Breast Surgery
Case history
Doctor asks patient about any changes in
breast during the menstrual cycle (painful,
tender ), if she has periods. Are there any
swellings or lumps, which she noticed , any
changes or discharge from the nipple. Did she
breast feed her children. Did her mother or
sister suffer from breast cancer.
Physical examination of the breast.
1. Woman must take off her clothes and bra
to palpate breast and detect any lumps.
2. She rests both hands on her lap.
3. She presses both hands firmly on her hips.
4. She raises both arms above her head.
5. She leans forward so that her breast
become pendulous ( look for “dimpling”).
6. She places her forearm on doctor’s
forearm and doctor feels under her armpit.
7. Doctor feels supraclavicular fossa (
standing behind the patient).
8. Woman lies on the couch and doctor uses
flat of fingers not the tips to detect any
lumps.
Incidence of breast mass lesions
Non neoplastic 55%
Neoplastic 45%
Cystic disease 40%
Duct ectasia 2%
Gynecomastia 5%
Inflammatory 5%
Fibroadenoma 6%
Duct papilloma 3%
Carcinoma 35%
Other 4%
-Gynecomastia- enlargement of the breast in
the male ( sometimes in Klinefelter
syndrome).
-Fibrocystic disease (chronic cystic
mastitis)- epithelial and stromal
proliferation, repeated hypertrophy in
response to stimulation by estrogen,
progestin and prolactin. Fibrocystic disease
is a risk factor for breast cancer.
-Mammary Duct Ectasia- disease of
involuting breast. The collecting ducts in the
subareolar area are dilated and filled with
cellular debris.
-Fibroadenoma- the most common tumor in
women under 25 years of age.Treatment
consists of enucleation.
-Cystosarcoma phyllodes (leaflike)- it is not
cystic tumor and in majority is not
malignant. Enucleation may lead to
recurrence so it should be removed with rim
of surrounding breast tissue. It may manifest
a malignant behavior when there is local
invasion. Metastases occur in about 10% of
cases and are bloodborne. Regional node
dissection is not indicated because lymph
nodes are not involved.
-Intraductal papilloma- tumor is 1 to 2mm in
diameter and bleeds easily. The hallmark is
serous or bloody discharge from nipple.
When it is 3 to 4mm in diameter can be
palpable. Diffuse process is called
papillomatosis. The incidence of malignancy
is increased.
-Inflammatory processes-
Acute mastitis as diffuse streptococcal
cellulites or abscess due to staphylococcal
infection.
Mondor disease- thrombophlebitis of
superficial thoracoepigastric vein.
Screening
Self-examination of the breast by all women
at least monthly. Visit a doctor once a year.
First mammography is recommended after
40 years of age. (Every 1-2 year).
An annual mammogram is indicated when
there is a strong family history of breast
cancer or previously treated for breast cancer
and post menopausal women.
Breast ultrasound, CT scan or magnetic
resonance imaging MRI are not applied in
screening. They only complete
mammography and palpable examination.
Ultrasound can diagnose a cyst but not
distinguish benign from malignant solid
lesions.
Cytological examination can be performed
on fluid aspirated from cyst.
Nipple discharge is placed on a slide and
fixed as for Papanicolaou smear.
Thin needle biopsy should be performed on a
solid mass in the breast during ultrasound .
When the result is positive it is an excellent
means to diagnose breast cancer.
Negative result can not rule out cancer so
open biopsy must be performed.
Open biopsy of mass in the breast may be
excisional or incisional.
Diagnostic accuracy is almost 100%.
Excisional biopsy may be both diagnostic
and therapeutic in the case of benign tumor.
When solid lesion is greater than 4 cm in
diameter an incisional biopsy by knife or
biopsy forceps is performed.
Depending on frozen section biopsy and
final diagnosis further tissue is removed.
Special strategy is required for biopsy of a
lesion which is detected on mammography
but is not palpable.
A wire with hook is passed into area of the
tumor with radiographic control and next
wire with rim of tissue is excised.
That method is very helpful in case of
microcalcification aggregation because
cancer in situ is in 20% of them.
Methylene blue (dye) labeling is applied for
localization tumor which is not palpable but
detected in ultrasound examination.
The ability of breast tumor cells to bind sex
steroids: both estrogen ER+ (two third of
breast cancer) and progesterone PR+ should
be established in all cases of malignancy.
This information is important in selection of
subsequent therapy.
The Breast Cancer
The breast is the most frequent site of cancer
among women.
Approximately 90,000 new cases of breast
cancer are diagnosed annually in the USA
and almost 40,000 die of breast cancer each
year.
In Poland new incidence of disease is about
10,000 annually (19% of all neoplasms in
women) and 4,500 women die of breast
cancer.
Breast cancer is more likely in white than
black women and more often in western
culture.
The cause of breast cancer is unknown but
factors: hereditary, biologic and
environmental are known or suspected:
Strong family history of breast cancer,
nulliparous women,
menarche before age of 12, late menopause
administration of reserpine.
