Diagnosis of breast diseases. Diseases of the mammary glands. Causes. Symptoms Diagnostics. Treatment. Mastitis: causes and symptoms

Questioning

In the anamnesis, attention is paid to the past diseases of the mammary gland, to symptoms such as pain, thickening of individual parts of the mammary gland, discharge from the nipples, skin changes, etc., arising in connection with the menstrual cycle, pregnancy, lactation. Find out the nature of the menstrual cycle, at what age menstruation appeared and at what end, when there was the first birth; the course of pregnancy, childbirth, the nature of lactation. Clarify the presence of gynecological diseases, operations on the genitals, the number of abortions.

Physical research methods

Examination of the mammary glands is carried out in a bright room (the woman must be stripped to the waist) in the patient's position - standing with her arms down, standing with her arms raised and in a supine and side position. This technique allows you to identify subtle symptoms. Pay attention to the development of the mammary glands, their size, shape, the level of standing of the mammary glands and areolas (symmetry), as well as the condition of the skin, nipples, areolas. It is known that the vascular pattern, skin coloration, retraction of it, deformation of the contours, ulceration of the nipple and areola can be very important signs of cancer and other diseases of the breast.

Palpationproduced in a standing position, lying on the back and side. With superficial palpation with fingertips, the area of \u200b\u200bthe areola is examined, then the peripheral parts of the gland - sequentially, starting from the upper outer quadrant to the upper inner, and then - from the lower inner to the lower outer quadrant. Deep palpation is performed in the same sequence. First, a healthy mammary gland is palpated. When a tumor-like formation is detected, its size, consistency, surface character, mobility in relation to the skin are determined. Then the axillary, subclavian and supraclavicular lymph nodes are palpated. The patient should relax her arms, placing them on her waist or on the examiner's shoulders. When palpating the supraclavicular lymph nodes, it is better to stand behind the patient; she should tilt her head slightly towards the examination to relax the sternocleidomastoid muscle. Determine the size, consistency, quantity, mobility, pain of the lymph nodes.

Breast self-examination technique

For early detection of precancerous changes and tumors of the mammary glands, all women over 25 years of age are advised to independently monitor the condition of the mammary glands, that is, to learn self-examination techniques, which should be carried out on any day of the 1st week after each menstrual cycle.

Inspection begins with the laundry, especially in those places where it came into contact with the nipples. The presence of spots (bloody, brown, or discolored) indicates a discharge from the nipple. They appear in diseases of the breast. The exception is milk-like discharge from the nipples in recently nursing mothers, when the changes associated with pregnancy and lactation have not yet been completed.

Then, the mammary glands are examined in front of the mirror, first in the position with the hands down, and then with the hands raised to the back of the head. In this case, you need to slowly turn to the right, then to the left. These techniques make it possible to determine whether the shapes and sizes of the mammary glands are the same, whether the mammary glands and nipples are located at the same level, whether there have been changes in the area of \u200b\u200bthe nipple and areola, whether there is skin retraction or bulging

Palpation of the mammary glands and armpits is facilitated by lying on the back. When examining the outer half of the right mammary gland, put a pad or a small roller of a towel under the right shoulder blade, stretch the right hand along the body, with the fingertips of the left hand, gently pressing gently on the mammary gland with soft circular movements, feel all its sections. First, the center of the mammary gland (nipple area) is examined, and then the entire gland is palpated, following from the nipple towards its outer edge along the radius upward, then outward, downward. When feeling the inner half of the right breast, the right hand is placed under the head, and the examination is performed with the left hand in the same sequence - from the center to the inner edge of the breast along the radius upward, then inward, downward. All these techniques are repeated when examining the left breast.

Special research methods

Mammography - X-ray examination of the mammary glands without the use of a contrast agent. On a special apparatus, radiographs of the mammary glands are performed in two projections. If necessary, sighting radiographs with magnification are taken. The method allows you to establish changes in the structure of the breast tissue, to identify a tumor with a diameter of less than 10 mm, i.e., a tumor of such a size that the doctor, as a rule, cannot determine by palpation (non-palpable tumors), especially if it is located in the deep parts of the large breast size. Mammography remains the most sensitive method for detecting breast cancer, although the specificity of the method is not high enough. Some changes on mammograms and palpation data are not always accurate: a mammogram gives the same image of a malignant and benign node and even variations of the normal architecture of the gland. Therefore, it is advisable to combine the study with ultrasound, which makes it possible to distinguish a cystic node from a solid one, and other methods.

