Showing posts with label Breast disease. Show all posts
Showing posts with label Breast disease. Show all posts
There are so many conditions of the breast that go poorly understood because of the emphasis on detecting breast cancer early. While finding breast cancer early is indeed of utmost importance, this column is devoted to the other conditions that are significantly encountered in the breast.
Breast size: There is often some difference in the size of a woman’s breast. This is often magnified because of a woman’s concern that this means something is wrong or that she looks “funny”. Even though there are rare cases of women with only one breast developing, most commonly there is only a slight variation in the size, usually only noticed by the woman herself. This is benign when it has “always been that way” and unless it gets to be a psychological barrier for the woman, does not need to be addressed. Plastic surgery is the answer when the difference is significant for the woman.
Breasts that are too large is another problem that sometimes is significant. Some women are just genetically programmed to have breasts that are painfully large. This tendency is not dependent on being “fat” but carrying extra weight can aggravate the condition. Women can be miserable. It can affect a woman’s choice of activities, causing women to avoid playing tennis, jogging, or other vigorous activities. Some women develop deep tender grooves over their shoulders from bra straps digging in and/or they suffer from chronic neck and upper back pain that can cause daily misery. It is a woman’s judgement call to decide when this condition needs to be addressed surgically. Many of my patients are grateful to have had the surgery and never look back. However, scarring can be a problem especially in keloid-formers and successful breast feeding can be made impossible. It is a big decision.
Breast lumps: Benign lumps can be divided into solid or cystic lesions. Many breast cysts that I see in my practice are discovered by the patient. They appear all of a sudden resulting in a visually obvious, tender lump. We usually go ahead with draining the cyst in the office. If it goes away completely with draining, the fluid is clear to milky, and the cyst does not recur, nothing further needs to be done. Some women are prone to this problem and are very familiar with this plan. Other cysts are not noted until a mammogram is done. Often, an area of density on the mammogram will turn out to be a cyst or simple fluid collection when examined by ultrasound. As long as all the cyst criteria are benign, i.e. thin-wall, single cavity, clear, etc., nothing further needs to be done. Anytime the cyst is complicated in appearance, recurrent, or filled with bloody fluid, biopsy should be considered.
The most common solid lump in the breast is something called the fibroadenoma. These can be seen even in the teenage years. They have specific criteria associated with them and sometimes are just observed over time. I lean towards recommending removal for lesions of any size for several reasons. First, patients worry if we are wrong and there is something in their body that will “get them”. Second, these lesions can grow and the bigger it is when removed, the larger the scar or breast defect may be. Third, follow-up can be difficult because of distortion from the lesion.
After a blow to the breast, especially after something like a shelf or table corner hit, or a car accident with seat belt bruising, the breast can undergo fat necrosis in that area, forming a firm nodule that eventually softens but may lead to some long-term distortion.
Nipple discharge: This is very common. When it comes from both nipples, is milky, and is not associated with pregnancy, it can represent an abnormal increase in Prolactin hormone and should be evaluated. Bizarre nipple discharge that is green or black is associated with fibrocystic change in the breast and usually only comes from one nipple at the time. Despite the strange appearance, this is a non-worrisome process. Bloody nipple discharge can be associated with a benign growth in a milk duct called a papilloma. Still, any bloody drainage should be further evaluated to exclude a cancer as the cause.
Commonly, many of the above symptoms are seen in women with fibrocystic change. Up to 40% of women have this condition that can promote the development of cysts, densities that can make the breast feel like beanbags, and colorful nipple discharge. Forty percent, that is a lot of women. All of the conditions mentioned here are very common. Benign changes including swelling before a period or any of the changes mentioned above will often be encountered by a woman. The above descriptions are provided to let women know that most changes don’t represent cancer. One should not be afraid! It is certainly prudent however to see your doctor about any change you notice that is different for you. Particularly, bloody drainage, lumps, or thickened areas should prompt a visit. Let your physician help to determine what evaluation should be done to help you rest assured.
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Several methods may be used to remove tissue for the pathologist to examine. The choice of which biopsy method is used depends on the size and location of your abnormality, and whether is can be felt or not.
