General Surgery

BREAST
Ma. Salome F. Fernandez, MD, FPCS, FPSGS

NORMAL BREAST
ANATOMY OF THE

Breast

Relevant Breast Anatomy

Modified sweat gland of ECTODERMAL ORIGIN
Lies cushioned in fat
Enveloped by superficial and deep layers of superficial fascia of
anterior chest wall
Each mammary gland consists of 15-20 lobules
drained by LACTIFEROUS DUCTS that open separately on
the nipple
COOPERS LIGAMENTS)
Fibrous septae
interdigitate the mammary parenchyma
extend from deep pectoral fascia to the superficial layer
of fascia within the dermis.
SKIN DIMPLING in breast cancer
d/t traction on Coopers ligaments.
Breast frequently extends into axilla
AXILLARY TAIL OF SPENCE.
4 quadrants of the Breast:
Upper inner quadrant (UIQ)
Lower inner quadrant (LIQ)
Upper outer quadrant (UOQ)
Lower outer quadrant (LOQ)
Quadrants of the Breast
BASE OF THE BREAST
nd
th
extends from 2 to 6 rib
MEDIAL BORDER:
lateral border of sternum
LATERAL BORDER:
MIDAXILLARY LINE/ LATISSIMUS DORSI
AXILLARY TAIL OF SPENCE
pierces the deep fascia and enters the axilla
Lymphatic Drainage
Lymphatic drainage is of importance during mastectomy and
axillary node dissection
The lymphatic drainage of the breast is important because of its
role in the metastasis of breast cancer.
AXILLARY NODES
75% of drainage from the ipsilateral breast
Contains 40-50 nodes
They drain secondarily to
Supraclavicular nodes
jugular nodes
Levels of Axillary Lymph Nodes
Level I lateral to pectoralis minor
Lateral:
EXTERNAL MAMMARY NODES
HUMERAL NODES
Posterior:
SUBSCAPULAR NODES
SCAPULAR
Anterior:
AXILLARY VEIN NODES
PECTORAL AXILLARY
Level II located superficial or deep to the pectoralis
minor
Central group
Interpectoral group/ ROTTERS NODES
Found b/w pectoralis mm
Level III medial to or above the upper border of
pectoralis minor
SUBCLAVICULAR NODES

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INFRACLAVICULAR GROUP
APICAL NODES
Lymph tends to pass from the nipple, areola, and lobules of the
gland to the SUBAREOLAR LYMPHATIC PLEXUS.
Most lymph (more than 75%), especially from the LATERAL
QUADRANTS drain to the Axillary Lymph Nodes.
Most of the remaining lymph, particularly from the MEDIAL
QUADRANTS, drains to the Parasternal Nodes (INTERNAL
MAMMARY NODES) or to the opposite breast
Lymph from the LOWER QUADRANTS passes deeply to the
Inferior Phrenic Nodes.
INTERNAL MAMMARY NODES
Accounts for 20% of drainage;
Drains the UIQ and LIQ
ABDOMINAL AND PARAVERTEBRAL NODES
Account for 5% of drainage
Associated Nerves of Surgical Importance
INTERCOSTOBRACHIAL NERVE
From chest wall to axilla to supply cutaneous nerve
sensation to upper medial arm
Sacrificing this nerve hyposthesia or anesthesia of
upper medial arm
LONG THORACIC NERVE OF BELL
From roots of C5, C6, and C7
Courses close to the chest wall along medial border of
axilla to innervate SERRATUS ANTERIOR MUSCLE
Injury results in a winged scapular deformity
THORACODORSAL NERVE
From the POSTERIOR CORD of the brachial plexus C5, C6,
C7
Courses along the lateral border of axilla to innervate
LATISSIMUS DORSI
LATERAL PECTORAL NERVE
Arises from the LATERAL CORD of brachial plexus
Innervates both PECTORALIS MAJOR & MINOR muscles

General Surgery

PHYSIOLOGY OF THE

Breast

Relevant Physiology
Phases of breast development depend on mammographic
effects of:
Pituitary Hormones
PROLACTIN
involved in milk production
OXYTOCIN
involved in milk ejection
Ovarian Hormones
ESTROGEN
promotes ductal development & fat deposition
PROGESTERONE
promotes lobular-alveolar development and
prepares breast for lactation
MENOPAUSE
Cessation of ovarian hormonal stimulation
Results in involution of breast tissue
atrophy of lobules
loss of stroma
Replacement with fatty tissue
DIAGNOSIS
HISTORY & PHYSICAL EXAMINATION OF THE

Breast

History
AGE
Fibroadenoma
most common breast lesion in females <30 years of
age
Risk for breast CA increases with increasing age
Over 70% of all cases occur in patients >50 years of
age
MASS
Determine
When first noted?
How first noted?
Tender or non-tender?
Change in size over time?
Relation to menstrual cycle?
NIPPLE DISCHARGE
Determine
Nature of discharge?
Unilateral or bilateral?
From single or multiple duct orifices?
Spontaneous or induced?
Association with mass?
Type of Discharge
Bloody?
Ddx: Intraductal Papilloma Or Invasive Papillary
CA
discharge should be sent for cytology
Milky
DDx:
Galactorrhea
Pregnancy
Lactation
pituitary adenoma
acromegaly
hypothyroidism
stress
drugs
oral contraceptives

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antihypertensives
certain psychotropic drugs
Evaluation may include:
urine or serum pregnancy tests
prolactin levels
Serous
Normal menses
Oral contraceptives
Fibrocystic change
Early pregnancy
Yellow
Fibrocystic change
Galactocele
Purulent
Superficial or central breast abscess
BREAST PAIN (Mastodynia or Mastalgia)
may be associated with:
Menstrual irregularity
premenstrual symptom
Administration of exogenous ovarian hormones during or
after menopause
Fibrocystic change
responsible for cyclic pain
Rarely a symptom of breast CA
TREATMENT
NSAIDs (Ibuprofen)
Evening primrose oil
OCP
Vitamin E
AVOID
Caffeine
red wine
chocolate intake
CYCLICAL BREAST PAIN
Symptoms:
pain is usually in both breasts
usually worst in the upper and outer part of the
breasts
usually worst 3-7 days before a period
relieved by menstruation
GYNECOLOGIC HISTORY
PAST MEDICAL HISTORY
Prior history of
benign breast disease
breast cancer
radiation therapy to the breast or axilla
PAST SURGICAL HISTORY
Prior history of:
breast biopsy
lumpectomy
mastectomy
axillary node dissection
hysterectomy
oophorectomy
adrenalectomy
FAMILY HISTORY OF BREAST DISEASE
Mother
Sisters
Daughters
CONSTITUTIONAL SYMPTOMS
Anorexia
Weight loss
Dyspnea
Cough
Chest pain
Hemoptysis
Bony pain
Physical Examination
INSPECTION
Positions
Patient seated with arms at her side