Breast ductography - X-ray examination of the ducts of the mammary gland after the introduction of a contrast agent into them. The indication is nipple discharge. The area of \u200b\u200bthe areola and nipple is treated with alcohol. A drop of secretion is sought for the outer opening of the secerinating milky duct. Into it to a depth of 5-8 mm. a thin needle with a blunt end is inserted. 0.3-1 ml of a 60% solution of verografin or urografin is injected through a needle under low pressure into the duct until a feeling of slight swelling or mild pain appears. The analysis of the images makes it possible to judge the shape, outlines, defects of the filling of the ducts.

Ultrasound procedure is currently one of the main methods of instrumental examination of the mammary glands. Ultrasound makes it possible to determine changes in the structure of the mammary gland, to identify tumor nodules, to make a differential diagnosis between cancer and benign breast tumors, to identify small formations (cysts are detected from 0.5 cm in diameter). Puncture fine-needle biopsy, carried out under the control of ultrasound, allows you to obtain material for cytological examination and verification of the diagnosis faster and more accurately than with mammography. Immediately before the operation, ultrasound allows you to accurately indicate the location of the tumor and a more acceptable access to it. In recent years, special devices for ultrasound stereotaxic breast biopsy have appeared. The stereotactic method allows not only a fine-needle biopsy for cytological examination, but also a biopsy to obtain a tissue column and subsequent histological examination of the specimen. The equipment for such a study of the mammary glands is still available only to large oncological institutions. Due to the absence of radiation exposure, ultrasound can be used repeatedly in any age group.

Magnetic resonance imaging (MP tomography) allows not only to visualize the pathological focus in the mammary gland, but also to characterize it (cyst, tumor containing little fluid), as well as changes in the surrounding tissue. This expensive method should be used for special indications.

Morphological research is the main method of differential diagnosis. For this purpose, a fine-needle biopsy of the tumor under ultrasound control is used. The resulting material, as well as the discharge from the nipple, is subject to cytological examination. A negative answer does not exclude the presence of a malignant tumor. Only the detection of tumor cells gives confidence in the diagnosis and allows you to outline a treatment plan for the patient before surgery. The final answer in doubtful cases can be obtained only after histological examination of the removed sector containing the tumor. Biopsy should be performed only in those hospitals where it is possible then to perform urgent radical surgery.

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Breast cancer: description. Trends. Statistics. Diagnostic issues.

V. A. Sinitsyn, T. V. Rudneva
Scientific Center for Obstetrics, Gynecology and Perinatology of the Russian Academy of Medical Sciences (Dir.Acad. RAMS, Prof. V. I. Kulakov) Moscow

The pathology of the mammary glands includes malformations and developmental anomalies, inflammatory diseases, dyshormonal dysplasias, benign and malignant tumors, tuberculosis, actinomycosis, etc.

Breast cancer ranks first in the structure of cancer incidence among women. Early diagnosis is one of the real ways to improve treatment outcomes. The effectiveness of treatment directly depends on the prevalence of the tumor process.

It is necessary to dwell on the so-called risk factors, the knowledge of which can help in predicting the occurrence of breast cancer and the formation of risk groups. Risk factor is more epidemiological than etiological. Risk factors do not predetermine the development of the disease, but increase the likelihood of its occurrence.

It has been proven that in families of patients with breast cancer among their blood relatives, this disease occurs more often 4.5-7 times.

The time of the onset of menarche is of certain importance: an unfavorable factor is the age under 12 and over 15 years. The risk of developing breast cancer is associated with a woman's age at the onset of natural menopause: the onset of it at the age of 55 and older leads to an increase in risk by 2-3 times.

When assessing the generative function, attention is paid to the number of births or their absence: the risk increases in nulliparous, is the same in those who have given birth 1-4 times, and significantly decreases with the birth of 5 children or more. A negative factor is the lack of lactation. Very high and very low indicators of height and body weight negatively affect.

Risk factors also include ionizing radiation, work at chemical plants, living in ecologically unfavorable regions, which, apparently, can explain the higher (1.5-2 times) morbidity in women living in large industrial cities. The direct influence of nutritional factors is controversial. Age is considered as a risk factor. The older the woman, the higher the likelihood of the disease.

