Each mammary gland consist of 15-20 glandular lobes or acini, much like a bunch of grapes, with the stems representing the ramifying duct system, the duct are surrounded by specialized connective tissue, the periductal tissue, witch is under hormonal control.
Each lactiferous duct enlarges as it picks up more ductles and run toward the nipple, the nipple is surrounded by pigmented circular skin called the aerola, witch contains contractile smooth fibers to facilitate nipple contraction.
The lymphatic network of the breast is exceedingly rich, and drainage is extensive in many directions from the breast itself. The major and primary route of drainage is the axillary pathway, Lymphatics from the lobules and ducts pass through the axillary fascia along with the lateral thoracic vessels to the lateral or external mammary group of nodes, which are closest to the breast.
Scapular and lower axillary vein nodes are the next stop in the progression of flow toward the apex of the axilla. The central nodes are along the main portion of the axillary vein, and highest axillary nodes include the subclavicular lymph glands, lie beneath the clavicle on top of first rib and medital to the pectoralis minor muscle.
The internal mammary lymph nodes and the highest axillary nodes drain toward the medial end of the clavicle near the junction of the subclavian and internal jugular veins. Internal mammary modes also drain directly into the anterior mediastinum by multiple interlocking channels.
Careful inspection of both breasts should be the initial procedure. Variation in symmetry, size, shape, skip color ,and venous patterns should be observed.
The examiner must pay special attention to the nipple, looking for excoriation, inversion, discharge, edema, or redness. The skin of the nipple should be critically examined, since papillomas, eczema, and infection can occur in the nipple. These must be differentiated from Paget’s disease of the nipple. Which always is associated with an underlying carcinoma, often undetected by palpation.
The skin of the breast may show diffuse edema, as seen with cellulitis; peaud’ orange or “pigskip” edema, as seen with underlying lymphatic obstruction; or dimpling tethering, or retraction due to contraction of Cooper’s ligament by tumor growth in the deeper portions of the breast.
Palpation of the breast is most efficient when the patient lies down, with her ipsilateral hand behind her head. Gentle palpation with fingertips is essential and a systematic examination, quadrant by quadrant, must be carried out . Changes in skin temperature, thickness should be noted. Breast palpation is completed with gentle squeezing of the nipple-areolar complex to detect subareolar masses and latent nipple discharge.
A mass that is smooth, movable, firm, and totally separable from the adjacent lobular tissue is easily identified and probably benign. It is much more difficult to decide whether firm, irregular areas, within a breast containing cystic hyperplasia , Such cystic changes are most common in the upper outer quadrants and in the axillary tail of the breast and are often symmetric.
Nipple discharges always are abnormal except during lactation, but they do not always indicate malignancy. Serous, colorless discharge can occur during normal menstrual cycles, result from intraductal papilloma, or accompany early pregnancy.
A milk-white discharge, usually bilateral, not related to lactation or breast stimulation is galactorrhea. The presence of bilateral galactorrhea prompts evaluation for an endocrinopathy causing increased prolactin secretion by the pituitary gland
A bloody discharge is usually associated with either intraductal papilloma or ductal carcinoma. Milky discharge may persist after lactation has finished and is of no consequence in the diagnosis of breast cancer. Yellow discharge may indicate a cystic hyperplasia and is rarely associated with carcinoma. Bloody discharge is the most common type, present 50 to 75 percent of the time in most studies.
Mammography is particularly useful in the older woman with large, fatty woman, Where bulky soft tissue makes palpation difficult but where the high fat content mades X-ray identification of a malignant lesion easier.
X-ray identification of a malignant lesion easier. The more definite radiologic signs of breast cancer are mass lesions with poorly defined margins, particularly when the edges are either speculated or irregular. Fine stippled soft tissue and periductal calcification or clustered microcalcifications, not vascular calcification, are also important findings.
With either a Tru-Cut or spring-loaded Monopty device,can be used to obtain more tissue. The needle is infiltrated into the mass and fired. Three to five cores are taken and placed in formalin. Invasion, grade, and receptor status can be determined.
