Powerpoint : Breast Surgery

HYSTORY CLINICAL EXAMINATION LAB. TESTS IMAGISTIC INVESTIGATIONS

TREATMENT MODALITIES SURGERY - CLASIC OR

MINIMALLY INVASIVE (LAPAROSCOPIC) MEDICAL- COMORBIDITIES, DEFFICITS CORRECTION: SEVERE ANEMIA, HYPOVOLEMIA, DISELECTROLYTEMIA, ANTIBIOTICS, ANTICOAGULANTS ADJUVANT, NEOADJUVANT: RADIOTHERAPY, CHEMOTHERAPY

SURGICAL TREATMENT 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. 

If the suspensory ligaments are affected then they may

shorten and cause a dimpling of the skin ( tethering). 

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. 

Lymphatic drainage

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

Microscopic anatomy 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.

Microscopic anatomy 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

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  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

Clinical examination Breast exanimation involves six distinct

manoeuvres: 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).

Breast lump  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)

Breast lump  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.

Palpation 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.

Palpation Relation to the skin Relation to the muscle Palpate the nipple Palpate the axillae and supraclavicular fossae

Palpation 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

hyperprolactinaemia, clear discharge is physiological, green discharge might suggest perimenopausal or

duct ectasia  blood-stained discharge may happen in

carcinoma or intraduct papilloma

Axillae 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. Because of the high rate of false negative

examinations, clinical suspicion alone is enough to justify further investigations.

Investigations Mammography Screenig Diagnostic

Ultrasound Magnetic resonance imaging Fine needle aspiration cytology Core biopsy Open biopsy

Screening mammography 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

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.

Malignant lump

Microcalcifications

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 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 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

Core biopsy-immunocytichemistry RE/ RPg, HER2/neu  Ki-67 ,angiogenetic markers. 

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.

Disorders of the development Juvenile hypertrophy Fibroadenoma

Juvenile hypertophy 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

discomfort.

 Women suffering VBH often

experience an excessive growth of their nipples.

Fibroadenoma 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

Fibroadenoma 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).

FIBROADENOMA

FIBROADENOMA

FIBROADENOMA-USS-greater diameter is parallel to the skin – sign of benignity

FIBROADENOMA-USS- well delineatedsign of benignity

FIBROADENOMA Fibroadenoma removed

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.

FIBROADENOMA

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

Management  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 Cyclical mastalgia

Nodularity

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. Treatment should be considered for women who have moderate to severe pain.

Cyclical mastalgia 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.

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

Disorders of involutionaberrations of normal aging process Breast cysts Sclerosis Duct ectasia Epithelial hyperplasia

Breast cysts  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

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.  Symptomatic palpable cysts are treated by aspiration and

provided the fluid is not bloodstained it can be discarded.

Breast cyst  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

Breast cysts 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.

Breast cyst

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.

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.

DUCT ECTASIA

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 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

Benign neoplasms Duct papillomas - bloodstained

nipple discharge Lipomas - fatty tissue tumours Phyllodes tumours- fibro-epithelial

tumour with malignant potential

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 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.

Lactating 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.