Breast diseases: causes, symptoms, diagnosis, treatment

The mammary glands are part of the female reproductive system, mammary gland tissues are targets for ovarian steroid hormones, prolactin, placental hormones and indirectly hormones from other endocrine glands of the body.

Traditionally, oncologists are involved in the diagnosis and treatment of breast diseases. However, recently, obstetricians and gynecologists have begun to deal more deeply with the problem of benign breast diseases.

Risk factors for the development of breast diseases

Currently, conditions have been identified that contribute to the emergence and development of mammary gland diseases, which makes it possible to identify a group of women with an increased risk of disease.

Since benign diseases and breast cancer have much in common in etiological factors and pathogenetic mechanisms, the risk factors for their development are largely identical.

Of primary importance is the hereditary factor - the presence of benign and malignant diseases in relatives on the maternal line.

One of the most common adverse factors is chronic salpingo-oophoritis, since inflammation disrupts the production of sex hormones.

Most patients with various forms of mastopathy have thyroid pathology. Hypothyroidism increases the risk of mastopathy by 3.8 times.

An important cause that contributes to the development of mastopathy are various diseases of the liver, bile ducts and gall bladder. The liver plays a major role in the metabolism of excess endogenous estrogens. With its diseases, this ability is reduced and even lost, as a result of which the hormone content increases.

Of the other risk factors, obesity may play a certain role, especially when combined with diabetes and arterial hypertension. It is known that with the presence of the entire triad, the risk of mastopathy, as well as breast cancer, increases threefold.

Another risk factor for the development of dyshormonal changes in the mammary glands is iodine deficiency, which contributes to disturbances in the hypothalamus-mammary gland system.

A woman is at high risk of getting sick under stress, neurosis, depression, therefore chronic stress is one of the factors in the development of mastopathy.

Hormonal imbalances in the female body are also caused by irregular sexual activity, which can contribute to the development of pathological processes in the mammary gland.

Indirect risk factors include addiction to alcohol and smoking.

The risk of developing breast disease may be increased by exposure to ionizing radiation.

Injuries and microtraumas to the mammary gland can have serious consequences for the development of mammary gland diseases.

Artificial termination of pregnancy significantly increases the risk of developing pathology of the mammary glands. After an abortion, proliferative processes in the mammary glands cease and the tissue undergoes reverse development. These regressive changes occur unevenly, so the structure of the glands can acquire a pathological character.

The risk of developing mastopathy and breast cancer increases under the influence of such unfavorable factors as lack of pregnancy or late first pregnancy, lack of breastfeeding.

Women who have given birth to two children before the age of 25 have a three times lower risk of developing breast diseases compared to those who have had only one child. Age is also an important risk factor for cancer: the incidence of breast cancer increases with age and reaches, according to some authors, up to 30% by the age of 75.

A link has been found between an increased risk of the disease and early onset of menstruation and late cessation of menstruation.

Factors that have a protective effect include early childbirth (20-25 years), breastfeeding, and the number of births (more than two) with full lactation.

Often, the causal factors are interrelated, creating a general unfavorable background. The complexity of assessing the totality of causal factors dictates the need for regular comprehensive examination (self-examination of the mammary glands, mammography, consultation with a mammologist) for each woman.

Diagnosis of breast diseases

Clinical examination

The examination begins with anamnesis analysis. Data on risk factors for breast diseases are of great importance in understanding the causes of their occurrence.

Next, they specify the complaints, the time of their appearance, the connection with the menstrual cycle, the presence of discharge from the nipples, their color, consistency, duration and constancy.

An objective examination includes inspection and manual examination, which determines the degree of formation of the glands, shape, size, condition of the skin, and nipple.

Superficial and deep palpation of glands and lymph nodes is performed; the presence of compactions and their nature are revealed. Particular attention is paid to existing nodular formations.

Palpation is performed with the patient in a vertical and horizontal position. Palpation allows one to determine the location of the tumor, its size, boundaries, consistency, and relationships with the underlying tissues. It is first performed with light touches of the pads of the 2nd, 3rd, and 4th fingers, placed flat on the palpated mammary gland. Then they move on to deeper palpation, but it should also be painless. Palpation of the mammary gland in a horizontal position can significantly facilitate the diagnosis of minimal tumors, as well as their distinction from dyshormonal hyperplasia. In this position, the entire mammary gland becomes softer, which allows one to detect small areas of compaction in it. In addition, with the horizontal position of the woman being examined, areas of dyshormonal hyperplasia become softer to the touch or are not determined at all, while the tumor node does not change its consistency compared to the examination while standing.

Scale for assessing changes detected in the mammary glands

Cipher	Characteristics of palpated areas	Clinical conclusion
3	In one or both mammary glands, localized areas of compaction are clearly defined against a background of diffuse	Localized fibroadenomatosis on the background of diffuse
2	In one or both uterine glands, compacted areas without clear contours are determined against the background of diffuse fibroadenomatosis	Localized fibroadenomatosis against the background of diffuse
1	Fine-grained areas of diffuse compaction are detected in one or both mammary glands	Diffuse cystic or fibrous fibroadenomatosis
0	On palpation, the structure of the glands is uniform.	Absence of physical signs of a pathological process

An objective assessment of the condition of the glands is based on examination and palpation data, as well as mammographic, ultrasound and other special studies of mammary gland tissue.

