First Aid For Surgery - Breast

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Basic Breast Anatomy

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(1) Modified sebaceous gland composed of glandular, fibrous, and adipose tissue; (2) Lies within layers of superficial pectoral fascia; (3) Each mammary gland consists of 15-20 lobules, each of which has a lactiferous duct that opens on areola; (4) Has ligaments that extend from deep pectoral fascia to superfical dermal fascia that provide structural support referred to as Cooper's ligaments; (5) Frequently extends into axilla as axillary tail of Spence

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Breast Blood Supply

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ARTERIAL: axillary artery via lateral thoracic and thoracoacromial branches, internal mamary artery, adjacent intercostal arteries; VENOUS: follows arterial supply: axillary, internal mammary, and intercostal veins; axillary vein responsible for majority of venous drainage

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Venous drainage of breast

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Is largely done by axillary vein; however, venous drainage is also largely responsible for the mets to spine via paravertebral plexus of Batson

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Lymphatic Drainage of Breast

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(1) Level I nodes: Lateral to lateral border of pec minor; (2) Level II nodes: Deep to pec minor; (3) Level III nodes: Medial to medial border of pec minor; (4) Rotter's nodes lie between pectoralis major and pectoralis minor muscles

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How does lymph node involvement by tumor tend to progress?

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From Level I to Level II and then to Level III nodes. The higher the level, the worse the prognosis

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What causes skin dimpling and nipple retraction in breast cancer?

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Traction on Cooper's ligaments

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Medial and Lateral Pectoral Nerve

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The medial pectoral nerve is actually lateral to the lateral pectoral nerve. The nerves are named according to their origin from the brachial plexus, not by their relation to one another on the chest wall.

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Lymphatic Drainage by quadrants

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(1) Lateral quadrants drain to Axillary nodes and supraclavicular through the pectoral, interpectoral (Rotter's) and deltopetoral; (2) Medial quadrants drain to parasternal nodes; (3) Lower quadrants drain to inferior phrenic (abdominal) nodes

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Long thoracic nerve

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Innervates Serratus anterior; if injured, see winging of scapula [C5, 6, 7 = winged scapula in heaven]

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Thoracodorsal nerve

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Innervates Lattissimus dorsi; if injured, cannot push oneself up from a sitting position

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Medial and Lateral Pectoral nerves

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Innervate Pectoralis major and minor; if injured, get weakness of pectoralis muscles

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Intercostobrachial nerve

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Innervates axilla transversely to supply inner aspect of arm; if injured, get area of anesthesia on inner aspect of arm

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Only presentations nonsuspicious for cancer

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(1) Lactating woman with focal erythematous warm swelling; (2) Cyclical changing mass in young woman with clear aspirate; ALL ELSE IS WORKED UP!

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Non-breastfeeding woman presents with similar picture to mastitis: Dx?

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Likely inflammatory carcinoma

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Hidradenitis Suppurativa

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Chronic inflammatory condition of accessory areolar glands of Montgomery; also affects axilla; Women with acne predisposed to develop Hidradenitis, and may mimic other chronic states (Paget's, invasive carcinoma). Skin may be involved contiguously or multifocally. RX: ANTIBIOTICS, I&D

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Fat necrosis of breast

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(1) Presentation: firm, irregular mass of varying tenderness; (2) History of trauma elicited in 50% of patients with predisposing chest wall/breast trauma very common. (3) PE: irregular mass w/o discrete borders that may or may not be tender; later, collagenous scars predominate; (4) Often indistinguishable from carcinoma by clinical exam or mammography; (5) Diagnosis/Tx: excisional biopsy with pathologic evaluation for carcinoma

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MCC of persistent breast mass after trauma

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Fat necrosis; Think of a 25yoF with painful breast mass several weeks after sustained breast trauma by seat belt in car accident

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Clinical Scenario: 20yo female with well-circumscribed mass in left breast; mobile, nontender w/ defined borders

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Think: Fibroadenoma until proven otherwise