Is performed in the operating room using local anesthesia and intravenous sedation. All incisions should be planned such that they can be incorporated into a mastectomy incision.Masses should be excised as a single specimen.
A ductogram, also called a galactogram, is another test that is sometimes helpful in finding the cause of a nipple discharge. This is a type of x-ray test in which a fine plastic tube is placed into the opening of the duct into the nipple. A small amount of dye is injected, which outlines the shape of the duct on an x-ray picture and will show whether there is a mass inside the duct.
The patient usually has local pain and fullness accompanied by cold feel and fever initially. Then erythema, Tender mass and cellulitis are tended to be produced, often with systemic toxic manifestations. Infections develop rapidly, and abscess may form within 1~2 days with throbbing pain, pitting edema fluctuation.
Radial incision, semicircular incision-subareolar abscess. For retromammary abscess, large beneath the breast. inframammary incision should be performed. (1)All septa should be broken down with finger and the incision should be large enough, or counter incision be made.
Occurs as a result of duct ectasia with periductal mastitis, infected cysts, infected hematoma. If the abscess is subareolar, anaerobes are the most common causative agent. Treatment is with the appropriate antibiotics or surgical drainage for an abscess. These abscesses have a high recurrence rate, treatment is a central duct excision.
Excision biopsy should be done on those over 40 years old ,with solid ,hard lumps and family history. If biopsy shows excessive epithelial ductal hyperplasia, excision of mammary lobe or simple mastectomy should be performed .If malignancy is proved, radical mastectomy should be done.
It causes more deaths than any other disease or injury in women ages 45~49 and 60~64, cancer of the breast is second only to lung cancer as a cause of death from cancer among women
Risk factors for breast cancer Benign proliferative changes with atypia Noninvasive carcinoma( ductal or lobular carcinoma in situ) Personal history of contralateral breast cancer Low dose radiation Family history(mother, sister, or daughter with premenopausal or bilateral breast cancer Late nenopause(after age 50) Age older Early menarche(<12) Gender (female>male) ninor major
If diagnosed at an early stage, breast cancer has an encouraging cure rate: up to 97% of women diagnosed with localized breast cancer will survive five years after their diagnosis. Even if the cancer is found at a more advanced stage, new therapies have enabled many people with breast cancer to experience the same quality of life as before their diagnosis. About 90% of all breast cancers originate in the ducts or lobes. Almost 75% of all breast cancers begin in the cells lining the milk ducts and are called ductal carcinomas. Cancers that begin in the lobules are called lobular carcinoma. Lobular carcinoma has a higher chance of occurring in the contralateral (the other) breast either at the time of diagnosis or in the future.
Breast cancer cells may spread to other sites in the body by migrating through the blood vessels and/or lymph vessels. The lymph nodes can be located under the arm (axillary), in the neck (cervical), or just above the collarbone (supraclavicular). The most common sites of distant metastasis are the bones, lungs, and liver. The cancer can also recur locally in the skin or tissues of the chest.
Doctors may also test the tissue obtained during a biopsy to help guide treatment decisions. The tests include:
Tumor features: Examination of the tumor under the microscope determines whether it is invasive or in situ; ductal or lobular; well, moderate, or poorly differentiated; and whether it detects the presence of vascular or lymphatic invasion.
Estrogen receptor (ER) and progesterone receptor (PR) tests: These help determine both the prognosis (chance of recovery) and whether the cells respond to hormone therapy. Generally, ER or PR positive (+) tumors will respond to hormone therapy. The ER/PR status helps guide treatment decisions.
HER-2/neu tests: This is a protein that is overexpressed (too much of it) in about 25% of breast cancers. The HER-2 status helps guide treatment decisions.
Alkaline phosphatase levels: High levels of this enzyme could signify disease in the liver, bone cells, or bile ducts.
Tumor markers: Carcinoembryonic antigen (CEA), CA 15-3, or CA 27.29 may indicate the presence or degree of cancer.