General Surgery
Patient seated with arms raised over head
Patient seated with hands on hips
Patient supine
Note for:
Breast size, shape, contour
Breast symmetry
Skin coloration
Skin dimpling, edema, erythema, peau de orange
Excoriation
Nipple inversion or retraction
Nipple discharge
PALPATION
Patient in sitting position:
Support patients arm, palpate each axilla to detect
axillary adenopathy
Supraclavicular fossae and cervical region should also
be palpated
Note node size and mobility
Patient in supine position with arms stretched above the
head
Palpation of breast to identify any masses
4 Ds to distinguish a true lump from a lumpy area:
Dominant
Discrete
Dense
Different
Carcinoma Characteristics
typically firm,
nontender
poorly circumscribed
relatively immobile
Palpate nipples to identify any discharge
Emphasize Breast Self-Examination (BSE)
Should be performed
~5 days AFTER completion of menses in the
PREMENOPAUSAL female
Monthly in POSTMENOPAUSAL female
Recommended follow-up
BSE on monthly basis beginning at age 20- 25;
majority of breast masses are found by
patients themselves
Physician exam every 1-3 years, depending upon risk
factors

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Breast Self-Examination (BSE)

All women should perform a self-breast examination MONTHLY
AFTER the menstrual period when breast swelling and
fibrocystic changes are less likely to interfere with the detection
of a lump or mass.
This is also followed by a yearly clinical breast exam.
HOW TO DO THE EXAM
First, lift your right hand and place it behind your head.
Keep the first 3 fingers of your hand firmly together.
Press the outermost point of your right breast (near
armpit) firmly in a little circular motion with the pads of
your fingers. Then continue in a large circle all around your
breast.
Move your finger an inch closer to the nipple and feel
another circle around the breast. Continue circling until
you have felt every part of the breast, including the nipple.
Squeeze the nipple gently to see if any fluid comes out.
Now change hands and repeat the procedure for the other
breast.
NON-INVASIVE
DIAGNOSTIC EXAMINATION OF THE

Breast
Film Based Mammography
MAMMOGRAM
MOST IMPORTANT TOOL doctors have to diagnose and
evaluate women who have breast cancer.
Used for SCREENING & DIAGNOSTICS
It tends to identify 5 cancers/ 1,000 women
It is 85-90% sensitive
10-15% failure to detect palpable lesions
Gives false positives 10%, false negatives 6-8%
More useful in ages >30
large proportion of fibrous tissue in younger
womens breast make more difficult to interpret.
accuracy in
dense breast as seen in younger women
LCIS
Recommendation for annual mammograms start at the
age of 40
women with risk factors for breast carcinoma should
have ~ yearly mammograms at an earlier age.
Detects synchronous lesions or nonpalpable calcifications
American College of Radiology Diagnostic Code interprets
the mammograms from negative to highly suggestive of
malignancy.
Indications For Mammography:
Screening (Current American Cancer Society
recommendations)
Baseline mammogram for women ages 35- 39 years.
Mammogram every 1-2 years for women ages 40-50
years.
Annual mammogram for women older than 50 years.
Metastatic adenocarcinoma without known primary.
Nipple discharge without palpable mass Mammography
American College of Radiology BI-RADS SCORE
BI-RADS
is a quality assurance tool

General Surgery
designed
to
standardize
mammography
reporting, reduce confusion in breast imaging
interpretations,
and
facilitate
outcome
monitoring.
Results are communicated to the referring
physician in a clear fashion with a final
assessment that indicates a specific course of
action.
BI-RAD SCORE
0: incomplete assessment, needs additional
imaging
1: negative
2: benign finding
3: probably benign
recommend short term follow up
4: suspicion abnormality
consider biopsy
5: highly suggestive of malignancy
Mammographic Findings Suggestive of Malignancy
Solid mass with or without STELLATE FEATURES
Asymmetric localized fibrosis/ thickening of breast
tissues
Clustered microcalcifications
Fine microcalcifications with a linear, branched,
or rod-like pattern, esp.
When focal or clustered likelihood of
cancer w/ number of microcalcifications
Architectural distortion with retraction and
spiculation
Increased vascularity
Altered subareolar duct pattern
Mammogram showing a cluster of microcalcifications
INVASIVE DUCTAL CARCINOMA
gives a stellate appearance in the left breast on
MLO view.
associated thickening of the skin (white arrows)
well appreciated on this digital mammogram
Spiculated mass in upper breast
Types of Mammography
SCREENING MAMMOGRAPHY
Used to detect unexpected breast cancer in
asymptomatic women
Supplements history taking and physical examination
2 views are obtained:
Craniocaudal (CC) View
Provides better visualization of MEDIAL
aspect of the breast
permits greater breast compression
Mediolateral Oblique (MLO) View
Images the GREATEST VOLUME of breast
tissue, including the UOQ and the axillary
tail of Spence
DIAGNOSTIC MAMMOGRAPHY
Used to evaluate women with abnormal findings such
as a breast mass or nipple discharge
Uses different views:
CC view
MLO view
90-Degree Lateral View
Used along with CC view to triangulate the
exact location of an abnormality
Spot Compression View
May be done in any projection by using a
small compression device which is placed
directly over a mammographic abnormality
that is obscured by overlying tissues
AMERICAN CANCER SOCIETY
Screening Recommendations
Self-Breast
Clinical Breast
Examination
Examination
MONTHLY
every 3 years
Monthly
Annually
Monthly
Annually

AGE
20-39
40-49
50 +

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Mammography
Diagnostic
Annually
Annually

AGE
< 40
40-49
50 +

NATIONAL CANCER INSTITUTE

Screening Recommendations
Self-Breast
Clinical Breast
Examination
Examination
Seek expert
Seek expert
opinion if high
opinion if high
risk
risk
With regular
Monthly
healthcare
Monthly
1-2 years

Mammography
Seek expert
opinion if high
risk
1-2 years
1-2 years

The compression device

minimizes motion artefact
improves definition
separates overlying tissues
decreases radiation dose needed to
penetrate the breast

Xeromammography
Identical to mammography with the exception that the image is
recorded on a xerography plate, which provides a positive
rather than a negative image
Details of the breast and the soft tissues of the chest wall may
be recorded with one exposure
Screen Film Mammography
has replaced xeromammography because it requires a
lower dose of radiation and provides similar image quality
Initially, xeromammograms were produced in the positive
mode with pathological and anatomical densities appearing
blue (Image1)
With increasing concern over radiation dosage in
mammography, Xerox shifted its emphasis from technological
development to the reduction of dose.
By reversing xeromammograms from the positive to the
negative mode where densities were white (Image 2) on a blue
background, the dose could be further decreased by about
30%.
Digital Mammography
Full-Field Digital Mammography
uses computers and specially designed digital detectors to
produce images that are displayed on a high-resolution
computer monitor and stored like other computer files
the procedure is very similar to a conventional screen film
mammogram:
Both use compression and x-rays to create images of the
inside of the breast
Unlike
film-based
mammography
however
,digital
mammograms produce images that appear on the
technologists monitor in a matter of seconds.
radiologists are able to refine the digital image and obtain a
more detailed and accurate assessment of certain findings,
such as calcifications and subtle masses.
Since theres no waiting for film to develop, theres usually less
time spent in the breast-imaging suite.
Digital vs. Screen Film Mammography
Digital mammography (DM) is especially useful in:
women with dense breasts
women <50 years of age
Prospective trials have found that DM and SFM had similar
accuracy, however
DM was more accurate in:
Women <50 years of age
Women with mammographically dense breasts
Premenopausal or perimenopausal women
Ductography
PRIMARY INDICATION:
nipple discharge, particularly when fluid contains blood
Radiopaque contrast media is injected into 1 or more of the
major ducts and mammography is performed.
A duct is gently enlarged with a dilator and then a small blunt
cannula is inserted under sterile conditions into the nipple
ampulla.

