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Premenopausal and Postmenopausal Breast Anatomy

Discuss About The Anatomy And Physiology Of Breast Surgery.

The breast is an organ that is used in the production of milk during lactation in adult women. The components of the tissue are made up of lobules that are responsible for the production of milk. According to Pandya and Moore (2011), the lobules are connected to ducts that proceed to nipples p. 92. The main mass of the breast is made up of adipose and fibrous tissues where the lobules and ducts are spread out. The male and female breasts are almost similar in structure apart from the absence of specialized lobules in male breasts due to the lack of physiologic need of milk production in men (Hassiotou and Geddes, 2013, p. 35).

The breast of an adult is located above the pectoralis muscle that is located above the ribcage. The breast tissues spread horizontally from the sternum’s edge towards the midaxillary line. The tail of the breast tissues also referred to as the axillary tail of Spence extends into the axilla (Gabriel and Long, 2016). It is worth noting that a mass of breast cancer can develop in the axillary tail. The breast tissues are surrounded by fascia which is a thin layer of fibrous tissues. Fascia’s deep layer is situated atop the pectoralis major whereas the superficial layer is located just beneath the skin.

The lymphatic drainage of the breasts flows from the lobules into the sub-areolar plexus that is known as Sappey’s plexus. The lymphatic drainage occurs in three routes from Sappey’s plexus. These routes include the axillary or lateral pathway, internal mammary pathway, and retro-mammary pathway (Pandya and Moore, 2011, p. 93). The axillary pathway is supplied by the ducts satellite lymphatic and the Sappey’s plexus. It runs around pectoralis major’s inferior edge to the axillary nodes. Conversely, the internal mammary pathway comes from the medial and lateral halves of the breasts and goes to the contralateral breast via the pectoralis muscle. Finally, the retro-mammary pathway flows from the posterior section of the breast. It is important to note that more than 75% of lymph drained by the breast is received by the axillary lymph node.

In premenopausal women, there are around 15-20 lobes in each breast with every lobe having between 20 and 40 lobules. Each breast has around 10 duct systems with every system having an opening to the nipples. The breasts are normally mature after puberty but only become active after pregnancy (Ellis and Mahadevan, 2013, p. 13). In premenopausal women, the breasts have higher breast density implying that the breast has more tissue than fats. Postmenopausal, however, is when the breast has more fats than tissue thus a lower breast density. It is also important to note that the lobules begin to reduce after menopause (Johnson and Cutler, 2016, p. 9). The breast, as a result, remains comprised mainly of ducts, fibrous tissues, and adipose tissues.

Differential Diagnoses

In premenopausal breasts, the glandular tissues are kept firm for milk production. However, after menopause, these tissues shrink, and are replaced by fatty tissues (Johnson and Cutler, 2016, p. 11). It is also important that the breasts sag after menopause due to the loss of strength by the fibrous tissues. These changes in the anatomy of the breast after menopause could be attributed to the absence of ovarian hormones in postmenopausal women (Ellis and Mahadevan, 2013, p. 13). As a result, there is a degeneration of the secretory cells of the alveoli and the breast gland atrophy. The fibrous tissues also degenerate and the degeneration is accompanied by a decrease in stromal cells and collagen.

For a woman of Carol’s age, the differential diagnosis for palpable lumps could include cysts, fibrocystic changes, cancer, and fat necrosis. A cyst is a common cause of palpable lumps in women aged above 40 years like Carol. Cysts fluctuate depending on the menstrual cycle of the woman and are more common when there are irregular hormones (Errolozdalga.com, 2018). They are characteristically round, soft, mobile, and usually tender. Fibrocystic changes are characterized by rope-like or lumpy breast tissues. It is normally painful and the pain gets worse accompanied by an increase in size during pre-menses (Errolozdalga.com, 2018). This condition increases the risk of breast cancer if there is a variant with the proliferation of the epithelial. Fat necrosis, on the other hand, is a rare lesion that produces a mass accompanied by a retraction of the skin or nipples. It is presumed that this condition is caused by trauma and biopsy is used to diagnose it (Errolozdalga.com, 2018). Finally, cancer, the other differential diagnosis is characterized by firm, stellate, and irregular tissues. It results in a clear delineation from adjacent tissues.   

The following are some of the risk factors associated with breast cancer (Stuckey, 2011, p. 100)

  1. Gender
  2. Age
  • A history of breast cancer in the family
  1. Genetics
  2. Individual history of breast cancer
  3. Obesity
  • Menstrual history
  • Alcohol
  1. Dense breasts
  2. Smoking

These risk factors, however, differ in postmenopausal and premenopausal women. The chances of having breast cancer increase as a woman ages and therefore women who experience menopause past the age of 55 years possess a greater risk of suffering from breast cancer (Butt et al., 2012, p. 120). It is additionally worth noting that women who started experiencing their menses before the age of 12 years are at an increased risk of having breast cancer to long-term exposure to estrogen hormone.

