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Breast Surgery By Harry O’Neill and Megan BoultonThanks to our partners! Breast Anatomy • The breast can be divided into 2 parts, with the nipple in the centre: • Circular body – largest part • Axillary tail – small part running towards the axilla • Most of the breast is made from adipose tissue. • The milk is produced in the lobules of the breast. These lead into the ducts which open out into the nipple. The nipple is surrounded by the secrete an oily lubricating substance duringh pregnancy. • Each lobule consists of many alveoli which drain into a single lactiferous duct. . • In females, the breast contains the mammary glands which are a key structure in lactation.What condition does this picture show? Examination and Investigations: • Firm tissue behind the areola which is the growth of Gynaecomastia gland and duct tissue • Enlargement of the glandular breast tissue in males. • This can help distinguish the condition from pseudogynaecomastia • ↑oestrogen and ↓ androgens • If malignancy is suspected then patients require the • ↑ prolactin (dopamine has an inhibitory effect triple assessment. on prolactin) • LH levels and testosterone levels are checked: • LH high and testosterone low = testicular failure Raised Oestrogen Decreased Medications and • LH low and testosterone low = increased Androgens Drugs oestrogen • LH high and testosterone high = androgen - Obesity - Testosterone - Anabolic steroids resistance or gonadotrophin-secreting malignancy - Testicular cancer deficiency - Antipsychotics (Leydig cell tumour) - Hypothalamus or - Digoxin Management: - Liver cirrhosis pituitary conditions - Spironolactone • Reverse the underlying cause e.g. by stopping a - Hyperthyroidism - Klinefelter - GnRH agonists - hCG secreting syndrome - Opiates causative medication. tumour (SCLC) - Orchitis - Marijuana • Tamoxifen (a selective oestrogen receptor - Testicular damage - Alcohol modulator) – reduces the effect of oestrogen on the breast • Surgery – for later stages of fibrosis if medical treatments have failed. Inflammatory Breast Disease What conditions do these pictures show? Mastitis • Inflammation of the breast tissue and it’s a common complication of breastfeeding. • Caused by • Obstruction in ducts leading to the accumulation of milk • Infection where bacteria (most commonly staph aureus) can enter the nipple and travel through the ducts Presentation: Management: • Unilateral pain in the • 1 line = continue breastfeeding, expressing breast milk and breast massage. • Erythema over infected • Heat packs, warm showers and simple analgesia • Flucloxacillin if conservative management is not area effective (erythromycin if allergic to penicillin) • Warmth over infected area • Nipple discharge • Fever Complication • Breast abscess – may need surgical incision and drainage Breast Abscess • Management: • Usually caused by a bacterial infection and is filled • Referral to the on-call surgical team in the hospital for with pus (which contains WBCs and other waste management products). Can be: • Antibiotics • Lactational abscess (associated with • Ultrasound (confirm the diagnosis and exclude other breastfeeding) pathology) • Non-lactational abscess (unrelated to • Ddrainage)needle aspiration or surgical incision and breastfeeding) • Microscopy, culture and sensitivities of the drained fluid • Causes • Continue breastfeeding or express breast milk if it’s • Staphylococcus aureus (the most common) too painful • Streptococcal species • Enterococcal species • Anaerobic bacteria (such as Bacteroides species and anaerobic streptococci) • Presentation: • Swollen, fluctuance, tender lump within the breast. • Fluctuant = being able to move fluid around within the lump. Infection without an abscess = not fluctuance. • Generalised symptoms of infection: • Muscle aches, fatigue, fever, signs of sepsisBreast Cysts • They are benign, individual, fluid-filled lumps and are the most common cause of breast lump. • They are epithelial lined fluid-filledcavities which usually form when the lobules become distended due to blockage. • Occur between ages 30-50 and more common in perimenopausal period. • They require further investigation to exclude cancer. Aspiration can resolve symptoms in patients with pain • On • May fluctuate in size over the menstrual cycle • Smooth • Well-circumscribes • Mobile • Investigations: • Halo shape on mammography and can