"A Man can't make a mistake can't make anything"

Tuesday, 14 February 2012

Abnormalities in the breast

I. Preliminary

 In this paper will be discussed on breast pathology, both benign or malignant lesions, although in general. God willing, the future will be discussed each of these breast disease, breast abnormalities often gives the impression of scary, especially when found in women aged over 40 years. Even many of the oncologists argue that any tumor in the breast carcinoma, especially in women considered at high risk groups such as fibroadenoma, although benign tumors, dysplasia (fibrocystic, adenosis), mastitis and fat necrosis can not be ignored. This opinion is understandable, given the frequency of breast carcinomas are relatively high, giving rise to the problem health dala especially for women, not only in developed countries, but also in developing countries including Indonesia. The frequency of breast carcinoma in developed countries is the most that is the ratio of 5:1, compared with carcinoma of the cervix uteri, while in Indonesia ururtan neoplasms are located in the second after the cervix uteri karsinomaa.

Anatomic pathology or anatomic abnormalities of the breast is most often caused by a tumor. Tumor composed of benign and malignant tumors. Benign tumor cells have a character very similar to native tissue and is relatively harmless because it is generally a benign tumor remains localized, it can not spread to other places, and easy to do with the surgical removal of the tumor locally. Said to be malignant if the tumor can penetrate and destroy adjacent structures and spread to distant sites (metastasis) and generally can cause death. These properties in accordance with the naming of cancer that originates from the Latin word for crab, attached to each section and gripping her tightly like a crab.
Breast cancer is cancer that is very scary women , in addition to cervical cancer. Problem of unknown etiology; problem prevention efforts are difficult to implement and difficult course of the disease is suspected and when in a state of the patient will go up in the era of suffering pain and disability is scary towards the end of a life.         
However, the efforts for early detection of ( early detection ) can be done well by involving the community malalui counseling's ( health education ) . When found in early stages and mendaapat appropriate and adequate therapy is not unlikely that breast cancer can be cured. Advances in early detection that comes with the progress of therapy in the last decades of both surgical techniques, radiation, hormonal therapy and chemotherapy, and immunotherapy or combination therapy management of the above treatment modalities; which is based on staging accuracy of the determination and recognition of biological properties cancer is good; increasingly bringing new hope to sufferers of breast cancer.
Breast carcinoma in women occupy a place second only to the United States uterus.Di cervical carcinoma of breast carcinoma was 28% of cancers in black women.
Age incidence curve moving up steadily since the age of 30 are at highest tahun.Angka 45-66 age tahun.Insiden mammary carcinomas in males only 1% of the incidence in women.

II. Anatomy and Physiology

To be able to recognize breast cancer journey well and understand the basics of surgery in breast cancer it is important to know the anatomy of the breast itself.
Breast lies in hemithoraks right and left with the following limits:
A.       The boundaries of the breast that looks from the outside:
-           Superior: ribs II or III
-           Inferior: VI or VII ribs
-           Medial: the edge of the sternum
- Lateral: anterior axillary line.
Second.       limits real breasts:
-           Superior: almost to the clavicle
-           Medial: midline
-           Lateral: m.latissimus dorsi                                               
Structure of the Breast
Breast consists of various structures:
-           parenchymal epithelial
-           fat, blood vessels, nerves and lymphatic channels
-           muscle and fascia

Figure 1. Anatomy of the breast.