Several studies have revealed that breast cancer is more prevalent in late menopause and an early onset of menarche in both premenopausal and postmenopausal women (Nelson et al., 2012, p. 640). Additionally, failure to practice breastfeeding has been discovered to increase the risks of breast cancer between both sets of women. Longer duration of breastfeeding has been reported to lower the risks of breastfeeding in premenopausal women; however, the same may not be confirmed in postmenopausal women (Butt et al., 2012, p. 120). Finally, having dense breast tissues also increased the risk of breast cancer among both sets of women.

Main risk factors of breast cancer

A history of breast cancer in the family is very significant in the risk assessment of this condition. In fact, breast cancer in a first-degree relative is the most commonly recognized risk factor for breast cancer. Women who have a member of the family with a history of ovarian or breast cancer should be screened to ascertain the family history that may be linked to increased risks for mutations of the susceptibility genes of breast cancer. These genes include BRCA1 and BRCA2. Positive screening results should mean that the women receive genetic counseling (Robertson et al., 2010). Conversely, women without such a family history should not be subjected to BRCA testing or genetic counseling.

Physically examining the breast can also be useful in identifying the possibility of breast cancer. The presence of lumps, an increase in the size of breasts, changes in the skin such as swelling and redness, axillary lump, and nipple discharge could be some of the signs and symptoms of breast cancer (Robertson et al., 2010, p. 365). An assessment of the patient’s breasts should be done to detect changes in the contour of the breasts and skin tethering. From the assessment, some of the following findings should be a cause for concern; dilated veins, inverted nipples, ulceration, skin tethering, and mammary page disease. Palpable lumps can be characterized by irregularity, hardness, focal nodularity, and fixation to muscles or skin. Robertson et al. (2010) further ascertain that a complete examination of the sites of skeletal pain and the chest in addition to a neurological and abdominal examination should help in identifying some of the following symptoms; pain in the bones, breathing difficulties, jaundice, and abdominal distention among others p. 365.

Lesions are graded on a scale of one to three depending on the aggressiveness of the cancerous cells. These grades include low grade (1), intermediate grade (2), and high grade (3) (Ward and Thoolen, 2011). Low-grade tumors share a resemblance with normal tissues when viewed under the microscope and are thus referred to as well-differentiated. These tissues tend to spread at a slower rate when compared to the tissues in grade 2 and grade 3. In the intermediate grade, the tissues are moderately differentiated and slight abnormalities can be viewed under a microscope. High-grade tumors, on the other hand, show more abnormalities than the normal tissues under a microscope (Ward and Thoolen, 2011). Additionally, their growth and spread are more aggressive compared to the other grades.

The Clinical Presentation for Breast Cancer

DCIS implies that the cancer is contained in the milk and has not invaded any other breast tissues out of the ducts. It is caused by an unrestrained growth of cancerous cells within the breast ducts. It usually does not cause breast lumps that can be felt (Harris, Lippman Osborne and Morrow, 2012). It is characterized by bloody discharge from the nipples and breast pains. Infiltrating ductal carcinoma, on the other hand, begins at the duct and spreads to other breast tissues. It can be characterized by hard, immovable lumps in a woman’s breast. It may also cause an inversion of the nipples.

During a biopsy, the cancerous cells in the breast are taken out and tested for the presence of proteins that may act as estrogen and progesterone receptors. The growth of breast cancer is fueled when estrogen and progesterone attach themselves to the receptors (Chlebowski et al., 2010, p. 1687). From Carol’s test results, we are told that the estrogen and progesterone receptors were negative. This implies that cancer has been contained from growing and spreading to other tissues. Knowledge of the hormone receptor knowledge is important in making decisions on the best treatment options (Liu et al., 2010, p. 53). It is worth noting that treating this type of cancer with hormone therapy drugs may not be helpful.

The two most common treatments for breast cancer are surgery and radiotherapy. These two methods are highly effective and are in most cases done in combination. They, however, have several side effects that may be dangerous to the patient. Surgery can be in the form of lumpectomy, mastectomy, or bilateral mastectomy. One of the most common side effects of surgery as a treatment option for breast cancer is the change in breast sensation. This can further affect a woman’s sexual well-being. Additionally, the risks of lymphedema are increased due to the removal of lymph nodes during surgery which is normally an incurable swelling that is experienced on the arm located on the same side as the breast where the surgery had been performed (Veronesi et al., 2010, p. 148). Furthermore, there are increased risks of infection with the procedures involved I mastectomy and lumpectomy. Some patients may also experience adverse anesthetic reactions that can also be dangerous medical risks.

Radiotherapy is normally prescribed after surgery to kill any remaining cancerous cells. Radiotherapy could be responsible for both acute and chronic side effects. The acute side effects show up during treatment while the chronic side effects are experienced may be months or years after treatment. Acute side effects may consist of skin irritation, a painful swelling of the breast, sore throat, loss of air in the armpits, and elevated risks of lymphedema (Veronesi et al., 2010, p. 148). 

