Lecture of benign breast disease

2021-03-21 12:00 AM

The first milk, also known as colostrum, is produced by fat degeneration of the follicular cells and white blood cells. Estrogen and progesterone levels decreased after birth.

Breast anatomy

In adult women the normal size and shape of the breast can vary considerably. When standing, the nipple is equal to the quadruple space, the breast can be seen extending from the sternum to the anterior axillary line and an area called the axillary tail, where part of the breast tissue spreads to each side of the armpit. The breast tissue is located on the chest scale, below is the pectoral muscle, above the anterior serrated muscles on the sides and surrounded by a shallow and deep layer of the subcutaneous scale. Chest scale only penetrates the armpit at the tail armpit. The breast is a mass supported and hung up by Cooper ligaments, which are the fibrous connective tissue walls that attach the deep layers to the shallow layers of the scale under the skin and from there to the skin. If Cooper ligaments are affected, such as an inflammatory or neoplastic process that develops in the breast mass will lead to skin contraction and is often seen as an indirect sign of breast cancer.

Pigmentation circles contain sebaceous glands that help lubricate the nipples during lactation. Smooth muscle bundles sit in the skin and help the nipples to erect when the breasts are stimulated.

The female mammary gland has 10 to 20 lobes, arranged in a spokes shape, each lobe contains numerous small lobes made up of clusters of follicles. The keratinized epithelium goes from the skin of the nipple into the ducts followed by the cylindrical cells, which separates the keratinized epithelium from the glandular epithelium. The ducts are lined with one or two layers of the cylindrical epithelium. These tubular epithelial cells are located on the basal membrane that separates them from the interstitial and surrounding adipose tissue. The milk ducts have no muscle fibers, but the surrounding epithelial cells and elastic fibers respond to hormonal stimuli (eg Oxytocin), leading to the transport of milk towards the nipple. The ducts connect to the tubes in the lobules, and these tubes connect again to the follicles. The lumen of the follicle is covered with a low cylindrical epithelium that helps create milk during late pregnancy and lactation.

If there is no medical condition (eg dilation of the ducts), the diameter of the duct is about 0.5mm. Balloon is the expansion of the system to store milk during lactation. Each lobe is submerged in adipose tissue and the same ligament Cooper has a major role in shaping the breast.

The breast receives blood from three main sources: the inner thoracic artery (below and the side of the sternum), the lateral thoracic artery, the head and shoulders - thoracic artery of the axillary artery.

Venous blood collects in a ring that connects the surrounding, sub-nipple vein and is continuous with the axillary or inner thoracic vein through the branches.

Lymph vessels originate along tubes in the inter-lobular space and drain fluid from the lower inner quadrant to the parietal lymph nodes. Lymph in the center of the breast, nipple, and the outer and lower outer quadrants are led to the group of thoracic lymph nodes in the armpit. Understanding the lymphatic drainage of the mammary gland is essential to understanding how breast cancer has spread through the lymphatic tract.

Mammary gland physiology

Infancy period

Breast buds and neonatal lactation, due to the influence of maternal hormones (high estrogen levels) during pregnancy, disappear within a few weeks after birth.

Puberty

The first stimulus for the breast to develop is the ovarian hormone, which then leads to development of the breast. In response to estradiol, ductal epithelial cells proliferate and ducts develop.

Estrogen, progesterone, prolactin, insulin, cortisol, thyroxine and growth hormone are required for the full differentiation of the breast including lactation.

Changes according to the menstrual cycle

The adult breast responds to hormonal changes that occur during the menstrual cycle. During the follicular phase, the ducts and breast parenchyma proliferate. During the luteum phase, dilation of the ducts, an increase in tubular secretion activity, and an edema between the lobules under the influence of progesterone lead to an increase in breast volume.

With the onset of the period, the breasts return to their smallest size by day 8 of the menstrual cycle. This time is ideal for breast exams and mammograms for high quality images.

Pregnancy and lactation period

As described above, even though the breast is mature but remains inactive until pregnancy, this is the time when a complete differentiation of the terminal follicular cells in the milk-producing cells occurs. Enlarged breasts are one of the first indirect signs of pregnancy, as a result of gland proliferation.

