4-The Breast.pdf

The Breast Dr. Ali Abdel Kader Assistant Professor of General Surgery General Surgery Department 1  INTENDED LEARNING OBJECTIVES (ILO) By the end of this module the student will be able to: 1. Describe the anatomy of the breast 2. Analyze symptoms and man...

The Breast Dr. Ali Abdel Kader Assistant Professor of General Surgery General Surgery Department 1  INTENDED LEARNING OBJECTIVES (ILO) By the end of this module the student will be able to: 1. Describe the anatomy of the breast 2. Analyze symptoms and management of benign breast disease. 3. Explain the rationale of management for patients with genetic predisposition to cancer. 4. Discuss how and when to take a family history and to request genetic tests, to discuss the significance of this and how this guides surveillance and gene testing. 5. Explain the patient pathway for breast screening and subsequent cancer management, including one-stop clinics, triple assessment and multidisciplinary team management. 2 General Surgery Department  INTENDED LEARNING OBJECTIVES (ILO) 6. Identify staging of breast cancer and the principles of sentinel node biopsy. 7. Explain different types of surgical operations available and indications for mastectomy and breast conservation operations. 8. Describe the scientific basis for current breast cancer therapies. 9. Define the principles behind adjuvant / hormone therapy and radiotherapy. 10. Explain the need and indications for oncoplastic breast surgery. 11. List the reconstructive options available to patients undergoing mastectomy. Breast Plastic surgery 3 General Surgery Department  Contents Surgical anatomy Breast physiology Congenital anomalies Diseases of the male breast Inflammations of the breast Fibrocystic disease of the breast Cysts of the breast Nipple discharge Breast neoplasms classification and benign tumours Carcinoma of the breast General Surgery Department 4  Learning Methods Lectures Small group teaching sessions Clinical teaching : history taking and clinical examination Cases : Breast lump : fibroadenosis, fibroadenoma, breast cancer, etc.. Nipple discharge : duct ectasia Skill lab : Breast Examination and checklists Self –directing learning (SDL) Assignments General Surgery Department 5  Surgical Anatomy Embryology and Functional Anatomy (SDL) Development The breast is a modified sweat gland. The mammary glands develop from two ectodermal thickenings, right and left that are known as the "mammary ridges". These ridges extend from the axillae to the groins (Fig. 1). In humans only the middle part of the upper third of each ridge persists to form the breast while the rest of the line disappears. General Surgery Department 6 The "mammary ridges , milk lines (Fig.1) General Surgery Department 7  Functional Anatomy 15-20 lobes (Fig.2),each composed of several lobules Fibrous bands of connective tissue travel through the breast(Coopers suspensory ligaments),insert perpendicularly into the dermis , and provide structural support The breasts lie between the skin and the pectoral fascia to which they are loosely attached. Breast Components (Fig.2) The epithelial elements. The supporting tissue General Surgery Department 8  Functional Anatomy(cont.) Position and Extent The mature female breast overlies the area from the 2nd or 3rd rib to the inframammary fold at the 6th or 7th rib It extends transversely from the lateral border of the sternum to the anterior axillary line. The deep or posterior surface of the breast rests on the fascia of the pectoralis major, serratus anterior, and external oblique abdominal muscles, and the upper extent of the rectus sheath. The actual extent of the breast is important for the surgeon who aims at removal of the whole organ for malignancy. The axillary tail (of Spence)is a prolongation of the parenchyma which passes deeply through an opening in the deep fascia to blend with the axillary fat. General Surgery Department 9  Functional Anatomy (cont.) Nipple –Arreola Complex Inactive and Active Breast Blood supply ,Innervation and Lymphatics NB. : Blood supply: Arteries Veins Lymphatic drainage General Surgery Department 10 Arteries The arterial supply comes from the following arteries in order of their contribution: (a) Perforating branches of the Internal mammary artery ; These branches are encountered in the operation of mastectomy, and should be ligated or clamped before their division, otherwise the cut end of the artery retracts and bleeds in the mediastinum and is difficult to control. (b) Lateral branches of the posterior intercostal arteries; and (c) Branches from the axillary artery, including the highest thoracic, lateral thoracic and pectoral branches of the thoracoacromial artery; (acromiothoracic) artery. General Surgery Department 11 Veins The venous return is primarily through the axillary and internal mammary veins. The intercostal veins are clinically important as they drain into the azygos system and communicate with the valveless vertebral venous plexus(Batson’s). This communication could explain the tendency of breast cancer deposits to affect the