Total bilirubin count, serum glutamic-oxaloacetic transaminase (SGOT), and serum glutamate pyruvate transaminase (SGPT) levels: These tests evaluate liver function. High levels can indicate liver damage, a signal of possible spread to that organ
It is frequently diagnosed and treated as dermatitis or bacterial infection, leading to unfortunate delay in detection. When the lesion consists of nipple change only, the incidence of axillary metastases is about 5%, and the prognosis excellent.
This is the most malignant form of breast cancer and constitute less than 3% of all cases. The clinical findings consist of a rapidly growing, sometimes painful mass that enlarges the breast. The overlying skin becomes erythmatous, edematous, and warm. Often there is no distinct mass, since the tumor infiltrates the involved breast diffusely.
The inflammatory changes often mistaken for an infection process, are caused by carcinoma invasion of the dermal lymphatics, with resulting edema,and hyperemia, if the physicin suspects infection but the lesion does not respond rapidly( 1-2 weeks) to antibiotics, biopsy examination must be performed. Metastases tend to occur early and widely, and for this reason inflammatory carcinoma is rarely curable. Mastectomy is seldome, if ever, indicated. Radiation, hormone therapy, and antcancer chemotherapy are the measures more likely to be of value.
According to the clinical, pathological findings and patients condition, operation, radiation, hormone and chemotherapy can by applied, Yet early operation still remains the most satisfactory method. Surgical operation
Involves removal of level 1 ( lateral to the pectoralis minor muscle) and level 2 lymph nodes (posterior to the pectoralis minor muscle) and if grossly involved, possibly level 3 nodes. An adequate dissection should remove at least eight lymph nodes.
Intraoperative complications of axillary dissection include damage to the long thoracic, medial pectoral, thoracodorsal and intercostobrachial nerves. Postoperatively , the most frequent complications include wound infections and seromas.
It involves introperative lymphatic mapping using lymphazurin blue dye or technetium labeled sulfur colloid ( or both ) to identify the primary draining lymph nodes in the nodal basin. If the SLN is negative, a more extensive lymph node dissection can be avoided.
If the SLN is positive, a standard axillary dissection is performed or radiation therapy is givens to the axilla.
A blue dye in lumpectomy site B axillary lymph nodes: levels I C axillary lymph nodes: levels II D axillary lymph nodes: levels III E large lymphatic channels F small lymphatic channels G sentinel lymph nodes taking up dye
Adjuvant means "in addition to," and these therapies are given in addition to surgery or surgery plus radiation therapy to decrease the risk of the breast cancer returning. Adjuvant therapies include radiation therapy, chemotherapy, and hormonal therapies. They are intended to eliminate any breast cancer cells lingering in the body. Adjuvant therapy decreases the risk of recurrence but does not necessarily eliminate it.
It is used to reduce local recurrence and sterilize internal mammary lymph nodes in postoperative patients. It is also the first choice therapy in advanced cases.
Radiation therapy is given regularly for a number of weeks following a lumpectomy or partial mastectomy in order to eliminate remaining cancer cells near the tumor site. Radiation therapy is also recommended for many women after a mastectomy depending upon the size of their tumor, number of involved lymph nodes under the arm, and width of the margin of resection obtained by the surgeon. Sometimes radiation therapy is given before surgery to shrink a large tumor and make it easier to remove.
Chemotherapy is the use of drugs to kill cancer cells. Chemotherapy drugs travel through the bloodstream to cancer cells throughout the body and destroy cancer cells that have migrated from the original site of the tumor. It may be given orally or intravenously and is usually given in cycles. Chemotherapy generally does not require a hospital stay; women are usually treated in an outpatient setting.
It is and adjuvant therapy to increase survival and reduce the incidence of recurrence alone or in combinations.
Chemotherapy for node-positive patient. Six months of CMF or CAF therapy, typically giving nine cycles of CMF, is a stantard regiman given to women with node-positive breast cancer who are less than 50 years of age.
