Breast & Endocrine Surgery PDF

Shock 5welling Nutrition @ Copyright 2013 by Mohammed El-Matary All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission, except in the case of brief quotations embodied in critical articles or reviews. Thepublishers ha...

Shock 5welling Nutrition @ Copyright 2013 by Mohammed El-Matary All rights reserved. No part of this book may be used or reproduced in any manner whatsoever without written permission, except in the case of brief quotations embodied in critical articles or reviews. Thepublishers have made every effort to trace the copyright holders for borrowed material. If they have inadvertently overlooked any, they will be pleased to make the necessary qrrangements at the first opportunity. First Edition 2012 Second Edition 2013 For further lnformation, visit our web site: www.mataryonline.net What do you think about this book? Or any other Mohammed El-Matary title? Please send your comments to [email protected] Dedication Allah the all merciful, ! beg Thee To accept this effort For the soul of my mother She was your gift for me Acknowledqement The author wishes to acknowledge with gratitude: Dr. Kareem Mohamed Ali M.B.B.C.H. Ain Shams University Dr. Mohamed Sokar M.B.B.C.H. Kasr El-Einy University  This book provides an update for medical students who need to keep abreast of recent developments. I hope also it will be useful for those preparing for postgraduate examination. This book is designed to provide a concise summary of breast, endocrine surgery & general surgery, which medical students and others can use as study guide by itself or with readings in current textbooks, monographs, and reviews. Summaries of relevant anatomical considerations are included in every chapter, taking into account that this book is written primarily for those who have some knowledge of anatomy, physiology, biochemistry and pharmacology. The author is extremely grateful to all the contributors for the high standard of the new chapters, and hopes that you, the reader, will enjoy going through these pages as much as he had. M. El-Mutury  Table of Contents THE BREAST C_onge4{al Anolnalfes , 3 1,4 i _D_t_s_e.e_ee_p_ _e_t lttl_ele _B_r_e_ep_! '40i :4gi i Cysts of the Breast , Merygqmgn! g_f _Bfe_e_s_t l-_Ump_ :48. r..H3l:3:H:ll3lifii,?'i-Billlurn. - 48 '- -48:-j iChapter 2: THE THE,OID ; Ane_tomy- ;Isoi ---,:-- -- oiseise-s of tne rtrrroid Girnd r Congenital Anomaf!es ,50. , Goitre '52: -:.53: - rhy19_t_9xis_sqis_ p_ _EXqphthalmgg - Retrosternal Goitre i :._ r_hy.r_o_i_a[is_ r T_h.y11_o_!d Neqple_s_m t78: :89: 1 Swellin€s ltdz 2 Cysts llt 3 Salivary System t40 4 Sur€ical infections t58 b Traumatolo€y 208 6 Pre-operation 258 7 Anesthesia z5g I Post-oneration 284 I Water & Electrolyte imbalance ZEE to Tumor (Oncolo€v) 278 Nutrition Sur€ical Tran inS UISER Clinical Audit Sur€ical Ethics Surdica! Drains  lmportant Keys 1- NB: is put in a rectangular like that: 2- Applied anatomy is put in a rectangular like that: 3- Oral questions are put in rectangular like that: 4- Data which is important in MGQs questions for Ain Shams University is written in blue color like that (bleeding....) 5- (*) indicates the reference (look at the bottom of the page).  Abbreviations AJCC: American Joint Committee of Cancer ANDI: Aberration of Normal Development and Involution A-V: Arteriovenous ARDS: Adult Respiratory Distress Svndrome AXR: Abdominal X-ray BP: Blood Pressure CA: Cancer Antiqen Ca: Calcium CBC: Comolete Blood Picture CCA: Common Cartoid Arterv CEA: Carcino-embrvonic Antioen CNS: Central Nervous Svstem CMF: Cvcolophosohamide. Methotrexate. 5- Fluorouracil CRP: C-reactive orotein C & S: Culture and Sensitivitv CT: Comouterized Tooooraohv CXR: Chest X-rav DD: Differential Diaonosis DCIS: Ductal Carcioma ln Situ DIC: Disseminated Intravascular Coaoulopathv DM: Diabetes Mellitus ECG: Electrocardioqram ESR: EMhrocvte Sedimentation Rate FNABC: Fine Needle Asoiration Bioosv and Cvtoloov GFR: Glomerular Filtration Rate. HTN: Hvoertension ICA: Internal Carotid Arterv IJV: lnternal Juoular Vein IV: lntravenous IVC: lnferior Vena Cava IVU: Intravenous urooraohv KFT: Kidnev Function Tests LCIS: Lobular Carcinoma In Situ LN: Lvmph Node MEN: Multiple Endocrine Neoplasia MRI: Maonetic Resonance lmaqino PT: Prothrombin Time TB: Tuberculosis TLC: Total Leucocvtic count TRAM: Transverse Rectus Abdominis Mvocytaneous Flap TTT: Treatment UK: United Kinqdom UO: Urine Outout U/S: Ultrasound gHAPTf,R 1 2 GHAPTER,I BREAST Anatom of the Breast See su cal anatomy book. Consenital Anomalies l. Anomalies of the Nipple 4 Athelia: (very rare) - Absence of the nipple. - Usually associated with absent breast (amazia). c) Polvthelia: - Multiple nipples along either or both milk lines (from axillae to groins) - lncidence:.2-6oh of human females have accessory nipple. - DD: Cample de Morgan spots, mole or wart. 4 Gonqenital retraction of the nipple: It must be differentiated from ired retraction re Con-qenita[ Reffaction Acouhed retraction History Since Birth Recent Side Bilateral Unilateral Mass No breast mass Presence of breast mass Pulling Can be pulled Can not be pulled TTT: o Frequent pulling of nipple o Ashford's operation: purse string - suture around the '1i,, +Causes of acquired nipple retraction: 1. Cancer breast) circumfrential retraction. 2. Mammary duct ectasia. 3. Chronic breast abscess or chronic inflammation (eg.TB). 4. Retraction at puberty (simple nipple inversion) of unknown etiology (bilateral in 25Yo of cases). Duct ectasis ) slit like nipple retraction. Congenital nipple retraction '. Nipple rctraction €taccessory nipple dueto canrcerbreast i * Amastia :a condition where breast tissue, nipple, and areola is absent Poland syndrome: Athelia or amastia is sometimes associated with (i.e., absent sternal portion of pectoralis major muscle, absence of ribs 2-5, deformities of hands or vertebrae). lt is more common in males.  BREAST & ENDOCRINE SURGERY 3 q) Amazia: Absence of the mammary gland but the nipple and areola remain present (usually unilateral) Usually associated with absent sternal pectoralis major M. Bilateral accessory axillary breast tissue in a24 year old pregnant woman sti Multiple breasts may be present along the milk line (or even in thigh). Most common to occur in axilla. They may function during lactation c) Micromazia= - Small Breast - TTT: augmentation mammoplasty. * Macromazia (beniqn virqinal hvpertrophv): - Diffuse hypertrophy of the breast. - Occur at puberty due to alteration of normal breast sensitivity to estrogen. - TTT: reduction mammoplasty. There are 11 possible sites for polymazia on milk line on each side. 4 lnfantile qvnecomastia: - Diffuse enlargement of male infant breast (unilateral or bilateral) - Due to effect of circulating maternal sex hormones. - Usually disappears in 6 months (requires no treatment). Breast Trauma Blunt trauma to the breast produces 2 types of lesions that may be clinically difficult to distinguish from carcinoma; breast hematoma & traumatic fat necrosis.. Sometimes, this trauma draw the attention of the t to an already existing l.Breast Hematoma. Following blunt trauma or breast surgery.. lf there is no external bruising, a deeply seated old hematoma may form a hard mass that greatly resembles breast carcinoma.. Biopsv will confirm the diagnosis. Z.Traumatic Fat Necrosis OIOIilAI: '. Trauma) Fat Necrosis) Release of Fatty Acids) F.A. + Ca ) Ca Soaps. This soap invites foreign body reaction.. The result is one of two forms 1. A cyst that contains thick oily fluid 2. A hard mass (less frequent) that resembles breast carcinoma requiring biopsy to settle the diagnosis (cut section shows a characteristic chalky white appearance)  4 GHAPTEB { BREAST GJfini'rq,ft lPryarurle. History of trauma (only En 50% of cases).. Hard, irregular, painless mass. iUD. Carcinoma as this mass will be (hard, dimpling lf it occurs near cooper's ligament, retracted nipple if near milk duct). r;. Biopsy ) foamy fat laden macrophages. There is absence of yellow specks and gritty texture of carcinoma. Mammography is not conclusive. Tfrr*,{tmrqnit fnflammation of the Breast lnflammation of the Breast Acute lnflammation Acute lactational mastitis Acute non-lactational Non-specific Specific & breast abscess Chronic Breast Abscess Mammary Duct Ectasia TB, Syphilis Acute lnflammation A. Acute Lactational Mastitis & Breast Abscess (most common mostitis) ipXi,ftnf,fyo.rnr Y Etiology: staph.aureus (direct, blood). Acute bacterial inflammation of the Y C/P:4 stages (engorgement, cellulitis, breast which occurs during lactation. acute abscess, chronic abscess) i"lrr ffe F Comp: general, local (sepsis) Invesf..'sepsis + U/S. Most common type of mastitis TTT : prophylactic, curative (incision ) Gausative Organism. Staph. aureus (coagulase positive).. The organism produces clotting of milk in ducts producing obstruction & stasis.  