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HOUSSAM OSMAN
Functional Anatomy :
Location. Structure. Nipple areola complex. Blood supply: internal mammary artery, posterior intercostal arteries, axillary artery, and lateral thoracic artery . Veins: internal thoracic vein, posterior intercostal veins, and axillary vein.
Lymphatic: the axillary vein group (lateral), the external mammary group (anterior or pectoral group), the scapular group (posterior or subscapular), the central group , the subclavicular group (apical), the interpectoral group (Rotter's). Level I : located lateral to or below the lower border of the pectoralis minor muscle. Level II : located superficial or deep to the pectoralis minor muscle. Level III : located medial to or above the upper border of the pectoralis minor muscle.
Gynecomastia
enlarged breast in the male. Physiologic gynecomastia: the neonatal period, adolescence, and senescence. (excess of circulating estrogens in relation to circulating testosterone) In the nonobese male, breast tissue measuring at least 2 cm in diameter must be present before a diagnosis of gynecomastia may be made does not predispose the male breast to cancer. clinical classification of gynecomastia: Grade I : Mild breast enlargement without skin redundancy Grade IIa : Moderate breast enlargement without skin redundancy Grade IIb : Moderate breast enlargement with skin redundancy Grade III : Marked breast enlargement with skin redundancy and ptosis, which simulates a female breast
The pathophysiologic mechanisms: I. Estrogen excess states A. Gonadal origin B. Nontesticular tumors C. Endocrine disorders D. Diseases of the livernonalcoholic and alcoholic cirrhosis E. Nutrition alteration states II. Androgen deficiency states A. Senescence B. Hypoandrogen states (hypogonadism) C. Renal failure III. Drug-related IV. Systemic diseases with idiopathic mechanisms Therapy.
Mycotic Infections :
blastomycosis or sporotrichosis.. Amphotrericin.
Hidradenitis Suppurativa :
chronic inflammatory condition that originates within the accessory areolar glands of Montgomery or within the axillary sebaceous glands. Antibiotic therapy with incision and drainage. Excision may be required which may necessitate coverage with flaps or STSG.
Mondor's Disease
thrombophlebitis involves the superficial veins of the anterior chest wall and breast. present as a tender, cord-like structure. ? Biopsy anti-inflammatory medications, warm compresses, restriction of motion, and brassiere support of the breast. When symptoms persist or are refractory to therapy, excision of the involved vein segment is appropriate.
Disease Giant fibroadenoma Gigantomastia Subareolar abscess Mammary duct fistula Disease Incapacitating mastalgia
Periductal mastitis
Cancer Risk Associated with Benign Breast Disorders and In Situ Carcinoma of the Breast:
Nonproliferative lesions of the breast Sclerosing adenosis Intraductal papilloma Florid hyperplasia Atypical lobular hyperplasia Atypical ductal hyperplasia Ductal involvement by cells of atypical ductal hyperplasia Lobular carcinoma in situ Ductal carcinoma in situ
No increased risk No increased risk No increased risk 1.5 to 2-fold 4-fold 4-fold 7-fold 10-fold 10-fold
Fibroadenoma:
Sclerosing disorders:
Periductal mastitis:
Risk-Assessment Models :
The average lifetime risk of breast cancer for newborn U.S. females is 12%. Two risk-assessment models are currently used to predict the risk of breast cancer.
Risk Management :
Postmenopausal hormone replacement therapy. screening mammography in women age 50 years and older reduces mortality from breast cancer by 33%. Tamoxifen: *Gail relative risk of 1.70 or greater -> reduce the incidence of breast cancer by 49%. *DVT, PE, endometrial CA, cataract.
BRCA Mutations:
BRCA-1 and BRCA-2, autosomal dominant, tumor-suppressor genes. BRCA-1 : *chromosome 17q *90% lifetime risk for developing breast cancer and up to a 40% lifetime risk for developing ovarian cancer. *invasive ductal carcinomas, are poorly differentiated, and are hormone receptor negative.