Parenchymal epithelial formed by approximately 15-20 lobes, each of which has its own channel to drain the product, and comes down to putting susu.Tiap lobe-lobule lobules formed by each of which consists of 10-100 asini grup.Lobulus-lobule This is the basic structure of the mammary gland.
Breast is covered by the superficial pectoral fascia of the anterior and posterior surfaces which are connected by a ligament which serves as a buffer Cooper.
Breast Lymphatic System                          
a.        lymphatic vessels
Axillary lymph vessels:
This axillary lymph vessel draining lymph from the area surrounding the areola mammae, the lateral quadrant and the upper lateral quadrant of the breast.
The internal mammary lymph vessels:
These lymph channels drain lymph from the inside and the medial breast. This vessel runs above the pectoralis fascia and through the fascia, and into major m.pektoralis. Then the road to the medial together with penetrating perforating system m.interkostalis and empties into the internal mammary lymph nodes. Of the internal mammary glands, lymph flow through the internal mammary lymph trunks. Some will lead to v.cava, some will lead to the duct torasikus ( to the left) and lymph duct artery ( to the right side ) .
3. Lymph vessels in the medial edge of the lower medial quadrant of the breast. These vessels take a walk along the superior epigastric vasa, through the rectus fascia and into m.rektus abdominis. This channel empties into the lymph nodes that terletek preperikardial anterior edge of the falciform ligament above the diaphragm. Lymph nodes also contain lymph from the diaphragm, falciform ligament and the antero-superior hepar.Dari this gland, lymph flow through the internal mammary lymph trunks.
b.       lymph glands
- Axillary lymph nodes
There are six axillary lymph node group:
1.            External mammary lymph nodes. Strands gland is located below the lateral edge m.pektoralis mayor, along the medial edge of the axilla. This group is divided into two groups.
a) The superior: The lymph nodes are located as high as intercostal II-III.
b) Group inferior.Kelompok lymph nodes are located as high as intercostal IV-V-VI.
2.            Lymph nodes of the scapula.
Lymph nodes are located along the vasa-torako subscapular and dorsalis, ranging from a vein subscapular v.aksilaris branching, up to their entrance into the dorsal v.torako-m.latissimus dorsi.
3.       central lymph nodes ( Nodes Central )
Lymph nodes are located in fatty tissue in the center of the armpit. Sometimes some of them are located very superfisisal, under the skin and fascia at the center of the armpit, at approximately the mid-axillary fold front and back. Lymph nodes are glands that are relatively easily palpable.And the axillary glands of the largest and most in number.
4.       interpektoral lymph nodes ( Rotter's Nodes )
Lymph nodes are located between m.pektoralis 

Figure 2. Breast lymphatic system.

Five.       v.aksilaris lymph nodes.
These glands are located along the lateral v.aksilaris, ranging from white m.latissimus dorsi tendon to the medial bit of branching v.aksilaris - v.torako-acromion.
6.       subklavikula lymph nodes.
These glands are located throughout v.aksilaris, ranging from slightly medial branching v.aksilaris - v.torako-acromion to where v. axillary disappeared under m.subklavius ​​tendon. Axillary lymph glands is the highest and termedial located. All lymph nodes derived from the glands into the axillary lymph glands. The entire axillary lymph nodes are located under the fascia kostokorakoid.

7.       Lymph nodes prepektoral
Sometimes located under the skin or in the upper lateral quadrant of the breast tissue called fascia prepektoral because it is located above the pectoral.
8.       the internal mammary lymph nodes.
These glands are spread along the internal mammary lymph trunks, approximately 3 cm from the edge of the sternum. Located in the fat over the fascia endotorasika, in between the ribs.Estimated number of these glands have 6-8 pieces.
Phase of breast development arising as a result of the effects of ovarian hormone secretion mamotropik and anterior pituitary, where the breast had three kinds of changes that affected the hormone:
A.        first change is the start of the lifetime of the child through puberty, a period of fertilization, to klimakterium and menopause. Since puberty the hormones estrogen and progesterone production in the ovaries and pituitary hormones has led to the emergence of the ducts and acini grown.
Second.        second change is the change in accordance with the menstrual cycle, about day-to-8 menstrual breasts become larger and in a few days before the next menstrual period maximal enlargement. Sometimes - sometimes uneven bumps arise. For several days before menstruation breast pain became so tense and physical examination, especially palpation is not possible. At that time the examination is not useful because the mammogram image contrast is too large glands. Once menstruation begins, everything is reduced.
Changes that occur during pregnancy and lactation. In pregnancy the breasts become huge because lobul duct epithelium and alveolar ducts proliferate and grow a new duct. Secretion of prolactin from the anterior pituitary hormones trigger lactation. The milk produced by the cells of the alveoli, filling the acini, and then expelled through the ducts to the nipple
Breasts are composed of fatty tissue containing glands responsible for milk production during pregnancy and after childbirth. Each breast is made up of about 15-25 lobes in groups, called lobules, mammary gland, and a formation like sacs that contain milk (alveoli). Channel to drain the milk to the nipple are called ducts. About 15-20 channels will go dark circular part around the nipple (areola) forming part of the store breast milk (ampullae) before exiting to the surface.
Both breasts do not always have the same size and shape. Of the breasts begin to form a complete one or two years after menstruation pertamakali.Hamil and breast feeding will lead to increase in size and will experience a diminution (atrophy) after menopause.
Breasts will cover most of the chest wall. Breast is limited by the collarbone (clavicle) and the breastbone (sternum). Breast tissue could reach into the underarm area and the muscles that are on the lower back until your upper arms (latissimus dorsi).
Lymph nodes consist of white blood cells that are useful to fight the disease. Drained by the lymph nodes of breast tissue through lymph channels and into the lymph glands around the breast till the armpit and collarbone. Lymph nodules play an important role in the spread of breast cancer especially in the armpit lymph nodules.