BREAST & ENDOCRINE SURGERY 5 Route of lnfection. Direct spread (Main route) ) from mouth of suckling infant through nipple cracks & opening of lactiferous duct.. Blood spread (less common) from a septic focus. Predisposing Factors. Milk engorgement due to blockage of ducts by inspissated milk & epithelial debris.. Nipple cracks & fissures caused by suckling. R6tiacted nipple is more likely to be injured by the baby (who tries to get hold of it).. Bad hygiene. I condition as diabetes, steroid therapy. on is usually diffuse. Milk engorgement ) not treated well ) acute mastitis ) necrosis by staphylococci ) multilocular abscess. Milk engorgement -> cellulitis -) abscess + Chronicity t. Stage oJ + Svmptoms: - Dull aching pain. - Mild persistent pyrexia. + Siqns: enlargement & induration of the breast with no srgrns of inflammation. 2.s of Celtulitis astitis]; + Svmptoms: - The pain worsens - Continuous high pyrexia o Stol"oiffuse redness, hotness & tenderness of the breast (signs of inflammation) - Enlarged elastic tender LNs. 3. Stage of ute Abscessr " t"T+tfl#;iins - pain. Discharge (pus). 4 Siqns: - Hectic fever (i.e. at night it may reach 40o or more due to absorption of toxins due to vasodilatation). - Edema of the overlying skin. - No response to medical treatment. (Persistence of local signs > 5 days or severe systemic upset > 2 days after full antibiotic treatment) - Fluctuation is a late sign. (NEVER WAIT FOR FLUCTUATION lN BREAST ABSCESS) 4. Stage of See later) ission & exacerbation - Tender swelling with yielding center (Paget's Test). , septicemia, pyemia....... 2- Local'. chronicity.  CHAPTER 1 BREAST 1- Retro mammarv abscess: pain on pushing breast not on bimanual examination. 2- Mastitis carcinomatosis: Acute Lactational Mastitis Mastitis Carcinomatosis Svmptoms: 1. General FAHM Anorexia & loss of weioht Pain of acute onset & rapidly Pain of gradual onset & 2. Local proqressive course slowlv orooressive course Siqns: 1. General Hioh fever Low fever, cachexia 2. Local Siqns of inflammation +ve -ve Enlarged, not tender, hard, Axillary LNs Enlarged, tender, firm, mobile flxed Skin Rosy Duskv red lnvolvement One breast sector is affected More than 113 of breast The lesion either cured by Ab No response to Ab for 1 wk Fate: or forms an abscess is an indication for bioosv (It's mainly a clinical diagnosis) 1. TLC, ESR & CRP > lncreased. 2. Gulture & sensitivity after drainage and to exclude mastitis carcinomatosis. 3. U/S ) for detection of maturity of pus loculus and its location. + Prophvlactic: ")o,',i"'fi";,;?iE3ilt";,e,r#?ioflii;"#irudins - Good hygiene of nipple (Panthinol). b) After deliverv: Clean nipple after suckling by wet tissue (alcohol free). lf the nipple is fissured ) paint it with antiseptic cream. lf milk engorgement occurs ) Pump evacuation. Gurative: l. Bofore devolopmont of an abso€ Medloal troatmont b Lactation should be stopped from the affected side with treatment according to stage :- a) Mrlx ENeonceuENt: evacuate the breast with a breast pump in combination with hot backs b) CELLULTTTS: as before with use of anti staph antibiotics (flucloxacillin or Augmentin @) and analgesics , if the child is older than 9 monthes weaning should be adviced  BREAST & ENDOGRINE SURGERY 7 !!. Stage of pyogenic abs ss : Surqical (incision and drainaqe): Once pus loculus = drainage Do not wait for fluctuation (late sign). l- General anesthesia. ll- lncision: a- Radial incision of the skin, not reaching areola b- if small abscess ) circum-areolar incision may be used for cosmetic purpose. c- Counter incision might be needed to leave a drain (if the abscess is large & in a non dependant region). lll- lntroduce finger to destroy loculi and send pus for C & S. lV- Antibiotics & postoperative dressing (till healing is complete). V- Drain is removed when stops Some authors advise in cases of early breast abscess repeated aspiration guided by U/S under antibiotic cover and this often allows resolution without the need for an incision scar and will also allow the patient to carry on breast feeding. Antibioma: if antibiotic is used in the presence of undrained pus antibioma will occur in the form of large sterile brawny edematous swelling that takes many weeks to resolve. To Wean or Not to Wean 1- lf baby > 9 months )stop feeding and give parlodel 2.5 mg twice daily start with smaller dose then gradually increase. 2- lf baby < 9 months )continue feeding with healthy breast and evacuation of diseased one by using pump. B. Acute Non-lactational Mastitis + Mastitis Ngonator 1- lt is due to withdrawal of mother estroqen. 2- Clinical Picture: Breast enlargement o; 3'd or 4th day with breast discharge "Witch milk" 3- lt is seen only in full developed infants. 4- TTT: leave it alone as it is self-limiting by 3'o week of life. + Mastitis of Pubeftv: 1. Painful tender enlarged breast (unilateral or bilateral) 2. Of both male & female at 14-15 years. 3. Self-limited within 2 years. + Traumatic Mastitls due to ill fit brassiere. + Secondarv infection - Caused by anaerobes & treated by metronid azole 4OO mg I 4 times daily for 5 days. + Pre mammaru Abscess: - lnfection of Montgomery gland (apocrine, sweat gland of breast) - TTT: incision & drainage. + Retro mammarv Absce 3. Drai!]egg by Thomas incision in the mammary groove. * : Barly & love 25th Edition 8 CHAPTER { BREAST Chronic Inflammation A. Noh-s ific Chronic Breast Abscess @'tlEr*. lnadequate treatment of acute abscess. '. Persistence of predisposing factors (i.e. Lactation). Bad General condition of the patient. Y Etiology; bad (ttt + general condition Prifurelre$,y + lactation). The abscess contains sterile pus. C/P.. mass + pus + LNs. The organism present in the wall. lnvest.: U/S + aspiration. Excess fibrosis. TfI; prophylactic + curative(excision) E&!s + Tvoe of patienfu history of maltreated abscess. $ Svmotoms: - Attacks of remission & exacerbation. - Breast mass: may be associated with nipple retraction or skin puckering - Pus discharge per nipple. + srgnsi - Slightly tender breast swelling with yielding center (Paget test). - Axillary LNs. are enlarged elastic, tender & mobile. DD Excess fibrosis makes the mass harder DD. ) malignancy 1) Fibro-adenoma. 2) Breast carcinoma. Chronic breast abscess Carcinoma of breast Svmotoms:. History of acute abscess +ve -ve. Purulent nioole discharoe Mav be oresent Absent Sions:. Fever Low grade Absent. Surface convex Flat. Tenderness oresent Absent. Axillary LNs Firm, mobile, discrete and Hard may be fixed & tender. painless. lnvestiqations:. Asoiration Reveals pus Nothino. Leucocytosis Moderate Absent. U/S (cyst) & needle aspiration (reveals pus and to exclude carcinoma). + Prophvlactic Treatm adequate drainage of acute abscess. 4 Gurative Treatment: Excision of the whole abscess.  