PATHOPHYSIOLOGY, CLINICAL

PATHOPHYSIOLOGY, CLINICAL
MANIFESTATIONS, PHYSICAL
MANIFESTATIONS, PHYSICAL
SIGNS AND DIAGNOSTIC
SIGNS AND DIAGNOSTIC
FEATURES OF BREAST DISEASES
FEATURES OF BREAST DISEASES
PROFESSOR TURGUT IPEK
PROFESSOR TURGUT IPEK
BREAST DEVELOPMENT AND
BREAST DEVELOPMENT AND
PHYSIOLOGY
PHYSIOLOGY

Puberty
Puberty
begins
begins
at
at
about
about
12
12
years
years
of
of
age
age
.
.

This
This
process
process
of
of
growth
growth
entails
entails
cell
cell
division
division
and
and
is
is
under
under
the
the
control
control
of
of
estrogen
estrogen
,
,
progesterone
progesterone
, adrenal
, adrenal
hormones
hormones
,
,
pituitary
pituitary
hormones
hormones
,
,
and
and
trophic
trophic
effects
effects
of
of
insulin
insulin
and
and
thyroid
thyroid
hormone
hormone
.
.

The
The
term
term
prepubertal
prepubertal
gynecomastia
gynecomastia
refers
refers
to
to
the
the
symmetrical
symmetrical
enlargement
enlargement
and
and
projection
projection
of
of
the
the
breast
breast
bud
bud
in a
in a
young
young
girl
girl
before
before
the
the
average
average
age
age
of 12,
of 12,
unaccompanied
unaccompanied
by
by
the
the
other
other
changes
changes
of
of
puberty
puberty
.
.

The
The
mature
mature
or
or
resting
resting
breast
breast
contains
contains
fat
fat
,
,
stroma
stroma
,
,
lactiferous
lactiferous
ducts
ducts
,
,
and
and
lobular
lobular
units
units
.
.

With
With
pregnancy
pregnancy
,
,
there
there
is
is
diminution
diminution
of
of
the
the
fibrous
fibrous
stroma
stroma
to
to
accommodate
accommodate
the
the
hyperplasia
hyperplasia
of lobular
of lobular
units
units
.
.
After
After
birth
birth
,
,
there
there
is
is
sudden
sudden
loss
loss
of
of
the
the
placental
placental
hormones
hormones
and
and
the
the
continued
continued
high
high
level
level
of
of
prolactin
prolactin
.
.

When
When
breast
breast
-
-
feeding
feeding
ceases
ceases
,
,
there
there
is a
is a
fall
fall
in
in
prolactin
prolactin
and
and
no
no
stimulus
stimulus
for
for
release
release
of
of
oxytocin
oxytocin
.
.
The
The
breast
breast
then
then
returns
returns
to
to
a
a
resting
resting
state
state
and
and
to
to
the
the
cyclic
cyclic
changes
changes
induced
induced
when
when
menstruation
menstruation
begins
begins
again
again
.
.

For
For
the
the
breast
breast
,
,
menapause
menapause
results
results
in
in
involution
involution
and
and
a general
a general
decrease
decrease
in
in
the
the
epithelial
epithelial
elements
elements
of
of
the
the
resting
resting
breast
breast
.
.
These
These
changes
changes
include
include
increased
increased
fat
fat
deposition
deposition
,
,
diminished
diminished
connective
connective
tissue
tissue
,
,
and
and
the
the
disappearance
disappearance
of lobular
of lobular
units
units
.
.
ABNORMAL PHYSIOLOGY AND
ABNORMAL PHYSIOLOGY AND
DEVELOPMENT
DEVELOPMENT
Gynecomastia
Gynecomastia

Hypertrophy
Hypertrophy
of
of
breast
breast
tissue
tissue
in men is
in men is
a
a
common clinical entity.
common clinical entity.