III. Classification

Most benign breast lumps are from normal changes in breast development, hormonal cycles, and changes in reproduction. There are 3 cycles of life that can describe the difference in the lives of women of reproductive phase-related breast changes, namely:
1.            In the early reproductive phase (15-25 years) there is formation of breast ducts and stroma. In this period generally occurs bump FAM and juvenile hypertrophy (excessive breast development)
2.            Mature reproductive period (25-40 years). Changes in hormonal cycles affect the glands and stroma payuddara
3.            The third phase is the involution of the lobules and ducts that have occurred since the age of 35-55 years

Benign tumors have a variety of forms, among others:
·                     Fibrocystic disorders
Fibrocystic change is a range of disorders where there is a result of the increase and the distortion of cyclic changes that occur in normal breast during menstrual cycle. Fibrocystic changes are divided into nonproliferatif changes and proliferative changes. Nonproliferatif changes include cysts and fibrosis without epithelial cell hyperplasia (sderhana fibrocystic changes). Proliferative changes include a series of epithelial cell hyperplasia or ductal duktulus and banal or atypical adenosis sklerotikans.
Nonproliferatif changes characterized by an increase in fibrous stroma accompanied by dilatation of the ducts and the formation of cysts of various sizes. Stroma surrounding all forms of cysts are usually composed of fibrous tissue loss miksomatosa picture.Lymphocytic infiltrates are often found in the stroma of these lesions and other variants of fibrocystic changes. Proliferative changes including epithelial hyperplasia and adenosis sklerotikans. The term epithelial hyperplasia and proliferative fibrocystic changes include a series of proliferative lesions in the duktulus, terminal ducts, and sometimes the breast lobules. Mostly these are mild epithelial hyperplasia and irregular and do not carry the risk of carcinoma, but on the other hand a significant risk of atypical hyperplasia mamiliki.Sklerotikans adenosis have similar clinical picture and morphology of the carcinoma. In these lesions Rampak intralobularis striking fibrosis and proliferation of small duktulus and acini. Excessive growth of fibrous tissue may suppress lumen acini and ducts so that they appear as genjel-genjel cells. The existence of multiple layers of epithelial and myoepithelial elements of identification indicating that the disorder is benign.
Symptoms include swelling and tenderness in the breast before menstrual periods. The signs are free-moving mass palpable in the breast, felt the granularity of the breast tissue, and sometimes bloody discharge from the nipple is not. Many women do not complain of symptoms and a new look after examination kesehetan feel a mass.         
·                     Fibroadenoma
Fibroadenoma is a benign tumor that is widely available to young women. The tumor is not attached to the surrounding tissues and so easily moved. These lumps are usually painless, can grow a lot of (multiple). The tumor is composed of fibrous tissue that is round, smooth, rubbery solid berkonsistensi, bounded up, and easily moved.Fibroadenomas appear as discrete nodes, usually single, and diameters of 1 to 10 cm.Lesions may be enlarged at the end of the menstrual cycle and during pregnancy. In the postmenopausal, lesions may shrink and calcifies. Although rare, tumors may be multiple and the diameters of more than 10 centimeters (giant fibroadenoma). Absolute or relative increase in estrogen activity is estimated to play a role in the process of its formation, and similar lesions may occur simultaneously with fibrocystic changes (fibroadenosis).Fibroadenomas usually teradi in young women where the incidence peaks at the age of 30. Tumor growth can be rapid once during pregnancy and breastfeeding or approaching menopause when estrogen stimulation after menopause high but this type of tumor is not found anymore.  Fibroadenoma almost never become malignant. Pananganan fibriadenoma is through surgical removal of the tumor. Sistosarkoma filoides is one type of fibriadenoma which may recur if not removed completely

