Lidia Ionescu

The 3rd Surgical Unit

Reasons for surgical
referral
Pain in the breast
Lump in the breast
Nipple discharge

Consider the lump possibly malignant till

proved by biopsy otherwise
Anatomy
Self-palpation
The cheapest screening
test
History taking
Ask the patient about:
Menstruation
Pregnancies
Abortions
Ingestion of contraceptive pills
Family history of breast cancer
Normal changes in the
breast
Menstrual cycle

Pregnancy

Lactation
Examination of the
breast
Inspection

Palpation
Examine the arms, axillae, supraclavicular
fossae
General examination
Position of the patient
Expose the whole upper half of the patient

Relax the patient in semi-recumbent position

Inspection
Size
Symmetry and contour
The skin
Nipple discharge, duplication
Look to the axilae, arms and supraclavicular
fossae
Breast lump
 Finding a lump in one of your breasts can cause you a lot of
anxiety.
 Most breast lumps, particularly in younger women, are not
caused by cancer but are benign

 Look with her arms at her sides and with her arms above
her head.
 Is a lump visible?
 Do the breasts look symmetrical? Slight asymmetry is quite
normal.
 Is there an inverted nipple and if so is it unilateral or
bilateral?
 Is there puckering of the skin or peau d’orange (orange
Breast lump
 The next stage is palpation and a systematic search pattern
improves the rate of detection.
Ask the patient to lie supine with her hands above her head.
 Examine from the clavicle medially to the mid-sternum, laterally to
the mid-axillary line and to the inferior portion of the breast.
 Remember the axillary tail of breast tissue.
 Examine the axilla for palpable lymphadenopathy.
 Be aware that 50% of breast tissue is found in the upper outer
quadrant and 20% under the nipple.
 Using the second, third and fourth fingers held together moved in
small circles is the most sensitive technique.
 Begin with light pressure and then repeat the same area using
medium and deep pressure before moving to next area.
Palpation
Three search patterns are generally used:
Radial method (wedges of tissue examined
starting at the periphery and working in towards
the nipple in a radial pattern).
Concentric circle method examining in expanding
or contracting concentric circles.
Vertical strip method examines the breast in
overlapping vertical strips moving across the
chest. The vertical strip method has been shown
to be more sensitive because the entire nipple-
areolar complex is included and examiner is able
to keep track better.
Palpation
Relation to the skin
Relation to the muscle
Palpate the nipple
Palpate the axillae and supraclavicular fossae
Carcinoma of the female
breast

Cancer of the breast is an adenocarcinoma:

Atrophic scirrhous
Acute inflammatory carcinogenous mastitis
History
Age- any age after menarche,
pick incidence: mid-fifties
More common- nulliparous women
Less common-women with many kids whom
breast-fed them
Symptoms- painless lump
Enlarging lump may distort the shape and
size of the breast
Nipple- deviated, distorted, retracted,
destroyed
Symptoms
Painless lump

Enlarging lump may distort the shape and

size of the breast

Nipple- deviated, distorted, retracted,

destroyed
Symptoms
Mass underneath the arm- enlarged lymph
node
Swelling of the arm caused by lymphatic or
venous obstruction
Backache- bony metastases
Dyspnea- lung MTS
Jaundice- liver MTS
Mental changes, fits- brain MTS
General malaise
Loss of weight
Local examination
Site
Size
Tenderness
Shape
Surface
Composition
Mobility
Relations to the surrounding
structures
Tethering:
Infiltration of fibrous septae- Cooper’s
ligament-from breast to subcutaneous fat and
skin.
Infiltration of these strands by tumour makes
them shorter, inelastic.
This pulls the skin inwards, puckerind the skin
surface
The lump can be moved but the skin dimples
Fixation:
Fixity to the skin, direct, continuous
Tethering/fixation
Tethering- edema of the overlying skin
between the many small pits- blockage of the
lymphatics
Orange-peel appearance “peau d’orange”

Fixation of a lump to the skin is almost

diagnostic of a carcinoma
PEAU D’ORANGE AND
INVERTED NIPPLE
BREAST CANCER

Breast cancer is the most common form of

cancer affecting women in Malaysia.
About one in 19 women in this country are
at risk, compared to one in eight in Europe
and the United States
Type of breast
cancer.
 Ductal carcinoma in situ (DCIS): This is the most common
type of noninvasive breast cancer. DCIS means that the
cancer is confined to the ducts.
 Lobular carcinoma in situ (LCIS): This condition begins in the
milk-making glands but does not go through the wall of the
lobules.

