MAMMARY GLAND

From Big Medical Encyclopedia

MAMMARY GLAND [glandula mammaria (PNA); synonym: chest gland, mamma] — the ferruterous body of mammals producing at female individuals after the delivery milk. At male individuals of M. remain underdeveloped and do not function.

COMPARATIVE ANATOMY AND EMBRYOLOGY

M. develop from an ectoderm and are modified skin sweat apocrenic glands. At cloacal mammal M. consist of tubular bags with the smooth muscle cells covering them outside, to-rye open in bags of hair on the special ferruterous field. At viviparous mammal M. have more complex structure, they treat glands of alveolar type. The ferruterous field is limited to the small area which is stuck out in the form of a nipple. On character of output channels distinguish so-called true nipples, at top to-rykh numerous output channels of glands, and false open, inside to-rykh there is a general spew way opening one opening. The first type is characteristic of the majority of marsupials, monkeys and the person, the second — for predatory and hoofed. An arrangement and number of glands and nipples at different representatives of mammals variously. At polycarpous forms they are located in two ranks along all belly body surface, the number them can reach twenty and more, however is more often observed 1 — 8 couples of glands and nipples. So, at hoofed animals of 1 — 2 pair of nipples are located in inguinal area, at semi-monkeys one couple on a breast and quite often one more couple on a stomach, at bats, monkeys and the person one couple on a breast.

At the person of M. begin to develop on the 6th week of an antenatal life. At first on ventrolateralny body walls from an axillary hollow to inguinal area there are two tape-like thickenings of an epithelium carrying the name of «milk lines». From this epithelium as a result of its thickening and growth in the form of tyazhy, extending in the subject connecting fabric, M are formed. Within the 3rd and 4th month these tyazh grow and give a vystilka of the main channels, and groups of cells located on their ends form further small channels and trailer secretory departments. By the time of the birth only the main channels form.

Nipple of M. forms after the birth of the child within the first two years of life. It develops from the remains of primary ferruterous rudiment and the skin roller surrounding it. On the 3rd year of pacifiers it is already quite created, further there is an increase in its sizes. The delay in development of a nipple is sometimes observed, and at adults it has an appearance of a small flat eminence (a flat nipple) or even lower than the level of skin (the pulled-in nipple) is located.

Fig. 1. The diagrammatic representation of a shape of a mammary gland at various functional states and at different age: 1 — at the newborn, 2 — at early children's age, 3 — at the beginning of puberty, 4 — at the beginning of puberty, 5 — at the young woman, 6 — in the period of feeding, 7 — after a lactation, 8 — in old age.

At women with approach of puberty of M. their branchings and formations of trailer departments begin to increase in sizes at the expense of an adiposity and a loosening of a connective tissue stroma, further development of lacteal channels. On average to 17-year age development of M. comes to an end, however before pregnancy they undergo periodic changes in connection with menstrual cycle (see). In the premenstrual period the tendency to formation of new (additional) lacteal alveolar channels is noted, density of networks circulatory and limf, capillaries and diameter of vessels increases. Full development of ferruterous segments with formation of alveoluses is observed only during pregnancy and a lactation when M. increase in sizes, lacteal channels extend, around them the dense network of capillaries appears. The greatest development of M. reach by the time of childbirth (fig. 1), later to-rykh they begin to produce milk.

At adult men of M. remain at the same stage of development, on a cut they were in the childhood.

ANATOMY AND HISTOLOGY

Female M. are located on a front surface of a thorax at the level from III to VI or VII edges, everyone between front axillary and okologrudinny lines of the relevant party. Form, sizes, provision of M. depend on age of the woman, extent of development of its generative organs, from the period of pregnancy and a menstrual cycle and have specific features. Out of the period of a lactation two forms of M most often meet.: semi-spherical and conic. Their outward depends substantially on the number of fatty accumulations and their distribution around ferruterous fabric. Skin in the field of M. it is thin and gentle, hypodermic cellulose is well-marked, surrounds gland from all directions, forming its adipose capsule (capsula adiposa mammae). Body of M. has the form of a convex disk, color its light pink, a consistence dense, average diameter at the basis of 10 — 12 cm, thickness of 2,5 — 3 cm Due to the roughnesses of a contour of the basis of M. in it for practical reasons distinguish subclavial, axillary and one-two belly shoots, to-rye quite often are surprised tumors with peculiar a wedge, a picture.

M. lies on a front surface of a big pectoral muscle and partially on a lobby gear. It is separated from them by a superficial plate of a chest fascia, about a cut is connected by friable connecting fabric. M. it is surrounded with the fibrous capsule (capsula fibrosa mammae). From a front surface of a body of M., getting through a fatty tissue and a superficial fascia to deep layers of skin and to a clavicle, the large number dense connecting tyazhy, the interlobular partitions which are continuation — the sheaves supporting M goes., or kuperova of a sheaf (ligg. suspensoria mammae). The same sheaves connect a back surface of a body of M. with a fascia of a big pectoral muscle. At germination of these sheaves characteristic skin symptoms arise cancer tumors as a result of their infiltrative growth.

Fig. And. 1 — 3. Microdrugs of not lactating and lactating mammary glands are normal. Fig. 1. The lactating mammary gland: 1 — an expanded lacteal sine, 2 — alveoluses of a mammary gland. Fig. 2. Not lactating mammary gland: 1 — not lactating segments of a mammary gland divided by connective tissue layers (2), 3 — lacteal channels. Fig. 3. The lactating mammary gland; shooters specified unevenly expanded glands with the cosecreting epithelial cells-laktotsitami. Fig. 4. Microdrug of a mammary gland at a perikanalikulyarny fibroadenoma; shooters specified growth of connecting fabric around lacteal channels of various sizes. Fig. 5. Microdrug of a mammary gland at an adenocarcinoma; shooters specified growth of atipichesky glands. Fig. 6. Microdrug of a mammary gland at Pedzhet's disease: growth of an atipichesky epithelium with characteristic light cells of Pedzhet (separate cells are specified by shooters).

In M. distinguish actually ferruterous educations, a parenchyma (parenchyma gl. mammariae) and connective tissue stroma (stroma gl. mammariae). M. the puberal woman consists of 15 — 25 shares (lobi gl. mammariae), each of them represents a difficult alveolar piece of iron with a share lacteal channel (ductus lactiferi lobaris) opening at top of a nipple (papilla mammae). Before an exit to a nipple channels extend and form lacteal sine (sinus lactiferi; tsvetn. rice. A.1), in to-rykh collects the milk formed in alveoluses. Between shares layers of friable fibrous connecting and fatty tissue with the vessels and nerves passing in them lie.

Shares consist of segments (lobuli gl. mammariae) formed by repeatedly branching lacteal channels. Lacteal channels of segments out of the period of a lactation come to an end with blind tubules — lacteal alveolar ductules (ductuli alveolares lactiferi), on to-rykh in the period of a lactation alveoluses develop (alveoli gl. mammariae). Segments are separated from each other by interlobular connective tissue partitions (septa interlobularia; tsvetn. rice. A.2), in to-rykh, in addition to fibroblasts, histiocytes, mast cells and eosinophilic granulocytes meet.

Walls of alveoluses are covered by a single-layer cubic epithelium, knaruzh from to-rogo lie korzinchaty myoepitheliocytes (myoepitheliocyti corbiformes).

Fig. 2. Diffraction pattern of secretory cells of a mammary gland: 1 — a gleam of a secretory trailer trunk; 2 — a cytolemma; 3 — microvillis; 4 — granules of a protein; 5 — secretory vacuoles; 6 — fatty drops; 7 — border of two adjacent cells; x 30 000.

In the period of a lactation epithelial cells will be transformed to the large cosecreting cells — laktotsita (lactocyti) having the prismatic form with the tops turned into a gleam of an alveolus. Cytoplasm of these cells abounds with threadlike mitochondrions, at tops of cells droplets of fat, proteinaceous granules and vacuoles (fig. 2) collect. Secretion of milk is made on apocrenic type at the expense of an otshnurovyvaniye of tops of cells together with the saved-up inclusions. In a cavity of an alveolus there is the subsequent formation of milk. Alveoluses cosecrete not at the same time, in this regard in the period of a lactation have a different appearance (tsvetn. rice. A.3). The secretory cycle of laktotsit is repeated.

Small branches of lacteal channels are covered by a cubic or prismatic epithelium. In large channels it becomes multilayer.

Upon termination of a lactation of M. is exposed fiziol. involution. At senile age there is a reduction of M. as a result of disappearance of alveoluses, fall of lacteal channels of ii of wrinkling of ferruterous segments, ferruterous fabric is replaced fibrous and fatty.

Nipple of M. represents a ledge of skin with strongly pigmented epidermis. The derma of a nipple and a peripapillary circle (areola) presses in epidermis the branching nipples; it is rich with nerve terminations. Smooth muscle cells are grouped at the basis of a nipple, forming a sphincter around mouths of lacteal channels; the cells lying radially at reduction promote protrusion of a nipple. In a peripapillary circle hillocks are disseminated, on to-rykh output channels grease and sweat glands of a peripapillary circle open (gll. areolares).

M. men on gistol, to a structure are similar to glands of newborns: a small amount of fatty segments is divided by thin connective tissue layers, in to-rykh poorly branched main lacteal courses or channels covered by a two-layer cubic or cylindrical epithelium are located; at the basis of a nipple they merge to larger output canals covered by a multilayer flat epithelium. Rudimentary ferruterous fabric and channels at men are expressed unequally: from hardly distinguished channels against the background of fatty tissue to quite differentiated segments with blindly coming to an end output channels and the milk courses.

Arteries of M. are branches of a lateral chest artery, internal chest artery and 3 — the 7th back intercostal arteries.

Veins are presented superficial (skin) and deep. Deep veins accompany arteries p fall in axillary, internal chest, lateral chest and intercostal veins, and also partially — into an outside jugular vein. Superficial and deep veins form networks and textures in the thickness of gland, in skin and hypodermic cellulose and widely anastomose between themselves and with veins of the neighboring areas, including with veins opposite

M.Zh. Limf, vessels are presented by networks limf, capillaries of skin, a parenchyma p capsules of gland and textures small limf, vessels. Around segments and in interlobular connecting fabric the three-dimensional network limf is located, capillaries, to-rye, merging among themselves, create limf, the vessels going towards a nipple and falling into a subareolar texture. Extent of development limf, capillaries and vessels of M. depends on age and it is connected with a menstrual cycle, with the period of pregnancy and a lactation. Large limf, the vessels which are going from a texture and collecting a lymph from lateral departments of M., go to the axillary limf, nodes located on the course of lateral chest and infrascapular arteries in the II—III area of mezhreberiya on a front gear muscle (nodi lymphatici pectorales) and then to the central and lateral axillary nodes (nodi lymphatici centrales et laterales). At the basis of gland the texture formed limf, vessels and capillaries with lacunary expansions is located. From it vessels depart, one of to-rykh probodat a fascia, a big pectoral muscle and go to the apical nodes (nodi lymphatici apicales) lying under a clavicle, lateral and central axillary limf, to nodes, and others penetrate a big pectoral muscle and follow to the chest limf, nodes located between big and small pectoral muscles (nodi lymphatici Rotteri) and behind small chest and then to the central axillary nodes. From a medial part of gland limf, vessels, pro-butting big chest and intercostal muscles, get into a chest cavity, approaching okologrudinny limf, nodes (nodi lymphatici parasternales), the lying no to the course of an internal chest artery. From a verkhnemedialny part of M. limf, vessels can reach to deep cervical limf, nodes (nodi lymphatici cervicales profundi) located over a clavicle.

In addition to the main directions, outflow of a lymph to regional limf, nodes of M is possible. the opposite side, to limf, to the nodes located at an upper part of a vagina of a direct muscle of a stomach and to phrenic limf, nodes.

Fig. B. Vessels, nerves and lymph nodes of a mammary gland: 1 — a big pectoral muscle; 2 — lateral lymph nodes; 3 — an infrascapular lymph node; 4 — an infrascapular artery and a vein; 5 — a lateral saphena of a hand; 6 and 8 — an axillary artery and a vein; 7 and 9 — lateral and medial bunches of a brachial plexus; 10 — the central lymph nodes; 11 — a lateral chest artery and a vein; 12 — a small pectoral muscle; 13 — apical lymph nodes; 14 — supraclavicular lymph nodes (BNA); 1 5 — subchest lymph nodes (BNA); 16 — interchest lymph nodes (BNA); 17 — an internal chest artery and a vein; 18 — okologrudinny lymph nodes; 19 — the pro-butting branches of an internal chest artery; 20 — textures of circulatory and absorbent vessels; 21 — medial branches to a mammary gland from intercostal nerves; 22 — a branch to a mammary gland from an internal chest artery; 23 — limf, the vessels of a mammary gland going to okologrudinny lymph nodes; 24 — the absorbent vessels of a mammary gland going to preperitoneal cellulose; 25 — a branch to a mammary gland from a back intercostal artery; 26 — a lacteal sine of a share of a mammary gland; 27 — lacteal channels; 28 — a peripapillary circle of a mammary gland; 29 — a grudonadchrevny vein; 30 — the absorbent vessels of a mammary gland going to chest lymph nodes; 31 — lateral branches to a mammary gland from a lateral chest artery; 32 — chest lymph nodes; 33 — the absorbent vessel of a mammary gland going to interchest lymph nodes.

Innervation of M. it is carried out by front branches of intercostal nerves (from the 2nd to the 7th), to-rye on a back surface of gland form a texture. The branches getting into depth of gland depart from it, following on connective tissue layers. Skin in the field of M. it is innervated by branches of supraclavicular nerves (from a cervical plexus) and front branches 2 — the 6th intercostal nerves. The areola and a nipple receive an innervation preferential from lateral branches of the 4th, is more rare than the 5th and 6th intercostal nerves (the diagrammatic representation of vessels and nerves of M. — see tsvetn. rice. C).

PHYSIOLOGY

Main function of M. — synthesis and secretion of milk (see. Lactation ), the baby intended for feeding. The foundation for studying of physiology of a lactation was laid by Ekhard (S. of Eckhard, 1858).

In the course of life of the woman of M. undergo changes in connection with a menstrual cycle, pregnancy, childbirth, a lactation, age involute processes. These changes are defined by function of endocrine organs: ovaries, adrenal glands, hypophysis, thyroid gland. Interaction of these bodies is regulated by hypothalamic area and a cerebral cortex. With 10 — 12-year age at girls begin to be developed by an adenohypophysis actively follicle-stimulating hormone (see) and luteinizing hormone (see), to-rye cause transformation of premordialny follicles of ovaries in mature, cosecreting is oestrogenic (see). Under the influence of estrogen the intensive growth and maturing of generative organs and M begins.

With approach of a menstrual cycle also other hormones — progesterone of a yellow body join (see. Progesterone ). The sex hormones allocated throughout this cycle regulate processes of a hyperplasia and involution of ferruterous structures in M., the lives of the woman observed monthly in the reproductive period.

