FOCUS

DATA S:

ACTION

RESPONSE

O: T: 36.2 P: 78 R: 21 BP: 120/80

FOCUS

DATA S:

ACTION

RESPONSE

O: T: 36.2 P: 78 R: 21 BP: 120/80

Pathophysiology(PAROTIDECTOMY) Malignant mixed tumors

Malignant mixed tumors arise most commonly as a focus of malignant degeneration within a preexisting benign pleomorphic adenoma (carcinoma ex pleomorphic adenoma). These tumors also may develop de novo (carcinosarcoma). The longer pleomorphic adenoma has been present, the greater the chance of carcinomatous degeneration. Carcinosarcomas, true malignant mixed tumors, are rare. Overall 5-year survival is 56%, and 10-year survival is 31%. Pleomorphic adenomas, commonly called a benign mixed tumor, are

histologically composed of 2 subtypes of cells: epithelial and mesenchymal. The tumors are typically well demarcated from the surrounding tissue by a fibrous capsule, which varies both in thickness and completeness. These lesions have been reported to contain small protrusions (pseudopodia) that extend beyond the central mass, caused by variability in the growth rates of the various cell types. This factor contributes to recurrence rates as high as 50%, depending on the type of surgical intervention. Hemorrhage, calcification, and necrosis are occasionally present. Most pleomorphic adenomas are confined to the superficial lobe of the parotid gland, but they can occasionally arise in the deep lobe in other salivary glands. Malignant degeneration, most commonly carcinoma ex pleomorphic adenoma, has been reported to occur in as many as 25% of untreated cases. In rare cases, pleomorphic adenomas degenerate into a true malignant mixed tumor and a metastasizing benign mixed tumor.

Mammary gland, milk-producing gland characteristic of all female mammals and present in a rudimentary and generally nonfunctional form in males. Mammary glands are regulated by the endocrine system and become functional in response to the hormonal changes associated with parturition. In the primitive monotreme mammals (e.g., platypus), milk is expressed directly from the ducts onto the fur, from which the young lap it up. Unique in monotremes, the mammae lack nipples and are functional in both sexes. In marsupial mammals (e.g., kangaroo), the mammae are located on the ventral surface of the body and in some species are protected by a skin fold or by a pouchlike structure. The tiny newborn sucks the nipple, which then expands in its mouth and thus attaches the young to the females body. It remains attached until it is fairly well developed, after which time it nurses at will, as do the more advanced mammals (see suckling). In cattle, horses, and whales, the mammary glands are located in the inguinal (groin) region; in primates, they are on the chest. Most small mammals have several pairs spread along the ventral surface. Mammary glands are derived from a modification of sweat glands. They first appear in embryonic life as clumps of cells proliferating from a longitudinal ridge of ectoderm (the outermost of the three germ layers of the embryo) along the so-called milk line, from the buds, or beginnings, of the lower limbs to those of the upper limbs. The number of these clumps that ultimately become breasts, or mammae, varies with each mammalian species according to the size of its litter. In the human normally only one develops on each side of the chest. A lesser development of one or more breasts (polymastia) or nipples (polythelia) may, however, occur anywhere along the milk line. The human breast The mammary gland of a woman who has not borne children consists of a conical disk of glandular tissue, which is encased in variable quantities of fat that give it its characteristic shape. The glandular tissue itself is made up of 1520 lobes composed of solid cords of ductal cells; each lobe is subdivided into many smaller lobules, separated by broad fibrous suspensory bands

(Coopers ligaments), which connect the skin with the fascia, or sheet of connective tissue, that covers the pectoral muscles beneath the breast. Each lobe is drained by a separate excretory duct. These converge beneath the nipple, where they widen into milk reservoirs, before narrowing again to emerge as pinpoint openings at the summit of the nipple. Circular and radiating muscles in the areola, a circular disk of roughened pigmented skin surrounding the nipple, cause the nipple to become firm and erect upon tactile stimulation; this facilitates suckling. The areola also contains sebaceous glands to provide lubrication for the nipple during nursing. Blood is supplied to the breast through the axillary, intercostal, and internal thoracic vessels. The nerve supply is from branches of the fourth, fifth, and sixth intercostal nerves. Hormonal relationships Under the primary influence of estrogens from the maturing ovary at puberty, the ductal cells proliferate and form branches. After ovulation, progesterone from the corpus luteum, an organ that develops in the ovary each time an ovum has been shed and has the function of preparing the uterus for receiving the developing embryo, causes the terminal ductal cells to differentiate into the milk-producing cells, which form acini. Interspersed with these cells are smooth muscle cells, which can contract and assist in the ejection of milk. The acini are collapsed or filled with desquamated epithelium (epithelium that has been shed), until the stimulus of pregnancy causes proliferation of all the epithelial cells. The breast becomes enlarged, tense, and sensitive, and the areola widened and more deeply pigmented. The actual secretion of milk is induced by hormonesprolactin from the pituitary and somatomammotropin from the placenta. At the end of lactation the mammary glands and areolae return almost but not completely to their state before pregnancy. After menopause the glands atrophy and are largely replaced by connective tissue and fat. Diseases and abnormalities of the breast. The occurrence of supernumerary breasts and nipples has been mentioned. Absence of one or both breasts occurs, but rarely. Inequality in size is frequent, the left breast being larger more often than the right. Variations in size and shape are commonly of racial or genetic origin, but may be induced by a tight-fitting garment or by manipulation to cause elongation for the greater convenience of nursing an infant carried on the back. Painful breasts may occur whenever estrogens are present in large amounts, as at puberty, during pregnancy, prior to menstruation, or after administration of the estrogens. Fibrocystic disease, also called chronic cystic mastitis, may result in later reproductive life from the cumulative effect of the ebb and flow of endocrine stimulation with each menstrual cycle; this produces nodular fibrosisor lumps of fibrous tissueand cysts of various sizes. The condition can usually be distinguished from cancer because it is intermittently painful and tends to subside after menstrual periods. It may predispose to carcinoma, however. Early biopsy is indicated for any nodules that persist.

Endocrine disorders may cause precocious breast development or gynecomastia (enlargement of the breast in the male). Gynecomastia may also be an indication of a sex chromatin abnormality called Klinefelters syndrome. The only common infectious disease unique to the breast is acute mastitis, which occurs during lactation as the result of an invasion of pyogenic skin organisms through the nipple. The severe local inflammation, with high fever and prostration, responds promptly to antibiotics, usually without suppuration. Mastitis is ordinarily prevented by proper hygiene. Benign tumours include fibroadenoma, more common in women under 30, and intraductal papilloma, which may cause bleeding from the nipple. These tumours should be removed. Malignant tumours may arise from any of the cell types contained in the breast, but sarcomas make up only 3 percent of all breast tumours. Carcinoma of the female breast is the commonest form of malignant tumour in the Western world, afflicting about 4 percent of all adult women. Rare under the age of 25, it increases in incidence up to menopause and then levels off. Hereditary factors play a role, but their exact importance has not been clearly established.