Great importance is attached to the presence of benign diseases of the mammary glands. This conclusion is based on the concept: "every risk has its precancer." Indeed, many clinical and epidemiological studies show that the onset of tumors, as a rule, is preceded by precancerous conditions. The study of the epidemiology of benign diseases has made it possible to identify risk factors that are common for the development of breast cancer. All benign breast diseases are, to one degree or another, risk factors. However, the most significant are intraductal papilloma, cyst, nodular forms of mastopathy. Fibroadenoma carries the lowest risk. Sometimes breast cancer develops without previous benign changes, at least without their clinical manifestations. The division of risk factors into different groups is rather arbitrary. This, apparently, is explained by the complex, polyetiological aspects of carcinogenesis.

Despite the urgency of the problem of breast cancer, it should be noted that it accounts for only 3-5% of all breast pathology. The diagnosis of breast cancer and benign diseases is based on the same principles. It is complex in nature and is carried out with the participation of an oncologist, a radiologist, a specialist in ultrasound diagnostics, a morphologist, as well as (if necessary) other specialists. Obstetricians-gynecologists should play a significant role in the diagnostic process. These are the specialists most "visited" by women, so their oncological alertness can save more than one life. Do not forget about teaching women self-examination techniques. Pay attention to the anamnestic data, taking into account all the listed risk factors, concomitant diseases, especially gynecological and endocrinological ones. Clinical examination makes it possible to assess the condition of the skin, areolas and nipples (in this case, you should pay attention to areas of flattening, retraction, edema of the skin, retraction and erosion of the nipples), allows you to determine the presence and nature of discharge from the nipples. Palpation in various positions will determine the presence of tumor-like formations, their size, consistency, mobility, contours, connection with surrounding tissues, skin and nipple. Areas of regional lymph outflow must be examined: axillary, nadi subclavian areas.

Various methods are used to study the condition of the mammary glands. Mammography is an X-ray examination of the mammary glands, which is highly efficient (98%). The study is performed in the first phase of the menstrual cycle, and in menopause - at any time. In addition to film mammography, electromammography has been developed, in which the image is obtained on paper. However, due to insufficient quality, it did not gain adherents.

In addition to non-contrast mammography, artificial contrasting techniques are used: ductography (contrasting of the milk ducts) and pneumocystography (contrasting of the cyst cavity). Indications for ductography are nipple discharge, especially bloody or "amber". Such discharge may be a symptom of intraductal papilloma or cancer. Ductography data show the topography of the duct, the type of branching, patency and the presence of intraductal tumors. If a cyst is detected, a puncture biopsy is performed, its contents are evacuated and air is introduced in the volume of the removed contents. On radiographs (pneumocytograms), the inner surface of the cyst walls is displayed, which makes it possible to detect intracystic growths.

Ultrasound examination of the mammary glands is widely used. It is most informative in the study of "dense" mammary glands in young women, in the identification of cysts, including very small, intracystic growths, in the differential diagnosis of cysts and fibroadenomas. Puncture of the breast can be performed under ultrasound guidance. The disadvantage of this method is the relatively large percentage of false positive conclusions in benign tumors and false negative in malignant tumors located in adipose tissue.

Recently, magnetic resonance imaging has been used in the complex diagnosis of breast diseases. Sometimes they resort to radionuclide diagnostics, which is especially informative for "dense" mammary glands with palpable formation, as well as for recurrent cancer. In some cases, thermography is used - a method of recording thermal radiation. The effectiveness of this method is low. The use of tumor markers is of low diagnostic value for early detection of cancer, and is more often used to predict the course of the disease.

An essential step in establishing a diagnosis is the morphological method. The material for cytological examination is nipple discharge, punctates from tumor-like formations, scrapings from ulcerated areas, contents of cysts, etc.

Special attention is paid to screening programs, in particular mammography screening. The main task of such programs is the early detection of malignant tumors, which can reduce mortality in breast cancer by 23-50%.