Prolactin levels increase from 8 weeks gestation to full term. Estrogen from the placenta stimulates the pituitary gland to produce and release prolactin.

The first milk, also known as colostrum, is produced by fat degeneration of the follicular cells and white blood cells. Estrogen and progesterone concentrations decreased after birth resulting in prolactin release and lactation was established 3-4 days postpartum.

Breast changes during menopause

After menopause, the glandular tissue shrinks and is replaced by adipose tissue.

Define

Benign breast disease is all breast conditions, except for breast cancer and other breast infections.

This pathology is often found in the epithelium of the ductus ducts, or in the connective and adipose tissue.

Classification of benign breast diseases

Disseminated benign breast disease:

There are 2 common types:

Fibrocystic breast disease, common age 29-49, rate 34% to more than 50%.

Ductal ectasia, age 35 -55, rate 4%

Local benign breast disease:

Fibroadenoma of the breast, common age 20 -49 years, accounting for 19%.

Intraductal papilloma.

Other benign tumors

About 10%.

Hamartoma. Most appear in women over 35 years old.

Hemangioma (Hemangioma).

In my (Lipoma).

Common benign breast disease

Cystic fibrosis of the mammary glands

This pathology may or may not have clinical manifestations such as pain or discomfort.

Pathology:

It is a diffuse lesion that includes many coordination abnormalities. There are 3 main components:

Tubes: tubular proliferation and cyst formation.

Cyst: is due to the dilated and secreted parts of the milk ducts. The number and size of these cysts varies from case to case.

Fragments: hyperplasia gland (segmental hyperplasia) and sclerotic gland proliferation.

Buffering: Fibrosis.

The proliferative lesions (epithelial proliferation, sclerotic gland proliferation, papilloma) increase the risk of breast cancer. The proliferation associated with dysplasia increases this risk 4-5 times. Non-proliferative changes (glandular proliferation, follicles, dilation of the ducts) do not increase the risk of breast cancer.

Pathophysiology:

This is a hormone-dependent disease. For a long-term imbalance between estrogen and progesterone, the breast organization undergoes various morphological changes. At the time of estrogen secretion, epithelial cells proliferate in the ducts (tubular proliferation) and segments (glandular proliferation). With reduced estrogen levels, coiled epithelium, ducts become follicles, and the lobules and buffers increase fibrosis organization (increased sclerenchyma of the gland and stromal sclerosis).

This pathology disappears when the secretion of estrogen and progesterone (menopause) stops. Stopping ovulation through the use of oral contraceptives, depo-provera injections, etc. may partially relieve symptoms, but not in all cases. 

Clinical:

Year old:

The disease usually begins after 30 years old, commonly seen between the age of 40-50. Symptoms go away after menopause.

Mechanical signs:

Cyclical breast pain: usually appears about 8 days before menstruation, disappears after menstruation, spontaneous pain, spread to hands.

Entity markers:

Characteristic cysts: The tumor is round, well-defined, slightly stiff, often painful, the location is usually in the outer 1/4, the size and number of changes.

Hard plaques: Clinically often find indeterminate plaques on the breast, the most common location is the outer 1/4, which disappear after menstruation.

Breast increase in volume.

Subclinical:

X-ray of the breast (mammography): On the radiograph showed.

Breast density increases.

The blurred background corresponds to the edematous areas.

The circular contrast corresponds to the cyst.

Large and small calcified traces scattered, not concentrated in groups.

Ultrasound can help distinguish between cysts and hard lesions.

Aspiration to make cells.

The aspiration of the cyst allows an assessment of the color of the fluid. When puncture and bloody fluid must think of cystic cancer. However, if the fluid is clear, cloudy, yellow or green, then the follicle is usually benign. After cystic aspiration, it is necessary to re-examine the breast to ensure that the tumor is completely removed. If the tumor persists, a biopsy is needed.

