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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, when
the 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 suspicion
of 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 the
production 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 is
responsible 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 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"
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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 a
nonmalignant 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
Muscle
5. 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
woman’s 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 d’orange, surface erithema, surface ulceration, nipple inversion,
“eczema” around nipple (Paget’s).

Peau d’orange 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 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 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 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.

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 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).

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 is
called 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 that


phyllodes 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 specific
treatment 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 patients
with 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 in


their 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 cyst
aspiration, 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 cause
diagnostic 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 discharge
is 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 acute
inflammatory 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 left


breast 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?