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Breast surgery

This document provides information about breast surgery and breast cancer. It discusses the anatomy of the breast including its structure, blood supply, and lymphatic drainage. It also covers common benign breast diseases such as fibroadenoma, duct papilloma, and breast abscess. The document discusses clinical assessment of breast cancer including history, examination, and investigations. It provides details on TNM staging and pathological classification of breast cancer. Finally, it describes different surgical procedures for breast cancer including simple mastectomy, modified radical mastectomy, and breast conserving surgery.

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BREAST SURGERY Faisal Azmi
• Introduction • Situation and deep relations • Structure • Blood supply • Lymphatic drainage
Situation and deep relations Lies in superficial fascia of the pectoral region (except for tail) Axillary tail of Spence pierces the deep fascia & lies in the deep fascia Extent Vertically; 2nd to 6th ribs Horizontally; lateral border of sternum to the mid- axillary line Deep relations Pectoral fascia: the deep fascia which the breast lies on Muscles which lies deeper to the breast Pectoralis major Serratus anterior External oblique Retro mammary space: loose areolar tissue which separates the breast from the pectoral fascia
The skin Nipple Conical projection Just below the centre of the breast At the level of 4th intercostals space Pierced by 15 to 20 lactiferous ducts Contains circular smooth muscles : make the nipple stiff Contains longitudinal smooth muscles : make the nipple flatten Has few modified sweat & sebaceous glands Rich in nerve supply Has many sensory end organs at the termination of nerve fibres Devoid of hair
The parenchyma • glandular tissue • 15 to 20 lobes • each lobe is a cluster of alveoli • drained by a lactiferous duct • lactiferous ducts converge towards the nipple & open on it • each duct has a dilation called a lactiferous sinus near its termination
The stroma Fibrous stroma Supporting framework of the gland Forms septa known as the suspensory ligaments of Cooper Anchor the skin to the pectoral fascia Fatty stroma Main bulk of the gland Distributed all over the breast; except beneath the areola & nipple
Blood supply Arterial supply : arteries converge on the breast & are distributed from the anterior surface; the posterior surface is relatively avascular Internal thoracic artery : through its perforating branches Some branches of axillary artery; • Lateral thoracic artery • Superior thoracic artery • Acromiothoracic artery (thoracoacromial artery) Lateral branches of the posterior intercostal arteries
Venous drainage : veins follow arteries; first converge towards the base of the nipple & form an anastomotic venous circle, from where veins run in superficial & deep sets The superficial veins drain into; Internal thoracic vein Superficial veins of the lower part of the neck The deep veins drain into; Internal thoracic vein Axillary vein posterior intercostal veins
Nerve supply Anterior & lateral cutaneous branches of the 4th to 6th intercostal nerves Convey sensory fibres to the skin Convey autonomic fibres to smooth muscle & to blood vessels Nerves do not control the secretion of milk (controlled by prolactin hormone)
Breast Anterior Posterior Central Lateral Apical Supraclavicular Posterior intercostal Parasternal Axillary 75% 20% 5% Bergs level 1. Lateral and below the P.M(PAL) 2. Behind the P.M (Central) 3. Above and medial to P.M
• FibroAdenoma • Duct Ectasia • Duct Papilloma • Phylloides Tumour • Breast Abscess Benign Breast Diseases
Fibroadenoma Simplex • Young women • Rubbery firm, smooth, very mobile mass • Mostly a clinical diagnosis • Early years after Menarche 16-25 years • Overall incidence is highest in 30s and 40s • Lobular in origin / Mostly remain static • 1-3cm in size increase over 1-5 years • Most common in left breast and upper outer quadrants.
Giant Fibroadenoma • 30 % of all Fibroadenoma • Greater than 6 cm • Differential diagnosis with Phyllodes Tumor • Confirmed via histology • 4% are reported in pregnancy and lactating adenomas. • Women on HRT has increased incidence.
Investigations • Triple assesment • Mammography  Age above 35  Typical solitary lesion, Stippled calcification  ( Popcorn Appearance)
Managment • Overall Conservative. • Reassurance • Offer exicision • if >3cm / rapid increase • Symptomatic • Patients choice, patients satisfaction. • Surgical- If within 3cm of nipple, periareolar incision. • Alternative- Laser Ablation, Cryosurgery • Hormonal- Tamoxifen. Not favored due to unwanted side effects.
