1.1 breast surgery

8/14/2019 1.1 Breast Surgery

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Breast surgery

Anatomy

The mammary glands are specialized accessory glands of the skin. The base of

the breasts extends from the second to the six rib and from the lateral margin of

the sternum to the midaxillary line. The gland lies in the superficial fascia, a

small part called the axillary tail extends upward and laterally, pierces the deep

fascia, and comes into close relationship with the axillary vessels.

The parts of the breast

The breast has 7 parts: 1) mammary glands, 2) lactiferous ducts, 3) fat, 4)

suspensory ligaments, 5) areola /nipple, 6) lymphatic ducts and 7) the overlying

skin.

The connective tissue layer that separates the breast from the muscle is called

deep fascia. In between the deep fascia and breast is an area called the

retromammary space. The breast may move freely over the major pectoralis

muscle but is firmly attached to the deep fascia via suspensory ligaments. To

assess clinically the fixity of the breast tumour to the major pectoralis muscle,

the physician should mobilize the tumour over major pectoralis muscle, whenthe patient relaxes and then contracts the muscle, by pressing the hips with her

hands. Reduced mobility with tensed muscle signifies deep tumour fixity.

There are 15-20 mammary glands in each breast. These glands produce milk

after a woman gives birth (lactation). The milk drains into a lactiferous duct that

empties at the nipple. The bulk of the breast develops at puberty and increases

in size during pregnancy and lactation.

Cancer commonly begins in the ducts. Most of the ducts are found in the upper

outer quadrant and because of this 50% of breast cancer is first detected there .

At the site of cancer, lymphatic ducts can be blocked and the thickening of the

overlying skin may develop. This thickening may look similar to an orange

peel and can be detected on a mammogram. If the suspensory ligaments are

affected then they may shorten and cause a dimpling in the breast, more evident

when the patient raises the arms over the head. In later stages, the cancer can

invade the underlying retromammary space, deep fascia and eventually the

pectoralis major causing fixation of the breast.

The cancer cells can move to other areas of the body if not detected early.These metastatic cells move to the lymph nodes located in the axilla. They


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will feel like hard lumps or nodules under the skin. There is usually not

tenderness associated. The metastatic cells may move through blood vessels

into different organs of the body, finding a nest of proliferation and inducing

distant metastases in lungs, liver, bones, brain. For the general assessment of a

patient with breast cancer, these organs must be checked if there is a suspicionof distant metastases.

The Microscopic Anatomy:

The breast is a milk producing organ and its microscopic anatomy is based on

this function.

The Lobules: The lobules, also called the

lobular units, are responsible for theproduction of milk.

The Ductal System: The milk is collected

by distal lactiferous ducts or acini which

merge into minor and then major

lactiferous ducts. In most instances, these

empty into the major duct or sinus which

ends in the nipple. The ductal system has a

ductal epithelium surrounded by a myo-

epithelium. This ductal epithelium isresponsible for the propulsion of milk

through the ductal system as it has

contractile capabilities. This ductal system

is sealed and surrounded by an

uninterrupted basement membrane.

The Stroma: This interlobular tissue, also

referred to as connective tissue, contains

capillaries and other specialized cells.

Cooper's Ligaments: These are densestrands of fascia found throughout the

entire breast which end on the skin itself.

The Basement Membrane of the Ductal

System: It is essential to visualize the

basement membrane in the microscopic

analysis of a malignant breast tumor. This

will assist in the assessment as to whether a

tumor is "in situ" (has not grown through

the basement membrane) or "invasive"


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(has grown through the basement

membrane).

Age Dependant Anatomical Changes of the Breast:

With age, the breast tissue will change. In a young woman, the breast tissue is

dense and parenchyma rich. As the woman ages, the fat content of the breast

tissue will increase. This explains the overall aspect of the breast, as it will

begin to droop. The increased fat content of the breast in older patients accounts

for the higher quality of their mammograms (increased fat content equals

increased image quality).

Pathology Dependant Anatomical Changes:

Peau d'Orange: From the French term, orange skin, this identifies a

malignant obstruction of the superficial lymphatic channels.

Skin Retraction: Skin or Cooper's ligament pulled in by a malignant

lesion.

Nipple Inversion: Inward retraction of the nipple by a malignant ductal

lesion.

Breast Abscess: Fluctuant, purulent collection within the breast

parenchyma

Mondor's Disease: Thrombophlebitis of a superficial vein, usually by anonmalignant lesion

Inflammatory Breast Carcinoma: Malignant invasion of the superficial

skin lymphatic channels seen in advanced breast cancer.