BREAST & ENDOCRINE SURGERY 9 Mammary Duct Ectasia (Plasma Gell Mastitis) (most common breost dischorge) Y Etiology.'unknown. lt is dilated inflamed major milk ducts. (Milk=AG, anaerobic infection ) C/P: discharge + mass 14'llfeiwy Y D.D: cancer breast } lnvesf.; mass + discharge Y TTT: antibiotics + excision a) Milk is a sequestrated antigen, so in multipara milk may escape from milk ducts during lactation ) Ag-Ab reaction ) fibrosis ) traction on the ducts ) dilated ducts. b) Anaerobic periductal infection followed by major duct dilatation : tir.,ili{o.)lgreI)I. Dilatation of major ducts which is filled with creamy secretion.. Peri-ductal inflammatory reaction & fibrosis with plasma cell (Round cell) infiltration.. Ductectasia is not a pre-cancerous condition @tntre'llWrst[fice Type of patient. Middle-aged female. More common in smokers. Symptoms. May be asvmptomatic or presenting by one of the following: 1. Nipple discharqe: (Duct ectasia is the most common cause one or more ducts 2) May be creamy white, serous, yellowish or blood-stained 2. subareolar Painless or painful swelling if an abscess develops 3. Recurrent and chronic mastitis Signs. The affected area may be hard with skin dimolinq & retraction of nipole (Fibrosis) DD. Breast carcinoma.  GHAPTER { BREAST lf the patient presenting with subareolar mass, If the patient presenting with nipple discharge with or without nipple retraction l I I Triple assessment to exclude breast cancer Benzidene test to exclude presence of blood (ductectasia shows coarse calcification in Cytological examination to exclude intraductal mammography) tumors 1) Early & mild cases are treated by combination of antibiotic (flucloxacillin & mitronidazole). 2) Correction of nipple inversion. 3) Persistent cases are treated by excision of major duct through circumareolar incision (Hadfield's operation). B. Specific Breast Inflammation 1. TB Breast Abscess: I. Rare with active pulmonary TB or 2ry lo cervical. TB toxemia (night fever & sweat, Loss of appetite & weight).. Multiple nodules in the breast or skin cold abscesses.. Axillary nodes )enlarged and matted. ) TB granuloma.. Anti-tuberculous drugs + simple mastectomy for resistant cases. 2. Syphilis:. 1v: Chancre in nipple & areola + axilllary lymphadenopathy.. 2v'Condylomata lata + generalized lymphadenopathy.. 3ry' Gumma at skin.. Antisyphilitic drugs. 3. Actinomycosis:. Rare with same character of fasciocervical actinomycosis.  BREAST & ENDOGRINE SURGERY.l1l Fibroadenosis (most common breost disorder @J'llrsi l$F,fifiga Y Etiology: unknown (hormonal changes) 1) ANDI ) aberration in normal Y Path.: fibrosis, adenosis, epith., cyst. development & involution of breast. Y C/P: cyclic (pain + mass + discharge) 2) Fibrocystic disease of the breast. Y Comp.: anxiety + hge.&inf. + malignancy 3) Sector mastitis. F Invesf.; mass + discharge 4) Mammary dysplasia. D TTT: mainly conservative 5) ) Chronic interstitial mastitis misnomer as in this condition there is no evidence of inflammation. Eyfifmilltr,n - Fibrocystic breast disease refers to benign (noncancerous) changes in the tissues of the breast. The term "disease" in this case is misleading, and many health care providers prefer the term "change." - The condition is so common that it is believed to be a variation of normal.. llnrolrdrEnrsrE. The most frequent breast disorder (it occurs after puberty and before menopause).. Most common between 30-50 years old Eireiqy (unknown 1. The breast undergoes changes throughout the woman's reproductive life with cyclic changes during the menstrual cycle. The high prevalence of the disease in women in child bearing period points to a relation to ovarian cycle 2. Other Factors a) High unopposed estrogen level with abnormal breast response b) High Prolactin levels c) Viral infection %itiroiWy + The upper outer quadrant of the breast is the commonest site of affection. + lt is Characterized 1. Adenosis ) Glandular hyperplasia with f number acini. It is characterized by: 2. Fibrosis ) fibrous tissue replaces elastic & fatty tissue o Fibroadenosis. 3. Fibrosis ) obstructs duct ) retention cyst formation. Fibrocystic dysplasia. 4. lt may be unilateral or bilateral or affecting sector of breast oo Sector mastitis. 5. Epitheliosis ) Epithelial hyperplasia in small ducts. 6. Extensive epitheliosis ) intra-ductal papillary growth which is termed papillomatosis 7. Rarely, there's "Atypical epithelial hyperplasia" ) precancerous 8. Extensive fibrosis may resemble schirrous carcinoma & called "sclerosing adenosis" 9. Round cell infiltration. 10.Cyst formation ) The cvst miqht be: - Small (microcyst). - Large macrocyst. - The cysts may coalesce to form (blue domed cyst of Bloodgood): A large cyst contains altered blood. 12 GHAPTER,I BREAST + lt is NOT Precancerous: , Most of the surqeons: -Consider the fibroadenosis not precancerous. -Except if there is marked papillomatosis or atypical epithelial hyperplasia. t Hyperplasia and papillomatosis increase risk of malignancy 1.5-2times but atypical hyperplasia increase risk of malignancy 5 times ] l GJttti'rsiJtPrrGtWe + Tvpe of patient:. lt occurs after puberty or before menopause, multiple painful lumps that may be unilateral or bilateral and it is related to menstrual cycle. + Symplomsl. lt may be completely asymptomatic.. These changes are usually CYCLIC. 1- Breast pain (Mastalqia. Mastodvnia):. Exaggerated pre-menstrual tension. Dull aching or stitching pain. A Pre-menstrually & by breast movement & V post-menstrually & by breast support.. Associated with enlargement and increase nodularity of breast 2- Breast lump (Cvsts or sclerosinq adenosis):. The Most frequent complaint. May disappear when the patient is re-examined 1 week after menstrual cycle 3- Breast discharge:. Usually clear or yellow.. Sometimes brown or green. + Local Examination: 1- Breast Lump: -iV-ay b-esolid or cystic, freely mobile, commonly bilateral and diffuse.. Better to be felt by tip of fingers not by flat of the hand (painful nodularity). 2- Discharse:. With gentle squeeze.. Colorless fluid or greenish discharge. 3- Axillarv LNs:. M?y be elastic, enlarged, tender and mobile with shotty distribution. Non-cvclic Mastalqia. lt may be associated with ANDI or with periductal mastitis.. lt is more common in premenopausalfemales than postmenopausal.. lt should be differentiated from referred pain as musculoskeletal disorders.. Breast pain in postmenopausal women not taking hormone replacement therapy is usually derived from chest wall. eWtl 1. lf marked epitheliosis and papillomatosis increased risk of malignancy. 2. Hemorrhage and infection in cyst of Bloodgood. Anxiety (if severe pain). i,D9 1. Breast pain: 1. Premenstrual tension. 2. lnflammation. 3. Malignancy (if advanced or mastitis carcinomatosis) * : Kasr El-Aini Introduction to Surserv 25th Edition  BREAST & ENDOCRINE SURGERY {3 2. Breast !ump: Jibro-adenoma. 2. Breast carcinoma. (The most dangerous). 3. Breast discharqe: @ecommonest). 2. Fibroadenosis. 3. Duct papilloma (the commonest cause of bloody discharge). -l4. Duct carcinoma. 5. Galactorrhea of pituitary adenoma. lnvestigations are usually not required but the following are indicated to rule-out breast cancer in suspected cases For lump For discharge (Triple assessment) 't-*-- I Cytologica! examination and benzidine test Cystic Solid I I Aspiration (not blood FNABC or open Biopsy if stained aspirate, mass FNABC was not conclusive disappears completely, and does not recur within 2 weeks Reassurance of the patient from cancer phobia is the most important A. Ghanqe life-stvle: 1. Firm bra. 2. Avoid coffee, tea and chocolate. 3. Regular intake of 400 lU of vitamin E may be helpful. B. Medical treatment: 1. Analgesic. 2. Regulation of the cycle. 3. Prim-rose oil single evening dose. 4. Parlodel 2.5 mg tab/twice /day (anti-prolactin). 5. Danazol tab!!! (last line of TTT as it causes acne & hirsutism) 6. Psychotherapy. c. su Biopsy ) if doubtful diagnosis. 2 Excision of the cyst ) large cyst (cyst of Bloodgood). 3 Cysts are treated by asplration; recurring cysts, sclerosing adenosis or any cancer doubt are excised for biopsy. Cases with atypical epithelial hyperplasia (discovered by biopsy) should be instructed to perform breast self examination monthly, physical examination every 3-6 months & mammography yearly. 14 GHAPTER ,| BREAST :?