Differential diagnosis:

Pain:

Premenstrual Syndrome: Usually less pain and begins 2-3 days before menstruation, no marked increase in breast volume, regular and soft breast examination.           

Intercostal pain: Usually unilateral pain, transient position at a certain point, not related to the menstrual cycle.

U nang:

May be confused with fibroids. Distinguishing between cysts and solid tumors by physical examination will not give a reliable result. In this case, an ultrasound or aspiration / biopsy should be performed.

Hard array:

It can be difficult to distinguish from a case of breast cancer, which usually go away after menstruation, improving with progest√©rone therapy. Sclerosis associated with cystic fibrosis is usually on both sides, and has a feeling of a thick patch different from a hard mass. Any hard mass that persists for more than 2 menstrual cycles requires biopsy.

Treatment:

Treatment can be started if the patient feels uncomfortable and wants to be treated. The pain usually goes away spontaneously, and in this case it is usually enough to reassure the person.

Diet: Foods containing methylxanthines (coffee, tea, coca, chocolate) should be avoided. However, there is no clear evidence that this is an effective remedy.

Endocrine treatment:

Luteal phase alone, from day 15-25 of the menstrual cycle, 5mg medroxy - progesterone acetate (MPA).

Dopamine agonists (prolactin inhibitors), bromocriptine 2.5mg, dose escalation, starting with 0.5mg, 1mg, 2.5mg. Side effects include nausea and dizziness.

Estrogen resistance, Danazol 100-200mg / day, from 15-25 menstrual cycle. Because these drugs have an androgenic effect, their use is limited.

Tamoxifen (Nolvadex) at a dose of 10mg / day from day 5 to 25 of the menstrual cycle.

Nonsteroidal anti-inflammatory drugs.

Surgery: 

Cyst removal in the following cases:

Bleeding with blood.

There are papillomas in the cyst.

Suspected cells.

A simple drainage can be performed for a painful follicle.

Pathological biopsy in the following cases:

Plaque persists after cystic drainage or after 2 menstrual cycles.

Doubt.

There are dysplastic cells during biopsy.

Fibroids

Define:

Tumors develop from connective tissue between lobules.

Clinical:

Usually occurs before the age of 35.

Symptoms: The tumor has the following characteristics:

Firm, fibrous, regular, round or ovoid, moving under the skin, painless, unrelated to the menstrual cycle.

Size varies about 2-3cm.

Quantity: usually only 1u, sometimes many tumors appear next time.

Subclinical:

Chest X-ray: shows circular, well-defined contrast.

Ultrasound: confined images with rich echo. Ultrasound and mammography have little diagnostic value for a hard mass

Cytology: for a hard mass, a fine needle puncture or biopsy should help confirm the diagnosis and rule of cancer.

Clinical form:

Recurrent fibroids.

Enlarged fibroids: often fast-growing, easy to confuse with leaf tumors.

Evolution:

Fibroids do not constitute a risk factor for cancer, are usually stable and do not respond to endocrine therapy. .

Treatment:

Before the age of 35:

Monitoring periodically every 6 months.

Surgery when:

 Tests for different results.

The tumor is large and rapidly growing.

After 35 years:

Surgery to remove the tumor makes surgery to the disease.

Dilation of the ducts

Dilation of the ducts is a common process, but with little accompanying clinical distress. This is a nonspecific dilatation of the ducts under the areola.

Clinical:

Age: most common at the age of 25 - 50.

Symptom:

Nipple discharge, may be one or two sides, natural discharge, usually clear or gray fluid.

Recurrent surrounding areola abscesses are a complication of ducts.

Treatment:

No treatment is needed if cancer has been ruled out.

Papilloma’s in the milk ducts

Define:

It is the central epithelial proliferation on the connective axis and development in the lumen of the ducts. Organizationally, papillomas form papillary leaves with fibrous granules and covered proliferative epithelium. In addition, solid regions are often found, either on a wall or in a well-defined array. The proliferative epithelium consists of epithelial and muscle-epithelial cells.

Mechanical symptoms:

Natural blood or discharge on one or two breasts,. Squeezed around the areola can see fluid dripping from the nipple. This symptom is most common in milk duct papilloma. 

