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7/27/2019 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, weight loss and cachexia, are rare in patient with

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breast cancer. Even those with disseminated fatal diseaseusually feel well in themselves until the final stages.

Examination;

Site; half of carcinomata of the breast occur in upper outerquadrant, which include the axillary tail.Colour:

If the tumor is close to the surface, the overlying skin may be

discolored.Tumor fixed to the skin first give the skin a smooth, rednessappearance, but as the process advance and ulceration isimminent, the skin becomes paler.

Tenderness: most carcinomata are not tender, but palbationmay produce mild discomfort.

Temperature: only the very rare ' inflammatory type' of breastcarcinoma feel warm.

Shape; in early stages, it is roughly spherical.

Surface: the surface is usually indistinict, which makes itdifficult to define the shape. Few cancer are encapsulated andhave smmoth surface, mimicking cysts and fibroadenoma.

Composition: carcinomas are solid, so they do not fluctuate,transilluminte or have a fluid thrill.

Their consistency is normally quit firm.Some are soft as a lipoma.

Fixation of a lump to the skin is almost diagnostic of acarcinoma. The only other condition producing fixation istraumatic fat necrosis or pointing abscess.Peau d, orange ( already mentioned(

Lymph gland containing metastases are usually hard anddiscrete. Ulceration in the axilla is rare.

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General examination:Essential to detect the metastasis;

The skeleton; especially the lumbar spine, causing back painand reduced spinal movements.

The lung: plural effusion, lung parenchyma, in the form ofdiffuse lymphatic involvement known as lymphangitiscarcinomatosa, may cause severe dyspnea.The liver; making it palpable and causing jaundice and ascities.The skin; producing multiple hard nodules within the skin.

Condition mimicking breast cancer;1-Fat necrosis; fat necrosis occur in the elderly after an injury

or trauma. There may be focal necrosis of subcutaneous fat

with local scaring which causes skin tethering. 2-Mondor,s disease; it is thrombophlebitis of the lateral thoracicvein which produce a cord like, linear skin puckering. Itrexsolve spontaneously.

Treatment;Early breast cancer:

1-wide local excision >>> removal of the lump with margin ofnormal breast.

2-simple mastectomy involve excising the breast tissue ( itusually combined with reconstructive surgery) + axillary nodeclearance. By this combination we avoid the needs ofpostoperative radiotherapy in most cases.

3-adjuvnt therapy;Pt. with early BC should be considered for chemotherapy with

or without antiestrogen (tamoxifin.(Antiestrogen therapy should be given only in females who have

estrogen receptors are positive.

In Stage 4 ( palittation(1-local radiotherapy for fungation2-radiotherapy to bone metastasis.

3-aspiration of pleural effusion.4-tamoxifine

5-chemotherapy.N.B.patients with bone metastasis>>> hormonal therapy isbetter than chemotherapy.

While patients with liver metastasis>>> chemotherapy is

better.

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Complication of mastectomy:1-wound seroma

2-stiffness of the shoulder

3-lymphedema of the arm.4-psychological.

the cardinal signs of a late cancer of breast:1-hard, non tender, irregular lump.

2-tethering or fixation of lump

3-palpable axillary lymph gland.

Benign breast tumor1-fibroadenoma ( breast mouse:(

The commonest breast tumor in young women.A fibroadenoma is a benign neoplasm of the breast in which

fibromatous element is the dominant feature.There are 2 histological varieties of fibroadenomata,

pericanalicular, which mainly consist of fibrous tissue, andintracanlicular, which contain more glands.

Most fibroadenomata present in young women, age between 15and late 20.

History:The patient present with painless lump, that it is highly mobile.Examination:

Will demarcated, spherical, painless, smooth, firm swelling thatcan present anywhere in the breast.

It is the most mobile of all breast lesions.Deferential diagnosis:

Breast cyst, but cysts are found in a different age group and arenot usually mobile.all fibroadenoma must be investigated by triple assessment.The largest lump should undergo core biopsy.

Surgery should be avoidable in the majority of cases but shouldbe considered in the following circumstances;

1-lump increase in size

2-symptomatic lump- pain or tenderness

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3-patient preference.

Phylloides tumor ( cystsarcoma phyllodes or brodie tumor:(This is rare, large and massive, irregular, bosselated tumor that

dose not metastasis. LN enlargement is rare.It present as a slow- growing, smooth swelling in the middleage>40.It can be big enough to cause skin necrosis.

Treatment:Removal of the tumor with a wide margin of normal breast.

If massive tumor>>>> total mastectomy with axillary nodesampling.

Intraduct papilloma:This due to hyperplasia of the duct epethelia lining.Predispose to malignant >>>> ductal carcinoma- in situ.It is the only benign breast disease that may lead to malignancy.The most common cause of Bleeding from nipple.

Papilloma can be felt as a small nodule at the areolar margin,pressure at that point >>> discharge.Treatment:Surgical excision of the involved duct.

Lipoma of the breast:Lipoma may occur anywhere in the body where there is fat, whichinclude the breast, both SC and more deeply seated between thelobule.

Lumps and nodularity:The symptoms of lumps and nodularity occur during the years ofovarian activity, from early menarche to menopause, beginning inthe early 20 and reaching the peak in the 30.

Symptoms:Pt. present with more than 1 lump in the breast which arecommonly tender. The pain is Intermittent related to menstrualcycle, mostly in premenstrual phase and resolving when themenses begin.

On examination:Benign breast lump vary from a diffuse nodularity to quite discrete

lesion.