\"frtsJi ' Exacerbations may occur at any time until the menopause except in patient neceive hormonal reolacement theraov. Breast Neonlasm G{re r Benign Malignant Epithelial Duct papilloma Eoithelial Carcinoma Mixed epithelial Sarcoma Fibroadenoma Mesenchymal and mesenchvmal Lvmohoma I- Benisn Tumors of the Breast Duct Papilloma ign f{e Y C/P: discharge, mass, no LNs F Inyesf..' discharge, mass,. Usually in young woman (30-40 years).. lt may be Unilateral or bilateral. galactography. The most common cause of bleeding per nipple. ) fII; Micro-dochectomy + Histopathology FE4t:r, Site. Usually situated in one of the main ducts near the nipple. Macroscopic ' Single pedunculated mass that may ulcerate causing blood-stained discharge from the nipple.. lt may block the duct causing a retention cyst. Microscopic. Vascular connective tissue core + overlying hyperplastic epithelium. GJfuffcd] Blood stained discharge Type of Patient. 30-40 years female with bleeding per nipple. Symptoms 1. Discharge: - Bloody or blood stained nipple discharge 50%. (Commonest symptom). - May be serosanginous discharge. 2. Swelling ) retention cyst.  BREAST & ENDOGRINE SURGERY ,15 Signs No pain. tutalotrrr,lfre- 1. Bleedinq per nipple: I ficrci,,o.!*. By pressure on the swelling.. lf there is no palpable swelling, zonal pressure will reveal the discharge. 2. Swellinq:. Small, fusiform, usually lateralto the areola with its long axis pointing to the nipple. 3. Axillarv LNs: are not enlarged. , breast lump. 1) Benzidine test ) to make sure is it blood or not. 2) Galactography the papilloma appears as a regular filling defect. Mammography) to screen the rest of the breast and the other breast. !t's a pre-cancerous (10%1, so the treatment is: 1. Micro-dochectomy (remove the affected duct) through circumareolar incision and wedge of the wdotfiA.il tissue 2.5 cm around it. l,odatilfrc @EboJ.r*2!t 2. Histopathology. oe[dla €--,1C;zl< How can you identify the affected duct intra-operatively? 1- By the lump. 2- lf there is no lump, the duct is identified by passing needle through the discharging nipple opening.  GHAPTER 1 BREAST Fibroadenoma (most common breost moss in Path. : fibrous, glandular Fibroadenoma is the commonest cause of breast C/P: painless (painful) lump mass in young females lnvest.: as mass (The usual age is 15-30 years) Y TTT: hard: enucleation Soft: excision 1. Fibroadenoma is a benign neoplasm of the breast that affects both fibrous & glandular tissues but fibrous element predominates. *{1fyffi Peri-canalicular (Hard) Intra-canalicu r (Soft)Ia [Benign simple) (Giant fibroadenoma) Age: Aqe: 20 - 30 vears 30 - 50 vears Macroscopic picture: Macroscopic picture: 1. Size: small 1. Size: large 2. Surface: smooth. 2. Surface: lobulated. 3. Color: whitish 3. Golor: whitish 4. Gonsistencv: firm or hard. 4. Gonsistencv: soft 5. Cut section: whorly appearance. 5. Cut section: might show central 6. Capsule: 2 capsules true and false necrosis capsule and a pedicle. 6. Capsule: incomplete caosule. Microscopic picture: Microscopic picture: - Formed mainly of fibrous tissue - Contains more glands - Fibrous tissue proliferation occurs - Fibrous tissue proliferation around the acini & ducts. invaqinates the ducts. Gomplication: Complication: - Never turn malionant. - Liable to turn to sarcoma. l- Hard fibroadinoma Type of patient 20 - 30 years aged female. Symptoms Painless lump that is discovered accidentall Signs Breast swelling: - Usually small, non tender, firm, well-circumscribed with smooth surface & with high mobility in breast tissue (breast mouse). with no LN enlarqment ll- Soft fibroadinoma patient 30-50 years old female Type of Symptoms painful rapidly growing lump  BREAST & ENDOGRINE SURGERY 17 Signg Breast swelling - May reach huge size, soft, mobile swelling in breast. with no LN enlaqment 1.Breast carcinoma. 2. Duct ectasia. 3. Localized fibroadenosis. Clinical picture is usually enough for diagnosis Mammography ) reveals well-circumscribed lesion. U/S) may be needed. 1. For peri-canalicular: - lt is enucleated through circum-areolar incision. 2. For intra-canalicular: - lf small, excision is better with a part of the normal breast tissue as a safety margin. - lf large (Cystosarcoma phylloides) ) wide local excision (to prevent recurrence) or if the tumor is the whole breast ) Cystosarcoma Phylloides (seroqrstic disease of Brodie) characterized bv: 1- Highly cellular. 2- Rapidly growing, painful and reaching a large size (20 - 30 cm). 3- lt might ulcerate through skin but not attached to it. The name cvstosarcoma phvlloids (is a wronq name): - Cvst: may be cystic degeneration if hugely enlarged due to insufficient blood supply (but usually it is not cystic) - Sarcoma: it is rarely malignant. - Phvlloids: the cut surface resembles leaf. - So, it is better named "Phylloides Tumor" Spectrum of activitv: - Variable from almost benign to locally aggressive & sometimes metastatic tumors. Differential Diaqnosis: carcinoma bv probe test passing a probe of glass between the tumor & skin: - lf the probe can pass ) benign. - lf the probe cannot pass ) malignant. Treatment: wide local excision to prevent recurrence or simple mastectomy if occupying the whole breast. {8 GHAPTER { BREAST Massive swellings of the breast include: 1- Cystosarcoma phylloides. 2- Diffuse hypertrophy. 3- Giant fibroadenoma fI- Malisnant Tumors of the Breast Breast Cancer (most common concer in Egyption femoles) F lypes; ductal, lobuar, paget dis. Incidence F Spread.' direct, lymphatic, blood, transcelomic Age D Sfaging.' Manchester, TNM Sex D C/P: painless mass in upper outer quadrant Predisposing factors D lnyesf.; diag., staging, pre- op., follow up Classification according to origin Y TTT: l.prophylactic: early detection Spread 2.definitive.' early, late 3.TTT of complications Complications Grading Staging Prognosis Itrnrtrr:rnrtl=c - 1 in every 9 females in USA is expected to develop it. - Breast cancer is the commonest malignancy in Egyptian females (35% of total malignancies).  BREAST & ENDOGRINE SURGERY Epidemiological data indicate well-defined factors increase the liability to develop fhe drbease called relative risk (RR) I,. Age - Carcinoma of breast is extremely rare below age of 20 years. - Mean age of affection is 60 years. - By the age of 90y nearly 20Yo of females are affected. 2. Sex 1) Breast cancer is 100 times more common in women than in men (RR 100) 3. Famillr historXr a) lt has been proven that 5 - 10 % of breast cancers are due to mutation in suppressor genes (autosomal inheritance) 1. Mutation in 2 suppressor genes: BRCA-I (on chromosome 17) & BRCA-ll (On chromosome 13) It usuallv occurs: : fllY-?::gilxgi"t","r 2. Mutation in tumor suppressor gene P53: producing Li Fraumeni $ - Breast cancer. - Ovarian cancer. - Carcinoma of the colon. - Lymphoma (or leukemia). b) Positive family history increases the risk:. ln mother or sister ) ,f the risk by 2.3 times.. ln both mother & sister ) ,1. the risk 14 times.. 20 % of breast cancers are familial 4" Previous altectlon witlr qlncer lrreast - Patient with breast cancer in one side, 4 the risk to develop cancer in the other breast (cases of lobular carcinoma in situ RR 10). - Bilateral breast cancer occurs in about 15 -20 %. (Up to 25 - 50 o/o if nlobular carcinoma) 5. Nutliparitlr. Breast cancer is'commoner in single & nulliparous women (RR 1.5) 6. Precancerous leslon 1) Duct papilloma (especially if multiple) ) A the risk 1.5 - 2 times. 2) Lobular carcinoma in situ ) 4 the risk by 5 - 10 times and it does not cause microcalcifications Age of rnenarche & menoparrse - Early menarche (< 12 years) (RR 2.3). - Late menopause (> 50 years) Radiation ttrerapy to the chest - Women who had radiation therapy to the chest (including breasts) before age of 30 are at an increased risk of cancer breast e.g. Mantle radiotherapy in treatment of Hodgkin disease. 3. Obestty - As there is peripheral conversion of steroid hormones into estradiol (E1) by aromatase enzyme in fatty tissues. 4. Benign breast dlseases - Atypical epithelial hyperplasia ) ,f the risk 2 - 5 times.  20 CI{APTER { BREAST G. Minor risk factors r. Alcoholic intake: 2. oral contraceprtive pitls €l hormonal replaeement therapy (HRT): - Long term exposure to combined preparations of HRT does significan[ly J risk of developing breast cancer. 3. Ptrysicat inactivitSr: - Women who are physically inactive have an increased risk of breast caner because physical activities may help to reduce risk by preventing weight gain. 1. 2. 3. 4. 