At approach of pregnancy to a condition of M. the hormones produced by a placenta have effect — chorionic gonadotrophin (see), Prolaktin (see), and also hormones of a true yellow body. Synthesis of hormones of a hypophysis during this period is reduced. Under the influence of placental hormones during pregnancy in M. there is a hyperplasia of ferruterous segments due to development of channels and trailer alveoluses.

After the delivery and the otkhozhdeniya of a placenta becomes more active influence of gonadotropic hormones of an adenohypophysis on M again. The lactation begins: under the influence of prolactin milk cosecretes, in allocation to-rogo a big role plays posterior pituitary hormone oxytocin (see).

In a climacteric in process of depression of function of ovaries the level of oestrogenic hormones decreases and kompensatorno products of follicle-stimulating hormone of a hypophysis raise. According to age endocrine reorganization in a female body gradually there occurs involution of ferruterous structures in M. Ferruterous segments and channels zapustevat, atrophy, replaced with fibrous and fatty tissue.

METHODS of the RESEARCH

Inspection of women with diseases of M. it is carried out in a complex using all-clinical and additional methods.

Anamnesis. Collecting the anamnesis includes obtaining data on existence of the complaints indicating a disease of M. (pain, consolidations, allocations from a nipple, changes from skin, etc.), their dynamics, communication with a menstrual cycle, pregnancy, a lactation; about features of the obstetric and gynecologic status (character of a menstrual cycle, the course of pregnancies, childbirth, duration, character, number of lactations, ginekol. diseases, operations on generative organs, abortions, etc.); about associated diseases, especially endocrine organs, cardiovascular and nervous systems, liver, etc.

Survey of patients, at to-rykh is supposed defeat of M., make or in a standing position (hands are laid on the head), or lying on spin, and degree of manifestation patol, changes in these provisions can be various. Pay attention to symmetry of M., their sizes, form, existence of deformation. Carefully study a state kozhn (coloring, existence of retractions, ulcerations, hypostasis, strengthening of the venous drawing), a condition of an areola (contours, puffiness) and nipples (flattened or involved).

The palpation is carried out at first in position of the patient standing, then lying on spin. In both cases palpate one gland in the beginning, then another, comparing data of symmetric sites. The palpation is begun with easy palpation of M. finger-tips of one or both hands on a spiral from an areola to the periphery of gland. At the same time superficially located consolidations or tumors can be found, painful sites come to light. Then make deeper palpation of fabric of glands. At identification of consolidation determine its sizes, a form, a consistence, mobility, communication with skin and surrounding fabrics, a painful symptom. Establish existence of a symptom of Keniga: at a palpation of consolidation the cancer node equally accurately is defined by a palm both in usual and in the spread provision of M., and consolidations of the dishormonal nature in the spread condition of gland are expressed less accurately or at all are not defined.

At M, big by the sizes. this symptom is revealed in position of the patient lying on spin, palpating gland between palms, at small — having risen behind the patient and pressing patol, the center to a chest wall. An easy prelum and rapprochement of skin over a tumoral node reveal changes from skin — symptoms of rugosity of skin, umbilication (retraction), the platform (flattening of skin, restriction of its mobility), an orange-peel.

Check a condition of nipples and an areola, noting existence of consolidation of a nipple, limited or its full retraction, allocations from it. Taking pleated skin of an areola on both M., define whether there is a thickening of a fold on the party of defeat (Krause's symptom).

After a palpation of M. make a bilateral palpation of axillary, subclavial and supraclavicular areas. The patient shall relax hands, to rest brushes against crests of ileal bones or to put them on shoulders of investigating.

At palpation of supraclavicular areas the patient shall incline slightly the head towards tension inspecting for the purpose of removal grudino - a clavicular and mastoidal muscle.

It is better to palpate supraclavicular areas, having risen behind the patient. Define existence the increased limf, nodes, their number, the sizes, a consistence, mobility, morbidity.

At detection of pathology, to-ruyu it is necessary to otdifferentsirovat from cancer of M. (indistinctly konturiruyemy consolidations increased condensed axillary and deep cervical limf, nodes, changes of skin and nipples, etc.), and also other changes, not clear for the clinical physician, it is necessary to resort to additional methods of inspection — radiological (mammography, a duktografiya), cytologic and histologic. In the specialized centers of inspection of women with pathology of M. and in clinics apply also a termografiya, an ultrasonic ekhografiya, tracer techniques, rentgenol, methods with contrasting of vessels (see below).

X-ray inspection takes the important place in complex diagnosis of diseases of M. The large picture frame flyuoromammografiya and mammography were of particular importance (an electrox-ray analysis and a X-ray analysis of M.). Flyuorogramma make on the photofluorographs supplied with a prefix holder of M. (see. Fluorography ), the Prefix allows to carry out laying and a compression of M. and to receive projective blowup. Technical specifications on a flyuoromammografiya depend on type of the device and fluctuate in the following limits: tension — 45 — 60 kV, current — 40 — 50 ma, endurance — 0,1 — 0,15 sec.

Fig. 3. Position of the patient and a X-ray apparatus at mammography: at the left — a direct (axial) projection; on the right — a side projection.
Fig. 4. Mammograms of normal mammary glands in various stages of involution (a side projection): and — with well-marked ferruterous fabric; — in a phase of involution of ferruterous fabric; in — in the absence of ferruterous fabric (1 — skin, 2 — fatty tissue, 3 — ferruterous fabric with network of blood vessels, 4 — a nipple).

At mammographies (see) in most cases do survey pictures in direct (axial) and side projections (fig. 3) with the image of all of M. In pictures (fig. 4) skin is excreted in the form of a homogeneous dark strip 0,5 — 2 mm wide. Under it hypodermic cellulose, a layer is located the cut gradually extends from an areola to the basis of M. Against the background of cellulose shadows of blood vessels appear. Ferruterous fabric causes blackout of triangular shape, the basis turned to a chest wall, against the background of to-rogo it is not always easy to distinguish shadows patol, the centers. With age, in process of substitution of ferruterous fabric cellulose, such educations as limited tumors, cysts and so forth, clearly are defined on mammograms.

In need of detailed studying of structure of any site of M. in addition to survey mammograms make aim pictures.

At inspection of women, at to-rykh allocations from nipples are observed, resort to artificial contrasting of lacteal channels — a duktografiya (galaktoforografiya). The area of an areola is processed alcohol. On localization of a drop of a secret find an opening of a setserniruyushchy channel. On depth of 0,5 — 0,8 cm enter stupidly ground needle or a polyethylene cannula into it to dia. 0,3 — 0,7 mm. Under small pressure into the canal enter 0,3 — 1 ml of 60% of solution of a triyodirovanny contrast agent (Verografinum, Urografinum, Hypaque, triombrin) before emergence of feeling of a raspiraniye and easy morbidity. Then make a X-ray analysis in two projections. On duktogramma the system of lacteal channels of the corresponding share of a mammary gland is displayed.

For specification of character patol, educations in M. and identifications of parasternal metastasises of cancer were developed special techniques: pneumography and pnevmokistografiya of M. (see. Pnevmokistografiya ), the selection arteriography of an internal chest artery on Seldingera (see. Seldingera method ), chrezgrudinny flebografiya (see) for contrasting of an internal chest vein, direct and indirect limfografiya (see). Except for a pnevmokistografiya these techniques were not widely adopted.

The radio isotope research is conducted by outside radiometry (see) later introductions to an organism of radionuclide or by means of radio isotope scannings (see). Radiometry of M. using radionuclide of phosphorus ( 32 P) it was offered by Lowe-Bir (V. to Y. A. Low-Beer, 1946).

Inspected drinks solution, containing shchiya 32 P at the rate of 1,3 — 1,5 mkkyur on 1 kg of body weight. In 3 hours measure by the beta counter a radiation intensity over the center of defeat and over the symmetric site other M.

According to I. P. Melenchuk (1964), in a malignant tumor there is more intensive and long accumulation 32 P, than in normal fabrics or in high-quality new growths. Beta particles 32 P differ in a small run. It limits possibilities of radiometry with this radionuclide. It is reasonable to apply it only at differential diagnosis patol, the centers located not more deeply than 1 cm under skin and also to identification of a recurrence of cancer in a postoperative hem after a mastectomy. An indicator of the malignant nature of process consider the size of a radiation intensity, equal 126±3,2% in relation to the symmetric healthy site.

In modern a wedge, practice apply also other method of a radio isotope research of M., offered by G. R. Berg with soavt, in 1973 — scanning after intravenous administration of radio pharmaceuticals of technetium ( 99m Tc) or gallium ( 67 Ga), to-rye in the increased quantity concentrate in cancer tumors of M. The gamma quanta which are let out by radionuclides have big penetration that allows to register accumulation of drug in any part of M. and to receive the image of a tumor on a skanogramma in 20 min. after administration of drug of technetium and in 48 — 72 hours — drug of gallium. Beam loading on critical bodies (see) and gonads are much lower marginal. During the scanning large tumors (more than 2,5 cm) therefore the method is a little suitable for detection of tumors of the smaller sizes are displayed.

Tracer techniques of a research can be used in the differential and diagnostic purposes and for assessment of efficiency of radiation therapy and chemotherapy of cancer.

The cytologic research is a part morfol, diagnoses. As objects for it prints, smears and scrapings from the ulcerated surface of skin of M can serve., allocations from nipples, the material received at a puncture patol, the center by a fine needle (aspiration biopsy), and also smears from the surface of the site of fabrics removed at an intsizionny biopsy.

Most the research of material of an aspiration biopsy was widely adopted tsitol.

Necessary conditions of this research are the accuracy of capture of material from the center, use of the sterile dry syringe with a fine needle and well adjusted piston. After a puncture the piston is extended to the full, remove the syringe from a needle, let out from it the air, leaving contents, and repeat the procedure of aspiration 3 — 4 times.

The received material is placed on slide plates and do the native and painted smears, at microscopic examination to-rykh along with normal cells groups of cells with the initial or expressed degree of atypia or a cell of a malignant new growth can be found (see. Cytologic research ).

The histologic research of the fabrics received at a biopsy is the most reliable diagnostic method of tumors of M. At the same time apply both a puncture and intsizionny biopsy. Gistol, a research of the received material, especially in case of emergency, it is reasonable to combine with tsitol, a research. At an intsizionny biopsy in cases of suspicion of cancer of M. it is impossible to enucleate a tumoral node, and it is necessary to delete it together with surrounding fabrics (a sectoral resection of M.).

Termografiya is based that in the centers patol, proliferation under the influence of the strengthened blood supply (e.g., at a mastopathy) or the increased metabolism (e.g., at a malignant tumor) more intensive is observed, than normal, infrared radiation, a cut is registered the device «Thermal imager» in the form of the thermogram (see. Termografiya ). The method gives up to 20% false-negative and approximately as much false positive answers therefore has no independent diagnostic value. In specialized institutions in combination with other methods of inspection the termografiya (at use of the computer equipment) can be useful to specification of the diagnosis of a malignant tumor of M., especially at differentiation with a mastopathy, and also for diagnosis of a recurrence of cancer in fabrics of a chest wall and regional limf, nodes (tsvetn. fig. B).

The ultrasonic ekhografiya (bioecholocation) is based on reflection of ultrasonic waves from places of contact with each other of fabrics of various density. Reflected waves are fixed on a tape or are visible on the screen of special ultrasonic devices (UZD-5, UDA-724, etc.), to-rye are applied to the diagnostic purposes (see. Ultrasonic diagnosis ).

By means of an ekhografiya it is possible to find various patol, the centers in M. (cysts, abscesses, nodes), but cancer tumors as in them much more the structures reflecting sound waves than in normal fabrics of M are found more accurately.

The method allows to specify structure, the sizes and a depth patol, the centers in M.

Transillumination — raying of M. — it is applied seldom, but has that advantage that it can be used in any conditions. The research is conducted in the dark room. Under M. or bring a light source of average intensity to it and consider gland on a gleam. At the same time, depending on density patol, the centers, different expressiveness of a shadow can see, on the Crimea judge existence of cysts and tumoral nodes.

PATHOLOGICAL ANATOMY

Fig. 5. Microdrug of a mammary gland at cancer (adenocarcinoma). Adjournment of spherical mikrokaltsinat (1) in ferruterous cells (2) and a stroma of a tumor; reaction of the Braid for identification of deposits of calcium; X 200.

From dystrophic processes for M. limy dystrophy is most characteristic. Small deposits of salts of calcium — a mikrokaltsinata — meet at cancer, a fibroziruyushchy adenosis (see. Mastopathy ), papillomas of channels etc. According to Millis (R. M of Miliis) and soavt. (1976), spherical mikrokaltsinata are found in complexes of cancer cells and in a stroma of a tumor (fig. 5). V. B. Zolotarevsky (1976) found in mikrokaltsinata, except salts of calcium, the cementing matrix. According to electronic and microscopic data of Shtegner and the Father (H. E. Stegner, S. of Pape, 1972), Ahmed (A. Ahmed, 1975), deposits of salts of calcium appear in a part of cytoplasm of epithelial cells rich with organellas near membranes of mitochondrions in the beginning. In process of accumulation of salts of calcium of a cell perish, and calcium accumulates for the second time in a stroma. Adjournment of salts of calcium happens also in the condensed secret filling expanded channels. Large kaltsinata meet in the sclerosed stroma of old fibroadenomas, cicatricial fabric of postfatty necroses.

Fig. 6. Microdrug of a mammary gland at a fatty necrosis: on site a necrosis granulyatsionny fabric with diffusion limfogistiotsitarny infiltrate (1) and a lipophage (2); coloring hematoxylin-eosine; x 120.

Fatty necrosis in the form of a focal necrosis of a fatty tissue of M. can result from an injury, an operative measure, action of volumetric, thermal and beam factors. Macroscopically center of a necrosis of whitish-yellow color, grease look, dense to the touch. Sometimes in it the cavity filled with oily contents is formed. Sites of a fatty necrosis become «opaque» because of saponification of fat, there is a disintegration of a fatty tissue, crystals of cholesterol appear. In a zone of a necrosis the inflammatory infiltrate containing polinukleara and macrophages like lipophages and colossal cells of foreign bodys is noted. Further necrotic masses resolves and replaced with granulyatsionny fabric (fig. 6), forming lipogranulomas (see). At the same time gistol, the picture can remind tubercular defeat. In the final fibrous changes, scarring, calcification develop.

Vascular disorders in M. can be shown in the form of a deep vein thrombosis, as a result to-rogo in iron heart attacks (e.g., a hemorrhagic heart attack sometimes develop at fibrinferment of jugular and subclavial veins).

Thrombophlebitis of superficial veins of M. it is shown by a picture endo-and a periphlebitis (see. Phlebitis ) with a thrombogenesis (see. Thrombophlebitis ). At gistol, a research the sclerosing endophlebitis with an obliteration of a gleam of a vein or obstruction by its organized blood clot, places from a rekanalizatsiy vein comes to light.

Bleedings, hematomas arise at an injury of M., intra pro-current proliferation of an epithelium with formation of nipples (a mastopathy, intradural and intra cystous papillomas, intra pro-current cancer). There is a separation of epithelial nipples therefore there are bleedings, and in channels and cysts blood appears. In such cases bloody allocations from a nipple are observed.

A nonspecific inflammation — the most frequent disease of M., it is characterized various morfol, changes (see. Mastitis ).