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With patient in supine position, 0.1-0.2 ml of dilute contrast
media is injected and CC and MLO views are obtained without
compression.
INTRADUCTAL PAPILLOMAS:
small filling defects surrounded by contrast media.
CLINICAL CASE:
A 42-year-old woman with serous discharge from her
left nipple. Ductography reveals contrast-agent filling
defects approximately 1.5 cm from her nipple.
Histopath after surgery revealed intraductal
papilloma
Normal ductography.
Magnified view of the ductogram with filling of the
lobule.
COMMON Ductographic Findings in Cancers
Complete ductal obstruction
Multiple irregular filling defects in the nondilated
peripheral ducts
Ductal wall irregularities
Periductal contrast extravasation
Ductal displacement.
CLINICAL CASE #2
A 52-year-old woman with a 2.2 cm ductal carcinoma in
situ with microinvasion who presented with bloody nipple
discharge The mediolateral oblique ductogram reveals
complete obstruction with a distal, irregular, moth-eaten
appearance (arrows), and associated microcalcifications.
MRI
INDICATIONS
Non-palpable mass w/ axillary nodes
Dense breast
BRCA gene mutation
Screening for HIGH risk patients
Evaluate integrity of implants
Assess extent for malignancy
Annual screening for BRCA CA
Detection of occult CA
Ultrasound
Frequently used to evaluate breast abnormalities that are
found with screening mammography or during a physician
performed breast examination.
Allows significant freedom in obtaining images of the breast
from almost any direction
NOT approved by FDA as a screening tool for breast cancer.
Yet, used as a first tool in women under 30 years of age
when a breast abnormality is found secondary to the large
amount of fibrous tissue found in women of this age.
Advantages:
They are good for distinguishing between cystic and solid
masses in NON-palpable lesions
Can assist in therapeutic aspiration
Directs FNAB or core biopsy of the lesion
Confirms position of the needle
Localize NON-palpable lesion for excision
It has excellent contrast resolution
Helps quantify response of tumor & nodal metastasis to
neo-adjuvant
Disadvantages:
It lacks spatial resolution (fine detail)
It cannot detect most calcium deposits on breast tumors
It cannot document how much breast tissue has been
imaged
Will not identify lesions <1cm
CLINICAL CASE
A 26 year old woman with 1 year history of breast lump.
Ultrasound showed a 1.5cm nodule at 6 o'clock position
about a cm from the nipple. The nodule is consistent with
a FIBRODENOMA.

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INVASIVE
DIAGNOSTIC EXAMINATION OF THE

Breast Mass
Procedures Done to Evaluate of Breast Mass
Fine Needle Aspiration Biopsy
Core Needle Biopsy
Vacuum-Assisted Biopsy (Mammatome or MIBB)
Large Core Surgical (ABBI)
Open Surgical (Excisional or Incisional)
Fine Needle Aspiration Biopsy (FNAB/ FNAC)
FOR PALPABLE SOLID MASSES
FNAB done especially if clinical suspicion for malignancy is
high, can easily proceed in outpatient setting
PROCEDURE
1.5 in, 22-G needle attached to a 10-ml syringe is
used, with or without local anesthetic.
Make multiple passes at different angles through the
mass while aspirating on syringe.
Once cellular material is seen on the hub of the
needle, the suction is released and the needle is
withdrawn.
Immediately air-dried and then fix with % ethanol
FOR PALPABLE CYSTIC LESIONS:
If serosanguinous or grossly bloody send fluid for
cytology
EXCISIONAL BIOPSY is indicated when:
Needle aspiration produces no cyst fluid and solid
mass is diagnosed
Cyst fluid is blood-tinged or grossly bloody
Cyst fluid is withdrawn, but mass fails to resolve
completely
Mass reappears in the same area after more than 2
aspirations.
Cyst reaccumulates within 2 weeks after initial
aspiration
Accuracy rates approach 90%
When a breast mass is clinically and mammographically
suspicious, the sensitivity and specificity of FNA biopsy
approaches 100%
ADVANTAGES:
Fastest and easiest method of biopsy, where the results
are easily available.
It is excellent for confirming breast cysts
Has a low morbidity
only 1-2% false-positive rate
DISADVANTAGES:
The procedure only removes very small samples of tissues
or cells from breast
If the sample is benign fluid, then the procedure is ideal.
However, if the tissue is solid or a cloudy sample, the small
number of cells removed by FNA only allow for a cytologic
(cell) diagnosis.
False negatives rate up to 10%
May miss deep masses
Core Needle Biopsy
It is also a PERCUTANEOUS procedure that involves removing
small samples of breast tissue using a hollow core needle.
This procedure is usually for palpable lesions.
It differs from FNA in that is also uses a larger G-14 needle,
such as the Tru-Cut needle
Automated devices are also available
Tissue specimens are placed in formalin and then processed to
paraffin blocks
Advantages:
core needle biopsy usually allows for a more accurate
assessment of a breast mass than FNA because the larger
core needle usually removes enough tissue for the
pathologist to evaluate abnormal cells.

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Disadvantages:
Still a chance of sampling error
Again, like FNA it only removes a sample of the mass and
not the entire area of concern.
Vacuum-Assisted Biopsy
This is a relatively new biopsy that is PERCUTANEOUS
procedure that relies on stereotactic mammography or
ultrasound imaging.
STEREOTACTIC MAMMOGRAPHY
involves using computers to pinpoint the exact location of
a breast mass based on mammograms taken
Two Different Angles.
Vacuum-assisted biopsy is minimally invasive procedure
that allows for the removal of multiple tissue samples.
It has been becoming more common than open surgical
biopsies due to its advantages.
AKA:
Stereotactic (mammographically guided) breast biopsy
Stereotactic core needle biopsy
Stereotactic-guided biopsy
Breast stereotaxy
Mammotome vacuum-assisted biopsy
Advantages:
Minimally invasive
Usually no significant scarring
Does not require stitches
No breast deformity
Procedure takes less than hour
Cost effective
Through a small incision or cut in the skin, a special biopsy
needle is inserted into the breast and, using a vacuum-powered
instrument, several tissue samples are taken.
The vacuum draws tissue into the centre of the needle and a
rotating cutting device takes the samples.
The biopsy procedure is performed under imaging guidance
(mammogram, MRI or US).
pictures or images obtained from scans allow the
radiologist performing the biopsy to make sure the needle
is correctly positioned.
EXAMPLES
Finesse Ultra Vaccum-Assisted, handheld,
Breast Biopsy System
Large Core Surgical (ABBI)
AKA: Advanced Breast Biopsy Instrumentation (ABBI)
Surgical technique that involves removing an entire intact
breast lesion (abnormality) under image guidance.
It requires the use of a prone biopsy table and a stereotactic
mammography.
It can remove 5 mm to 20 mm of breast tissue
Not widely accepted
Bought controversy secondary to that in large core biopsy it
requires the removal of a significant portion of normal breast
tissue just to reach the lesion.
Open Surgical Biopsy
Traditional open surgical biopsy
GOLD STANDARD to which other methods of breast biopsies
are compared.
It tends to require a 1.5 cm to 2 cm incision in the breast.
Types of Open Biopsy
EXCISIONAL BIOPSY:
The surgeon will attempt to completely remove the
area of concern, often along with the surrounding
margin of normal breast tissue.
INCISIONAL BIOPSY:
Similar to excisional biopsy except that the surgeon
removes only part of the breast lesion, usually
performed on large lesions.
Advantages:
Yields the largest breast tissue sample of all breast biopsy
methods
GOLD STANDARD

