BREAST
Anatomy
Adult breast lies between the 2 nd
and the 6 th
ribs, and extends from the lateral sternal edge to the midaxillary line. Breast develops along the intrauterine milk ridge that extends from the axilla to the groin. This is the line along which extra breasts/nipples may be present very occasionally. Poland’s syndrome is congenital absence of a breast.
Arterial supply:
perforating branches from the internal mammary artery
intercostal arteries
branches of the lateral thoracic and acromiothoracic arteries in the axillary tail
Venous drainage:
follows the arterial supply
can also cross to the contralateral breast via superficial veins
Lymphatic drainage:
mainly to the axilla
medial quadrants may also drain to the internal mammary chain
the axillary nodal basin is divided into three levels depending on the relationship to pec minor: o level 1 – inferior to lower border of pec minor o level 2 – deep to pec minor o level 3 – superior to upper border of pec minor
Breast lumps
Likely diagnosis varies with age…
Young woman – usually fibroadenoma
Middle-aged woman (30-50) – breast cyst
Post-menopausal (>50) – any new lump is breast cancer until proven otherwise
Triple assessment
All patients presenting with a breast lump should undergo triple assessment during their first visit to the clinic. This involves clinical + radiological + pathological assessment.
1.
Clinical assessment a.
History i.
Age ii.
Age at menarche/menopause iii.
FHx of breast ca (number affected 1 st
and 2 nd
degree relatives, age of onset) iv.
Number of children and age at childbirth v.
Drug history – OCP, HRT vi.
Length of time since onset of lump, is it enlarging or reducing,
LMP

b.
Physical examination i.
Inspect both breasts for skin changes, tethering, dimpling in good light ii.
First sitting upright, hands by sides. Then raise hands up. Then on hips. iii.
Palpate each separate quadrant. iv.
Palpate LNs – axilla and supraclavicular
2.
Radiological assessment a.
<35 years old – U/S is preferred method b.
>35 years old – mammography is preferred. 2 views, including normal breast c.
US is particularly useful to assess whether lump is solid/cystic d.
On mammography… i.
Benign lump – well demarcated, may have surrounding halo ii.
Malignant lump – spiculated, architectural distortion, calcification
3.
Pathological assessment a.
FNAC – cytological assessment, looking for atypia b.
If cytology is inadequate or unhelpful – next step is core biopsy under
LA. This is a histological assessment. Can tell tumour grade, and Oe receptor status can be assessed.
Benign breast disease
Fibroadenomas
Very common in reproductive years. Totally benign. Subject to same hormonal control as the rest of the breast and often enlarge in pregnancy and involute during the menopause.
20% involute, 20% increase in size, and 60% remain the same.
Like all breast lumps, a triple assessment should be carried out. Small adenomas <2cm are usually left, large ones may be excised. (giant fibroadenomas >5cm can be confused with a phylloides tumour).
Fibrocystic disease
A common breast condition consisting of fibrous (rubbery) and cystic changes in the breast. Features include cyclical mastalgia, cysts, lumpy breast. Management involves stopping caffeine! Also NSAIDs, evening primrose oil…
Breast cysts
Very common in women coming up to the menopause, part of normal process of breast involution. Treat only if persistant lump, recur repeatedly, blood-stained cyst fluid, intracystic papilloma on U/S.

Nipple discharge
Things to assess…
is the nipple discharge from a single duct or from multiple ducts?
Is it unilateral or bilateral?
Blood or no blood?
Cosmetically disfiguring or not?
What to do?...
Non-cosmetically disfiguring, non-bloodstained discharge from multiple ducts requires no intervention.
Duct ectasia is a physiological condition in which the large terminal duct dilates and retains secretions, causing a physiological discharge as patients get older.
B/L milky discharge – do a serum prolactin to r/o prolactinoma
U/L bloodstained discharge usually due to intraductal papilloma, but an intraductal carcinoma must be ruled out. These patients should have a full triple assessment, including U/S of retroareolar area. Can also dipstick the discharge to confirm blood, and do a ductography – show a SOL in the duct. Patients should undergo a microdochectomy (surgical excision of duct) via a periareolar incision.
Breast pain – mastalgia
Very common and usually not associated with breast cancer.
Can be cyclical and non-cyclical mastalgia. Can also be caused by non-breast pathology.
Cyclical mastalgia – very common. Often premenstrual mastalgia. Intervene if sever or prolonged >3-5 days. Management involves reassurance, evening primrose oil,

-linoleic acid x 3 months. In half, the mastalgia will not recur. Can also try tamoxifen. Danazol and bromocriptine have also been used.
Non-cyclical mastalgia – less common and more difficult to treat. R/o costochondritis
(Tietze/s syndrome) – usually self-limiting and responds well to NSAIDs. Benign breast disprders can also cause myalgia. Treatment with a combination of evening primrose oil,
NSAIDs, topical massage of NSAID cream.
Breast abscess
Usually infection of a pregnant or lactating breast with staph aureus. Redness, swelling, heat, pain. Treat with flucoxacillin initially, and if an abscess develops with incision and drainage. Breastfeeding should continue.
Fat necrosis
Often a history of trauma. Injury causes haematoma and necrosis of breast fat with subsequent scarring. Do triple assessment, usually excise to r/o malignancy.

