BREAST - Common Benign Disorders and Diseases of the Breast | SCHWARTZ SURGERY скачать в хорошем качестве

BREAST - Common Benign Disorders and Diseases of the Breast | SCHWARTZ SURGERY

SCHWARTZ SURGERY BREAST "Common Benign Disorders and Diseases of the Breast" covers a wide array of clinical and pathological conditions. Surgeons require a detailed understanding of these disorders to provide clear explanations, institute appropriate treatment, and avoid unnecessary long-term follow-up. Classification: Aberrations of Normal Development and Involution (ANDI) 1. Early Reproductive Years (Age 15–25 y): • Fibroadenomas are typically seen in younger women. Small fibroadenomas (≤1 cm) are considered normal, larger ones (≤3 cm) are disorders, and giant fibroadenomas (more than 3 cm) are defined as disease. Multiple fibroadenomas (more than five lesions in one breast) are also considered disease. • Nipple inversion is a disorder of development. Failure of a pit to elevate above skin level results in this congenital malformation, seen in 4% of infants. Nipple inversion can predispose to major duct obstruction, leading to recurrent subareolar abscess and Mammary duct fistula (disease). 2. Later Reproductive Years (Age 25–40 y): • Cyclical changes of menstruation typically involve cyclical mastalgia and nodularity, regarded as normal. Incapacitating mastalgia or painful nodularity persisting for more than one week of the menstrual cycle is viewed as a disorder. • Epithelial hyperplasia of pregnancy may result in bloody nipple discharge, which is classified as a disease. 3. Involution (Age 35–55 y): • Disorders of involution are common when breast stroma and epithelium do not involute in an integrated manner. • Macrocysts develop when the stroma involutes too quickly, leaving alveoli to form microcysts (precursors to macrocysts). They are common, often subclinical, and generally do not require specific treatment. • Duct ectasia (dilated ducts) and Periductal mastitis are also characteristic of this period. Periductal fibrosis can occur as a sequela of periductal mastitis, resulting in nipple retraction. Pathologic Classification and Cancer Risk The classification system developed by Page separates benign breast disorders into three groups based on their relationship to cancer risk: 1. Nonproliferative Disorders: • These account for 70% of benign breast conditions. • They carry no increased risk for developing breast cancer. • This category includes cysts, duct ectasia, mild ductal epithelial hyperplasia, calcifications, fibroadenomas, and related lesions. • Duct ectasia is characterized by dilated subareolar ducts often associated with thick nipple discharge. 2. Proliferative Disorders Without Atypia: • This group includes sclerosing adenosis, radial and complex sclerosing lesions, ductal epithelial hyperplasia, and intraductal papillomas. • Sclerosing adenosis has no malignant potential and is managed by observation. • Florid ductal epithelial hyperplasia is associated with an increased cancer risk (1.5 to 2-fold). • Radial scars and complex sclerosing lesions often present with imaging features (mass density with spiculated margins) similar to invasive cancer, frequently requiring excisional biopsy or vacuum-assisted biopsy to exclude malignancy. 3. Atypical Proliferative Diseases: • These lesions exhibit some features of carcinoma in situ but are not fully developed. • This group includes Atypical lobular hyperplasia (ALH) and Atypical ductal hyperplasia (ADH). • Women diagnosed with ADH or ALH have a fourfold increase in breast cancer risk. Cysts: • Needle aspiration is often the first investigation for palpable breast masses and can be used to diagnose cysts. • Cysts are aspirated to dryness, and the fluid is discarded unless it is bloodstained, as routine cytologic examination is not cost-effective. Most cysts are now aspirated under ultrasound guidance. Fibroadenomas: • Most fibroadenomas are self-limiting, and a conservative approach (observation) is reasonable. • Diagnosis is accurately provided by careful ultrasound and core-needle biopsy. For young women (e.g., under 25) with pathognomonic ultrasound features, core-needle biopsy may be avoided. • Treatment options include surgical removal, cryoablation, vacuum-assisted biopsy (especially for lesions less than 3 cm), or observation. Sclerosing Disorders: • Sclerosing adenosis can clinically and mammographically imitate cancer, often requiring excisional biopsy and histological examination to rule out malignancy. • Due to suspicious mammographic findings, radial scars and complex sclerosing lesions also frequently require large tissue biopsy (vacuum-assisted or surgical excision). Periductal Mastitis and Abscess: • Initial management involves antibiotics and repeated ultrasound-guided aspiration. • For recurrent abscess with fistula (recurrent retroareolar infections, sometimes called Zuska’s disease), the preferred initial surgical treatment is fistulectomy and primary closure with antibiotic coverage.