Surgery

The Breast
Rose Belle E. Rahon-Sucgang, MD
August 24, 2020

OUTLINE Mammary Gland Development

EMBRYOLOGY AND ANATOMY OF THE BREAST ....................................... 1 Primary bud is from ingrowth of ectoderm
Embryology ..................................................................................................................... 1
Breast Development Abnormalities ............................................................................... 1
Anatomy........................................................................................................................... 2 15 to 20 secondary buds
PHYSIOLOGY OF THE BREAST ..................................................................... 3
Hormones ........................................................................................................................ 3 Major lactiferous ducts form and open to mammary pit
Breasts at Physiologic Levels ......................................................................................... 3

BREAST CANCER............................................................................................ 4 Proliferation of mesenchyme transforms mammary pit into a nipple

Breast Cancer Risk Factor and Assessment ................................................................. 4
Breast Cancer Diagnosis, Pathology and Staging ........................................................ 4

DIAGNOSIS: PALPABLE MASS SUSPICIOUS FOR CANCER ...................... 5

DIAGNOSIS: NON-PALPABLE BREAST LESION SUSPICIOUS FOR

CANCER ........................................................................................................... 5

PATHOLOGY: HISTOLOGIC TYPES .............................................................. 5

PROGNOSTIC AND PREDICTIVE FACTORS ................................................. 5

BREAST CANCER BIOMARKERS .................................................................. 5

STAGING: AJCC 7TH EDITION ........................................................................ 6

T = Primary Tumor .......................................................................................................... 6
N = Regional (axillary) lymph nodes .............................................................................. 6
pN = Pathologic Regional................................................................................................ 6
M = Distant Metastases ................................................................................................... 6

TREATMENT FOR BREAST CANCER ............................................................ 6

Adjuvant Systemic Treatment ........................................................................................ 7

BREAST SELF EXAMINATION (BSE) ............................................................. 7

When to do BSE? ............................................................................................................. 7
Figure 2. Mammary Gland Development
Sauce: (Taken from Schwartz 11th ed.)
- The breast remains underdeveloped in the female until puberty
- The breasts remain incompletely developed until pregnancy occurs
EMBRYOLOGY AND ANATOMY OF THE BREAST
Embryology
Breast Development Abnormalities
- 5th or 6th week of Fetal Development
Amastia
o 2 ventral bands of thickened ectoderm (mammary ridges / milk
lines) evident in the embryo - Absence of the breast
- Rare condition; due to arrest in mammary ridge development

Figure 3. Bilateral Amastia

Poland’s Syndrome
- Hypoplasia or complete absence of the breast tissue
- Accompanied by costal cartilage and rib defects, hypoplasia of the
subcutaneous tissues of the chest wall, and brachysyndactyly
Figure 1. The Mammary Milk Line
(abnormal shortness of fingers ad toes combined with a webbing
between the adjacent digits)

1 of 8
 Surgery | The Breast
Borders of the Breast:
- Level of 2nd / 3rd rib to the inframammary fold at the level of 6th / 7th rib
- Transversely: Lateral border of the sternum (medial) to the anterior
axillary line (lateral)
- Posteriorly: Fascia of the pectoralis major, serratus anterior, and
external oblique abdominal muscles, and upper extent of the rectus
sheath

Figure 4. Bilateral Poland’s Syndrome

Figure 8. Anatomy of the Breast

Figure 5. Poland’s Syndrome: (L) unilateral hypoplastic pectoralis major,
(R) major brachydactyly Nipple-Areola Complex
- The areola contains sebaceous glands, sweat glands, and
Symmastia mammary glands; produces small elevations on the surface –
- Rare anomaly; webbing between the breasts across the midline Montgomery tubercles
- Smooth muscle bundle fibers are responsible for the nipple
erection, occur with various sensory stimuli
- The dermal papilla at the tip of the nipple contains numerous
sensory nerve endings and Meissner’s corpuscles

Blood Supply
Principal Blood Supply
1) Perforating branches of Internal Mammary / Thoracic artery
2) Lateral branches of the Posterior Intercostal arteries
3) Branches from the Axillary artery

