemaEdema of of thethe skin, skin, frequentlyfrequentlyaccompaniedaccompanied byby erythemaerythema, , producesproduces a a clinicalclinical signsign knownknown as as peaupeau dd’’arongearongeTheThe secondsecond clinicalclinical featurefeature of of carcinomacarcinomathatthat directlydirectly involvesinvolves thethe nipplenipple waswasdescribeddescribed byby SirSir James James PagetPaget in 1874 in 1874 andandnamednamed PagetPaget’’ss diseasedisease. .

FineFine--NeedleNeedle AspirationAspirationItsIts mainmain utilityutility is is thethe differentiationdifferentiation of of solidsolidfromfrom cysticcystic massesmasses..CarcinomaCarcinoma willwill not be not be missedmissed ifif surgicalsurgicalbiopsybiopsy is done is done whenwhen 1)1)needleneedle aspirationaspirationproducesproduces no no cystcyst fluidfluid andand a a solidsolid massmass is is diagnoseddiagnosed 2)2)thethe cystcyst fluidfluid producedproduced is is thickthick andand bloodblood tingedtinged. 3). 3)fluidfluid is is producedproducedbut but thethe massmass failsfails toto resolveresolve completelycompletely..

BREAST IMAGINGBREAST IMAGING

TheThe goalgoal of of radiographicradiographic imagingimaging is is toto detectdetectsmallsmall abnormalitiesabnormalities in in thethe breastbreast whichwhich areare not not palpablepalpable byby physicalphysical examinationexamination ..

DiagnosticDiagnostic MammographyMammographyTheThe mammographicmammographic featuresfeatures of of malignancymalignancy can can be be broadlybroadly divideddivided intointo densitydensity abnormalitiesabnormalities((includingincluding massesmasses, , asymmetriesasymmetries andandarchitecturalarchitectural distortionsdistortions) ) andand microcalcificationsmicrocalcifications..

NonpalpableNonpalpable MammographicMammographic AbnormalitiesAbnormalitiesMammographicMammographic abnormalitiesabnormalities thatthat cannotcannot be be detecteddetected byby physicalphysical examinationexamination areare classifiedclassifiedin in thethe broadbroad categoriescategories. 1). 1)lesionslesions consistingconsisting of of microcalcificationsmicrocalcifications onlyonly 2)2)densitydensity lesionslesions((massesmasses, , architecturalarchitectural distortionsdistortions, , andandasymmetriesasymmetries) ) andand 3)3)thosethose withwith bothbothcalcificationscalcifications andand densitydensity abnormalitiesabnormalities..

ScreeningScreening MammographyMammographyAt At presentpresent screeningscreening mammographymammography shouldshould be be offeredoffered toto womenwomen olderolder thanthan 50 50 yearsyears andand be be done done eithereither annuallyannually oror at at leastleast biannuallybiannually. . ForForwomenwomen in in theirtheir 40s 40s recommendationsrecommendations forforstandardstandard practicepractice areare harderharder toto makemake. . YoungerYoungerwomenwomen withwith a a significantsignificant familyfamily historyhistory, , histologichistologic risk risk factorsfactors oror a a historyhistory of of priorprior breastbreastcancercancer shouldshould be be offeredoffered routineroutine screeningscreening..

ReferencesReferencesIglehartIglehart JD, JD, KaelinKaelin CM CM DiseaseDisease of of thethe BreastBreast. . SabistonSabiston TextbookTextbook of of SurgerySurgery Ed. Ed. TownsendTownsend CM WB CM WB SaundersSaunders CompanyCompany Pennsylvania 2001, 555Pennsylvania 2001, 555--601.601.BlandBland KI, KI, CopelandCopeland EM EM BreastBreast. . PrinciplesPrinciples of of SurgerySurgeryEd. Ed. SchwartzSchwartz JI JI McGrawMcGraw HillHill 1994, 5311994, 531--593.593.Onat D Meme anatomisi ve fizyolojisi. Temel Cerrahi Onat D Meme anatomisi ve fizyolojisi. Temel Cerrahi Ed. Ed. SayekSayek İİ GGüüneneşş KitabeviKitabevi Ankara 1991, 493Ankara 1991, 493--530.530.