Breast

• Breast

General Information

The breast is a specialized milk-secreting organ located under the skin. It is a cloth. Breastfeeding ensures that the baby receives nutrients that will enable it to survive until it is fed. Breast tissue 2-6. It is located between the ribs and the superfascial and deep layers of the pectoralis major fascia. Breasts take different shapes depending on age, weight and race. There may be asymmetry between the two breasts. It reaches the highest volume 1 week before the start of menstruation and the lowest level 5-6 days after the start of menstruation. Every woman should perform breast self-examination at regular intervals starting from the age of 20. Women between the ages of 20-39 should be examined regularly by a specialist physician every 3 years, and from the age of 40 onwards, they should have an annual examination. Every woman age 40 and over should have a mammogram every year and continue annual mammograms as long as her health permits. Every woman aged 40 and over should go to the doctor regularly and have a breast examination every year. The best time for breast self-examination is 7-9 days after the beginning of menstruation. days. If you do not have a menstrual period, you should have an examination on the same days of each month.

Follow in order for breast self-examination.

Standing in front of the mirror, stretch your arms up and down. Check if there are any changes in your breasts. Later; Check if there is any shrinkage, mass, swelling or indentation on your breast skin by pressing your arms against your waist. Then; First, lie on your back by placing a pillow under your right back and put your right arm under your head. You should perform the examination using the tips of the middle three fingers of the left hand. Examine your breasts by first pressing lightly and moderately, then pressing deeply, making circular movements from top to bottom and from inside to outside. Then repeat the same examination for the left breast. In the last step; When you take a shower, soap your breast and examine it by repeating the above-mentioned movements using the lubrication. Meanwhile, do not forget to check both of your armpits.

Imaging in breast diseases

• Mammography and Ultrasound X-ray:

During conventional mammography, less than 0.1 rad of radiation is received. Therefore, there is no relationship between radiation received during mammography and breast cancer. The purpose of mammography is to detect patients with palpable or nonpalpable lesions in their breasts at an early stage before they become symptomatic. Because the prognosis of patients detected at an early stage is better. Mammography is a routine two-way film. Magnified spots can be taken in suspicious masses. Malignant criteria are sought in films. These may be masses, asymmetries, stellate opacities or tissue distortion, or they may appear as clusters of microcalcifications. Axillary lymph node, skin or nipple changes may also be observed. The American Cancer Society recommends that every woman should have a self-examination after the age of 20 and have a "base-line" mammogram after the age of 35. A mammogram should be taken annually between the ages of 40-50.

Mammography;

1- What cannot be determined by examination and in the evaluation of lesions with suspicion of neoplasm

2- In the evaluation of multiple cysts or masses for which the biopsy indication is not certain.

3- In the follow-up of patients who underwent segmental mastectomy + radiotherapy

4- In the follow-up of the contralateral breast of patients who underwent segmental or total mastectomy

5- It is used in the evaluation of fatty and large breasts that are symptomatic but do not have a palpable mass in the breast.

6- It is used in the evaluation of synchronous or multicentric lesions.

With advanced ultrasonography devices, the size of the masses, Reliable and effortless biopsy can be performed under the guidance of solid cystic and ultrasonography. The biopsy decision should be made by a surgeon who knows the patient's clinic, with the results of an experienced radiologist.

INFLAMMATORY AND INFECTIOUS DISEASES OF THE BREAST

• Bacterial Infection :

The causative agent is often Staphylococcus aerus or streptococcus. The abscess form usually occurs with lactation and in the first weeks of lactation. Streptococcal infections mostly cause cellulitis. Staphylococcus aerus, on the other hand, is a more localized, deep-invading infection. forms active abscesses. Abscess is usually multiloculated. Treatment is surgical drainage + antibiotics. Rarely, simple mastectomy may be required in chronic infections

• Puerperal mastitis:

It usually occurs with Staphylococcus aerus. It passes to the mother while the baby is breastfeeding. There is usually a crack in the nipple. Milk stasis occurs, and draining the milk from the breast ensures that the symptoms regress. Mastitis regresses with antibiotic treatment. Lactation should not be continued during mastitis.