Gynecomastia: This is an activation and hypertrophy of the breast tissue

in men. It can occur frequently in young men (pubertal hypertrophy) and

in older men. It can also be caused by numerous medications and

hormones.

The axilla

The anatomy of the axilla is important to all oncologic surgeons as it represents

the principal lymphatic drainage region of the breast. For inner quadrant lesions,

it can occur in the internal mammary chain. Lymphatic metastasis can also be

present in the supraclavicular nodes.

The surgeon should have an extensive knowledge of the anatomy of the axilla

and its contents in order to perform a safe, precise and appropriate axillary

dissection.


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The lymph node bearing area has been divided into three axillary regions:

Level I: Lymph nodes lateral and inferior to the pectoralis minor muscle

Level II: Lymph nodes under the pectoralis minor muscle

Level III: Lymph nodes under and deep to the pectoralis minor muscle

Most axillary dissections include lymph nodes from Level I and II. In order to

remove these lymph nodes with minimal morbidity, several structures will have

to be identified. They are as follow:

1. The lateral border of the Pectoralis Minor and Major muscle

2. The Latissimus Dorsi Muscle

3. The Axillary Vein

4. The Long Thoracic Nerve which innervates the Serratus Anterior

Muscle5. The Thoraco-Dorsal Nerve which innervates the Latissimus Dorsi

Muscle

6. The Intercostal Brachial Nerve which is a sensory nerve for the inferior

aspect of the arm and the posterior aspect of the axilla

7. The Lateral Pectoral Nerve which innervates portions of the pectoralis

muscle


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BENIGN BREAST DISEASES

Virtually every woman with a breast lump, breast pain or discharge from the

nipple fears that she has cancer, might die or be mutilated. The possible effects

of mastectomy on sexual attractiveness and femininity are often uppermost in a

womans mind, so psychological care should accompany every stage in the

management of breast disorders.

Symptoms

The commonest symptoms: breast lump, painful or painless, pain alone, nipple

discharge, nipple retraction, breast distortion, swelling or inflammation, scaling

nipple or eczema.

Special points in history taking

The most important pointer to the diagnosis is the age of the patient.

Although malignant disease can occur in young women, benign conditions are

much more common. Bear in mind that a lump may have been present much

longer that the woman is aware.

Periodicity of pain in relation to the menstrual cycle suggests a hormone-related

condition rather than malignant disease.


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The duration of any symptom is important- breast cancers usually grow slowly,

but cysts may appear overnight.

Drug history should be recorded; contraceptive pills and hormone replacement

therapy for menopausal symptoms.

Parity, age at first pregnancy and history of breast feeding must be known for a

complete history of the patient.

Clinical examination

Breast exanimation involves six distinct manoeuvres:

1. Observation with the patient sitting up

2. Observation with the patient raising and lowering her arms

3. Examination of the nipples

4. Palpation of each breast quadrant

5. Palpation of the axillae

6. General examination for signs of distant metastases: lungs, bones,

brain, liver.

Inspection

The breasts should be inspected for asymmetry, skin tethering or dimpling,

change in colour, nipple distortion or retraction.

Characteristic signs of breast cancer on inspection are: skin dimpling, visible

lump, peau dorange, surface erithema, surface ulceration, nipple inversion,

eczema around nipple (Pagets).

Peau dorange is caused by a combination of cutaneous infiltration by tumour

and skin oedema.

Palpation


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Breast palpation is performed with the patient lying flat or semirecumbant

position with her arms above the head. All breast tissue is examined, keeping

the hand flat but using the fingertips to detect any abnormality.

The technique of palpating the breast may need to be modified according to thetype of breast being examined. Palpation with the flat of one hand is usual, but

it may be more appropriate to examine large breasts between two hands.

Suspicious physical signs should be compared with the breast on the opposite

side because physiological and other hormonally induced changes tend to be

symmetrical.

If a lump is found, the overlying skin must be examined for mobility and

tethering.

Deep fixation- fixation to the muscles or chest wall, is assessed by asking the

patient to tense the pectoralis major muscle, by asking her to press her hands on

her hips.

The size and site of the palpable lump should be assessed.

If the patient complains of a nipple discharge, you should squeeze gently the

nipple:

- milky discharge suggests pregnancy or hyperprolactinaemia,

- clear discharge is physiological,

- green discharge might suggest perimenopausal, duct ectasia,

- blood-stained discharge may happen in carcinoma or intraduct papilloma.