Subclinical:

X-ray: to rule out breast cancer.

Galactography: after injecting contrast into the ducts, clogged milk ducts and papillomas are found in the ducts.

Treatment:

Surgery is the main method. One can mark the tumor before surgery by methylene blue injection ..

Evolution:

Papillomas in milk ducts are usually benign.

Fatty tumor

Is the proliferation of fat cells, creating a sheath tumor.

Diagnose:

Ultrasound of adipose tissue like mammary adipose tissue, poorly reflective, easy to compress. When there is less fibrous tissue, the adipoma may be less than homogeneous with the phonogenetic component, a hypertonic border due to the envelope may be typical. The tumor is 35mm in diameter, has a smooth margin, and has a uniform structure.

Treatment:

Removal of the tumor when symptomatic or for cosmetic reasons. The procedure is performed with an incision around the areola.

Milk bag

Duct obstruction in a lactating patient can lead to the formation of a hydrocele, called a milk sac. Milk bags in cases of lactation unrelated to postpartum are rare.

To solve:

Since the diagnosis of milk bags is clear during lactation, aspiration is recommended for diagnosis and treatment. This procedure may be repeated in case of relapse.

Breast exam

For premenopausal women, breast screening is best from day 8 to 10 of the menstrual cycle. Women who are menopausal or have had a hysterectomy should choose at a fixed time for the exam.

Perform the steps of the examination process in 2 positions:

Stand up straight, hands on hips.

Lie with your arms around your head.

Observe

Breast balance, deformation, skin variability, change in color

Palpate both breasts

Proper breast examination of all nipples and areas (upper and lower exam from left to right or spiral examination starting from the nipple going out)

Check for any discharge from the nipple, for any changes in the skin.

Record examination results by region and clockwise, size, uniformity (cystic form, solid, soft-elastic), mobile, have clear outward boundaries or (conversely, yes part of the breast parenchyma), tenderness.

Compare the suspect area with the area opposite the other breast.

Examination of the lymph nodes: the armpit area, the region on the collarbone.  

Breast scan

Should conduct annual screening at the age of 50-60, while for the age 40-50 and over 65 there is still a lot of debate about whether the annual screening is necessary or not. The scan does not yield sufficient sensitivity and specificity in young women because of the higher density of the breast at the time of the scan.

Sensitivity: 80-94%: the sensitivity of the result will increase with age. Sensitivity is significantly reduced in premenopausal women. Specificity: about 95-98%

A mammography for a diagnostic breast mass (mammography) is different from screening and screening mammography and this procedure needs to be done by a different procedure. Diagnostic mammography can include: overview, point-by-point scan, tangent imaging etc.

Mammography in the case of palpable abnormal mass is first to screen and check for symmetrical breasts for cancers that are undetectable through palpation (3% of cases with cancers on both breasts) . A normal mammogram in the presence of a palpable tumor typically about 15-20% does not provide any further information, so further examination (biopsy) is needed.

A mammogram cannot help distinguish between benign and benign tumors accurately, however, in some cases it can help provide more information about the tumor's identity. According to one review (Layfield), mammograms were misinterpreted as benign tumors in 8% of cancer cases and were diagnosed as cancer in 16% of cases with benign tumors. The recent BI-RADS system analysis shows that 20% of breast cancers are diagnosed as normal and 0% of the cases have a high degree of malignancy in the absence of cancer (20% in benign cases). interpreted in terms of BI-RADS results 3 or 4). Therefore, it is necessary to continue testing to confirm the diagnosis.

The mammograms should be systematically recorded. One of the most popular archiving systems is the BI-RADS (Short for Breast Disease Reporting and Imaging Systems) classification of the United States School of Radiology. :

  1. Incomplete evaluation, need more imaging diagnostics.
  2. Normal.
  3. Abnormally benign.
  4. Potentially benign / potentially malignant. Needs further follow-up for a short period: 2% risk of cancer.
  5. Suspected tumor malignancy.
  6. Considered malignant until evidence confirming the diagnosis is found.