ultrasound definitively diagnosed using • Breast cysts can slightly increase the chances of breast cancer Mammary Duct Ectasia • Benign condition involving the dilation of the large • Other investigations: ducts. • Ductography – contrast injected and mammograms used to • Inflammation in the duct can lead to intermittent visualize the duct discharge from the nipple • Nipple discharge cytology – examining cells in nipple discharge • Risk factors: • Ductoscopy – passing a tiny camera into the duct • Perimenopausal women • Smoking = significant • Management: • Resolves without treatment • Not associated with an increased risk of cancer • Presentation: • Conservative • Discharge which may be white, grey or green • Reassurance • Pain • Symptomatic management (supportive bra and warm • Nipple retraction/inversion compress) • Lump (pressure may produce discharge) • Antibiotics if infection • Surgical excision (microdochectomy) • Diagnosis: • Clinically • Imaging • Histology = fine needle aspiration or core biopsy Fat Necrosis • Benign breast lump which is most commonly • Investigation: triggered by trauma • Ultrasound or mammogram to exclude breast • It causes localised degeneration and scaring cancer. of fat tissue in breast. • May show hyperechoic mass on ultrasound • surgery. be triggered by radiotherapy, • Treatment: • Causes an inflammatory reaction resulting in • with time.ve as it may resolve spontaneously fibrosis and necrosis of fat tissue. • Analgesia • Surgical excision may be used for symptoms. • On examination: • Painless • Firm • Irregular • Fixed • Skin dimpling or nipple inversionBenign Breasumours Fibroadenoma Adenoma • Common benign tumours of proliferation of the • It is a benign glandular tumour. stromal/epithelial breast duct tissue • More common in younger women between the • tender limp.a palpable, mobile non- ages of 20 – 40 and regress after menopause • Usually don’t have any associated skin or • Tprogesterone.e they respondto oestrogen and nipple changes • They are nodular in appearance and • On examination: easily mimic malignancy therefore most • Painless cases will involve further investigation • Smooth (triple assessment). • Round • Histopathological analysis will usually • Well defined borders differentiate adenomas from malignancy • Mobile • Up to 3cm • Thy are non cancerous and are not associated with an increased risk of breast cancer. • The main indicator for possible incision is if they are >3cm in diameter or patient preference.Intraductal Papilloma • Warty lesion which grows in one of the ducts. It results in proliferation of epithelial cells. Benign however they are associated with atypical hyperplasiaor breast cancer (especially if they are multi-ductal papillomas). They most commonly occur in the subareolar region. • Most commonly affect ages 35-55 years • Presentation: • Often asymptomatic • Clear or blood stained nipple discharge • Tenderness • Palpable lump • Diagnosis: • Triple assessment • Ductography • Management • Biopsy as they can mimic ductal carcinomas. • Require complete surgical excision • Tissue is then examined for atypical hyperplasia Lipoma Phyllodes T umour • They can occur in other places aroundsue. • Very rare and they are tumours of the the body, not just on the breast. connective tissue (stroma) and the epithelial. • They have a very low malignant potential. • Most commonly occurs between the ages of 40 and 50. • On examination • Large and fast growing tumours. • Soft • They are can be benign, borderline or malignant • Painless and malignant tumours can metastasise. • Mobile • Do not cause skin changes • Treatment: • Surgical removal of • Management tumours and • Management is usually conservative with surrounding tissue reassurance However they can). • Surgical removal if they are significantly reoccur (around 10%). reasons., causing symptoms or for aesthetic • Chemotherapy in metastatic tumours.Breast Examination 1.) Introduction 2.) Inspection 3.) Palpation 4.) Completing the examination1.) Introduction - Introduce yourself - Wash hands - Explain to patient what the examination involves - Position patient at 45 degrees - Ensure a chaperone is present - Ask patient to remove their clothing to expose their chest, from above the waist - Offer a blanket to the patient to cover themselves whilst not being examined2.) Inspection Inspect from end of bed: - Ask patient to place their hands by their sides, look for • Obvious scars