Dr.Amal Al-Abdulkareem. Upper border - Collar bone. - Collar bone. Lower border. - 6 th or 7 th...
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Transcript of Dr.Amal Al-Abdulkareem. Upper border - Collar bone. - Collar bone. Lower border. - 6 th or 7 th...
![Page 1: Dr.Amal Al-Abdulkareem. Upper border - Collar bone. - Collar bone. Lower border. - 6 th or 7 th rib. Inner Border - Edge of sternum. Outer border.](https://reader038.fdocuments.us/reader038/viewer/2022110319/56649c815503460f94939dc9/html5/thumbnails/1.jpg)
BREAST DISEASEDr.Amal Al-Abdulkareem
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Breast Modified Sebaceous Glands
Upper border - Collar bone. Lower border.
- 6th or 7th rib. Inner Border
- Edge of sternum. Outer border - Mid-axillary line.
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Breast Divisions5 Segments
Four Quadrants - By horizontal and vertical lines.
Tail of Spence Majority of benign or malignant tumors
in the Upper Outer Quadrant
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External Anatomy of the Breast
Nipple -Pigmented, Cylindrical -4th inter-costal space * at age 18
Areola -Pigmented area surrounding nipple
Glands of Montgomery -Sebaceous glands within the areola -Lubricate nipple during lactation
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Montgomery’s Tubercles
BlockedMontgome
ryTubercle
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GLANDULER TISSUE
15-20 Lobes -Radiate around nipple and under areola
Lobe - 20-40 lobules
Lobules - Alveoli cells or acini - Milk producing cells
Lactiferous ducts - Drain milk into nipples
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Terminal Lobular Unit and Branching Systems of Ducts
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Terminal Duct Lobular Unit
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Tissue Types
Glandular Tissue - Milk producing tissue
Fibrous Tissue Fatty Tissue
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Internal Anatomy of the Breast
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Fibrous Tissue
Cooper’s Ligaments -Suspensor ligaments
- Extending through the breast to underlying muscle - Benign or malignant lesions may affect these ligament - Skin retraction or dimpling
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Fatty Tissue
Subcutaneous and retro-mammary fat
Bulk of breast. No fat beneath areola and nipple
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Chest Muscles
Pectoralis Major/Minor Serratus Anterior Latissimus Dorsi Subscapularis External Oblique Rectus Abdominus
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Lymph Nodes
Most drain towards axilla.
Superficial lymphatic nodes drain skin .
Deep lymphatic nodes drain mammary lobules
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Lymph Drainage of Breast
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Levels of Axillary Nodes
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Lymph Nodes
Palpate ALL nodes - From distal arm to under arm with deep palpation
Axillary Supraclavicular Infra-clavicular Nodes deep in the chest or abdomen Infra-mammary ridge
- Shelf in the lower curve of each breast
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Normal Variations of Breast
Accessory breast tissue. Supernumerary nipples. Hair Lifelong Asymmetry
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Milk LinesSites of Accessory Nipples and Breasts
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Accessory Beast Tissue
Accessory Tissue
Biopsy
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Accessory Nipple
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Accessory Nipple and Bilateral Accessory Breasts
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Breast with Two Nipples
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Breast Hair
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Physiology of Breast
Puberty - Need estrogen and progesterone
Estrogen - Growth and appearance - Milk-producing system
Progesterone - Lobes and alveoli - Alveolar cells become secretory
Asymmetry is common.
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Breast Asymmetry
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Breast Asymmetry
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Physiology of Breast
Progesterone - 3-7 days prior to menses - Engorgement
Physiologic nodularity - Retained fluid
Mastalgia
Menses
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Physiology of Breast
Glandular tissue displaces connective tissue
Increase in size Nipples prominent and darker Mammary vascularization increases Colostrum present Attain Tanner Stage V with birth
Pregnancy and lactation
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Physiology of Breast
Perimenopause - Decrease in glandular tissue - Loss of lobular and alveolar tissue
Flatten, elongate, pendulous Infra-mammary ridge thickens Suspensory ligaments relax Nipples flatten Tissue feels “grainy”
Aging
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Clinical Breast Exam
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Clinical Breast Exam
Inspect Both Breasts - Arms at sides - Arms over head - Arms on hips with valsalva - Leaning forward
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Inspect Both Breasts
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Skin Dimpling and Change in Contour
Dimpling due toCarcinoma
Change in contourdue to carcinoma
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Skin Dimpling Both Breasts Involution Due to Aging
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Skin DimplingBreast Infection
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Skin DimplingPrevious Breast Surgery
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Inverted Nipple Since Puberty
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Clinical Breast ExamPalpate
Palpate Sitting Rest arm in your hand and palpate
axilla -Her arm should be relaxed
Palpate supra-clavicular and infra-clavicular nodes
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Palpate Axilla and Clavicular Nodes
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Clinical Breast Exam
Lay supine Place pad under shoulder to flatten
breast Raise arm over head Abnormal finding? Check the other
breast!