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Fibroadenoma

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(1) DEFINITION: fibrous stroma surrounds ductlike epithelium and forms a benign tumor that is grossly smooth, white, and well circumscribed; (2) RISK FACTORS: blacks > whites; (3) INCIDENCE: late teens to early 30s, estrogen sensitive [increased tenderness during pregnancy]; (4) S&S: smooth, discrete, circular, mobile mass; (5) Dx: FNA: (6) If FNA diagnostic, may observe depending on symptoms and size; If nondiagnostic and patient is over age 30 or is symptomatic, must excise mass

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Mondor’s Disease

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(1) DEFINITION: superficial thrombophlebitis of lateral thoracic or thoracoepigastric vein; (2) PREDISPOSING FACTORS: local trauma, surgery, infection, repetitive movements of upper extremity; (3) PRESENTATION: acute pain in axilla or superior aspect of lateral breast; (4) PE: tender cord palpated; (5) DX: confirm with U/S; (6) Treatment: confirm dx with U/S; salicylates, warm compresses, usually resolves in 2-6 wks; if not, can resect vein

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Fibrocystic changes

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(1) Usually dx in 20s-40s; (2) PRESENTATION: breast swelling (often bilateral), tenderness, and/or pain; (3) PE: discrete areas of nodularity within fibrous breast tissue; (4) EVALUATION: serial physical exams with documentation of fluctuating nature of symptoms is usually sufficient unless a persistent discrete mass is identified; definitive dx requires FNA or bx; (5) Symptoms thought to be of hormonal etiology, fluctuate with cycle; (6) RX: NSAIDS, OCPs; avoid xanthine-containing products (coffee, tea, tobacco, cola)

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Typical scenario: A 45-year-old female presents with breast pain that does not vary with her menstrual cycle with lumps behind the nipple–areolar complex and a history of a nonbloody nipple discharge.

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Think: Mammary duct ectasia.

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Mammary Duct Ectasia (Plasma Cell Mastitis)

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(1) DEFINITION: inflammation and dilation of mammary ducts; (2) Most commonly occurs in perimenopausal years; (3) PRESENTATION: noncyclical breast pain with lumps under nipple/areola w/ or w/o nipple discharge; (4) PE: palpable lumps under areola, possible nipple discharge; (5) DX: based on exam; excision bx req'd to r/o cancer; (6) TX: excision of affected ducts

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Phyllodes Tumor (Cystosarcoma Phyllodes)

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Variant of fibroadenoma - majority are benign and tend to present later than those with fibroadenoma (>30 years); (1) CHARACTERISTICS: indistinguishable from fibroadenoma by U/S or mammogram - distinction made on basis of their histologic features (phyllodes tumors have more mitotic activity). Most are benign and have a good prognosis; (2) Dx: definitive diagnosis requires biopsy with pathologic evaluation; (3) Rx: smaller tumors: wide local excision with at least 1-cm margin; large tumors: simple mastectomy

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Is axillary node dissection necessary for cystosarcoma phyllodes?

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No; lymph node mets are rare with phyllodes tumor

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MCC of unilateral bloody nipple discharge

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Intraductal papilloma

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Intraductal Papilloma

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(1) DEFINITION: benign local proliferation of ductal epithelial cells; (2) CHARACTERISTICS: unilateral serosanguineous or bloody nipple discharge; (3) PRESENTATION: subareolar mass and/or sponteanous nipple discharge; (4) EVALUATION: radially compress breast to determine which lactiferous duct expresses fluid; mammography; (5) Dx: definitive diagnosis by path of resected specimen; (6) Rx: excise affected duct

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Typical scenario: A 35-year-old female presents with a 1-month history of a spontaneous unilateral bloody nipple discharge. Radial compression of the involved breast results in expression of blood at the 12 o’clock position.

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Think: Intraductal papilloma

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Causes of gynecomastia

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(1) Increased estrogen [tumors, endocrine dz, liver failure, obesity]; (2) Decreased testosterone [aging, primary or secondary testicular failure, Klinefelter's, renal failure]; (3) Drugs [spironolactone]

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Infiltrating Ductal Carcinoma

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(1) MC invasive breast cancer [80% of cases]; (2) MC in perimenopausal and postmenopausal women; (3) Ductal cells invade stroma in various histologic forms; (4) Metastatic to axilla, bones, lungs, liver, and brain

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What cancer likes to met to bone?

