Kingdom of Bahrain Arabian Gulf University College of Medicine and Medical Sciences

1. Kingdom of BahrainArabian Gulf UniversityCollege of Medicine and Medical Sciences General Surgery The Breast Ali Jassim Alhashli

2. Anatomy • Breast is a modified sweat gland which is composed of: glandular, fibrous and adipose tissues. • It lies on pectoralis major muscle and its fascia. • Each mammary gland has 15-20 lobules, each of which has its own lactiferous duct that opens on the areola. • Suspensory ligament of the breast = Cooper’s ligament. • A portion of the breast extends to the axilla= tail of Spence. • The 4 quadrants of the breast: upper outer (site of 50% of breast cancer), lower outer, upper inner and lower inner. • Breast development: • It is derived from ectoderm milk streak. • Estrogen: for development of ducts. • Progesterone: for lobular development. • Blood supply of the breast: • Arterial supply: • Axillary artery: lateral thoracic artery + thoracoacromial artery. • Internal thoracic artery: anterior intercostal arteries + perforating branches. • Thoracic aorta: posterior intercostal arteries. • Venous drainage: lateral thoracic vein + internal thoracic vein + intercostal veins. • Lymphatic drainage: • Level-I: lateral to lateral border of pectoralis minor muscle. • Level-II: deep to pectoralis minor muscle. • Level-III: medial to medial border of pectoralis minor muscle. • Rotter’s node: between pectoralis major and pectoralis minor muscle. • 97% of lymphatic drainage of breast to → axillary lymph nodes. • 2% of lymphatic drainage of breast to → internal mammary lymph nodes. • Nipple, areola and lobule drain to → subareolar lymphatic plexus.

3. Anatomy

4. Innervation of the breast: • Supraclavicular (medial, intermediate and lateral) from C3 and C4. • Medial branches of thoracic intercostal nerve. • Lateral branches of thoracic intercostal nerve. • Neural structures encountered during major breast surgery: • Long thoracic nerve: innervates serratus anterior. If injured results in winged scapula. • Thoracodorsal nerve: innervates latissimusdorsi. If injured, one cannot push himself up from a sitting position and he will have weak adduction of upper extremities. • Medial and lateral pectoral nerves: innervate major and minor pectoral muscles. If injured result in wekaness of pectoral muscles. • Boundaries of mastectomy: • Superior: clavicle. • Inferior: inframammary fold. • Medial: sternum. • Lateral: latissimusdorsi. • Boundaries of axillary dissection: • Superior: axillary vein. • Posterior: long thoracic nerve. • Medial: medial to the medial border of pectoralis minor muscle. • Lateral: latissimusdorsi. Anatomy

5. Anatomy

6. Evaluation of A Palpable Breast Mass • If the age of your female patient is > 30 years and she presents with a breast mass → DO NOT JUMP IMMEDIATELY TO A CONCLUSION. Follow her with serial physical examinations and observe her for 2-4 weeks. • The only presentations which are non-suspicious of cancer: • A young female presenting with a cyclical changing mass with clear aspirate. • Lactating female presenting with erythematous, warm swelling of the breast. • Differential diagnoses of breast conditions: • Infectious/inflammatory: mastitis, Mondor’s disease or fat necrosis. • Benign lesions: fibroadenoma, fibrocystic changes, mammary duct ectasia, intraductalpapilloma and gynecomastia. • Pre-malignant disease: Ductal Carcinoma In Situ (DCIS) or Lobular Carcinoma In Situ (LCIS). • Malignant tumors: infiltrating ductal carcinoma, infiltrating lobular carcinoma, inflammatory breast carcinoma or Paget’s disease.

7. Infectious/Inflammatory Conditions of The Breast • Mastitis: • It is a superficial infection of the breast (cellulitis) caused by S.aureus or Streptococcus species. • Physical examination: focal erythematous, warm swelling. • Diagnosis: US to localize an abscess. If it is present, aspirate and send for Gram stain and culture. • Treatment: • Advice your patient to continue breast feeding but use a pump instead. • Cellulitis: antibiotics (anti-staphylococcal penicillins). • Abscess: drainage followed by antibiotics. • Fat necrosis: • There is a history of direct trauma to the breast in 50% of patients. • Physical examination: firm, irregular mass with varying tenderness (may or may be not tender). • Diagnosis and treatment: you have to take and excisional biopsy and send it for pathologic evaluation to exclude carcinoma.