axial skeleton and central nervous system. General Surgery Department 12  Lymphatic drainage Lymph vessels follow the course of blood vessels The six axillary lymph node groups : A. Axillary nodes(lateral) B. Anteromedial (pectoral);external mammary, C. Posterior (subscapular) group, D. Central group, E. Apical group(subclavicular) and F. Interpectoral (Rotter), General Surgery Department 13  Lymphatic drainage For the purpose of determining the prognosis after radical or modified radical mastectomy, the axillary lymph nodes are divided by the pectoralis minor muscle into three levels Level I nodes are located low in the axilla lateral or below the lower border of the pectoralis muscle. Level II nodes are located superficial or deep to( behind) the pectoralis minor muscle. Level III nodes are located medial or above the muscle in the apex of the axilla. General Surgery Department 14  Physiology of the Breast Hormonal control Breast development and function are initiated by a variety of hormonal stimuli, with the major trophic effects being modulated by estrogen, progesterone, and prolactin. Physiological changes At puberty Menstrual changes. During pregnancy, Lactation. After menopause General Surgery Department 15  Congenital Anomalies Anomalies of the nipple Anomalies of the breast General Surgery Department 16  Congenital Anomalies (cont.) Accessory breasts (polymastia) Accessory nipples (polythelia) Inverted nipple Enlarged breasts Amastia Accessory axillary breast General Surgery Department 17  Diseases of the male breast Gynecomastia Male breast Cancer General Surgery Department 18  Infectious and Inflammatory Disorders of the Breast Acute lactational mastitis and breast abscess Non lactational mastitis Chronic Inflammatory Conditions of the Breast Mammary duct ectasia (plasma cell mastitis) Chronic pyogenic breast abscess Hidradenitis Suppurativa Tuberculosis of the breast Mondor’s disease General Surgery Department 19  ANDI Syndrome Fibrocystic Disease of the Breast This is the most frequent disorder of the breast. There is a spectrum of breast conditions that ranges from normal to disorder to disease. "Aberrations of Normal Development and Involution.“ANDI. (a) Early reproductive years(age 15-25y) (b) Later reproductive years(age 25-40y) (c) Involution (age 35-55y) General Surgery Department 20  ANDI Syndrome (cont.) Pathological types: Adenosis Epitheliosis Fibrosis Cyst formation. General Surgery Department 21  Clinical Features of ANDI Asymptomatic Felt lump Painful nodularity Mastalgia (breast pain) Nipple discharge General Surgery Department 22  Investigations Investigations are usually not required, but are indicated to rule out breast cancer in suspected cases. General Surgery Department 23  Treatment for ANDI is individualized Exclusion of malignancy and reassurance of the patient are most important. Accidentally discovered cases deserve no treatment. Cysts are treated by aspiration. A recurring cyst is excised for biopsy. Cyclic mastalgia. - In mild cases reassurance and wearing (night and day) a brassiere that gives good support and protection are usually enough. - Giving up caffeine consumption (coffee, tea, and chocolate) may be useful. - Prolactin inhibitor as bromocriptine 2.5 mg b.d. gives gratifying results in many patients. - Danazol, which is a synthetic androgen, is effective in controlling cyclic pain.( The dose is 100-200 mg twice daily orally. Its androgenic effects, as acne and hirsutism, limit its use to the unusual severe cases.) - Primerose oil is symptomatic treatment Cases with atypical epithelial hyperplasia, discovered by biopsy, should be instructed to perform a monthly breast self examination. Meanwhile, regular medical follow-up examinations are arranged. General Surgery Department 24  Cysts of the breast Acinar cysts Retention cysts Galactocele (milk cyst) Intracystic papilliferous carcinoma Interacinar cysts General Surgery Department 25  Nipple discharge Causes: Duct ectasia Fibrocystic disease Duct papilloma Duct carcinoma Contraceptive pills Hyperprolactinaemia General Surgery Department 26  Diagnosis History and examination should provide the following information: Nature of discharge. Association with a mass. Unilateral or bilateral. Single duct or multiple duct discharge. The use of contraceptive pills. General Surgery Department 27  Investigations Test for occult blood in the discharge if it is not apparent. Cytology of the discharge for exfoliated cancer cells. Soft tissue mammography. Duct galactography may be useful in cases of single duct discharge.( The test entails cannulation of the duct and injection of a contrast material (lipiodol) prior to taking the radiography. It may show a filling defect or obstruction by a papilloma or carcinoma. The test is not so practical and has been superceeded by the simpler mammography). Serum prolactin estimation in suspected cases of galactorrhoea. General Surgery Department 28  Treatment A palpable mass should be excised for histology and treated accordingly. A single duct bloody discharge calls for excision of this duct by the operation of microdochectomy.