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ЗмістPhysiology of the breast
Infectious and inflammatory disorders of the breast
Common benign disorders and diseases of the breast
Risk factors for breast cancer
Epidemiology and natural history of breast cancer
Histopathology of breast cancer
Diagnosing breast cancer
DISEASES OF BREAST
FUNCTIONAL ANATOMY OF THE BREAST
The breast is composed of 15.20 lobes, which are each composed of several lobules. Each lobe of the breast terminates in a major (lactiferous) duct (2 - 4mm in diameter), which opens through a constricted orifice (0,4 – 0,7 mm in diameter) into the ampulla of the nipple. Fibrous bands of connective tissue travel through the breast (suspensory ligaments of Cooper), which insert perpendicularly into the dermis and provide structural support. The axillary tail of Spence extends laterally across the anterior axillary fold. The upper outer quadrant of the breast contains a greater volume of tissue than do the other quadrants.
Blood supply, innervation, and lymphatics.
The breast receives its blood supply from (1) perforating branches of the internal mammary artery; (2) lateral branches of the posterior intercostal arteries; and (3) branches from the axillary artery, including the highest thoracic, lateral thoracic, and pectoral branches of the thoracoacromial artery. The veins and lymph vessels of the breast follow the course of the arteries with venous drainage being toward the axilla. The vertebral venous plexus of Batson, which invests the vertebrae and extends from the base of the skull to the sacrum, can provide a route for breast cancer metastases to the vertebrae, skull, pelvic bones, and central nervous system. Lateral cutaneous branches of the third through sixth intercostal nerves provide sensory innervation of the breast (lateral mammary branches) and of the anterolateral chest wall. The intercostobrachial nerve is the lateral cutaneous branch of the second intercostal nerve and may be visualized during surgical dissection of the axilla. Resection of the intercostobrachial nerve causes loss of sensation over the medial aspect of the upper arm. The boundaries for lymph drainage of the axilla are not well demarcated, and there is considerable variation in the position of the axillary lymph nodes. The 6 axillary lymph node groups recognized by surgeons are (1) the axillary vein group (lateral); (2) the external mammary group (anterior or pectoral); (3) the scapular group (posterior or subscapular); (4) the central group; (5) the subclavicular group (apical); and (6) the interpectoral group (Rotter’s).
The lymph node groups are assigned levels according to their relationship to the pectoralis minor muscle. Lymph nodes located lateral to or below the lower border of the pectoralis minor muscle are referred to as level I lymph nodes, which include the axillary vein, external mammary, and scapular groups. Lymph nodes located superficial or deep to the pectoralis minor muscle are referred to as level II lymph nodes, which include the central and interpectoral groups. Lymph nodes located medial to or above the upper border of the pectoralis minor muscle are referred to as level III lymph nodes, which make up the subclavicular group. The axillary lymph nodes usually receive more than 75 percent of the lymph drainage from the breast.
Breast development and function. Breast development and function are initiated by a variety of hormonal stimuli, including estrogen, progesterone, prolactin, oxytocin, thyroid hormone, cortisol, and growth hormone. Estrogen, progesterone, and prolactin especially have profound trophic effects that are essential to normal breast development and function. Estrogen initiates ductal development, although progesterone is responsible for differentiation of epithelium and for lobular development. Prolactin is the primary hormonal stimulus for lactogenesis in late pregnancy and the postpartum period. It upregulates hormone receptors and stimulates epithelial development. Secretion of neurotrophic hormones from the hypothalamus is responsible for regulation of the secretion of the hormones that affect the breast tissues. The gonadotropins luteinizing hormone (LH) and follicle-stimulating hormone (FSH) regulate the release of estrogen and progesterone from the ovaries. In turn, the release ofLH and FSH from the basophilic cells of the anterior pituitary is regulated by the secretion of gonadotropin-releasing hormone (GnRH) from the hypothalamus. Positive and negative feedback effects of circulating estrogen and progesterone regulate the secretion of LH, FSH, and GnRH.