or masses • Skin changes or ulceration (erythema, puckering or peau d’orange) • Nipple changes (discharge or inversion) To accentuate any asymmetry: - Ask patient to place both hands behind their head, repeat inspection • Inspect axillae for obvious masses - Ask patient to place both hands on their hips, repeat inspection3.) Palpation - Ask the patient to place both hands behind their head - Start with the unaffected side first, examining any painful areas last Technique - Use a flat hand and press the breast against the underlying chest wall, rolling the underlying soft tissue - Examine each quadrant of the breast, including the axillary tail (Tail of Spence) and both axilla Assess for potential metastasis: • Palpate spine for tenderness • Palpate abdomen for hepatomegaly • Percuss and auscultate lungs for masses • Palpate for any lymphadenopathy4.) Completing the Examination - Thank patient - Ask them to redress - Follow up with remaining components of the Triple Assessment The Triple Assessment A hospital-based assessment clinic that allows for the early detection of breast cancer Components: • History and Examination • Imaging • Histology The clinical, radiological and pathological information gained from the Triple Assessment is then combined and a diagnosis can be madeHistory and Examination - A detailed history and examination are performed by a breast surgeon or associate specialistImaging Mammography - Involves compression views of the breast across 2 views • Oblique • Craniocaudal - Allowing for the detection of mass lesions or microcalcifications Ultrasound - More useful in women <35 years and in men - Due to the increased density of breast tissue Histology A biopsy is required of any suspicious mass or lesion Core biopsy - Most common method - Provides full histology (entire block of tissue) - Allows differentiation between invasive and in-situ carcinoma - Provides information about tumour grading and staging - Higher sensitivity and specificity for detecting breast cancer than FNA Fine needle aspiration (FNA) - Only provides cytology (looking at a single cell type) - If a woman has recurrent cystic disease, this can be aspirated using FNA to relieve symptoms and for cytologyLO: Describe common breast presentations, their differentials, and the management options - Galactorrhoea - Mastalgia - Breast lumpsGalactorrhoea - Galactorrhoea is the production of milky discharge, not associated with pregnancy or lactation - Occurs almost exclusively in females (most commonly adults) Lactation physiology - Lactation is primarily regulated by the hormone prolactin (secreted from the anterior pituitary gland) - Dopamine (released by the hypothalamus) inhibits prolactin secretion - Oestrogen and TRH act to stimulate the release of prolactin Galactorrhoea can be split up into • Hyperprolactinaemic (most common) • NormoprolactinaemicCauses of hyperprolactinaemic galactorrhoea Normoprolactinaemic galactorrhoea - Idiopathic (40% of cases) - Less common - Pituitary adenoma - Typically idiopathic - Drug-induced - Diagnosis is only made once all other - Neurological causes have been excluded - Hypothyroidism - Damage to pituitary Management - Identifying and treating underlying cause - Dopamine agonists can be used to treat the symptoms (e.g. bromocriptine or carbergoline) - Trans-sphenoidal surgery is used for patients with a confirmed prolactinoma - Patients with normoprolactinaemic galactorrhoea can be reassured and observedMastalgia - Refers to breast pain - Very common presenting complaint in women - Can occur in men with gynaeocomastia - Incidence of a breast malignancy associated with a presenting complaint of mastalgia is low Non-cyclical pain Cyclical pain - Around 1/3 of mastalgia - Most common - Can be caused by medication (e.g. SSRIs, - Pain associated with menstrual cycle anti-psychotics) - Usually affects both breasts - Starts a few days before the beginning of menstruation and stops at the end Extramammary pain - Caused by hormonal changes - e.g. chest wall pain, shoulder pain Mastalgia - Management Any underlying cause suspected should be investigated and managed appropriately In most cases, the pain will be idiopathic, management includes - Wearing a supportive bra - NSAIDs, paractemaol - Avoid caffeine - Applying heat to area If first-line options are unsuccessful, specialist referral may be needed - Hormonal treatments (e.g. danazol, tamoxifen)Breast Lumps - Many