5. Duct carcinoma Lobular carcinoma Paget Disease of the nipple Non-infiltrating lnfiltrating Non-infiltrating lnfiltrating 10% (Duct carcinoma in (lobular carcinoma situ) in situ) 1% I Subtvpes: Subtvpes: 25 0h 1- Comedo type. 1- Schirrous ("ot oth"r*ise specified) Bilateral a Cribriform type 2Yo. 1 Medullary carcinoma L- a Multi-centric J- Micropapillary ffie 3- Mastitis carcinomatosis 4- Papillary type 3%. 4- Mucinous carcinoma (colloid) 5- Solid ffie. Subtypes. lt now accounts for over 2OYo of cancers detected by screening in UK.. May be ductal (DCIS) or lobular (LCIS). + LCIS often bilateral and multifocal.. The comrnonest histologic type of breast cancer.. Fibrous tissue is more prominent than malignant cells.. Macroscopic picture: hard mass infiltrating edge + area of hemorrhage and necrosis and gritty sensation on cut surface and concave.. Microscopic picture: malignant rounded cells and fibrous tissue.. Spread : rapid lymphatic spread occurs through breast and there may be multiable satelli masses within the breast  BREAST & ENDOCRII{E SURGERY I Malignant cells > fibrous tissue. ! Macroscopic picture: tumor cuts core soft in consistency like brain (so called encephaloid) Cut surface has central necrosis as if there is a co(ex and medulla so called medullary carcinoma. Microscopic picture: malignant cells with little fibrous tissue + lymphocytic ) infiltration Occurs most commonly during pregnancy and lactation. ls a rare and highly aggressive cancer involves at least 113 of breast and may mimic a breast abscess. Macroscopic picture: tumor soft jelly-like with honey-comb appearance in formalin jar due to diluted mucin. Microscopic picture: spheroidal cells distended with mucoid material giving signet ring appearance. i Mucinous carcinoma in breast has a good prognosis unlike elsewhere in the body which usually has the worst prognosis.. Central necrosis of cancer cells ) pasty blood tinged material on cut surface lntraductal carcinoma, begins in the epithelium of main milk duct and spreads within the epithelium up to skin of the nipple and down to breast substance t Macrocopic picture: an eczema-like lesion and nipple is eroded I Microscopic picture:. Paget's cell: large vacuolated cells, deeply stained nuclei (occur alone or in clusters).. Hyperplasia of all layers of the epidermis.. Lymphocytic infiltration ) good prognosis. 22 GHAPTER { "**"' A. Direct Spread: 1. Breast tissue. 2. Skin. 3. Pectoralfascia. 4. Pectoralis major. 5. Serratus anterior. 6. Chest wall. B. LVmphatiC Spread; (Commonest method of spread) (By both embolization & permeation) - Axillary LNs (common) - lnterna! mammary LNs (next common) - Supraclavicular LNs (in advanced disease) 1- Lymphatics from lower inner quadrant may pierce rectus sh | )falciform ligament ) umbilical nodules (sisterJoseph). i 2- Obstruction of skin lymphatics causes edema of hreast skin that is marked in Ir Oepenaent area giving the appearance of an orange peel; hence the French name 'Peau d'orange". pierce the pectoralis major muscle to drain into the interpectoral p,Es-s along the intercostals bundles to reach the posterior G. Blood Stream Spread: - Gives metastasis to bone, liver, lung & brain - Bone secondaries are mainly osteolytic lesions - The commonly affected bones by metastasis are lumbar vertebrae, femur, ribs & skull. - The metastases to vertebrae are due to free (valveless) communication between posterior intercostals veins and paravertebral venous plexus. Now it is we!! realized that cancer breast may spread by" early producing distant micrometastasis. D. Transcelomic Spread: (Aft e r liv e r affe cti o n) 1. Ovaries ) Krukenburg's tumor (by retrograde lymphatic spread) 2. Douglas pouch ) Plummer's shelf nodules 3. Peritoneum ) malignant ascites.  Manchester Staqinq (Better in Clinica Stage I. Mobile mass in the breast.. Not attached to pectoral muscles or chest wall.. With or without skin tethering (in area less than tumor periphery).. No palpable axillary LNs. Stage. II Mobile mass in the breast. Not attached to pectoral muscles or chest wall.. With or without skin tethering (in area less than tumor periphery).. Palpable mobile ipsilateral axillary LNs. S-tagell Grncer ntdt.b lyDph nqta! GlaiEtb Iuqa ld!6t En 2oEI dEg6 the56 Stage III (stage of wide local spread) Any of thefollowing:. Skin affection (in area more than tumor periphery but limited to breast). , Fixed to pectora! muscles.. Ipsilateral axillary LNs matted together.. Ipsilateral supra clavicular LNs affection.. Edema of the arm. 5Lgoll c.ffi hrnE lFphn@ 24 CHAPTER { BREAST Stage IV. Skin affection wide of the breast (Cancer en cuirasse).. Fixed to chest wal!.. lnvolvement of opposite breast or axilla. , Distant metastasis. Multlple lymph nod6s melasta$s lnternational TNM classification (more accurate) Tumor moh Node T0 = not clinically felt (detected by screening). N0 = No palpable L.N. Tis = carcinoma in situ (detected by histopathology) N1 = Mobile ipsilateral axillary LNs or paget's disease with no palpable tumor. N2 = Fixed ipsilateral axillary LNs T1 =Tumor5cm. arm. T4 = any size but fixed to the skin or chest wall or inflammatory carcinoma NB: NB: Tx = tumor cannot assessed clinically as previous Nx = nodes cannot assessed operation clinically as previous operation Metastasis M0 = No evidence of distant metastasis. M1 = Distant metastasis Mx = Distant metastasis cannot be assessed Staging of the UIGC (union international contre cancer T1. N0. M0 T3, NO, MO T1-3, N0-2, M0 Locally advanced breast cancer T, any N, M1  BREAST & ENDOCRINE SURGERY Female 50- 60 years with painless swelling in upper lateral quadrant ofthe breast r- Pain[ess breast [ump:. Discovered accidentally (or during routine screening) and progressive course. z- Less comrnonly: a) Watery (mostly) , Blood stainded nipple discharge or pasty material. b) Nipple retraction c) Breast Pain il" """"r. Mastitis carcinomatosis (inflammatory carcinoma) Paget's disease of the nipple. 3- Menstrual historv: a) Early menarche. b) Late menopause. c) Use of OCPs. 4- Past historv: a) Cancer of the contra lateral breast b) lrradiation to the breast 5- Familv historv:. Cancer breast in first degree relatives. 6- Occasigna[ presentation:. Bone ) bone ache & pathological fractures.. Lung ) dry cough, hemoptysis & dyspnea.. Liver ) malignant jaundice and right hypochondrial pain.. Brain (Rarely affected) ) headache and mental changes and blurring of vision.. Axillary LNs ) axillary lump. General (Cachexia * metastasis) 1. Cachexia and Troisier's sign (enlarged left supraclavicular lymph node). 2. Liven jaundice, malignant ascites, hepatomegaly, sister Joseph nodules or peritoneal nodules (by PR or PV) 3. Lunq: chest examination. 4. Bone: skull and spine examination. Local - Both breasts, axillae & supra-clavicular LNs must be exami - Examine the normal site first. r. lnspeetion; 1- Breast enlarqemen 2- Skin mainfestaions: a' t{iPPle'Nippre Retraction: - Due to infiltration of milk duct. - Not diagnostic as it occurs in any fibrotic process e.g. chronic breast abscess & duct ectazia. b. Arcola- eroded in paget's disease of the nipple.  