In accordance with the radiographic signs, breast diseases are divided into benign dysplasias, malignant tumors and other pathological conditions. Among benign dysplasias, diffuse and local forms are distinguished. Diffuse benign dysplasias (mastopathies) include adenosis, fibroadenosis, diffuse fibrocystic mastopathy. Local forms of dysplasia include cysts, fibroadenomas, ductasias, and nodular proliferations. With diffuse cystic fibrous mastopathy, the X-ray picture is diverse: a violation of the structure of the mammary gland is revealed, a lot of rounded vague shadows are determined, thickened cords and large-loop deformation of the stroma, islands of adipose tissue with areas of fibrosis are visible.

With adenosis-mastopathy with a predominance of the glandular component, a lot of rounded blurry shadows are determined on mammograms. Fibroadenosis is represented by a combination of hyperplastic glandular lobules and intralobular connective tissue. Diffusely located multiple microcalcifications can be seen on radiographs.

On echograms with diffuse benign dysplasia, the parenchyma of the mammary glands can acquire a higher echogenicity due to the alternation of hyperechoic connective tissue elements with less echogenic glandular structures. There is a thickening of the walls, an increase in the lumen, uneven contours of the ducts, pocket-like expansions in the form of hypoechoic zones along the main axis of the duct.

Against the background of mastopathy, cysts are often found. Palpation of the cyst is defined as a tumor-like formation of a round shape, dense elastic consistency, not associated with the surrounding tissues. On radiographs, cysts give round or oval shadows of various sizes: from 0.5 to 4-5 cm or more. The cyst shadow is uniform, the outline is even. Echography determines the typical signs of formations containing fluid: round shape, clear even contours, anechoic structure without reflection, compressibility.

As a rule, if a cyst of more than 1 cm is detected, it is punctured with aspiration of its contents. The contents of the cyst are subject to mandatory cytological examination.

Nodular mastopathy (nodular proliferation) is palpably defined as nodular formation of a dense consistency with indistinct contours. On the roentgenogram, limited areas of hyperplastic glandular tissue of high density without clear boundaries are revealed. With echography, single or multiple areas of reduced echogenicity are found without clear contours and boundaries. With nodular mastopathy, a puncture biopsy with a cytological examination is necessary.

Fibroadenoma is a benign tumor arising from the epithelium of the glandular lobules. Palpation is defined as a dense, rounded, mobile formation with smooth contours. On radiographs, a regular oval or round formation with clear contours without a perifocal reaction is visualized. Long-term fibroadenomas can be calcified. A peculiar variant of fibroadenomas is a phylloid tumor resembling fibroadenoma, but reaching large sizes: up to 7-10 cm in diameter. Echographically, fibroadenoma is visualized as a rounded formation with clear, even contours without additional acoustic effects. In the presence of such formations, a puncture biopsy with cytological examination is performed.

Intraductal papilloma is a tumor located in the lumen of the milk duct. In this case, discharge from the nipples is observed, which are subject to mandatory cytological examination. If this pathology is suspected, ductography is performed to clarify the diagnosis. Intraductal papilloma is also visualized with echography in the form of an isolated expansion of the duct or a solid formation of a rounded shape.

The vast majority of breast cancers are cancers (adenocarcinomas). Non-epithelial malignant tumors are rare. Secondary malignant tumors include metastatic lesions. On palpation, they have a dense consistency, are inactive, soldered to the surrounding tissues, and have indistinct contours. Enlarged regional lymph nodes are often palpated, there are so-called skin symptoms ("lemon crust", umbilization, wrinkling, etc.). In diffuse forms of breast cancer, attention is drawn to an increase in the mammary gland, hyperemia and swelling of the skin, soreness, fever, which resembles a picture of acute purulent mastitis. Malignant tumors of various histological structures do not have any specific features on mammograms. Tumors up to 1 cm in diameter are usually not palpable, especially with large mammary glands. The possibilities of mammography depend on the structure of different tissues. With the predominance of glandular tissue, it is difficult to notice the tumor node. In such a situation, ultrasound can provide additional information. Against the background of fatty involution, typical for older ages, mammograms can even detect a formation of 2-3 mm in size. The shadow of a malignant tumor in the image is always smaller than its size on palpation, since wrinkling processes, areas of tissue infiltration and edema develop around the tumor. "Cancer" node usually has the shape of a circle or oval, often an additional protrusion extends from it, directed towards the nipple, called a cancerous bridge. Often the tumor consists, as it were, of several nodes adjacent to each other. Microcalcification is a very important radiological sign of cancer on mammograms. This term denotes the smallest accumulations of lime salts in the zone of neoplasm. Microcalcifications are usually located in the central areas of the tumor at the site of decaying cancer cells, in the lumen of the ducts. The more microcalcifications are detected in a limited area, the higher the likelihood of malignant formation. The identification of microcalcifications is of particular importance in those cases when it is not possible to outline the image of the neoplasm with confidence. Then the symptom of microcalcification can be decisive. It is necessary to carefully evaluate the outline of the tumor. Its contours are uneven, jaggedness and small waviness of the edges of the node are observed, and rays-spicules of various sizes and shapes can depart from it. A significant sign of a growing tumor may be a change in the structural pattern of the gland in a limited area. Moreover, if we compare the mammograms of the right and left mammary glands, then we can notice the local asymmetry of their structure in the area of \u200b\u200bthe growing tumor.

