Breast Surgery

Question 1

The Breasts - Gross Anatomy

Answer 1

The breasts consist of glandular and supporting fibrous tissue embedded within a fatty matrix.

They lie over the 2nd-6th ribs between the sternum and mid axillary line - the lateral continuation is called the axillary tail. The areola is the pigmented area around the nipple where lactiferous ducts emerge.

Divide the breast into 4 quadrants – lower outer and inner, upper outer and inner and tail of Spence.

Question 2

Parts of the Breast

Answer 2

• Parenchyma – lactiferous ducts give rise to 15-20 gland lobules of milk secreting alveoli arranged in clusters. Lactiferous sinus – dilated portion of each duct where droplet of milk accumulates in lactation.
• Sebaceous glands – these secrete an oily substance to protect the nipple and the areola.
• Suspensory ligaments – these attach the mammary glands to the dermis and help to support gland lobules.

Question 3

Breasts - Blood, Lymph and Nodes

Answer 3

• Blood supply - from medial mammary branches of the internal thoracic, lateral mammary branches of the lateral thoracic branch of the axillary artery and cutaneous branches of intercostal arteries.
• Lymph drainage – passes to subareolar plexus from which >75% drains to axillary lymph nodes and the remainder to the parasternal lymph nodes.
• Nerve supply – from the anterior and lateral cutaneous branches of the 4th-6th intercostal nerves.

Question 4

Examination - General Inspection

Answer 4

• If the presenting complaint is a lump ask the patient to show you where it is.
• Ask patient to sit on the side of the bed with their arms on their thighs to relax the pectoral muscles.
• Ask the patient to press firmly on her hips to contract and relax pectoral muscles - repeat inspection.
• Also inspect with hands straight above head and leaning forward so that skin dimpling is exacerbated.
• Assess asymmetry, local swelling or skin changes of the breast and nipple changes or discharge

Question 5

Inspection - Skin Changes

Answer 5

• Skin dimpling – the skin remains mobile over the malignancy.
• Indrawing of the skin – the skin is fixed to the malignancy.
• Lymphoedema – the skin is swollen between the hair follicles and looks like the peel of an orange = peau d’orange. This is caused by infection and often accompanied by erythema, warmth and tenderness. Investigate for malignancy any infection that does not respond to one course of antibiotics.
• Eczema of the nipple and areola – this may be part of a generalised skin disorder, due to Paget’s disease (only affects nipple) or invasion of epidermis by an intraductal malignancy.

Question 6

Inspection - Nipple Changes

Answer 6

• Nipple inversion – retraction of the nipple is common – if benign it is usually symmetrical and slit like or if malignant it is usually asymmetrical, distorting or nipple pulled to the side.
• Nipple discharge – it may be clear, yellow, white or green in colour. Investigate persistent single duct discharge or blood stained discharge to exclude ductal ectasia, periductal mastitis, intraductal papilloma or intraductal malignancy.
• Galactorrhoea – a milky discharge from multiple ducts in both breasts due to hyperprolactinaemia. There is often hyperplasia of Montgomery’s tubercles – small rounded projections that cover the areola.

Question 7

Gynaecomastia

Answer 7

Enlargement of the male breasts that often occurs in pubertal boys. In chronic liver disease gynaecomastia is caused by high levels of circulating oestrogens.

Question 8

Examination - Palpation

Answer 8

• Ask to lie down (with one pillow) with the hand of the side of the breast to be examined above head – palpate the breast systematically and examine the axillary tail between your thumb and forefinger.
• Palpate or ask the patient to palpate the nipple and observe for any discharge – note the colour and consistency. You can test the nipple discharge for blood using urine testing sticks.
• Ask the patient to sit up – palpate regional LN while you support the full weight of her arm at the wrist – palpate axillary, supraclavicular and cervical nodes (warn patient before palpating the axilla).