Figure 6. Congenital Symmastia

Polythelia
- Accessory nipples; occurs in <1% of infants
- Usually associated with abnormalities in the urinary and
cardiovascular systems
- Extra nipples may develop along the primitive mammary ridge or line

Figure 9. Blood Supply of the Breast

Figure 7. Polythelia
Venous Drainage
Anatomy - Principal Groups of Veins:
- Composed of 15 -20 lobes, each composed of several lobules 1) Perforating branches of the Internal Thoracic veins
- Fibrous bands / Cooper’s Suspensory Ligaments 2) Perforating branches of Posterior Intercostal veins
o Inserts perpendicularly into dermis, provides structural support 3) Tributaries of the Axillary vein

2 of 8
 Surgery | The Breast
- Batson’s Vertebral Venous Plexus Breasts at Physiologic Levels
o Invests the vertebrae and extends from the base of the skull to Adolescence
the sacrum - Increase in the estrogen and progesterone secretion of the ovaries
o Provides the root of breast cancer metastasis to the - Menstrual cycle is established
vertebrae, skull, and pelvic bones - Resultant increase in the size and density of the breasts, followed
by the engorgement of the breast tissue and proliferation of the
epithelium

Pregnancy
- Dramatic increase in the circulating ovarian and placental estrogens
and progestins
- These adders deform end substance of the breast (?)
- Breast further enlarges as ductal and lobular epithelium
proliferates
- Areolar skin becomes darker; accessory areolar glands /
Montgomery glands become more prominent

Figure 10. Venous Drainage of the Breast
Axillary Lymph Node Groups
- Generally parallel blood vessels, boundaries for drainage are not well
demarcated but grouped into 3 (pectoralis minor is the border):
Level I – Lateral to the Pectoralis Minor muscle
Level II - Deep into the Pectoralis Minor muscle
Level III – Medial to the Pectoralis Minor muscle
Lactation
- In late pregnancy, fat droplets accumulate in the alveolar epithelium
- Colostrum fills the alveolar ductal space
- After delivery, circulating estrogen and progesterone levels would
then decrease, permitting full lactogenic action of progestins
during lactation
Senescence
- With menopause, there is decreased secretion of estrogen and
progesterone -> involution of the ducts and alveoli of the breasts
- Surrounding tissues replaced by adipose tissues

Figure 11. Axillary lymph node groups

PHYSIOLOGY OF THE BREAST

Hormones
Breast development and function are initiated by a variety of hormonal
stimuli:
- Estrogen
o Ductal development
- Progesterone
o Differentiation of epithelium
o Lobular development
- Prolactin
o Lactogenesis in late pregnancy and postpartum period
o Upregulates hormone receptors
o Stimulates epithelial development
- Oxytocin
- Thyroid Hormone
- Cortisol
- Growth Hormone

Estrogen, Progesterone, and Prolactin have profound 3 trophic Figure 12. The breast at different physiological stages:
A) Adolescence, B) Pregnancy, C) Lactation, D) Senescence
effects essential to normal breast development and function.

3 of 8
 Surgery | The Breast
BREAST CANCER o Carcinomas present as:
- Most common site-specific cancer in women ▪ Mass
- Three (3.3) out of 100 women would have had a likelihood of getting ▪ Asymmetry
breast cancer ▪ Microcalcifications
- Still the highest mortality cancer type among females • Amorphous, indistinct, pleomorphic, fine, linear or
branching
Breast Cancer Risk Factor and Assessment
- Breast Ultrasound
- Men can develop breast cancer but is 100x more common in females o May be used to:
- Increased estrogen exposure ▪ Resolve equivocal mammographic findings
- Early menarche, late menopause, delayed age at first live birth, etc. ▪ Define cystic masses
- -Risk assessment tools:
▪ Demonstrate echogenic qualities of specific solid masses
o Gain model:
▪ Initial imaging test of palpable findings in patients <30,
▪ Age at menarche
pregnant or lactating
▪ # of biopsies/history of benign breast disease
st
▪ Guide biopsies
▪ Age at 1 livebirth
▪ # of 1st degree relatives with breast cancer