The left axilla is palpated with the right hand and the right axilla is palpated

with the left hand. It is important to relax the axillary muscles. The fingers of

the examining hand are firmly held in a curve, pressed high into the apex of the

axilla against the chest wall and drawn downwards. The hand will then ride

over any enlarged axillary nodes.

The experienced clinician can probably detect 85% of carcinomas bigger than 1

cm. in diameter. Even among experts, there is at least a 25% error in detecting

axillary node involvement by palpation.


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Because of the high rate of false negative examinations, clinical suspicion alone

is enough to justify further investigations.

Investigations of breast disorders

Mammography

Screening mammography

Screening mammography is performed in the asymptomatic patient and consists

of two standard views, a medio-lateral and cranio-caudal. There is the practical

evidence that screening mammography reduces mortality from breast cancer.

Diagnostic mammography

A diagnostic examination is performed in the symptomatic patient.

Mammographyc findings most predictive of malignancy include spiculated

masses with associated architectural distortion, microcalcifications,

microcalcifications with a mass.

Benign-appearing masses are well-defined, with smooth edges.

Because the breasts are relatively radiodense in women under 35 years of age,

mammography is of little value in this group.

Mammography gives up to 90-95% diagnostic accuracy in the presence of a

palpable lump. The false- negative rate of mammography is 5-10%.

Solid masses cannot be distinguished from cysts by mammography.

Sensitivity= TP/TP+FN (TP=true positive, FN=false negative)

Sensitivity = probability that a person who does have a disease will be correctly

identified by a clinical test.

Specificity=TN/TN+FP (TN=true negative, FP=false positive)

Specificity= the probability that a person who does not have a disease will be

correctly identified by a clinical test

Disease


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+ _

Tests / TP TN

Tests/ FN FP

Ultrasonography

High frequency waves are beamed through the breast and reflections are

detected and turned into images.

Ultrasonography is used as an adjunct to mammography to differentiate solid

from cystic masses. In the patient younger than 30, it is the primary imaging

modality. It is also used to localise breast abscess.

Cysts show up as transparent lesion with well demarcated edges whereas

cancers usually have an indistinct outline and absorb sound, resulting in a

posterior acoustic shadow.

Magnetic resonance imaging

This is an accurate way of imaging the breast. It has a high sensitivity for breast

cancer and may be of value in demonstrating the extent of both invasive and

non-invasive disease. It is useful in differentiating a scar lesion from recurrence.

Fine-needle aspiration cytology

It is a reliable and accurate investigation, with sensitivity of 90-98%, depending

largely on the skill and experience of the cytologist. False-negative findings are

caused by inadequate sampling, improper specimen processing, or the inability

of the cytologist to make the definite diagnosis.

Needle aspiration can differentiate between solid and cystic lesions. If the lesion

is cystic, the fluid is aspirated and, providing it is not bloodstained, discarded.

Aspiration of solid lesions requires skill to obtain sufficient cells for cytological

analysis and expertise is needed to interpret the smears. Aspiration is usually

performed with a 21-or 23-gauge needle attached to a syringe. The needle is

introduced into the lesion and suction applied by withdrawing the plunger;

multiple passes are then made through the lesion. The plunger is then released


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and the material spread on to microscope slides. These are then either air-dried

or fixed in alcohol and later stained.

Core biopsy

Core biopsy either with a cutting needle or special device is a useful technique

for large, palpable, solid masses. It is performed under local anesthesia.

Several cores are removed from a mass. Estrogen and progesterone receptors

are assessed by immunocytochemistry.

Open biopsy

Excisional biopsy is performed in the operating room. After specimen removal,

it should be oriented (e.g., short suture superior, long suture lateral) and sentfresh for pathologic inking and processing.

Incisional biopsy removes a wedge of tissue from a palpable breast mass. It is

indicated for the evaluation of a large breast mass that is suspected to be

malignant and for which a definitive diagnosis cannot be made by FNAB or

core biopsy.

I. DISORDERS OF DEVELOPMENT

Most benign breast conditions occur during either development, cyclical activity

or involution, and are so common that they are best considered as aberrations

rather than true disease.

1. Juvenile hypertrophy

Uncontrolled overgrowth of breast tissue occurs occasionally in adolescent

girls. These changes are usually bilateral, but may be limited to one breast or

part of one breast. There is an increase in the amount of stromal tissue rather

than in the number of lobules and ducts.

These excessive growth is an aberration rather than a true disease.

Simptoms: pain in the shoulder, neck and back due to large breasts.


