The Breast

Lidia Ionescu The 3rd Surgical Unit

Reasons for surgical referral Pain in the breast Lump in the breast Nipple discharge

Consider the lump possibly malignant till proved by biopsy otherwise

Anatomy

Self-palpation The cheapest screening test

History taking Ask the patient about: Menstruation Pregnancies Abortions Ingestion of contraceptive pills Family history of breast cancer

Normal changes in the breast Menstrual cycle Pregnancy Lactation

Examination of the breast Inspection Palpation Examine the arms, axillae, supraclavicular

fossae General examination

Position of the patient Expose the whole upper half of the patient Relax the patient in semi-recumbent position

Inspection Size Symmetry and contour The skin Nipple discharge, duplication Look to the axilae, arms and supraclavicular

fossae

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

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.  Examine from the clavicle medially to the mid-sternum, laterally to the mid-axillary line and to the inferior portion of the breast.  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 nippleareolar 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

Carcinoma of the female breast Cancer of the breast is an adenocarcinoma: Atrophic scirrhous Acute inflammatory carcinogenous mastitis

History Age- any age after menarche, pick incidence: mid-fifties More common- nulliparous women Less common-women with many kids whom breast-fed them Symptoms- painless lump Enlarging lump may distort the shape and

size of the breast Nipple- deviated, distorted, retracted, destroyed

Symptoms Painless lump Enlarging lump may distort the shape and

size of the breast Nipple- deviated, distorted, retracted,

destroyed

Symptoms Mass underneath the arm- enlarged lymph

node Swelling of the arm caused by lymphatic or venous obstruction Backache- bony metastases Dyspnea- lung MTS Jaundice- liver MTS Mental changes, fits- brain MTS General malaise Loss of weight

Local examination Site Size Tenderness Shape Surface Composition Mobility

Relations to the surrounding structures Tethering: Infiltration of fibrous septae- Cooper’s

ligament-from breast to subcutaneous fat and skin. Infiltration of these strands by tumour makes them shorter, inelastic. This pulls the skin inwards, puckerind the skin surface The lump can be moved but the skin dimples Fixation: Fixity to the skin, direct, continuous

Tethering/fixation Tethering- edema of the overlying skin

between the many small pits- blockage of the lymphatics Orange-peel appearance “peau d’orange”

Fixation of a lump to the skin is almost

diagnostic of a carcinoma

PEAU D’ORANGE AND INVERTED NIPPLE

BREAST CANCER Breast cancer is the most common form of

cancer affecting women in Malaysia. About one in 19 women in this country are at risk, compared to one in eight in Europe and the United States

Type of breast cancer.  Ductal carcinoma in situ (DCIS): This is the most common

type of noninvasive breast cancer. DCIS means that the cancer is confined to the ducts.  Lobular carcinoma in situ (LCIS): This condition begins in the milk-making glands but does not go through the wall of the lobules.  Invasive (infiltrating) ductal carcinoma (IDC): This is the

most common breast cancer. It starts in a milk passage or duct, breaks through the wall of the duct, and invades the tissue of the breast.  Invasive (infiltrating) lobular carcinoma (ILC): This cancer starts in the milk glands or lobules. It can spread to other parts of the body.

Fix Risk Factor  Age-The older you get the more chance you have.Women age more 50

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years old have 8-10 times fold more chance of get it compare to younger age. Women-women has 100 times more risk than men. Family history-if you have family history of breast cancer,you are at a high risk get the cancer. Past history of Breast cancer-if you was diagnosed to have breast cancer before than you are prone to get it on the same breast or the other one. Menstrual period-the early you have your menarche(1st period),you are slightly high risk get it when you are older. Genetic factor-5%-10% link to mutation of gene and breast cancer.BRCA1 and BRCA2 are 80% the involve genes

Changeable risk factor  Breast feeding-women who breast fed their child 1-2 years will lower the

risk of get breast cancer.  Alcohol-women who have 2-5 drink daily have 1.5 chance than women who

not consume alcohol.  Exercise-women who do exercise will reduce the risk of getting breast

cancer.The more you exercise the lower the risk. The question is how much we need to exercise. Study shown exercise 30 minutes per day for 5 days is enough.

What Causes Breast Cancer? Low Fibre Intake (below 25gm daily) BMI above 25 Smoking Alcohol Low in Antioxidants Poor Immune system

What Causes Breast Cancer?                1.  Prevention                2.  Early Detection by self-

examination                3.  Intervention

Symptoms of breast cancer The most common sign of breast cancer is a

new lump or mass. A lump that is painless, hard, and has uneven edges is more likely to be cancer. But some cancers are tender, soft, and rounded. Other signs of breast cancer include the following: a swelling of part of the breast skin irritation or dimpling nipple pain or the nipple turning inward redness or scaliness of the nipple or breast skin

How breast cancer found?  Breast self examination - women should do self breast examination regularly. you

should start do breast examination at age of 20 years  Mammogram - A mammogram is an x-ray of the breast. This test is used to look for

breast disease in women who appear to have no breast problems. It can also be used when women have symptoms..