Figure 13. Carcinoma seen in mammogram

BRCA
Clinical Anticipated
BI-RADS Detected
Assessment Management CA after
Category Rate /
Recommendation biopsy
1000
Need Review prior
additional studies and/or
0
imaging complete
evaluation additional imaging
Cont. routine
1 Negative 0.7 -
screening
Cont. routine
2 Benign 1.2 -
screening
Short term ff-up
Probably mammogram at 6
3 8.1 < 2%
benign mo., then every 6-
12 mo for 1-2 yrs
Suspicious Perform biopsy,
4 135.8 23 – 34%
abnormality preferably needle
Highly
Biopsy and
suggestive
5 treatment as 605.3  95%
of
necessary
Table 1. The Gail model malignancy
Biopsy- Assure that
Breast Cancer Diagnosis, Pathology and Staging 6 proven treatment is
malignancy completed
- Mammography
Table 2. Breast Imaging Reporting and Data Systems: BI-RADS Category
o Preoperative mammography to detect subclinical disease
▪ Contralateral breast: if for MRM
▪ Bilateral: if for possible BCS

4 of 8
 Surgery | The Breast
o 10-30% of screening-detected malignancies
o Mammogram: microcalcifications
- Lobular Carcinoma in Situ
o Marker of increased risk of invasive breast cancer and NOT as
an anatomic precursor
▪ Invasive breast cancer may develop in either breast
▪ Majority (65%) of subsequent invasive breast cancer are
ductal, not lobular
o Invasive breast cancer develops in 25-35%

Figure 14. Breast Ultrasound: (L) Benign cyst, (R) Malignant tumor
DISEASE Frequency (%)
Paget’s Disease of the Nipple
DIAGNOSIS: PALPABLE MASS SUSPICIOUS FOR CANCER
Invasive Ductal Carcinoma:
- First step is to obtain a biopsy of the mass
Adenocarcinoma with productive fibrosis 80%
- Fine needle aspiration biopsy (FNAB) attached to a syringe, passes (scirrhous, simplex, NST)
to the tumor 2-4x to obtain samples and fixed with 95% alcohol onto
slides Medullary Carcinoma 4%
- Core Needle Biopsy (CNB) is 24 gauge, requires 3-4 tissue passes Mucinous (Colloid) Carcinoma 2%
o gold standard for breast tumors
- Surgical Biopsy can be either incisional (larger tumor) or excisional Papillary Carcinoma 2%
(smaller tumor) Tubular Carcinoma 2%
- Needle biopsies are preferred over open biopsy due to less
invasiveness and excellent diagnostic accuracy Invasive Lobular Carcinoma 10%
Rare cancers
(adenoid cystic, squamous cell, apocrine)
Table 3. Foote and Stewart Classification for Invasive Breast Cancer

PROGNOSTIC AND PREDICTIVE FACTORS

- With tubular, mucinous and invasive papillary carcinoma have
favorable prognosis

Figure 15. Biopsy options based on increasing invasiveness

DIAGNOSIS: NON-PALPABLE BREAST LESION SUSPICIOUS FOR

CANCER
- When doing needle / wire localization it is important to do have a
specimen radiograph to ensure all the specimen has been removed

Table 4. Traditional prognostic and predictive factors for invasive breast cancer