Supersonic

Not considered a suitable screening test because of its low sensitivity.

Support for mammography in case it is necessary to distinguish between a cyst and a solid mass.

It can be started with ultrasound and / or isolating (before a mammogram) for young women (under 35 years of age) with suspicion of a cyst.

It is beneficial in guiding biopsy of cysts or locating calcification points or solid masses during tumor center biopsy.

Needle puncture

In contrast to fine needle aspiration (FNA), this is follicular aspiration using syringes and standard needles that do not absorb the cell organelles. This is a simple, inexpensive procedure, and the worker needs basic training. Blood aspirated fluid should be sent for cytology and need to be performed with fine needle aspiration or biopsy.

In the case of clear suction, no further procedures are needed, the cyst disappears, does not recur and the mammogram results are normal.

Mammography should be done with follicle aspiration, even in cases where fluid is drawn from the inner follicle. The aspiration can be done before or after the mammogram, however, keep in mind that the aspiration procedure just before the mammogram can create a hematoma, which may obscure or partially interfere with the mammogram. It is advisable to wait 2 weeks between these procedures.

When the breast follicle is identified by mammography but cannot be palpated, aspiration can be performed with the guidance of an ultrasound. For palpable tumors, aspiration may not require ultrasound assistance.

Small needle aspiration (FNA)

This is a procedure that sucks the tissue in place using a special syringe and suction techniques.

This is a diagnostic and therapeutic (analgesic) procedure. For this reason, ultrasound is the preferred procedure of choice for diagnosing palpable cysts.

Guaranteed close to 100% specificity. False positive results may occur with fat necrosis, mastitis, milk duct papillomas, fibroids, and radiation-related alterations.

It is impossible to differentiate invasive and non-invasive cancers or between lymphoma and less differentiated cancers.

The sensitivity of the procedure is 85-94% and depends on the skill of the practitioner. False negative results are often caused by incorrect puncture site selection.

The person performing the procedure should be trained and have an experienced cytologist in reading the results.

Biopsy of the tumor center

Help remove the tumor center (palpable type) or be identified by X-ray.

Usually size 14 needle is used, can be used with a vacuum or not. This procedure removes the center of the tumor for a cytology.

This procedure is less expensive and risky than biopsy and open surgery, leaving no scars.

Open surgical biopsy

Tumor resection and lumpectomy (with the exception of benign tumors such as fibroids, which are usually removed with a minimal extension from the tumor boundary). u)

Combination methods

Screening combines 3 methods.

A combination of physical examination, fine needle aspiration (FNA) or central tumor biopsy and a mammogram will increase the accuracy of diagnosis.

When all 3 tests above give the same results, it is possible to confirm the accuracy and certainty of diagnosis up to 99%.

Process of diagnosis

The choice of diagnostic methods depends on

Availability and accuracy of methods: fine needle aspiration (FNA), mammography, ultrasound and surgical indications.

There is suspicion of malignancy.

Procedures combine different diagnostic tests in the order and when they are administered. In most cases, 3 combined diagnosis will be required: physical examination, mammography and / or ultrasound, and biopsy.

Other options include

Fine needle aspiration or simple aspiration is generally considered option 1 compared with ultrasound in suspected cysts.

For young women with suspected fibroids, if a fine needle aspiration confirms the diagnosis, there is no need for additional tests such as a mammogram.

For women under 35 years of age (except for those with a prominent family history of breast lumping), a mammogram is not an option. An ultrasonic diagnosis and / or needle aspiration should be performed first.

 Points to note

Regular fine needle aspiration does not completely rule out the diagnosis of cancer. Tumour central biopsy will provide diagnostic tests with greater sensitivity and accuracy.

Conventional mammography in the case of a palpable tumor does not rule out cancer.

If the diagnostic tests give different results: in case of a mammogram showing suspicious results, and a negative needle aspiration result, further diagnosis and close monitoring are required.

Regular follow-up is required (eg every 3-6 months every 18 months) even when a benign tumor is diagnosed to detect false negative results.