Fig. 7. Microdrug of a mammary gland at tuberculosis: specific granulyatsionny fabric (1) with multinucleate colossal cells of Pirogov — Langkhansa (2) around a channel (3); coloring hematoxylin-eosine; x 200.

Tuberculosis of a mammary gland. Morfol, a picture differs in diversity. Are visible single or the multiple centers (a knotty form), a softening and disintegration, soft grayish-yellow inclined to a tyromatosis, to-rykh lead to development of cavities. Also fistular courses on skin are formed. Tubercular ulcers have the hanging subdug edges covered with miliary hillocks and a yellowish bottom (an ulcer and fistular form). In other cases the growth of connecting fabric leading to consolidation and wrinkling of M prevails. (sclerosing form). Histologically in M. find specific granulyatsionny fabric with colossal cells of Pirogov — Langkhansa (fig. 7) and a tyromatosis.

Syphilis of a mammary gland. In the secondary period, in addition to papules on skin, the mastitis leading to consolidation and increase in M is observed. In the tertiary period there can be gummas. Occasionally in this period intersticial mastitis develops hron.

From fungal infections of a mammary gland meets more often actinomycosis (see), at Krom in granulyatsionny fabric yellowish grains with numerous druses are found.

A hypomastia — an underdevelopment of M., it is characterized by plentiful development of connecting fabric, among a cut there are underdeveloped ferruterous segments and lacteal channels; all picture reminds a structure men's M.

Hyperplastic processes in M. are observed at dishormonal disturbances — mastopathies (see), gynecomastias (see), hypermastias.

Fig. 8. Microdrug of a mammary gland at a mastopathy with an apokrinization of an epithelium (it is specified by shooters); coloring hematoxylin-eosine; X 200.

The so-called apokrinization of an epithelium (fig. 8) is very characteristic of a mastopathy, at a cut of a wall of alveoluses of channels and cysts are covered in places is high them and the prismatic epithelial cells with light cytoplasm reminding cells of apocrenic sweat glands («a pale epithelium»). The separation of particles of cytoplasm from an apical surface of cells is often observed. Apokrinization results from a metaplasia of a usual («dark») epithelium in «light».

At a hypermastia (hypertrophy) of one or both M. microscopically the picture of a diffusion dishormonal adenosis with abundance of the segments increased in sizes comes to light or the expanded channels with small papillary proliferata of an epithelium of a vystilka lying in a friable stroma of a miksoidny look are defined, bridges the picture is presented by more dense fibrous fabric.

Additional milk than glands and — the malrelated tissue of M located usually in the field of a muscular pole is more rare in other places on the milk line. Histologically the rudimentary ferruterous channels and alveoluses among rough connecting fabric reminding a picture men's M come to light.

Additional M. can become the place of development of a mastopathy or a malignant tumor (see below).

PATHOLOGY

Due to the distinctions in morphology and function of M. during various age periods of a female body (from the birth before puberty, the reproductive period, the period of a menopause) there are big differences of the nature of diseases of this body.

At newborns, both at girls, and at boys, in connection with receipt in blood during childbirth of hormones from an organism of mother the swelling of glands, mastitis of newborns with allocation of a secret ooze of colostrum can be observed; anomalies of rudiments of M can take place. with the subsequent development of inborn defects of this body.

During development of a children's organism both in girls, and in boys also malformations of M can take place. (a delay, premature or overdevelopment), to-rye are connected with disturbances of the neuroendocrinal status. Less often inflammatory processes develop or injuries take place.

In the reproductive period women, especially in the period of a lactation, most often have inflammatory processes in M., dishormonal a hyperplasia (see. Mastopathy ), benign and malignant tumors. At advanced and senile age the most frequent disease of M. the malignant tumor — cancer is.

Malformations, anomalies

Inborn malformations. Total absence of gland (amastia) or nipples (athelia) meets extremely seldom and is combined with other malformations of a fruit. Also seldom meet quite created one - or the bilateral additional mammary glands (polymastia) having an areola and a nipple. More often underdeveloped additional M take place., not having an areola and nipples, or additional nipples (polythelia).

Fig. 9. The woman with additional nipples and an areola.

Additional M. or additional nipples are located on milk lines (fig. 9), is the most frequent — in axillary poles. In the premenstrual period, during pregnancy and a lactation they bulk up, become intense, painful. Severe pains in them can arise in the period of a lactation if glands are able to cosecrete milk, a cut has no exit due to the lack of output channels. Additional M. cause to women of inconvenience, especially at their localization in axillary poles. The constant of traumatization, accession of consecutive infection quite often lead to development of inflammatory processes. In additional M. more often than in normal, the dishormonal hyperplasia, benign and malignant tumors can develop.

Treatment of inborn defects of M. operational. Additional M. or additional nipples delete, but to an occasion of other anomalies according to indications perform plastic surgeries.

Hypomastia (micromastia) — a symmetric underdevelopment of M. — takes place at diseases of endocrine system of a children's organism. Usually the hypomastia is followed by signs of a hermaphroditism, intersexuality, infantility and is most often observed at a pituitary microsomia, pituitary infantility, an adiposagenital syndrome, a pubertal hypo-ovaria, an injury or after operational removal of ovaries at children's age.

At adult women the hypomastia can develop owing to falloff of function of ovaries and other hemadens under the influence of heavy intoxication, persistent and acute infections, tumors of endocrine organs and operative measures on them.

Fig. 10. The woman with an underdeveloped left mammary gland (a unilateral hypomastia).

Moderate underdevelopment of one M. without disturbance of its functions meets quite often and it is shown unequal both to the sizes and glands. In the period of a lactation both M. can function it is equivalent therefore anomaly disturbs the patient only in the cosmetic relation. A considerable difference in sizes of M. in connection with an underdevelopment of one of them (fig. 10) meets seldom. The nature of this malformation is not studied.

Treatment of a bilateral hypomastia consists in correction of endocrine disturbances, as a result to-rogo a malformation of M. can be partially or it is completely liquidated. Adult women at a hypomastia can recommend plastic surgeries with the cosmetic purpose.

The hypermastia (hypertrophy) happens especially expressed at children's and pubertal age and during pregnancy. In less expressed look it can meet and women in the active reproductive period have lives out of pregnancy.

The hypermastia at girls up to 10 years is caused by the diseases of endocrine system causing premature puberty (hormonal and active tumors of ovaries, adrenal glands, a hypophysis, strobiloid gland and other diseases which are followed by hypersecretion of sex hormones). The hypermastia can be observed also at boys at hormonal and active feminizing tumors of gonads (see. Gynecomastia ).

At the hypermastia which arose in the pubertal period and at pregnancy the impetuous growth of gland reminding in character tumoral is observed; however morfol, the research does not reveal signs of malignant growth, process does not exceed the limit of M.

Fig. 11. The girl of 14 years with a hypermastia.

The hypermastia in the pubertal period can begin before periods or match the first periods, and after establishment of menstrual cycles rapid growth of M continues., the reaching enormous sizes (fig. 11). There are pains, breath is at a loss, the mentality of the girls taking the ugliness hard suffers. At the same time in all other relations development of girls proceeds normally.

Fig. 12. The woman with the hypermastia which developed in time of pregnancy; in the right axillary area there is an additional mammary gland (it is specified by an arrow).

The hypermastia connected with pregnancy arises in its second half more often. M., reaching the huge size (fig. 12), can fall below a navel, press on the increased stomach and inflict additional suffering on pregnant women. Skin over hypertrophied M. it is stretched, slightly hyperemic or cyanotic, local temperature is moderately increased, saphenas are expanded. At the same time pregnancy develops normally the N comes to an end with births in time with the healthy child.

In cases of a moderate hypermastia pregnant women after the delivery and lactations can have a spontaneous involution of glands. At repeated pregnancy the disease recurs.

At the hypermastia coming in the active reproductive period of life of the woman out of pregnancy, growth of M. has no such impetuous character, as at pubertal age and at pregnancy.

Fig. 13. Mammary glands of the patient with the hypermastia which arose during pregnancy; 1 — before operation; 2 — in 3 weeks after a resection of mammary glands with movement of nipples and an areola; 3 — in 6 months after operation (growth of mammary glands continues).

Treatment of a hypermastia shall be differentiated. At children's age it is directed to normalization of the endocrine status of the child, i.e. to treatment of a basic disease. Treatment of the hypermastia which arose at pubertal age and at pregnancy, generally operational — is made simple mastectomy (see), to a cut it is necessary to resort at sharply expressed process even at pregnant women. Attempt to be limited to a resection of M. often terminates in failure since leaving even of small sites of glands leads to their further growth (fig. 13). At the hypermastia at adult women which arose out of pregnancy resections of M are possible. and plastic surgeries for cosmetic reasons.

A mastoptosis — omission of M. It is observed at corpulent, elderly women, at to-rykh a fatty tissue it is excessive it is postponed in M. At this M. considerably increase and under own weight are displaced from top to bottom, droop. The loss of elasticity of fabrics occurring with age promotes progressing of a disease. In case of strong weight loss of M. take a form of the drooping skin bags. Loose-hanging M. hurt the woman owing to disturbance in them of blood circulation, formation of a lymphostasis and hypostasis. Saphenas extend, the intertrigo and maceration of skin pleated under M develop.; there is a cosmetic defect of a figure. All these phenomena are very burdensome for patients.

At moderately expressed mastoptosis wearing free bodices by the individual order from cotton or linen fabrics, without rough seams, with a wide coat hanger and a fastener in front is recommended. At this M. are not squeezed, and rise and are evenly spread on a chest wall therefore in them conditions of a blood-groove and outflow of a lymph improve and burdensome feelings decrease. To young women make plastic surgeries generally for cosmetic reasons.

A dishormonal hyperplasia of mammary glands at women (see. Mastopathy ) and at men (see. Gynecomastia ) treats the anomalies connected with disturbance of the neuroendocrinal status.

Damages, cracks

Outside arrangement of M. contributes to their frequent injuries. Most often bruises or burns of M meet.

The bruise of mammary glands can cause development of extensive hypodermic or deep hematomas. At deeply located hematomas development of pseudocysts is possible, at accession of consecutive infection of a hematoma abscess. At elderly women with plentiful adjournment of a fatty tissue in M, big by the size. owing to a bruise sometimes there are limited fatty necroses with development of a lipogranuloma and scarring. The M coming at the same time deformation., retraction of skin can simulate a skirrozny form of cancer.

On mammograms in fresh cases the hematoma has an appearance of roundish intensive blackout with uneven contours. The necrosis of a fatty tissue gives a picture of the center of blackout. At posttraumatic deformations of M. to a zone of the main hem cicatricial tyazh from its nearby departments are directed that complicates differential diagnosis on mammograms.

The diagnosis is based on characteristic clinical and anamnestic data, in doubtful cases resort to additional methods of inspection up to a biopsy.

Treatment of bruises of M. carry out by the general rules (see. Hurt ). Gland is given the raised situation with the help of a bandage or a bra. In late cases, in the presence of complications (pseudocysts, lipogranulomas, suppuration, cicatricial changes) carry out operational treatment — a resection of an affected area of M., opening of abscesses, etc.

The burn of mammary glands at adult women proceeds generally as well as burns of other areas of a body (see. Burns ). Burns of III and IV degrees conduct to a necrosis of ferruterous fabric with the subsequent scarring and deformation of M. Feature of burns of M. III and IV degrees at children are danger of the necrosis of rudiments of gland leading to a partial underdevelopment or total absence of one or both M.

Treatment of burns of M. it is carried out by the general rules. At development of rough hems or deformation of M. treatment operational — excision of hems, a resection of gland, plastic surgeries.

Wounds of mammary glands have the same character, as wounds of soft tissues in other areas of an organism (see. Wounds, wounds ). Course of wounds of M. in the period of a lactation can be complicated by development of fistulas, from to-rykh milk is emitted; such wounds heal slowly, after the termination of a lactation.

Nipple cracks arise after the delivery in the first days and months of a lactation. The reasons promoting development of cracks are various, the features of a structure of nipples (involved underdeveloped nipples), easy vulnerability of integuments of a nipple, weak erectile excitability of the neuromuscular device of a nipple concern to them at suction by the child, an insufficient gigabyte. care of nipples during the feeding of the child.

Cracks can be single and multiple, superficial and deep, on one or both nipples. Infection of cracks leads to hypostasis, a hyperemia, formation of superficial excoriations or ulcers. At deep cracks bleedings are possible. The pain amplifying during suction and forcing to exclude feeding by a breast that leads finally to the termination of a lactation is characteristic of cracks. The joined infection, is more often staphylococcal or fungal (at the milkwoman at babies), can lead to development of mastitis.

Treatment of nipple cracks shall pursue the aim of their bystry healing that is important for preservation of a lactation. At small cracks it is not recommended to stop feeding of the child a breast. Apply solutions with the antiseptic, cauterizing and tanning pharmaceuticals (tetraethyl-diamino-triphenyl-carbohydride sulfate, alcohol, potassium permanganate, tannin, silver nitrate, etc.). At cracks on dry nipples it is recommended to wash nipples after feeding of the child and to put to them a gauze napkin with the lanolin, vaseline, fish oil, ointments containing corticosteroids, 5% metiluratsilovy ointment to-rye before feeding delete. Consistently apply aero ionization of area of a nipple 15 min. to activation of a trophicity of the damaged fabric, Ural federal district (from 2 to 10 biodoses), darsonvalization (see) 5 — 8 min. daily, on a course prior to 6 — 10 procedures. In cases of infection of cracks they can be powdered with streptocide or to apply the ointments and emulsions containing antibiotics to the Crimea the bacterial flora is sensitive, also fortifying treatment of patients is necessary.

Prevention of nipple cracks shall begin before childbirth and be carried out according to recommendations of the doctor. The careful pulling of a nipple, grinding by its burlap, washing by a warm and cold water alternately for development and a training of erectile ability of a nipple belong to measures of prevention. Observance of rules of personal hygiene is of particular importance in the period of a lactation. Nipples should be washed before feeding and after it, the brassiere, next-to-skin and bed linen need to be changed often. It is desirable to wear in the period of a lactation a free brassiere from cotton or linen fabrics.

Diseases

Considerable group make inflammatory diseases of M. and among them the acute and chronic mastitis caused by a nonspecific pyogenic infection and also chronic not purulent plazmokletochny mastitis (see).

A galactorrhoea (grech, gala, galaktos milk + rhoe a flow, a current) — the spontaneous expiration of milk from nipples in breaks between feedings of the child or the expiration of milk from a nipple the second M. at the time of feeding. It is observed at the increased nervous irritability of the feeding woman (see. Lactation ).

Release of milk out of the period of a lactation — during the long period after the termination of feeding, and also release of colostrum after abortion has a bit different character or at a diffusion form of a mastopathy. Dysfunction of endocrine organs, long secretion of prolactin a hypophysis or reduced oestrogenic activity of ovaries is the cornerstone of these deviations.

Treatment of a galactorrhoea in the period of a lactation fortifying using psychotherapy, local faradisation of nipples. At the galactorrhoea arising out of the period of a lactation, patients are subject to observation, it is necessary to observe a gigabyte. rules of care of M. Eventually release of colostrum stops, it is necessary to resort to specific hormonal therapy seldom.