26 CHAPTER,I BREAST Skinnroper Skin tethering:. Dimpling appears only in movement of breast as cancer infiltrates cooper's ligament but not to the degree of the appearance of dimpling. Infiltration l. Skin Dimpling: of cooperrs ligament - lt's the earliest skin sign. i - Due to contracture of Cooper's ligament - Not diagnostic as it occurs in any Skin Ulceration fibrotic process e.g. chronic breast abscess & duct ectazia. Skin Puckering. Skin Nodules: - May appear away from mother carcinoma. - Due to retrograde lymphatic permeation. - Diagnostic (sure sign of malignancy). Skin Ulceration: - Can be differentiated from benign tumors by probing test. Cancer en Cuirasse: - Late stage of retrograde lymphatic permeation. - Skin is very thick, leathery, brownish & metallic simulating shields of war Peau d'orange: - Due to obstruction of lymphatics so lymphedema of skin occurs except at site of hair follicles & sweat glands. Brawny Edema [Lymphedema of the Arm): + Due to: o Obstruction of lymph. Vessels by: - Tumor metastasis - Surgical. - lrradiation. o Obstruction of axillary vein. Sister Joseph Nodules: - Lymphatic spread to umbilicus.. Special forms: w4 o Mastitis :t?,ffiIil::il,,, & edematous. Brawny edema: Skin edema due to infiltration of lymph vessels. Sister Joseph Nodules Elephantiasis surgica: Skin edema due to surgical removal of L.N.s  BREAST & ENDOGRINE SURGERY 27 Palpation-(start with examination of normal breast & axilla at first). Site ) common in upper lateral quadrant (but may affect any site).. SurfaCe ) irregular & flattened.. Edge ) ill defined.. Consistency> hard (soft in medullary carcinoma ' Mobility ) restricted mobility within the breast. Fixation to skin or muscle or chest wall is diagnostic of carcinoma 2- Lvmph-l{odesl (Bilaterally). Axillary LNs: if enlarged ) hard, early mobile & late fixed.. Supra=clavicularlNs 3. Examination for oos Potentialfor invasive It is a marker of increased risk of canGer malignancy in the same or other breast As invasive cancer Early Breast Cancer - (TzNrMo) or Late Breast Cancer - (>TrM,Mo) or stage l,ll in Manchester stage,lll, M"in Manchester Symptoms o Painless swelling o Painful swelling o neqative occult presentations o Positive occult presentations May be positive for evidence of General signs Negative metastasis Local signs: 1- Breast enlargement and 1- Breast enlargement and a- lnspection asymmetry. asymmetry. 2- Skin lesions: 2- Skin lesions: a- Nipple retraction and skin a- Skin nodules. dimpling. b- Sister joseph nodules. b- Peau de'range c- Cancer en cuirasse d- Skin ulceration. e- Brawnv edema b- Palpation 1- Firm to hard mass freely mobile. 1- hard fixed mass. 2- Axillary LNs: negative or may be 2- Axillary LNs: hard and fixed. enlarged (hard and mobile) -_,_39 cHAprER { BREAST 1- Fibro-adenoma 2- Fibrocystic disease 3- Breast cyst... 4- Chronic breast abscess 5- Duct ectasia 6- Chronic fat necrosis. Smooth (may be B. C. lll defined A breast lump mav be felt D Affects more than 1/3 of the breast Affects one sector of the breast Gradual onset & No or low qrade fever Non-tender axillary LNs No response to antibiotics in one Responds either to antibiotics or an abscess will be formed  BREAST & ENDOCRINE SURGERY lnvestigations For pre-operative, For Diagnosis For staging For follow uP pieparation. Taking a detailed family history is the first step in investigating a possible inherited to breast cancer. 1. Soft tissue mammographv: (To evaluate the whole breast), )95ok accuracy in diagnosis of breast cancer with expert hands * lndications:. Screening for high risk group (main value).. It is the only way to detect impalpable cancer breast.. To evaluate the other breast in a patient with cancer breast. * Findinq in mammographv suqqestive of maliqnancv: occur in du I & not lobular carcinoma..2OYo of micro-calcifications are malignant. 2.Star shaped mass. 2. Ultra Sonoqraphv: (Differentiate solid tumorsfrom cystic) 4 For cvstic swelling we do: Aspiration - Hemorhagic fluid. refilling. - Residual mass after aspiration. ant cells in the aspirate. =) For solid swellins we do: FNABC t Mammography is of less diagnostic value in young women, on differs a little from normal tissue, so U/S in young women is useful ; mammography is done with complementary U/S. 3. Biopsv: a) FNABC: simple, inexpensive and very accurate. b) Core-cut biopsy. c) Open biopsy. 4. MRI of breast:. Gold standard of woman with synthetic prosthesis. 1. Sentinel Lymph Node Study:. Standard investigation in patients with clinically -ve LN affection.. By injection of methylene blue or radioactive isotope ) follow-up ) till we find the sentinel lymph node.. Then it is excised and frozen section is done for it to know whether affected by the cancer or not. 30 cHAprER { BREAsT 2. Lung ) CXR. 3. Liver ) abdominal ultra sound and liver function tests. 4. Bone ) bone scan (Tc 99). 5. Brain ) CT scan and MRl. LFTs, KFTs. Tumor markers: CA15-3 and CEA. I About 60% of patients with breast cancers have estrogen receptors (ER- positive). I Other breast cancers may have progesterone receptors. I Staining for estrogen and progesterone receptors is now considered routine and their presence will indicate the use of adjuvant hormonal therapy with tamoxifen. Recently, tumors are stained for c-erb 52 (a growth factor receptor as patient can be treated with monoclonal antibody against this receptor to decrease relapse) Treatment Special cases: - Breast cancer with pregnancy - Familial breast cancer Early Late breasf cancer Prophylactic Treatment. There is no method to prevent breast cancer however, prognosis is markedly affected by early detection through the triad of: 1. Self assessment. 2. Physical examination. 3. Mammography every 2years. Definitive Treatment of Breast Cancer , Breast cancer is now widely accepted to be a systemic disease.. ln other words once it is evident clinically, it metastasize in the form of micrometastasis.. Therefore, local and systemic treatments are indicated whatever the stage is.. Basic principles for treatment of cancer breast: - Reduce the chance for local recurrence. - Reduce the risk for metastatic spread.  BREAST & ENDOCRINE SURGERY 31 Early breast cancer Advanced breast cancer (Potentiallv curablel fincurablel T2 N1 M0 or less More than T2 N1 M0 Definition Manchester staoe I or ll Manchester staoe lll or lV Aim Cure Palliation Mainly local disease + Disease status Mainly systemic disease micro-metastasis Chemotherapy & endocrinal Surgery + radiotherapy Primary treatment therapy (Systemic (Loca! treatment) treatment) Simple mastectomy & radio- Adjuvant treatment Endocrinal & chemotherapy therapy have limited role in (Palliative) local control Treatment of Early Cancer Breast (curabte) Primary TTT Adjuvant systemic therapy Radiotherapy llormonal Chemotherapy Immunotherapy Primary TTT L. surgery Types of Advantages of Contraindications of Surgery conservative surgery conservative surgery  32 A- Types of Surgery Modified Radical Mastectomy Conservative Surgery followed by breast reconstruction i Removal of Breast LumP Whole breast tissue with or Block dissection of the without removal of pectoralis axilla followed by post- i minor followed by post- operative radiotherapy in operative adjuvant dose of LN positive patients radiotherapy on chest wall Breast Lump Breast tissue I I Local control of axilla Wide localexcision with safety Post-operative radical in conservative Reconstructive surqerv after mastectomv: margin 2cm by dose of radiotherapy. I!-M.g_(playing an important role in physical and Lumpectomy or surgery emotional outcomes among survivals: I I Quadrantectomy. lf the lesion - 1ry (at the time mastectomy). is close to the skin part of it - Delayed may be exicied to ensure the ' Iegh-d@. required safety margin - Myo-cutaneous flaps' ) Latissimus dorst. lf clinically Negative ) Transverse rectus abdominis lf clinicallv Positive myocutaneous flap (TRAM) { LN sampling Sentinel Biopsy - Prosthesis & tissue expander. Block dissection is done ) lf positive block dissection - (Silicon gel implant). through a separate incision ) lf negative follow-up  {: BREASTGHAPTER 33 B.Advantages of conservative surgerv over modified radical 1. Although local recurrence is high but the overall survival rate is the same. 2. Decrease psychological morbidity although recent studies show that 30% of the patients have anxiety or depression for fear of recurrence. C. Contraindications of conservative surgerv = indications of modified radical mastectomv: @ce) l- Tumor: 1. Bilateral & multi-focal disease. 2. Central lesions (surgery will cause bad cosmetic appearance). 3. Paget's disease of the nipple (bad cosmetic appearance, radio-resistant). 4. Tumor > 4 cm or small breast: (we will need to remove additional 2 cm as a safety margin & therefore the cosmetic advantage of lumpectomy will not be achieved). 5. Distant metastasis. 6. Fixed to muscle. 7. High grade (grade III). 8. lnsito breast cancer more than 20 o/o due to the common incidence of multicentricity ll- Patient: 1. Pregnancy. 2. Patient preference. 