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Breast Disease

Anatomy of breasts: large modified sebaceous glands within superficial fascia of the anterior chest wall.

Wt: 200-300g, 20% glandular tissue and 80% fat and connective tissue.

Composed of 12-20 lobes arranged radial fashion from the nipple.

Lymphatics: 75% regional axillary nodes (30-60 #), other route internal mammary, direct spread to mediastinum-intercostal glands, subpectoral and subdiaphragmatic. Lymphatic drainage usually flows toward the most adjacent group of nodes. Thus the concept represents basis for sentinel node mapping.

Benign breast disease                                                            

  1. Fibrocystic changes- cysts within ducts and increased fibrous tissue, irregular, nodular and cyclically painful breasts. Exaggeration of normal psychological response of breast tissue to cyclic levels of ovarian hormones. Occurs 20-50 years old.
  1. Fibroadenomas second most common. Usually adolescents and women in their 20’s. Don’t change size with meses, no pain or tenderness. Rx conservative 6 month follow-up vs. surgery. Fine needle aspiration should be performed to rule out any malignancy with either histologic or cytologic evaluation.
  2. Cystosarcoma phyllodes- most frequent breast sarcoma rapidly growing fifth decade of life. 1:4 is malignant. Rx benign cystosarcoma is exision with wide margin of normal tissue.
  3. Intraductal papilloma- bloody discharge from one nipple, perimenopausal women, and spontaneous and intermittent. Can be watery, serous or serosanguineous. Located under areola in 75%. With pressure, you should identify whether it’s a single duct or multiple ducts. With single duct, can be intraductal papilloma or cancer vs. multiple ducts most likely cancer. Rx biopsy of involved duct and surrounding tissue.
  4. Nipple discharge- milky-galactorrhea, multicolored and sticky-ductal ectasia, purulent-mastitis, serous/serosanguineous. Can be either intraductal papilloma, fibrocystic, or cancer.
  5. Fat necrosis- rare, related to trauma. Mammography stippled calcification and stellate contractions. Skin associated skin retraction similar to cancer. Rx- excisional biopsy.
  6. Breast cyst- variant fibrocystic changes, present in 30-50 year olds, frequent pain and tenderness which worsens premenstrually then regresses.

#1 cause of cancer in women. Increase diagnosis whites > blacks, death in blacks > whites

#2 cause of death after lung cancer.

Risk: 1/50 at 50 years old, 1/24 at 60 years old, and 1/10 at 80 years old

Hereditary breasts and ovarian cancer (HBOC) gene mutation explains 5-10% breast cancer. 80% due to BRCA 1-2 gene mutation. BRCA 1-2 is responsible for preventing DNA errors, but mutated BRCA genes allow DNA errors.

Risks of HBOC:

  1. Personal history of early breast cancer, bilateral, in multiple sites, ovarian cancer (at any age)
  2. Previously indentified BRCA 1-2 mutation in family
  3. 1st degree relative (mother/sister) with premenopausal breast cancer
  4. More than 2 family members (maternal or paternal) with breast or ovarian cancer
  5. Ashkenazi Jewish heritage with family history of breast cancer at any age
  6. Family history: Cowden of Li-Fraumeni syndrome

No increased risk-adenosis, fibroadenoma, mastitis, mild hyperplasia

Slight increased risk- moderate hyperplasia, papilloma

Increased risk- atypical hyperplasia, high breast density

Mammographic breast density- 3-5 times greater risk of breast cancer in women with high breast density on mammo vs. women with low density

Breast cancer and endogenous hormones-

Breast cancer and exogenous hormones-

Prevention of breast cancer in high risk women-

Breast cancer screening in high risk women-

 

Author
Dr. Khalil

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