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the accuracy is close to 100% for a diagnosis

Disadvantages:
Requires stitches and leaves a scar
Chances of bleeding, infection, or problems with wound
healing
Mortality risk associated with anesthesia
ABNORMAL BREAST
INTRODUCTION ON

Breast Cancer
Incidence
Average American Lifetime Risk: 11%
Risk of Death: 3-4%
rd
> 2/3 of female diagnosed w/ breast CA have no identifiable
risk
Factors Associated w/ Increased Risk for Breast CA
Increasing age
30 yo: 2%
40 yo: 1/93
50 yo: 1/50
60 yo: 1/24
70 yo: 1/14
80 yo: 1/10
Age at Menarch: < 11 years old
Age at Menopause: > 55 years old
Age at first pregnancy: > 30 years old
Nulliparity
Absence of Lactation
Use of Hormonal Replacement Therapy for fertility Regimens
Prior breast biopsy (+) for
benign proliferative disease
atypia
lobular carcinoma in-situ
Family history of:
Breast CA
Ovarian CA
Prostate CA
Known carrier of BRCA 1 or 2 mutation
40% familial breast CA
45% lifetime risk ovarian CA
Autosomal dominant
Personal History of thoracic radiation
Alcohol consumption
Controversial
Prior abortion
High fat diet
Obesity
Histologic Risk Factors
Histologic Diagnosis
Relative Risk Estimates
Non-Proliferative Disease
1.0
Proliferative Disease w/o atypia
1.3-1.9
Proliferative Disease w/ atypia
3.7-4.2
(+) strong family history
4-9
(+) premenopausal or age > 50
5-7
Lobular Carcinoma In-Situ
>7
General Manifestations
Pain
Usually BENIGN
Nipple discharge
Mass
Abnormal MMG
Vague thickening, nodularity
Breast Infection

General Surgery

BENIGN DISEASES OF THE

Breast

Benign Breast Disease

NONPROLIFERATIVE
Examples:
Fibrocystic changes
Duct ectasia
Fibroadenomas and related lesions
NO INCREASED RISK for malignancy
PROLIFERATIVE
Sclerosing adenosis
Radial and complex sclerosing lesions
Intraductal papillomas
Ductal epithelial hyperplasia
Other BENIGN Breast Tumors
Breast cysts
Hamartomas & Adenomas
Breast Abscess
ATYPICAL PROLIFERATION
ATYPICAL HYPERPLASIA
4-5X INCREASED RISK OF CANCER
Fibrocystic Change
AKA: Chronic Cystic Mastitis
May represent an exaggerated response of normal breast
stroma and epithelium to circulating and normally produced
hormones and growth factors
Incidence greatest around age 30-40 years
may persist into the 8th decade
SYMPTOMS
Breast pain
Swelling
Tenderness
Frequently BILATERAL
Not associated with increased risk of breast CA unless biopsy
specimen reveals ductal or lobular hyperplasia with atypia
TREATMENT:
R/O carcinoma by aspiration or excisional biopsy of any
discrete mass that persists without change over several
monthly cycles
Frequent breast examinations (BSE and MD)
Mammography to identify any new or changing lesions
Baseline mammogram for ages 35-39
Annual mammogram for women older than 40
Avoid xanthine-containing products
Coffee
Tea
Chocolate
cola drinks
Danazol
a weak androgen
DOSE
50-200 mg po BID for severe symptoms
must be continued to 2-3 months to see a potential
effect
50% recurrence within 1 year of discontinuing the
drug
S/E:
Amenorrhea
body fat resistribution
weight gain
acne
hirsutism
Tamoxifen
DOSE
20 mg po QID for severe symptoms
Administer 4-6 wk course, then d/c to assess for
continued symptoms
Anti-estrogenic;
binds estrogen receptors

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Fibroadenoma
Most common breast lesion in women < 30 yo
It is a fibrous stroma that surrounds ductlike epithelium
BENIGN tumor
Grossly smooth, well-circumscribed, nontender mass 1-5 cm in
diameter
GIANT FIBROADENOMAS
Lesions >5 cm
must be differentiated from cystosarcoma phyllodes
estrogen-sensitive
has increased tenderness during pregnancy.
BREAST EXAM:
smooth, discrete, circular and mobile mass
Diagnosis:
Excisional biopsy to remove the tumor
Treatment:
Observation
Followed clinically if static in young patient
Cystosarcoma Phyllodes
Variant of fibroadenoma, in which the majority are BENIGN
Patients tend to present later than those with fibroadenoma
MOST COMMON in the 5th decade
They tend to be indistinguishable from fibroadenoma by
ultrasound or mammogram, but can only be distinguished on
their histologic features
phyllodes has more mitotic activity
BREAST EXAM
large, bulky mass
overlying skin is red, warm and shiny, with venous
engorgement
Medium size of 4-5 cm; characterized by rapid growth
Diagnosis:
Biopsy with pathologic evaluation
Treatment:
Small Tumors:
Wide local excision with a least a 1 cm margin
Larger Tumors:
Simple mastectomy
Intraductal Papilloma
It is a benign local proliferation of ductal epithelial cells
Has UNILATERAL serosanguineous or bloody nipple discharge
in PREMENOPAUSAL women.
Patients usually present with subareolar mass and/or
spontaneous nipple discharge.
In examination one must radially compress breast to determine
which lactiferous duct express fluid
Major DDx is between intraductal papilloma and invasive
papillary CA
Diagnosis:
Definitive diagnosis by pathologic evaluation of resected
specimen.
Treatment:
Excise affected duct after localization by physical
examination
Gynecomastia
It is the development of female-like breast tissue in males,
which can either be physiologic or pathologic.
There is at least a 2 cm of excess subareolar breast tissue
present to make the diagnosis.
PHYSIOLOGIC GYNECOMASTIA:
Newborns:
due to exposure to maternal estrogens
Pubertal (ages 13-17)
may be bilateral or unilateral
regresses with adulthood
treated with reassurance
Senescent (>age 50)
due to male menopause with relative estrogen
increase
freq. unilateral

General Surgery
breast tissue is enlarged, firm and tender
usually regresses spontaneously in 6-12 months
DRUG-INDUCED GYNECOMASTIA:
Associated with use of:
Estrogens
Digoxin
Thiazides
Phenothiazines
Phenytoin
Theophylline
Cimetidine
Reserpine
Spironolactone
Methyldopa
Diazepam
Tricyclics
antineoplastic drugs
marijuana;
Treatment
discontinuation of offending drug.
PATHOLOGIC GYNECOMASTIA:
associated with
cirrhosis
renal failure
malnutrition
hyperthyroidism
adrenal dysfunction
testicular tumors
hermaphroditism
hypogonadism (eg. Klinefelters syndrome)
Treatment:
Treat underlying cause if specific cause identified
Any dominant or suspicious mass should be biopsied
to rule out carcinoma, esp. in the senescent male.
Sclerosing Adenosis (SA)
a benign (noncancerous)condition of the breast in which extra
tissue develops within the breast lobules
Its clinical significance lies in its mimicry of cancer
may be confused with cancer on PE, mammography, and
at gross pathologic exam.
Excisional biopsy and histologic exam
frequently necessary to exclude the dx of cancer.
The diagnostic work-up for radial scars and complex sclerosing
lesions
frequently involves STEREOTACTIC biopsy.
It is usually not possible to differentiate these lesions with
certainty from CA by mammogram, so biopsy is
recommended.
Mammogram
appearance of a radial scar or SA (mass density with
speculated margins) will usually lead to an assessment that
the results of core needle biopsy showing benign disease
are incompatible
breasts radiologists therefore often forego imageguided needle biopsy of a lesion suspicious for radial
scar and refer the case directly to a surgeon for WIDE
LOCALIZED EXCISION BIOPSY.
Infectious/Inflammatory
MASTITIS:
which mainly affects breastfeeding women
It is usually caused by
MOST COMMON
S. aureus
S. epidermidis
Less common
Streptococcus spp.
It commonly occurs during early weeks of breast feeding