Benign Duct Papilloma 1. Discrete Duct papilloma- common 2. Multiple duct papillomas-rare Discrete Papilloma 2-3mm diameter, grows along the length of duct, no pre malignant potential. Either observe or excise. Multiple Papilloma Involve peripheral ductules, premalignant potential, complete excision with healthy margins.
Duct Ectasia • Dilatation of the ducts • Leads to stagnation and accumulation of discharge • May cause ulceration • If Blood discharge- Duct excision Mx Microdochetomy Had Field operation( in case of multiple)
Duct Exicision
Breast Abscess
BREAST CANCER
CLINICAL ASSESSMENT Clinical assessment History Clinical Examination General Survey Local Examination of Breast Systemic Examination • Inspection • Palpation
MAJOR POINTS TO BE NOTED: • Age • Lump in breast: Mode of onset, duration, rate of growth • Pain • Breast or axillary changes • Nipple: Retraction, Discharge • Past history: H/O irradiation, cancers • Personal history: Marital status, menstrual history • Family history HISTORY TAKING
POSITIONS: • Arms by her side • Arms straight up in the air • Hands on her hips (with and without pectoral muscle contraction) • Arms extended forward in a sitting position leaning forward • Semi recumbent position with head raised by 45° INSPECTION
MAJOR POINTS TO BE NOTED: • Breast: Symmetry, Size, Shape, Edema (peau d’ orange), Any visible lump or fungation • Skin: Retraction, Erythema, Ulceration • Nipple: Retraction, Erythema, Ulceration, Discharge INSPECTION
• In sitting, semi-recumbent and recumbent position • Examination of all quadrants of the breast, along with the axillary tail • Done with the pads of the middle 3 fingers; avoid grasping and pinching motion PALPATION OF BREAST
POINTS TO BE NOTED IN CASE OF BREAST LUMP: • Temperature • Tenderness • Number • Situation • Size • Shape • Surface • Consistency • Margin • Mobility or fixity of lump Fixity to skin, breast tissue, pectoral muscle and fascia, chest wall PALPATION OF BREAST
• Assessment of axillary lymphadenopathy • Patient’s arm is supported on the non examining arm of examiner to maintain relaxation • Examination with pads of middle 3 fingers in a circular motion PALPATION OF AXILLA
INVESTIGATION OF BREAST CARCINOMA
TO CONFIRM THE DIAGNOSIS: Imaging • Mammography • USG • MRI Biopsy • FNAC • Trucut biopsy INVESTIGATIONS
TNM staging Stage Tumor Node Metastasis Stage 0 Tis N0 M0 Stage I T1 N0 M0 Stage IIA T0 N1 M0 T1 N1 M0 T2 N0 M0 Stage IIB T2 N1 M0 T3 N0 M0 Stage IIIA T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1 M0 T3 N2 M0 Stage IIIB T4 N0 M0 T4 N1 M0 T4 N2 M0 Stage IIIC Any T N3 M0 Stage IV Any T Any N M1
BREAST CARCINOMA: PATHOLOGICAL CLASSIFICATION
Breast Carcinoma Carcinoma in situ Invasive Carcinoma 1. Ductal Carcinoma in situ 2. Lobular Carcinoma in situ 1. Paget’s disease of the nipple 2. Invasive ductal carcinoma 3. Medullary carcinoma 4. Mucinous (colloid) carcinoma 5. Papillary carcinoma 6. Tubular carcinoma 7. Invasive lobular carcinoma 8. Rare cancers (adenoid cystic, squamous cell, apocrine )
Mastectomy
Operative procedures-Mastectomy 1. Simple mastectomy. 2. Modified radical mastectomy. 3. Breast conserving surgery.
Total or simple mastectomy: • Removal of the entire breast tissue, • No dissection of lymph nodes or removal of muscle. • Sometimes adjacent lymph nodes are removed along with the breast tissue.
Pre-operative management •Triple assessment. •Metastatic workup. •Routine blood investigations. •Pre-anesthetic evaluation. •Control of medical conditions like diabetes and hypertension. •Counseling and written informed consent. •Parts preparation- neck to mid thigh including pelvic region, axilla and arm.
