L1 - Breast Diseases PDF

General surgery Breast diseases L1 L1 By Dr. Ibrahim falih noori OBJECTIVES Surgical Anatomy of The Breast. Presentations of breast diseases. Diagnosis of breast diseases. Investigations.  Breast is a m...

General surgery Breast diseases L1 L1 By Dr. Ibrahim falih noori OBJECTIVES Surgical Anatomy of The Breast. Presentations of breast diseases. Diagnosis of breast diseases. Investigations.  Breast is a modified sweat gland derived from ectoderm, as branching epithelial cords which form lactiferous ducts.  The paired mammary glands embryologically develop along the milk line that extends between the limbs buds from the axilla to the inguinal region. ‫براعم األطراف من اإلبطني‬  About 15- 20 lobes develop during puberty , each of which drains into a single lactiferous duct.  True secretory alveoli develop during pregnancy and lactation under the influence of estrogen , progesterone and prolactin  Surgical Anatomy of The Breast  The breast is partitioned into 4 quadrants by vertical and horizontal lines across the nipple  Upper outer quadrant  Upper inner quadrant  Lower outer quadrant  Lower inner quadrant  The upper outer quadrant has axillary extension called axillary tail of Spence  Majority of benign and malignant tumors in the upper outer quadrant. - The mature female breast extends superiorly from the level of second rib to infra mammary fold inferiorly at the level of six rib. - Medially , the breast extends from the lateral border of sternum to the anterior or mid-axillary line laterally. - The upper half of breast , particularly the outer quadrant contains the greater volume of glandular tissue than the remainder of the breast  Blood supply of breast Lateral thoracic artery from 2nd part of axillary artery. Perforating branches of internal mammary artery. Lateral branches of second, third and fourth intercostal artery. Pectoral branches of acromiothoracic artery  Venous drainage of breast  Superficial veins from the breast drains to axillary , internal mammary and intercostal veins  Phlebitis of one of these superficial veins feels like a cord immediately beneath the skin … Mondor’s disease. ‫مثل الحبل تحت الجلد مباشرة‬  Through posterior intercostal veins, venous drainage communicate with para vertebral venous plexus “ Batson plexus”, so secondaries in vertebrae is common in breast cancer.  Lymphatic drainage of the breast  Commonly into the axillary lymph nodes  These lymph nodes drain later into supra and infra-clavicular lymph node  25% drains mainly from medial half of the breast into 2nd, 3rd and 4th intercostal space internal mammary lymph nodes. Anterior group Medial group Posterior group (pectoral) ( central ) ( subscapular ) along the lateral thoracic next most common rarely to involve in vessels. carcinoma Main drainage nodes. Interpectoral group Apical. Lateral group ( Rotter‘s node ) along the axillary vein lies between pectoralis , rare to involve in major and minor. breast cancer  Presentations of breast diseases  Lumps  Pain ( Mastalgia)  Swelling or changes in size or shape of the breast  Nipple ( discharge , retraction, displacement , ulceration)  Skin Changes  Abnormal mammographic findings Diagnosis of breast diseases  History and physical examination are essential for diagnostic evaluation of breast abnormalities.  The history includes details about :  Presenting symptom whether it be a mass, pain, nipple discharge, palpable adenopathy or abnormal imaging. ‫تاريخ أمراض الثدي السابقة‬  History of previous breast diseases.  Risk factors for breast cancer.  Menstrual history. Physical examination  The physical examination should be performed with respect for patient privacy, and comfort, without compromising the complete evaluation.  Examination begins with inspection.  The both breasts are inspected and compared for any obvious masses , asymmetries and skin changes.  The nipples are inspected for the presence of retraction , inversion or excoriation Palpation  The breast is palpated with patient in upright sitting position with arms relaxed and supine with ipsilateral arm raised above the head.  The regional lymph nodes should be examined and followed which include axillary , infraclavicular, supraclavicular and cervical nodes.  If mass is detected , it should be measured and its location, mobility, and consistency must be documented  True masses will persist throughout the menstrual cycle.  Diagnosis should not be delayed.   In patient who presented with nipple discharge, the nipple discharge is often elicited during palpation of the breast  The character , color , and location of discharging duct or ducts should be identified.  