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MANIFESTATION
focal tenderness with erythema and warmth of
overlapping skin.
redness, swelling and pain in one breast
Most common etiologic agents in NONLACTATING
FEMALES:
S. aureus
anaerobes Bacteroides
Peptostreptococcus
Treatment:
Local measures:
application of heat, ice packs
use of mechanical breast pump on affected side
Broad spectrum antibiotics
Incision and drainage
if fluctuant and not improved with antibiotic tx
For recurrent infection:
excision of diseased subareolar ducts

Fat Necrosis
It usually presents as ecchymotic, firm, irregular mass of
varying tenderness
often accompanied by skin or nipple retraction
history of a local trauma elicited in 50% of patients.
exam represents irregular mass with no discrete borders
may or may not be tender
Pain is characteristic.
Diagnosis and Treatment:
Excisional biopsy to rule out carcinoma.
Atypical Ductal Hyperplasia
It is the name given to a condition that can occur in the lining of
the milk ducts in the breast.
Typically is BENIGN in both males and females
Can be at risk for developing cancer; hence, further studies
are needed.
In women
disease rarely proceeds on towards cancer
it is not cancer.
In men
when ADH is diagnosed with a background of
gynecomastia there is a 4-5 times increased risk for
the development of invasive breast carcinoma.
Some may be an under-diagnosed ductal carcinoma in situ.
Diagnosis:
Biopsy
Treatment:
Observation
Excisional Biopsy
do not need clear margins
MORPHOLOGY
duct would normally be there but some cells are not
typical
irregular in shape and size
NORMAL milk duct
lined with one even layer
ATYPICAL DUCTAL HYPERPLASIA
there are more cells lining of uniformly shaped cells
there may be many layers of cells.
Mondors Disease
Painful, cordlike superficial thrombophlebitis
Thrombophlebitis of superficial veins of the chest wall
thoracoepigastric vein
Presents as acute pain over superolateral breast or axilla,
often related to local trauma
Finding of PALPABLE CORD is diagnostic.
Treatment:
reassurance, heat, analgesics

General Surgery

CANCER OF THE

Breast

Breast Cancer
Second most common cause of cancer death in women.
Main cause of death in women ages 45 to 55.
male breast cancer is rare in contrast to female breast cancer.
Breast cancer is 100 times more common in females than
males.
median age of onset in males is 65-67 years of age.
Risk Factors for Breast Cancer
Females
Early menarche
Late menopause
Nulliparity or 1st pregnancy >30 y.o.a.
White race
Old age
Family history of breast cancer
Genetic predisposition (BRCA 1, BRCA 2, Li Fraumeni
Syndrome)
Prior personal history of breast cancer
DCIS or LCIS
Atypical ductal or lobular hyperplasia
Males
Testicular Abnormalities
Undescended testes
Congenital inguinal hernia
Orchitis
testicular injury
Infertility
Positive family history
Klinefelter Syndrome
Elevated endogenous estrogen
Previous irradiation
Trauma
Jewish ancestry

TNM
TUMOR
Tx
T0
Tis
T1

T1a
T1b
T1c
T2
T3
T4
T4a
T4b
T4c
T4d
NODE
Nx
N0
N1
N2
N3
METASTASIS
Mx
M0
M1

Classification of Primary Breast CA

INVASIVE EPITHELIAL CA
Invasive Lobular CA (10-15%)
Invasive Ductal CA
Invasive Intraductal CA, NOS (50-70%)
Tubular CA (2-3%)
Mucinous or Colloid CA (2-3%)
Medullary CA (5%)
Invasive Cribriform CA (1-3%)
Invasive Papillary CA (1-2%)
Adenoid Cystic CA (1%)
Metaplastic CA (1%)
MIXED CONNECTIVE & EPITHELIAL TUMORS
Phyllodes tumors
Benign & Malignant
Carcinosarcoma
Angiosarcoma
Screening for Breast Cancer
Breast screening is a method of detecting breast cancer at a
very early age.
There are several methods to screen for breast cancer, and it
can begin at a very early age.
The simple ways to begin to screen for breast cancer are:
Breast Self Examination
Mammography
Ultrasound*
Staging of Breast Cancer
TNM Staging for Breast Cancer
Tx:
Cannot assess primary tumor

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TNM Staging System for Breast Carcinoma

DESCRIPTION
Primary tumor cannot be assessed
No evidence of primary tumor
CA in situ (LCIS / DCIS)
Pagets disease of the nipple w/o tumor
< 2 cm
< 0.5 cm
> 0.5 cm to 1 cm
> 1 cm to 2 cm
> 2 to 5 cm
> 5cm
any size, with direct extension into the chest wall
or with skin edema or ulceration
extension to chest wall
edema / ulceration of the skin / satelite nodule
both T4a and T4b
Inflammatory carcinoma
Cannot assess lymph nodes
No nodal metastasis
Movable ipsilateral axillary nodes
Fixed ipsilateral axillary nodes
Ipsilateral internal mammary nodes
Cannot assess metastasis
No metastasis
Distant metastasis or supraclavicular nodes

CLINICAL STAGING
(AMERICAN JOINT COMMITTEE)
STAGE
I

II

III

IV

TUMOR
< 2cm in diameter

2-5 cm in diameter
> 5cm in diameter
Tumor any size w/
invasion of skin
attached to chest
wall
Any

NODES
Nodes, if present,
not felt to contain
metastases
Nodes, if palpable,
not fixed, same
side
Nodes in
supraclavicular
area, same side

Any

METASTASIS
NONE

NONE

NONE

With distant
metastases

General Surgery

AMERICAN JOINT COMMITTEE

Breast CA CLINICAL STAGING
STAGE

0
I
II

Tis
T1

N0
N0

M0
M0

T0
T1
T2
T2
T3

N1
N1a
N0
N1
N0

M0
M0
M0
M0
M0

IIA
IIB
III

5 yr
survival
100%
85%
66%

IIIB
IV

T0-2

N2

M0

T3

N1-2

M0

T4
Any T
Any T

Any N
N3
Any N

M0
M0
M1

82-94
47-74

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Breast

7-80%

10%

Treatment of Breast CA
PRIMARY GOAL OF LOCAL THERAPY
To provide optimal control of the disease in the breast and
regional tissue while providing the best possible cosmetic
result.
Different types of treatment
Surgery
radiation therapy
adjuvant chemotherapy
adjuvant endocrine therapy
combination of modalities.
SURGICAL TREATMENT FOR BREAST CA
The optimal surgical approach is determined by the
following factors:
Disease stage
Tumor size
Tumor location
Breast size and configuration
Number of tumors in the breast
Radical mastectomy:
Resection of all breast tissue, axillary nodes, and
pectoralis major and minor muscles.
Modified radical mastectomy:
Same as radical mastectomy except
pectoralis muscles left intact.
Simple mastectomy:
Resection of all the breast tissue, except
pectoralis muscle left intact
no axillary node dissection.
Lumpectomy and axillary node dissection:
Resection of mass with rim of normal tissue and
axillary node dissection
good cosmetic result.
Sentinel node biopsy:
Recently developed alternative to complete axillary
node dissection.
Lymph nodes are identified on preoperative
scintigraphy and blue dye is injected in the
periareolar area.

