Dronkers / Hendriks / Holland The Practice of Mammography

Pathology - Technique - Interpretation - Adjunct Modalities
1. Auflage 2001
ISBN: 978-3-13-257869-2
Verlag: Thieme
Format: EPUB
Kopierschutz: 6 - ePub Watermark

E-Book, Englisch, 280 Seiten, ePub

Reihe: Thieme

Even with the advent of many new radiographic techniques, mammography remains the most important and effective method of breast examination available today. This outstanding guide, using anatomy and pathology as a starting point, gives you clear and accurate instructions on all facets of performing breast mammograms, from proper positioning to analyzing the findings. In addition to mammography, this teaching guide focuses on the non-radiological aspects of breast carcinoma such as clinical diagnosis, treatment, epidemiology, and risk factors. You'll also learn about screening methods to detect and avoid potential problems. The instructive nature of this text makes it an excellent resource for students and residents. Radiologists and OB/GYN's who need a quick update or refresher will also appreciate its value. Here is the book that belongs on the shelves of every medical school library, residency program, and specialist's office!

Dronkers

Zielgruppe

Ärzte

Autoren/Hrsg.

Dronkers, Daniel J.

Hendriks, Jan H.C.L.

Holland, Roland

Rosenbusch, Gerd

Fachgebiete

• Medizin | Veterinärmedizin Medizin | Public Health | Pharmazie | Zahnmedizin Medizinische Fachgebiete Bildgebende Verfahren, Nuklearmedizin, Strahlentherapie Radiologie, Bildgebende Verfahren

Inhaltsverzeichnis

1 Clinical Characteristics of Breast Cancer
2 Anatomy
3 Benign and Malignant Disorders of the Breast
4 Epidemiology and Treatment of Breast Cancer
5 Physical and Technical Aspects of Mammography
6 Positioning in Mammography
7 Supplemental and Advanced Examinations
8 Mammographic Findings and Their Interpretation
9 Breast Cancer Screening
10 Diagnosis of Breast Diseases in Males
11 Retrospective View of Diagnostic Radiology of the Breast

Leseproben

1 Clinical Characteristics of Breast Cancer

Th. Wobbes

To a woman, any change in the breast is cause for concern. The fear of breast cancer makes most breast complaints a great emotional burden on the patient. The omnipresent possibility of breast cancer means that any breast complaint, even if it is only pain or swelling, should be taken seriously. The adage that any lump in the breast is malignant until proven otherwise still holds true today. Modern diagnostic modalities almost always enable the distinction between a benign or a malignant lump, though only histological biopsy can provide the final diagnosis.

To avoid missing a malignancy, it is necessary to know the limitations of the various diagnostic methods.

The typical complaints encountered in daily practice and their underlying clinical findings are summarized in Table 1.1.

Table 1.1 Typical complaints and specific pathological condition

• Physiologic lumps and tenderness – Mastalgia (mastodynia) • Nodularity • Dominant lumps – Breast cancer – Fibroadenoma – Cysts • Nipple discharge • Inflammation and infections – Lactation – (Peri-) Subareolar – Mondor disease • Skin and nipple changes – Eczema – Retraction – Edema

Physiological Lumps and Tenderness

Mastalgia

During a woman's menstrual years, the breasts are continuously under the influence of cyclic hormonal stimulation. Almost half of all women experience some pain during the luteal phase of their cycle, often associated with some swelling.

The normal nodularity is often rather pronounced, particularly in the upper outer quadrants. This is a physiological condition with no increased incidence of breast cancer. Up to half of women older than 30 years complain of some breast pain (mastalgia) in the period preceding menstruation. This pain is not necessarily accompanied by the nodularity mentioned earlier, and may be diffuse throughout the breasts as well as local in the outer halves. Sometimes the pain is unilateral. Mastalgia is probably caused by parenchymal swelling during the luteal phase of the cycle because of increased water retention (Milligan et al., 1975). This cyclic painful swelling is commonly regarded as physiological, but is reported as something abnormal or pathological in 5% of women. Besides cyclic mastalgia, noncyclic breast pain can be experienced, particularly by women after age 40, and is described as a continuously burning or shooting sensation.

Nodularity

Swelling that may fluctuate with the menstrual cycle is physiological, but some women have a definite nodularity that is always present. The irregular lumps are mostly in the upper outer quadrants and are frequently painful. It is difficult to distinguish a normal finding from a pathological condition. Some consider such a nodularity pathological if it lasts for more than a week (Love et al., 1987). The clinician has to be concerned not to overlook an early carcinoma, although nodularity as such has no direct relationship with the development of a carcinoma. It is difficult to detect a malignancy in these breasts with either palpation or mammography. A discrete palpable lump that does not change during the menstrual cycle should be biopsied and examined histo-logically.