Figure 3. Mammary fibroadenomas

·                     Tumor filoides
Phylloides is a large tumor in the breast fibroadenoma, with similar-stromal sarcomas are highly mobile. These tumors include benign neoplasms, but it can sometimes become malignant. These tumors are locally aggressive and can metastasize, and are thought to originate from the stroma intralobulus. Generally, these tumors are 3 to 4 cm in diameter, but can grow to large size, may be so massive breasts enlarged. Much has lobulasi and become cystic. Because the pieces of the leaves show a similar gap, then the tumor is called a tumor filoides. The most detrimental changes are accompanied by an increase in stromal selularitas anaplasia and high mitotic activity, and an increase in size rapidly, usually with the surrounding breast tissue invasion by malignant stroma. Most of these tumors remains lokalisata and cured by excision. Malignant lesions may recur, but these lesions also tend terlokalisasikan
·                     Papilloma intraduktus
Intraduktus papilloma is a neoplastic tumor growth in a water channel milk (lactiferous ducts) and 75% growth in the breast areola. Most of the lesions are solitary, found in the sinuses or the main duct laktiferosa. These lesions cause clinical symptoms include: (1) discharge of serous or bloody discharge from nipple (2) the presence of small subareola tumors with diameters of several millimeters that is too small to be palpable, or (3) retraction of the nipple (rare). In some cases, formed many in a duct papilloma or papilometosis intraduktus. Lesions are sometimes become malignant, while the solitary papilloma almost always remain benign.
·                     Sclerosing adenosis
Clinically, the tumor was palpable as fibrocystic disorder but appears histopathologically benign proliferation.
·                     Plasma cell mastitis
This tumor is a subacute inflammation of the channel system obtained under the areola of the breast. The picture is difficult to distinguish from a malignant tumor that is berkonsistensi hard, can be attached to the skin, and cause the nipple retraction due to the formation of connective tissue (fibrosis) around the channel and may have enlarged underarm lymph nodes.
·                     Fat necrosis
Usually caused by injury to a hard mass that is often somewhat painful but not enlarged.Sometimes there is a retraction of the skin and the limit is usually not flat. Clinically, it is difficult to distinguish from malignant tumors.
·                     Other abnormalities
Benign fatty tumors (lipomas), benign tumor of smooth muscle (leimioma), and sebaceous cysts (sebaceous glands) is a tumor that may be contained in the breast but not related to glandular breast tissue.
Malignant tumor or breast cancer also have several types, among others:
·                     Ductal Carcinoma In-Situ (DCIS)
Breast cancer is a type of the earliest and only in the duct system.
·                     Infiltrating Ductal Carcinoma (IDC)
The most common type, reaching 78% of all malignancies. Lesion on a mammogram obtained star-shaped (stellate) or circular. If the lesion is shaped like a star or the prognosis of patients is very low cure rate.
·                     Medullary Carcinoma
This type is most common in women aged 40 years and the end of 50 years. Produce a picture of the cell as part of the gray (medulla) of the brain. Rate of approximately 15% of cases of breast cancer.
·                     Infiltrating lobular carcinoma (ILC)
Type of breast cancer that usually appears as a thickening in the outer upper quadrant of the breast. These tumors respond well to hormone therapy. Rate of approximately 5% of cases of breast cancer.

·                     Tubular Carcinoma
This type is commonly found in women aged 50 years or older. On microscopic examination tubulusnya very typical picture of the structure. Rate of approximately 2% of breast cancer cases and the number 10 ysr (year survival rate) reached 95%.
·                     Mucinous carcinoma (colloid)
Breast cancer is the most high recovery rate. The changes occurred primarily in the production of mucus and cell image is difficult to determine. Rate of approximately 1% -2% of all breast cancer cases.
·                     Inflammatory Breast Cancer (IBC)
Type of breast cancer the most aggressive and rare. This can lead to cancer of the breast and lymph channels terbuntu skin. Called inflammatory (inflammation) due to the appearance of cancer that are swollen and red. In America, there was a 1% -5% of all breast cancer cases.

IV. Diagnosis

                Tumor (lump) in the breast, especially the malignant types generally do not have symptoms at the beginning and can only be detected through careful physical examination or screening using mammography. During the premenstrual phase, most women experience breast enlargement and lumps in the breast and become hardened. This can obscure breast examination to look for suspicious lumps. Examination should be repeated a month later or after the next menstrual period.
Diagnosis of breast abnormalities by:
1.            History is full:
-           Regarding complaints
-           Course
-           Additional Complaints
-           high risk factors
-           Common signs of malignancy associated with body weight and appetite.
2.            Systematic physical examination / legeartis and ethical .
            Clinical symptoms of breast cancer may include:

 Lump in the breast

Usually a painless lump in the breast. The lump was small at first, grew larger, and then attached to the skin or cause changes in the skin of the breast or the nipple.

