Professional Documents
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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 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 breast is a milk producing organ and its microscopic anatomy is based on
this function.
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).
• 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 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:
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.
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.
The duration of any symptom is important- breast cancers usually grow slowly,
but cysts may appear overnight.
Parity, age at first pregnancy and history of breast feeding must be known for a
complete history of the patient.
Clinical examination
Inspection
Palpation
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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.
If the patient complains of a nipple discharge, you should squeeze gently the
nipple:
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.
Mammography
Screening mammography
Diagnostic mammography
Because the breasts are relatively radiodense in women under 35 years of age,
mammography is of little value in this group.
Sensitivity = probability that a person who does have a disease will be correctly
identified by a clinical test.
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.
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.
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
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
Simptoms: pain in the shoulder, neck and back due to large breasts.
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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).
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.
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.
1. Cyclical mastalgia
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.
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.
2. Nodularity
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.
Clinically they are smooth discrete lumps that can be painful and are sometimes
visible.
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.
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
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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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.
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
V. BREAST INFECTION
1. Lactational infection
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.
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
Study questions: