HYSTORY CLINICAL EXAMINATION

LAB. TESTSIMAGISTIC INVESTIGATIONS

TREATMENT MODALITIESSURGERY - CLASIC OR MINIMALLY INVASIVE (LAPAROSCOPIC)MEDICAL- COMORBIDITIES, DEFFICITS

CORRECTION: SEVERE ANEMIA, HYPOVOLEMIA, DISELECTROLYTEMIA, ANTIBIOTICS, ANTICOAGULANTS

ADJUVANT, NEOADJUVANT: RADIOTHERAPY, CHEMOTHERAPY

SURGICAL TREATMENTTHE RIGHT OPERATION PERFORMED WELLTHE RIGHT OPERATION PERFORMED BADLYTHE WRONG OPERATION PERFORMED WELLTHE WRONG OPERATION PERFORMED BADLY

In only one case the patient will have the best result

Surgery is the branch of medicine that treats diseases, injuries, and deformities by manual or

operative methods.

Mammary glands-specialized accessory glands of the skin

Gland tissue, milk ducts, fibrous tissue, fat, areola/nipple, lymphatic ducts, skin

Between the deep fascia and breast is an area called the retromammary space. The breast may move freely over the pectoralis muscle but is firmly attached to the deep fascia via suspensory ligaments.

How does the breast produce milk?

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 consists of mostly fat. 

When a woman begins to lactate the mammary glands increase in size and the breast enlarges

Cancer commonly begins in the ducts

Most of the ducts are found in the upper outer quadrant - 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-orange peel- can be detected on a mammogram. 

If the suspensory ligaments are affected then they

may shorten and cause a dimpling of the skin ( tethering). 

Cancer commonly begins in the ducts In later stages, the cancer can invade the

underlying retromammary space, deep fascia and eventually the pectoralis major causing deep fixation of the breast. 

The cancer cells can move to other areas, these “metastatic” cells move to the lymph nodes located in the axilla - painless hard lumps or nodules under the skin. 

Lymphatic drainage

Perform a safe, precise and appropriate axillary dissection.

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:

The Axillary Vein The Long Thoracic Nerve

which innervates the Serratus Anterior Muscle

The Thoraco-Dorsal Nerve which innervates the Latissimus Dorsi Muscle

The Intercostal Brachial Nerve which is a sensory nerve for the inferior aspect of the arm and the posterior aspect of the axilla

The Lateral Pectoral Nerve which innervates portions of the pectoralis muscle

Microscopic anatomyThe Lobules: The lobules, also called the lobular

units, are responsible for the production of milk.

The Ductal System: The milk is collected by distal lactiferous ducts

which merge into minor and then major lactiferous ducts which ends in the nipple.

The ductal system has a ductal epithelium. This ductal system is sealed and surrounded by an uninterrupted basement membrane.

Microscopic anatomyThe Stroma: This interlobular tissue, also referred to

as connective tissue, contains capillaries and other specialized cells.

Cooper's Ligaments: These are dense strands 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" (has grown through the basement membrane).

The microscopic anatomy of the breast demonstrates why most breast cancers are ductal or lobular in origin.

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 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.

Benign breast disease

Symptoms and signs:Breast lumpBreast painNipple dischargeNipple retractionBreast distortionBreast inflammationNipple scaling

Special points in history taking

AgeRelation of the pain with menstrual cycleDuration of symptomsDrug historyParityAge of the first pregnancyHistory of breast feeding

Clinical examinationBreast exanimation involves six distinct

manoeuvres:Observation with the patient sitting upObservation with the patient raising and

lowering her armsExamination of the nipplesPalpation of each breast quadrantPalpation of the axillaeGeneral examination for signs of distant

metastases

Characteristic signs of breast cancer on inspectionskin dimpling, visible lump, peau d’orange - caused by a combination of

cutaneous infiltration by tumour and skin oedema,

surface erithema, surface ulceration, nipple inversion, “eczema” around nipple- scaling nipple

(Paget’s).

Breast lumpFinding a lump in one of your breasts can cause you a lot of

anxiety. Most breast lumps, particularly in younger women, are not

caused by cancer but are benign

Look with her arms at her sides and with her arms above her head.

Is a lump visible? Do the breasts look symmetrical? Slight asymmetry is quite

normal. Is there an inverted nipple and if so is it unilateral or bilateral? Is there puckering of the skin or peau d’orange (orange peel)

Breast lumpThe next stage is palpation and a systematic search pattern

improves the rate of detection. Ask the patient to lie supine with her hands above her head.

Remember the axillary tail of breast tissue. Examine the axilla for palpable lymphadenopathy.

Be aware that 50% of breast tissue is found in the upper outer quadrant and 20% under the nipple.

Using the second, third and fourth fingers held together moved in small circles is the most sensitive technique.

Begin with light pressure and then repeat the same area using medium and deep pressure before moving to next area.

PalpationThree search patterns are generally used:Radial method (wedges of tissue examined starting

at the periphery and working in towards the nipple in a radial pattern).

Concentric circle method examining in expanding or contracting concentric circles.

Vertical strip method examines the breast in overlapping vertical strips moving across the chest. The vertical strip method has been shown to be more sensitive because the entire nipple-areolar complex is included and examiner is able to keep track better.

