Breast & it's problems and treatment made by sonal Patel

Breast & it's problems and treatment made by sonal Patel

• 2.
  Anatomy of femalebreast : The breast lies between the 2nd and 6th ribs on the vertical axis and between the sternal edge and the midaxillary line on the horizontal axis. Breast tissue also projects into the lower axilla as the axillary tail. The breast is made up of the secretory glandular tissue and surrounding adipose tissue. The glandular tissue comprises between 15 and 20 lobes with varying numbers of ducts and lobules surrounded by connective tissue. Each lobe connects to a lactiferous duct, several of which converge to form a lactiferous sinus or milk chamber .
• 3.
  These sinuses emptyinto the nipple where there are a number of duct openings. The nipple is surrounded by a pigmented area, the areola, which is lubricated by secretions from the sebaceous glands. Beneath the tissues of the breast lie the muscles of the chest wall and between the two is a layer of connective tissue known as the fascia. Anatomy of the breast
• 4.
  Blood supply: theinternal mammary artery, the axillary artery and the intercostal arteries Lymph drainage: is from superficial to deep - The major drainage is then to the axilla and internal mammary chain. - To lesser extent, lymph also drains by intercostal routes to nodes adjacent to vertebrae. The axillary nodes found below the level of the axillary vein are divided into 3 groups in relation to pectoralis minor muscle. Level I lymph nodes: lateral to the lateral border of pectoralis minor . Level II lymph nodes: behind pectoralis minor . Level III lymph nodes: medial to the medial border of pectoralis minor
• 5.
  Physiology of lactation: Lactationis inhibited during pregnancy by the action of estrogen on the hypoth. & pituitary. Inhibition is removed immediately after delivery  PRL  initiate lactation which is then maintained by suckling (nerve reflex via hypothalamus),  PRL, GH & ACTH and  Gonadotropins. Delivery of milk from the nipple is by contraction of myoepithelial cells around acini by the action of oxytocin secreted by neurohypophysis.
• 6.
  Breast diseases: I- Beningbreast problems: A) Congenital abnormalities and development : 1- Supernumerary or accessory nipple 2- Supernumerary or accessory breast 3- Excessive breast enlargement 4- Hypoplasia or aplasia 5- Inversion of the nipples. B) Breast pain (Mastalgia):  Due to breast causes: Cyclic: premenstrual and relieved with the onset of menstruation. It may be unilateral or bilateral and radiate to axilla. Non cyclic: various causes as hormonal fluctuation, firm adenomas, duct ectasia, macrocysts and soreness in the pectoralis muscle from exertion or trauma  Due to non – breast causes : e.g. angioma, cholelithiasis, costochondritis, …..etc
• 7.
  Treatment: 1) Bromocriptine :Reduce PRL  relief cyclic mastalgia, Dose: 2.5 mg twice daily 2) Danazol: Relief symptoms and reduce nodularity, Dose : 200 mg 3) Tamoxifen : Reduce breast pain, Dose 20 mg 4) Gammalenolenic acid ( GLA ): Dose 6- 8 capsules / day 5) Non medical measures: A well fitting brassier worn 24 hours / day,  caffeine intake , regular exercise, phytoestrogen
• 8.
  C) Nipple discharge:Common, not all nipple discharge is pathologic Types: i) Physiologic: not associated with underlying breast disease, Bilateral, from multiple ducts and serous in character. Causes: exogenous estrogen and nipple stimulation Require no treatment. ii) Galactorrhea: see hyperprolactinemia iii) Pathologic discharge: Localized to a single duct and spontaneous. May be greenish , gray , serosangunous , serous or bloody Causes :Benign breast disease Investigation: mammography, biopsy from a mass
• 9.
  D) Duct ectasia:in women over 35 years. Presentation: - Nipple discharge (from several ducts – cheesy in nature or with a palpable mass which may be hard or doughy) - Nipple retraction - Duct dilate & shorten (inspissated material ) Treatment: - formation - Antibiotics to avoid abscess Total duct excision with histological examination
• 10.
  E) Fibrocystic diseases:most common benign breast complaint in 10% of women < 21 years and more common in the premenopausal period. It produces bilateral pain and tenderness 7-10 days before menstruation General lines of Treatment: - Regular examination - OCS - NSI - Diuretic therapy - Avoid coffee, tea, chocolate and caffeinated soda
• 11.
  Types:  Fibroadenoma (breastmouse ): It is the most common mass lesion < 25 years Palpable breast mass in upper outer quadrant, well circumscribed, firm, mobile discrete and may be multiple or bilateral Treatment: conservative or excision and biopsy. Needs careful follow up  Breast cyst: Common in perimenopausal age. Small discrete lump (fluctuant) Treatment: aspiration Galactocele: - During or after pregnancy or breast feeding - Contain breast milk Treatment: Aspiration (diagnostic and therapeutic)
• 12.
  II- Bening neoplasticlump: 1- Duct papilloma: rarely common. Treatment: may need excision of the duct 2- Lipoma: Treatment: excise only if suspicion of malignancy or if troublesome
• 13.
  III -Breast cancer: Incidence:One in 12 women will develop breast cancer at some time in life. Risk factors: 1) Reproductive factors and endogenous hormones: 2) Family history of breast cancer 3) Other gynecological cancers: e.g. ovarian and endometrial cancer 4) Oral contraceptive pills: slight risk. 5) Hormone replacement therapy: increased risk with long term use 6) Other hormones: DES use in pregnancy and DMPA used by very young the risk 7) Radiation exposure 8) Breast disease: as atpyical Hyperplasia, intraductal carcinoma in situ 9) Obesity 10) Diet: Fat, alcohol
• 14.
  Breast cancer duringor shortly after pregnancy : more worse than women with the same age and not pregnant which may be due to delay of the diagnosis and immunosuppressive effect of pregnancy. So, breast examination should be a part of prenatal examination, and mammography can be done if suspicion with the use of shield. Cancer breast diagnosed during pregnancy should be staged and treated in the same manner as in non pregnant.
• 15.
  Abnormal signs andsymptoms: 1. Change in breast size, puckering , dimpling or retraction, thickening of skin or lump 2. Nipple discharge, retracted nipple, change in nipple position, Scaling around nipples 3. Pain or tenderness and redness 4. Sore on breast that does not heal Screening of breast cancer: all women should be screened at the age 50 – 64 every 3 years with single oblique view mammography. In women with family history, mammography is routine before 50 years
• 16.
  Diagnosis: 1- Careful breastexamination 2- Conventional mammography 3- U/S 4- Fine needle aspiration or biopsy 5- Excision biopsy: the only definitive diagnosis Management: Breast surgery: conservative lumpectomy with axillary dissection in combination with radiotherapy is as effective as mastectomy for local control in most cases.  Tamoxifen: prolongs disease – free interval.  Chemotherapy: has survival benefit in premenopausal women.  Endocrine therapy: aromatase inhibitors, LHRH analogues and ovarian ablation. Steroid receptor is best predictive Follow up: life long follow up is required
• 17.
  Subsequent contraception, pregnancy andHRT: Contraception: OCs is not recommended. Other alternative should be considered  Pregnancy: subsequent pregnancy have no adverse effect. Patients are advised to wait 2 years before becoming pregnant. HRT: Tamoxifen is recommended if menopausal symptoms are severe.