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Clinical Breast ExamPalpate
Using preferred patter Palpate with pads of three fingers Palpate in circular fashion Compress through all layers of tissue Note any discharge
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Breast Palpation
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Galactorrhea
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Physiological Secretions in Normal Breast Lobule
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Common Benign Breast Disorders
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Common Benign Breast Disorders
Fibrocystic changes Fibroadenoma Intraductal papilloma Mammary duct ectasia Mastitis Fat necrosis Phylloides tumor Male gynecomastia
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Fibrocystic Changes
Lumpy, bumpy breasts 50-80% of all menstruating women Age 30-50
- 10% in women less than 21 Caused by hormonal changes prior
to menses Relationship to breast cancer
doubtful
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Signs and Symptoms
Mobile cysts with well-defined margins Singular or multiple May be symmetrical Upper outer quadrant or lower breast
border
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Signs and Symptoms
Pain and tenderness Cysts may appear quickly and
decrease in size Lasts half of a menstrual cycle Subside after menopause
-If no HRT
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Treatment
Aspirate cyst fluid Imaging for questionable cysts Treatment based on symptoms Reassure ‘’Atypical Hyperplasia’’ on pathology
report indicates increased risk of breast cancer
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Comfort Measures
Eliminate Methylxantines (coffee, chocolate) - May take 6 months for relief
Local heat/cold Support bra Low-Sodium diet Vitamin E
- Antioxidant - Do not take more than 1200/day
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Medications for Mastalgia
NSAIDS Monophasic oral contraceptive pills Spirinolactone
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Medications for Mastalgia
Dopamine Agonists -Bromocriptine
Rare or former use - Danazol - Tamoxifen - GnRH agonist (Luprolide)
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Fibroadenoma
Second most common breast condition
Most common in black women Late teens to early adulthood Rare after menopause
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Signs and Symptoms
Firm, rubbery, round, mobile mass Painless, non-tender Solitary
- 15-20% are multiple Well circumscribed Upper-outer quadrant 1-5 cm or larger
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MammogramMultiple Calcified Fibroadenomas
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Treatment
Imaging Biopsy Excision Close follow-up
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Intraductal Papilloma
Slow-growing Overgrowth of ductal epithelial tissue Usually not palpable Cauliflower-like lesion Length of involved duct Most common of bloody nipple
discharge 40-50 years of age
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Signs and Symptoms
Watery, serous, serosanguinous, or bloody discharge
Spontaneous discharge Usually unilateral Often from single duct
- Pressure elicits discharge from single duct
50% no mass palpated
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Bloody Breast Discharge
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Treatment
Test for occult blood Ductogram Biopsy Excision of involved duct
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Intraductal Papilloma
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Mammary Duct Ectasia
Inflammation and dilation of sub-areolar ducts
behind nipples May result in palpable mass because
of ductalrupture Greatest incidence after menopause Etiology Unclear
- Ducts become distended with cellular debris causing obstruction
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Mammary Duct Ectasia versus Breast Cancer
Left breast – slit-like nipple characteristic of mammary duct eclasia
Right breast – nipple retraction from carcinoma
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Signs and symptoms
Multi-colored discharge - Thick, pasty (like toothpaste) - White, green, greenish-brown or serosanguinous
Intermittent, no pattern Bilaterally from multiple ducts Nipple itching Drawing or pulling (burning)
sensation
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Dried Secretions from Mammary Duct Ectasia
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Yellow Breast DischargeDuct Ectasia
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Multi-colored Breast Discharge
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Treatment
Test for occult blood Imaging
- Mammogram - Sonogram
Biopsy - Excision of ducts if mass present
Antibiotics Close follow-up
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Mastitis
Breast infection when bacteria enter the breast via the nipple
Ducts infected Fluid stagnates in lobules Usually during lactation Penicillin resistant staphylococcus
common cause
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Puerperal Mastitis
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Puerperal MastitisLeft Breast
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Inflammatory Carcinoma
Erythema and peau d’orange
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Signs and Symptoms of Mastitis
Pain Nipple discharge
- Pus - Serum - Blood
Localized induration Fever
Breast Abscess
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Breast Abscess
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Non-Lactating Breast Abscess
Arrow points to inverted nipple
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Treatment
Antibiotics
Empty breast if PP Incision and drainage of abscess
‘’Oxacillins’’ for PP mastitis Cephalosporin for other abscesses
- Cephalexin - Keflex
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Draining Breast Abscess
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Abscess Drained under Local Anesthesia
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Puerperal Breast Abscess
Before treatment After treatmentLocal anesthetic
Abscess occurred during lactation
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Peripheral Breast Abscess
Left – before management Right – after recurrent aspiration and
antibiotics
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Fat Necrosis
Cause - Trauma to breast - Surgery
Necrosis of adipose tissue Pain or mass
- Usually non-mobile mass - Resolves over time without treatment -may be excised
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Fat Necrosis
Seat Belt Trauma
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Breast Hematoma
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Phylloides Tumor
Giant fibroadenoma with rapid growth Malignant potential Often occurs in women aged 40+ Treatment
- Excision
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Giant Fibroadenoma
Before Surgery After Surgery
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Cross Section of Giant Fibroadenoma
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Malignant Phylloides Tumor
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Male Gynecomastia
Diffuse hypertrophy of breast 30-40% of male population Adolescence and older men Caused by imbalance of
estrogen/testosterone Medical conditions (hepatitis, COPD,
hyperthyroidism, TB) May be associated with genetic
cancer families
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Left-Sided Gynecomastia
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Medications Associated with Gynecomastia
Marijuana Narcotics Phenothiazines Diazepams Anything that affects the CNS
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Treatment
If pre-puberty - Wait to see if it resolves
Change medication Treat underlying illness Occurs in families with genetic
mutation - Colon, prostate cancer
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Differential Diagnosis of Nipple Discharge
Common causes in non-pregnant women
Carcinoma Intraductal papilloma Fibrocystic changes Duct ectasia Hypothyroid Pituitary adenoma
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Clinical Characteristic
Physiologic - Usually bilateral - Multiple ducts - Non-spontaneous - Screen for phenothiazine use and stimulation
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Physiological Breast Discharge
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Clinical Characteristic
Pathologic discharge - Spontaneous - Unilateral - Single duct - Discolored discharge
Bloody discharge
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Evaluation
Clinical Exam Test for presence of blood in
discharge Lab tests
-Thyroid, prolactin Imaging
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Treatment
Physiologic - Treat cause if present - Follow-up 6 months
Pathologic - Biopsy and excise
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