BREAST CANCER BIOMARKERS

- Determined through immunohistochemical techniques
- Estrogen and Progesterone Receptors
o Identifies patient who will benefit from endocrine therapy
Figure 16. Image-guided biopsy options for non-palpable breast lesions
- Her2/neu Receptors
o Prognostic and predictive factor in breast cancer
PATHOLOGY: HISTOLOGIC TYPES
- Ductal Carcinoma In Situ o Enhances growth and proliferation of breast cancer
o Neoplastic intraductal lesion characterized by: o Increases invasive and metastatic capabilities
▪ Increased epithelial proliferation o Identifies patients who will benefit from targeted therapy with
anti-Her2/neu
▪ Cellular atypia
▪ Tendency to progress to invasive breast cancer (relative
risk 8-11)
5 of 8
 Surgery | The Breast
STAGING: AJCC 7TH EDITION
N3c Ipsilateral supraclavicular
T = Primary Tumor
Table 6. TNM Staging System for Breast Cancer:
- Paget’s disease of the nipple is characterized by exudates/ crusting N = Regional (Axillary) Lymph Nodes
of the areola
o Histologically there is infiltration of epidermis by non-invasive pN = Pathologic Regional
breast cancer epithelial cells
- T4 are those with skin or chest wall involvement pN Category Description
- Skin involvement is limited to ulceration, ipsilateral satellite nodules No regional lymph node metastasis identified
pN0
or edema <1/3 of the breast histologically
- Nipple retraction and skin dimpling are NOT considered to be T4 pN1
- Inflammatory carcinoma is characterized by diffuse erythema and
pN1mi Micrometastases
edema (peau d’orange) involving 1/3 or more of the skin of the
breast +/- dermal lymphatic invasion on biopsy pN1a 1-3 axillary lymph nodes

Micro/macrometastases in internal mammary

T Category Description pN1b
nodes detected by SLN but NOT clinically
TX Primary Tumor cannot be assessed 1-3 axillary lymph nodes AND
T0 No evidence of primary tumor micro/macrometastases in internal mammary
pN1c
nodes detected by SLN but NOT clinically
Carcinoma in situ Ipsilateral
Tis Table 7. TNM Staging System for Breast Cancer:
Ductal Carcinoma in situ
Tis (DCIS) pN = Pathologic Regional
Lobular Carcinoma in situ
Tis (LCIS)
Paget’s disease of the nipple NOT associated with
Tis (Paget’s) M = Distant Metastases
invasive carcinoma and/or carcinoma in situ

T1 Tumor  20 mm in greatest dimension M Category Description

T1mic Tumor  1 mm No regional lymph node metastasis identified
T1a Tumor  1 mm but,  5 mm M0 clinical or radiographic evidence of distant
T1b Tumor  5 mm but,  10 mm metastases
T1c Tumor  10 mm but,  20 mm
Distant detectable metastases as determined by
T2 Tumor  20 mm but,  50 mm M1 classical clinical and radiographic means and/or
histologically proven larger than >0.2 mm
T3 Tumor  50 mm
(+) deposits of molecularly or microscopically
Tumor of any size with direct extension to the chest detected tumor cells in circulating blood, bone
T4
wall and/or skin (ulceration / skin nodules) marrow, or other non-regional tissues,
*cM0(i+) MUST BE:
Extension to the chest wall NOT including only * no larger than 0.2mm
T4a
pectoralis muscle adherence / invasion * no clinical or radiographic evidence
Ulceration and/or ipsilateral satellite nodules and/or * patient without signs or symptoms
T4b edema (including peau d’orange) of the skin which do Table 8. TNM Staging System for Breast Cancer:
not meet criteria for inflammatory carcinoma M = Distant Metastases