The enlargement in teenage boys is common

The enlargement in teenage boys is common
and is frequently bilateral, although it may be
and is frequently bilateral, although it may be
unilateral .Unless it is unilateral or painful, it
unilateral .Unless it is unilateral or painful, it
passes unnoticed and regresses with adulthood.
passes unnoticed and regresses with adulthood.
Pubertal hypertrophy is general treated by
Pubertal hypertrophy is general treated by
reassurance and without operation
reassurance and without operation

Hypertrophy in older men is also common

Hypertrophy in older men is also common
and may regress spontaneously. It is
and may regress spontaneously. It is
frequently
frequently
unilateral.A
unilateral.A
number of
number of
commonly used medications, such as
commonly used medications, such as
digoxin
digoxin
,
,
thiazides
thiazides
, estrogens,
, estrogens,
phenothiazines
phenothiazines
and
and
theophylline
theophylline
may
may
exacerbate senescent
exacerbate senescent
gynecomasty
gynecomasty
Nipple Discharge
Nipple Discharge

The
The
appearance
appearance
of a
of a
discharge
discharge
from
from
the
the
nipple
nipple
of a
of a
nonlactating
nonlactating
woman
woman
is
is
frequently
frequently
frightening
frightening
to
to
the
the
patient
patient
.
.
Nipple
Nipple
discharge
discharge
is
is
common
common
and
and
is
is
rarely
rarely
associated
associated
with
with
an
an
underlying
underlying
carcinoma
carcinoma
.
.

A
A
milky
milky
discharge
discharge
from
from
both
both
breasts
breasts
is
is
termed
termed
galactorrhea
galactorrhea
may
may
be
be
associated
associated
with
with
increased
increased
production
production
of
of
prolactin
prolactin
.
.

Unilateral
Unilateral
nonmilky
nonmilky
discharge
discharge
coming
coming
from
from
one
one
duct
duct
orifice
orifice
is
is
rare
rare
and
and
is
is
surgically
surgically
significant
significant
and
and
warrants
warrants
special
special
attention
attention
.
.

To
To
conclude
conclude
,
,
nipple
nipple
discharge
discharge
that
that
comes
comes
from
from
a
a
single
single
duct
duct
and
and
contains
contains
blood
blood
must
must
be
be
investigated
investigated
further
further
.
.

The
The
most
most
common
common
cause
cause
of
of
spontaneous
spontaneous
nipple
nipple
discharge
discharge
from
from
a
a
single
single
duct
duct
is a
is a
solitary
solitary
intraductal
intraductal
papillom
papillom
in
in
one
one
of
of
the
the
large
large
subareolar
subareolar
ducts
ducts
directly
directly
under
under
the
the
nipple
nipple
.
.

In
In
summary
summary
nipple
nipple
discharge
discharge
that
that
is
is
bilateral
bilateral
and
and
comes
comes
from
from
multiple
multiple
ducts
ducts
is
is
usually
usually
not a
not a
surgical
surgical
problem.
problem.
Bloody
Bloody
discharge
discharge
from
from
a
a
single
single
duct
duct
does
does
require
require
surgical
surgical
biopsy
biopsy
to
to
establish
establish
a
a
diagnosis
diagnosis
.
.
Intraductal
Intraductal
papilloma
papilloma
is
is
found
found
in
in
most
most
of
of
these
these
cases
cases
.
.
If
If
an
an
occult
occult
cancer
cancer
is
is
found
found
.
.
It
It
is
is
usually
usually
an
an
intraductal
intraductal
carcinoma
carcinoma
.
.
Breast
Breast
Pain
Pain

Breast
Breast
pain
pain
may
may
occur
occur
in
in
young
young
women
women
associated
associated
with
with
menstrual
menstrual
irregularity
irregularity
or
or
as
as
a
a
premenstruel
premenstruel
symptom
symptom
.
.
In
In
addition
addition
fibrocystic
fibrocystic
change
change
or
or
ctstic
ctstic
mastopathy
mastopathy
may
may
cause
cause
breast
breast
pain
pain
.
.
Fibrocystic
Fibrocystic
Change
Change
(
(
Cystic
Cystic
Mastopathy
Mastopathy
,
,
Cystic
Cystic
Mastitis
Mastitis
)
)

Fibrocystic
Fibrocystic
change
change
popularly
popularly
referred
referred
to
to
as
as
fibrocystic
fibrocystic
disease
disease
,
,
represents
represents
a
a
spectrum
spectrum
of
of
clinical
clinical
and
and
histologic
histologic
findings
findings
and
and
describes
describes
a
a
loose
loose
association
association
of
of
cystic
cystic
formation
formation
,
,
breast
breast
nodularity
nodularity
,
,
stromal
stromal
proliferation
proliferation
and
and
epithelial
epithelial
hyperplasia
hyperplasia
.
.