Operative procedure •Anesthesia •General anesthesia. •Position •The patient is placed in supine position with the arm abducted < 90 degree. •Sandbag or folded sheet is placed under the thorax and shoulder of affected side.
Operative procedures- Simple Mastectomy • Indications: • Stage I and stage IIa carcinoma • Large cancers that persist after adjuvant therapy • Multifocal or multicentric CIS. • Incision: • Horizontal elliptical incision is marked so as to include the entire areolar complex. • Should be 1-2cm away from the tumor margins. • Skin sparing incision- if breast reconstruction is planned • Two skin edges should be of equivalent length Type of Incision….....
Simple Mastectomy-procedure •Skin incision is deepened with electro- cautery. •A plane between breast fat and the subcutaneous fat, seen as white fibrous plane. •Dissection is carried in this plane and flaps are raised inferiorly and superiorly. •Ideally thickness of the flap should be 7- 10mm.
Simple Mastectomy-procedure •Extent of dissection: •Superiorly till clavicle, •Laterally till P.major lateral border •Medially to the sternal border, and •Inferiorly till infra-mammary fold •Breast tissue along with the pectoral fascia (controversial) is dissected from the P.major.
Simple Mastectomy-procedure •Care must be taken to ligate perforating branches of lateral thoracic and anterior intercostal vessels. •Wound irrigated with sterile water to crenate (shrivel or shrink) cancerous cells. •Subcutaneous tissue is closed using 00 absorbable interrupted sutures. •Skin closed using 00 non-absorbable mattress sutures or using staples.
Modified Radical Mastectomy (MRM): • Removal of breast tissue and axillary lymph nodes. • No removal of pectoral muscle. • 3 Modification 1. Patey’s Modified Radical Mastectomy: Pectoralis major muscle is preserved and Pectoralis minor removed + level III 2. Scanlon’s Modified Radical Mastectomy: Pectoralis minor muscle is divided but not removed + Level III 3. Auchincloss’ Modified Radical Mastectomy: Pectoralis minor is retraced but not divided + Level 1, Level II Cleared but Level III are left Auchincloss’ Modified Radical Mastectomy is widely practiced nowadays.
Operative procedures- Modified radical Mastectomy • Indications: • Early breast cancer (most commonly done) • Residual large cancers that persist after adjuvant therapy • Multifocal or multicentric disease. • Incision: • Oblique elliptical incision angled towards axilla. • Should include the entire areolar complex and previous scars, if present. • Should be 1-2cm away from the tumor margins. • Two skin edges should be of equivalent length
Modified radical Mastectomy-procedure •Procedure till approaching axilla is same as simple mastectomy. •Extent of dissection: •Superiorly till clavicle, •Laterally till anterior margin of latissimus dorsi. •Medially to the sternal border, and •Inferiorly till the costal margin near the insertion of the rectus sheath.
Modified radical Mastectomy-procedure •The specimen is retracted upwards and laterally to expose P.minor. •The dissection is continued to axillary lymph node clearance. •Care must be taken not to injure medial pectoral nerve and vessels. •The axillary investing fascia is incised to expose the axillary group of lymph nodes.
Modified radical Mastectomy-procedure • The inter-pectoral (Rotter) group of lymph nodes are removed. • Then dissection can be done either from medial to lateral or vise- versa. • The loose lateral areolar tissue in axillary space is dissected to expose the axillary vein. • The investing layer of axillary vessels is cut, the tributaries are transfixed and cut. • Dissection is carried out laterally including lateral grp (level I) of lymph nodes.
Modified radical Mastectomy-procedure • The level II lymph nodes between superior trunk of intercostobranchial bundle and axillary vein are removed. • The central grp of lymph nodes are removed carefully separating from axillary vein and its tributaries. • While dissecting medially, long thoracic nerve is encountered, which lies anterior to the subscapular muscle. The dissection carried out anterior and medial to long thoracic nerve and the specimen delivered.
Modified radical Mastectomy-procedure •Care must be taken while dissecting in axillary area to preserve, •Medial and lateral pectoral nerve. •Long thoracic vessels and nerve •Nerve to latissimus dorsi. •Axillary vein. •Wound irrigated with sterile water to shrink/crenate cancerous cells. •2 drains, 1 below and other above P.major are secured. •Subcutaneous tissue is closed using 00 absorbable interrupted sutures. •Skin closed using 00 non-absorbable mattress sutures or using staples.