BRCA-2: chromosome 13q The breast cancer risk for BRCA-2 mutation carriers is close to 85% and the lifetime ovarian cancer risk Identifying carriers: (1) obtaining a complete, multigenerational family history. (2) assessing the appropriateness of genetic testing for a particular patient (3) counseling the patient (4) interpreting the results of testing Cancer prevention measures: *Prophylactic mastectomy and reconstruction; *Prophylactic oophorectomy and hormone replacement therapy; *Intensive surveillance for breast and ovarian cancer; and *Chemoprevention.
Distant metastases:
Hematogenously seed the pulmonary circulation via the axillary and intercostal veins or the vertebral column via Batson's plexus of veins, which courses the length of the vertebral column. the most common cause of death in breast cancer patients. bone, lung, pleura, soft tissues, and liver.
The age at diagnosis is 44 to 47 years 12 times more frequently in white women than in African American women Cytoplasmic mucoid globules; distinctive cellular feature Neighborhood calcification Invasive breast cancer develops in 25 to 35% of cases; either breast, regardless of which breast harbored the initial focus of LCIS 65% of subsequent invasive cancers are ductal, not lobular in origin A marker of increased risk for invasive breast cancer rather than an anatomic precursor
Xeromammography Ductography
Primary indication: nipple discharge
Ultrasonography Magnetic Resonance Imaging (MRI) Strong family history of breast cancer MRI of the contralateral breast in women with a known breast cancer (5.7% positive)
Core-needle biopsy
alternative to open biopsy low complication rate, avoidance of scarring, and a lower cost.
Open biopsy
breast tissue architecture invasive cancer is present
Palpable Lesions
Fine-needle aspiration (FNA) biopsy Core-needle biopsy (sampling error)
Tis
T1 T0 T1 T2 T2 T3 T0 T1 T2 T3 T3 T4 T4 T4 any T any T
N0
N0 N1 N1 N0 N1 N0 N2 N2 N2 N1 N2 N0 N1 N2 N3 any N
M0
M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M0 M1
Stage IIB
Stage IIIA
Stage IIIB
surgery is integrated with radiation therapy and chemotherapy. operable stage IIIa : modified radical mastectomy, followed by adjuvant chemotherapy, followed by adjuvant radiation therapy. Neoadjuvant can be considered. inoperable stage IIIa and for stage IIIb: neoadjuvant chemotherapy is used to decrease the locoregional cancer burden and may permit subsequent surgery to establish locoregional control. In this setting, surgery is followed by adjuvant chemotherapy and adjuvant radiation therapy.
Locoregional Recurrence:
Women with a previous mastectomy undergo surgical resection of the locoregional recurrence and appropriate reconstruction. Chemotherapy and antiestrogen therapy are considered and adjuvant radiation therapy is given if the chest wall has not previously received radiation therapy. Women with previous breast conservation undergo a mastectomy and appropriate reconstruction. Chemotherapy and antiestrogen therapy are considered.
Adjuvant chemotherapy:
reduce in the odds of recurrence and of death in women age 70 years or younger with stage I, IIa, or IIb breast cancer. age 70 years or older, adjuvant chemotherapy is recommended those with blood vessel or lymph vessel invasion, high nuclear grade, high histologic grade, HER2/neu overexpression, and negative hormone receptor status.
Neoadjuvant chemotherapy:
For operable advanced locoregional breast cancer . inoperable stage IIIa and for stage IIIb breast cancer, neoadjuvant chemotherapy is used to decrease the locoregional cancer burden.
Antiestrogen Therapy :
all women with in situ cancer, reduce in the incidence of invasive breast cancer. Node-negative women with hormone receptorpositive breast cancers that are 1 to 3 cm in size. Node-positive women and for all women with a cancer that is more than 3 cm in size. Can be added to the neoadjuvant therapy regimen for women with advanced locoregional breast cancer, especially for women with hormone receptorpositive cancers.
Bilateral
Suggestive of a benign condition: Multiductal in origin 39 years or less Milky or blue green in color
Phyllodes Tumors : Benign, borderline, or malignant Borderline tumors have a greater potential for local recurrence Sharply demarcated from the surrounding breast tissue Always monoclonal (fibroadenomas are either polyclonal or monoclonal) Small: excised with a 1-cm margin of normal-appearing breast tissue Large phyllodes tumors may require mastectomy Axillary dissection is not recommended
LYMPHOMAS