causes of breast lumps, many of which are benign - The most significant differential of a breast lump is breast cancer - Any breast lump needs a thorough assessment to exclude breast cancer (the differentials of a breast lump (including management) will be covered later on in the presentation!)LO: Understand the relevant breast and mammary gland anatomy to describe the following breast conditions. Briefly describe these conditions, their clinical features, differential diagnosis, investigations, management options, and prognosis/complicationsBreast Cancer Divided into two classifications based on if they have spread beyond the local tissue • Invasive • Non-invasive (carcinoma in situ) - Breast carcinoma in situ are neoplasms that have not spread into the surrounding breast tissue - They represent a precursor to invasive breast cancer - Typically identified solely on imaging as they are rarely symptomatic at presentation - 2 main types • Ductal Carcinoma In Situ (DCIS) • Lobular Carcinoma in Situ (LCIS)Ductal Carcinoma in Situ (DCIS) - Arises from the epithelial cells lining the ducts - Most common type of non-invasive breast malignancy - Usually asymptomatic Investigations - Often detected during mammogram screening - 90% have suspicious microcalcifications on mammography, with the diagnosis then subsequently confirmed via biopsy Management - Surgical excision, either • Breast conserving surgery (wide local excision) • Mastectomy (if widespread)Lobular Carcinoma in Situ (LCIS) - Much rarer than DCIS - Arises from the epithelial cells inside the lobules - Predominantly occurs in pre-menopausal women - Usually asymptomatic - More often found in both breasts compared to DCIS Investigations - Unlike with DCIS, LCIS is not associated with microcalcifications - It is usually diagnosed as an incidental finding during biopsy of the breast Management - Dependent on disease extent - Low grade LCIS is usually treated with monitoring - Bilateral prophylactic mastectomy can be indicated if individuals possess the BRCA1 or BRCA2 genesBreast Cancer Divided into two classifications based on if they have spread beyond the local tissue • Invasive • Non-invasive (carcinoma in situ) Presentation - Can present symptomatically or - These tumour cells have invaded the basement asymptomatically via screening - Clinical features may include membrane • Breast lump • Asymmetry or swelling - Can be classified into: • Abnormal nipple discharge • Invasive ductal carcinoma (70-80%) • Invasive lobular carcinoma (5-10%) • Nipple retraction • Other subtypes • Skin changes • MastalgiaInvasive ductal carcinoma (IDC) - Most common type of breast cancer (80%) - Originates in epithelial cells from the breast ducts - More common in older women Investigations - Gold-standard = triple assessment - Microscopically, it is composed of nests and cords of tumour cells with associated gland formation - Can be seen on mammogramsInvasive lobular carcinoma (ILC) - Around 10% of invasive breast cancers - Originates in epithelial cells from the lobules Investigations - Not always visible on mammograms - Microscopically, characterised by a diffuse (stromal) pattern of spread that makes detection more difficultNon-Surgical Treatment Endocrine treatment - Aim is to reduce oestrogen activity to reduce tumour growth - Tamoxifen (SERM) for pre-menopausal women - Aromatase inhibitors (e.g. anastrozole) for post-menopausal women Chemotherapy - used in one of three scenarios • Neoadjuvant therapy = shrink tumour before surgery • Adjuvant therapy = given after surgery to reduce recurrence • Treatment of metastatic or recurrent breast cancer Radiotherapy - Recommended to patients who have had breast-conserving surgery to reduce the risk of recurrenceSurgical Treatment Breast conserving surgery - Only suitable for patient with localised disease - Wide local excision involves removing the breast cancer, with wide margins to prevent the cancer coming back - Considered when the size of the breast cancer is small relative to the breast size Mastectomy - Used when there is a high risk of disease recurrence or when the size of the tumour is large compared to the breast size - Involves removing the entire breast - Potentially with an immediate or delayed breast reconstruction Axillary surgery - Used when cancer has metastasized to the lymph nodes - Usually the majority or all the lymph nodes are removed from the axilla@supta_uk @SUPTAUK www.supta.uk