The extent of the tumor process, in particular with metastatic lesions of the axillary lymph nodes, can be judged by the results of the so-called axillography (X-ray of the axillary zones).

Intracystic cancer is detected by the described pneumocystography: flat, arcuate or lobular growths are found on the inner walls of the cyst. With echography, in most cases, nodular forms of breast cancer are hypoechoic formations. Their echo structure is diverse and depends on the presence of areas of necrosis, fibrosis, calcifications, and tumor vessels. In the diffuse form, a thickening of the skin, an increase in the echogenicity of adipose tissue, a network of hypoechoic, parallel and perpendicular to the skin tubular structures (dilated infiltrated lymphatic vessels) are determined. Moreover, against the background of increased echogenicity of the parenchyma of the mammary gland, it is impossible to differentiate its constituent parts.

In addition to benign dysplasias and malignant tumors, one should dwell on other pathological conditions of the mammary glands. Mammography is informative for some developmental anomalies. So, for example, with an ectopic anlage of glandular tissue, the condition of the accessory mammary gland or accessory lobe (often located in the axillary region) is specified.

Inflammatory processes such as acute mastitis are common, especially in the postpartum period. Mammograms show intense homogeneous darkening with indistinct boundaries and infiltration of the subareolar region. With an unfavorable course, an abscess may form. You should be very careful about patients in whom mastitis occurs outside the lactation period, since often the clinical manifestations of mastitis can be masked by the so-called mastitis-like cancer.

In inflammatory diseases of the mammary gland, ultrasound is of great diagnostic value. The diffuse form of mastitis is characterized by thickening of the skin, an increase in the echogenicity of the subcutaneous tissue and parenchyma with a loss of clarity of their differentiation. The lacteal ducts involved in the inflammatory process are characterized by the presence of hypoechoic purulent contents. Both with X-ray mammography and with echography, it is very difficult to differentiate inflammatory changes from edematous-infiltrative forms of breast cancer.

The pathological secret secreted by the mammary glands, regardless of menstruation, pregnancy, lactation, is due to various pathological changes. The reason for this secretion can be both extra- and intramammary. The most common intramammary causes are intraductal papilloma, intracanalicular fibroadenoma, hyperplastic proliferation of the epithelium in some forms of mastopathy and, most importantly, a malignant tumor. Pathological discharge can be unilateral and, rarely, bilateral. The secret can be released from the nipple spontaneously or with pressure. All secretions are subject to mandatory cytological examination.

Comprehensive mammological examination is a real way to improve the quality of early diagnosis, and, consequently, to improve the results of treatment of breast cancer and benign diseases.

1980 0

Key provisions

The complaints of young women about the mammary glands should never be regarded solely as benign.

The best strategy for mastalgia is to dispel the patient's suspicions about breast cancer.

A thorough direct examination of the patient should include a complete examination of the mammary glands, chest, back, and lymph nodes (axillary, supraclavicular, subclavian, and cervical).

In the process of a diagnostic search for pain in the mammary gland, one should make sure that the history is fully collected and a complete examination of the patient is carried out to exclude bursitis, diseases of the musculoskeletal system and reflected pain, the source of which is a disease of the abdominal organs.

A breast mass with suspicious characteristics should be biopsied even if no change is found on imaging. If a malignant tumor is suspected, a tissue sample should always be taken for histological examination (by biopsy).

The most important feature of mastitis management is observation to make sure the process is resolving and that the formation is not an inflammatory form of breast cancer.