If the discharge is not grossly bloody, a Hem occult test may be used to detect occult blood.  Pathological discharge characterized by:  Unilateral  Uniduct  Spontaneous and / or bloody discharge should be evaluated with surgical duct excision  Investigations Mammography Ultrasound MRI Computed tomography , CT Fine needle aspiration cytology and biopsy. ‫تصوير الثدي الشعاعى‬ Mammography  Soft tissues X- ray of the breast taken by placing the breast in direct contact with ultra-sensitive film.  The dose of radiation is approximately 0.1 cGy and so, ‫تحقيق آمن للغاية‬ mammography is very safe investigation.  Mammography is the most sensitive and specific imaging test currently available. The sensitivity of this investigation increases with age as the breast becomes less dense.  In total , 5% of breast cancers are missed by mammographic screening programs.  Digital mammography is being introduced which allows manipulation of images and computer-aided diagnosis Types of mammography  Screening mammography : is used to detect cancer in asymptomatic women when cancer is not suspected.  Diagnostic mammography: is used to evaluate the breasts of patients with symptoms or complaints, such as nipple discharge or palpable mass or patients who have had breast cancer treated with breast conservation therapy. Findings in mammography  Microcalcifications signify malignancy.  Soft tissue shadow may be smooth and regular in benign conditions or irregular in carcinomas.  Size and location of mass lesion.  Spiculations, duct distortion. Mammographics findings of cancer A- stellate mass B-clustered microcalcifications  Ultrasound  Ultrasound initially used to differentiate solid masses from cystic masses, margin of the lesion , internal echoes, signal retro-tumor loss and a dark appearance acoustic shadowing , compressibility, dimension.  It has become an important adjunct to mammography and is an excellent method for guiding some interventional procedures.  Ultrasound is not a breast screening tool and remains an operator dependent.  Irregular margin, irregular internal echoes, hypoechogenecity, posterior shadowing, non – compressibility, taller than wide dimensions are features of malignancy.  Benign lesion are smooth, rounded with well defined margins with weak internal echoes and compressibility.  FNAC can be done under Ultrasound guidance.  It is cheaper , easily available and there is no risk of radiation  Disadvantage is lesion less than 1 cm may not be identified.  MRI Breast  MRI is being used with increasing frequency for screening and diagnosis of breast cancer.  While the mammography remains the gold standard , MRI is emerging as an important modality for evaluating breast diseases.  MRI has several advantages. There is no ionizing radiation to the patient with MRI.  MRI is not limited by breast density and is an excellent tool for the screening of young woman with increased risk for inherited breast cancer.  Disadvantages of MRI are cost , limited availability. Breast MRI , Breast Cancer Computed Tomography, CT scan of breast: Appears to be the best way to image internal mammary nodes and to evaluate the chest and axilla after mastectomy  Needle cytology and biopsy  Fine - Needle Aspiration Cytology (FNAC).  Core – Needle ( Cutting – Needle) Biopsy.  Image –Guided :  Stereotactic  Ultrasound-Guided Core – needle biopsy of the breast under Ultrasound guidance  Fine-needle aspiration cytology (FNAC) is the least invasive technique of obtaining a cell diagnosis and is rapid and very accurate if both the operator and the cytologist are well expert.  The diagnostic accuracy of FNAC of breast masses is approximately range  False –negative results occur in approximately 15% of cases and the False –positive result is rare.  Core needle biopsy is considered more sensitive and more specific than FNAC.  Triple assessment  Any patient who present with a breast lump or other symptoms suspicious of carcinoma  The diagnosis should be made by a combination of :  Clinical assessment : detailed history and thorough physical exam.  Radiological imaging : mammogram , ultrasound , MRI and CT scan  Cytology and biopsy.  The diagnosis by triple assessment should exceed 99%  Triple assessment  Any patient who present with a breast lump or other symptoms suspicious of carcinoma  The diagnosis should be made by a combination of :  Clinical assessment : detailed history and thorough physical exam.  Radiological imaging : mammogram , ultrasound , MRI and CT scan  Cytology and biopsy.  The diagnosis by triple assessment should exceed 99%