Gynecomastia refers to an enlarged breast in the male. Physiologic gynecomastia usually occurs during three phases of life: the neonatal period, adolescence, and senescence. Common to each of these phases is an excess of circulating estrogens in relation to circulating testosterone. Neonatal gynecomastia is caused by the action of placental estrogens on neonatal breast tissues, although in adolescence, there is an excess of estradiol relative to testosterone, and with senescence, the circulating testosterone level falls, resulting in relative hyperestrinism. In gynecomastia, the ductal structures of the male breast enlarge, elongate, and branch with a concomitant increase in epithelium. During puberty, the condition often is unilateral and typically occurs between ages 12 and 15 years. In contrast, senescent gynecomastia usually is bilateral. In the nonobese male, breast tissue measuring at least 2 cm in diameter must be present before a diagnosis of gynecomastia is made. Dominant masses or areas of firmness, irregularity, and asymmetry suggest the possibility of a breast cancer, particularly in the older male. Mammography and ultrasonography are employed for diagnostic purposes.
Bacterial infection. Staphylococcus aureus and Streptococcus species are the organisms most frequently recovered from nipple discharge from an infected breast. Breast abscesses are typically seen in staphylococcal infections and present with point tenderness, erythema, and hyperthermia. These abscesses are related to lactation and occur within the first few weeks of breast-feeding. Progression of a staphylococcal infection may result in subcutaneous, subareolar, interlobular (periductal), and retromammary abscesses (unicentric or multicentric), necessitating operative drainage of fluctuant areas. Preoperative ultrasonography is effective in delineating the extent of the needed drainage procedure, which is best accomplished via circumareolar incisions or incisions paralleling Langer lines. Although staphylococcal infections tend to be more localized and may be located deep in the breast tissues, streptococcal infections usually present with diffuse superficial involvement. They are treated with local wound care, includingwarm compresses, and the administration of intravenous antibiotics (penicillins or cephalosporins). Breast infections may be chronic, possibly with recurrent abscess formation. In this situation, cultures are taken to identify acid-fast bacilli, anaerobic and aerobic bacteria, and fungi. Uncommon organisms may be encountered and long-term antibiotic therapy may be required.
Hidradenitis suppurativa. Hidradenitis suppurativa of the nipple-areola complex or axilla is a chronic inflammatory condition that originates within the accessory areolar glands of Montgomery or within the axillary sebaceous glands. When located in and about the nipple-areola complex, this disease may mimic other chronic inflammatory states, Paget disease of the nipple, or invasive breast cancer. Involvement of the axillary skin is often multifocal and contiguous. Antibiotic therapy with incision and drainage of fluctuant areas is appropriate treatment. Complete excision of the involved areas may be required and may necessitate coverage with advancement flaps or split-thickness skin grafts.
Mondor’s disease. This variant of thrombophlebitis involves the superficial veins of the anterior chest wall and breast. In 1939, Mondor described the condition as Ѓgstring phlebitis, a thrombosed vein presenting as a tender, cordlike structure. Typically, a woman presents with acute pain in the lateral aspect of the breast or the anterior chest wall. Atender, firm cord is found to follow the distribution of one of the major superficial veins. Mostwomen have no evidence of hrombophlebitis in other anatomic sites. When the diagnosis is uncertain, or when a mass is present near the tender cord, biopsy is indicated. Therapy for Mondor disease includes the liberal use of antiinflammatory medications and warm compresses that are applied along the symptomatic vein. Restriction of motion of the ipsilateral extremity and shoulder and brassiere support of the breast are important. The process usually resolves within 4.6 weeks. When symptoms persist or are refractory to therapy, excision of the involved vein segment is appropriate.
