The female breast COPY Flashcards
Younger woman presents with recent or acute onset red, swollen and warm area in the breast without distinct lump. Skin appears pitted (peau d’orange) or bruised.
Inflammatory breast cancer–a rare, but aggressive form of breast cancer (1-5%)
Older female presents with hx of chronic scaly red-colored rash resembling eczema on the nipple/areola that does not heal. Sometimes itches.
Paget’s disease of the breast (Ductal carcinoma in situ). Skin lesion slowly enlarges and evolves to include crusting, ulceration, and/or bleeding on the nipple.
Histology of the adult female breast
Glands, ducts, and stroma consisting of fibrous tissue that binds individual lobes together, and adipose tissue within and between the lobes.
Each breast contains how many lobes?
12-20 conical lobes.
The base of each lobe is in close proximity to the ribs. The apex, which contains the major excretory duct of the lobe, is deep to the areola and nipple. In turn, each lobe consists of a group of lobules. The lobules have several lactiferous ducts, which unite to form a major duct that drains the lobes as they course toward the nipple–areolar complex. Each of the major ducts widens to form an ampulla as they travel toward the areola and then narrow at its individual opening in the nipple. The lobules are held in place by a meshwork of loose, fatty areolar tissue. The fatty tissue increases toward the periphery of the lobule and gives the breast its bulk and hemispheric shape
What percentage of the breast is adipose tissue?
80-85%
Breast changes during pregnancy
During pregnancy, the alveoli hypertrophy, and their lining cells proliferate in number. During lactation, the alveolar cells secrete proteins and lipids, which comprise breast milk.
Fascial bands that support the breast in its upright position on the chest wall.
Coopers ligaments
Skin dimpling by breast cancer is caused by distortion of what?
Coopers Ligaments
Breast growth during puberty is a result of
multiglandular stimulation, causing increase in
acinar tissue,
ductal size
branching
deposits of adipose
Response of the breast to progesterone
increased breast size and turgidity
Deepened pigmentation of nipple/areola
Nipple enlargement
areolar widening
Increased number and size of lubricating glands in areola
In late pregnancy, the fatty tissue of the breast is almost completely replaced with
cellular breast parenchyma
Breast resopnse after rapid drop in progesterone (delivery of baby)
Breasts are fully mature
Begin to secrete milk
Breast changes at cessation of nursing (or administration of estrogens)
breast rapidly returns to prepregnancy state.
Marked diminution of cellular elements and increase in adipose tissue
Breast changes during menopause (5th decade)
Gradual process of atrophy and involution.
Decreased number and size of acinar and ductal elements
Breast tissue regresses to almost infantile state.
Adipose tissue may or may not atrophy with dissappearance of the parenchymal elements
Breast location by rib
From just below the level of the second rib inferiorly to the sixth or sevents rib.
(2-6/7)
multiple small, elevated nodules on the skin of the areola
sebaceous glands of Montgomery
Sebacous glands of Montgomery function
lubrication of the nipple–prevention of cracking during breastfeeding
During the third trimester of pregnancy, the sebaceous glands of Montgomery markedly hypertrophy
breast vessels, lymphatics, nerves
Axillary artery and vein
Internal mammary artery and vein
Lateral thoracic artery
Thoracoepigastric vein
Nipple and areola–smooth muscle
A circular smooth muscle band surrounds the base of the nipple. Longitudinal smooth muscle fibers branch out from this ring of circular smooth muscle to encircle the lactiferous ducts as they converge toward the nipple. The many small punctate openings at the superior aspect of the nipple represent the terminals of the major lactiferous ducts. As discussed earlier, the ampullae of the lactiferous ducts are deep to the nipple and the areola
Breast lymphatic drainage importance
Implications in several disease etiologies including breast cancer.
2 main categories of lymphatic drainage
Superficial (including cutaneous) drainage
Deep parenchymatous drainage
Superficial lymphatic drainage of the breast
Drains:
areola and nipple–
including cutaneous and subcutaneous tissues adjacent to the nipple-areolar complex.
Deep parenchymatous lymphatic drainage
Small periductal and periacinal lymph vessles–larger interlobar lymphatics–axilla
Level 1 lymph nodes
Lymph located lateral or below pectoralis minor
level 2 lymph nodes
Deep to the pectoralis minor muscle
level 3 lymph nodes
located medially or superiorly to the upper margin of the pectoralis minor muscle.
Which spinal nerves supply the cutaneous tissue covering the breasts?
T4-6
Painful, often multiple, usually bilateral mobile masses in the breast.
Rapid fluctuation in the size of the masses is common.