At the plentiful spontaneous expiration of milk or colostrum maceration of skin of M can develop. and as a result of it — eczema. For prevention of maceration put to a nipple and often change dry sterile gauze napkins. At development of maceration or eczemas (see) carry out the corresponding treatment.

A hyperthely — a hypertrophy of one or both nipples. Arises sometimes at repeated lactations. One of the reasons of a hyperthely — hron, an inflammation of large lacteal channels. Significant increase in nipples at the same time is observed seldom. Differential diagnosis is carried out with a tumor of M. with the help tsitol, researches, biopsies. Patients with a hyperthely do not need treatment, they are subject to observation. Forecast favorable.

Lipogranuloma of a mammary gland.

The disease develops at corpulent elderly women, with big M more often., with a plentiful adiposity in them. It is preceded by an injury and a hematoma, and also injections in M. antibiotics or novocaine, carried out many years ago concerning inflammatory processes or a mastopathy. On site injuries and hematomas the necrosis of a fatty tissue develops, accession of inflammatory subacute process is possible. Develop in later terms fibrosis, lipogranulomas (see). Spayaniye with skin, reminding a symptom of the platform at cancer, and indistinct consolidation in this site of gland simulate a skirrozny form of cancer. The diagnosis is based on data of mammography, at a cut the center of blackout in a hypodermic and fatty layer, and tsitol, researches is found. If there is no confidence in correctness of the diagnosis, it is necessary to make a sectoral resection with an urgent gistol, a research. Treatment operational — a resection of M. Forecast favorable.

Thrombophlebitis of saphenas of M. it is more often observed at Mondor's disease (thrombophlebitis of superficial veins of a perednebokovy wall of a thorax) as a result of distribution of process on veins of M. There can be also an isolated damage of veins of M., when the infection gets directly into them through the injured skin of gland. There is a feeling of painful tension on the limited site of skin, in this place mobile shnurovidny consolidation is palpated, a cut becomes noticeable at a tension of skin; erubescence on the course of a cord can take place. As a rule, noticeable general reaction is not observed. In some cases the similar phenomena can be observed at widespread cancer of M. in connection with a vascular embolism cancer cells, accession of an infection and development of a vein thrombosis. In these cases the diagnosis is facilitated by existence of other displays of cancer of M. Treatment of thrombophlebitis out-patient — the bandages with Unguentum Heparini warming compresses, use of medical bloodsuckers, anticoagulants (heparin, Pelentanum, Dicumarinum), antibiotics. At inefficiency of conservative treatment excision of the affected vein together with adjacent sites of skin and hypodermic cellulose is shown (see. Thrombophlebitis ). The forecast is usually favorable.

Tuberculosis of a mammary gland is observed seldom, hl. obr. at women; falls to the share of men apprx. 4% of cases of total number of suffering from tuberculosis M. Tubercular mycobacteria can get into M. through lacteal channels, on limf, to ways (from a root of a lung, limf, nodes of a mediastinum, axillary limf, nodes) and a hematogenous way (at acute miliary tuberculosis).

Acute miliary tubercular mastitis in modern practice meets extremely seldom, the knotty, fistular, ulcer and sclerosing forms are more often observed.

The knotty form begins with emergence in the thickness of M. dense limited painful nodes, to-rye, quickly increasing, merge in infiltrate. Infiltrate, extending to skin and large lacteal channels, loses the clearness of contours, causes retraction of a nipple. In axillary area are defined plotnovaty increased limf. nodes. On the basis of these signs tubercular process can be taken for cancer. At further development transition of a knotty form in fistular or ulcer is possible.

At a fistular form tubercular granulomas break up, formed is long not healing fistulas with characteristic slivkoobrazny separated.

Fig. 14. The patient with an ulcer form of tuberculosis of the left mammary gland; the arrow specified the ulcer which is located near a nipple.

At an ulcer form skin in the field of tubercular infiltrates ulcerates. The ulcer has typical character — its regions are not flat, podryta, a bottom with the sluggish granulations covered serous and purulent separated. At penetration of an infection through a nipple infiltrate and an ulcer (fig. 14) are localized usually near a nipple and an areola, reminding a picture of cancer of Pedzhet.

In some cases at tubercular process in M. the development of connecting fabric leading to wrinkling, consolidation and deformation of body prevails, it is frequent with existence of fistulas, superficial excoriations and ulcerations (sclerosing form). This picture can remind an armor-clad form of cancer of M.

At tubercular damage of edges and pleurae in a zone of M. accumulation of pus is possible — natechnik (see). They are located usually in the thickness of a chest wall, mezhmyshechno, and, raising M., cause disturbance in it of a blood-groove and lymph drainage that leads to hypostasis and diffusion consolidation of gland.

Diagnosis of tuberculosis of M. establish on the basis of the anamnesis, the course of a disease, existence of the accompanying general intoxication, positive skin tests (see. Tuberculosis , Tuberculinodiagnosis ) and data tsitol, and gistol, researches.

At all forms of tuberculosis of M. the course of a disease bystry in the beginning is replaced slow, hron, by a current. Increase axillary limf, nodes can come to light before display of a disease in M., and limf, nodes at their large sizes keep mobility and are less dense, than at metastasises of cancer. The isolated tuberculosis of M. it is extremely rare, displays of this disease in other bodies and the general tubercular intoxication in most cases take place. Besides, in the anamnesis it is almost always possible to establish existence of various forms of tuberculosis in the past. In cases of doubt in the diagnosis the final decision of a question is reached after the microscopic examination of material of a biopsy, at Krom tubercular granulomas around channels with colossal cells of Pirogov — Langkhansa are found.

Treatment of tuberculosis of M. it is necessary to begin with specific medicamentous and fortifying. At incomplete effect excision of the remaining infiltrates with the fistulas which are not giving in to healing is shown or it is necessary to resort to a mastectomy.

Treatment of natechnik operational, is carried out against the background of specific medicamentous therapy.

Syphilis of a mammary gland meets extremely seldom. Primary defeat is more often localized in a zone of a nipple and an areola where there is primary affect (hard ulcer) — a limited ulcer with dense infiltrate. Regional limf, nodes are increased, leaky. In the secondary period only typical syphilitic papules and rashes on skin

of M are observed. Acute syphilitic mastitis in the second period of syphilis — the phenomenon extremely rare. Tertiary syphilis of M. proceeds in the form of a single gumma or gummous intersticial mastitis, to-rye can end with a specific ulcer. At first in the thickness of M. dense, accurately limited node is probed, to-ry quickly increases in sizes, grows together with skin, forming dense infiltrate. Skin over infiltrate accepts blue-crimson coloring, ulcerates that reminds the breaking-up cancer tumor; sometimes the picture reminds tuberculosis. Further the typical syphilitic ulcer with dense accurately limited crateriform edges and a necrotic bottom is formed. Axillary limf, nodes are increased since the beginning of a disease, but are mobile and less dense, than at cancer. Mammography at syphilis of M. has no distinctive rentgenol. devil. On mammograms various sites of blackout with uneven contours, infiltration of hypodermic cellulose and a thickening of skin are noted.

Syphilis in the anamnesis, existence of other displays of this disease, a rapid current at the beginning of the tertiary period and slow in the subsequent, positive Wassermann reaction (see. Wasserman reaction ), cytologic, and in doubtful cases and gistol, a research (a biopsy of edge of an ulcer) give the chance to establish the correct diagnosis. The differential diagnosis is carried out with tubercular and cancer defeat of M.

Antisyphilitic drug treatment leads to treatment (see. Syphilis ).

The actinomycosis of a mammary gland meets seldom. It can be primary when the activator gets to gland from the environment through skin or on output lacteal channels through a nipple, and also secondary when the activator gets to gland from the affected edges, a pleura or a lung in the lymphogenous way or in the way of direct transition.

The disease begins with emergence in skin and fabric of M. in places of implementation of a fungus (is more often near a nipple) the small abscessing small knots, to-rye then merge in the dense infiltrate taking skin and the subject fabrics, infiltrate is softened and opened with places with education is long not healing fistulas and superficial ulcers. In later stages, during the healing of fistulas and ulcers, the sclerosis of fabrics leading to wrinkling and deformation of M develops. In this stage it is possible to diagnose a skirrozno-armor-clad form of cancer of M mistakenly.

The diagnosis of an actinomycosis (see) is based on data of the anamnesis on drift of a disease, existence of the scanty allocations from fistula containing characteristic accumulations of the druses of a fungus of yellow color seen with the naked eye and with reliability defined under a microscope, and also manifestations of an actinomycosis in other bodies (edges, a pleura, lungs).

The most radical treatment — operational (a resection of an affected area of gland). At the same time carry out fortifying therapy, vitamin therapy, appoint iodide drugs. In nek-ry cases the roentgenotherapy, an immunotherapy, treatment of an aktinolizatama are effective.

The forecast at the correct treatment favorable.

The echinococcus of a mammary gland belongs to very rare diseases. Germs of an echinococcus get into M. usually on blood vessels also settle in connective tissue interlobular layers, leading to formation of the cyst which is slowly increasing. The cyst has a smooth surface, accurate contours, an elastic consistence; at a superficial arrangement fluctuation can be defined. As a result of infection it can suppurate.

The diagnosis is established by data a wedge, inspections, is confirmed at mammography, a puncture of a cyst, and also at positive skin reaction to intradermal introduction of contents of a cyst (see. Skin tests ).

Treatment — operational: the cyst is excised together with the capsule within healthy fabrics. At suppuration the cyst is opened, walls delete it (see. Echinococcosis ).

Tumors

Benign tumors

Fig. And. 7. Bloody and serous allocations from the lacteal courses at sick intra pro-current papilloma of a mammary gland. Fig. 8. Microdrug of papilloma of a channel of a mammary gland; the arrow specified papillary growths in a gleam of a channel. Fig. 9. Suffering from cancer left mammary gland; nipples and peripapillary circles of mammary glands are at the different levels. Fig. 10. Flatness of bottom edge of a mammary gland and a vtyanutost of skin in an outside lower quadrant at cancer of the right mammary gland. Fig. 11. The resected mammary gland on a section after the radical mastectomy made concerning infiltrative cancer; the tumor is specified by an arrow. Fig. 12. Microdrug of a mammary gland at infiltrative cancer; among fibrous connecting fabric the cancer cells developing in tyazh and ferruterous educations are located.

Majority of benign tumors of M. — epithelial origin. According to the international WHO classification (1968), adenomas of M concern to them. and pacifier, papillomas of a channel (tsvetn. rice. A.8), fibroadenomas (see. Adenoma ; Papilloma, papillomatosis ; Fibroadenoma ). Treat benign tumors of not epithelial origin fibroma (see. Fibroma, fibromatosis ), lipoma (see), angioma (see), myoma (see), etc. They are observed very seldom.

A fibroadenoma — the most frequent benign tumor of M., it is observed preferential at the age of 15 — 35 years, is more often at girls. This nodal education consisting of proliferating epithelial elements of channels and a connective tissue stroma. On the nature of growth distinguish perikanalikulyarny (tsvetn. rice. A.4) and intrakanalikulyarny fibroadenomas. Nek-ry oncologists carry fibroadenomas to a kind of a dishormonal hyperplasia — mastopathies (see).

Fibroadenomas are observed in any site of M., is slightly more often in verkhnenaruzhny quadrants, sometimes happen multiple. Usually the tumor has an appearance roundish, well delimited from surrounding fabrics and well movable node to dia, to 1 — 3 cm.

A kind of an intrakanalikulyarny fibroadenoma is leaflike (filloidny or huge) the fibroadenoma which is characterized by rapid growth and reaching the big sizes (to dia, to 20 cm). It is more often observed at the age of 40 — 50 years, can recur, at the big sizes causes sharp deformation of M., erubescence over a tumor, sometimes is followed by expansion of venous vessels of a chest wall.

At changes of a hormonal state (during puberty, pregnancy, childbirth and a lactation) fibroadenomas can change — in one cases quickly to increase, in others (after normal pregnancy and childbirth) — to decrease and even to disappear. Cancer against the background of a fibroadenoma develops less than against the background of dishormonal giperplaziya.

Fig. 15. The roentgenogram of a mammary gland at a single fibroadenoma: 1 — high-quality (the shadow of a tumor is homogeneous, has regular shape and accurate contours; around a tumor the light rim — is specified by an arrow); 2 — malignizirovanny (the arrow specified the place of break of a light rim and roughness of a contour of a tumor).

The diagnosis is based on existence of accurate contours at a palpation of a node, its mobility, development is preferential at young age. On x-ray films the fibroadenoma gives a roundish or oval intensive shadow with accurate arc-shaped contours. The shadow of a fibroadenoma is homogeneous, but at long existence, especially at advanced age, in it deposits of lime appear. They have an appearance large glybok, sometimes connecting in fancy accumulations. Around a fibroadenoma the light rim from 0,1 to 1 cm wide is quite often observed, At malignant transformation the break of this rim and the expressed roughness of a contour of a fibroadenoma in the respective site (fig. 15) is noted. The leaflike (huge) fibroadenoma gives a big shadow of rounded shape with scalloped outlines. Differential diagnosis data tsitol facilitate, researches.

Adenoma of a mammary gland is in pure form observed seldom and is clinically indistinguishable from a fibroadenoma. It is often combined with a diffusion mastopathy. Adenoma of a nipple is also seldom observed. Clinically it is difficult to distinguish it from Pedzhet's disease since the disease is shown by hypostasis, increase and even an ulceration of a nipple therefore at differential diagnosis resort to a puncture or intsizionny biopsy,

Papillomas of channels milk glands y develop more often in the channels connected with a nipple, but can be also in smaller channels. At them allocations from a nipple are observed, is more often brownish or yellowish-green, bloody (tsvetn. fig. A.7). Intra pro-current papillomas are distinguished at a duktografiya; they form small defects of filling with accurate contours. The differential diagnosis can be also specified tsitol, a research separated from nipples.

Lipomas — the most frequent benign tumors of M. not epithelial origin.

They usually are located over gland less often retromammarno; a version them — a fibrolipoma. Tumors are soft, lobular, from 1 to 10 cm in size. At deep localization they cause deformation of gland, are sometimes painful. Are observed preferential at elderly women.

On roentgenograms the lipoma is allocated against the background of ferruterous fabric in the form of an enlightenment, and the fibrolipoma is characterized by heterogeneity of a shadow since sites of fibrous fabric alternate in it with sites fatty.

Treatment of benign tumors — operational. In some cases at fibroadenomas, lipomas and other benign tumors enucleation (enucleation) of a tumor can be made. At impossibility to absolutely reject malignant process by means of all modern diagnostic methods it is necessary to execute a sectoral resection with an urgent gistol, a research. At the big leaflike fibroadenomas occupying all with M., the mastectomy is shown.

The forecast at benign tumors of M. in case of their operational treatment favorable. In order to avoid a malignancy removal them shall be the rule.