 Biopsy - A biopsy is done when other tests show that you might have breast cancer.

The only way to know for sure is for you to have a biopsy. During this test, cells from the area of concern are removed so they can be studied in the lab.

Staging Staging is important to determine if the

patient is potentially in a curable early stage or otherwise: Stage 0 - Cancer in Situ Stage I - Cancer is less than 2 cm. Stage II - Cancer is between 2 to 5 cm with or

without involvement of the glands in the armpit Stage III - Cancer is larger than 5 cm or there is extensive involvement of the glands in the armpit Stage IV - Cancer has spread outside the breast and involves other organs in the body Stage I & II are considered early and curable. 

Treatment  Some patient was operated first than was given

chemotherapy.  This is called adjuvant chemotherapy.  If the surgeon think they need to shrink the size of the

cancer before surgery, chemotherapy/radiotherapy will be given, pre-operativelly  This is called neo-adjuvant chemo/radiotherapy

Advanced breast cancer

Mammogram

Computer-assisted mammography reading and digital mammography are now being studied as ways to improve the accuracy of mammography interpretation. Annual breast MRI, an imaging technique that does not involve radiation exposure, is now routinely recommended as a way to improve detection of early breast cancers when screening women at high genetic risk of breast cancer

Type of surgery - The purpose of surgery is to remove as much breast cancer tissue as much as possible  Lumpectomy - involves removing only the breast lump and some normal     

tissue around it. Partial (segmental) mastectomy - involves removing more of the breast tissue than in a lumpectomy. It is usually followed by radiation therapy. Simple or total mastectomy- the entire breast is removed but not the lymph nodes under the arm or muscle tissue from beneath the breast. Modified radical mastectomy - involves removing the entire breast and some of the lymph nodes under the arm Radical mastectomy - extensive removal of entire breast, lymph nodes, and the chest wall muscles under the breast Axillary dissection- this operation is done to find out if the breast cancer has spread to lymph nodes under the arm. Some nodes are removed and looked at under a microscope.

This shows the right breast being larger than the left. Look carefully and you can see that the level of the nipples are not the same and the right nipple is pointing downwards.

The lump can be seen mainly in the upper part of the breast. The “pointing down” nipple is better appreciated in the view from the side.  There is some discolouration of the skin in the upper outer part of the right breast and the skin is thin and stretched. The breast lump is enlarging and with time, without surgery, the cancer will break through the skin.

This is another lump in the right breast. Here, the “bulge” caused by the lump can be seen. The lump is therefore growing in the superficial parts of the breast tissue

The right nipple is at a lower level than the left nipple. With the hands down beside the body, this is noticeable already. However, it becomes more obvious when both arms are raised.  Both the position and direction of the nipples are better appreciated. The close up view shows what has been described.  This illustrates the importance of going through all the positions while standing and “looking” at your breasts.

There is a “depression” or sunken dip in the skin of the upper part of the left breast, above the nipple. This is known as dimpling of the skin. In this patient, even with the hands down the dimpling is visible. Normally when the arms are raised this becomes apparent or more obvious.

Dimpling occurs as a result of a growth deep to the skin within the breast tissue, that is “drawing” the surrounding tissue and overlying skin towards it. This is one character of a cancerous growth in the breast. So, even without touching or feeling your breasts, you can see the effects of a growth within your breasts. Hence the importance of the “LOOK” and “FEEL” aspects of Self Breast Examination.

The skin of the breast appears patchy red and “thickened”. This is an example of a type of breast cancer that looks as if your breast has an infection. This is a sign of an inflammatory cancer of the breast

Compare both nipples. The one to your right is drawn inwards and this is called retraction of the nipple.  The picture on the right shows the nipple retraction from the side view.

Mastectomy scar

Mastectomy scar

Chemotherapy  Chemotherapy (commonly called just "chemo") is the use of cancer-

killing drugs injected into a vein or taken as a pill. These drugs enter the bloodstream and reach throughout the body. If chemo is given after surgery it can reduce the chance of breast cancer coming back. Chemo can also be used as the main treatment for a woman whose cancer has already spread outside the breast and underarm area or that spreads widely after the first treatment.  Chemo may be given before surgery, often to shrink the tumor in order to make it easier to remove.  Chemo is given in cycles, with each period of treatment followed by a break. The total course of treatment usually lasts for 3 to 6 months. Often several drugs are used together rather than a single drug alone.  The side effects of chemo depend on the type of drugs used, the amount given, and the length of treatment.