This
This
condition
condition
is
is
commonly
commonly
painful
painful
and
and
tender
tender
to
to
touch
touch
masrocysts
masrocysts
,
,
microcysts
microcysts
,
,
stromal
stromal
fibrosis
fibrosis
,
,
adenosis
adenosis
and
and
a
a
variable
variable
amount
amount
of
of
epithelial
epithelial
metaplasia
metaplasia
and
and
hyperplasia
hyperplasia
.
.
There
There
is no
is no
consistent
consistent
association
association
between
between
fibrocystic
fibrocystic
complex
complex
and
and
breast
breast
cancer
cancer
.
.
Galactocele
Galactocele

A
A
galactocele
galactocele
is a
is a
milk
milk
-
-
filled
filled
cyst
cyst
that
that
is
is
round
round
well
well
circumscribed
circumscribed
and
and
easily
easily
movable
movable
within
within
the
the
breast
breast
.
.
The
The
pathogenesis
pathogenesis
of
of
galactocele
galactocele
is not
is not
known
known
but it is
but it is
thought
thought
that
that
inpissated
inpissated
milk
milk
within
within
duct
duct
is
is
responsible
responsible
Absent
Absent
or
or
Accessory
Accessory
Breast
Breast
Tissue
Tissue

Absence
Absence
of
of
breast
breast
tissue
tissue
(
(
amastia
amastia
)
)
and
and
absence
absence
of
of
the
the
nipple
nipple
(
(
athelia
athelia
)
)
are
are
very
very
rare
rare
anomalies
anomalies
.
.
In
In
contrast
contrast
accessory
accessory
breast
breast
tissue
tissue
(
(
polymastia
polymastia
)
)
and
and
accessory
accessory
nipples
nipples
(
(
supernumerary
supernumerary
nipples
nipples
)
)
are
are
both
both
common
common
.
.
Supernumerary
Supernumerary
nipples
nipples
are
are
usually
usually
rudimentary
rudimentary
and
and
occur
occur
along
along
the
the
milk
milk
line
line
from
from
the
the
axilla
axilla
to
to
the
the
pubis
pubis
in
in
both
both
males
males
and
and
females
females
.
.
Accessory
Accessory
breast
breast
tissue
tissue
is
is
comonly
comonly
located
located
above
above
the
the
breast
breast
in
in
the
the
axilla
axilla
.
.
DIAGNOSIS OF BREAST DISEASE
DIAGNOSIS OF BREAST DISEASE
History
History

The
The
age
age
of
of
menarche
menarche
,
,
menstruel
menstruel
irregularities
irregularities
and
and
the
the
age
age
at
at
menapouse
menapouse
should
should
be
be
sought
sought
.
.

In
In
younger
younger
women
women
the
the
history
history
of
of
pregnancy
pregnancy
and
and
location
location
should
should
be
be
recorded
recorded
. A
. A
drug
drug
history
history
should
should
pay
pay
particular
particular
attention
attention
to
to
HRT
HRT
or
or
the
the
use
use
of
of
hormones
hormones
for
for
contraception
contraception
.
.
The
The
family
family
history
history
should
should
be
be
directed
directed
to
to
cancer
cancer
of
of
the
the
breast
breast
in
in
primary
primary
relatives
relatives
(
(
mother
mother
,
,
sisters
sisters
,
,
and
and
daughters
daughters
).
).
Risk
Risk
Factors
Factors
for
for
Breast
Breast
Cancer
Cancer

Gender
Gender
is an
is an
important
important
risk
risk
factor
factor
.
.
Males
Males
at risk
at risk
for
for
breast
breast
cancer
cancer
although
although
the
the
incidence
incidence
in
in
males
males
is
is
less
less
than
than
%1 of
%1 of
the
the
incidence
incidence
in
in
the
the
females
females
.
.