- • Fine Needle Aspiration: A type of biopsy that is performed with a small needle and syringe. Cells are removed that can be examined under the microscope.
- • Core Needle Biopsy: A type of biopsy that is performed using a larger, hollow needle and a spring loaded instrument. Several cores of tissue are removed for examination under the microscope. Additional information can be obtained with these slightly larger pieces of tissue.
- Excisional Biopsy: A type of biopsy that is performed in an operating room. A small incision is made on the skin above the lump. The area of concern is then removed for examination under the microscope. The incision is closed with stitches.
- Ultrasound Guided Core Needle Biopsy: A type of biopsy that is performed using a larger, hollow needle and a spring loaded instrument. Using ultrasound guidance, the area of concern is found. Several “cores” or samples of tissue are removed and then examined under the microscope.
- Mammotome Biopsy: A type of biopsy is done by using a larger, hollow needle. The area of concern is found by using ultrasound as a guide. Several samples or cores of tissue are removed to be examined under the microscope.
- Stereotactic Biopsy: A type of biopsy that utilizes a special computerized mammogram and instrument. Lying face down, the breast hangs through an opening in this special table. A needle apparatus is inserted into the breast; an additional needle withdraws tissue from the area of concern. This tissue is then examined under the microscope.
- Needle Localization Biopsy: A type of biopsy that uses radiology guidance to insert a needle close to the area of concern. A small incision is made on the skin near this needle. The area of concern is then removed for examination under the microscope. The incision is closed with stitches.
Sourch University Medical Center
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Breast Tissue
The breast is made up of various types of tissues. These tissues change over a woman's lifetime as her hormones change. Before menopause, a woman's breasts are mostly made of dense, fibrous tissue and fat. As a woman passes through menopause, this fibrous tissue often turns to fat. This causes the breasts to feel much softer and less lumpy. If a woman takes estrogen after menopause, her breasts may often remain fibrous.
Fibrous tissue can sometimes hide a small cancer making it more difficult to feel or find on a mammogram. It is still important to obtain annual mammograms and examine your breast regularly. As you become older with less hormonal influence on your breast tissue, visibility on a mammogram should improve.
There are several types of breast cancers.
- Infiltrating Ductal Carcinoma (most common type) is a breast cancer that starts in the milk duct and spreads through the ductal wall into surrounding tissue. Once that invasion has occurred, the cells can enter lymph vessels and blood vessels. These vessels are pathways that can carry cancer cells to other parts of the body. For this reason, breast cancer is often described as a system wide disease.
- Ductal Carcinoma in Situ (DCIS) is a non-invasive type of breast cancer. It cannot spread. It is important to surgically remove all traces of the DCIS to improve local control of the cancer.
- Infiltrating Lobular Carcinoma is a cancer that starts in the lobule of the breast. It has microscopic projections that can break through the lobule wall and start moving into the surrounding tissue, often making this a more difficult cancer to diagnose at an early stage. It is treated the same as infiltrating ductal carcinoma, although sometimes clear lumpectomy margins are more difficult to obtain. It is also considered a system wide disease.
- Inflammatory Breast Cancer is characterized by redness and swelling of the breast with skin changes. This breast cancer can grow very rapidly. It has a higher chance of spreading elsewhere in the body and must be treated more quickly. It is treated first with chemotherapy, followed by surgery and radiation therapy.
Sourch University Medical Center
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- 1. Maintain your ideal body weight.
- 2. Participate in regular (3-4 times per week) aerobic exercise.
- 3. Avoid exposure to tobacco products. Do not smoke. If you do smoke, seek assistance in quitting.
- 4. Be moderate in the use of alcohol. For women, one drink per day is considered within acceptable alcohol consumption limits.
- 5. Adopt a healthy diet which emphasizes fresh fruits and vegetables, and reduces the consumption of animal fat and beef.
- 6. Prevent exposure to sexually transmitted diseases by practicing safe sexual behavior.
- 7. Avoid excessive sun exposure. Do not get sunburned.