Malignant tumors

Breast cancer

Statistics. Cancer of M. — the most frequent form of malignant new growths of this localization at women. In many countries of the world (Great Britain, VNR, GDR, Canada, Norway, the USA, etc.) cancer of M. wins first place among malignant new growths at women. According to WHO data (1977), incidence on 100 thousand women makes: in Canada — 80, in Great Britain and the USA — 76,1, in Switzerland — 70,6, in Denmark — 49,1, in Germany — 48,4, in VNR — 28,3, in Japan — 12,1. Universal increase of incidence of this form of malignant tumors is noted.

According to V. M. Merabishvili and L. Yu. Dymarsky (1978), in the USSR incidence in various republics of the country considerably varies. The highest rates of incidence are noted in the Estonian SSR, the Latvian SSR, the Lithuanian SSR, low — in the Tajik SSR, the Turkmen SSR, the Uzbek SSR. In general across the USSR cancer of M. takes the fourth place in structure of incidence of women of malignant new growths.

The highest rates of incidence among women fall on age groups 50 years are more senior.

Cancer cases of M. at men makes 0,2 on 100 thousand male population.

Etiology and pathogeny. Data epidemiol, researches, pointing out various incidence and mortality from cancer of M. in the different countries and in different regions of one country, shed certain light on character of the etiological or contributing factors of developing of cancer of M. So, in the USSR cancer cases of M. in the central regions, in the republics of the Baltics above, than in the republics of Central Asia, districts of Far North, Transbaikalia; in the large cities above, than in rural areas. At the same time the role of endocrine disturbances at women of various ethnic groups becomes clear important etiol, to-rye are connected with way of their life.

Low incidence is observed at women of those ethnic groups where in connection with tenor of life they early begin sex life, almost do not use contraceptives, seldom resort to abortions, give birth to the first children at young age, have more repeated childbirth, normal lactations (Buryats, Nenets women, Uzbeks, Tajiks, Turkmens, etc.).

In those ethnic groups where women late begin sex life, resort to abortions more often, use contraceptives, early interrupt a lactation after the delivery, dishormonal disturbances, a mastopathy are much more often observed, to-ruyu most of oncologists consider as a precancerous disease, and cancer of M.

According to L. M. Shabad, E. L. Prigozhina, A. Lakassanya, A. Lipschutz, etc., in an experiment development of cancer of M. the easiest was caused by long introduction an experimental animal of estrogen or stimulation of oestrogenic function of ovaries, and in N. I. Lazarev's experiences — also dysfunction of ovaries by beam and surgical methods.

Opinion on dishormonal disturbances, and first of all about the increased oestrogenic activity as one of the main reasons for development of a mastopathy and cancer of M., divides most of scientists. Diseases and dysfunction of those bodies lead to dishormonal disturbances, in addition to the factors stated above, hormones to-rykh influence processes of proliferation of an epithelium in M. (ovaries, adrenal glands, hypophysis, hypothalamus, etc.). Considerable value inflammatory processes in female generative organs have hron, the acute milk fevers leading to the termination of a lactation in one M., frustration of menstrual ovarian function, etc.

Virus nature of cancer of M. the person it is not proved. Only at mice of pure lines the factor of milk called Bittner's virus is revealed (see. Cancer of mammary glands viruses ).

A certain value in developing of cancer of M. has a hereditary and genetic factor though this question is studied insufficiently. Nek-ry oncologists consider that the hereditary and constitutional predisposition, apparently, causes a susceptibility of M. to oncogenous to influences of hormonal character. It is proved by a row a wedge, observations.

V. M. Dilman (1975) recognizes genetic predisposition to dishormonal frustration. H. N. Petrov (1959) attached great value in genesis of cancer to changes from a nervous system. So, it is known that disturbances of nervous activity at the woman quite often are leaders in a pathogeny of a precancerous disease — a mastopathy.

In general it is considered the most probable that development of cancer of M. most likely is result of cumulative influence of many factors (hereditary and genetic predisposition, a hormonal imbalance, insufficiency of reproductive and lactic function, organic diseases of generative and endocrine organs, changes from a nervous system), each of to-rykh separately is not specific in developing of cancer of M.

The tumor grows in bigger (at infiltriruyushchy forms) or smaller (at neinfiltriruyushchy forms) degrees, getting into fabrics of M. (tsvetn. fig. A.11). In process of growth infiltration of adjacent fabrics of gland increases, the tumor extends on interfabric cracks, lacteal channels, blood vessels lymphatic less often within body in the beginning, and then and out of its limits. At lymphogenous innidiation, a cut takes place most often, tumor cells get in limf, textures in the beginning, and from there on the main outflow tracts of a lymph — into regional limf, nodes, first of all in axillary, deep cervical and apical (regional metastasises). At further distribution, especially on blood vessels, there are remote metastasises in various bodies.

Pathological anatomy. Cancer of M., as well as cancer of other bodies — a tumor of an epithelial origin (see. Cancer ). A source of its development more often are lacteal channels (preferential small); the lobular cancer developing from an epithelium of alveoluses makes apprx. 1 — 2% of all cases of cancer of M.

In the International histologic WHO classification (1968) also infiltriruyushchy crayfish of M are allocated neinfiltriruyushchy (intra pro-current and lobular)., and also special gistol, options (mucous, medullary, giant-cell, Pedzhet's cancer, etc.). Neinfiltriruyushchy forms (lobular and intra pro-current genesis) are observed seldom, the forecast at them more favorable. Carry to infiltriruyushchy crayfish solid (80 — 85% of all cases), medullary, a scirrhus (tsvetn. fig. A.12), adenocarcinoma (tsvetn. fig. A.5), undifferentiated forms (giant-cell or clear cell cancer, etc.). Pedzhet's cancer considers most of authors as intra pro-current epidermotropny cancer of M. At gistol, a research of a tumor find characteristic cells of Pedzhet (tsvetn. fig. A.6). At men skirrozny cancer of M is more often observed., deforming gland.

For cancer of M., just as for a mastopathy, papillomas of channels, etc., small deposits of salts of calcium — a mikrokaltsinata are characteristic.

Classification. On the International clinical classification of a breast cancer (the TNM system; WHO) four stages of prevalence of tumoral process distinguish. During the definition of a stage of a disease extent of spread of primary tumor (T) to M is considered., defeat regional limf, nodes (N) and existence of the remote metastasises (M).

T — primary tumor of TIS — a preinvazivny carcinoma (carcinoma in situ), not infiltrative intra pro-current carcinoma or cancer of a nipple (Pedzhet's cancer), when palpatorno a tumor in M. T0 — a tumor in M is not defined. T1 — a tumor of 2 cm or less in its largest diameter T1a — not fixed to the subject chest fascia and (or) a muscle of T1b — fixed to the subject chest fascia and (or) a muscle of T2 — a tumor more than 2 cm, but no more than 5 cm in its largest diameter T2a — not fixed to the subject chest fascia and (or) a muscle of T2b — fixed to the subject chest fascia and (or) a muscle of T3 — a tumor more than 5 cm in its largest diameter T3a — not fixed to the subject chest fascia and (or) a muscle of T3b — fixed to subject to a chest fascia and (or) a muscle of T4 — a tumor of any sizes with direct distribution on a chest wall (including edges, intercostal muscles and a front gear muscle, not including pectoral muscles) or skin T4a — T4b fixed to a thorax — does not decide on hypostasis, infiltration or an ulceration of skin of M. (including a symptom of an orange-peel) or affiliated small knots (satellites) on skin of gland the Note: rugosity of skin, retraction of a nipple or any other skin changes, except for listed in T4b, can take place also at T1, T2, and T3. Existence they do not influence classification.

N — regional limf, the N0 nodes — axillary limf, nodes on the party of defeat are not palpated by N1 — axillary limf, nodes on the party of defeat are palpated by N1a — limf, nodes are estimated as not metastatic N1b — limf, nodes are estimated as metastatic N2 — axillary limf, nodes on the party of defeat are soldered with each other or with other structures of N3 — are palpated limf, nodes over or under a clavicle or there is hypostasis of a hand on the party of defeat. Note: there can be additional information on a state regional limf, nodes (N-— the characteristic of nodes, in to-rykh is histologically proved lack of metastasises; N + — nodes, in to-rykh is histologically proved existence of metastasises).

M — the remote metastasises. There is no M0 — signs of the remote metastasises M1 — there are remote metastasises, including damage of skin outside M.

Being guided by this classification, separate stages of cancer of M. it is possible to characterize as follows:

The I stage — T1a, T1b, N0, N1a, M0

the II stage — T0, T1a, T1b, N1b, M0, T2a, T2b, No, N1a, N1b, M0

the III stage — any degree of T3, T4, any degree of N, M0, any degree of T,

N2, N3, M0 IV a stage — any degree of T, any degree of N, Mi

the Note: degree of T and N is specified gistol, a research.

Along with the international classification in the USSR, especially in practical work, kliniko-anatomic classification, in a cut, according to the methodical indications M3 of the USSR (1956) is widely used, four stages of prevalence of tumoral process are also allocated:

The I stage — the tumor less than 3 cm in the largest diameter which is located in the thickness of M., not passing to surrounding cellulose and covers; defeat regional limf, nodes is histologically not established

to IIA a stage — the tumor from 3 to 5 cm in the largest diameter passing from fabric of M. on cellulose, with existence of skin symptoms, but without defeats limf,

the IIB nodes a stage — a tumor of the same size and a look or the smaller sizes, but with defeat single axillary limf, nodes of the first collector

of IIIA a stage — the tumor from 5 to 10 cm in the diameter or any size burgeoning or ulcerating an integument or getting into the subject fascial muscular layers, but without regional metastasises

of IIIB a stage — a tumor of any size with multiple metastasises in axillary or subclavial and infrascapular areas and clavicular and chest triangles

of IIIV a stage — a tumor of any size with metastasises in limf, nodes in the field of a supraclavicular pole

the IV stage — widespread defeat of M. with dissimination in skin or an extensive ulceration; the tumor of any size which is densely fixed to a chest wall with metastasises in regional limf, nodes or without them; tumor of M. with the remote metastasises.

Clinical picture. Both M. approximately equally often are surprised cancer, bilateral defeat meets seldom. The tumors arising in the second M., quite often are metastatic. Most often tumors are localized in a verkhnenaruzhny quadrant of M.; from two side half of gland is surprised outside, from two vertical more often — upper. Occasionally tumors develop from malrelated ferruterous cells outside M., is more often on the course of so-called milk lines.

In the beginning cancer of M. proceeds usually asymptomatically, and the tumor is found accidentally during the washing, change of clothes etc. At the same time most often in M. nodes to dia, from 2 to 5 cm come to light. At dispensary inspection of women using modern diagnostic methods detection of tumors up to 0,5 cm in size in the diameter is possible, to-rye cannot be revealed by a palpation yet.

Wedge, forms of cancer of M. differ in a big variety. Distinguish nodal (more frequent) and diffusion forms.

According to S. T. Ikhsanova, at nodal forms of cancer of M. the tumor can be spherical (so-called mozgovidny crayfish), star-shaped (are more inherent to skirrozny crayfish) or mixed.

Fig. 16. A palpation of the left mammary gland affected with a limited nodal form of cancer: the symptom of rugosity of skin over a tumoral node is expressed.

Quite accurate limited consolidation in this or that quadrant of M is defined. or in the central area. The tumoral node of a dense consistence, usually painless, is displaced only with fabric of M. Often already in early (I — IIA) stages over it the symptom of rugosity of skin is defined. Its early emergence is explained by the fact that most intensively the tumor grows to the surface of gland, sprouting an adipose capsule and connective tissue kuperova of a sheaf located in it connecting skin to ferruterous segments. Germination of kuperovsky sheaves changes a form and depth of the skin folds which are formed during the moving of skin over a tumor (fig. 16). At the central localization of a tumor already in initial stages of cancer there is an embolism cancer cells subareolar limf, textures that conducts to a cutaneous dropsy of an areola and a nipple (Krause's symptom).

Fig. 17. A palpation of the right mammary gland affected with a common nodal form of cancer: the arrow specified retraction of skin over a tumoral node (a symptom of umbilication).
Fig. 18. Palpation of the right mammary gland, cancer-stricken III stage: the arrow specified the site of the flattened skin over a cancer node (a symptom of the platform).

The node, bigger by the size, or consolidation in M is characteristic of more widespread defeats (the III—IV stage). (to dia. 5 cm and more). The tumor sprouts kuperova of a sheaf on a bigger extent, the retraction of skin over a tumoral node sometimes reminding a navel (a symptom of umbilication, or retraction) develops to-ry comes to light during the moving of skin (fig. 17) or it is found at survey (tsvetn. fig. A.10). In other cases there is a site of flattening of skin with restriction of its mobility — a symptom of the platform (fig. 18).

Fig. 19. Palpation of the right mammary gland, cancer-stricken IV stage: at easy moving of skin over a tumoral node the increased skin time (a symptom of an orange-peel) are visible.

Tells a so-called symptom of an orange-peel about prevalence of process, to-ry arises in connection with an embolism cancer cells deep skin limf, cracks, leading to limited hypostasis, expansion of skin follicles over a tumor. During the moving of skin over a tumor in these cases the time giving to skin looking alike an orange-peel (fig. 19) comes to light. The symptom of an orange-peel defined outside a tumoral node of M., can take place also at extensive metastasises in regional limf, nodes, at to-rykh outflow of a lymph is at a loss and there is secondary hypostasis of gland.

Over a tumoral node erubescence with a cyanochroic shade, sometimes its ulceration is quite often observed.

In widespread stages of cancer of M. it is possible to find also retraction and fixing of a nipple if the tumor grows on large output channels and is located in the central departments of gland. At an arrangement of a tumor the nipple is improved in peripheral departments of gland when smaller lacteal channels burgeon, towards a tumor (tsvetn. fig. A.9).

Diffusion forms of a breast cancer proceed more zlokachestvenno. Forms concern to them edematous and infiltrative (more frequent), mastitopodobny, rozhepodobny and armor-clad.

At an edematous and infiltrative form, edges develops preferential at young age, and also during pregnancy and a lactation and differs in an acute current, the progressing consolidation of the site of a mammary gland without accurately notable borders is observed.

Due to the extensive blockade by cancer cells of deep and superficial skin lymphatic cracks and vessels of a hypodermic lymphatic texture of a mammary gland, and also intra lobular limf, cracks considerable hypostasis of gland and skin over it, the symptom of an orange-peel over the most part of gland revealed even without palpation (primary edematous and infiltrative form) develops. At blockade extra organ limf, nodes and vessels secondary hypostasis (a secondary otechnoinfiltrativny form) develops. Considerable cutaneous dropsy and areola of M. hides a nipple that can simulate a vtyanutost of a nipple.

At an armor-clad form tumoral infiltration takes not only ferruterous tissue of a mammary gland, but also skin and hypodermic cellulose, extending out of limits of gland, sometimes to the second gland.

The mammary gland decreases in sizes; it is fixed to a chest wall, skin over it and over a chest wall is condensed, reminds the armor squeezing the patient.

Rozhepodobny (erizipeloidny) cancer is shown not only by infiltration and consolidation of the gland, but also reddening and a hyperthermia of skin over it and adjacent sites of a chest wall; the centers of reddening quickly extend. These phenomena are connected with the strengthened spread of a tumor on limf, to ways (cancer limfangiit) and predictively are extremely adverse.