Breast cancer
Most common cancer in women.
Predisposing factors:
Gender – women
Age – increasing risk with age, esp >35 years
Genetics o BRCA 1, 2 (80% lifetime risk of developing breast ca) o P53 mutation – Li Fraumeni syndrome – breast ca at very young age o Lynch syndrome (HNPCC) o Ataxia telangiectasia
Hormonal – prolonged exposure of the breast to oestrogens o HRT o Early menarche, late menopause, nulliparity, later first birth
Familial o 1 x first degree relative with breast ca under 40 yrs old o 2 x first degree relatives with breast ca under 60 yrs old o 3 x first degree relatives with breast ca at any age o 1 st
degree relative with breast + ovarian ca o 1 st
degree relative with bilateral breast ca
-
Patient’s past Hx o Hx breast ca in the other breast – 3% risk of synchronous cancer in other breast. o Alcohol may be a risk factor
Breastfeeding is protective! OCP has no proven influence either way.
Presentation
asymptomatic – discovered on screening etc
if symptomatic, most common presentation is with a lump (>60%). Most often in upper outer quadrant. Usually painless, hard, and irregular.
Could also present with nipple discharge . If bloody – be highly suspicious. Most common cause of bloody discharge is intraductal papilloma, but may also be due to ductal carcinoma – must rule out.
Eczematous lesion around the nipple. Must be differentiated from Paget’s disease of the breast.
Always ask about systemic symptoms like weight loss.
Histological types
Invasive ductal ca – 85%
Invasive lobular ca – 10%
Inflammatory ca
Paget’s disease
Carcinoma in situ

DCIS – more likely to get cancer than LCIS
LCIS – better prognosis than DCIS
Note that carcinoma in situ raises your risk of developing breast cancer, but the cancer may well develop in a different quadrant or even in the contralateral breast. These patients are usually managed by close surveillance rather than surgery.
Clinical features
50% of breast cancers develop in the upper outer quadrants. Invasive ductal ca accounts for 85% of breast cancers.
Staging
TNM staging, based on clinical assessment of the breast.
Where does breast ca metastasise to? – to the liver, brain, bone, lung, contralateral breast.
Patients with tumours <3cm and clinically node negative have operable breast ca. In these patients, pre-op scanning for mets is not necessary.
In more advanced cases, should do a liver U/S, a bone scan, and blood tests (FBC, LFTs,
CEA, ca15.3)
Grade is the level of differentiation of the cells. Graded 1-3.
Management/treatment
Surgery is the cornerstone of treatment. For early disease, do conservative breast surgery
(WLE) followed by radiotherapy. Indications for mastectomy include large tumour in a small breast, margins involved, multifocal disease, previously treated carcinomas and cases where radiotherapy is contraindicated (connective tissue disorders/scleroderma, pregnancy T1), genetic breast ca, lobular ca, personal preference.
Prognostic factors
Most important prognostic factor is axillary nodal status. Others include the presence of receptors (ER, PR, Her-2), the size of the tumour, and the grade (1-3).
Axillary surgery
Axillary nodal status is the single most important prognostic factor in breast cancer.
Patients who have no involved nodes have an almost 80% chance of long-term survival.
There is a direct correlation between the risk of nodal disease and the size of the primary tumour. Sentinel node biopsy more popular now. Alternative means of staging the axilla is doing axillary clearance – at least a level 2 clearance. There are 10-40 LNs in the axilla. Remove the fat and the LNs, so you’re skeletelising the axilla.
Sentinel node biopsy becoming increasingly popular. Stems from concept that lymph flows in an orderly direction from the primary site to a single gate-keeper or sentinel node, and then migrates to other nodes. Thus if the sentinel node is found to be benign, no other nodes need to be removed. Diadvantage is that there is a definitive learning curve, and even in the best of hands there is a 5% false-negative rate. The subareolar area is injected with blue dye + radioactive dye (technetium). This is taken up by macrophages and carried to the sentinel node, and is retained there. Intra-op can visually see the blue node, and also use a gamma probe to identify the sentinel node.