Frequently, pain occurs or increases, as does size during the premenstrual phase of the cycle.
Most common age is 30–50 years; occurrence is rare in postmenopausal women
Fibrocystic breast
Treatment for fibrocystic breats
Reassurance
If treatment still desired:
Avoid trauma with supportive bra
May try abstaining from caffeine
mild analgesics
Danazol and tamoxifen–side effects
Symptoms subside at menopause
This common, benign neoplasm occurs most frequently in young women, usually within 20 years after puberty. It is somewhat more frequent and tends to occur at an earlier age in black women than in white women. can increase in size during pregnancy or with estrogen therapy and usually regress after menopause. Multiple tumors in 1 or both breasts are found in 10–15% of patients.
Fibroadenoma of the breast
round, firm, discrete, well defined, relatively movable, nontender mass 1–5 cm in diameter. The tumor is usually discovered accidentally.
Fibroadenoma
Difinitive diagnosis with core biopsy
No risk of breast cancer unless proliferative change or complex–then only slight
fibroepithelial tumors that tend to grow rapidly–sometimes confused with benign fibroadenomas. Tumor may grow to be large, and if inadequately excised, will recur. Rarely malignant.
Phyllodes tumors of the breast
fibroadenoma treatment
local excision with a margin of surrounding normal breast tissue.
Most common cause of pathologic nipple discharge
(serous, bloody, or serosanguineous)
Intraductal papillomas
Less frequently, carcinoma and fibrocystic change with ectasia of the ducts.
Causes of galactorrhea
Idiopathic
Drug induced: Phenothiazines, butyrophenones, reserpine, methyldopa, imipramine, amphetamine, metoclopramide, sulpiride, pimozide, oral contraceptive agents
Central nervous system (CNS) lesions
Pituitary adenoma, empty sella, hypothalamic tumor, head trauma
Medical conditions:Chronic renal failure, sarcoidosis, Schüller-Christian disease
Cushing’s disease, hepatic cirrhosis, hypothyroidism
Chest wall lesions
Thoracotomy, herpes zoster
Bilateral multiductal milky nipple discharge in nonlactating breasts
galactorrhea
result of hyperprolactinemia d/t medications etc…
unilateral, spontaneous serous or seosanguineous discharge from a single nipple duct
Pathologic nipple discharge
- intraductal papilloma or intraductal malignancy.*
- Palpable mass may not be present*
What type of discharge is more suggestive of cancer?
Bloody–but usually caused by a benign papilloma in the duct
Treatment of pathologic nipple discharge
Surgical excision of the involved duct after ruling out additional breast findings
Purulent discharge from the nipple
subareolar abscess–escision of abscess and related lactiferous sinus
benign condition that produces a mass, accompanied by skin or nipple retraction clinically indistinguishable from carcinoma.
Accompanied by ecchymosis occasionally
Possible tenderness.
Fat necrosis of the breast
Trauma and surgery are presumed etiology, though many have no recollection of trauma to the breast.
If left untreated, mass will disappear. If no regression for several weeks, consider biopsy.
Surgical excision usually not necessary.
Redness, tenderness, and induration in the breast of a lactating woman
mastitis
If caught early, continue breastfeeding and administer antibiotic.
Palpable mass with local and systemic signs of infection in lactating breast
Breast abscess–I&D
Breastfeeding may still continue and may help control the pain and shorten the duration of infection.
Breast abscess in non-lactating women
usually subareolar, and tends to recur after I&D.
Usually requires excision of involved lactiferous duct or ducts at the base of the nipple.
Otherwise, breast infection is rare.
If patient with suspected breast infection does not respond to treatment, suspect
Inflammatory breast cancer
Especially with associated lymphadenopathy
Complete absence of one or both breasts
amastia
accessory nipples
polythelia
Early findings: Single, nontender, firm to hard mass with ill-defined margins; mammographic abnormalities and no palpable mass.
Later findings: Skin or nipple retraction; axillary lymphadenopathy; breast enlargement, redness, edema, brawny induration, peau d’orange, pain, fixation of mass to skin or chest wall.
Late findings: Ulceration; supraclavicular lymphadenopathy; edema of arm; bone, lung, liver, brain, or other distant metastases.
Carcinoma of the female breast
Breast cancer incidence is highest in which race
White
Clinical staging of breast cancer
TNM
Tumor, node, metastasis
How are the majority of breast cancer cases diagnosed?
Abnormal mammogram findings–less often because of palpable mass
Initial evaluation breast cancer
Assessment of the local lesion
bilateral mammogram
breast ultrasound as indicated
CBC
LFT
Alk phos