Mastitopodobny form of cancer of M. occurs preferential at young people, and also at pregnant women and the feeding women, proceeds sharply. At it diffusion increase and more expressed is noted, than at a rozhepodobny form, consolidation of all mammary gland. Skin over gland is sharply hyperemic. The disease quickly progresses, large metastatic nodes in regional zones early appear.

To rare forms of cancer of M. Pedzhet's cancer belongs. E. V. Litvinova (1949), A. P. Bazhenova and G. N. Hakhanashvili (1975), Hagensen (Hagensen, 1956) distinguish Pedzhet's cancer with damage only of a nipple (the I group), with damage of a nipple and a tumoral node in M. (The II group), only with a tumor in M. (III group).

Fig. 20. Mammary gland, cancer-stricken Pedzheta: in a nipple and an areola ekzemopodobny cancer proliferation is visible.

Such variety of localization is explained by the fact that Pedzhet's cancer develops from an epithelium of lacteal channels and but to them extends towards a nipple earlier, affecting skin of a nipple and an areola. At the same time the picture of ekzemopodobny damage of skin (fig. 20) — a moderate itch, formation of densely sitting crusts and scales, the superficial bleeding sores, a peeling is noted in the beginning. Gradually ulcers of a nipple go deep up to its final fracture; cancer process, extending on the course of lacteal channels in depth of gland, leads to formation of a dense node in its thickness (the II group). The tumoral form of cancer of Pedzhet is less often observed, at a cut only the node in M is formed. Many authors carry this kind of cancer of Pedzhet to nodal forms of cancer of M.

Course of cancer of Pedzhet quite slow; skin manifestations can keep from 6 months to 3 years, and sometimes and up to 16 years.

Innidiation. Regional metastasises develop more often in axillary and apical, is more rare in deep cervical, okologrudinny and infrascapular limf, nodes. By the time of establishment of the diagnosis of cancer of M. regional metastasises are found in 50% of patients. At other patients they can come to light in 6 — 12 months after detection of a tumor, and at quickly growing (diffusion, infiltriruyushchy) crayfish — in earlier terms (up to 3 months). At slowly developing forms of cancer (intra pro-current cancer) regional metastasises are observed less often and arise later.

Gradual development of tumoral process in regional limf, nodes leads quite often to a prelum of vessels and nerves of podmysheny area and area of a clavicular and chest triangle with painful neuralgia and hypostasis of a hand (see. Lymphostasis ). In far come cases the prelum of venous trunks of a neck with development of venous stagnation in a neck and a face is possible.

The remote metastasises can be shown both during the early periods of a disease, and through long terms after an initiation of treatment of primary tumor (in 15 — 20 years). However most often they arise in the first 2 — 3 years after detection of primary tumor. According to S. A. Holdin (1968), among the M which died from cancer. patients the remote metastasises in bones were observed at 23,7%, in lungs and a pleura — at 13,7%, in a liver — at 9,7%, in a brain — at 3,2%. From bones metastasises bodies of vertebrae, haunch bones, edges, femoral and humeral bones, a skull, a breast are surprised preferential.

The remote metastasises have the wedge, symptomatology, edges fully comes to light when process gained a certain development. So, metastasises in a bone are shown by local pains, sometimes patol, changes. Metastasises in lungs often at early stages proceed asymptomatically and come to light at rentgenol, a research in the form of the roundish single or multiple centers of blackout or a cancer limfangiit. Transition to a pleura or metastasises to a pleura are followed by emergence of an exudate in pleural cavities of serous or hemorrhagic character. Defeat by metastasises of a liver in an initial stage is diagnosed hardly. Only later there are undoubted signs of innidiation (the increased hilly liver, ascites, jaundice). Emergence of metastasises in a brain usually is followed by dizziness, headaches, sometimes vomiting, focal symptoms of defeat of c. N of page.

Considerable difficulties arise at the solution of a question of the nature of a tumor in other M., developing synchronously or through some time after treatment of a tumor of initially struck gland. This tumor can be and primary (primary and multiple metakhronny cancer), and secondary, metastatic. It is possible to resolve this issue only at the accounting of a number of factors — morfol, structures of a tumor, absence or existence of metastasises in other bodies, the term which passed after treatment of the first tumor, etc.

There are data indicating that cancer of M. proceeds heavier at women of young age, especially at pregnancy and a lactation. Explain this fact with the fact that tumors of M are more difficultly diagnosed for young women. in connection with frequent existence at them the dishormonal hyperplastic processes masking tumoral symptomatology therefore the number of advanced diseases increases; especially it is difficult to define small tumors against the background of a hyperplasia of ferruterous segments of M. at pregnant women. According to E. B. Kampova-Poleva, during the period from 1961 to 1974 70,5% of patients of this contingent came to a hospital already with widespread stages of a disease. High frequency of the most severe diffusion and infiltrative forms (24,2%) and considerable number of cases of plurality of the centers of growth of a tumor (19,6%) are characteristic. As for influence of pregnancy and a lactation on development and the course of cancer process, most of oncologists considers them one of the major factors accelerating local spread and innidiation of a tumor.

Diagnosis. Cancer detection of M., especially in initial stages of its development, often presents difficulties and demands along with good knowledge a wedge, symptomatologies of additional methods of inspection. Early diagnosis is possible at periodic inspection of the women making risk group (women are more senior than 35 years, the women having precancerous and other diseases of M.). Such routine maintenances are performed as dispensary observation (see. Medical examination ) using large picture frame fluorography of M. In early detection of cancer (especially nodal forms) correctly carried out self-inspection of M can play an important role., Krom needs to train all women. The medical examinations of the woman which are selected at the first stage with pathology of M. undergo comprehensive examination using all modern diagnostic methods. In these conditions, in addition to the palpated tumors of M., at 0,2 — 0,6% inspected not palpated educations come to light, at further overseeing to-rymi their cancer nature is confirmed. During the studying of the anamnesis pay attention to those data, to-rye can point to existence etiol, factors of a cancer disease of M. (frequent disturbances of an ovarian and menstrual cycle, repeated abortions, early interruptions of a lactation, a disease of generative organs, the previous mastopathy, existence of diseases of cancer of M. at the immediate family, etc.). At survey and a palpation of M. it is necessary to remember that are usually characteristic of a cancer node density, tuberosity, homogeneity, limited mobility, a positive symptom of Keniga.

Are very characteristic of cancer of M. skin symptoms and changes from a nipple and an areola: earlier — a symptom of rugosity and Krause's symptom, later (at widespread defeats) — symptoms of umbilication, the platform, an orange-peel, retraction of a nipple. The listed symptoms are absent at benign tumors and at mastopathies. After an injury or the postponed mastitis cicatricial changes of skin, restriction of its mobility on certain sites of gland can develop, but they in character differ from skin symptoms at cancer. Increased, dense, painless limf, nodes in axillary areas, subclavial and supraclavicular zones in the presence of other data indicate innidiation of a tumor in regional limf. nodes.

Radiodiagnosis is widely applied to primary detection of tumors of M. (fluorography) and for specification of the diagnosis (mammography, a duktografiya, etc.).

Fig. 21. Flyuorogramma of mammary glands: at the left — norm; on the right — at a new growth (two shadows of a tumor are visible, are specified by shooters).

Flyuoromammografiya is applied to detection of pathology of M. at test inspections of women 35 years at the enterprises and in policlinics are more senior. On flyuorogramma select those women, to-rye are subject special kliniko-rentgenol. to a research. The main signs, on the Crimea on a flyuorogramma it is possible to assume a disease of M., following: focal shadows (fig. 21), small deposits of lime, dissimilarity of structure right and left M., discrepancy of structure to age of the woman, a sinuosity of a contour of a shadow of ferruterous fabric on the limited site. Usually the group for an additional examination is made to 5% of women, at to-rykh the fluorography is applied, among them there is cancer of M. it is found approximately in 3%. This indicator sharply increases if women are inspected 50 years are more senior.

Fig. 22. Mammogram of a mammary gland, cancer-stricken: the arrow specified a shadow of a tumor of irregular shape, with uneven outlines.

On mammograms a shadow of a cancer node, as a rule, the odinochna, has irregular shape and uneven outlines; sometimes she reminds a star-shaped, amebiform or wrong figure (fig. 22). At medullary and mucous cancer the shadow of a tumor can have the rounded or lobular shape and at first sight relatively equal contours. But in the careful analysis of a mammogram, especially in aim pictures, it is possible and to notice roughness of a contour of a tumor at least on the limited site here, and around a tumor to see the thin network of trabeculas and numerous uneven tyazh dispersing extensively. The size of a tumor happens various, but always the sizes of the probed node considerably surpass the sizes of its shadow on a mammogram.

A symptom of cancer, valuable to diagnosis, is existence in a tumor of small deposits of lime (mikrokaltsinat). Shadows of calcifications have an appearance of the grains of sand disseminated on the limited site or forming accumulations. This sign is noted approximately at 40% of suffering from cancer M., but it is most important when on mammograms the shadow of the tumor is not visible. At diffusion edematous forms of cancer the shadow of a tumor is often indiscernible; in these cases the great value gets existence of symptoms of a diffusion thickening of skin of M. (to 0,5 — 1,0 cm) and restructurings of M. with formation of indistinct focal shadows.

As an indirect symptom of cancer serves increase by 1,5 — 2 times of caliber of saphenas in comparison with symmetric department of other gland and strengthening of the vascular drawing in a circle of a tumor.

The vtyanutost and deformation of a nipple, a thickening and retraction of skin over a tumor, narrowing of retromammary space belong to later symptoms.

Fig. 23. Duktogramma of mammary glands: at the left the norm — is visible dense network of the lacteal courses which are evenly filled with a contrast agent: on the right — a picture of intraduktalny cancer: 1 — a head of the syringe with a needle; 2 — the section of the lacteal canal filled with a contrast agent; 3 — the defect of filling in a channel caused by a tumor; further this place a contrast agent got only slightly, the network of channels does not come to light.

The tumors developing in large lacteal channels are distinguished at a duktografiya. They cause defect of filling in shadows of a channel, its narrowing or obturation (fig. 23). Duktografiya at setserniruyushchy M. allows to reveal small intra pro-current formations of the cancer and not cancer nature.

A special role is played rentgenol, by a method in identification of initial forms of cancer of M. at that its stage when the tumor does not exceed 0,5 cm in the diameter and at a palpation is not defined. Recognition of not palpated tumors is also essentially a problem of timely diagnosis of cancer of M. At mammography in most cases it is possible to find such tumors.

The single not palpated educations revealed by means of mammography or a duktografiya are subject to excision together with adjacent fabrics of gland with the subsequent gistol, a research. In order that the surgeon could find at operation not palpated education, to the site of blackout under control of mammography or X-ray television (see. Television in medicine ) enter 0,5 ml of 1% of solution methylene blue into mixes from 0,5 ml of 60% of solution of a triyodirovanny contrast agent (Verografinum, Urografinum, Hypaque, triombrin, etc.). The surgeon makes a sectoral resection, being guided by the site marked by paint. Then do the roentgenogram of the remote sector and on a shadow of a contrast agent are convinced of correctness of excision. The resected site of M. direct to an urgent gistol. the research, results to-rogo define further tactics of the surgeon.

At the palpated tumors the indication to mammography is need of specification of the diagnosis if a wedge, the picture is insufficiently clear. L. D. Lindenbraten and I. N. Zaltzman (1970) consider that rentgenol, the conclusion about existence of cancer differs in high precision (94,9%). At undoubted a wedge, mammography is not obligatory for a picture of cancer. It provides overseeing by the course of process at inoperable patients during conservative beam, himio-and hormonal therapy.

Fig. B. It is normal of the thermogram of the woman also at some forms of pathology of a mammary gland. Fig. 1. Thermogram of the healthy woman. Mammary glands have an appearance of the symmetric dark gipotsrmichesky fields limited from below to light gipertermichny submammarny folds. Fig. 2. The thermogram of the patient with an acute milk fever. The left mammary gland is increased in sizes; a picture of the expressed thermal asymmetry with a hyperthermia of the left mammary gland. Fig. 3. The thermogram of the patient with a nodal form of a mastopathy. The centers of a hyperthermia in verkhnenaruzhny quadrants of mammary glands are visible (are specified by shooters). Fig. 4. The thermogram of the patient with a fibrocystic mastopathy. The color thermal picture is asymmetric, the uneven light hyper thermal centers are visible (are specified by shooters). Fig. 5. The thermogram of the patient with for the first time the revealed cancer of the right mammary gland. The thermal picture of mammary glands is asymmetric, in the right mammary gland the center of a hyperthermia (it is specified by an arrow). Fig. 6. The thermogram of the patient with a recurrence of cancer after removal of the left mammary gland. In a thermal picture in a zone of a hem the expressed center of a hyperthermia with transition to axillary, supraclavicular, sternal areas (it is specified by an arrow).

Termografiya is used at clinically defined centers of consolidation in M. as additional method of differential diagnosis of high-quality educations and cancer. On thermograms (tsvetn. fig. B. 1 — 6) can see zones of a hyperthermia, well-marked over the tumoral center.

The ultrasonic ekhografiya is in the same way used. At nodal forms of cancer of M. on ekhotomogramma the center with indistinct contours comes to light patol.

The weak konturirovaniye of back borders of a tumor is characteristic. In addition to intensive absorption of ultrasound, at a depth of a tumor acoustic heterogeneity of the reflected signals while at high-quality educations (fibroadenomas, nodal forms of a fibrous mastopathy) amplitude of the reflected ultrasonic signals is identical is noted. On the basis of these data there is an opportunity to suspect malignant tumoral process.

However by the main additional method in diagnosis of cancer of M. the research is morfol. At identification (palpatorno or radiological) consolidations in M. the aspiration biopsy with tsitol, a research of the received material is shown. For tsitol, researches take also allocations from nipples, and at skin changes — prints and scrapings from the surface of skin. According to pathologists, degree of reliance tsitol, a research reaches 80 — 85%. Detection of cells of a malignant new growth in combination with the data confirming the diagnosis of cancer a wedge, inspections and mammographies gives the grounds to carry out radical therapy. At a negative take tsitol, researches, to-ry it will not be coordinated about a wedge, data and mammography, it is impossible to exclude the diagnosis of cancer. In these cases it is necessary to carry out a puncture or intsizionny biopsy with an urgent gistol, a research.

The biopsy with tsitol, or gistol, a research is carried out also in the course of cancer therapy of M., at suspicion on metastasises in skin, soft tissues, limf, nodes, in the presence of an exudate in chest or belly cavities, at suspicion on metastasises of bones or marrow, available to a puncture.

For identification of metastasises of cancer of M., in addition to the mentioned diagnostic methods, apply also radio isotope research, in particular a liver and bones, a limfografiya), a chrezgrudinny flebografiya. At complex diagnosis in some cases it is possible to reveal metastasises in 2 — 3 months prior to their wedge, manifestations.

In the conditions of clinic complex diagnosis using additional methods of a research allows to make the authentic diagnosis of cancer of M. at 95% of patients. It allows to detail also distribution of cancer process in an organism that is important for development of treatment planning.