Ultrasound examination (ultrasound)remains an extremely valuable diagnostic method for mammological surgeons in the clinical setting, at the patient's bedside and in the operating room.

Despite the development of new devices and biopsy techniques, the choice of the most suitable combination for a particular case is made by the attending physician, based on specific needs. The doctor needs to have several types of biopsy devices on hand to be ready for any situation.

Cases of triple negative breast masses (benign lesions by direct examination, imaging, and biopsy) should be monitored.

An overview of breast diseases

The most common benign breast condition is called fibrocystic changes (FCI)... This condition is often referred to as fibrocystic disease due to its prevalence and is often viewed as a stage in the natural development of the breast. In fact, this condition is not a disease.

FKI - fibrous-glandular tissue in the form of nodules, usually manifested in the form of mastalgia and tenderness on palpation of the mammary gland. Fibrocystic changes are most often observed in women aged 35-45 years, in contrast to fibroadenomas, which are characteristic of younger women 15-25 years old. Fibroadenomas are usually clearly demarcated from adjacent tissues, painless, dense, and mobile.

Mastalgia, or breast pain, is probably the most common reason women seek medical attention. The cause of this condition is unknown, however, both benign and malignant formations can manifest as pain in the mammary gland, therefore, it requires a mandatory examination. You should also examine the heart, abdominal organs, and the musculoskeletal system, as their lesions can be accompanied by pain in the mammary gland.

Benign duct lesions, duct ectasia, or intraductal papillomas may manifest in a similar manner. In both conditions, clear, bloody, or non-bloody discharge may be present. In addition, if the epithelial lining of the ducts is ulcerated, their ectasia may manifest as inflammation.

Mastitis and abscess can manifest themselves in a similar way, accompanied by a local increase in temperature, pain on palpation and hyperemia. In order not to miss inflammatory forms of breast cancer, patients must be monitored for these benign conditions.

Certain benign breast conditions carry a higher risk of developing malignant neoplasms. In patients with atypical hyperplasia, the risk of breast cancer can increase more than fourfold, and in combination with a family history of breast cancer, it can increase ninefold. Atypical hyperplasia is sometimes difficult to distinguish from lobular cancer (DR) in situ and ductal cancer (PR) in situ.

Papillomas show an increased risk of developing cancer, especially when combined with atypical hyperplasia. Women with papilloma and atypical hyperplasia have a higher risk of later developing PR in situ compared with patients with papillomas without atypia. This chapter will cover the diagnosis and evaluation of benign breast disease.

Anamnesis of benign tumor formations

For this reason, it is required to assess the risk of breast cancer in the patient. Gender is the most important risk factor for breast cancer. Only 1% of cases occur in men. This is likely due not only to the difference in estrogen levels but also progesterone. Age is another significant risk factor.

The probability that a woman in her 30s will be diagnosed with breast cancer is 1 in 2212. Upon reaching the age of eighty, the probability increases to 1: 8. Previous morphological studies should be obtained, especially if atypia is found, which, as mentioned above, increases the risk four to nine times.

Information on previous radiation therapy should be obtained. Other significant risk factors for breast cancer include prolonged exposure to estrogen, such as early menarche, late menopause, no history of childbirth, late motherhood (childbirth over 35 years of age), or exogenous hormone therapy.

Missing labor increases the risk in women by about 30%. There are few benefits of combination hormone replacement therapy (reduction of osteoporosis, vaginal dryness and hot flashes), and significant disadvantages of hormone therapy (increased risk of uterine cancer, cardiovascular side effects, and breast cancer).

Family history is mandatory, as family cases account for about 5-10% of all breast cancer cases. The risk for a woman increases if the sick relative is in the first degree of relationship (mother or sister). The risk increases from three to four times if the sick relative was at the time of the onset of the tumor in premenopause.

You should also ask questions about a family history of ovarian cancer. Women with BRCA1 or 2 carriers have a 60-85% risk of developing breast cancer and a 40-65% risk of developing ovarian cancer throughout their lives. It is important to know that in a patient who has already had breast cancer, the risk of tumor recurrence increases by about 1% every year.

Tumor formation and tenderness when feeling the breast are the most common complaints that lead women to seek medical help for breast disease. During the collection of anamnesis and direct examination, the patients note the presence and time of the appearance of any tumor-like formations or changes in the mammary glands, any concomitant pain, increase in size and find out whether the formation changes in size during menstruation.

