Women's Health Medicine最新文献

Although many breast cancers are diagnosed early, some women still require a mastectomy for widespread ductal carcinoma in situ or they may chose to have a prophylactic mastectomy. In many of these cases women also choose reconstruction either to be performed at the time of the mastectomy or at a later date. There are a number of methods, including sub-pectoral tissue expander and the use of myocutaneous flaps such as a latissimus dorsi flap. An autologous tissue technique is the TRAM reconstruction, which gives the best cosmetic result but can be associated with a significant morbidity and a longer recovery period.

The breast develops from the milk streak (mammary ridge), which regresses in the human fetus to the site of the adult nipple. This buds into 15–20 epithelial columns, which canalize before birth in to the lactiferous ducts. At puberty, masses of cells proliferate at their endings. Secreting alveoli develop during pregnancy to secrete milk after delivery. The glandular tissue atrophies after the menopause. The bulk of breast tissue localizes to its upper outer quadrant. It lies mainly on pectoralis major, overlapping onto serratus anterior and rectus abdominis. A tongue, the axillary tail, projects into the axilla. Being an epithelial derivative, the breast is enclosed in its own pocket of superficial fascia, enabling its clean dissection at mastectomy.

Its rich blood supply is derived from the internal thoracic (internal mammary) artery and from branches of the axilllary artery, accompanied by the corresponding veins. Lymphatic drainage accompanies these blood vessels, and passes principally to the axillary lymph nodes (divided into levels one, two and three by pectoralis major), and to the internal thoracic nodes, with some drainage passing to the intercostals nodes near the heads of the ribs.

Online resources for breast disorders

Breast cancer is the most common form of cancer and the principal cause of death from cancer among women worldwide. Risk factors for breast cancer are manifold. Certain risk factors, such as age and family history are well established. Research in the past decade has further elucidated disease aetiology, in particular the role of hormones and the discovery of breast cancer susceptibility genes (e.g. BRCA1, BRCA2). In spite of the evidence concerning the risks of breast cancer, women often have a poor understanding of its causes and limited personal risk perception. The media are an important source of health information for many women, but the popular and general-interest media often misrepresent risk factors. Knowledge of breast cancer risk factors and perception of personal risk are significant behaviour motivators to prevent, detect and manage disease. This article will review the risk factors for breast cancer, and examine the research on women’s perception of risk and understanding of risk factors, and the reporting of breast cancer in the media.

The author’s personal experience of breast cancer is provided in this contribution.

Research on hormone replacement therapy (HRT) in the 21st century has been dominated by the findings of the Women’s Health Initiative (WHI) and Million Women Study (MWS). Clinical practice has changed accordingly. Both studies confirm an increase in the risk of breast cancer among women using combined HRT (oestrogen and progestogen) when compared with women who have never used HRT. The risk among women using oestrogen-only preparations of HRT, according to the MWS, is increased, but to a lesser extent than for women using combined HRT. In contrast the WHI Study suggests that oestrogen alone is not associated with an increased risk of breast cancer. Despite these different findings most evidence-based guidelines from professional organizations still advise use of HRT only for the relief of menopausal symptoms and only short term. Routine use of unopposed oestrogen for women with a uterus is being discussed but is still not recommended. New data have also led to the recommendation that HRT is contraindicated for women who have had breast cancer. More research is needed on the contribution of progestogens to the increased risk of breast cancer and on the safety of different routes of administration of both oestrogen and progestogen.

Recent media publicity about breast cancer has caused concern for many women. Most women with a relative with breast cancer are not at substantially increased risk. NICE released revised guidelines in 2004 classifying women into risk groups. When a woman presents with concerns, it is important to take a full family history. For those that fit into a high-risk group, referral to tertiary care may be appropriate. Genetic testing of BRCA1 and BRCA2 may be offered in families where there is a living affected family member to test first and can be offered to unaffected individuals when there is Ashkenazi Jewish background. Breast management options for those at high risk include breast screening from a young age. MRI screening also appears to be useful. The efficacy of ovarian screening is being studied although it is known that prophylactic oophrectomy before menopause reduces the risk of both breast and ovarian cancer. Prophylactic mastectomy is also an option for these women. Genetic counselling and psychosocial support are important.

A wide spectrum of benign changes may occur within breast tissue. These inlcude non-neoplastic conditions such as fibrocystic change and benign neoplasms (tumours). Conditions such as fibrocystic change are very common in middle-aged and elderly women, but vary enormously in degree and extent between individuals. Fibroadenomas are common causes of benign breast masses in young women. Benign breast conditions may clinically simulate malignancy and therefore result in the requirement for pathological examination of the tissue as part of ‘triple assessment’ (i.e., the diagnostic process for patients with potential breast disease). It is therefore essential that pathologists can identify these benign conditions accurately. Benign breast disease may not require surgical treatment over and above that needed to confirm the diagnosis, but some forms of cellular change (e.g. florid epithelial hyperplasia, radial scar, intraduct papilloma) may be associated with co-existent malignancy (i.e. breast cancer) and/or an increased risk of subsequent malignancy.

The accurate diagnosis of breast cancer and the pathological assessment of breast cancer tissue are key roles undertaken by pathologists working within the field of breast disease. It is essential to differentiate the pathological changes of benign breast disease from those of early and established breast cancer. Once cancer is confirmed, the pathologist is required to provide an evaluation of the pathological features determining prognosis and the requirement for further treatment(s). The pathologist undertakes these roles as a member of the breast cancer multidisciplinary team (MDT), who meet regularly within each breast cancer unit to discuss new patients who may have breast cancer and those with confirmed diagnoses in which the treatment plan requires definition.

Despite exciting advances in drug treatment, surgery remains the mainstay of breast cancer treatment. Diagnostic techniques have improved so that patients have a diagnosis of cancer before surgery is undertaken, so that they are able to discuss it in an informed manner. There has been an increasing trend towards breast conservation treatment as patients are diagnosed with early breast cancers. Mastectomy, however, is still needed in a number of cases. There have recently been significant developments in the assessment of the axilla with the development of the sentinel node technique. This is a useful diagnostic procedure to avoid the side effects of axillary clearance, but axillary node clearance is still the best treatment for pathological lymph nodes.