Differential diagnosis of initial forms of cancer of M. most often it is necessary to carry out with nodal forms of dishormonal giperplaziya — a fibrosing adenosis, cystous mastopathies (see), and also with fibroadenomas (see), not epithelial benign tumors, etc. As a rule, cancer tumors have considerably bigger density, than high-quality and the centers of a nodal mastopathy; at cancer of M. the symptom of Keniga whereas at a mastopathy it is negative is positive.

The symptom of Keniga can be positive at big benign tumors (fibroadenomas), but they possess a smooth surface and good mobility in fabric of gland whereas the surface of a cancer node is more often hilly, and its mobility is limited. However in doubtful cases both at a mastopathy, and at benign tumors of M. it is necessary to apply all complex of modern diagnostic methods up to an intsizionny biopsy.

Flattening or retraction of nipples, retraction of skin of M. injuries can be a consequence of the postponed mastitis, but at the same time recognition is helped by the anamnesis; at inborn flattening or retraction of nipples they are easily brought by fingers.

Are difficult for differential diagnosis of a lipogranuloma of M. and plazmokletochny mastitis, at to-rykh in M. dense nodes with indistinct contours, with a symptom of retraction of skin are probed characteristic and for cancer. In both of these cases the authentic diagnosis is established with the help tsitol, and gistol, researches.

A single cyst — to a galaktotsela (see) has accurate contours, on a mammogram it is shown in the form of the roundish education having equal contours. The diagnosis can be specified also on the basis tsitol, researches of punctate.

It is clinically also difficult to differentiate tuberculosis, an actinomycosis from cancer. However hron, course of process, formation of fistulas, tsitol. a research separated from them allow to make the correct diagnosis.

Mastitopodobny and rozhepodobny forms of cancer of M. it is necessary to differentiate with mastitis (see). The acute beginning of a disease, severe pains, temperature increase, emergence in the period of a lactation are more characteristic of inflammatory processes. However if antiinflammatory treatment does not give effect within several days, especially if process developed out of the period of a lactation, it is necessary to resort to additional diagnostic methods (tsitol, a research of punctate, an intsizionny biopsy).

Cancer of M. it is necessary to differentiate with patol, the centers observed sometimes at systemic lesions — leukosis (see), lymphogranulomatosis (see), to a lymphosarcoma (see), to a reticulosarcoma (see). However at these defeats the similar centers and in other bodies — a spleen, a liver, peripheral limf are observed, nodes, and also the general symptoms — temperature increase, a skin itch, the general weakness, changes are noted from blood, etc. On mammograms unsharply outlined shadows of different size are found.

Treatment cancer of M. it is carried out by three methods: operational, combined (a combination of operational and beam or operational and medicinal treatment) and complex (a combination of operational, beam, medicinal and hormonal treatment). Indications to use of this or that method are defined by hl. obr. prevalence of tumoral process, however at the same time considers also age of the patient, the general condition, existence of associated diseases, a condition of ovarialnomenstrualny function and some other data. Treatment planning depending on it is strictly individualized.

At the limited (localized) primary cancer of M. (stages of I, IIA; T1aN0M0; T1bN0M0; T2aN0M0) is recommended only operational treatment. At these stages of a disease depending on specific conditions various types can be executed mastectomies (see).

Radical mastectomy on Holsteda — to Maier (removal of M. together with big and small pectoral muscles and regional limf, nodes of an axillary and infrascapular and subclavial zone) it is most often applied as an independent method of treatment of the localized forms of cancer of M., and also as a component of the combined treatment.

Expanded radical (axillary and sternal) mastectomy (removal of M. together with big and small pectoral muscles, regional axillary, infrascapular, apical and okologrudinny limf, the nodes located on the course of internal chest arteries and veins) it is shown at the tumors which are located in the central department or medial quadrants of M., without metastasises or with single metastasises in axillary limf. nodes. In the presence of multiple metastasises in these limf, nodes or in apical limf, nodes this operation is not made since does not improve the long-term results of treatment. Certificates on efficiency of this operation are contradictory. So, according to S. A. Holdin (1962), at limited nodal forms of cancer of M. with localization in the central (subareolar) departments and internal quadrants the expanded mastectomy allows to improve results of treatment (increase in five-year survival) for 10 — 12%. According to Veronezi (U. Veronesi) et al. (1977), it does not improve results in comparison with a mastectomy on Holsteda — to Maier and is more traumatic. Owing to the specified reasons of the indication to this operation it is necessary to put carefully, and it was not widely adopted.

A radical mastectomy across Peyti and Daysona (removal of M. together with a small pectoral muscle and the block of cellulose with apical, axillary and infrascapular limf, nodes at preservation of a big pectoral muscle) it is shown at limited nodal tumors (stages of I, IIa, IIB; T1N0M0; T2N0M0; T1N1M0; T2N1M0) with localization in outside quadrants of M. Its fundamental difference from a radical mastectomy is preservation of a big pectoral muscle that provides smaller blood losses), the best cosmetic and funkts, results, less frequent emergence of puffiness (lymphostasis) of an upper extremity in the postoperative period.

Nek-ry surgeons at early stages of cancer of M. (T1N0; T2N0) make a simple mastectomy (amputation of M.) with removal regional axillary limf, nodes or a so-called radical resection of M. (removal of the considerable sector of gland and regional axillary, infrascapular, apical limf, nodes). V. I. Yanishevsky (1968), A. P. Bazhenova (1971) radical resection of M. combine with an intersticial gamma therapy, Veronezi (1977) — with radiation therapy. According to Veronezi, results of such treatment are similar to those, to-rye turn out at a radical mastectomy.

H. N. Blochin, O. V. Svyatukhina, V. V. Vishnyakova at limited nodal forms of cancer (T1 N0; T2 N0) with localization in verkhnenaruzhny quadrants resect apprx. 1/3 parts of M. together with a small pectoral muscle and with axillary, apical and infrascapular limf, nodes. Excision of the sector of M. carry out at distance 3 — 5 cm from borders of a tumoral node to all thickness of gland, including skin and a fascia of a big pectoral muscle.

The simple mastectomy (amputation) and simple sectoral resection as a main type of operation can be admissible in cases of the localized forms of cancer of M. only at flat refusal of the patient of radical operation or in the presence of vital contraindications to it. In early stages of cancer of M. after a sectoral resection F. I. Yanishevsky (1966), Keynes (Keynes, 1937) suggest to conduct a course of interstitial radium therapy, A. P. Bazhenova (1975) combines this therapy with a remote gamma therapy, O. V. Svyatukhina carries out chemotherapy.

Simple sectoral resection of M. often carry out as diagnostic operation when all complex of the sparing diagnostic methods cannot eliminate suspicion that the nature of a disease cancer. Considering that cancer infiltration can go beyond considerably the palpated borders of a tumor, excise all thickness of M. together with skin at distance of 3 — 4 cm from the palpated borders of a tumor. At confirmation of the diagnosis of cancer urgent gistol, a research at once after a sectoral resection make radical operation. In this regard sectoral resections should be made only in the conditions of a hospital. In cases of difficulty morfol. diagnoses on an urgent gistol. to a research the gap in time between a sectoral resection and radical operation shall not exceed, according to WHO experts (1969), 3 — 5 days. At a break of St. 5 days treatment should be begun not with a radical mastectomy, and with preoperative radiation or medicinal therapy.

At primary cancer of M. local and regional distribution (stage of IIB, IIIa; T1N1M0; T2N1M0; T3N0M0) carry out the combined or complex treatment. Radiation therapy (a remote gamma therapy) can be the first stage of the combined treatment.

The second stage perform surgery — a radical mastectomy. When after a careful morfol, studying of the fabrics removed during operation considerable prevalence of cancer process becomes clear, carry out the third stage — postoperative himio-or hormonal therapy.

In many onkol, institutions at IIA and IIIA stages of cancer of M. operational treatment is combined with chemotherapy. In 7 — 10 days prior to operation intravenously enter a high dose of Thiophosphamidum (50 — 60 mg) or 5-ftoruratsit (1 — 1,5 g); at the end of operation — 50 — 60 mg of Thiophosphamidum or 1 — 1,5 g of a 5-ftoruratsil in a subclavial artery; in 7 — 10 days intravenously — 50 — 60 mg of Thiophosphamidum or 1 — 1,5 g of a 5-ftoruratsil also finish treatment with fractional administration of drugs to a total dose of 180 — 200 mg of Thiophosphamidum or 3 — 4,5 g of a 5-ftoruratsil. Within the first year after operation every 3 — 4 month it is recommended to conduct repeated courses of medicinal treatment by the same drugs, and at the III stage, besides, up to two years to a gormonoprofilaktik.

At primary and widespread nodal and especially diffusion, edematous and infiltrative forms (a stage of IIIB, IIIV, IV) also recommend the combined treatment. At these stages patients are initially inoperable and it is necessary to begin treatment with beam or medicinal methods.

In cases of widespread process, especially at hormonedependent tumors, treatment is begun with impact on endocrine organs. At young women and at women in the first 5 years of a menopause make a bilateral ovariektomiya and appoint androgens or corticosteroids to long terms. At the same time carry out radiation of primary tumor and regional zones of innidiation or chemotherapy, to-ruyu carry out by regional intra arterial introduction of himiopreparat, other oncologists carry out polychemotherapy.

At positive effect of this treatment in 3 — 4 weeks after its termination make radical mastectomies) with the subsequent beam or chemotherapy and long (up to 2 years) hormonal treatment. At inefficiency of the carried-out treatment if the tumor continues to remain inoperable, are limited to radiation therapy, repeated courses of chemotherapy, it is better Thiophosphamidum or but the scheme CMF (Cyclophosphanum, a methotrexate, 5-ftoruratsit), and medicinal hormonal therapy according to the plan, individual for each patient. At inoperable forms of cancer of M., and also at a widespread recurrence and metastasises of H. N. Alexandrov, T. A. Pantyushenko (1971), Darzhan (M. of Dargent, 1967) recommend to make operational removal of the right adrenal gland and change of the left adrenal gland in one of abdominal organs having outflow of a venous blood in portal system (e.g., in a mesentery of intestines, a big epiploon). At this technique at 70% of patients objective remission more than 2,5 years was observed (on average 31 month).

Results at outside radiation of a hypophysis on the telegamma device are similar or a protonew bunch, and also at a surgical hypophysectomy. The adrenalectomy or a hypophysectomy are most effective at patients with multiple metastasises in a bone.

Radiation therapy is one of the main components of the combined treatment of malignant tumors of M., it can be used in respect of preoperative, postoperative radiation or in independent option (see. Radiation therapy ) .

Fig. 24. The diagrammatic representation of fields of radiation at local tumoral process in a mammary gland: 1 — the subclavial and axillary field; 2 — the outside field of a mammary gland; 3 — the internal field of a mammary gland; 4 — the supraclavicular field; 5 — the parasternal field; the fields irradiated after operation by method of usual fractionation are shaded; the fields irradiated before operation by method of large fractionation are not shaded.

At local tumoral process (T1,2,3 N0,1 of M0) in outside departments of M. conduct short courses (large fractionation) of radiation therapy, at to-rykh within 4 — 5 days to M. and a subclavial and axillary zone bring total focal doses respectively 2700 and 2125 I am glad. Supraclavicular and parasternal areas are irradiated only after operation with method of usual fractionation to 4500 I am glad (fig. 24).

At cancer of II6 — III of a stage with multiple metastasises in regional limf, nodes before operation apply radiation by method of usual fractionation of a dose with simultaneous radiation of primary tumor and all zones of regional innidiation from 4 — 5 fields. A single dose in the field 250 I am glad, a total focal dose on M. 4500 — 5000 I am glad, on podmyshechnopodklyuchichny area — 3500 — 4500 I am glad, supraclavicular and parasternal areas — 4500 I am glad. At an infiltrative and edematous form of cancer it is more reasonable to combine chemotherapy or radiation therapy with hormonal influences before operation and after it.

In cases if treatment was begun with operation, and at gistol, a research multiple metastasises in limf are revealed, nodes, after operation irradiate all zones of regional innidiation in total focal doses 4500 is glad in the field. If at operation the ablastika (a big tumor, the multitsentrichny or expressed infiltrative growth) was not fully reached, at the same time irradiate a postoperative hem to focal doses 5000 — 5500 is glad.

At flat refusal of patients of operation or impossibility of its performance radiation therapy is applied as an independent method or in a combination with chemotherapy. At the same time focal doses on M. make 6000 — 7000 I am glad, on zones of regional innidiation by big fields 4500 I am glad and locally on the metastatic center of 1500 more I am glad.

At a single small recurrence the short-distance roentgenotherapy in daily focal doses 300 — 500 is shown I am glad, total — 6000 — 7000 I am glad or radio surgical intervention — broad excision of the recuring tumor with introduction to a bed of drugs of 198 Au.

At multiple local recurrent tumors carry out radiation of all postoperative hem to focal doses 6000 — 6500 I am glad with simultaneous or the subsequent himio-and hormonal therapy.

In the presence of metastasises in bones (except a backbone) radiation in a single dose 500 is desirable I am glad, total — to 2000 — 2500 I am glad against the background of hormonal therapy. At metastasises carry out radiation in a single dose to bodies of vertebrae 200 — 250 I am glad, to a total dose to 4000 — 5000 I am glad since at higher doses there is a danger of radiation injury of a spinal cord. At metastasises in internals palliative radiation therapy against the background of chemotherapy (more preferably) or hormonal treatment is possible.

A contraindication for radiation therapy at a breast cancer is the expressed leukopenia.

Complications after correctly carried out treatment do not happen. At the wrong technology of radiation development of a beam pneumosclerosis, rigidity of a shoulder joint is possible, it is extremely rare — beam ulcers, beam plexites, developing of fractures of edges (see. Beam damages ).

The chemotherapy is applied as an additional method at the combined treatment of primary and resectable suffering from cancer M. (before - and postoperative chemotherapy) and as an independent method of treatment of primary and inoperable cancer of M. It has a bigger value for treatment of patients with the recurrence and metastasises appearing after initial treatment (see. Chemotherapy, tumors ).

From antineoplastic means (see) adriamycin, Vincristinum, a methotrexate are most effective, 5-ftoruratsit, Thiophosphamidum, Phthorafurum, cyclophosphamide, etc., especially at the combined use of drugs with the different mechanism of action (e.g. the scheme CMF — Cyclophosphanum, a methotrexate, 5-ftoruratsit; the scheme CMFVP — Cyclophosphanum, a methotrexate, 5-ftoruratsit, Vincristinum, Prednisolonum). Antineoplastic means enter through a mouth, intramusculary, intravenously, vnutriarterialno, into cavities. All of them render positive therapeutic effect, however not in all cases identical.

The best results note at treatment of metastasises in a chest wall, limf, nodes, a pleura, lungs. At multiple metastasises the chemotherapy should be carried out to bones extremely carefully since at the same time early there comes oppression of a hemopoiesis. Metastasises in a liver and a brain poorly give in to influence of antineoplastic drugs. On average under the influence of chemotherapy considerable regression of metastasises of cancer of M. it is reached at 30 — 60% of patients; remission continues from several weeks to 8 — 10 months. By means of repeated courses of chemotherapy it is possible to facilitate considerably a condition of patients and to prolong them life for 1 — 2 years, in some cases — for several years. At a combination of chemotherapy with long medicinal, ablative (an ovariektomiya, an adrenalectomy, a hypophysectomy) and hormonal therapy the number of remissions and their duration increases.