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Nodular lumps tend to be in the upper outer quadrants and havemoderate hardness, sometimes describe as rubbery.They are not fixed or tethered to skin or muscle.

Breast pain;Cyclical breast painNon- cyclical breast pain

1-cyclical breast pain:Cyclical breast pain is very common.It comes on during the second half of the cycle.

It is quite commonly unilateral, it may be felt through out thebreast, or more in the upper outer quadrent.

The pain is usually reduced by oral contraceptive.On examination, there may be tenderness but no discrete lump.Diffuse nodularity is common particularly in upper outer quadrantThe pain is never a symptom of cancer.

Treatment: If the pain is so severe:-bromcriptin ( dopamine antagonist.(-danazol ( gonadotropin antagonist.(

-tamoxifen.-firm supporting brassiere may help.

2-non- cyclical breast pain:This is less common.It occur at these condition:

-at puberty-at menopause due to cessation of hormone ( usually unilateral.(-tietze syndrome ( this is uncommon condition in which pain and

tenderness arise from costochondral junction lateral to thesternum). The pain is exacerbated by movement.

-duct ectasia-mondors disease.

-inflammatory disease.

Breast cyst:Breast cyst is probably the commonest of the discrete breastswelling.

Breast cyst is fluid filled cavity appears in the breast, without ademonstrated endothelial lining or a capsule.

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This condition occur at times when the pt. hormone environment ischanging, usually around the menopause ( before the age of 40,

the peak incidence is in the late in 40 and early 50.(Presentation:

They may develop sudden swelling, moderate pain andtenderness are common.

Examination;Solitary cyst is smooth, spherical swelling.

If it is large cyst, it may be visible and even appear blue or greenthrough the skin, but there will never be tethering or fixation to skinor muscle.

It is rarely possible to elicit fluctuation or fluid thrill or to

transilluminate the lesion.

The clinical diagnosis of a cyst, will processed immediately toneedle aspiration, the appropriate treatment.

The fluid that emerges is variable in color and clarity, varying fromvery dark green to clear yellow.

GalactoceleIt is milk containing cyst and occur during or after lactation. Itpresents as above and the physical signs are similar.

Aspiration produces milk, but the cyst rapidly refills and resolutionmust await cessation of breast feeding.

Paget disease of then nipple:Paget disease of the nipple is caused by cancer cells migrating orspreading along the duct system from a carcinoma situated deeplyin the breast, which in the early stages is usually confined to the

epithelium (DCIS.(THE presence of carcinoma cells in the skin of the nipple produce

a clinical appearance similar to that of eczema. patches of skinfirst become red and then encrusted and oozy. The edges ofthese lesions are distinict, unike eczema, and they do not itch.In time the nipple is destroyed, and replaced by a malignant ulcer.

Paget disease of the nipple always indicated underlying malignantprocess in the breast itself.

The different between eczema and paget disease of the nipple;

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Paget diseaseeczema

unlateralBilateral

Occur at menopauseCommonly occur at lactation

Dose not itchNo vesiclesNipple may be destroyed

ItchesVesiclesNipple intact

May be underlying lumpNo lump

Duct ectasia:This is common of unknown etiology.

It is dilatation of the mammary ducts, which are full of inspissatedmaterial containing macrophages and chronic inflammatorydebris.

It has the following presenting features:-nipple inversion, which is at first mild and readily everted.

There is characteristic transverse slit appearance. In many pt. this

is the only feature. -difficulty in breast feeding.-nipple discharge

-chronic low grade infection of the peri- areolar area, with tenderthickening around the nipple, going on abscess formation, knownas periductal mastitis.

-periductal abscess that may rupture and stay in communicationwith the duct system. This result in mammillary fistula.

Supernumary breast/ nipple;Extra nipple or breast develope along the primitive milk line as acongenital anamolies.

Breast absessAcute breast abscess is often associated with lactation.S. aureous is the commonest organism.

Bacteria may gain access to the engorged breast lobules, anexcellent medium for bacterial culture.

The pt. develop malise and fever accompanied by an ache in the

breast which progresses to throbbing pain.

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On examination:Signs of inflammation which are:

Pain, redness, swelling.It is safe to continues breast feeding even from the breast

containing the abscess.When a breast abscess occurs in a women who is not lactatingthere is often a predisposing risk factor such as diabetes mellitusor immunocompromise.

Recurrent and chronic breast abcess;It is usually associated with duct ectasia.Tuberculosis remain common in some part of the world.Mycobacterial infection is rare cause.

**the breast changes of pregnancy:-fullness and pricking sensation

-enlargement and distended subcutaneous vein.-increase nipple and areolar pigmentation with clear, expressed

secretion( colostrums.(-hypertrophy of subareolr sebaceous glands ( montogomery

tubercle.(

The male breast:There are 2 causes of enlargement of the male breast.

1-gynecomastia ( benign(The causes of gynecomastia are;

The pt. complain of painless, or slightly tender, enlargement ofone or both breast.

There is clearly palpable disk of firm breast tissue behind andattached to the areolar.

General examination, especially of liver and scrotum (testes), may

yield information that indicate the likely cause.

2-carcinoma of the male breast;It is uncommon, usually of elderly men.

Its symptoms and signs are identical to those of carcinoma offemale breast.There is little public awareness of the condition.

Because the male breast is small and not covered by a thick layerof SC fat, the disease spread rapidly.

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Physical signs such as skin and muscle fixation, ulceration andaxillary lymphadenopathy are often present by the time ofpresentation.

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