Radiation Therapy  Radiation therapy is treatment with high-energy rays (such as x-rays) to

kill or shrink cancer cells. The radiation may come from outside the body (external radiation) or from radioactive materials placed directly in the tumor (brachytherapy).  Radiation therapy may be used to destroy cancer cells remaining in the breast, chest wall, or underarm area after surgery or, less often, to reduce the size of a tumor before surgery  Treatment is usually given 5 days a week in an outpatient center over a period of about 6 or 7 weeks, beginning about a month after surgery. Each treatment lasts a few minutes.  The main side effects of radiation therapy are swelling and heaviness in the breast, sunburn-like changes in the treated area, and fatigue.

Hormone Therapy  The female hormone estrogen promotes the growth of breast

cancer cells in some women. For these women, several methods to block the effect of estrogen or to lower its levels are used to treat breast cancer.  A drug such as tamoxifen, which blocks the effects of estrogen.

Tamoxifen is taken in pill form, usually daily for 5 years after surgery, to reduce the risk the cancer will come back.  Aromatase inhibitors are a type of drug that stops the body

from making estrogen. They only work for women who are past menopause and whose cancers are hormone positive

Inflammatory breast cancer  Rare but aggressive type of breast cancer that develops rapidly,

making the affected breast red, swollen and tender.  It's a locally advanced cancer, meaning it has spread from its point of origin to nearby tissue and possibly to nearby lymph nodes.  The early signs of more-common forms of breast cancer — a breast lump or suspicious area on a routine, screening mammogram — are often absent in inflammatory breast cancer. Instead, the breast may appear normal until tumor cells invade and block lymphatic vessels in the overlying skin.  Inflammatory breast cancer can easily be confused with a breast infection, but if it's cancer, symptoms won't go away with antibiotics.  Inflammatory breast cancer accounts for between 1 percent and 6 percent of all breast cancer cases in the United States. Survival rates are lower than those observed in other locally advanced breast cancers. But new treatment approaches offer greater odds for survival than ever before.

Inflammatory breast cancer Signs and symptoms  Rapid change in the appearance of one breast, over the course of

days or weeks  Thickness, heaviness or visible enlargement of one breast  Discoloration, giving the breast a red, purple, pink or bruised appearance  Unusual warmth of the affected breast  Dimpling or ridges on the skin of the affected breast, similar to an orange peel  Itching  Tenderness, pain or aching  Enlarged lymph nodes under the arm, above the collarbone or below the collarbone  Flattening or turning inward of the nipple  Swollen or crusted skin on the nipple  Change in color of the skin around the nipple (areola)

Differential diagnosis  Other conditions have symptoms resembling those of inflammatory

breast cancer.  A breast infection (mastitis) also causes redness, swelling and

pain, but breast infections usually develop during breast-feeding.

 With an infection, you're likely to have a fever, which is unusual

(but not unheard of) in inflammatory breast

cancer

Inflammatory breast cancer

Inflammatory breast cancer Treatment for inflammatory breast cancer starts

with chemotherapy, followed by surgery and radiation therapy. This combined-treatment approach has improved

the outlook for women with inflammatory breast cancer. About half the women diagnosed with the

condition survive five or more years, and nearly one-third are alive 20 years after diagnosis.

Anatomy

Fibroadenoma Benign neoplasm of the breast Dominant feature is abundant fibrous tissue

Fibroadenoma Signs Site- any part of the breast Overlying skin- normal Not tender lump Shape- Spherical/ovoid Size-1-3 cm. Surface-Smooth and bosselated Margin- Distinct edge Composition- hard- firm rubber Relation- Highly mobile No lymphadenopathies

Fibroadenoma

Lumpectomy

Acute breast abscess Entry site:  lactiferous ducts- more common Blood stream

Symptoms, signs, treatment Dull ache- throbbing pain-tender area Signs of acute inflammation GA- malaise, night sweats, rigors Treatment-” ubi pus ibi evacuat”- incision and

drainage

Breast abscess

Paget’s disease Intraduct carcinoma in the nipple, spreading

into the skin of the nipple The appearance- skin eczema Nipple is destroyed leaving an ulceration Cancer spreads into the breast

Gynecomastia Increased size of the breast in men Drugs: estrogens, diuretics, digitalis, anti-H2

R Testicular atrophy- hormonal abnormality Hormone-secreting testicular tumor

Gynecomastia