Development and Physiology.
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During adolescence, the breast is composed primarily of dense fibrous stroma and scattered ducts lined with epithelium.In the breast, this hormone-dependent maturation (thelarche) entails increased deposition of fat, formation of new ducts by branching and elongation, and the first appearance of lobular units.
The postpubertal mature or resting breast contains fat, stroma, lactiferous ducts, and lobular units. During phases of the menstrual cycle or in response to exogenous hormones, the breast epithelium and lobular stroma undergo cyclic stimulation. In the late luteal (premenstrual) phase, there is an accumulation of fluid and intralobular edema. It is probable that this edema produces both pain and breast engorgement.
With pregnancy, there is diminution of the fibrous stroma to accommodate the hyperplasia of the lobular units. This formation of new acini or lobules is termed the adenosis of pregnancy and is influenced by high circulating levels of estrogen and progesterone and by levels of prolactin that steadily increase during gestation.
After birth, there is a sudden loss of the placental hormones. A continued high level of prolactin is the principal trigger for lactation.
It can be done with a 22-gauge needle, an appropriate size syringe. Its main utility is the differentiation of solid from cystic masses, but it may be done whenever a new dominant, unexplained mass is found in the breast.
A cytologic examination of the aspirated material is performed
This simple procedure is postponed only if mammography is necessary and there is worry that a small hematoma, resulting from needle puncture, might confuse the radiographic evaluation.
Carcinoma will not be missed if a surgical biopsy is done when (1) needle aspiration produces no cyst fluid and a solid mass is diagnosed, (2) the cyst fluid produced is thick and blood tinged, and (3) fluid is produced but the mass fails to resolve completely. (4)rapid accumulation of fluid after initial aspiration (<2 weeks).
• It can be useful to distinguish scar from recurrence in women who have had previous breast conservation therapy for cancer (although it is not accurate within 9 months of radiotherapy because of abnormal enhancement).
• It is the best imaging modality for the breasts of women with implants.
• It has proven to be useful as a screening tool in high-risk women (because of family history).
• It is less useful than ultrasound in the management of the axilla in both primary breast cancer and recurrent disease
Magnetic resonance imaging scan of the breasts showing carcinoma of the left breast (arrows).
(a) Pre-contrast; (b) postgadolinium
contrast; (c) subtraction image.
In any patient who presents with a breast lump or other symptoms suspicious of carcinoma, the diagnosis should be made by a combination of clinical assessment, radiological imaging and a tissue sample taken for either cytological or histological analysis the so called triple assessment.
Painful, often multiple, usually bilateral masses in the breast.
Rapid fluctuation in the size of the masses is common.
Frequently, pain occurs or worsens and size increases during premenstrual phase of cycle.
Most common age is 30–50. Rare in postmenopausal women not receiving hormonal replacement.
Fibroadenoma (adenofibroma) is a benign tumor composed of stromal and epithelial elements.
Fibroadenomas appear in teenage girls and women during their early reproductive years.
Clinically, they present as firm well circumscribed ,highly mobile within the breast tissue , solitary tumors that may increase in size over several months of observation. At operation, fibroadenomas appear to be well-encapsulated masses that may easily detach from the surrounding breast tissue.
Ultrasound usually clearly shows the difference between cysts and fibro adenomas.
The treatment of fibroadenoma follows that for any unexplained solid mass within the breast. Most patients undergo excisional biopsy to remove the tumor and establish the diagnosis.
Cryoablation is not appropriate for all fibroadenomas because some are too large to freeze or the diagnosis may not be certain.
Milk engorgement presented with dull aching pain associated with mild pyrexia , breast is enlarged with no signs of inflammation
Mastitis describes a generalized cellulites of breast tissue that may involve a large area of the breast but may not form a true abscess.
Mastitis presents with erythema of the overlying skin, pain, and tenderness to palpation. There is induration of the skin and underlying breast parenchyma. Mastitis commonly complicates lactation, possibly as a result of bacteria( staph. Aurieus) ascending in ductal tree of the breast through the nipple.
Predisposing factors includes : milk engorgement ,nipple retraction , cracked nipple ,bad hygiene , DM
Local measures such as application of heat, or use of a mechanical breast pump on the affected side, administration of broad-spectrum antibiotics. In many situations, the differential diagnosis of acute mastitis includes inflammatory carcinoma.
Breast abscess present with , thropping pain associated with hectic fever ( never wait for fluctuation )
Treatment of breast abscise is drainage
Hypertrophy of normal male breast tissue; can be divided into 2 categories:
pubertal hypertrophy (ages 13–17), senescent hypertrophy (age >50)
Associated with some recreational and therapeutic drugs:
digoxin, thiazides, estrogens, phenothiazines, theophylline
Symptoms and signs include unilateral or bilateral breast enlargement
Surgery is indicated if enlargement is primary and does not regress and breast is cosmetically unacceptable
What is the secondary causes
Fat necrosis is a rare lesion of the breast but is of clinical importance because it produces a mass (often accompanied by skin or nipple retraction) that is indistinguishable from carcinoma even with imaging studies.
Trauma is presumed to be the cause, though only about 50% of patients give a history of injury. Ecchymosis is occasionally present. If untreated, the mass effect gradually disappears.