Ask about the presence of retractions and lymphadenopathy. When asking questions about pain sensations, you should detail them, specifying the presence of cyclical changes in their nature, changes during movement, irradiation of pain and the presence of symptoms caused by bursitis.

The patient should be asked in detail about the nature of the diet, including in particular the consumption of caffeine, chocolate, cheese, wine and meat with a high fat content. Additionally, it is important to note a history of smoking. These factors can be the cause of breast pain and fibrocystic changes. When diagnosing any breast complaints, questions should be asked about the condition of the nipples, such as peeling, retraction, and discharge.

Unspontaneous nipple discharge that is green and free of blood, involving multiple ducts, is often caused by benign conditions. When discharge is observed from one duct, occurs spontaneously, contains a significant admixture of blood and / or is transparent, further diagnosis is required.

The patient is asked if she may be pregnant, which may be the cause of changes in the size of the mammary glands or the appearance of milk discharge from the nipples. Hormonal changes during pregnancy and / or lactation may be accompanied by bilateral bleeding from the nipples.

Asking questions about any recent trauma that may be the source of hematomas or fat necrosis, manifested by tumor-like formations. However, the patient should be cautioned that breast cancer often coexists with recent trauma, probably because the trauma attracts attention and forces an examination of the breast.

Finally, the patient should be asked if she has performed a breast self-examination and has noted any changes or differences in their condition. The technique for performing self-examination should be checked to make sure it is correct. During the direct examination, the physician should explain to the patient how she can apply these methods during self-examination.

In this part of the training, the patient is explained to her the mnemonic rule OVOPIKBU (Swelling, Retraction, Edema, Swelling in the Axillary Fossa, Skin Changes, Soreness / Thickening), an acrostic for memorizing some of the signs and symptoms of breast cancer (in the English version, this abbreviation looks like “BREAST ", But in Russian it is not so clear - Approx. Of the translation).

Additionally, the patient's attention is drawn to the fact that most of the cases of breast cancer are asymptomatic, and therefore it is important to conduct screening mammography.

Breast examination

A direct examination is easier to carry out a week after menstruation, when the mammary glands are not so painful and enlarged. The physical examination begins with an examination of both breasts in a sitting and supine position. Compare the size of the mammary glands, remembering that the smaller size distinguishes a healthy mammary gland.

Then they look for retraction of the skin, nipples or breast in general. Retraction may be due to tumor invasion of Cooper's ligaments. They also look for edema or a symptom of "orange peel", manifested by a change in the skin in the form of an orange peel when the tumor of the lymphatic vessels of the skin grows (Fig. 1.1).

Figure: 1.1. Symptom of "orange peel" in the breast area

Pay attention to erythema or a local increase in skin temperature in the area of \u200b\u200bthe mammary glands. Mastitis and abscess can be accompanied by the same symptoms, but it is important to remember that inflammatory breast cancer can manifest in the same way.

Examine the nipple and areola for scaling, which may indicate Paget's disease. Paget's disease occurs in about 1–2% of all women with breast cancer. Conversely, 90% of women with Paget's disease have breast cancer (Figure 1.2).

Figure: 1.2. Peeling and erosion of the nipple caused by Paget's disease

In the standing position of the patient, with arms lowered along the body, the axillary, subclavian and cervical lymph nodes are felt from behind, describing their localization, consistency and mobility.

Palpation of the mammary glands should be carried out in the patient's supine position with a hand behind the head on the same side, which allows the lateral quadrant and tail of the mammary gland to rest on the chest and facilitates palpation.

Regardless of the nature of the movements, that is, concentric, radial or "rubbing" movements, palpation should be carried out in an orderly manner and cover the mammary gland within its anatomical boundaries. Additional attention should be paid to areas that the patient herself points to and which bother her. The location of an individual nodule or nodule should be described by specifying the distance from the nipple and the position on the dial.

The size, mobility, consistency and boundaries of the tumor-like formation should be described in the history and examination section. The dominant tumor-like formation found during the examination requires additional investigation. The nipple-areola complex is gently squeezed to assess for discharge and / or subareolar masses.

Pain in the mammary gland can be caused by reflected pain in myocardial infarction, hiatal hernia, spinal diseases and cholelithiasis, so direct examination of the patient should also help to exclude these diseases.

