The breast disease

   The adult female breast lies between the 2-nd and 6-th ribs and extend from the sternal edge to the medaxillary line Breast tissue extends into the axillx as axillary tail of spence.

Poteriorly rest on the fascia of pectoralis major M. and inferolaterally on the fascia of the serratus anterior M.

 Coopers lig. – fibrous tissue bands support the breast and extend from the pectoralis fascia and the dermis.

 BREAST ---Composed of skin – subcutaneous tissue Subdivided into lobules which-branched into — – and breast tissue. breast consist of 15 to 20 lobs of glandular tissue tubuloalveolar glands

 Each lobe ends in a lactiferous duct, 2 to 4 mm in diameter. Beneath the areola, the lactiferous ducts dilate into lactiferous sinuses and then open through a constricted orifice onto the nipple

 Blood supply — 2 — 3 — and the 4-th perforaters of the internal mammary artery plus lateral thoracic artery

        Physical breast examination – pt-position putting her hands abovethe head.

– insemi setting position and her hand put on her weist then Mammogram-is apopular program for screening breast cancer.

Uses a low dose – film 0,1 rad per study.

Decrease sensitivity of the mammogram in---labular carcenoma in situ and in dense breast.

--early detection of an occult cancer before it reaches 5mm.

--define the abnormality.

--detect multicentric disease.

--identify the synchronous cancer.

       Positive mammographic signs of malignancy.

--parenchymal tissue distortion.

--poorly defined mass lesion.

--branching or linear microcalcefication.

--stellate opacities.

Women initiate breast self-examination at the age of 20 yrs.

Base line mammographic examination at the age of 35 yrs

         Breast ultrasound — to diffirentiate solid from cystic mass .used esp. in young Pt.

-in dense breast tissue.

-for guide needle biopsy.

BIOPSY technique for solid masses.

1-F.N.A

— high accuracy rate.

False neg.

— 10% and false positive-1%.

Core needle biopsy — tissue obtained for histologic examination.

Excisional biopsy – give definitive therapy for a benign mass.

Incisional biopsy – in large breast mass.

Figure 50.3

Ultrasound of the breast showing a cyst (arrow).

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Figure 50.6

Corecut biopsy of breast.

         Triple assessment.

-clinical assessment.

-tissue biopsy.

-radiological imaging.

-give accuracy of diagnosis---99,9% Breast pain-Mastalgia or Mastodynia.

50% of pt seen in the clinic.

2-groups of pt.

-a-cyclical – related to menstrual cycle.

 -b-non-ctclical – occurs in both pre. And post menopausal women — a-musculoskeletal pain.

   b-sclerosing adenosis C-post – operative d-cervical root pain

      Aetoilogy of cyclical mastalgia.

1-hormonal abnormality production.

— increased oestrogen secretion or decreased progesterone 2-abnormal prolactin secretion .

3-water retention in the breast .

4-excessive caffeine ingestion 0r inadequate essentional fatty acid intake 5-psychoneurosis.

 80% 0f pt in the clinic with mastalgia req. no treatment --- just reassurance.

    1-anti-oestrogen drug as tamoxifin 10 mg tablet dialy.

2-anti-gonadotrophin drug as danazol – 400mg dtaly.

3-prolactin-antigonist — bromocriptin.

4-primrose oil — unsaturated fatty acid.

      Breast lump.-about 40% of pt present in the clinic .

History; 1-lump duration.

2-pain . 3-change in size. 4-relation to mensis.

Fibro-adenoma.

— derived from the breast lobule.

Originated from – connective tissue and epithelium -its size -3cm but gaint fibroadenoma-5cm.

 In 10% of pt have multiple fibroadenomas.

  Dx by FNA .Mammogram is of little value.

Gaint fibroadenoma – 5 up to 10cm .

  Occur in extremes of reproductive age .

14---18yr and the45 — 50 yr age.

      Commonly – typical hypocellular stromal and epithelial component.

Phy llodes tumour.(phyllodes sarcoma or cystosarcoma.

Has much more cellularity ,pleomorphism and mitotic activity plus atypia.

-age of the pt – 30 – 50yr but rare in young pt.

Axillary L.N.enlargment is rare.

Treatmen-wider exceion with safety margine – 1cm even mastectomy may be done

  Galactocele-occur during lactation or when recently stopped breast feeding.

Aspiration — will resolve the problem.

 Sclerosing adenosis-peri-neural tissue invasion-.

   -trigor- spot zone causing mastalgia.

Fat necrosis — due to trauma . May confused with cancer Dx by FNA.

Lipoma – fat tissue in the breast.

  Breast cyst – are frequently confused with cyclical nodularity.

Most cyst size about 2 — 3mm due to aberation of normal lobular physiology.

  Pt compl. Of pain that may relate to menstrual cycle.

Treatment-by aspiration surgical excesion – cyst recurrence or blood stained aspiration

  Bacterial breast infection (Br. Abscess).

Staph. Aureus and strep. Species from an infected breast.

– are the most micro-organism are present in nipple discharge  Symptoms- piont of tenderness, erythema, hyperthermia.

 Related to lactation, and occur within the few weeks of breast-feeding.

        Classification.

-subcutaneous.

-subareolar -interlobullar.

-retromammary abscess.

Also into — 1-unicentric 2-multicentric.

Pre-oper. Ultrasound — may be requered Surgical treat. – Circumareolar incision or incision paralleling Langers lines.

 Staph aureus infection---more localized and deep in the breast.

  Strep. Infection-usually more superficial.

In chronic breast infection – requered cultures for 1-acid-fast bacilli   2-anaerobic and 3-aerobic bacteria 4-fungi.

Biopsy is req.during drainage to rule out underlying breast Cancer.