T4c Both T4a and T4b TREATMENT FOR BREAST CANCER

- Surgery
T4d Inflammatory carcinoma
- Chemotherapy
Table 5. TNM Staging System for Breast Cancer: T = Primary Tumor - Hormonal Therapy
- Radiation Therapy
N = Regional (axillary) lymph nodes
- Targeted Therapy
N Category Description - Treatment is based on stage, biological characteristics, patients age,
menopausal status, preferences, and risk + benefits
NX Regional lymph nodes cannot be assessed - Modified Radical Mastectomy includes removal of the whole breast
N0 No regional lymph node metastasis as well as axillary lymph dissection of node levels 1 + 2
- Breast Conservation Surgery involves lumpectomy (only portion of
N1 Metastases to MOVABLE, IPSILATERAL: Level I and II
breast removed) and some axillary dissection
N2 o Offers good cosmetics and lesser surgical field involvement
Metastases to CLINICALLY FIXATED / MATTED, - Sentinel Lymph Node Biopsy
N2a
IPSILATERAL: Level I and II o Primarily to assess regional lymph nodes in early breast CA
Metastases to CLINICALLY DETECTED ipsilateral o For clinically node-negative patients on physical examination
N2b internal mammary nodes in the ABSENCE of axillary o Increased risk of lymphedema & damage to nerves/vessels of
lymph node metastases the axilla
o Detection of the sentinel node can be done via injection of blue
N3
dye, radioisotope or by using both methods simultaneously
N3a Ipsilateral intraclavicular (increases detection if both methods are used)
Ipsilateral internal mammary AND axillary lymph o Not recommended:
N3b
nodes ▪ Inflammatory breast cancers
6 of 8
 Surgery | The Breast
▪ With biopsy proven metastases Neoadjuvant Chemotherapy
▪ DCIS without mastectomy - Indicated for locally advanced breast cancers to downstage the
▪ Prior axillary surgery tumors
- Monitor response of intact primary tumor and regional lymph nodes
Adjuvant Systemic Treatment to specific chemotherapy regimen
- Given after surgery to decrease odds of recurrence
Radiation Therapy
Antiestrogen Therapy - Can be used in all stages of breast cancer
- Antiestrogen Therapy are useful only for positively detected - Indications:
estrogen/progesterone receptor o Breast conservation therapy
- Tamoxifen o 4 or more lymph nodes positive for tumor
- Blocks uptake of estrogen in the breast tissue o Advance loco-regional breast cancer
- Toxicity
o Bone pain Targeted Therapy
o Hot flashed - Trastuzumab
o Nausea and vomiting - Treatment for Her2-neu-positive breast cancer
o Fluid retention - Standard of care: given for one year
o Thrombotic events
- Lapatinib
o Endometrial cancer
o Targets both Her2 and EGFR
- Aromatase Inhibitors
- First-line therapy for postmenopausal women
BREAST SELF EXAMINATION (BSE)
- Increased risk of osteoporosis
- Opportunity for woman to become familiar with her breasts
- Less risk for endometrial cancer compared to Tamoxifen
- Monthly exam of the breast and underarm area (axilla and the
supraclavicular areas)
Chemotherapy
- May discover any changes early
- Begin at age 20, continue monthly

When to do BSE?
- Menstruating women – 7-10 days after the beginning of their period
- Menopausal women – same date each month
- Pregnant women – same date each month
- Takes about 10 minutes to complete
- Perform BSE at least once a month
- Examine all breast tissue

How to do Self Breast Exam

- Step 1: Look at your breasts in the mirror with shoulders straight and
arms on your hips
o Bring to doctor’s attention if with:
▪ Dimpling, puckering, or bulging of skin
▪ A nipple that has changed position or inverted
▪ Redness, soreness, rash, or swelling

Table 9. Adjuvant chemotherapy regimens

Adjuvant Chemotherapy
- Factors for inclusion:
▪ High histologic grade
▪ Low or negative hormone receptor status
▪ Positive Her-2/neu status
Figure 17. Step 1 of BSE
▪ Triple negative status
▪ Lymphovascular invasion
- Step 2: Raise your arms and look for same changes
▪ Positive lymph nodes
o Bring to doctor’s attention if with:
▪ Dimpling, puckering, or bulging of skin
▪ A nipple that has changed position or inverted
▪ Redness, soreness, rash, or swelling

7 of 8
 Surgery | The Breast

Figure18. Step 2 of BSE

- Step 3: Look for signs of fluid coming out of one or both nipples
- Step 4: Feel your breasts while lying down. Use right hand to feel the
left breast and vice versa.
o Use a firm, smooth touch using the few finger pads of your
hand, keeping fingers flat and together
o Cover the entire breast from top to bottom, side to side

Figure 19. Step 4 of BSE

- Step 5: Feel your breasts while standing up or sitting.

o The easiest way to feel the breasts is when the skin is slippery
and wet, usually in the shower.
o Take note of any abnormalities and bring it to the doctor’s
attention immediately.

Figure 20. Step 5 of BSE

8 of 8