10

PRE-MALIGNANT DISEASES OF THE

41%

IIIA

Range

Axilla is opened and inspected for blue and/or hot

nodes identified by a gamma probe.
When sentinel node is positive
an axillary dissection is completed.
When sentinel node is negative
axillary dissection is not performed unless
axillary lymphadenopathy identified.

Pre-Malignant Diseases of the Breast

NON-INVASIVE Epithelial CA
Lobular CA In Situ
Ductal CA in situ
Papillary
Cribriform
Solid
ComedoCA
DCIS : LCIS (3:1)
Ductal CA In Situ
AKA: Tubular Carcinoma In Situ
Proliferation of ductal cells that spread through the ductal
system but lack the ability to invade the basement membrane.
Arises from the inner layer of epithelial cells in major ducts.
> the cases occur AFTER menopause/ POSTMENOPAUSAL
(+) palpable mass some of the times.
Diagnosis:
Clustered microcalcifications on mammogram
malignant epithelial cells in breast duct on biopsy.
TYPES
PAPILLARY
Duct epithelium are thrown into papillae with loss of
cohesiveness,
disorientation
of
cells
with
pleomorphism and increase mitotic figure
SOLID
CRIBRIFORM
COMEDOCARCINOMA

Hyperplasia is more extreme choking the entire duct

w/ masses of cells developing CENTRAL NECROSIS of
cells

Most aggressive
Risk of invasive cancer:
increased risk in ipsilateral breast, usually same quadrant;
infiltrating ductal carcinoma
MOST COMMON histologic type.
Treatment:
Treated as EARLY CA
If small (< 2 cm):
Lumpectomy with either close follow-up or radiation
If large (> 2 cm):
Lumpectomy with 1 cm margins and radiation
If breast diffusely involved:
Simple mastectomy
'in situ'
refers to pre-invasive breast cancer.
breast cancer has not yet penetrated ('invaded') through
the basement membrane (the membrane at the base of
the epithelial lining of ducts or glands).
Lobular CA In Situ
It is a multi-focal proliferation of acinar and terminal ductal
cells, which arises from cells of the TERMINAL DUCT LOBULAR
UNIT.
majority of the cases occur PRIOR TO MENOPAUSE or
PREMONOPAUSAL
One usually does not feel a palpable mass.

General Surgery
Diagnosis:
clinically occult lesion
undetectable by mammogram
incidental on biopsy.
Risk of invasive cancer:
EQUALLY increased risk in either breast
Infiltrating ductal carcinoma; associated with simultaneous
LCIS in the contralateral breast in over the cases.
Treatment:
None: Observation
Hormonal Treatment
Tamoxifen
Aromatase inhibitor
Use for 5 years
BILATERAL mastectomy an option if patient is at high risk.

MOST COMMON in PERImenopausal and POSTmenopausal

women.
Presentation:
Hard, fixed mass
peau d orange overlying the skin
ulceration of overlying skin
bloody nipple discharge,
inverted or retracted nipple.
Ductal cells tend to invade stroma in various histologic forms
described as:
SCIRRHOUS DUCTAL CA
AKA
Fibrocarcinoma
Sclerosing CA
78% (most common)

MORPHOLOGY
the lobular cells have developed the ability to multiply out
of control
one of the characteristics of cancer
cancerous cells have not yet spread beyond the lining of
the lobule.

AGE AT
PRESENTATION
INCIDENCE
CLINICAL SIGNS
INCICIDENCE of
SYNCHRONOUS
Invasive CA
MULTICENTRICITY
BILATERALITY
AXILLARY
METASTASIS
PE
MMG
DIAGNOSIS
RISK
SUBSEQUENT CA
Incidence
Laterality
Interval to Dx
Histology
TREATMENT

NON-INVANSIVE EPITHELIAL CA
LCIS
DCIS
Premenopausal
Postmenopausal
(44-47 y.o.)
(54-58 y.o.)
2-5%
5-10%
NONE
Mass, Pain, Nipple D/C
5%

2-46%

60 90%
50 70%

40 80%
10 20%

1%

1-2 %

NEGATIVE
NEGATIVE
Incidental
in all breast tissue

Occult to palpable mass

Microcalcifications
Workup of abnormality
At site of diagnosis

25 35%
BILATERL
15-20 yrs
Ductal
Observation vs
chemoprevention vs
bilateral prophylactic
mastectomy

25 70%
IPSILATERAL
5-10 yrs
Ductal
Lumpectomy + radiation
vs ipsilateral simple
mastectomy consider
tamoxifen

Increased Desmoplastic response to invading CA cells

(protective)

Neoplastic cells are arranged in small clusters or in

single rows occupying a space between collagen
bundles

Originate in the myoepithelial cells of the mammary

duct

Desmoplastic ---> shortened Coopers ligament --->

dimpling over the tumor
MEDULLARY CA
Invasive breast cancer that forms a distinct boundary
between tumor tissue and normal tissue.

2-15%

Large Round Cancer Cells arranged in broad

PLEXIFORM MASS surrounded by lymphocytes and
lymphatic follicles

Soft, bulky and large tumors w/ necrotic areas

MALIGNANT DISEASES OF THE

Breast

Infiltrating Ductal Carcinoma

MOST COMMON Invasive cancer in both males and females
(80% of cases).

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PROGNOSIS
5 year survival = 85 90%
Good prognosis
COMEDO
COLLOID (MUCINOUS) CARCINOMA
Formed by mucus producing cancer cells
2%

Soft, bulky w/ ill defined borders

Cancer cells floats in large mucinous lakes

Cut surface is glistening, glaring and gelatinous

General Surgery
PROGNOSIS
100% 5yr survival
Inflammatory Breast Carcinoma (IBC)
1-4% of all breast malignancies
Most rapidly lethal malignancy of the breast
Poorly-differentiated
PE:
Skin ridging w/ or w/o mass
Skin is scale w/ diffuse induration, warm, erythematous,
peau de orange
with or without palpable mass
nipple retract
axillary lymphadenopathy is almost always present

PAPILLARY CA
th
2 %; present in 7 decade
Thrown into papilla w/ well defined fibrovascular
stalks and multilayered epithelium
Has the lowest frequency of axillary nodal
involvement
has the best 5 and 10 yrs survival rates
Even if w/ axillary metastases, it is still indolent and
slowly progressive disease than
the common
adenocarcinoma
TUBULAR CA
Well differentiated
Ducts lined by a single layer of well differentiated
cancer cells
Absence of myoepithelial w/ well defined basement
membrane
Common in premenopausal and detected w/
mammography
5 yr survival ---> 100% if the CA contain 90% or more
of tubular components