Aberrations of normal development and involution. The basic principles underlying the aberrations of normal development and involution (ANDI) classification of benign breast conditions are (1) benign breast disorders and diseases are related to the normal processes of reproductive life and to involution; (2) there is a spectrum of breast conditions that ranges from normal to disorder to disease; and (3) the ANDI classification encompasses all aspects of the breast condition, including pathogenesis and the degree of abnormality. The horizontal component of Table 16-1 defines ANDI along a spectrum from normal, to mild abnormality (disorder), to severe abnormality (disease). The vertical component defines the period during which the condition develops. Reproductive Years: Fibroadenomas are seen predominantly in younger women age 15.25 years. Fibroadenomas usually grow to 1 or 2 cm in diameter and then are stable, but may grow to a larger size. Small fibroadenomas (1 cm in size or less) are considered normal, although larger fibroadenomas (up to 3 cm) are disorders and giant fibroadenomas (larger than 3 cm) are disease. Similarly, multiple fibroadenomas (more than 5 lesions in one breast) are very uncommon and are considered disease. The precise etiology of adolescent breast hypertrophy is unknown.Aspectrum of changes from limited to massive stromal hyperplasia (gigantomastia) is seen. Nipple inversion is a disorder of development of the major ducts, which prevents normal protrusion of the nipple. Mammary duct fistulas arise when nipple inversion predisposes to major duct obstruction, leading to recurrent subareolar abscess and mammary duct fistula.
TABLE ANDI Classification of Benign Breast Disorders
Normal Disorder Disease
Early reproductive Lobular development
Giant fibroadenoma years (age 15-25)
Nipple eversion, Nipple inversion
Mammary duct fistula
Later reproductive Cyclical changes of Cyclical mastalgia
Incapacitating mastalgia years (age 25 - 40) menstruation
Epithelial hyperplasia of pregnancy Nodularity
Bloody nipple discharge
Involution (age 35 - 55)
Duct involution Sclerosing lesions
.Dilation Duct ectasis Periductal mastitis
.Sclerosis Nipple retraction
Epithelial hyperplasia with atypia
ANDI = Aberrations of normal development and involution.
Modified with permission from Hughes LE: Aberrations of normal development and involution (ANDI): A concept of benign breast disorders based on pathogenesis. In Hughes LE, Mansel RE, Webster DJT (eds): Benign Disorders and Diseases of the Breast: Concepts and Clinical Management. London: WB Saunders, 2000, p 23.
Later Reproductive Years: Cyclical mastalgia and nodularity are usually associated with premenstrual enlargement of the breast and are regarded as normal. Cyclical pronounced mastalgia and severe painful nodularity that persists for more than 1 week of the menstrual cycle is considered a disorder. In epithelial hyperplasia of pregnancy, papillary projections sometimes give rise to bilateral bloody nipple discharge. The term fibrocystic disease is nonspecific. Too frequently, it is used as a diagnostic term to describe symptoms, to rationalize the need for breast biopsy, and to explain biopsy results. Synonyms include fibrocystic changes, cystic mastopathy, chronic cystic disease, chronic cystic mastitis, Schimmelbusch disease, mazoplasia, Cooper disease, Reclus disease, and fibroadenomatosis. Fibrocystic disease refers to a spectrum of histopathologic changes that are best diagnosed and treated specifically. Treatment of Selected Benign Breast Disorders and Diseases Cysts: In practice, the first investigation of palpable breast masses is frequently needle biopsy, which allows for the early diagnosis of cysts.A21-gauge needle attached to a 10-mL syringe is placed directly into the mass, which is fixed by fingers of the nondominant hand. The volume of a typical cyst is 5.10 mL, but it may be 75 mL or more. If the fluid that is aspirated is not bloodstained, then the cyst is aspirated to dryness, the needle is removed, and the fluid is discarded as cytologic examination of such fluid is not cost-effective. After aspiration, the breast is carefully palpated to exclude a residual mass. If one exists, ultrasound examination is performed to exclude a persistent cyst, which is reaspirated if present. If the mass is solid, a tissue specimen is obtained.When cystic fluid is bloodstained, 2 mL of fluid are taken for cytology. The mass is then imaged with ultrasound and any solid area on the cyst wall is biopsied by needle. The presence of blood usually is obvious, but in cysts with dark fluid, an occult blood test or microscopy examination will eliminate any doubt. The two cardinal rules of safe cyst aspiration are (1) the mass must disappear completely after aspiration, and (2) the fluid must not be bloodstained. If either of these conditions is not met, then ultrasound, needle biopsy, and perhaps excisional biopsy are recommended. Fibroadenomas: Removal of all fibroadenomas has been advocated irrespective of patient age or other considerations, and solitary fibroadenomas in young women are frequently removed to alleviate patient concern. Yet most fibroadenomas are self-limiting and many go undiagnosed, so a more conservative approach is reasonable. Careful ultrasound examination with core-needle biopsy will provide for an accurate diagnosis. Subsequently, the patient is counseled concerning the biopsy results, and excision of the fibroadenoma may be avoided.