Erosion or the nipple eczema

Skin or nipple had to be pulled in (retracted), pink or brown to be edema of the skin to look like an orange peel (peau d'orange), contract, or ulcers (ulcers) in the breast. ulcers were more greater length and depth so as to destroy the entire breast, often foul-smelling, and bleed easily. Other characteristics include:
·                     Bleeding on the nipple.
·                     Pain or new pain in general arise if the tumor is large, have ulcers, or if there are metastases to the bones.
·                     Then comes the enlarged lymph nodes in the armpit, swelling (edema) in the arm, and the spread of cancer throughout the body.
Advanced breast cancer is very easily recognized by knowing operbilitas Heagensen following criteria:
·                     there is extensive edema of the breast skin (over 1/3 area of ​​the breast skin);
·                     satellite nodules in the skin of the breast;
·                     Breast cancer types of mastitis karsinimatosa;
·                     There parasternal model;
·                     There supraclavicular nodule;
·                     edema of the arm;
·                     presence of distant metastases;
·                     and there are two of the signs of locally advanced, namely skin ulceration, skin edema, skin fixed to the thoracic wall, axillary lymph node 2.5 cm in diameter, and axillary lymph nodes attached to one another.
Influence of the menstrual cycle and changes in tumor complaints tumor size and tumor size changes; married or not; the number of children, disusukan or not; a history of cancer in the family, drugs that had been used primarily hormonal nature; if ever breast surgery and obstetrics- gynecology. Classified in the following high risk factors of breast cancer that is the circumstances where the likelihood of a woman gets breast cancer is higher than that do not have these factors are:
3.       Age over 30 years
4.       first child born in the mother's age> 35 years (2x)
5.       No mating (2-4 x)
6.       menarche <12 years (1.7-4x)
7.       Menopause late> 55 years (2.5-5x)
8.       Ever benign breast tumor surgery (3-5x)
9.       Got a long hormonal therapy (2.5 x)
10.   presence of a contralateral breast cancer ( 3-9x )
11.   Operations gynecologist (3-4x)
12.   Radiation Chest (2-3x)
13.   Family history (2-3x)
High risk factor is not the etiologic factor .


Staging of cancer is a condition of the doctor's judgment when diagnosing a disease suffered by cancer patients, is the extent to which either the rate of spread of cancer to other organs or tissues surrounding or distant spread of the place known only to the tumor stage malignant or cancerous and benign tumors do not exist in . To determine the stage, must be supported by clinical examination and other investigations which histopathology or PA, x-rays, ultrasound, and if possible with a CT Scan, etc. scintigrafi. Lots of ways to determine the stage, but the most widely adopted today is the stage cancer based on TNM classification system recommended by the UICC (International Union Against Cancer of WHO or World Health Organization) / AJCC (American Joint Committee On Cancer, sponsored by the American Cancer Society andAmerican College of Surgeons).

In the TNM system

TNM is an abbreviation of "T", namely tumor size or the size of the tumor, "N" is the Node or regional lymph nodes and "M" that is distant metastasis or spread. These three factors T, N, M assessed both clinically prior to surgery, even after surgery and histopathologic examination (PA). In breast cancer, TNM assessment as follows:

·                     T (tumor size), tumor size:
·                                             T 0: no primary tumor found
·                                             T 1: the size of the tumor diameter of 2 cm or less
·                                             T 2: the size of the tumor diameter of 2-5 cm
·                                             Q 3: The size of the tumor diameter> 5 cm
·                                             Q 4: How tumor size alone, but there have been spread to the skin or chest wall, or on both, may be ulcers, edema or swelling, redness of breast skin or a small lump on the skin outside of the primary tumor
·                     N (Node), regional lymph nodes (lymph nodes):
·                                             N 0: no metastasis to regional lymph nodes in the armpit / axilla
·                                             N 1: No metastasis to the axilla lymph nodes are still movable
·                                             N 2: No metastasis to the axilla lymph nodes are difficult to move
·                                             N 3: No metastasis to lymph nodes above the collarbone (supraclavicula) or the internal mammary lymph nodes in the bone near the sternum
·                     M (metastasis), distant spread:
·                                             M x: distant metastasis can not be assessed
·                                             M 0: no distant metastasis
·                                             M 1: there are distant metastases
After each faktot T, N, M obtained, three factors are then combined and stage of cancer obtained as follows:

·                     Stage 0: T0 N0 M0
·                     Stage 1: T1 N0 M0
·                     Stage IIA: T0 N1 M0 / T1 N1 M0 / T2 N0 M0
·                     Stage II B: T2 N1 M0 / T3 N0 M0
·                     Stage IIIA: T0 N2 M0 / T1 N2 M0 / T2 N2 M0 / T3 N1 M0 / T2 N2 M0
·                     Stage IIIB: T4 N0 M0 / M0 T4 N1 / N2 M0 T4
·                     Stage III C: Any T N3 M0
·                     Stage IV: Any T, Any N, M1.

Figure 4. Picture of the breast.
Can also be performed histopathological examination. B Ahan examination taken by:
A. Eksisional biopsy, and then were cut frozen or PA. These cases are still expected operabel / early stage

No comments:

Post a Comment