Different chemotherapy drugs are useful for different cancers, and research has shown that combinations of certain drugs are more effective than individual drugs. Some common regimens for breast cancer include combinations of two or three of the following chemotherapy drugs: cyclophosphamide (Cytoxan or Neosar) (C), methotrexate (M), fluorouracil (5-FU) (F), doxorubicin (Adriamycin) (A), epirubicin (Ellence) (E), paclitaxel (Taxol), and docetaxel (Taxotere) (T).
Common combinations of drugs include: CMF, CAF, CEF, T (docetaxel [in this case]) AC and AC followed by T (paclitaxel [in this case]). Chemotherapy drugs are powerful and affect both healthy and cancerous cells in the body. Normal cells that grow quickly, such as those lining the gastrointestinal tract or hair follicles, may be damaged or killed along with cancer cells.
Side effects can include fatigue, nausea, and vomiting, lowered white blood cell count, and a corresponding increased risk of infection, mouth sores, hair loss, and premature menopause. Most of these side effects go away once treatment is stopped and are not long term. However, long-term toxicities may occur including heart damage, nerve damage, or secondary cancers.
Hormonal therapy is useful to manage tumors that test positive for either estrogen or progesterone receptors. These tumors use hormones to fuel their growth. Blocking the hormones limits the growth of these types of tumors. .
If it is determined that the tumor uses estrogen or progesterone to grow than hormonal treatment may be used alone or together with chemotherapy. Examples of hormonal therapy used as adjuvant therapies are tamoxifen, anastrozole (Arimidex), letrozole (Femara), and exemestane (Aromasin)
Preliminary evidence suggests that cancers with a high level of estrogen receptors are more responsive to hormonal manipulation. Tamoxifen is a competitive antagnist of estrogen and will bind to estrogen receptors, preventing the binding of estrogen. 10mg bid at least 5 years.
Tamoxifen is a drug that researchers have studied the longest for its use as a hormonal therapy. It blocks estrogen from binding to tumor cells. It has been shown effective in reducing the risk of recurrence in the treated breast, the risk of developing cancer in the opposite breast, and the risk of developing cancer in women with no history of the disease but who are at higher than average risk of developing breast cancer. Current research shows that there is no benefit for taking tamoxifen longer than five years
Aromatase inhibitors decrease the production of estrogen and are effective in postmenopausal women. They work by blocking the aromatase enzyme, which is necessary for production of estrogen. They are emerging as the preferred treatment for women with hormone-sensitive cancers. Several of these drugs include anastrozole, letrozole, and exemestane.
Several promising new breast cancer drugs work by stopping the action of abnormal proteins that cause cells to grow and divide out of control. Monoclonal antibodies target proteins that are present in unusually large amounts in breast cancer cells.
Breast cancer is called recurrent if the cancer has come back after it was first diagnosed and treated. It may come back in the breast (a local recurrence), in the chest wall, or in another part of the body, including distant organs (such as the lungs, liver, and bones) called distant metastases.
Breast cancer may also spread to other organs such as the brain, the opposite breast, adrenal glands, spleen, and ovaries. If the tumor is metastatic (spread outside of the breast or local lymph nodes) it is generally not curable. The goal of treatment for advanced disease is to achieve remission (temporary or permanent absence of disease) or slow the growth of the tumor. Some patients live years after a recurrence of breast cancer and may undergo many different treatments. With the advent of earlier detection methods and new therapies, breast cancer may be considered a chronic disease for some patients.
Once metastatic disease is detected, a woman may undergo surgery to remove the metastases, or have chemotherapy, hormone therapy, radiation therapy, or targeted therapy (such as trastuzumab) to control it. Signs and symptoms depend on the site of the recurrence and may include:
A lump under the arm or along the chest wall
Bone pain or fractures, which may signal bone metastases
Headaches or seizures, which may signal brain metastases
Chronic coughing or trouble breathing, which may signal lung metastases
A biopsy of the recurrent site is often recommended to be certain of the diagnosis and to check for ER, PR, and HER-2/neu status. Often hormone therapy is used first if possible. Chemotherapy and targeted therapies are also used. Radiation therapy and surgery may be used in certain situations.