A
A
history
history
of
of
mammary
mammary
cancer
cancer
in
in
one
one
breast
breast
increases
increases
the
the
likelihood
likelihood
of a
of a
second
second
primary
primary
cancer
cancer
in
in
the
the
contralateral
contralateral
breast
breast
.
.
In
In
the
the
relative
relative
risk (
risk (
ratio
ratio
of
of
observed
observed
cases
cases
over
over
expected
expected
cases
cases
)
)
ranges
ranges
between
between
three
three
and
and
four
four
.
.
The
The
magnitude
magnitude
of
of
relative
relative
risk
risk
depends
depends
on
on
age
age
at
at
diagnosis
diagnosis
of
of
the
the
first
first
primary
primary
cancer
cancer

The
The
relationship
relationship
of
of
family
family
history
history
and
and
the
the
risk of
risk of
breast
breast
cancer
cancer
. 1)
. 1)
there
there
is a
is a
twofold
twofold
to
to
threefold
threefold
excess
excess
risk of
risk of
the
the
disease
disease
in
in
first
first
degree
degree
relatives
relatives
(
(
mothers
mothers
,
,
sisters
sisters
,
,
and
and
daughters
daughters
) of
) of
patients
patients
with
with
breast
breast
cancer
cancer
. 2) risk
. 2) risk
decreases
decreases
quickly
quickly
in
in
women
women
with
with
distant
distant
relatives
relatives
who
who
are
are
affected
affected
with
with
breast
breast
cancer
cancer
(
(
cousines
cousines
,
,
aunts
aunts
,
,
grandmothers
grandmothers
)
)
and
and
3)
3)
the
the
risk is
risk is
much
much
higher
higher
if
if
affected
affected
first
first
degree
degree
relatives
relatives
had
had
premenopausal
premenopausal
onset
onset
or
or
bilateral
bilateral
breast
breast
cancer
cancer
.
.

The
The
relative
relative
risk of
risk of
cancer
cancer
in
in
women
women
with
with
atypical
atypical
hyperplasia
hyperplasia
was
was
4.4
4.4
times
times
the
the
risk
risk
of
of
development
development
of
of
breast
breast
cancer
cancer
in
in
control
control
population
population
of
of
women
women
.
.
The
The
coexistence
coexistence
of
of
a
a
positive
positive
family
family
history
history
with
with
atypia
atypia
on
on
biopsy
biopsy
increased
increased
the
the
risk
risk
to
to
nearly
nearly
nine
nine
times
times
the
the
general
general
population
population
.
.
The
The
average
average
risk
risk
ratio
ratio
for
for
5
5
years
years
of HRT is 1.35
of HRT is 1.35
and
and
risk
risk
increases
increases
by
by
about
about
%2
%2
to
to
%3
%3
with
with
each
each
year
year
of
of
use
use
.
.
Physical
Physical
Examination
Examination

Edema
Edema
of
of
the
the
skin,
skin,
frequently
frequently
accompanied
accompanied
by
by
erythema
erythema
,
,
produces
produces
a
a
clinical
clinical
sign
sign
known
known
as
as
peau
peau
d
d

aronge
aronge

The
The
second
second
clinical
clinical
feature
feature
of
of
carcinoma
carcinoma
that
that
directly
directly
involves
involves
the
the
nipple
nipple
was
was
described
described
by
by
Sir
Sir
James
James
Paget
Paget
in 1874
in 1874
and
and
named
named
Paget
Paget

s
s
disease
disease
.
.
Fine
Fine
-
-
Needle
Needle
Aspiration
Aspiration

Its
Its
main
main
utility
utility
is
is
the
the
differentiation
differentiation
of
of
solid
solid
from
from
cystic
cystic
masses
masses
.
.