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Treatment: reduction mammoplasty

2. Fibroadenoma

Fibroadenomas are classified in most texts as benign tumors, but are best

considered as aberrations of development rather than true neoplasms. The

reasons are that fibroadenomas develop from a single lobule and show

hormonal dependence similar to that of normal breast tissue, lactating during

pregnancy and involuting in the perimenstrual period. Fibroadenoma are most

commonly seen immediately following the period of breast development, in the

15-25-year age group

Fibroadenomas are usually found as single lumps, but about 10 - 15% of women

have several lumps that may affect both breasts.

Black women tend to develop fibroadenomas more often and at an earlier age

than white women. The cause of fibroadenoma is not known.

Symptoms and signs

They are well circumscribed, painless, firm, smooth, mobile. They may be

multiple or bilateral. Although a number of fibroadenomas increase in sizeespecially during pregnancy, the majority do not and over a third become

smaller or disappear within 2 years. The lumps often get smaller after

menopause (if a woman is not taking hormone replacement therapy).

Exams and Tests

After a careful physical examination, the following tests may be done to

determine further information about a breast lump: breast ultrasound, FNAC,

biopsy (needle or open), mammogram.Women in their teens or early 20s may not need a biopsy if the lump goes away

on its own.

Management

If a biopsy indicates that the lump is a fibroadenoma, the lump may be left in

place or removed, depending on the patient and the lump. If left in place, it may

be watched over time with: physical examination, ultrasound, mammogram.

The lump may be surgically removed at the time of an open biopsy (this iscalled an excisional biopsy). The decision depends on the features of the lump


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and the patient's preferences. Once a diagnosis of fibroadenoma has been

established and provided the lesion measures less than 4 cm., options for

management include observation or excision.

Fibroadenomas over 4 cm. in diameter should be excised to ensure thatphyllodes tumours are not missed.

Often fibroadenomas will grow in the presence of hormonal stimulation, such as

pregnancy.

Outlook (Prognosis)

The outlook is excellent, although patients with fibroadenoma have a slightly

higher risk of breast cancer later in life. Lumps that are not removed should be

checked regularly by physical exams and imaging tests, following the doctor's

recommendations.

Possible Complications

If the lump is left in place and carefully watched, it may need to be removed at a

later time if it changes, grows, or doesn't go away.

II. DISORDERS OF CYCLICAL CHANGE

Premenstrual nodularity and breast discomfort are so common that they are

considered part of the normal cyclical changes. When premenstrual pain is

severe, interferes with daily activities and influences quality of life.

There is no association between cyclical brest pain and any underlying

histological abnormality.

The cause is unknown.

1. Cyclical mastalgia

Cyclic breast pain often is described as a heaviness or tenderness.

Many patients will experience symptomatic relief by reducing the caffeine

content of their diet and by ingesting vitamin E, 400-800 units/day, although

there is no scientific proof that these methods are valuable.

More than 85% of cyclical breast pain is of minor degree and no specifictreatment is required.


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Treatment should be considered for women who have moderate to severe pain.

Antibiotics, vitamin B6, progestogens, diuretics are not effective.

Evening primrose oil-EPO- two 500-mg. capsules three times a day. EPO is an

essential fatty acid supplement containing cis-linoleic acid and gamma-linoleic

acid. It is believed to act by increasing synthesis of prostaglandin E1,which

inhibits the action of prolactin peripherally.

Danazol ( a derivative of 17 ethinyl testosterone) is used in a dose of 100/day

PO for 2-3 months.705 of patients will respond.

Side effects are: hirsutism, weight gain, irregular periods.

Bromocriptine is rarely used because of its side-effects.

2. Nodularity

Lumpiness and nodularity in the breast can be diffuse or focal. Diffuse

nodularity is normal, particularly premenstrually. Diffuse nodularity is not

associated with any underlying pathological abnormality.

Patients with focal nodularity often report that the lump fluctuates in size in

relation to the menstrual cycle. Breast cancer should be excluded in patientswith localised asymmetric areas of nodularity, using triple assessment.

III. DISORDERS OF INVOLUTION

Aberrations of the normal ageing process include cyst formation, areas of

scarring (sclerosis) and epithelial hyperplasia.

1. Palpable breast cysts

Approximately 7% of women develop a palpable breast cyst at some time intheir life. Cysts constitute 15% of all discrete breast masses. They are distended

involuted lobules and are seen in the perimenopausal period.

Clinically they are smooth discrete lumps that can be painful and are sometimes

visible.

Mammographically they have characteristic halos and are easily diagnosed by

ultrasonography.


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Symptomatic palpable cysts are treated by aspiration and provided the fluid is

not bloodstained it can be discarded.

If aspiration results in the disappearance of the mass then the patient can be

reassured.