Dominant Lumps

Dominant lumps always need close attention. It is important to realize that breast cancer may present at any age. Fibroadenomas are found particularly in young women (age 20–30 years), and cysts are mostly found in older women (age 35–50 years). In pubertal girls, a giant fibroadenoma is sometimes diagnosed as a palpable firm lump in a unilaterally enlarged breast.

Breast Cancer

Breast cancer presents mostly as a painless lump and is difficult to separate from surrounding tissue. Almost 70% of carcinomas are located centrally or in the upper outer quadrants. Most women have no visible signs of the tumor. Cutaneous changes may occur if the tumor is located just beneath the skin, and nipple retraction is seen if the tumor is located in the nipple area. In addition, skin changes, nipple retraction, and edema (peau d'orange) with or without erythema or red to blue discoloration may be present as signs of cutaneous infiltration. Sometimes even ulceration can be seen. In some patients, breast cancer presents as diffuse induration of the gland, together with some shrinking of the breast. A special manifestation of breast cancer is the inflammatory carcinoma, a locally advanced stage with erythema of the skin, edema, and induration, but without a palpable dominant lump. The erythema is caused by tumorous infiltration of the skin.

If breast cancer is suspected, the regional lymph nodes should be palpated (axilla, supraclavicular and infraclavicular region).

Paget disease of the nipple is an eczematoid change of the nipple, sometimes preceded by itching and/or a pain sensation. This is at least the manifestation of a ductal in situ carcinoma (microcalcifications), and sometimes that of an invasive carcinoma.

Fibroadenoma

The fibroadenoma is a painless, circumscribed, mobile lump, usually measuring not more than 1–3 cm, although a giant fibroadenoma that exceeds 5 cm can occur in young girls. Histologically, the lump consists of both epithelial and stromal tissue. In case of a lump larger than most fibroadenomas found in women who are about 30 years of age, a phyllodes tumor should be considered. This tumor usually is benign but may display malignant behavior.

Cysts

Cysts are found primarily in perimenopausal women. It is frequently difficult to differentiate a cyst from a carcinoma despite its smooth surface. Fluctuation may be felt with superficial cysts. Often, additional cysts can be found in the same breast as a manifestation of cystic disease. Cysts are generally asymptomatic, but rapidly expanding cysts may be painful. A definitive diagnosis can be made by aspirating the contents.

Nipple Discharge

Several types of nipple discharge are encountered in clinical practice. A mostly bilateral milky discharge (galactorrhea) is physiological. A clear, but usually dis-colored (green, black, brown), discharge indicates ectasia of the major subareolar ducts; it also has no pathological significance. A bloody or serosanguinolent discharge may indicate intraductal pathological changes:

• Duct ectasia

• Benign intraductal epithelial proliferations

• Breast cancer.

It is important to search for a palpable lump as indication for an underlying malignant tumor. Mammography may disclose clinically occult pathology by displaying micro-calcifications. A carcinoma is found in not more than 5% of patients with bloody nipple discharge.

Inflammation and Infections

Breast infections are common, especially during lactation. Almost 10% of nursing women encounter a more or less severe infection of the breast, mostly occurring within six weeks after delivery. The infections present with pain, fever, and malaise. While the early phase of the infection might not have visible signs, full-blown mastitis presents with redness and swelling. Fluctuation may be elicited in superficially located abscesses. Antibiotic treatment of mastitis over a longer period of time may mask the abscess, which is then detectable only by sonography.

Out of the lactation period, periareolar or subareolar infections occur and are mostly seen in women between ages 30 and 35 years. The infection is located behind or just around the areola and causes erythema. It is attributed to an obstructed lactiferous duct, and in the early phase there is usually no sign of microorganisms. The infection frequently recurs even with adequate treatment. Smoking seems to be a predisposition. Mastitis is occasionally seen in women with cystic disease and presents clinically as an abscess.

Mondor disease is an inflammation of a superficial vein (thrombophlebitis) and is mostly located in the upper outer quadrant. It occurs primarily in older women. Redness and a cordlike painful infiltration develop along the involved vein. Thrombophlebitis may also be present in other parts of the body.

A special type of inflammation is the inflammatory carcinoma of the breast. This is an aggressive breast cancer that infiltrates the overlying skin. The breast may show redness and feel warmer than the contralateral breast. The skin shows edematous thickening, characteristically presenting as peau d

Skin and Nipple Changes

Changes of the skin and/or the nipple may reflect an infection but can indicate an underlying carcinoma.

• Eczema. Eczema of the nipple is called Paget disease. It is usually a manifestation of an underlying malignancy, but a real eczema can occur, mostly arising in the areola. The underlying carcinoma is generally a ductal carcinoma in situ, but invasive breast cancers also may induce this finding.

• Retraction. Retraction of the nipple and/or the skin or asymmetry of the breasts are suspicious for underlying breast cancer. If the tumor infiltrates the underlying muscle, the retraction characteristically appears more pronounced, with muscle contraction or elevation of the ipsilateral arm.

• Edema. Edema...

Über Autor(innen)

Dronkers