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TESTS IMAGISTIC INVESTIGATIONS
SURGERY - CLASIC OR
MINIMALLY INVASIVE (LAPAROSCOPIC) MEDICAL- COMORBIDITIES, DEFFICITS CORRECTION: SEVERE ANEMIA, HYPOVOLEMIA, DISELECTROLYTEMIA, ANTIBIOTICS, ANTICOAGULANTS ADJUVANT, NEOADJUVANT: RADIOTHERAPY, CHEMOTHERAPY
THE RIGHT OPERATION PERFORMED WELL THE RIGHT OPERATION PERFORMED BADLY THE WRONG OPERATION PERFORMED WELL THE 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. shorten and cause a dimpling of the skin ( tethering).
If the suspensory ligaments are affected then they may
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.
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
The 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.
The 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
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 lump Breast pain Nipple discharge Nipple retraction Breast distortion Breast inflammation Nipple scaling
Special points in history taking
Age Relation of the pain with menstrual cycle Duration of symptoms Drug history Parity Age of the first pregnancy History of breast feeding
Breast exanimation involves six distinct
Observation with the patient sitting up Observation with the patient raising and lowering her
arms Examination of the nipples Palpation of each breast quadrant Palpation of the axillae General examination for signs of distant metastases
Characteristic signs of breast cancer on inspection
skin 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).
Finding 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)
The 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.
Three 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.
Relation to the skin Relation to the muscle Palpate the nipple Palpate the axillae and supraclavicular fossae
The 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
clear discharge is physiological, green discharge might suggest perimenopausal or
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
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.
Ultrasound Magnetic resonance imaging Fine needle aspiration cytology Core biopsy Open biopsy
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 mammography Cranio-caudal incidence
Normal breastdense, homogenous , breast
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 510%.
Solid masses cannot be distinguished from
cysts by mammography.
Sensitivity and specificity
Sensitivity = 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+FP Disease + _ Tests/ TP TN Tests/ FN FP
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 - indications
Staging- tumour/lymph nodes,
multicentricity Follow-up after adjuvant chemotherapy Recurrence following conservative surgery Clinical suspicious with conventional negative investigations Screening 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 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
RE/ RPg, HER2/neu Ki-67 ,angiogenetic markers.
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
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 Treatment: 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
Women suffering VBH often
experience an excessive growth of their nipples.
Fibroadenomas - 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 1525-year age group
Fibroadenomas 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 signs
They 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).
diameter is parallel to the skin – sign of benignity
FIBROADENOMA-USS- well delineatedsign of benignity
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.
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
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
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 specific treatment is required. 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 gammalinoleic 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.
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 involutionaberrations of normal aging process
Breast cysts Sclerosis Duct ectasia Epithelial hyperplasia
Approximately 7% of women develop a palpable breast cyst
at some time in their life.
They are distended involuted lobules and are seen in the
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.
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
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.
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.
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 discharge is troublesome or if the patient wishes the nipple to be everted.
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 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
Duct papillomas - bloodstained
Lipomas - fatty tissue tumours Phyllodes tumours- fibro-epithelial
tumour with malignant potential
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
Give 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.
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.
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