The safest course is to obtain a biopsy. Needle biopsy is often adequate, but frequently the entire mass must be excised, primarily to exclude carcinoma.
Fat necrosis is common after segmental resection, radiation therapy, or flap reconstruction after mastectomy.
■ Aytpia or Cancer on Previous Biopsy
■ Atypical ductal hyperplasia (ADH)
■ Atypical lobular hyperplasia (ALH)
■ Lobular carcinoma in situ (LCIS)
■ Previous history ductal carcinoma in situ (DCIS)
■ Previous history of invasive breast cancer
■ Infant thymus radiation
■ Frequent fluoroscopy for TB
■ Multiple x-rays for scoliosis
■ Known or suspected gene mutation(BRCA1 and BRCA 2)
■ Early age onset <40
■ Bilateral breast cancer
■ Breast and/or ovarian cancer
■ Male breast cancer
■ Ethnicity , e.g., Jewish ancestry with family history
■ Cluster of rare tumors in a biological family
■ >5 years of combined estrogen/ progesterone hormone replacement therapy
■ Age at menarche <12
■ Age at firstborn >30
■ Age at menopause >55
• FNAC: Most experienced clinicians would not leave a suspicious dominant mass in the breast even when FNA cytology is negative unless the clinical diagnosis, breast imaging studies, and cytologic studies were all in agreement, such as a fibrocystic lesion or fibroadenoma.
• Biopsy (‘Trucut’/open surgical): usually provides definitive histology (may be radiologically guided if lump is small or impalpable bdetected by mammography as part of breast screening programme).
This one-step method is rarely used today except when a cytologic study has suggested cancer but is not diagnostic and there is a high clinical suspicion of malignancy in a patient well prepared for the diagnosis of cancer and its treatment options.
In general, the two-step approach—outpatient biopsy followed by definitive operation at a later date—is preferred in the diagnosis and treatment of breast cancer, because patients can be given time to adjust to the diagnosis of cancer, can consider alternative forms of therapy, and can seek a second opinion if they wish. There is no adverse effect from the short delay of the two-step procedure.
Once tissue diagnosis is reached we should stage the patient with
Breast ,skin, pectoral fascia ,muscle ,rips
Classification of Primary Breast Cancer
Lobular carcinoma in situ (LCIS)
Ductal carcinoma in situ (DCIS) or intraductal carcinoma Papillary, cribriform, solid, and comedo types
Invasive lobular carcinoma (10–15)
Invasive ductal carcinoma
Phyllodes tumors, benign and malignant
T0 No evidence of primary tumor
Tis Carcinoma in situ
Tis (DCIS) Ductal carcinoma in situ
Tis (LCIS) Lobular carcinoma in situ
Tis (Paget) Paget disease of the nipple with no tumor
T1, N1, M0
T2, N0, M0
T3, N0, M0
T1, N2, M0
T2, N2, M0
T3, N1, M0
T3, N2, M0
T4, N1, M0
T4, N2, M0
Vascular Endothelial Growth Factor (VEGF) Bevacizumab (Avastin) is a monoclonal antibody directed against VEGF.
The treatment of locally advanced breast cancer has been changing. The disease is heterogeneous and defies a uniform treatment approach. Prior to the 1970s, treatment included surgery and radiation, with little effect on survival. When surgery is used alone, local relapse rates in the range of 30% to 50% can be anticipated and the long-term cure rates rarely exceed 30%. Similar results are reported when radiation therapy is the sole modality of treatment. These poor results suggest that locally advanced disease is actually metastatic in most patients, emphasizing the role of chemotherapy in these patients. A trimodality approach with the addition of chemotherapy improved both disease-free and overall survivals.
Inflammatory breast cancer was once a uniformly fatal disease that claimed its victims after a median survival of 9 to 12 months. Current approaches emphasize aggressive use of combined modality treatment, which includes chemotherapy, mastectomy, and radiation therapy
The majority of men with breast cancer (50% to 97%) present with a breast mass. In addition to local pain and axillary adenopathy, other presentingnsymptoms include those of the nipple (retraction, ulceration, bleeding, and discharge). Evaluation includes breast imaging studies and, when there is uncertainty of a diagnosis of gynecomastia, needle or surgical biopsy.
The negative prognostic factors for breast cancer in men are the same as in women and include nodal involvement, tumor size, histologic grade, and hormone receptor status. When matched for age and stage, survival is similar to that in women.
The treatment of carcinoma in the male breast depends on the stage and local extent of the tumor.
Small tumors, movable across the chest wall, may be treated by local excision and radiation, if preferred and technically feasible, or by mastectomy. Nodal evaluation by sentinel node biopsy or axillary dissection is governed by the presence of invasive disease.
Breast tumors in men more commonly involve the pectoralis major muscle, probably because breast tissue in men is scant. If the underlying pectoral muscle is involved, modified radical mastectomy with excision of the involved portion of muscle is adequate treatment and may be combined with postoperative radiation therapy.
There is little experience with adjuvant chemotherapy or hormonal therapy in male breast cancer. Because most of these tumors are hormone sensitive, the use of adjuvant tamoxifen for node-positive and high-risk node-negative patients seems logical. For men at substantial risk for metastatic disease, adjuvant chemotherapy can be offered.