Carcinoma
Carcinoma
will
will
not be
not be
missed
missed
if
if
surgical
surgical
biopsy
biopsy
is done
is done
when
when
1)
1)
needle
needle
aspiration
aspiration
produces
produces
no
no
cyst
cyst
fluid
fluid
and
and
a
a
solid
solid
mass
mass
is
is
diagnosed
diagnosed
2)
2)
the
the
cyst
cyst
fluid
fluid
produced
produced
is
is
thick
thick
and
and
blood
blood
tinged
tinged
. 3)
. 3)
fluid
fluid
is
is
produced
produced
but
but
the
the
mass
mass
fails
fails
to
to
resolve
resolve
completely
completely
.
.
BREAST IMAGING
BREAST IMAGING

The
The
goal
goal
of
of
radiographic
radiographic
imaging
imaging
is
is
to
to
detect
detect
small
small
abnormalities
abnormalities
in
in
the
the
breast
breast
which
which
are
are
not
not
palpable
palpable
by
by
physical
physical
examination
examination
.
.
Diagnostic
Diagnostic
Mammography
Mammography

The
The
mammographic
mammographic
features
features
of
of
malignancy
malignancy
can
can
be
be
broadly
broadly
divided
divided
into
into
density
density
abnormalities
abnormalities
(
(
including
including
masses
masses
,
,
asymmetries
asymmetries
and
and
architectural
architectural
distortions
distortions
)
)
and
and
microcalcifications
microcalcifications
.
.
Nonpalpable
Nonpalpable
Mammographic
Mammographic
Abnormalities
Abnormalities

Mammographic
Mammographic
abnormalities
abnormalities
that
that
cannot
cannot
be
be
detected
detected
by
by
physical
physical
examination
examination
are
are
classified
classified
in
in
the
the
broad
broad
categories
categories
. 1)
. 1)
lesions
lesions
consisting
consisting
of
of
microcalcifications
microcalcifications
only
only
2)
2)
density
density
lesions
lesions
(
(
masses
masses
,
,
architectural
architectural
distortions
distortions
,
,
and
and
asymmetries
asymmetries
)
)
and
and
3)
3)
those
those
with
with
both
both
calcifications
calcifications
and
and
density
density
abnormalities
abnormalities
.
.
Screening
Screening
Mammography
Mammography

At
At
present
present
screening
screening
mammography
mammography
should
should
be
be
offered
offered
to
to
women
women
older
older
than
than
50
50
years
years
and
and
be
be
done
done
either
either
annually
annually
or
or
at
at
least
least
biannually
biannually
.
.
For
For
women
women
in
in
their
their
40s
40s
recommendations
recommendations
for
for
standard
standard
practice
practice
are
are
harder
harder
to
to
make
make
.
.
Younger
Younger
women
women
with
with
a
a
significant
significant
family
family
history
history
,
,
histologic
histologic
risk
risk
factors
factors
or
or
a
a
history
history
of
of
prior
prior
breast
breast
cancer
cancer
should
should
be
be
offered
offered
routine
routine
screening
screening
.
.

References
References

Iglehart
Iglehart
JD,
JD,
Kaelin
Kaelin
CM
CM
Disease
Disease
of
of
the
the
Breast
Breast
.
.
Sabiston
Sabiston
Textbook
Textbook
of
of
Surgery
Surgery
Ed.
Ed.
Townsend
Townsend
CM WB
CM WB
Saunders
Saunders
Company
Company
Pennsylvania 2001, 555
Pennsylvania 2001, 555
-
-
601.
601.

Bland
Bland
KI,
KI,
Copeland
Copeland
EM
EM
Breast
Breast
.
.
Principles
Principles
of
of
Surgery
Surgery
Ed.
Ed.
Schwartz
Schwartz
JI
JI
McGraw
McGraw
Hill
Hill
1994, 531
1994, 531
-
-
593.
593.

Onat D Meme anatomisi ve fizyolojisi. Temel Cerrahi
Onat D Meme anatomisi ve fizyolojisi. Temel Cerrahi
Ed.
Ed.
Sayek
Sayek

G
G

ne
ne

Kitabevi
Kitabevi
Ankara 1991, 493
Ankara 1991, 493
-
-
530.
530.