Pathology
It may arise from cells lining the ducts or
from cells in the breast lobule.
1.Paget’s disease of the nipple.
Adenocarcinoma of the breast in which the
tumor cells invade the nipple.
2.Duct cell origin- 75% of cases of breast
cancer.
A. In situ ( noninfiltrating, intraductal DCIS)
B. Infiltrating
-scirrhous (predominates)
-medullary
-comedo
-papillary
-colloid
-tubular
3.Lobular origin
A. In situ LCIS
B. Infiltrating
Slightly more favorable prognosis than
ductal ca. The majority of women with
lobular ca in one breast will have ca in
opposite breast.
Inflammatory cancer
Specific type of tumor highly aggressive and
invades the dermal lymphatics. Redness
includes one third of breast, positive result
thin needle biopsy and painful.
Male breast cancer less than 1% of breast
cancer.
Bilateral breast cancer- synchronic or
metachronic in about 7% of cases.
Breast cancer metastasizes lymphborne and
secondary bloodborne to lymphnodes 60%,
Lungs 55%, bones 50%, liver 50%, skin
35%, ovaries 12% and brain 10%.
TNM Classification
T0 tumor not present
T1 <2cm
T2 2-5cm
T3 > 5cm
T4 any size
T4a fixed chest wall
T4b edema (peau d’orange), satellites,
ulceration
T4c T4a+T4b
T4d inflammatory cancer
N0 nodes none palpable
N1 ipsilateral, axillary, palpable
N2 fixed axillary
N3 extra-axillary ( retrosternal) , arm edema
M0 metastasis not present
M1 distal metastasis (including
supraclavicular)
Staging
0 T is, N0, M0
I T1,N0, M0
IIA T0-2, N1-2,M0
IIB T2-3, N0-1,M0
IIIA T0-3, N1-2, M0
III B T4, any N,M0 any T, N3, M0
IV any T, any N, M1
Manual for treatment in breast cancer
Lumpectomy-tumor is removed without rim
of surrounding breast tissue.
Extended excision- tumor is removed with
1cm margin of tissue.
Quadrantectomy- tumor is removed with at
least 2cm margin. It does not mean that one
fourth of breast is removed.
Simple mastectomy- entire breast is removed
with pectoral fascia.
Madden modified radical mastectomyremoval of entire breast, pectoral fascia and
ipsilateral axillar contents.
Patey modified radical mastectomy- Madden
mastectomy and removal of pectoris minor
muscle.
Halsted radical mastectomy- removal of
entire breast with pectoris major muscle and
axillar lymphadenectomy.
Sentinel node biopsy-removal first axillar
node after radioisotope labeling and dye
labeling. In case of positive node radical
lymphadenectomy is indicated.
Breast conservative treatment BCT
Indication: Tis, T0-2, N0-1 tumor
diameter < 3cm
Contraindications:
Lack of consent for surgery
Multifocal and multicentre cancers
Diffuse cancer in situ
Bilateral synchronic cancer
Local recurrence of cancer after BCT
Pregnancy
Type of operation:
1.extended tumor excision with
lymphadenectomy
2.quadrantectomy with lymphadenectomy
After surgery entire breast must be irradiated
in 3-6 weeks.
Surgery
Indications:
1.Subcutaneous amputation
-multifocal and multicentre ca in situ
-women with BRCA1 and BRCA2 gene
mutations as prevention.
2.Simple mastectomy
-recurrence of cancer after BCT
-in advanced staging as palliative operation
- breast sarcoma when N0
3.Madden or Patey mastectomy
-breast cancer in I and II staging not
qualified to BCT
4.Halsted mastectomy
-breast cancer infiltrates pectoris major
muscle.
Contraindications to surgery
T3, T4, N2, N3 arm edema M1
Chemotherapy is indicated before surgery in
case T3,T4, N2,N3 for 3-4 months.
After downstaging woman can be operated
on breast cancer.
Systemic treatment as supplement after
surgery ( in 2-4 weeks) in women with
positive nodes, T2, ER-,PR-, G2-3,age<35
1.ER+,PR+ hormonal therapy
Tamoxifen 20mg per day for 5 years
2.Castration: surgical (ovariectomy ),
radiation or farmacological suppressionwomen before menopause ER+,PR+
3.Chemotherapy (for 4-6 months)
Women with positive nodes
Radiation therapy after surgery:
Metastases are present in min. 4 nodes
Tumor size>5cm
Positive surgical margin (incompletely
excised tumor)
Treatment in IV staging M1
Systemic treatment
Sometimes palliative surgery
Follow-up:
For 2 years every 3 months
Next 3 years every 6 months
After 5 years every 12 months
Mammography annually, chest x-ray
annually, abdomen ultrasound every 6
months, markers: Ca 15-3, Ca 125 every 3
months, gynecological examination
annually.
Prognosis
Approximately one-half of patients with
breast cancer will survive without disease for
5 years.
Untreated patient and in stage IV has 10% 5years survival.