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Remember PB-KTL: Prostate, Breast, Kidney, Thyroid, Lung

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Infiltrating Lobular Carcinoma

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(1) 2nd MC type of invasive breast cancer [10% of cases]; (2) Originates from terminal duct cells and, like LCIS, has high likelihood of being bilateral; (3) Presents as ill-defined thickening of breast; (4) Like LCIS, lacks microcalcifications and is often multicentric; (5) Tends to met to axilla, meninges, and serosal surfaces

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Paget's Disease (of the Nipple)

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(1) 2% of invasive breast cancers; (2) usually associated with underlying LCIS or ductal carcinoma extending within the epithelium of main excretory ducts to skin of nipple and areola; (3) PRESENTATION: tender, itchy nipple with or without a bloody discharge with or without a subareolar palpable mass; (4) Rx: modified radical mastectomy

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Inflammatory carcinoma

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(1) 2-3% of invasive breast cancers; (2) Most LETHAL breast cancer - >75% of patients have axillary mets at time of dx! (3) frequently presents as erythema, 'peau d' orange' and nipple retraction; (4) Dermal lymphatic invasion seen at path; (5) Inflammatory picture is 2/2 blockage of efferent lymphatic ducts causing edema - 'peau d' orange'; (6) Rx: chemo + surgery and/or radiation

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Typical scenario: A 65-year-old female presents with a pruritic, scaly rash of her nipple–areolar complex and a bloody nipple discharge.

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Thick: Paget's disease. Biopsy and pathology required to confirm diagnosis

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Ductal Carcinoma in situ

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(1) CELL OF ORIGIN: Inner layer of epithelial cells in major ducts; (2) DEFINITION: Proliferation of ductal cells that spread through ductal system but lack ability to invade the basement membrane; (3) AGE/SEX: More than half of cases occur after menopause; 5% of male breast cancer; (4) MASS: sometimes palpable; (5) DX: clustered microcalcifications on mammogram, malignant epithelial cells in breast duct on biopsy; (6) LYMPHATICS: <1%; (7) RISK OF INVASIVE: considered anatomic precursor to breast carcinoma. Increased risk in ipsilateral breast, usually same quadrant, infiltrating ductal carcinoma most common histologic type; comedo has worst prognosis

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Lobular Carcinoma in situ

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(1) CELL OF ORIGN: Cells of terminal duct-lobular unit; (2) DEFINITION: multifocal proliferation of acinar and terminal ductal cells; (3) AGE/SEX: Most cases occur prior to menopause, NEVER seen in males; (4) MASS: Never; (5) DX: Typically a clinically occult lesion; undetectable by mammogram and incidental on biopsy; (6) LYMPHATICS: rare; (7) RISK OF INVASIVE: Considered as marker of breast carcinoma. Equally increased risk in either breast, infiltrating ductal carcinoma also most common histologic type (counterintuitive); associated with simultaneous LCIS in contralateral breast in over half of cases

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Treatment for DCIS

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(1) If small <2cm, lumpectomy with close f/u or radiation; (2) If large >2cm: lumpectomy with 1cm margins and radiation; (3) If breast diffusely involved: simple mastectomy

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Treatment for LCIS

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None; bilateral mastectomy an option if patient is high risk

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Typical scenario: 45yo female presents with enlargement of left breast with nipple retraction, erythema, warmth, and induration

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Think: Inflammatory breast carcinoma

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Risk factors in breast cancer

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(1) Any change that causes increased exposure to estrogen without the protective effects of progesterone; (2) Early menarch or late menpause [<12, >55yo]; (3) Nulliparity or first pregnancy >30yo; (4) White race, old age; (5) History of breast cancer in mother or sister [esp. if bilateral or premenopausal]; (6) Genetic predisposition [BRCA1/2, Li-Fraumeni]; (7) Postmenopausal estrogen replacement (unopposed by progesterone)

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Genetic Syndromes associated with Breast Cancer