Any residual mass should be investigated by fine-needle aspiration cytology.

Cysts that rapidly and persistently refill or contain blood-stained fluid, require

excision to exclude an associated cancer.

Most cysts are asymptomatic and, provided they are appropriately investigated

by ultrasound, do not need aspiration.

All patients with cysts should have mammography, preferably before cystaspiration, as between 1 and 3% will have a cancer, usually remote from the

cyst, visible on mammography.

2. Sclerosis

Areas of excessive fibrosis or sclerosis can occur as part of stromal involution.

These lesions are of clinical importance only because they produce stellate

lesions that mimic breast cancer mammographycally, and so can causediagnostic problems.

3. Duct ectasia

The major subareolar ducts dilate and shorten with age and, when symptomatic,

this is known duct ectasia. By the age of 70 40% of women are affected, some

of whom present with nipple discharge or retraction. The discharge is usually

cheesy and the retraction is classically slit-like, which contrasts with breast

cancer, when the whole nipple is pulled in. Surgery is indicated if the dischargeis troublesome or if the patient wishes the nipple to be everted.

4. Epithelial hyperplasia

An increase in the number of cell lining the terminal duct lobular unit is known

as epithelial hyperplasia, the degree of which is graded as mild, moderate or

florid. If the hyperplastic cells show cellular atypia the condition is called


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atypical hyperplasia. Women with atypical hyperplasia have a significant

increase in their risk of breast cancer.

IV. BENIGN NEOPLASMS

1. Duct papillomas

These can be single or multiple, are very common, and should be considered as

aberrations rather than true neoplasms as they show minimal malignant

potential. They cause persistent and troublesome nipple discharge, which is

frankly bloodstained or serous.

Treatment comprises removal of the discharging duct , which removes the

papilloma and allows the exclusion of an underlying neoplasm, which is seen in

5% of women who present with a bloodstained nipple discharge.

2. Lipomas

These are soft, lobulated, radiolucent lesions and are common. Interest lies in

their confusion with a soft mass that can be felt around a cancer, caused by

indrowing of surrounding fat.

3. Phyllodes tumours

These rare fibroepithelial neoplasms may be malignant in their behaviour,

although most are benign. They are localized masses which clinically feel like

fibroadenomas. Up to 20% of benign phyllodes tumour recur locally following

simple excision.

Treatment of phyllodes tumour, whether malignant or benign, is wide excision

or, if necessary because of the size of the lesion, mastectomy.

V. BREAST INFECTION

Breast infection can be divided into lactational and non-lactational. Infection

can also affect the skin overlying the breast.

The principles in treating breast infection are:

1. Give appropriate antibiotics early to reduce the formation of abscesses

2. If an abscess is suspected, confirm pus is present by aspiration before

considering surgical drainage.


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3. Exclude breast cancer using imaging and cytology in an inflammatory

lesion which is solid on aspiration and which does not settle despite

adequate antibiotic treatment.

1. Lactational infection

Improvement in maternal and infant hygiene have considerably reduced the

incidence of infection associated with breastfeeding.

Symptoms and signs are pain, swelling, tenderness, cracked nipple or skin

abrasion. Usually the bacterias involved in lactating infection are:

staphylococcus aureus, staph. epidermidis and streptococci.

Early infection is treated with flucoxacillin or co-amoxiclav.

Established abscess is treated by incision and drainage.

Women should be encouraged to breastfeed as this promotes milk drainage.

2. Nonlactational mastitis

Nonlactational breast infections may occur due to duct ectasia with periductal

mastitis, infected simple cyst, infected hematoma of the breast, hematogenous

spread from another sourse of infection.

Management

Antibiotics should be given early to abort abscess formation

Hospital referral is indicated if the infection does not settle rapidly on

antibiotics.

If an abscess is suspected, this should be confirmed by aspiration

If the lesion is solid on aspiration, a sample of cells should be obtained for

cytology to exclude an underlying inflammatory carcinoma

Study questions:

1. A 21years old female patient, complains of a painless lump in the right

breast that she noticed two days ago. At the same time, following axillary

shaving, she also noticed a lump in the right axilla with acuteinflammatory signs. How would you manage this case?


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2. A young female patient who has a 2 months baby on breast feeding

comes to Casualty complaining of a very painful lump in the left breast,

fever and chills. What do you do?

3. 62 years old patient presents a painless lump of 3 cm in size in the leftbreast and two painless lumps of 2 cm in the left axilla. What do you

think is going on? What investigations would you request for diagnosis?

1.1 breast surgery

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