Post-operative care •Wound examined on post-op day 3. •Drain can be removed when it is < 30ml. •Any collection is to be aspirated under aseptic precautions. •Staples can be removed after 10days. •Arm movements started in the 1st week.. •Active shoulder and upper limb exercises are started from 2 weeks
OtherTypes of mastectomy 3.Halsted’s Radical Mastectoŵy: • Most extensive type. • Breast tissue, axillary lymph nodes and pectoral muscles are removed. • Disadvantages: • Bad scars and unacceptable deformity. • Reduced range of mobility of shoulder
Types of mastectomy 4.Subcutaneous mastectomy: • Simple mastectomy sparing nipple. • Rarely done, as a large amount of breast tissue is left in situ. 5.Skin sparing mastectomy: –Total/simple mastectomy or modified radical mastectomy with preservation of as much as breast skin as possible needed for breast reconstruction. –Local recurrence is acceptable, 0-3%. 6. Breast conserving surgery: •Wide local excision/Lumpectomy •Quadrantectomy.
Breast conserving surgery •Indications: •Stage 0 (CIS), Stage I, Stage IIa breast •Single lesion. carcinoma. • Method: •Wide local excision/Lumpectomy or Quadrantectomy + axillary lymph node clearance + radiotherapy.
Types of mastectomy 7. Toilet mastectomy: • Done in fungating or ulcerative growths. • Palliative simple mastectomy.
Breast conserving surgery •Advantages: •Maintenance of appearance and function of breast. •Disease free interval is same as MRM. •Better quality of life and psychological advantage. • Contraindications: • Multicentric tumor. • Positive margins after excision. • Size > 4cm (relative). • Advanced stages. • No assess to radiation/ poor patient compliance. • C/I for radiation: SLE/ Rheumatoid arthritis/ Scleroderma/ pregnancy/ prior chest radiation.
Breast conserving surgery-Procedure • Reshaping of breast tissue is done •Incision-circular/ radial/ subareolar incision near to the tumor, about 3-4cm. •Excision of the carcinoma tissue with a margin of atlaeast 1cm of normal breast tissue to get a 2-mm cancer-free margin. •If tumor is situated superficially then excision of that part of skin. •If tumor is deep then tumor is excised till pectoralis major. •Depending on post-surgical defect •Primary closure or
Breast conserving surgery-Lumpectomy •After skin incision, subcutaneous tissue is deepened using electric cautery. •Skin with subcuticular 3-0 absorbable sutures. •While dissecting the breast tissue, better to use scalpel. •Care must be taken while dissecting to palpate the tumor, so that entire lesion is excised. Specimen radiography can be done to check for clear margins. •Hemoclips are applied along the margins of the cavity. •Wound closed in 2 layers: •Subcutaneous tissue with interrupted inverted 3-0 absorbable suture. 136
Breast conserving surgery-Procedure Quadrantectomy: •Usually done for lesion in the upper outer and inner lower quadrants. •Radial incision is taken. •Entire breast tissue in that quadrant is excised till pectoral fascia. •Wound closed in multiple layers: •Breast tissue with interrupted 3-0 absorbable suture. •Subcutaneous tissue with interrupted inverted 3-0 absorbable suture. •Skin with subcuticular 3-0 absorbable suture.
Breast conserving surgery •Quadrantectomy v/s Lumpectomy. •Lumpectomy has more local recurrence risk. •Lumpectomy has better cosmetic outcome.
Breast conserving surgery •After BCS, radiotherapy is essential, otherwise the local recurrence rate is unacceptably high •Without radiotherapy, the local recurrence can be as high as 40%
Breast reconstruction surgery • The most common reason of breast reconstruction surgery, is for psychological well being. • Reconstructive surgery post mastectomy can be either immediate or delayed. • Immediate • Skin sparing • Better outcomes • Delayed • When immediate reconstruction is contraindicated. • Other reconstructive options
Breast reconstruction surgery • Types: • Latissimus dorsi myocutaneous flap. • Transverse rectus abdominus myocutaneous (TRAM) flap.
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