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(1) Autosomal Dominant: Li-Fraumeni, Muir-Torre, BRCA1 and BRCA2, Cowden's Syndrome, Peutz-Jeghers syndrome; (2) Autosomal recessive: ataxia-telangiectasia

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BRCA1

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Tumor-suppressor gene; chromosome 17q, also associated with ovarian cancer

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BRCA2

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Tumor-suppressor gene; chromosome 13q, also associated with male breast cancer

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Treatment for Early Invasive Breast Cancer (Stage I and II)

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Mastectomy with assessment of axillary lymph node status and breast conservation (lumpectomy with assessment of axillary lymph node status and radiation therapy) are considered equivalent treatments for stage I and II breast cancer

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When is adjuvant chemo considered?

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Adjuvant chemotherapy for early invasive breast cancer is considered for all node-positive cancers, all cancers that are larger than 1cm in size, and node-negative cancers that are large than 0.5cm in size when blood vessel or lymph vessel invasion, high nuclear grade, high histologic grade, HER2/neu overexpression, and negative hormone receptor status is present

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When is tamoxifen considered?

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In HER2/neu receptor positive women with cancers >1cm in size

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Prognosis for breast cancer

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Prognosis depends more on stage than on histologic type of breast cancer. Node positivity is the most important factor

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Treatment option for stages I and II only

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Lumpectomy with postoperative radiation is a viable treatment option only in stages I and II. Mastectomy is not required and has no additional survival benefit.

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Modified radical mastectomy

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Resection of all breast tissue and axillary nodes

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Radical mastectomy

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Resection of all breast tissue, axillary nodes, and pectoralis major and minor muscles (rarely performed nowadays due to increased morbidity without advantage).

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Breast-conserving surgery

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Lumpectomy and axillary node dissection: resection of mass with rim of normal tissue and axillary node dissection - good cosmetic result. Axillary disection is generally carried out in Zones I and II. Zone III is explored only if nodes are palpable

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Relative contraindications for breast conservation surgery

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(1) Prior radiation therapy to breast or chest wall; (2) Involved surgical margins or unknown margin status following re-excision; (3) Multicentric disease; (4) Scleroderma or other connective tissue disease

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Sentinel node biopsy

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Recently developed alternative to complete axillary node dissection; done only if there are no palpable nodes. Based on principle that metastatic tumor cells migrate in an orderly fashion to first draining lymph node; lymph nodes ID'd on preop nuclear scintigraphy and blue dye injected in periareolar area. Axilla is opened and inspected for blue and/or 'hot' nodes identified by gamma probe. When sentinel node positive, an axillary dissection is completed. When negative, an axillary dissection is not performed unless axillary LAD is present

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Raloxifene

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Another SERM that has been used for breast cancer prevention; not associated with increased uterine cancer risk

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Selective estrogen receptor modulator (SERM)

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Blocks uptake of estrogen by target tissues; side effects simulate menopause with hot flashes, irregular menses, thromboembolism and increased risk for endometrial cancer due to selective hormone agonist action; Therapy of choice for post-menopausal women with positive receptors.

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Breast cancer in Pregnant and Lactating women

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(1) Three breast cancers/10,000 pregnancies; (2) FNA should be done --> if solid, then bx; (3) Mammography possible with proper shielding; (4) Radiation not advisable for pregnant women; therefore for stage I or stage II cancer, modified radical mastectomy should be done rather than lumpectomy with axillary node dissection and postoperative radiation; (5) If nodes positive, delay chemotherapy until 2nd trimester; (6) Suppress lactation after delivery

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What will be common at diagnosis in males with breast cancer?

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Direct extension of cancer to the chest wall

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Breast cancer in Males

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(1) Predisposing factors: Klinefelter's syndrome, estrogen therapy, elevated endogenous estrogen, previous irradiation, and trauma; (2) Infiltrating ductal carcinoma is most common histologic type [men lack breast lobules]; (3) Diagnosis tends to be later, when patient presents with a mass, nipple retraction, and skin changes; (4) Stage by stage, survival is same as it is in women; however, more men diagnosed at later stage; (5) Treatment for early stage cancer involves modified radical mastectomy and postop radiation