Palpation

Relation to the skin

Relation to the muscle

Palpate the nipple

Palpate the axillae and supraclavicular fossae

PalpationThe technique of palpating the breast may need to be

modified according to the type 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 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 or duct ectasia

blood-stained discharge may happen in carcinoma or intraduct papilloma

AxillaeThe 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.

Because of the high rate of false negative examinations, clinical suspicion alone is enough to justify further investigations.

InvestigationsMammography

ScreenigDiagnostic

UltrasoundMagnetic resonance imagingFine needle aspiration cytologyCore biopsyOpen biopsy

Screening mammography

Screening mammography is performed in the asymptomatic patient.

Consists of two standard views, a mediolateral and craniocaudal.

There is the practical evidence that screening mammography reduces mortality from breast cancer

Screening mammographyCranio-caudal incidence

Normal breast-dense, homogenous, breast

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.

Malignant lump

Microcalcifications

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 and specificitySensitivity = probability that a person who does have a

disease will be correctly identified by a clinical test.Sensitivity = TP/TP+FN

Specificity = probability that a person who does not have a disease will be correctly identified by a clinical test

Specificity =TN/TN+FPDisease

+ _Tests/ TP TNTests/ FN FP

 

Ultrasonography

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 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

Valuable in demonstrating the extent of disease.

It is useful in differentiating a scar lesion from recurrence.

MRI - indicationsStaging- tumour/lymph nodes,

multicentricityFollow-up after adjuvant

chemotherapyRecurrence following conservative

surgeryClinical suspicious with conventional

negative investigationsScreening in young patients with

high risks.

Fine-needle aspiration cytology

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.

The needle is introduced into the lesion and suction applied by withdrawing the plunger

The plunger is then released and the material spread on to microscope slides.

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

Any breast lump must be investigated by FNAC/CB even if the mammography is negative

FNAC- cytologic investigation

Core biopsy-immunocytichemistry RE/ RPg, HER2/neu Ki-67 ,angiogenetic markers.

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 sent fresh 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.

Disorders of the development

Juvenile hypertrophy

Fibroadenoma

Juvenile hypertophyUncontrolled 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 breastsTreatment: reduction mammoplasty

Virginal breast hypertrophy (VBH) is the common name for the medical condition juvenile macromastia and juvenile gigantomastia

This condition causes a woman's breasts to grow rapidly to an excessive weight during puberty. The main symptom is pain in the breasts.

This causes great physical discomfort.

Women suffering VBH often experience an excessive growth of their nipples.

FibroadenomaFibroadenomas - benign tumors - 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.

Fibroadenomas are most commonly seen immediately following the period of breast development, in the 15-25-year age group

FibroadenomaFibroadenomas are usually found as single

lumps,

10 - 15% - multiple bilateral breast lumps.

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

The cause of fibroadenoma is not known.

Symptoma and signsThey are well circumscribed, Painless, Rubbery/firm, Smooth, Mobile. They may be multiple or bilateral.A number of fibroadenomas increase in size especially

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).

FIBROADENOMA

FIBROADENOMA

FIBROADENOMA-USS-greater diameter is parallel to the skin – sign of benignity

FIBROADENOMA-USS- well delineated-sign of benignity

FIBROADENOMAFibroadenoma removed

during breast biopsy.

This type of benign mass is usually quite mobile on physical examination and represents benign proliferation of connective tissue that encapsulates epithelial cells.

FIBROADENOMA

Exams and Tests

After a careful physical examination, Tests :

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.

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 is called an excisional biopsy).

The decision depends on the features of the lump and the patient's preference.

The lesion measures < 4 cm., options for management include observation or excision.

Fibroadenomas > 4 cm. in diameter should be excised to ensure that phyllodes tumours are not missed.

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

Disorders of the cyclical change

Cyclical mastalgia

Nodularity

Cyclical mastalgiaCyclic 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 specific treatment is required.

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

Cyclical mastalgiaAntibiotics, 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

Pain killers: Some women gain relief by taking simple painkillers, such as paracetamol or ibuprofen but they are generally only of value in milder cases.

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 period

Bromocriptine is rarely used because of its side-effects.

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 patients with localised asymmetric areas of nodularity, using triple assessment

Disorders of involution-aberrations of normal aging process

Breast cystsSclerosisDuct ectasiaEpithelial hyperplasia

Breast cystsApproximately 7% of women develop a palpable breast cyst

at some time in their life.

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.

Symptomatic palpable cysts are treated by aspiration and provided the fluid is not bloodstained it can be discarded.

Breast cyst 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.

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

Breast cysts

Cysts are fluid-filled sacs caused by dilated ducts.

Cysts are oval or round, smooth and firm, and they move slightly when you press them.

Breast cyst

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 cause diagnostic problems.

Duct ectasiaThe 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 discharge is troublesome or if the patient wishes the nipple to be everted.

DUCT ECTASIA

Epithelial hyperplasiaAn 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 severe.

If the hyperplastic cells show cellular atypia the condition is called atypical hyperplasia.

Women with atypical hyperplasia have a significant increase in their risk of breast cancer

Benign neoplasmsDuct papillomas - bloodstained nipple discharge

Lipomas - fatty tissue tumours

Phyllodes tumours- fibro-epithelial tumour with malignant potential

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 infectionGive appropriate antibiotics early to reduce the

formation of abscesses

If an abscess is suspected, confirm pus is present by aspiration before considering surgical drainage.

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.

Lactating 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.