8. Benign Diseases • Fibroadenoma: • Definition: it is a benign tumor which grossly looks white in color, well-circumscribed and smooth. • Features: it is the most common benign tumor in young females. It is more common among blacks. It is estrogen sensitive (there is increased tenderness during pregnancy). • Physical examination: firm, highly mobile, smooth mass. • Diagnosis: Fine-Needle Aspiration (FNA). • Treatment: • Asymptomatic; size > 2 cm → observe. • Symptomatic; size < 2 cm → surgical removal. • Mondor’s disease: • Definition: superficial thrombophlebitis of lateral thoracic or thoraco-epigastric vein. • Predisposing factors: surgery, infection, local trauma, excessive use of upper extremity. • Presentation: acute pain in axilla or superior aspect of lateral breast. • Physical exam: palpation of a tender cord. • Diagnosis: ultrasound. • Treatment: • Analgesia, warm compresses and limiting use of upper extremity. • Usually resolves within 2-6 weeks. If not → surgery.

9. Benign Diseases

10. Benign Diseases

11. Fibrocystic changes: • Physical examination: bilateral breast swelling and tenderness + areas of nodularity within fibrous breast tissue. Notice that it is related to the menstrual cycle. • Evaluation: • Serial physical examination with documentation. • Definitive diagnosis: biopsy with pathologic evaluation. • Treatment: • If there is no persistent mass: conservative management → NSAIDs (for pain), Oral contraceptives, danazol or tamoxifen. In addition, advice patient to avoid products containing xanthine (e.g. caffeine, tobacco and cola drinks). • If there is a single dominant cyst: aspirate fluid and send for cytology. If it is bloody → surgical excision. • If there is atypical ductal or lobular hyperplasia: surgical excision. • Mammary duct ectasia: • Definition: inflammation and dilation of mammary ducts. • Presentation: breast pain, lump under the nipple/areola with or without nipple discharge. • Treatment: excision of affected ducts. • Phyllodes tumor: • Definition: it is a fibroepithelial tumor which can be benign, intermediate or malignant (>10%). • It cannot be distinguished from fibroadenoma by ultrasound or mammography. A biopsy with pathological evaluation is needed (it has a higher mitotic activity). • Physical examination: large, freely movable mass with skin changes. • Treatment: • Small tumor: wide local excision with at least 1 cm margin. • Large tumor: simple mastectomy. No need for sentinel lymph node biopsy because malignant phyllodes spreads hematogenously commonly to the lung Benign Diseases

12. Benign Diseases

13. Intraductalpapilloma: • Definition: benign overgrowth of ductal epithelial cells. • Physical examination: unilateral bloody nipple discharge with subareolar mass. • Diagnosis: biopsy with pathologic evaluation. • Treatment: excision of the affected duct. • Gynecomastia: • Definition: It is a benign condition in which there is development of female-like breast tissue in a male. • Causes: • Physiological: neonatal, adolescent and senescent. • Pathological: • Increased estrogen: liver failure or obesity. • Decreased testosterone: aging or Klinfelter’s syndrome. • Drugs: spironolactone. • Or increased prolactin. • Diagnosis: at least 2 cm of breast tissue disc. • Treatment: surgical excision (subareolar mastectomy). Benign Diseases

14. Pre-Malignant Disease

15. Infiltrating ductal carcinoma: • It is the most common invasive breast cancer (80%). • Seen in post-menopausal females, unilateral breast involvement, comedo is the worst type, microcalcifications are detected by mammography. • Metastasize to: axilla, bone, lung, liver and brain. • Infiltrating lobular carcinoma: • It is the second most common invasive breast cancer (10%). • Seen in pre-menopausal females, high risk of bilateral breast involvement (20% of cases), lack of microcalcifications on mammography. • Metastasize to: axilla, meninges and serosal surfaces. • Paget’s disease of the nipple: • Invasive ductal carcinoma or LCIS reaching skin of the nipple. • Presentation of nipple: tender, itchy, has bloody discharge ± subareolar mass. • Diagnosis: biopsy shows Paget’s cells. • Treatment: modified radical mastectomy. • Inflammatory carcinoma: • It is the most lethal breast cancer. • Presents as: erythema, nipple retraction and peaud’orange. • Diagnosis: skin biopsy shows lymphocytic infiltration of the dermis. • Treatment: chemotherapy followed by surgery and/or radiation. Malignant Tumors