Sclerosing Disorders: The clinical significance of sclerosing adenosis lies in its mimicry of cancer. It may be confused with cancer on physical examination, by mammography, and at gross pathologic examination. Excisional biopsy and histologic examination are frequently necessary to exclude the diagnosis of cancer. The diagnostic work-up for radial scars and complex sclerosing lesions frequently involves stereoscopic biopsy. It is usually not possible to differentiate these lesions with certainty from cancer by mammography features, hence biopsy is recommended. Periductal Mastitis: Painful and tender masses behind the nipple-areola complex are aspirated with a 21-gauge needle attached to a 10-mL syringe. Any fluid obtained is submitted for cytology and for culture using a transport medium appropriate for the detection of anaerobic organisms. Women are started on a combination of metronidazole and dicloxacillin while awaiting the results of culture. Antibiotics are then continued based on sensitivity tests. Many cases respond satisfactorily, but when there is considerable pus present, surgical treatment is recommended. A subareolar abscess usually is unilocular and often is associated with a single duct system. Preoperative ultrasound will accurately delineate its extent. The surgeon may either undertake simple drainage with a view toward formal surgery, should the problem recur, or proceed with definitive surgery. In a woman of childbearing age, simple drainage is preferred, but if there is an anaerobic infection, recurrent infection frequently develops. Recurrent abscess with fistula is a difficult problem and may be treated by fistulectomy or by major duct excision, depending on the circumstances. When a localized periareolar abscess recurs at the previous site and a fistula is present, the preferred operation is fistulectomy, which has minimal complications and a high degree of success. However, when subareolar sepsis is diffuse rather than localized to one segment or when more than one fistula is present, total duct excision is the preferred procedure. The first circumstance is seen in young women with squamous metaplasia of a single duct, although the latter circumstance is seen in older women with multiple ecstatic ducts. However, age is not always a reliable guide, and fistula excision is the preferred initial procedure for localized sepsis irrespective of age. Antibiotic therapy is useful for recurrent infection after fistula excision, and a 2.4-week course is recommended prior to total duct excision.
Nipple Inversion: More women request correction of congenital nipple inversion than request correction for the nipple inversion that occurs secondary to duct ectasia. Although the results are usually satisfactory, women seeking correction for cosmetic reasons should always be made aware of the surgical complications of altered nipple sensation, nipple necrosis, and postoperative fibrosis with nipple retraction. Because nipple inversion is a result of shortening of the subareolar ducts, a complete division of these ducts is necessary for permanent correction of the disorder.
Increased exposure to estrogen is associated with an increased risk for developing breast cancer, whereas reducing exposure is thought to be protective. Correspondingly, factors that increase the number of menstrual cycles, such as early menarche, nulliparity, and late menopause, are associated with increased risk. Moderate levels of exercise and a longer lactation period, factors that decrease the total number of menstrual cycles, are protective. The terminal differentiation of breast epithelium associated with a full-term pregnancy is also protective, so older age at first live birth is associated with an increased risk of breast cancer.