( A needle with a blunt tip is introduced into the affected duct to act as a guide for the surgeon. This duct, with a rim of the surrounding tissues, is excised and is sent for histological examination). Discharge from multiple ducts with no palpable nor mammographic mass is initially treated conservatively by observation. Rarely the discharge is persistent and troublesome where it is surgically treated by excision of the major ducts General Surgery Department 29  Breast neoplasms classification and benign tumours Duct papilloma Fibroadenoma Cystosarcoma phylloides General Surgery Department 30  Carcinoma of the Breast Aetiology Risk factors Genetic factors(BRAC1&BRACA2) Endocrinal factors(Hormonal) Precancerous lesions Obesity Previous affection with breast cancer. Epidemiology Natural history General Surgery Department 31  Histopathology Carcinoma of the breast may arise from the lobules, the ducts or the nipple, with the tumour arising from the ductal epithelium in the majority of cases. The carcinoma may remain within the epithelium (in situ) or, more frequently, it invades (infiltrates) the basement membrane. Accordingly the following histological types are seen: Carcinoma of the ducts - Non-infiltrating duct carcinoma (ductal carcinoma in situ). - Infiltrating ductal carcinoma (75%). All grades of differentiation from anaplasia to well-differentiated tumours may occur. Carcinoma of the lobules - Non-infiltrating lobular carcinoma (lobular carcinoma in situ) is frequently multicenteric. - Infiltrating lobular carcinoma. The lesion is bilateral in 25% of cases. Paget's disease of the nipple. It is essentially an intraductal carcinoma which begins in the epithelium Multicentricity the occurrence of a second breast cancer outside the breast quadrant of the primary cancer(or at least 4cm away) Multifocality refers to occurrence of a second cancer within the same breast quadrant as the primary cancer(or within 4 cm of it)General Surgery Department 32  Classification of invasive carcinoma 1. Paget's disease of the nipple 2. Invasive ductal carcinoma 3. Adenocarcinoma with productive fibrosis( scirrhous, simplex, no special type; NST) 80% 4. Medullary carcinoma 4% 5. Mucinous (colloid) carcinoma2% 6. Papillary carcinoma 2% 7. Tubular carcinoma 2% 8. Invasive lobular carcinoma 10% 9. Rare cancers(adenoid cystic, squamous cell, apocrine) General Surgery Department 33  Spread Local spread Lymphatic spread (by embolism and permeation Blood stream spread General Surgery Department 34  Hormone receptors oestrogen progesterone General Surgery Department 35  Clinical features Symptoms Signs Breast Mass Nipple Axillary and supraclavicular nodes Distant metastases Special clinical forms Paget's disease of the nipple. Inflammatory carcinoma. General Surgery Department 36 Clinical features General Surgery Department 37  Clinical features Lump and nipple retraction and asymmetry General Surgery Department 38  Clinical features Asymmetry General Surgery Department 39 Clinical features General Surgery Department 40 Clinical features General Surgery Department 41  Clinical features Peau d’orange General Surgery Department 42  Clinical features Paget’s disease General Surgery Department 43 General Surgery Department 44  General Surgery Department 45 Manchester staging. A.A Normal mammogram..B Dense irregular opacity of B breast cancer. General Surgery Department 46 Clustered microcalcification is characteristic of early breast cancer. General Surgery Department 47  Investigations Imaging Techniques: Mammography Ultrasonography Ductography Magnetic Resonance Breast Biopsy Nonpalpable lesions Palpable lesions General Surgery Department 48  Early detection Breast self examination (BSE) Screening programs Routine use of screening mammography in women >50 years of age reduces mortality from breast cancer by 33% General Surgery Department 49  Treatment When diagnosis of breast cancer is made ,the surgeon should determine the clinical stage ,histologic characteristics, and appropriate biomarker levels before initiating local therapy Local-regional and systemic therapy decisions for an individual patient with breast cancer are best made using a multidisciplinary treatment approach Treatment of early (potentially curable) breast cancer Adjuvant chemotherapy and hormonal treatment Follow-up Reconstructive procedures after mastectomy Treatment of advanced (incurable) breast cancer General Surgery Department 50 General Surgery Department 51  Surgical Techniques in Breast Cancer Therapy Excisional biopsy with needle localization Sentinel lymph node dissection Breast conservation Mastectomy and axillary dissection Modified radical mastectomy Reconstruction of the breast and chest wall General Surgery Department 52  SUGGESTED TEXTBOOKS Kasr El-Aini Introduction to Surgery, 7th edition, University Book Center, Al Ahram Commercial Press Bailey and Love’s Short textbook of surgery, 26th edition, Norman Williams , P Ronan O'Connell Current Surgical therapy General Surgery Department 53 Thank You General Surgery Department 54