- 8. Follow general health guidelines related to screening for other diseases such as cervical cancer and colon cancer.
Cardiovascular Health Maintenance
- Monitor your blood pressure regularly (it should be less than 120/80), and treat high blood pressure if it is found.
- Maintain your ideal body weight (your body mass index* should be less than 25).
- Monitor your blood lipid levels (LDL cholesterol should be less than 100; HDL cholesterol target: 50-60), and treat unacceptable cholesterol levels.
- Monitor your blood sugar periodically, and treat diabetes if it is found.
- Keep your waist circumference less than 32 inches.
- Participate in regular (3-4 times per week) aerobic exercise.
- Do not smoke! If you do smoke, seek assistance in quitting.
Bone Health Maintenance
- Participate in regular (3-4 times per week) weight-bearing aerobic exercise.
- Monitor your bone density: Ask you doctor for a baseline bone density test, Repeat the scan periodically. Treat bone loss aggressively: Take calcium and vitamin D after undergoing RRSO.
Consider other medications, such as pamidronate, risedronate, tamoxifen or raloxifene, if your bone density continues to decline. Estrogen is also effective in the treatment of osteoporosis, but its safety for women who are at increased genetic risk of breast cancer is uncertain. - Do not smoke! Smoking can also increase the risk of osteoporosis. If you do smoke, seek assistance in quitting.
Breast Health Maintenance
- Consult your physician regarding breast self-examination, since all the women who participate in this study are at increased risk of breast cancer.
- Seek medical attention promptly if you detect an abnormality in your breast.
- Have a clinical breast exam by your health care provider twice a year.
- Undergo screening mammograms at least once per year.
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Although monthly self breast examination (SBE) is recommended, it has not been shown to lower the mortality from breast cancer. Advising women to be aware of their breasts and report any masses or skin changes immediately may be more realistic.
Clinical breast examination
It is difficult for clinicians to become proficient at physical examination of the breast. Unlike auscultation of the chest or assessment of cranial nerves, where normal findings do not vary among normal patients, normal breasts look and feel different among normal women. Similarly, normal mammograms look different from one woman to the next. It takes a long time before a doctor is comfortable stating that a woman’s clinical breast examination (CBE) is normal, and even when they do, the fact remains that CBE is not a very sensitive tool for detecting early-stage cancer.
One can approach CBE by trying to detect a finding in one breast such as a mass, that is not present in the other. Breasts should first be inspected with patients sitting with their hands at their side, then on their hips, and above their head. Breast size and any asymmetry, visible masses, and skin changes, such as ulceration, erythema, dimpling, skin thickening, or edema, should be noted. Clinicians should look for nipple inversion, retraction, discoloration, or dryness. Patients then recline to supine and the entire breast is systematically palpated. A circular, vertical, or horizontal approach can be used as long as the entire breast is palpated, including the nipple areolar complex, the retroareolar area, axillary tail of Spence, and the axilla. Large breasts
can be difficult to examine and in these cases it may be helpful to position the patient on her side and palpate the breast when it has fallen away from the chest wall. There is no need to squeeze the nipple to look for discharge unless the patient is concerned about nipple discharge. Fluid can be expressed from most nipples if enough pressure is applied, and this is considered normal.
Clinicians often use the term fibrocystic to describe a breast that is tender, nodular, or dense on clinical examination. Fibrocystic disease or fibrocystic changes is a pathologic term and should not be used to describe clinical findings. Most breasts are not smooth, soft, or homogeneous in texture; they may be nodular, hard, or dense, and all of these findings are within the spectrum of normal. Because normal breasts vary greatly among patients, often what a clinician describes as fibrocystic is a variation of normal breast tissue. Furthermore, most women report tenderness during CBE; it may be focal or generalized, unilateral or bilateral. Pain and tenderness associated with a palpable mass or erythema warrants investigation, but breast tenderness alone is not a sign of disease.
Screening mammogram
Adult women at normal risk for developing breast cancer should undergo baseline mammography at age 35 years and yearly screening mammogram beginning at age 40 years. This evaluation should be combined with CBE examination by a trained clinician.
Sources Elsevier
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