1.1 Breast Surgery

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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. •

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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 myoepithelium. 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. 2. 3. 4. 5. 6. 7.

The lateral border of the Pectoralis Minor and Major muscle The Latissimus Dorsi Muscle 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

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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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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?

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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?