Risk assessment. The average lifetime risk of breast cancer for newborn U.S. females is 12 percent. The longer a woman lives without cancer, the lower her risk of developing breast cancer. Thus, a woman age 50 years has an 11 percent lifetime risk of developing beast cancer, and a woman age 70 years has a 7 percent lifetime risk of developing breast cancer. As risk factors for breast cancer interact, evaluating the risk conferred by combinations of risk factors is difficult. From the Breast Cancer Detection Demonstration Project, a mammography screening program conducted in the 1970s, Gail and colleagues developed the most frequently used model, which incorporates age at menarche, the number of breast biopsies, age at first live birth, and the number of first-degree relatives with breast cancer. It predicts the cumulative risk of breast cancer according to decade of life. To calculate breast cancer risk with the Gail model, a woman’s risk factors are translated into an overall risk score by multiplying her relative risks from several categories. This risk score is then compared to an adjusted population risk of breast cancer to determine a woman’s individual risk. A software program incorporating the Gail model is available from the National Cancer Institute at http://bcra.nci.nih.gov/brc.
Risk management. Several important medical decisions may be affected by a woman’s underlying risk of breast cancer. These decisions include when to use postmenopausal hormone replacement therapy; at what age to begin mammography screening; when to use tamoxifen to prevent breast cancer; and when to perform prophylactic mastectomy to prevent breast cancer. Postmenopausal hormone replacement therapy reduces the risk of coronary artery disease and osteoporosis by 50 percent, but increases the risk of breast cancer by approximately 30 percent. Routine use of screening mammography in women age 50 years and older reduces mortality from breast cancer by 33 percent. This reduction comes without substantial risks and at an acceptable economic cost. However, the use of screening mammography is more controversial in women younger than age 50 years for several reasons: (1) breast density is greater and screening mammography is less likely to detect early breast cancer; (2) screening mammography results in more false-positive tests, resulting in unnecessary biopsies; and (3) younger women are less likely to have breast cancer so fewer young women will benefit from screening. However, on a population basis, the benefits of screening mammography in women between the ages of 40 and 49 years still
appear to outweigh the risks. Tamoxifen, a selective estrogen receptor modulator,was the first drug shown to reduce the incidence of breast cancer in healthy women. The Breast Cancer Prevention Trial (NSABP P-01) randomly assigned more than 13,000 women, with a 5-year Gail relative risk of breast cancer of 1.70 or greater, to tamoxifen or placebo. After a mean follow-up period of 4 years, tamoxifen had reduced the incidence of breast cancer by 49 percent. Tamoxifen currently is only recommended for women who have a Gail relative risk of 1.70 or greater and it is unclear whether the benefits of tamoxifen apply to women at lower risk. Additionally, deep venous thrombosis occurs 1.6 times, pulmonary emboli 3.0 times, and endometrial cancer 2.5 times as often in women taking tamoxifen. The increased risk for endometrial cancer is restricted to early stage cancers in postmenopausal women. Cataract surgery is required almost twice as often among women taking tamoxifen. Although no formal risk-benefit analysis is currently available, the higher a womanЃfs risk of breast cancer, the more likely it is that the reduction in the incidence of breast cancer conveyed by tamoxifen will outweigh the risk of serious side effects.
Epidemiology. Breast cancer is the most common site-specific cancer in women and is the leading cause of death from cancer for women age 40 - 44 years. It accounts for 33 percent of all female cancers and is responsible for 20 percent of the cancer-related deaths in women. It is predicted that approximately 211,240 invasive breast cancers will be diagnosed in women in the United States in 2005 and 40,410 of those diagnosed will die from that cancer. Breast cancer was the leading cause of cancer-related mortality in women until 1985, when it was surpassed by lung cancer. In the 1970s, the probability of a woman in the United States developing breast cancer was estimated at one in 13, in 1980 it was 1:11, and in 2002 it was 1:8. Cancer registries in Connecticut and upper New York state document that the age-adjusted incidence of new breast cancer cases has steadily increased since the mid-1940s. This increase was about 1 percent per year from 1973.1980, and there was an additional increase in incidence to 4 percent between 1980 and 1987, which was characterized by frequent detection of small primary cancers. The increase in breast cancer incidence occurred primarily in women age 55 years or older and paralleled a marked increase in the percentage of older women who had mammograms. At the same time, incidence rates for regional metastatic disease dropped and breast cancer mortality declined. From 1960.1963, 5-year overall survival rates for breast cancer were 63 and 46 percent in white and African American women, respectively, although the rates for 1981.1987 were 78 and 63 percent, respectively.