3. Contraindication to irradiation e.g. SLE. 4. Previous irradiation. lll- Breastl relatively small in size. Radiotherapy (Can be started after 14 days from surgery) 2. Radiotherapy Type of radiation i Indication ) A. Tvpe of Radiation:. Deep X- ray (External beam).. lrre2 wire implant (lnterstitial Beam). B. lndications: 1. Post-operative after conservative surgery to the remaining breast tissue by radical dose (5000 RAD). 2. Post-operative after radical mastectomy on the chest wall by adjuvant dose (1500 RAD) if: a- High grade tumor or large tumor. b- All LN positive patients. c- Medial tumors for possibility of internal mammary LN affection. C. Side Effects: 1. Local burn. 2. lnterstitialpulmonary fibrosis. 34 BREAST & ENDOGRINE SURGERY + DGIS: May be treated by Van Nuys system: Van Nuvs System - Non- high grade without necrosis. - Non-high grade with necrosis. - High grade. - Van Nuys system is according to: o Patient age. o DCIS o Presenceof micro-calcifications. - Patient with high grade ) benefit from radiotherapy after excision whereas of those of non high grade, who are completely excised ) need no further treatment. Adjuvant systemic treatment A. Hormonal B. Chemotherapy C. Immunotherapy - Indications - Indications - Lines of TTT - Preparations - Results - Regimen Hormonal Therapy A.lndications: 1. lf hormone receptors positive (used alone or with chemotherapy). B. Lines of treatment: Pre-menopausal Post-menopausal 1- First line of treatment: tamoxifen 20 First line of treatment: mg/day. tamoxifen 20 mglday. 2- Second line of treatment: Alternative hormona! aqents: - Bilateral oophorectomy by: 1- Aromatase inhibitors. a- Medical suppression (LHRH). 2- Raloxifene. b- Surgery c- Radiotherapy. - Adrenalectomy (rarely done) by : a- Surgery. b- Medicaltreatment by aminoolutethimide + cortisone. G. Results: 60% improvement in estrogen receptor positive patients. 80% improvement in progesterone receptor positive patients.  GHAPTER 1: BREAST 35 Chemo-therapy A.lndications: 1. +ve LN biopsy (in pre-menopausal females) 2. - ve hormonal receptors. 3. High grade even if -ve LN or postmenopausal. 4. All patients below 70 yrs El-Einy book 5. Tumors more than 1 cm. )rur. S-fluorouracil. G. Reqimen:. Every cycle 8 days repeated every month for 6 months. (Six cycles can reduce the risk of relapse 3O%) Target therapy. For her2lneu receptor +ve cases ) give monocolonal Ab (herceptin) against these receptors lAor e D etails abou t T r eatment A. Hormonaltherapv: 1- Tamoxifen (20 mq/dav for 5 vears):. Mechanism of action: anti-estrogen (agonist-antagonist) 'Advantaqes: a-Decrease annual rate of recurrence by 25o/o wilh 17% reduction in annual rate of death. b- Effective in pre-menopausal and post-menopausal state. c- lncrease bone density.. Side effects: hot flushes, increase risk of uterine cancer and thrombosis. 2- Aromatase inhibitors: (used post-menopausal only):. Mechanism of action: inhibit aromatase enzyme.. Advntaqes: no side effects of tamoxifen.. Side effects: increase risk of osteoporosis. 3- Raloxifene: same as tamoxifen but with less side effects. B. Prognosis: - Presence of axillary LNs is the best marker for prognosis, however treatment of axillary LNs does not prolong survival rate suggesting that it does not act as a reservoir but as a marker for metastatic potential. G. Radiotherapv - Postoperative radiotherapy does not improve survival but it reduce the incidence of local recurrence (not started untilthe 14th postoperative day). D. Chemotherapv - CMF is no longer considered adequate adjuvant chemotherapy and modern regimen include anthracycline (epirubicin) and newer agents as taxanes. - Adriamycin in commonly added in dose of 50mg/m2 Lvmohanqiosarcoma is a rare complication of Iymphedema occurring years after treatment. C/P: multiple subcutaneous nodules of upper limb, must be distinguished from recurrence. Prognosis: bad but some cases may respond to cytotoxic therapy.  36 Treatment of early breast cancer Primary Treatment Adjuvant Systemic Treatment ll- Radiotherapy A- Hormonal I!l G-lmmunotherapy - lndications :! - Lines of TTT - Results. -t 1- Modified radical mastectomy + reconstructive surgery. 2- Conservative surgery. t B- lndications 3- Radical mastectomy (not done now). i { i C- Side effects I 4- Extensive radical mastectomv (not done now) I....J. Factors affectinq the choice of treatment: 1- Stage and grade of the tumor. 2- Hormonal receptors. 3- Age and general health of the patient. 4- Menstrualstate.  lntermediate (Locally advanced) breast cancer * This cateqorv of patients have:. This category of patient have cancer above 5 cm diameter.. Fixed axillary L.N.s or internal mammary L.N.s. + For this:. Distant metastasis should be excluded by C.T. scan & PET scan. + Treatment:. Neoadjuvant chemotherapy > down staging: - lf good response ) breast conservative therapy. - lf poor response ) modified radical mastectom Treatment of Advanced Breast Cancef (rncurabre) A. Primary Systemic Treatment B- Adjuvant Local Treatment C- Treatment of i- Hormonal therapy. i- Radiotherapy. Complications ii- Ghemotherapy. ii- Pa!!iative surgery A- Primary Treatment i- Hormonal Therapv: a. Only given to hormone receptor +ve patient with 60-70 %o response b. More effective in post-menoposal women c. Not very effective in hormone negative patients ( response 1oo/o ), with visceral metastasis or young patient below 35 years old d. Tamoxifen ( anti-estrogen ) is given for not more than five years to avoid the risk of endometrial cancer or thrombogenicity. lf no response aromatase inhibitors may be used ii- Chemo-therapv: - lndications: 1. Rapidly progressive disease 2. Premenopausal women 3. Visceral metastasis 4. Hormonal receptor -ve cases. - combinStJilon..ohamide, methotrexate & 5-ftuorouracit (cMF).. Adriamycin is commonly added. B- Adiuvant Treatment i lt has a palliative role in the following situations: 1- Pain (due to bone or soft tissue involvement). 2- SVC obstruction. 3- used to control tumor fungation ii- Surqerv: 1. Modified radical mastectomy in stage lll. 2. Palliative simple mastectomy in stage lV to get rid of unpleasant fungating tumor. C- Treatment of Complications 1. Hvpercalcemia:. Correction of dehydration by lV fluids + furosemide. Prednisolone + biphosphonates 2. Patholoqical fractures:. lmmobilization + internal fixation. Radiotherapy to the fracture site. 38 BREAST & ENDOGRII{E SURGERY 3. Cerebral metastasis. Corticosteroids and radiotherapy 4. Spinal cord compression:. Surgical cord decompression with stabilization followed by radiotherapy 5. Superior vena cava obstruction:. Radiotherapy is the treatment of choice Post-operative radio- 6. Pleural effusion: therapy does not improve. Systemic therapy and chest tube drainage the survival but it reduces 7. Liver metastasis: the incidence of local. Treated by chemotherupy. recurrence. 8. Lvmphedema:. Can be treated stive thera Follow-up of Patients with Breast Cancer 4After treatment. everv 3 months for first 2 vrs ,then every 4 months next 2 vrs. then vearlv for life. to: 1- Detect and treat complications of mastectomy.Psychiatric morbidity caused by the loss of the breast.Arm edema results from excision of lymphatics, their obstruction by radiotherapy, lymphangitis caused by infection, or malignant axillary recurrence blocking them. Thrombosis of the axillary vein..Avoidance of radiotherapy to the axilla which has been surgically evacuated of its nodes reduces the possibility of lymphatics edema..The patient is warned to avoid minor trauma to the ipsilateral hand and should wear gloves when carrying out rough work. Arm elevation, massage, and elastic or pneumatic arm compression are partially effective. 2- Detect local recurrence or distant disease: because of the incidence of cancer in the other breast (1% per year) annual mammography of the contralateral breast is done. 3- lnstructions. Patients are instructed not to get pregnant for at least three years, and to use non-hormonal contraception, to avoid the stimulating effect of hormones on possible residual tumor Summary of Active Treatment of Cancer Breast Early Breast Gancer - Types ofsurgery 1- a- b- Whole breast tissue with or without removal of pectoralis minor followed by post- operative adjuvant dose of radiotherapy on chest wall c- Block dissection of the axilla followed by post-operative radiotherapy in LN positive patients 2- a- Removal of Breast Lump by Wide local excision by Lumpectomy or Quadrantectomy. b- Post-operative radical dose of radiotherapy for Breast tissue c- Local control of axilla if clinically +ve or with sampling by block dissection through a separate incision.  