Can have metastasis to

Axilla
Bones
Lungs
Liver
Brain
Infiltrating Lobular Carcinoma
SECOND MOST COMMON TYPE of invasive breast cancer (10%
of cases).
Originates from terminal ducts cells
Like LCIS, has a high likelihood of being BILATERAL.
20% of infiltrating lobular carcinoma have simultaneous
contralateral breast cancer.
Tends to present as an ill-defined thickening of the breast.
Like LCIS, does not form microcalcifications and is often
multicentric
Tends to metastasize to
Axilla
Meninges
Serosal surfaces.
Pagets Disease of the Nipple
2% of invasive breast cancers
Primary carcinoma of mammary duct that invaded the skin
Associated with underlying LCIS or ductal carcinoma just
beneath the nipple and areola.
Presentation:
Tender, eczematous, itchy nipple
with or without a bloody discharge
with or without a subareolar palpable mass
HISTOLOGY
PAGET cells:

Characteristic cells

Large cell w/ clear cytoplasm and binucleated

Treatment:
Modified radical mastectomy

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DIAGNOSIS
Biopsy
HISTOLOGIC FEATURES
No predominant histologic type
subdermal lymphatic & vascular channels invasion w/
highly UNDIFFERENTIATED tumors
absence of PMNs & lymphovytes near the tumor
RAPID growth
Majority has (+) cervical LN & Distant metastases common at
time of diagnosis (17-36%)
Locally Advanced Breast CA
Breast CA w/ any T & N but NO METASTASIS
TUMORS
Can be > 5cm
Nodes
Can be fixed & matted
MANAGEMENT
MULTIMODALITY
Neoadjuvant Radiotherapy
Chemotherapy

Surgery

MANAGEMENT
PRE-OP MANAGEMENT OF

Breast Cancer
Sentinel Lymph Node Biopsy
PURPOSE
to provide staging information
to determine the need for axillary lymph node dissection
(ALND) in breast cancer patients.
A properly performed negative SLNB should accurately identify
those patients without axillary node involvement, thereby
obviating the need for a more morbid ALND.
The risk of arm morbidity, particularly lymphedema, is
significantly lower after SLNB than ALND.
SLNB should be performed in most women with clinically node
negative invasive or microinvasive breast cancer.
SLNB can be omitted if the nodal information will not affect
adjuvant treatment decisions.
As an example, women 70 years of age who have a small
(<2 cm) estrogen receptor-positive tumor and a clinically
uninvolved axilla may be treated without a SLNB.
Indications

General Surgery

women with extensive ductal carcinoma in situ (DCIS),

who are undergoing mastectomy
SLNB will not be possible AFTER mastectomy if
invasive disease is found on final pathology,
necessitating an axillary dissection for staging
purposes.
When a SLNB is not successful or when clinically suspicious
nodes are encountered in the axilla the surgeon should perform
an AXILLARY DISSECTION for staging purposes and to ensure
locoregional control
PROCESS
radioactive substance and/or blue dye is injected near the
tumor (first panel).
injected material is detected visually and/or with a probe
that detects radioactivity (middle panel).
The sentinel nodes (the first lymph nodes to take up the
material) are removed and checked for cancer cells (last
panel).
TECHNIQUE
Patient is prepped and draped in the operating room.
Surgeon injects 3 to 5 mL of blue dye
classically isosulfan blue
Dye injected around the tumor periphery, at the palpable
edge of the biopsy cavity or into the subareolar plexus.
It is important not to inject the dye into the:
tumor itself
because the lymphatics can be occluded by
tumor
seroma cavity following breast biopsy
seroma itself does not contain lymphatic
channels
Errors in technique are likely to lead to a failure of
mapping.
Breast massage is then carried out for about five minutes
to dilate breast lymphatics
ISOSULFAN BLUE DYE
Used for SLNB
associated with SEVERE ANAPHYLACTIC REACTIONS
requiring resuscitation in 0.7 to 1.1 percent of cases
Prophylactic treatment with IV, just before or at the
induction of anesthesia appears to decrease the
severity but not the incidence of dye reactions
100 mg of hydrocortisone or
ALTERNATIVES
20 mg of methylprednisolone
4 mg of dexamethasone
50 mg of diphenhydramine
20 mg of famotidine
OPERATIVE MANAGEMENT OF

Breast Cancer
Surgical Treatment Options for Breast CA
DIFFERENT APPROACHES
Wide Local Excision (WLE)/ Lumpectomy/ Segmental
Mastectomy
Subcutaneous Mastectomy
Simple Mastectomy/ Total Mastectomy
Modified Radical Mastectomy (MRM)
Radical Mastectomy (Halsted) (RM)
PARTIAL MASTECTOMY
AKA: Wide Local Excision (WLE)/Lumpectomy/Segmental
Mastectomy or Tylectomy
BREAST CONSERVING THERAPY
Advent of supervoltage radiotherapy with skin sparing
effect
Major objectives:
Complete excision of the tumor with tumor-free
margins (1cm)
Good cosmetic result
Usually accompanied by
axillary node dissection

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done through a separate incision

postop radiation therapy to the whole breast
Eligibility Criteria:
Tumor size 4cm or less
Appropriate tumor size to breast size ratio
Breast volume adequate in size to allow uniform
dosage of radiation
No fixation of tumor to underlying muscle or chest
wall
No involvement of overlying skin
No multicentric cancer
No fixed or matted axillary nodes
Radiation therapist experience to avoid damage of
retained breast
INCISIONS
Curvilinear incision in upper quadrants
Radial incisions in the lower quadrants
Frozen section evaluation of margin
To determine adjuvant chemotherapy adequate sampling
of axillary LN (level I), curvilinear incision should be done
If LN (+) ----> adjuvant chemotherapy

SUBCUTANEOUS MASTECTOMY
Removes breast tissue only
SPARES the following structures
nipple-areolar complex
skin
nodes.
Not a cancer operation
leaves 1-2% of breast tissue behind
Rarely, if ever, indicated
INDICATIONS
mainly a prophylactic operation
patients with premalignant breast disease
high risk patients with widespread fibrocystic disease.
UNILATERAL S.C.M.
indicated in patients who have already had a
mastectomy for carcinoma and whose remaining
breast has an increased risk for also developing a
carcinoma.
may be performed according to total mastectomy
indications if an intraoperative frozen section (and the
corresponding HE histopathology) of the tissue next to the
nipple-areola skin is free of tumor.
QUADRANTECTOMY, AXILLARY, RADIOTHERAPY (QUART)
Quadrant of the breast that has the CA is resected
REMOVES

quadrant of breast tissue

overlying skin

underlying superficial pectoralis fascia

Unacceptable cosmetic result
Frequent treatment for STAGE I PREMENOPAUSAL
women which includes RADIATION treatment

General Surgery
SIMPLE MASTECTOMY/ TOTAL MASTECTOMY
Removes the breast tissue, the nipple areolar complex,
and skin
No axillary node dissection /minimal axillary node
dissection is performed
Often performed for DCIS or LCIS
Done w/ or w/o radiation
Crile
Total mastectomy only
Mc Whirter
Total mastectomy
Plus radiation in
Axilla
supraclavicular
internal mammary nodes

MODIFIED RADICAL MASTECTOMY (MRM)

Removes breast tissue, PECTORALIS FASCIA, nipple-areolar
complex, skin, and axillary lymph nodes in continuity
SPARES
Pectoralis MAJOR muscle.
Patey Procedure:
PRESERVED PECTORALIS MAJOR
REMOVES the Pectoralis Minor in order to remove
Levels I, II and III axillary lymph nodes
Madden/ Auchincloss Procedure:
PRESERVES both Pectoralis Major & Pectoralis Minor
Muscles.
Preservation of pectoralis minor limits high axillary
node dissection (Level III), but this does not seem to
be clinically significant in most cases.