Question 9

Lumps - SPACE

Answer 9

• Size – should be accurately measured with a ruler to detect significant changes over time.
• Position – which quadrant of the breast tissue or the tail of Spence is the lump located in.
• Attachments – lymphatic obstruction causes skin fixation with fine dimpling at openings of hair follicles - peau d’orange. Also fixation to underlying muscles may occur in breast cancer - determine whether fixed by asking the patient to place her hands on her hips and contract and relax the pectoral muscles – if it is attached the lump will move as the muscle contracts
• Consistency – may vary from soft to stony hard – hard swelling are often malignant or calcified.
• Edge – may be well delineated or ill defined, regular or irregular and sharp or rounded.

Question 10

Lumps - SPIT

Answer 10

• Surface and shape – may be smooth or irregular on palpation.
• Pulsations, thrills and bruits – arterial and highly vascularised swelling may be pulsatile.
• Inflammation – redness, tenderness and warmth – lipomas and skin metastases are painless.
• Transillumination – cystic swellings light up if the fluid is translucent and skin is not too thick.

Question 11

Examination - Mets and Triple Assessment

Answer 11

• Metastases – palpate the liver for hepatomegaly and percuss the spine for bone metastases.
• Triple assessment – the clinical assessment, mammography (or US) and fine needle aspiration cytology.

Question 12

Mastitis

Answer 12

Breast infections are uncommon but can occur during lactation where the organism (often staph aureus) gains access via cracks or fissures in the nipple or areola.

Without antibiotic therapy mastitis is followed by an abscess which may require surgical drainage.

Question 13

Fat Necrosis

Answer 13

Local inflammation occurs following breast trauma.

Necrotic adipose tissue causes infiltration of inflammatory cells and leads to fibrosis producing a hard, irregular breast lump.

Question 14

Ductal Ectasia

Answer 14

A completely benign condition where there is inflammation and dilation of the large ducts of the breast.

It usually presents with nipple discharge (this can be green, brown or can contain blood) but can also cause breast pain, a mass or nipple retraction.

Cytology of the nipple discharge will show proteinaceous material and inflammatory cells.

Question 15

Fibrocystic Changes

Answer 15

Alterations in breast tissue (fibrosis, adenosis, cysts, epitheliosis and papillomatosis) which reflect normal albeit exaggerated responses to hormones.

It is very common and presents with generalised breast lumpiness which can show cyclical variation.

Question 16

Fibroadenoma

Answer 16

A benign fibroepithelial neoplasm (growth) that commonly presents in young women aged between 20-30 years.

It presents as a small circumscribed mobile breast lump that is treated by ‘shelling out’ which is curative.

This is also known as a ‘breast mouse’.

Question 17

Phyllodes Tumour

Answer 17

A potentially aggressive fibroepithelial neoplasm that usually presents as an enlarging mass in women over the age of 50 years.

The majority of these are benign but others may behave more aggressively. Some of these may arise in pre-existing fibroadenomas.

Question 18

Intraductal Papilloma

Answer 18

Lesions of the mammary duct epithelium that may be solitary or multiple and usually occur in women aged between 40-60 years.

Solitary or central lesions are located in the larger lactiferous ducts near the nipple and often present with a watery orange or blood stained nipple discharge.

Peripheral lesions usually arise within small terminal ducts and can be clinically silent if they are small.

Malignant change is rare but carcinoma with papillary architecture is sometimes seen. Excision of the affected ducts will be curative.

Question 19

Breast Ca - Epidemiology

Answer 19

Affects 1 in 10 women with 20,000 new cases per year in the UK – this is rising!

Question 20

Breast Ca - Pathology

Answer 20

• Ductal carcinoma in situ (more common than lobular) is premalignant and causes microcalcification on mammography – 20-30% develop invasive malignancy in 10 years.
• Invasive ductal carcinoma is most common and accounts for 70% of cases whereas invasive lobular carcinoma accounts for 10-15% of malignancies.
• Medullary tumours (5%) affect younger patients whereas colloid tumours (2%) affect older patients.