Grading of Lesions

Wide re-excision lumpectomy may be defined as an additional surgery performed by the surgeon to remove any remaining cancerous cells that may be found in the margin that extend outwards the edge of the breast tissues that had been removed due to cancer.  

A seroma results from the buildup of fluids in the regions of the body where tissues had been initially removed. It may be one of the complications of a surgery. According to Lee et al. (2010), the seroma is normally filled with a serous fluid which is yellowish-to-white in color. Hematoma, on the other hand, results from the collection of blood in a dead space due to the opening up of small blood vessels as a patient recovers from a surgery p. 1389.

Post-operative seroma and hematoma pose significant effects to wound healing and the subsequent patient morbidity. Additionally, seroma and hematoma causes tension on flaps due to the accumulation of fluids (Lee et al., 2010, p. 1392). These complications may further result into an overall negative diagnosis that may significantly affect the safety of the patient thus limiting the possibilities of regaining the original physical appearance. It is additionally important to note that these complications may call for the need of therapeutic antibiotics to treat infections of wounds. There could also be a prolonged use of suction drains to get rid of the accumulated.

References

Errolozdalga.com. (2018). Breast Lump/Mass. [online] Available at: https://errolozdalga.com/medicine/pages/KC/BreastLump.mass.ck.8.2.10.html [Accessed 8 May 2018].

Butt, Z., Haider, S.F., Arif, S., Khan, M.R., Ashfaq, U., Shahbaz, U. and Bukhari, M.H., 2012. Breast cancer risk factors: a comparison between pre-menopausal and post-menopausal women. JPMA-Journal of the Pakistan Medical Association, 62(2), p.120.

Chlebowski, R.T., Anderson, G.L., Gass, M., Lane, D.S., Aragaki, A.K., Kuller, L.H., Manson, J.E., Stefanick, M.L., Ockene, J., Sarto, G.E. and Johnson, K.C., 2010. Estrogen plus progestin and breast cancer incidence and mortality in postmenopausal women. Jama, 304(15), pp.1684-1692.

Ellis, H. and Mahadevan, V., 2013. Anatomy and physiology of the breast. Surgery (Oxford), 31(1), pp.11-14.

Gabriel, A. and Long, J.N., 2016. Breast anatomy. Medscape Drugs & Diseases.

Harris, J.R., Lippman, M.E., Osborne, C.K. and Morrow, M., 2012. Diseases of the Breast. Lippincott Williams & Wilkins.

Hassiotou, F. and Geddes, D., 2013. Anatomy of the human mammary gland: Current status of knowledge. Clinical anatomy, 26(1), pp.29-48.

Johnson, M.C. and Cutler, M.L., 2016. Anatomy and physiology of the breast. In Management of Breast Diseases(pp. 1-39). Springer, Cham.

Lee, J., Nah, K.Y., Kim, R.M., Ahn, Y.H., Soh, E.Y. and Chung, W.Y., 2010. Differences in postoperative outcomes, function, and cosmesis: open versus robotic thyroidectomy. Surgical endoscopy, 24(12), pp.3186-3194.

Liu, S., Chia, S.K., Mehl, E., Leung, S., Rajput, A., Cheang, M.C. and Nielsen, T.O., 2010. Progesterone receptor is a significant factor associated with clinical outcomes and effect of adjuvant tamoxifen therapy in breast cancer patients. Breast cancer research and treatment, 119(1), p.53.

Nelson, H.D., Zakher, B., Cantor, A., Fu, R., Griffin, J., O'meara, E.S., Buist, D.S., Kerlikowske, K., van Ravesteyn, N.T., Trentham-Dietz, A. and Mandelblatt, J.S., 2012. Risk factors for breast cancer for women aged 40 to 49 years: a systematic review and meta-analysis. Annals of internal medicine, 156(9), pp.635-648.

Pandya, S. and Moore, R.G., 2011. Breast development and anatomy. Clinical obstetrics and gynecology, 54(1), pp.91-95.

Robertson, F.M., Bondy, M., Yang, W., Yamauchi, H., Wiggins, S., Kamrudin, S., Krishnamurthy, S., Le?Petross, H., Bidaut, L., Player, A.N. and Barsky, S.H., 2010. Inflammatory breast cancer: the disease, the biology, the treatment. CA: a cancer journal for clinicians, 60(6), pp.351-375.

Stuckey, A., 2011. Breast cancer: epidemiology and risk factors. Clinical obstetrics and gynecology, 54(1), pp.96-102.

Veronesi, U., Orecchia, R., Luini, A., Galimberti, V., Zurrida, S., Intra, M., Veronesi, P., Arnone, P., Leonardi, M.C., Ciocca, M. and Lazzari, R., 2010. Intraoperative radiotherapy during breast conserving surgery: a study on 1,822 cases treated with electrons. Breast cancer research and treatment, 124(1), pp.141-151.

Ward, J.M. and Thoolen, B., 2011. Grading of lesions.

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