RADICAL MASTECTOMY (Willi Meyer, Halsted) (RM)

Removes breast tissue, nipple-areolar complex, skin,
pectoralis major and minor, and axillary lymph nodes in
continuity.
Leaves BARE CHEST WALL with significant cosmetic and
functional deformity.
INDICATIONS
Stage III
Stage IV
Of historical interest only;
Clinical trials comparing MRM with RM reveal no
significant difference in
disease-free survival
distant disease-free survival
overall survival.
EXTENDED RADICAL MASTECTOMY
HARDLEY
21% of outer quadrant and 44% inner quadrant
tumor has (+) internal mammary nodal involvement.
WANGESTEEN

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Classical RM + Internal mammary mediastinal and

supraclavicular LN
URBAN
nd
th
CRM + ipsilateral half of sternum, part of 2 to 5 rib
and pleura and internal mammary LN

Staging System for Breast CA

SURGICAL TREATMENT BY STAGE
Stage 0 In Situ Breast CA
DCIS
Total ipsilateral mastectomy vs. WLE plus
radiation therapy (XRT)
General agreement that axillary node dissection
is not required for DCIS
Overall 5-yr survival rate of 95-100%,
independent of whether treated by TM or WLE
plus XRT
LCIS
Close observation vs. bilateral TM
Axillary node dissection is not required
Clinically occult invasive CA
MRM vs. WLE with axillary node dissection plus
XRT
Pagets Disease of the Nipple
TM vs. MRM
Stages I and II
Early Breast CA
Stage I
< 2 cm tumor, Axillary LN None
Stage II
2-5 cm tumor, Node or in the same side of
the breast
Approximately 85% of breast CAs
Current tx recommendations:
MRM
WLE with ALND plus XRT
Clinical trials have shown:
WLE + ALND + XRT = MRM in terms of
disease-free survival
distant disease-free survival
overall survival
WLE with ALND + XRT
offers breast conservation with clinical
outcome equivalent to MRM
Tumor-free margins are essential when WLE
is performed
Addition of XRT to WLE with ALND
improves disease-free survival
localregional recurrence
DOES NOT improve distant diseasefree survival or overall survival in
node(-) patients.
Adjuvant chemotherapy
INDICATIONS
node(+) patients
high-risk node(-) patients.
Factors associated with high risk of recurrence:
Age < 35 yrs
Tumor size > 2cm
Poor histologic and nuclear grade
Absence of estrogen and progesterone
receptors
Aneuploid DNA content
High proliferative fraction (S-phase)
Overexpression of epidermal growth factor
receptor
EGF-2
Presence of cathepsin D
Amplification of c-erb B-2 oncogene
Lobular CA:
use of mirror-image biopsy or total mastectomy
for the contralateral breast is controversial.
5-year survival rates

General Surgery

Stages I: 80%
Stage II: 60%
Stages III and IV
Multi-modality therapy including
Surgery
radiation therapy
systemic therapy
Surgical therapy
must be individualized based on
extent of tumor
technical ease of resection
Mastectomy (TM or MRM)
remains the mainstay of surgical therapy
Pre-op chemotherapy and local radiation therapy
is under investigation as potential treatment for
Inflammatory Breast CA
Goal of multimodality therapy
control of local-regional and distant disease.
Even with aggressive therapy, however,
most of these patients will die as a result of
distant metastatic disease.
5-year survival rates
Stages III : 20%
Stage IV: 0%
POST-OP MANAGEMENT OF

Breast Cancer
Chemotherapy & Hormonal Therapy
Surgery and radiation therapy
used to achieve local regional control.
Chemotherapy and hormonal therapy
used to achieve systemic control.
INDICATIONS FOR CHEMOTHERAPY AND HORMONAL THERAPY:
Adjuvant therapy for node (+) patients and high-risk
node(-) patients
Palliation for metastatic disease
PALLIATION FOR METASTATIC DISEASE
The decision to offer systemic therapy for metastatic
disease should be based on:
Extent and rate of progression of metastatic disease
Hormone receptor status
Degree and progression of symptoms
Patients ability to tolerate therapy w/o significant
toxicity
CHEMOTHERAPY or HORMONAL THERAPY?
Chemotherapy:
tends to have a shorter time to response (4-6 wks vs.
8-12 wks)
Better overall response rate (40-60% vs. 25-35%)
Shorter mean duration of action (8-12 months vs. 1418 months)
Increased toxicity compared to hormonal therapy
Should be considered for patients with:
Hormone receptor negative tumors
Aggressive metastatic disease
Ability to tolerate side-effects of cytotoxic drugs
SIDE EFFECTS
Nausea
Vomiting
Myelosuppression
Alopecia
Thrombocytopenia
Exercise intolerance
Hormonal therapy
should be considered for patients with:
Hormone receptor positive tumors
Relatively indolent metastatic disease
Tamoxifen
treatment of choice for most of these patients
ANTI-Estrogen

15

[Type the company name]

a non-steroidal anti-estrogenic compound that

compete w/ estrogen at receptor site
Estrogen receptor assay should be determined; if
negative chance of success is very low
OUTCOME
OUTCOME OF

Breast Cancer Treatment

Metastasis
Breast cancer tends to metastasize to the following places:
Lymph nodes (most common)
Lung/pleura
Liver
Bones
Brain
Prognosis
~ 50% of patients with operable breast cancer develop
recurrent disease unless they receive adjuvant chemotherapy
or hormone therapy.
Prognostic factors include:
Tumor size:
Tumors > 5 cm are a/w survival rate &
recurrence rate.
Axillary node status
Histopathology
Hormone receptor status
Oncogenic expression
5 Year Survival Rate According to Stage

STAGE
0
I
II
III
IV

AMERICAN JOINT COMMITTEE

Breast CA CLINICAL STAGING
5 yr survival
100%
85%
66%
41%
10%

Range
82-94
47-74
7-80%

SUMMARY
Summary
Breast cancer
most common female cancer, in contrast to male where it
is rare, with a ratio of 100:1.
When performing an initial evaluation of patients with possible
breast disease:
Remember to have a complete medical history, including
risk factors, such as:
Ask when first menarche, first child, any history of
breast cancer, when did menopause happen, how old
is the patient, any previous breast biopsy, etc.
Be sure to inquire about any history of nipple
discharge, or any changes in the size, shape,
symmetry, or contour of the breasts.
Remember to inspect and palpate all four quadrants of the
breast, the axillary lymph nodes, and the nipple-areolar
complex for any discharge.
Screening test of choice: Mammogram
Diagnostic Test: Biopsies
Treatments:
Surgical, Hormonal, Adjuvant Therapy [Chemotherapy,
Radiation Therapy]