Hormonal therapy is an additional method of treatment at initially widespread cancer of M., recurrence and metastasises. Hormonal therapy at cancer of M. the important role as in its emergence hormonal disturbances have paramount value belongs. For increase in efficiency hormonal therapy (see) previously establish degree of a gormonozavisimost of a tumor for what study hormonal balance, a hormonal profile (content in blood serum or urine of estrogen, progesterone, follicle-stimulating and somatotropic hormones, androgens, corticosteroids, etc.) an organism of the patient, hormonal receptors in fabric of a tumor, on the Crimea reactivity of tumor cells in relation to hormonal influences is defined.

Young women have cancer of M. develops against the background of increase in oestrogenic activity more often in an organism therefore at them resort to an ovariektomiya or beam suppression of function of ovaries; the compensatory oestrogenic activity of bark of adrenal glands coming after an ovariektomiya is suppressed with long reception of per os of corticosteroids (Prednisolonum — 10 mg a day or Triamcinolonum — 8 mg a day, etc.). In widespread stages of cancer carry out adrenalectomies). Suppression of follicle-stimulating function of a hypophysis reach purpose of androgens (after an ovariektomiya or as an independent method); propionate is most effective a medrotestrona (appoint to a long term daily 50 — 100 mg intramusculary). The androgenic drugs of the prolonged action (Prolotestonum, sustanon-250, etc.) applied intramusculary 1 time in 10 — 15 days are offered.

At patients with a long menopause cancer develops against the background of the raised products of follicle-stimulating hormone. It is reasonable to them to appoint the estrogen which is powerful inhibitor of follicle-stimulating function of a hypophysis to a long term (1 — 2 ml of 2% of solution of hexestrol intramusculary, once a day; diethylstulbestrole on 15 mg a day in tablets, etc.).

Hormonal medicinal therapy at initially widespread cancer of M. it has to be spent without breaks up to 2 years. At treatment of a recurrence and metastasises hormonal treatment continues the entire period of the occurred remission, practically until the end of life of patients.

At patients with widespread innidiation of cancer of M., having earlier remission, it is possible to gain positive therapeutic effect from an adrenalectomy or from change of an adrenal gland in bodies with outflow of blood in portal system, an operational hypophysectomy, and also by suppression of function of an adenohypophysis by beam methods (outside radiation on the telegamma device, radiation of a hypophysis a proton bunch, implementation of radioisotopes of yttrium or gold).

The combination of hormonal therapy to chemotherapy and radiation of the separate metastatic centers at patients with generalized innidiation leads more to the expressed objective remission than at a half of patients, considerably alleviates their suffering and prolongs life up to 2 and more years.

Long-term results of treatment and forecast. The forecast at cancer of M. without treatment it is extremely adverse. According to Yu. V. Petrov (1964), average life expectancy at uncured patients makes 27,4 months after emergence a wedge, symptoms of a disease.

Results of treatment depend hl. obr. from degree of prevalence of tumoral process by the time of an initiation of treatment and biol, features of a tumor (degree of an infiltrativnost of growth, an anaplaziya, hormonal sensitivity, etc.). The statistical data covering wide experience Soviet onkol of institutions, show that at I and IIA stages of cancer of M. (T1,2N0M0) of 5 years without signs of a recurrence of a disease live respectively 93,4% and 84,2% of treated patients. In the presence of metastasises (On a stage — T1,2N1M0) 5 years live in axillary limf, nodes, but rather limited spread of a tumor without signs of a recurrence and metastasises of 60 — 67% of patients. At tumors of a stage of IIa (T3N0M0) of 5 years without recurrence and metastasises there live 55,0 — 58,0% of patients.

Results of treatment at widespread (especially edematous and infiltrative) forms of cancer of M are less favorable. So, at a stage of IIIB (T1,2,3N3M0) the number of survivors during five-year term makes from 35,4 to 42,0%, and in the presence of multiple metastasises in limf, nodes — only 25% of treated patients.

Features of a breast cancer at men. Cancer of M. at men arises at more advanced age, than at women (average age of sick men for 4 years exceeds average age of women with this disease).

Fig. 25. The patient with an ulcerated cancer tumor of the left mammary gland.

Among etiol, factors, apparently, a nek-ry role is played by often found gynecomastia. Clinical symptoms and course of cancer of M. at men have features. Small sizes of M., lack of plentiful cellulose, proximity of skin, nipple and the subject fascia create conditions for bystry germination by a tumor of these fabrics and its distribution out of limits of body. In this regard more than in half of cases skin and a nipple are surprised, ulcerations (fig. 25), bloody allocations from a nipple, pains, an itch and a peeling are frequent. Metastasises in axillary limf, nodes are rather frequent. The diagnosis is based on data a wedge, and tsitol, inspections. In doubtful cases apply mammography and other additional diagnostic methods.

In early stages the radical mastectomy is recommended. Radiation therapy at primary cancer of M. at men it is applied less than at women, because of bigger danger of damage of edges and lungs. In respect of hormonal therapy carry out a bilateral orkhektomiya, prolonged treatment by corticosteroids. For chemotherapy use the same drugs, as at women.

The forecast at complex treatment same, as at women.

Sarcoma of a mammary gland

Sarcoma of M. meets seldom, makes no more than 1% of all malignant tumors of M.

On gistol, to a structure of sarcoma of M. belong more often to to fibrosarcomas (see), to-rye develop initially in a stroma of gland or for the second time in a fibroadenoma (usually in leaflike). On a section of a fibrosarcoma myxomatous fabric is visible fibrous, places. Microscopically sites from bunches and tyazhy spindle-shaped cells of an atypical look, and also sites of a myxomatous structure are defined; in a sarcoadenoma ferruterous tubes are observed.

Less often osteogene meet sarcomas (see), at to-rykh microscopically among fibroblastichesky fabric are found osteoblastic, and sometimes and cartilaginous inclusions, liposarcomas (see), myosarcomas (see), etc.

Klin, a picture of a disease it is connected with a structure of a tumor.

The fibrosarcoma arises more often on average, but meets also at young age, reaches enough big sizes. At a palpation the dense node of a rounded or oval shape is defined, to-ry grows rather long by moving away of fabrics, without germination of skin and innidiation in limf. nodes.

The osteosarcoma develops preferential at advanced age in the form of slowly growing, long remaining delimited nodes. The liposarcoma develops also at advanced age, but grows quickly, reaching for a short time the considerable sizes, grows together with skin, gives secondary nodes in cellulose and quite often metastasises in axillary limf. nodes. The myosarcoma grows quickly, differs in a high zlokachestvennost, gives the remote metastasises.

Fig. 26. The patient with a bilateral lymphosarcoma of a mammary gland.

Along with primary tumors in M. the centers of system malignant new growths can meet (see. Leukosis , Lymphogranulomatosis , Lymphosarcoma , Reticulosarcoma ). They arise in M. against the background of manifestations of process in other bodies. Lymphosarcomas meet more often at young age (fig. 26), reticulosarcomas — in elderly. Both forms of sarcoma are characterized by the short anamnesis (from several weeks to several months), rapid growth, a high zlokachestvennost, existence of the multiple centers in other bodies.

The diagnosis of sarcoma in initial stages is difficult. It can be taken for the leaflike (filloidny) fibroadenoma more often developing at young age. Sarcomas differ in bystry increase single or several in a number of the located nodes, dense at a fibrosarcoma and an osteosarcoma, less dense at other forms. The tumor stretches an integument, to-ry becomes thinner, becomes brilliant reddish-bluish with plentifully developed vascular network. On mammograms single roundish blackouts, on thermograms — the centers of a hyperthermia which are difficult differentiated from cancer are noted.

It is necessary to apply all complex of diagnostic means to differential diagnosis, but it becomes frequent the diagnosis clear only after gistol, researches.

Treatment is operational, with observance of the same rules of radicalism and an ablastika that at cancer therapy. In the presence of systemic lesion treatment of a basic disease is shown.

Forecast in most cases adverse.

OPERATIONS

Principles of anesthesia, quick accesses and methods of operations at the most frequent diseases of M. are stated in articles Mastitis (see), Mastectomy (see). In modern practice plastic surgeries on M are widely adopted. (mammoplastika), to-rye are carried out for the purpose of correction of volume of body or improvement of its form, than not only cosmetology, but also sotsialnopsikhologichesky rehabilitation of women is reached. With the inborn or acquired anomalies of M. at many women the resistant inferiority complex interfering their adequate communication with surrounding people easily develops. Loss of feminity interferes with creation of a family, leads to development of heavy neurosises and psychoses. After reconstructive and recovery operations these phenomena disappear at the vast majority of women.

Indications to a mammoplastika are malformations and deformations of M. — a hypertrophy, a mastoptosis, deformations after burns, mechanical injuries and operations, the expressed post-lactic involution, etc. Several types of plastic surgeries on M are developed.

Operations with the purpose of increase in volume of mammary glands are carried out at a hypomastia and atrophic processes in M. Increase in volume of M. it is reached by use biol, auto-and allogenic fabrics or by explantation of synthetics.

F. Burian, J. Langacre, Erich offered operation, at a cut the found lower than A M. and the skin and fatty rag deprived of epidermis on the feeding leg is brought under M., previously separated from a chest fascia, also fix to a periosteum of the III edge.

The skin and fatty rag can be moved from remote from M. body parts by method of change of a pedicle graft across Filatov (see. Skin plastics ). Also the method of increase in M is offered. at the expense of the free skin and fatty rag found from a rump. A rag deprive of epidermis, model in the form of a cone and implant into a pocket in retromammary space.

In 1976 K. Kalnberz offered a new way of a mammoplastika due to introduction to retromammary space of an implant from the allogenic fat which is in advance frozen in special glass forms. According to the author, success of operation is promoted by the fact that the local hypothermia created by the frozen implant has the haemo static, anesthetizing and antiinflammatory effect.

The beginning of explantation in plastics of M. Gershuni put (R. Gersuny, 1899), to-ry applied to increase in volume of M. injections of paraffin. In 1924 Mr. Shvartsmann and Torek (Schwarzmann, M. of Thorek) glass hemispheres implanted for this purpose. Pangman in 1951 for the first time applied ivalonovy prostheses, and Bing and Heymen (Bing, Hamen, 1951) — is looked through.

In 1962 Mr. Kronin (T. D. Cronin) offered essentially new type of an endoprosthesis from a soft silicone seamless cover, the cavity a cut was filled with silicone gel. On the physical and cosmetic properties it met all requirements and therefore was widely adopted. Silicone endoprostheses of M. Kronin's systems released by Dow Corning (USA) have the spherical and tear-shaped forms and the big range on the volume (from 130 to 340 cm3). On a back surface of an endoprosthesis there are dacron platforms providing a possibility of germination in them of fabrics and protecting a prosthesis from shift. In an experiment and in clinic inertness of an endoprosthesis, its safety concerning carcinogenicity is proved biol.

Endoprostheses of M. from various synthetics are issued in many countries (Japan, France, Czechoslovakia, etc.). However, according to many scientists, universal recognition and the best results are received during the use of silicone endoprostheses like Kronin's endoprostheses.

Operation of endoprosthesis replacement of M. make under local or general anesthesia. The section of skin and hypodermic cellulose 6 — 7 cm long most often do in the field of a submammarny fold, an axillary pole or on a circle of an areola. Then create a pocket in retromammary space according to the volume of the endoprosthesis placed in it. Special attention is paid to a stop of bleeding and observance of rules of an asepsis. After introduction of an endoprosthesis and centering it in relation to a nipple a wound is layer-by-layer taken in tightly. On skin put thin mylar stitches. M. fix the supporting bandage.

Operations with the purpose of reduction of volume of mammary glands carry out concerning the hypermastia which arose at adult women out of the period of pregnancy at endocrine frustration and concerning increase in M., connected with obesity, metabolic and ginekol, diseases, etc. Many methods of operational reduction of the sizes of M are offered. The majority provides them a resection of ferruterous fabric, surpluses of skin and movement up of an areolar zone on the feeding leg. These operations differ from each other generally in types of skin cuts, methods of a resection of ferruterous fabric and the equipment of plastics of peripapillary circles.

At an excessive hypertrophy of M., combined with sharply expressed ptosis, it is up inexpedient to move an areola on the feeding leg far. The disturbances of blood circulation arising at the same time owing to twisting of vessels conduct to a necrosis of an areola and a nipple. In these cases make total removal of ferruterous fabric with the subsequent formation of new M.

Formation of a new mammary gland is made after a simple or radical mastectomy, at an amastia and an athelia.

Need of carrying out a hypodermic mastectomy arises at precancerous conditions, benign tumors, tumors of unspecified character when multiple biopsies did not clear the diagnosis, the hypermastia which developed in the pubertal period or during pregnancy, increase in M. with sharply expressed mastoptosis. Plastics of M. in these cases consists in the room in the skin bag formed after removal of ferruterous fabric of M., synthetic or biological endoprosthesis.

After radical mastectomies formation of M. make at the expense of own tissues of the patient (by method of plastics a pedicle graft across Filatov, a dichotomy remained healthy M.) or due to use of the allogenic fabrics and silicone implants placed subcutaneously.

Formation new M. comes to the end with movement of a nipple and an areola to the new place or they form from the pigmented skin of small vulvar lips.

Plastics of a nipple and an areola is produced at excessive expansion of an areola and the pulled-in or flattened nipple.

Excessively expanded areola is reduced by excision of a circular strip of her skin.

Reconstruction of the pulled-in or flattened nipple is carried out as follows. The nipple is taken on a handle. After a circular section of skin at its basis from the skin adjacent to a nipple, find several triangular rags turned by tops to the center. Edges of the formed triangular wounds are sewed owing to what the nipple is extended. Hem edge of an areola to the basis of the created nipple. After a mammoplastika skin seams remove on 6 — the 7th days.

In the next 2 — 3 months after operation by the patient recommend to abstain from sharp movements by hands.

In the postoperative period such complications as are possible hematoma (see), suppuration (see. Wound fevers ), a necrosis of skin (see. Necrosis ), the anesthesia of a nipple and an areola, developing of konstriktivny fibrosis owing to overreaction of fabrics to an endoprosthesis, etc. that quite often forces to delete a prosthesis and to resort to a repeated mammoplastika.



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See also bibliogr, to St. Lactation , Mastitis .


O. V. Svyatukhina; V. N. Babichev (and.), A. A. Vishnevsky, V. P. Olenin (plastic surgeries), E. A. Vorobyova (An., gist., embr.), V. S. Datsenko (I am glad.), V. B. Zolotarevsky (stalemate. An.), L. D. Lindenbraten (rents.), G. V. Falileev (PMC.), G. of II. Zenovko (thermograms — tsvetn, fig. 1 — 6), I. V. Kuzmin (tsvetn, fig. 7, 9—11).

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