Carcinoma in situ. Cancer cells are in situ or invasive depending on whether or not they invade through the basement membrane. BroderЃfs original description of in situ breast cancer stressed the absence of invasion of cells into the surrounding stroma and their confinement within natural ductal and alveolar boundaries. As areas of invasion maybe minute, the accurate diagnosis of in situ cancer necessitates the analysis of multiple microscopy sections to exclude invasion. In 1941, Foote and Stewart published a landmark description of lobular carcinoma in situ (LCIS), which distinguished it from ductal carcinoma in situ (DCIS). Multicentricity refers to the occurrence of a second in situ breast cancer outside the breast quadrant of the primary in situ cancer, whereas multifocality refers to the occurrence of a second in situ breast cancer within the same breast quadrant as the primary in situ cancer. Multicentricity occurs in 60-90 percent of women with LCIS, although the rate of multicentricity for DCIS is 40 – 80 percent. LCIS occurs bilaterally in 50.70 percent of cases, although DCIS occurs bilaterally in 10.20 percent of cases.
Lobular Carcinoma In Situ: LCIS originates from the terminal duct lobular units and only develops in the female breast. It is characterized by distention and distortion of the terminal duct lobular units by cancer cells, which are large but maintain a normal nuclear-to-cytoplasmic ratio. The frequency of LCIS in the general population cannot be reliably determined because it usually presents as an incidental finding. The age at diagnosis is 44.47 years, which is approximately 15.25 years younger than the age at diagnosis for invasive breast cancer. LCIS has a distinct racial predilection, occurring 12 times more frequently in white women than in African American women. Invasive breast cancer develops in 25.35 percent ofwomen with LCIS. Invasive lobular cancer may develop in either breast, regardless of which breast harbored the initial focus of LCIS, and is detected synchronously with LCIS in 5 percent of cases. In women with a history of LCIS, up to 65 percent of subsequent invasive cancers are ductal, not lobular in origin. For these reasons, LCIS is regarded as a marker of increased risk for invasive breast cancer rather than an anatomic precursor.
Ductal Carcinoma In Situ: Although DCIS is predominantly seen in the female breast, it accounts for 5 percent of male breast cancers. Published series suggest a detection frequency of 7 percent in all biopsy tissue specimens. The term intraductal carcinoma is frequently applied to DCIS, which carries a high risk for progression to an invasive cancer. Histologically, DCIS is characterized by a proliferation of the epithelium that lines the minor breast ducts. DCIS is now frequently classified based on nuclear grade and the presence of necrosis. The risk for invasive breast cancer is increased nearly 5-fold in women with DCIS. The invasive cancers are observed in the ipsilateral breast, usually in the same quadrant as the DCIS that was originally detected, suggesting that DCIS is an anatomic precursor of invasive ductal carcinoma. Invasive breast carcinoma. Invasive breast cancers are described as lobular or ductal in origin with histologic classifications recognizing special types of ductal breast cancers (10 percent of total cases), which are defined by specific histologic features. To qualify as a special-type cancer, at least 90 percent of the cancer must contain the defining histologic features. Eighty percent of invasive breast cancers are described as invasive ductal carcinoma of no special type (NST). These cancers generally have a worse prognosis than special-type cancers. Foote and Stewart originally proposed the following classification for invasive breast cancer:
I. Paget disease of the nipple
II. Invasive ductal carcinoma
A. Adenocarcinoma with productive fibrosis (scirrhous, simplex, no special type (NST)) 80 percent
B. Medullary carcinoma 4 percent
C. Mucinous (colloid) carcinoma 2 percent
D. Papillary carcinoma 2 percent
E. Tubular carcinoma (and invasive cribriform carcinoma (ICC)) 2 percent
III. Invasive lobular carcinoma 10 percent
IV. Rare cancers (adenoid cystic, squamous cell, apocrine)
Paget disease of the nipple was described in 1874. It frequently presents as a chronic, eczematous eruption of the nipple, which may be subtle, but may progress to an ulcerated, weeping lesion. Paget disease usually is associated with extensive DCIS and may be associated with an invasive cancer. A palpable mass may or may not be present. Biopsy of the nipple will show a population of cells that are identical to the underlying DCIS cells (pagetoid features or pagetoid change). Pathognomonic of this cancer is the presence of large, pale, vacuolated cells (Paget cells) in the rete pegs of the epithelium.