Question 21

Breast Ca - Risk Factors

Answer 21

Related to family history, age and uninterrupted oestrogen exposure – nulliparity, 1st pregnancy >30 years, early menarche, late menopause, HRT (million women study – small increase in risk), obesity, no breast feeding, oral contraceptive pill (when used for >4 years before the first pregnancy), previous breast malignancy or BRCA genes (40-80% risk).

Question 22

Breast Ca - Presentation

Answer 22

With a lump, nipple discharge or inversion or skin changes e.g. peau d’orange.

Question 23

Breast Ca - Triple Assessment

Answer 23

Performed for all lumps – clinical examination, ultrasound for <35 years or mammography and ultrasound for >35 year olds and histology (FNA) or cytology (core biopsy).

Question 24

Ultrasound and Mammography

Answer 24

• Ultrasound – not useful screening tool for malignancy but excellent for detecting cysts.
• Mammogram – warn the patient it could be painful – the breast is compressed between 2 plates. The upper plate is made of clear Perspex and the one below contains the x-ray plate. Malignancy is characteristically a white asymmetrical speculate lesion containing micro-calcification.
• Mammography misses 7% of cancers but this rises to 12% in premenopausal women (dense breast tissue) – this is often lobular carcinoma.

Question 25

Fine Needle Aspiration

Answer 25

A 10ml syringe is attached to a green needle and inserted into the lump. A cyst will disappear when aspirated giving an immediate diagnosis.

The contents of the needle are expressed onto a slide, smeared with another slide, air dried or fixed and sent to a pathologist.

The slide is stained with haematoxylin and eosin and assigned a cytology code:

• C1 – aspirate inadequate to make a diagnosis (only fat cells).
• C2 – benign.
• C3 – uncertain of diagnosis.
• C4 – probably carcinoma.
• C5 – carcinoma.

Question 26

Core Biopsy

Answer 26

Performed if the FNA is C1 or C3 and examination and radiology are suspicious.

Histological diagnosis allows discrimination between in situ and invasive malignancy. Local anaesthetic is used (superficial followed by deep infiltration), the skin is punctured with a scalpel and the core biopsy needle inserted into the lump.

Question 27

Sentinal Node Biopsy

Answer 27

Decreases needless axillary clearance in lymph node negative patients.

Blue dye is injected into the periareolar area or tumour and a gamma probe or visual inspection is used to identify the sentinel node – this can then be biopsied.

Question 28

Breast Ca - Clinical Staging

Answer 28

• Stage 1 – confined to breast and mobile.
• Stage 2 – confined to breast, mobile but ipsilateral axillary lymph nodes affected.
• Stage 3 – tumour fixed to muscle (but not chest wall) with ipsilateral lymph nodes affected.
• Stage 4 – fixation to chest wall and metastases.

Question 29

Breast Ca - TNM staging

Answer 29

• Tumour – 1 is <2cm, 2 is 2-5cm, 3 is >5cm and stage 4 is attached to skin or chest wall.
• Nodes – 0 – no palpable lymph nodes, 1 – mobile lymph nodes on ipsilateral side, 2 – fixed lymph nodes on ipsilateral side or 3 – supraclavicular or infraclavicular nodes.
• Metastases – 0 – no evidence of distant metastases or 1 – distant metastases present.

Question 30

Breast Ca - Prognostic Factors

Answer 30

Tumour size, grade, lymph node involvement, ER/PR status, presence of vascular invasion all help assess prognosis.

The Nottingham Prognostic Index (NPI is widely used to predict survival and relapse = 0.2 x tumour size (cm) + histological grade + nodal status.

Question 31

DCIS - Management

Answer 31

Wide local incision, and if the margins are clear and the tumour is small and not aggressive, radiotherapy.

If the margins are not clear, re-excise and treat as below.

If the DCIS is extensive mastectomy with reconstruction may be better.