 Invasive (infiltrating) ductal carcinoma (IDC): This is the

most common breast cancer. It starts in a milk passage or
duct, breaks through the wall of the duct, and invades the
tissue of the breast.
 Invasive (infiltrating) lobular carcinoma (ILC): This cancer
starts in the milk glands or lobules. It can spread to other
parts of the body.
Fix Risk Factor

 Age-The older you get the more chance you have.Women age more 50
years old have 8-10 times fold more chance of get it compare to younger
age.
 Women-women has 100 times more risk than men.
 Family history-if you have family history of breast cancer,you are at a
high risk get the cancer.
 Past history of Breast cancer-if you was diagnosed to have breast
cancer before than you are prone to get it on the same breast or the other
one.
 Menstrual period-the early you have your menarche(1st period),you are
slightly high risk get it when you are older.
 Genetic factor-5%-10% link to mutation of gene and breast cancer.BRCA1
and BRCA2 are 80% the involve genes
Changeable risk
factor

 Breast feeding-women who breast fed their child 1-2 years will lower the
risk of get breast cancer.

 Alcohol-women who have 2-5 drink daily have 1.5 chance than women who
not consume alcohol.

 Exercise-women who do exercise will reduce the risk of getting breast

cancer.The more you exercise the lower the risk. The question is how much
we need to exercise. Study shown exercise 30 minutes per day for 5 days is
enough.
What Causes Breast
Cancer?

Low Fibre Intake (below 25gm daily)

BMI above 25
Smoking
Alcohol
Low in Antioxidants
Poor Immune system
What Causes Breast
Cancer?

               1.  Prevention

               2.  Early Detection by self-
examination
               3.  Intervention
Symptoms of breast
cancer

The most common sign of breast cancer is a

new lump or mass. A lump that is painless,
hard, and has uneven edges is more likely to
be cancer. But some cancers are tender, soft,
and rounded.
Other signs of breast cancer include the
following:
a swelling of part of the breast
skin irritation or dimpling
nipple pain or the nipple turning inward
redness or scaliness of the nipple or breast skin
How breast cancer
found?

 Breast self examination - women should do self breast examination regularly. you
should start do breast examination at age of 20 years

 Mammogram - A mammogram is an x-ray of the breast. This test is used to look for
breast disease in women who appear to have no breast problems. It can also be used
when women have symptoms..

 Biopsy - A biopsy is done when other tests show that you might have breast cancer.
The only way to know for sure is for you to have a biopsy. During this test, cells from
the area of concern are removed so they can be studied in the lab.
Staging
Staging is important to determine if the
patient is potentially in a curable early stage
or otherwise:
Stage 0 - Cancer in Situ
Stage I - Cancer is less than 2 cm.
Stage II - Cancer is between 2 to 5 cm with or
without involvement of the glands in the armpit
Stage III - Cancer is larger than 5 cm or there is
extensive involvement of the glands in the
armpit
Stage IV - Cancer has spread outside the breast
and involves other organs in the body
Stage I & II are considered early and curable.

Treatment
 Some patient was operated first than was given
chemotherapy.
 This is called adjuvant chemotherapy.

 If the surgeon think they need to shrink the size of the

cancer before surgery, chemotherapy/radiotherapy will be
given, pre-operativelly
 This is called neo-adjuvant chemo/radiotherapy
Advanced breast cancer
Mammogram
Computer-assisted mammography reading and digital mammography
are now being studied as ways to improve the accuracy of
mammography interpretation. Annual breast MRI, an imaging
technique that does not involve radiation exposure, is now routinely
recommended as a way to improve detection of early breast cancers
when screening women at high genetic risk of breast cancer
Type of surgery - The purpose of surgery is to
remove as much breast cancer tissue as much as
possible

