Sunday 26 June 2016

Breast Examination-Mammography-Breast Abscess-Lymph Drainage and Carcinoma of the Breast-Carcinoma in the Male Breast-

Breast Examination
 Because The breast is one of the common sites of cancer in women. It is also the site of different types of benign tumors and may be subject to acute inflammation and abscess formation. For these reasons, the clinical personnel must be familiar with the development, structure, and lymph drainage of this organ.
With the patient undressed to the waist and sitting upright, the breasts are first inspected for symmetry. Some degree of asymmetry is common and is the result of unequal breast development. Any swelling should be noted. A swelling can be caused by an underlying tumor, a cyst, or abscess formation. The nipples should be carefully examined for evidence of retraction. A carcinoma within the breast substance can cause retraction of the nipple by pulling on the lactiferous ducts. The patient is then asked to lie down so that the breasts can be palpated against the underlying thoracic wall. Finally, the patient is asked to sit up again and raise both arms above her head. With this maneuver, a carcinoma tethered to the skin, the suspensory ligaments, or the lactiferous ducts produces dimpling of the skin or retraction of the nipple.

Mammography
Mammography is a radiographic examination of the breast. This technique is extensively used for screening the breasts for benign and malignant tumors and cysts. Extremely low doses of x-rays are used so that the dangers are minimal, and the examination can be repeated often. Its success is based on the fact that a lesion measuring only a few millimeters in diameter can be detected long before it is felt by clinical examination.

Breast Abscess
during lactation An acute infection of the mammary gland may occur. Pathogenic bacteria gain entrance to the breast tissue through a crack in the nipple. Because of the presence of the fibrous septa, the infection remains localized to one compartment or lobe to begin with. Abscesses should be drained through a radial incision to avoid spreading of the infection into neighboring compartments; a radial incision also minimizes the damage to the radially arranged ducts.




Lymph Drainage and Carcinoma of the Breast
The importance of knowing the lymph drainage of the breast in relation to the spread of cancer from that organ cannot be overemphasized. The lymph vessels from the medial quadrants of the breast pierce the 2nd, 3rd, and 4th intercostal spaces and enter the thorax to drain into the lymph nodes alongside the internal thoracic artery. The lymph vessels from the lateral quadrants of the breast drain into the anterior or pectoral group of axillary nodes. It follows, therefore, that a cancer occurring in the lateral quadrants of the breast tends to spread to the axillary nodes.

Thoracic metastases are difficult or impossible to treat, but the lymph nodes of the axilla can be removed surgically. Approximately 60% of carcinomas of the breast occur in the upper lateral quadrant. The lymphatic spread of cancer to the opposite breast, to the abdominal cavity, or into lymph nodes in the root of the neck is caused by obstruction of the normal lymphatic pathways by malignant cells or destruction of lymph vessels by surgery or radiotherapy. The cancer cells are swept along the lymph vessels and follow the lymph stream. The entrance of cancer cells into the blood vessels accounts for the metastases in distant bones.

In patients with localized cancer of the breast, most surgeons do a simple mastectomy or a lumpectomy, followed by radiotherapy to the axillary lymph nodes and/or hormone therapy. In patients with localized cancer of the breast with early metastases in the axillary lymph nodes, most authorities agree that radical mastectomy offers the best chance of cure. In patients in whom the disease has already spread beyond these areas (e.g., into the thorax), simple mastectomy, followed by radiotherapy or hormone therapy, is the treatment of choice. Radical mastectomy is designed to remove the primary tumor and the lymph vessels and nodes that drain the area. This means that the breast and the associated structures containing the lymph vessels and nodes must be removed en bloc. The excised mass is therefore made up of the following: a large area of skin overlying the tumor and including the nipple; all the breast tissue; the pectoralis major and associated fascia through which the lymph vessels pass to the internal thoracic nodes; the pectoralis minor and associated fascia related to the lymph vessels passing to the axilla; all the fat, fascia, and lymph nodes in the axilla; and the fascia covering the upper part of the rectus sheath, the serratus anterior, the subscapularis, and the latissimus dorsi muscles. The axillary blood vessels, the brachial plexus, and the nerves to the serratus anterior and the latissimus dorsi are preserved. Some degree of postoperative edema of the arm is likely to follow such a radical removal of the lymph vessels draining the upper limb. A modified form of radical mastectomy for patients with clinically localized cancer is also a common procedure and consists of a simple mastectomy in which the pectoral muscles are left intact. The axillary lymph nodes, fat, and fascia are removed. This procedure removes the primary tumor and permits pathologic examination of the lymph nodes for possible metastases
Carcinoma in the Male Breast
Carcinoma in the male breast accounts for about 1% of all carcinomas of the breast. This fact tends to be overlooked when examining the male patient.
Since the amount of breast tissue in the male is small, the tumor can usually be felt with the flat of the examining hand in the early stages. However, the prognosis is relatively poor in the male, because the carcinoma cells can rapidly metastasize into the thorax through the small amount of intervening tissue.































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