Question 32

Stage 1 and 2 Ca - Breast Surgery

Answer 32

80% of patients are treated with wide local excision followed by 50 Grays of external beam radiation given 5 days a week for 5 weeks to the remaining ipsilateral breast. Radiotherapy reduces the risk of local reoccurrence from 30% to 7%.

Simple mastectomy is performed if the lump is too large to remove with a good cosmetic result, if the nipple is involved, if the disease is multifocal or if the patient chooses a mastectomy. A radical mastectomy involves removal or pectoral muscles.

Question 33

Stage 1 and 2 Ca - Axillery Surgery

Answer 33

The number of lymph nodes in the axilla varies from 10 to 30 – involvement is the single best predictor of outcome as it is thought cells of the primary malignancy invade the local lymphatics and blood vessels with equal force.

Can either remove a critical number of lymph nodes or the sentinel node for histology - if there is evidence of malignancy in this node a second operation must be performed.

Axillary clearance involves removing lymph nodes up to the axillary vein (level 1), up to the medial border of pectoralis minor (level 2) or up to the border of the first rib (level 3).

Risks – damage to sensory nerves of the axilla and hand or arm lymphoedema.

Question 34

Stage 1 and 2 Ca - Chemotherapy

Answer 34

90% will receive – this may be cytotoxic or endocrine therapy or a combination of both. Usually 6 cycles of cytotoxic chemotherapy given once a month is sufficient.

The most common regime is FEC – 5-flourouracil, epirubicin and cyclophosphamide. Side effects include exhausation, nausea, vomiting, hair loss, suppression of bone marrow and infertility.

Adjuvant endocrine therapy e.g. Tamoxifen is given to women who are oestrogen receptor positive for 5 years (increases the risk of endometrial cancer). 30% of women will experience menopausal symptoms – hot flushes, vaginal dryness, pruritis and loss of libido.

Another drug available is Herceptin – a humanised monoclonal antibody which binds to the Her2/neu oncoprotein.

Question 35

Stage 1 and 2 Ca - Reconstruction

Answer 35

Can be carried out at the same time as mastectomy, after a course of chemotherapy or later in life depending on the wishes of the patient.

• Beckers prosthesis is a tissue expander which is placed under pectoralis major. It consists of an inner bag of silicone and an outer sheath which can be inflated with saline through a subcutaneous port. It is overinflated to cause tissue expansion and deflated after 2 months so that the breast droops naturally.
• Myocutaneous flap – taken from latissimus dorsi and swung through the axilla into the defect or from the lower part of rectus abdominus. The muscle flap is attached to pectoralis major and a prosthesis placed within the muscle pocket.

Question 36

Stage 3 and 4 Ca - Investigations

Answer 36

Assess LFTs, calcium, chest x-ray, skeletal survey, bone scan, MRI or PET-CT and liver ultrasound.

Malignant spread is often to bones, lungs and liver.

Question 37

Stage 3 and 4 Ca - Management

Answer 37

• Non-metastatic disease – can be treated with cytotoxic and endocrine (where receptor positive) chemotherapy to shrink the primary tumour allowing surgical excision.
• Metastatic disease – only 15% of patients will survive 5 years so treatment is often palliative. For example – treatment of hypercalcaemia, radiotherapy for painful bony lesions, bisphosphonates to decrease bone pain and fracture risk, fixation of any fractures and urgent decompression where there are spinal metastases.

Question 38

Screening Programs in General

Answer 38

The disease must be a significant cause of mortality, there must be an effective treatment and the screening test must be simple, cheap, acceptable to the population and unambiguous in its interpretation with high specificity and sensitivity.

Question 39

Breast Screening

Answer 39

2 view mammography is performed every 3 years for women aged 50-65 years in the UK.

The test is expensive, only detects 93% of cancers, 2 thirds are recalled and investigated unnecessarily, 2 years or less may be more appropriate for picking up interval cancers (but this increases expense) and should screening continue beyond 65 years.