GHAPTER {: BREAST 39 B. ,/ Post-operative after conservative surgery to the remaining breast tissue by radical dose (5000 RAD). / Post-operative after radical mastectomy on the chest wall by adjuvant dose (1500 RAD) * Adiuvant Svstem,ic Treatment A. Hormonal therapy: if hormone receptors positive ""nipp",Ir#l;trI'ff i"i*:"i,:::f"""1"i1?;'ili",1f#orouracir) - +ve histological involvement of removed axillary nodes c. Prirnary Treatment A. Hormonal therapy: if hormone receptors positive or bone metastasis. e. Ghemotherapy: by combination of CMF + Adriamycin Adiuvant Treatment A. Radiotherapy: in cases of pain or SVC obstruction B. Surgery: palliative simple mastectomy Breast Cancer with Pregnanqf The effect of pregnancy on breast cancer is not well-understood but if breast cancer develops in pregnancy, it tends to be at a later stage because it is masked by symptoms of pregnancy and lactation. (also may be due to increase vascularity) Treatment: 1- Mastectomy is more optional than conservative surgery. 2- Radiotherapy is contraindicated. 3- Chemotherapy is not give in the 1"t trimester. 4- Hormonal treatment is usually not given because most of the tumors are with -ve hormonal Familial Breast Cancer I lncidence: less then 5%. T Genes involved: a- BRCA-1: in chromosome 17, associated with ovarian cancer (50%) b- BRCA-2: on chromosome 13, associated with male breast cancer. c- P53 - Age at onset, - Bilateral disease. - Male breast cancer. - Multiple cases in one side of the family. - Ovarian cancer, notfall into a high risk group and do not deve breast cancer. 40 BREAsT & ENDocRINE sURGERY. HOw tO Deal: '9 Gene positive patients Gene negative patientsvvith strong family history 30-50% risk of developing breast cancer Just regular follow-up Therefore, prophylactic tamoxifen may be -t tried to decrease the risk. Prognostic Factors of Breast Cancer Type of the tumour. The best prognosis is provided by the in situ carcinoma, and paget's disease, while the worst is the inflammatory carcinoma 2. The T stage of the primary tumour. The higher the T stage, the worse is the prognosrs. 3. Size, mobility, number, and location of the involved lymph nodes. - Large fixed nodes are of bad prognosis - The number of involved nodes largely affects the prognosis. Patients with negative axillary nodes have a 10 years survival rate 650/o o Patients with 1-3 positive axillary nodes have a 10 years survival rate of 38Yo. Patients with more than 4 +ve axillary nodes have a 10 years survival rate of 13Yo - The prognosis worsens the higher the affected nodes in the axilla. lnvolvement of level lll nodes carries a bad prognosis 4. The presence of distant metastasis markedly worsens the prognosis 5. Hormone receptor status 6. The site of the tumour. Medial half tumour have a worse prognosis than those of lateral half due to early involvement of the internal mammary lymph nodes Cancer Breast in Male o lncidence: It's a rare disease, the incidence is only about 1%o of that of women There may be an increase incidence of breast cancer in men with prostatic cancer in addition BRACA-2 mutation are common in men with breast cancer. Clinical findinqs: Painless lump beneath the areola at 50 years. Nipple discharge or retraction or ulceration. Spread: Rapid spread to skin and chest wall due to deficient breast tissue Blood born metastases are common. a DD: gynecomastia & metastasis from other tumors. a Treatment: Like cancer breast of female. NB: castration in advanced breast cancer is a successful measure and more benefital than the same procedure in women but is rarely used. Prognosis: The prognosis of breast cancer is poor in men than in women.  GHAPTER {: BREAST Gynecomastia Etiology : idiopathic, physiological,. lt's painless enlargement of male breast due pathological, iatrogenic, genetic to increased glandular elements # C/P : bilat.(unilat. ) breast enlargement O/E: tender disc Grading:3 grades lnvest.: cause + mammogram 1. About 65 percent of 14-year-old boys have 77L' reassurance. ttt of the cause gynecomastia; the condition often will improve after two to three years without 1. ldiopathic. (the commonest cause) 2. Phvsioloqical: a- Neonatal ) from exposure to high maternal estrogen. b- Pubertal ) resolves in 2 years. c- Old age ) I testicular function. 3. Patholosical: a- 4 Estroqen: 1- Feminizing tumors of testis (Sertoli cell tumor). 2- Feminizing tumors of adrenals. 3- Paramalignant syndrome as bronchogenic carcinoma. b- V Testosterone: 1- Orchidectomy. 2- Testicular atrophy:mumps, lepsory and heat exposure' c- I Metabolism of estroqen. liver cel! failure. 4. latrogenic: 1- Digitalis. 3- Reserpine. 2- Aldactone. 4- Cimitidnine. 5- Estrogen therapy as in cancer prostate. 5. Genetic: Klinefelter syndrome. -History of drug intake. -Abdomen ) hepato-sPlenomegalY -Testis ).@:asmall amountof increase in breast tissue is present with no extra skin..@: amoderateamount of enlargement of the breast can be seen with or without extra skin..@anexceptional enlargement of the breast with extra skin.  BREAST & E]{DOGRIilE SURGERY 1. Blood tests (including liver function tests and hormone studies) 2. Urine tests 3. Consultation with an endocrinoloqist : a physician who specializes in the functioning of hormones and how the hormones affect multiple organs. a low-dose x-ray of the breast. A- lt 2l,.: TTT of the cause. B-ll1rv: (most cases require no treatment) 1. Subcutaneous mA5lgslo4lL 2.@: This is a form of lip uction that allows for tapering of the edges of the tissue without unwanted side effects. 3. Endoscopic surqerv: - This newer procedure uses a small, flexible tube with a light and a camera lens at the end (endoscope) to examine the inside of the breast. - Tissue is then removed without placing a large, open, surgical incision.  CHAPTER'l: BREAST 43 Early Detection of Cancer Breast ' Finding cancer before it starts to cause symptoms.. Makes the treatment more successful. 1. A lump ---+ single, firm, and most often painless. 2. Unusual appearance of--- the skin on the breast, underarm. 3. Veins on the skin surface become more prominent on one breast. 4. lnverted nipple develops a rash or has a discharge other than breast milk. 5. A depression on the breast surface Clinical breast examinations (CBE) every 3 years from ages 20-39, then every year thereafter. Monthly self-breast examinations (SBE) beginning at age 20. Look for any changes in your breasts. O How to do a Breast Self-Examination: lN THE SHOWER Fingers flat, move gently over every part of each breast. Use your right hand to examine left breast, left hand for right breast. - Check for any lump, hard knot or thickening. Carefully observe any changes in your breasts. BEFORE A MIRROR inspect your breasts with arms at your sides. Next, raise your arms high overhead. - Look for any changes in contour of each breast, a swelling, a dimpling of skin or changes in the nipple. Then rest palm on hips and press firmly to flex your chest muscles. Left and right breasts will not exactly match - few women's breasts do LYING DOWN Place pillow under right shoulder, right arm behind your head. With fingers of left hand flal, press right breast gently in small circular motions, moving vertically or in a circular pattern covering the entire breast. Use light, medium and firm pressure. Squeeze nipple; check for discharge and lumps. Repeat these steps for your left breast../ -: 45 years ) Radio-active iodine. 2. Malignant changes (Follicular carcinoma).. Total or near total thyroidectomy.. Supplementary L{hyroxin.. Radioactive iodine for metastasis. 3. Retrosternal extension: surgical excision. 4. Hemorrha€e: urgent aspiration or even emergency subtotal thyroidectomy. Nlore details I - Accidentally discovered ma