Surgical therapy for Paget disease may involve lumpectomy, mastectomy, or modified radical mastectomy, depending on the extent of involvement and the presence of invasive cancer. Invasive ductal carcinoma of the breast with productive fibrosis (scirrhous, simplex, NST) accounts for 80 percent of breast cancers and presents with macroscopic or microscopic axillary lymph node metastases in 60 percent of cases. This cancer usually presents in perimenopausal or postmenopausal women in the fifth to sixth decades of life as a solitary, firm mass. It has poorly defined margins and its cut surfaces show a central stellate configuration with chalky white or yellow streaks extending into surrounding breast tissues. The cancer cells often are arranged in small clusters, and there is a broad spectrum of histologies with variable cellular and nuclear grades.
In 33 percent of breast cancer cases, the woman discovers a lump in her breast. Other less frequent presenting signs and symptoms of breast cancer include (1) breast enlargement or asymmetry; (2) nipple changes, retraction, or discharge; (3) ulceration or erythema of the skin of the breast; (4) an axillary mass; and (5) musculoskeletal discomfort. However, up to 50 percent of women presenting with breast complaints have no physical signs of breast pathology. Breast pain usually is associated with benign disease. Misdiagnosed breast cancer accounts for the greatest number of malpractice claims for errors in diagnosis and for the largest number of paid claims. Litigation often involves younger women whose physical examination and mammography may be misleading. If a young woman (age 45 years or younger) presents with a palpable breast mass and equivocal mammography finding, ultrasound examination and biopsy are used to avoid a delay in diagnosis.
Inspection: The surgeon inspects the womanЃfs breast with her arms by her side, with her arms straight up in the air, and with her hands on her hips (with and without pectoral muscle contraction). Symmetry, size, and shape of the breast are recorded, and any evidence of edema, nipple or skin retraction, and erythema.With the arms extended forward and in a sitting position, the women leans forward to accentuate any skin retraction. As part of the physical examination, the breast is carefully palpated. Examination of the patient in the supine position is best performed with a pillow supporting the ipsilateral hemithorax. The surgeon gently palpates the breast from the ipsilateral side, making certain to examine all quadrants of the breast from the sternum laterally to the latissimus dorsi muscle, and from the clavicle inferiorly to the upper rectus sheath. The surgeon performs the examination with the palmar aspects of the fingers avoiding a grasping or pinching motion. The breast may be cupped or molded in the surgeon’s hands to check for retraction. A systematic search for lymphadenopathy then is performed. By supporting the upper arm and elbow, the shoulder girdle is stabilized. Using gentle palpation, all three levels of possible axillary lymphadenopathy are assessed. Careful palpation of supraclavicular and parasternal sites also is performed. A diagram of the chest and contiguous lymph node sites is useful for recording location, size, consistency, shape, mobility, fixation, and other characteristics of any palpable breast mass or lymphadenopathy.