If sentinel node is positive – do an axillary clearance, radiotherapy, chemotherapy.
If palpable nodes – no point doing a sentinel node, just go ahead and do axillary LN clearance.
Can also do a pre-op U/S to look for nodes that stand out (bigger, abnormal cortex).
If node negative, look at other prognostic factors to assess prognosis – ER/PR, size, grade, Her-2
Triple neg is worse than triple pos. Triple refers to presence of ER, PR, Her-2. ER and
PR are good, Her-2 is bad.
Local recurrence
Important to ensure negative margins. Following conservative breast surgery, local recurrence occurs in about 8% of cases by 5 years and 13% by 10 years.
Radiotherapy
This kills rapidly dividing cells and constricts arterioles. Note that sentinel node Bx after radiotherapy would not be reliable – as the radiotherapy interferes with the blood supply and lymphatics.
All patients who have had breastf-conservative surgery need radiotherapy. If the patient has had a mastectomy, radiotherapy is required if the tumour was close to muscle or if >4 nodes were involved.
Mammographic screening programmes
To detect breast ca earlier. Do a 2-view mammogram, read by 2 radiologists. Do at 2yearly intervals in women aged 50-70 years.
Adjuvant therapy
Hormone therapy . Give to all patients with hormone-sensitive tumours. Assess this by measuring Oe and Prog receptor status by immunohistochemistry of the resected tumour. Tamoxifen is usually used. It is an Oe receptor antagonist and reduces the risk of mets by about 15% in all Oe/Prog receptor positive patients, regardless of age. Apart from reducing metastatic potential, it also has a prooestrogenic effect that reduces bone loss/osteoporotic potential and improves the circulatory lipid profile. Diadvantages include that it increases the risk of endometrial cancer, postmenopausal bleeding, and thromboembolism. It can also tip someone into menopause. More recently, aromatase inhibitors have also been used - Taremidex? o ER+ PR+

give tamoxifen

>70% chance of responding o ER+ PR-

give tamoxifen

~40% chance of responding o ER- PR-

don’t give hormone therapy
Adjuvant chemotherapy . This significantly decreases the risk of metastatic spread. Is most effective in node-positive patients. Use combination chemo – eg cyclophosphamide + MTX + 5-FU. Recently, paclitaxel (Taxol) has been used more.

Do not give hormone therapy together with chemotherapy – this significantly increases the risk of thromboembolism! Also, because the two modalities sort of contradict each other – you want cells to be dividing fast for chemo to be effective, but tamoxifen puts cells to sleep.
-
Can’t get pregnant while on hormonal or chemotherapy.
Breast reconstruction
Can be done either immediately following mastectomy, or as a delayed procedure.
Immediate reconstruction is best if NOT having chemo/radiotherapy, as this could cause scarring and capsule formation around the implant. Can use an autologous flap or prosthetic material like silicone. Commonly used autologous flaps are a Lat Dorsi flap and the TRAM flap (transverse rectus abdominis muscle flap). TRAM flaps may be used as a pedicled flap or as a free flap, in which case the inferior epigastric vessels are anastomosed to either the internal mammary or the thoracodorsal vessels.
Question:
A 60 year old women presents with a right breast lump, confirmed on clinical examination.
Mammography confirms a suspicious 2cm mass. What special investigations would you perform to reach a diagnosis?
Answer:
To reach a definitive diagnosis a biopsy has to be performed to obtain tissue and allow a tissue diagnosis, this is the gold standard. This should be done in the form of a fine needle aspiration and a core needle biopsy. These 2 methods complement each other and allow a preoperative diagnosis to be reach in the vast majority of cases. This case highlights the 'triple approach' which is used to reach a diagnosis in any breast lump namely the combination of Clinical examination, Imaging and Pathology.
Question :
A 52 years old woman presents with a breast lump. How would you arrive at a diagnosis?
Answer :
History. Take a history of the lump and any associated symptoms--for example, pain, nipple discharge. Secondly, take a history for risk factors--for example, family history of breast cancer, early menarche, late menopause, lack of parity and breast feeding, and use of oral contraceptive pill and/or hormone replacement therapy.
Physical examination. This would include examination of the involved breast and in particular the lump as well as the contralateral breast and the axillary lymph nodes. In addition, a general examination should be performed. A hard, irregular lump fixed to the skin or underlying muscle

with distortion of the breast is likely to be a carcinoma whereas a mobile, smooth, regular lump is more likely to be benign.
Special investigations. Imaging in the form of a two view mammography of the affected and the normal breast is the next step. (Ultrasound scanning is used to investigate the premenopausal breast, which is glandular and therefore considerably denser.) As well as demonstrating the lump, imaging also allows detection of any additional impalpable lesions.
Following imaging a biopsy (FNA or core biopsy) of the lump is performed for pathological examination, which provides the definitive diagnosis.
Triple assessment is the term given to the key combination of physical examination, imaging, and biopsy in the diagnosis of a breast lump.
Question:
What are the surgical options for this woman if her lump turns out to be a cancer?
Answer :
In general, the options are wide local excision (breast conserving surgery); quadrantectomy
(removal of the affected quadrant of the breast); simple mastectomy (removal of entire breast tissue as well as skin, nipple, and areola).
The choice will depend on the size of the lump in relation to the size of the breast, the position of the lump, and whether there is any additional disease in the breast which may be multifocus--for example, ductal carcinoma in situ (DCIS). Therefore a small lump with surrounding normal tissue is amenable to treatment by WLE, while mutiple tumours, a single large tumour, or multifocus
DCIS usually require a mastectomy to ensure complete clearance.
An axillary lymph node dissection is also usually performed to treat any lymph node metastases and provide prognostic information which will guide further treatment.
If a mastectomy is to be carried out the patient is usually offered an immediate or delayed reconstruction of the breast. Reconstruction of the breast can be carried out using prosthetic implants (usually either silicone or the saline filled Becker implants) and/or a muscle flap--for example, latissimus dorsi flap.