16. Epidemiology: • It is the second most common cause of cancer deaths among females (after lung cancer). • 1% of cases occur in males. • Risk factors: • Early menarche (> 12 years). • Late menopause (< 55 years). • Increased age (< 50 years). • Past history of breast cancer. • Family history of breast cancer (especially among first-degree relatives). • Genetic predisposition (BRCA1 or BRCA2 – positive). • Nulliparity. • Post-menopausal estrogen replacement therapy (unopposed by progesterone). • Radiation exposure. • Genetic predisposition: • BRCA1 and BRCA2 are both inherited as autosomal dominant (AD) with varying penetrance. • BRCA1: found on chromosome 17; associated with ovarian cancer. • BRCA2: found on chromosome 13; associated with male breast cancer. • Screening recommendations: Breast Cancer

17. Diagnosis: • Triple assessment of breast mass: • History and physical examination. • Imaging: mammography; ultrasound. • Histopathologic evaluation: FNA, stereotactic core biopsy. • Mammography: • Start yearly mammograms 10 years before the age at which a first-degree relative was diagnosed with breast cancer. • Mammography is highly sensitive and detect early disease (80% of detected cases have negative lymph nodes). • Suspicious finding on mammogram = microcalcifications. • Results: • 0: incomplete assessment. • 1: negative. • 2: benign. • 3: probably benign. • 4: suspicious for malignancy. • 5: highly suspicious for malignancy. • 6: proven by biopsy to be cancer; treatment pending. • Ultrasound. • FNA: • Advantages: cheap; 1-2% false positive results. • Disadvantages: 10% false-negative results; skilled pathologist needed . • Stereotactic core biopsy. Breast Cancer

18. Staging of breast cancer (TNM classification): Breast Cancer

19. Staging system for breast cancer: • Treatment options: • Stage-I and II breast cancer: • Lympectomy + sentinel lymph node biopsy + radiation. • Notice that chemotherapy is indicated for tumors < 1 cm or if there is lymph node involvement. • Stage-III: mastectomy with axillary lymph node dissection followed by chemo/radiation. • Stage-IV (advanced disease): palliative treatment. • Prognosis: • The most important prognostic factor in breast cancer is lymph node involvement! Breast Cancer

20. Breast Cancer

21. Types of operations: • Radical mastectomy (rarely done nowadays): removal of all breast tissue + axillary lymph nodes + pectoralis major and minor muscles. • Modified radical mastectomy: removal of all breast tissue and axillary lymph nodes (level-I). • Simple mastectomy: removal of all breast tissue. • Lumpectomy and axillary node dissection: removal of the lump with a margin of normal tissue + axillary lymph node dissection (levels I and II) + radiation therapy. This breast conservative operation is an option for stage I and II breast cancer. • Sentinel lymph node biopsy: • It is done when there are no palpable lymph nodes. • A blue dye is injected in the peri-areolar area. Then, axilla will be opened and inspected for blue and or “hot” nodes identified by a gamma probe. • Results: • Positive sentinel node(s):axillary dissection. • Negative sentinel node(s):axillary dissection not performed. • Hormonal therapy: • Selective estrogen receptor modulator (tamoxifen) is given for ER+/PR+ tumors < 1 cm in size (80% response). • Side effects: hot flashes, irregular menstruation, thromboembolism and increased risk for endometrial cancer. • Notice that Raloxifene does not increase the risk for endometrial cancer. • Chemotherapy: • Herceptin is used for HER-2-neu positive patients. • Breast reconstruction: • Autologous implants: rectus muscle or latissimusdorsi muscle. • Prosthetic implants: saline or silicone-based. Breast Cancer

22. Breast Cancer

23. Breast Cancer • Breast cancer in pregnant and lactating women: • Stage I and II: do modified radical mastectomy instead of lympectomy + axillary lymph node dissection + radiation (why?) → because you cannot expose a pregnant female to radiation. • If there are involved lymph nodes and chemotherapy is indicated → delay chemotherapy until 2nd trimester. • Termination of pregnancy is not part of the treatment plan for breast cancer and does not improve survival. • Breast cancer in males: • Predisposing factors: trauma, estrogen therapy, endogenous estrogen, previous exposure to radiation or Klinefelter’s syndrome. • Most common type: invasive ductal carcinoma. • Diagnosis tends to be late (at this time most males will have direct extension of the chest wall). • Treatment for early-stage disease: modified radical mastectomy with post-operative radiation.