Mammography: Mammography has been used in North America since the 1960s and the techniques used continue to be modified and improved to enhance image quality. Conventional mammography delivers a radiation dose of 0.1 centigray (cGy) per study. By comparison, a chest radiograph delivers 25 percent of this dose. However, there is no increased breast cancer risk associated with the radiation dose delivered with screening mammography. Screening mammography is used to detect unexpected breast cancer in asymptomatic women. In this regard, it supplements history and physical examination. With screening mammography, two views of the breast are obtained, the craniocaudal (CC) view and the mediolateral oblique (MLO) view. The MLO view images the greatest volume of breast tissue, including the upper outer quadrant and the axillary tail of Spence. Compared with the MLO view, the CC view provides better visualization of the medial aspect of the breast and permits greater breast compression. Diagnostic mammography is used to evaluate women with abnormal findings such as a breast mass or nipple discharge. In addition to the MLO and CC views, a diagnostic examination may use views that better define the nature of any abnormalities, such as the 90-degree lateral and spot compression views. The 90-degree lateral view is used along with the CC view to triangulate the exact location of an abnormality. Spot compression may be done in any projection by using a small compression device, which is placed directly over a mammography abnormality that is obscured by overlying tissues. The compression device minimizes motion artifact, improves definition, separates overlying tissues, and decreases the radiation dose needed to penetrate the breast. Magnification techniques often are combined with spot compression to better resolve calcifications and the margins of masses. Mammography also is used to guide interventional procedures, including needle localization and needle biopsy. Specific mammography features that suggest a diagnosis of a breast cancer include a solid mass with or without stellate features, asymmetric thickening of breast tissues, and clustered microcalcifications. The presence of fine, stippled calcium in and around a suspicious lesion is suggestive of breast cancer and occurs in as many as 50 percent of nonpalpable cancers. These microcalcifications are an especially important sign of cancer in younger women, in whom it may be the only mammography abnormality. Current guidelines of the National Cancer Center Network (NCCN) suggest that normal-risk women age 20 years or older should have a breast exam at least every 3 years. At age 40 years, breast exams should be performed yearly along with a yearlymammogram. Prospective, randomized studies of mammography screening confirm a 40 percent reduction for stages II, III, and IV cancer in the screened population, with a 30 percent increase in overall survival.
Ultrasonography: Ultrasonography is second only to mammography in frequency of use for breast imaging and is an important method of resolving equivocal mammography findings, defining cystic masses, and demonstrating the echogenic qualities of specific solid abnormalities. On ultrasound examination, breast cysts are well circumscribed, with smooth margins and an echofree center. Benign breast masses usually show smooth contours, round or oval shapes, weak internal echoes, and well-defined anterior and posterior margins. Breast cancer characteristically has irregular walls, but may have smooth margins with acoustic enhancement. Ultrasonography is used to guide fine-needle aspiration biopsy, core-needle biopsy, and needle localization of breast lesions. It is highly reproducible and has a high patient acceptance rate, but does not reliably detect lesions that are 1 cm or less in diameter.
Nonpalpable Lesions: Image-guided breast biopsies are frequently required to diagnose nonpalpable lesions. Ultrasound localization techniques are employed when a mass is present, although stereotactic techniques are used when no mass is present (microcalcifications only). The combination of diagnostic mammography, ultrasound or stereotactic localization, and fine-needle aspiration (FNA) biopsy is almost 100 percent accurate in the diagnosis of breast cancer. However, although FNA biopsy permits cytologic evaluation, coreneedle or open biopsy also permits the analysis of breast tissue architecture and allows the pathologist to determine whether invasive cancer is present. This permits the surgeon and patient to discuss the specific management of a breast cancer before therapy begins. Core-needle biopsy is accepted as an alternative to open biopsy for nonpalpable breast lesions. The advantages of core-needle biopsy include a low complication rate, avoidance of scarring, and a lower cost.
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