Laboratory and instrumental methods of research of diseases of mammary glands

Laboratory methods

An obligatory component in a comprehensive examination of patients with breast diseases is the determination of the individual hormonal status of the woman; first of all, the level of prolactin and estrogen.

In order to examine the probability of developing pathological processes in the mammary glands, in the last two decades, the definition of tumor markers has been proposed. Literature data indicate an increased level of tumor markers in groups of women with pronounced diffuse forms of mastopathy. It is more rational to determine the role of markers in predicting the occurrence of mammary gland pathology in patients with genetic or anamnestic factors of predisposition to a malignant process or with proliferative forms of mastopathy.

Tumor markers such as carcinoembryonic antigen (CEA), high-molecular antigens CA-125 and CA19-9, and mucin-like cancer-associated antigen (MRA) allow monitoring the effectiveness of treatment.

Radiation methods

Mammography. The accuracy of mammographic diagnostics ranges from 75-95%. The high percentage of false negative results is due to the fact that in young women, especially during lactation, nodes and tumors are difficult to distinguish against the dense background of the gland. For this reason, it is considered inappropriate to perform mammography in women under 30 years of age. Detecting a tumor against the background of mastopathy is very difficult. In these conditions, a tumor node is detected in no more than 50% of cases. The minimum size of a tumor detected by mammography is 0.5-1.0 cm.

It is advisable to conduct this study on the 5th-12th day of the menstrual cycle.

X-ray mammography should be performed in women over 35 years of age, in cases where the tumor is not clearly palpable; when the formation is localized directly behind the nipple; with developed premammary adipose tissue; pronounced involutional changes in the tissue of the mammary gland; as a screening method of examination (Fig. 15.2).

Currently, women over 40 are recommended to undergo mammography every 2 years, after 50 - annually. If local compactions are detected, determined by palpation, mammography is performed on women of any age.

Pneumomammography is used to improve the contouring of a node located deep in the breast tissue, as well as for tumors located on the periphery of the gland (at the edge of the sternum, in the projection of the subclavian and axillary processes), for which obtaining an X-ray image is difficult. X-ray examination is performed after the introduction of 200-500 ml of nitrous oxide through several needles located in different quadrants of the mammary glands.

Pneumocystography is an additional differential diagnostic method for cystic forms of fibroadenomatosis and cystadenopapillomas. After puncturing the cyst and evacuating its contents, 10 ml of air is introduced into the cavity. The X-ray allows one to trace the structure of the cyst walls and the relief of its internal surface.

Ductography or galactography is a method used to diagnose non-palpable ductal tumors. The information content of this method is 80-90%.

Electroradiography (xerography) is an informative method, but its disadvantage is the high dose of radiation exposure, which is 3 times higher than the dose in conventional mammography.

Echography. Preference should be given to this diagnostic method: when examining patients under 30 years of age, when the lesion is localized in areas of the mammary gland that are difficult to access for mammography (subclavian process, submammary fold, retromammary space, axillary process), in differential diagnostics of solid and cystic formations, when performing targeted puncture biopsy. The information content of the method is 87-98%.

Mammography and ultrasound are complementary methods.

Computer tomography. A highly informative method for examining patients with unclear data from conventional tomography and "dense" mammary glands. Computer tomography allows for the detection of tumors up to 2 mm, assessment of their spread, and differential diagnostics of mastopathy and malignant neoplasms.

Magnetic resonance imaging (MRI). The harmlessness of the procedure, combined with good execution of sections of arbitrary direction, allows us to consider that it will become one of the leading methods. However, such an early sign of cancer as microcalcifications is not visible with MTP.

Transillumination (diaphanoscopy). The method is based on the evaluation of the structures of the mammary gland in transmitted light. The examination is conducted in a darkened room. The light source is placed under the mammary gland and the structure of the organ is visually examined. Modern devices for diaphanoscopy use a television camera and monitor, which allow for enhancing the contrast of the image. The undoubted advantages of the diaphanoscopy method include non-invasiveness, absence of ionizing radiation, cost-effectiveness, and simplicity of the examination. However, the method is not sensitive enough. Its further development is expected through computer evaluation of the results and the use of lasers with low radiation energy.

Histological methods

Puncture biopsy is the insertion of a needle into the thickness of the compaction and aspiration of tissue particles through it. In 80-85% of cases, cytological examination of punctures makes it possible to make a diagnosis. In dyshormonal hyperplasia, puncture biopsy allows one to establish the degree of proliferation and atypia of the epithelium, and to detect the presence of a cystic cavity.

Excisional biopsy involves excision of the detected lump along with a section of surrounding tissue. If benign changes in the mammary gland are detected, such an intervention is therapeutic and prophylactic.

Trepanobiopsy is performed using special needles that allow obtaining a tissue column sufficient for histological examination. Trepanobiopsy may increase the risk of tumor dissemination. Therefore, it should be performed immediately before the start of antitumor treatment, and not as a routine examination for all patients with a palpable tumor. The informativeness of this method for breast cancer is about 95%.

Cytological examination of nipple discharge allows detection of malignant cells in intraductal tumors.

Of the listed methods, the following are of practical importance today: X-ray mammography, ultrasound of the mammary glands, puncture and excisional biopsy, cytological examination of nipple discharge. The remaining methods are rarely used in everyday practice.

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