• Granulomatous Mastitis

Granulomatous mastitis (GM), It is a rare, chronic inflammatory disease whose etiology is not fully elucidated. Patients are mostly women who present with a unilateral mass or purulent discharge, are of reproductive age, have recently given birth, and have a history of oral contraceptive use. Diagnosis can be made histopathologically by the inflammatory reaction that disrupts the breast lobules and the appearance of numerous non-caseating granulomas. Clinically and radiologically, breast carcinoma can be confused with idiopathic GM. It may cause skin retraction, fistulization and ulceration. It is seen as a hard, regular or irregular mass in the breast. Axillary lymphadenopathy is observed in 15% of patients. Generally, it can be localized to all quadrants except the subareolar region. Treatment of idiopathic GM is controversial. While surgical resection and drainage is generally the treatment method of choice, the extent of resection is also controversial. In addition to publications that recommend only incision and drainage, there are also publications stating that wide incision is more beneficial. An important problem is the recurrences that occur after surgery and the fistulas that form in the breast skin. Fistula is observed in 20-30% of patients. Considering that autoimmunity is involved in the etiology and in cases where relapses occur after surgical excision, immunosuppressive treatment has been recommended. There are publications reporting that relapse cases were successfully treated with low-dose methoraxate as an immunosuppressant and to reduce the steroid dose.

GYNECOMASTIA

Men have female-type breast tissue. . During puberty, it is usually unilateral and occurs between the ages of 12-15. In the elderly, it is usually bilateral. Gynecomastia is the presence of at least 2 cm of subareolar breast tissue in non-obese people. USGand mammography are used in diagnosis. Gynecomastia does not predispose men to breast Ca. Gynecomastia caused by excess estrogen may be testicular or nontesticular. Gynecomastia occurs due to excess estrogen in hypothyroidism, hyperthyroidism and cirrhosis. With aging, androgen deficiency occurs and gynecomastia also occurs. Secondary testicular failure; It may occur due to reasons such as trauma, orchitis, cryptorchidism, abdominal or genital radiation, hydrocele, varicocele, spermatocele. Gynecomastia may also occur in chronic renal failure. Estrogenic drugs or drugs with estrogen-like activity (digital, estrogens, steroids) may cause gynecomastia. The best treatment for young men is subareolar excision

Benign (non-cancerous) neoplastic diseases of the breast:

• Adenosis:

They are benign neoplastic formations that occur with the proliferation of the epithelial elements of the breast, that is, the duct and acini structures of the lobules. It is most commonly seen in the upper outer quadrant. As a physical examination finding, they are palpable as rubbery nodularity with unclear borders. Although they may soften and disappear on their own, biopsy is required for definitive diagnosis

• Fibrocystic disease:

Palpable lesions caused by a single cyst or many small cysts. are the masses. In microscopic cystic disease, there are many cysts up to a few mm in diameter. It can occur in all parts of the breast, it is most seen in the upper outer quadrant

On physical examination, it is palpable as a rubbery nodularity with regular borders. It can hold both breasts together. Diagnosis is made with USG and can be aspirated with FNAB.

Pain due to fibrocystic disease increases in the 2nd half of the menstrual cycle and decreases with the start of menstruation. Cystic disease is the most common benign disease of the breast. It is seen in 60% of women. It is more common in middle age. It is most common between the ages of 30 and menopause.

Indications for surgical treatment of cysts:

• If there is a cyst larger than 3-4 cm
• In the presence of recurrent cyst
• The wall is irregular Cyst with cyst
• Bloody fluid on aspiration
• Family history of Breast Ca
• Fibroadenoma (Adenofibroma):

It is the second most common benign disease of the breast after cystic disease. It is seen in young girls, especially between the ages of 20-30. When their diameter reaches 2-3 cm, their growth usually stops. Clinically, a mobile, hard mass with sharp borders is palpated. Sometimes it may be slightly lobulated. Their diameter can reach 7-8 cm and turn into giant fibroadenoma. Its presence does not increase the risk of cancer, but lobular carcinoma in situ within fibroadenoma has been found in 100 cases in the literature. Tubular adenoma is a component of fibroadenoma and is also known as “lactation adenoma”. Surgical excision is recommended.

• Cystosarcoma phyllodes:

It is considered a type of fibroadenoma. It is usually a benign tumor. Very rarely, a malignant form is also seen. It is palpable clinically as a hard, mobile, lobulated mass. Its size is usually over 3-4 cm. In treatment, the mass should be completely excised, including the borders of intact breast tissue. Local recurrence develops in half of the cases. In large tumors, a simple mastectomy may be necessary; axillary dissection is not necessary.

• Intraductal papilloma:

It manifests itself with bloody nipple discharge. It does. It forms in the lactoferous ducts just below the areola. It increases the risk of breast cancer by 1.5-2 times. It is usually unilateral. It is the most common cause of seroanginous or bloody nipple discharge. In the examination of patients presenting with nipple discharge, the area where the discharge comes from is determined by pressing the edges of the areola and the papilloma is removed by surgical intervention.

Malignant (cancerous) neoplastic diseases of the breast:

• Breast Cancer:

Breast cancer is the most common tumor in women. One in every 8 women will get breast cancer during her lifetime. The female/male ratio is approximately 100/1.

• Etiology and Risk Factors:

Gender and age: In men Gender is an important factor because it is very rare. It is very rare under the age of twenty. Insida from the age of 20

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