Chest pain can be musculoskeletal in nature and trigger points should therefore be fully explored. The most common cause of difficult-to-treat breast pain is bursitis. Breast pain caused by bursitis is critical for diagnosis because it is often overlooked and easy to treat with physical therapy or trigger point injections.

Diagnostic methods

The sensitivity and specificity of clinical breast examination is imperfect and other diagnostic tests are required to complement the triple negative test (physical examination, imaging examination, and percutaneous biopsy). Patients can be observed without any fear if there is a "triple negative test".

Diagnostic imaging techniques include mammography and ultrasound. Mammography is currently the only imaging test with proven efficacy in screening for breast cancer. Mammography reduces mortality by 17% in women aged 40-49 and by about 44% in women over 50.

However, the method often, in 10-30% of patients, gives a false-negative result, and therefore, if tumor-like formations are suspicious, palpable or visible on ultrasound examination, even if mammography is negative, a biopsy should be performed.

Ultrasound is becoming increasingly popular in the diagnosis and treatment of breast diseases (Fig. 1.3).

Figure: 1.3. Tumor formation withultrasound examination

Although not currently used as a screening method, ultrasound offers significant advantages in the diagnosis of mammographic changes or palpable lesions. It may be preferred in young, high-risk women with dense breasts, when mammography can be difficult, and in pregnant women to avoid radiation exposure.

Ultrasound can also be used to treat breast conditions. It is most often used to determine the location of lesions in outpatient percutaneous biopsy and diagnosis (Fig. 1.4).

Figure: 1.4. Ultrasound picture of trepanobiopsy

Often, the method is used to aim the needle or place a guidewire during a breast biopsy, or as a control study for intraoperative removal of masses visible on ultrasound or hematomas after trepanobiopsy of invisible masses.

Magnetic resonance imaging (MRI)the mammary gland is successfully used in the diagnosis of mammary gland formations due to its sensitivity and specificity, reaching 94-100% and 37-100%, respectively. MRI provides more detailed information on breast masses, but it is more expensive.

The costs of magnetic resonance imaging are covered by Medicare and private insurance companies if the strict indications for the appointment are met. Clinical applications include evaluating the efficacy of neoadjuvant chemotherapy, diagnosing multicentric cancer, evaluating the state of the tumor resection margin, and diagnosing breast implant rupture and axillary lymphadenopathy with an unidentified primary source of metastasis.

Several different biopsy techniques will provide diagnosis. The application of this or that technique will depend on the manifestations of the pathological formation (palpable or non-palpable), the patient and the availability of imaging research methods to control the biopsy. These techniques include fine needle aspiration biopsy (TAB), trepanobiopsy and open surgical biopsy (Fig. 1.5 and 1.6).

Figure: 1.5. Tactical algorithm for palpable tumor formation

Figure: 1.6. Tactical algorithm for non-palpable tumor formation

TAB is performed with a 22 gauge needle and provides cytological rather than histological information, which leads to a lack of diagnostic data in 36% of cases with non-palpable lesions. Fine needle aspiration biopsy may be preferred only in patients with bleeding disorders.

Trepanobiopsy can be used to diagnose palpable masses or non-palpable masses under ultrasound or mammography guidance. Needle sizes range from 14th to 8th, and when biopsies are performed using vacuum devices, trepanobiopsy provides large specimens sufficient for high-quality histological diagnosis (Figure 1.4). Fibroadenomas are easily diagnosed and removed with a vacuum trepanobiopsy in a hospital setting.

Trepanobiopsy

Patients for whom this technique is contraindicated include those whose formation is not clearly visualized by the stereotaxic installation and have small mammary glands, as well as those who have a body weight that is too large for the carrying capacity of a stereotaxic table, are unable to lie on their back and have limited mobility of the upper limbs.

Open surgical biopsy

For microcalcifications or non-palpable lesions, needle localization can be used as a guide for excision. Both interventions are performed in the operating room; anesthetic benefits range from local anesthesia to general anesthesia.

Research shows that open surgical biopsy is not only more expensive, but it also increases the time to complete surgical treatment and requires re-surgery.

K.I. Blenda, M.U. Bukhler, A. Xendes, M.G. Sarah, O.D. Gardena, D. Wang