 Lumpectomy - involves removing only the breast lump and some normal
tissue around it.
 Partial (segmental) mastectomy - involves removing more of the breast
tissue than in a lumpectomy. It is usually followed by radiation therapy.
 Simple or total mastectomy- the entire breast is removed but not the
lymph nodes under the arm or muscle tissue from beneath the breast.
 Modified radical mastectomy - involves removing the entire breast and
some of the lymph nodes under the arm
 Radical mastectomy - extensive removal of entire breast, lymph nodes,
and the chest wall muscles under the breast
 Axillary dissection- this operation is done to find out if the breast cancer
has spread to lymph nodes under the arm. Some nodes are removed
and looked at under a microscope.
This shows the right breast being larger than the left.
Look carefully and you can see that the level of the
nipples are not the same and the right nipple is pointing
downwards.
The lump can be seen mainly in the upper part of the
breast. The “pointing down” nipple is better
appreciated in the view from the side.  There is some
discolouration of the skin in the upper outer part of the
right breast and the skin is thin and stretched. The
breast lump is enlarging and with time, without surgery,
the cancer will break through the skin.
This is another lump in the right breast. Here,
the “bulge” caused by the lump can be seen.
The lump is therefore growing in the
superficial parts of the breast tissue
The right nipple is at a lower level than the left nipple. With
the hands down beside the body, this is noticeable already.
However, it becomes more obvious when both arms are
raised.  Both the position and direction of the nipples are
better appreciated. The close up view shows what has been
described. 
This illustrates the importance of going through all the
positions while standing and “looking” at your breasts.
There is a “depression” or sunken dip in the skin of the
upper part of the left breast, above the nipple. This is
known as dimpling of the skin. In this patient, even with
the hands down the dimpling is visible. Normally when
the arms are raised this becomes apparent or more
obvious.
Dimpling occurs as a result of a growth deep to the skin
within the breast tissue, that is “drawing” the
surrounding tissue and overlying skin towards it. This is
one character of a cancerous growth in the breast. So,
even without touching or feeling your breasts, you can
see the effects of a growth within your breasts. Hence
the importance of the “LOOK” and “FEEL” aspects of
Self Breast Examination.
The skin of the breast appears patchy red and
“thickened”. This is an example of a type of
breast cancer that looks as if your breast has
an infection. This is a sign of an inflammatory
cancer of the breast
Compare both nipples. The one to your right is drawn
inwards and this is called retraction of the nipple.  The
picture on the right shows the nipple retraction from the
side view.
Mastectomy scar
Mastectomy scar
Chemotherapy
 Chemotherapy (commonly called just "chemo") is the use of cancer-
killing drugs injected into a vein or taken as a pill. These drugs enter the
bloodstream and reach throughout the body. If chemo is given after
surgery it can reduce the chance of breast cancer coming back. Chemo
can also be used as the main treatment for a woman whose cancer has
already spread outside the breast and underarm area or that spreads
widely after the first treatment.
 Chemo may be given before surgery, often to shrink the tumor in order
to make it easier to remove.
 Chemo is given in cycles, with each period of treatment followed by a
break. The total course of treatment usually lasts for 3 to 6 months.
Often several drugs are used together rather than a single drug alone.
 The side effects of chemo depend on the type of drugs used, the
amount given, and the length of treatment.
Radiation Therapy
 Radiation therapy is treatment with high-energy rays (such as x-rays) to
kill or shrink cancer cells. The radiation may come from outside the
body (external radiation) or from radioactive materials placed directly in
the tumor (brachytherapy).
 Radiation therapy may be used to destroy cancer cells remaining in the
breast, chest wall, or underarm area after surgery or, less often, to
reduce the size of a tumor before surgery
 Treatment is usually given 5 days a week in an outpatient center over a
period of about 6 or 7 weeks, beginning about a month after surgery.
Each treatment lasts a few minutes.
 The main side effects of radiation therapy are swelling and heaviness in
the breast, sunburn-like changes in the treated area, and fatigue.
Hormone Therapy
 The female hormone estrogen promotes the growth of breast
cancer cells in some women. For these women, several
methods to block the effect of estrogen or to lower its levels are
used to treat breast cancer.

 A drug such as tamoxifen, which blocks the effects of estrogen.

Tamoxifen is taken in pill form, usually daily for 5 years after
surgery, to reduce the risk the cancer will come back.

 Aromatase inhibitors are a type of drug that stops the body

from making estrogen. They only work for women who are past
menopause and whose cancers are hormone positive
Inflammatory breast
cancer
 Rare but aggressive type of breast cancer that develops rapidly,
making the affected breast red, swollen and tender.
 It's a locally advanced cancer, meaning it has spread from its point
of origin to nearby tissue and possibly to nearby lymph nodes.
 The early signs of more-common forms of breast cancer — a breast
lump or suspicious area on a routine, screening mammogram —
are often absent in inflammatory breast cancer. Instead, the breast
may appear normal until tumor cells invade and block lymphatic
vessels in the overlying skin.
 Inflammatory breast cancer can easily be confused with a breast
infection, but if it's cancer, symptoms won't go away with
antibiotics.
 Inflammatory breast cancer accounts for between 1 percent and 6
percent of all breast cancer cases in the United States. Survival
rates are lower than those observed in other locally advanced
breast cancers. But new treatment approaches offer greater odds
for survival than ever before.
Inflammatory breast
cancer
Signs and symptoms
 Rapid change in the appearance of one breast, over the course of
days or weeks
 Thickness, heaviness or visible enlargement of one breast
 Discoloration, giving the breast a red, purple, pink or bruised
appearance
 Unusual warmth of the affected breast
 Dimpling or ridges on the skin of the affected breast, similar to an
orange peel
 Itching
 Tenderness, pain or aching
 Enlarged lymph nodes under the arm, above the collarbone or
below the collarbone
 Flattening or turning inward of the nipple
 Swollen or crusted skin on the nipple
 Change in color of the skin around the nipple (areola)
Differential diagnosis
 Other conditions have symptoms resembling those of inflammatory
breast cancer.

 A breast infection (mastitis) also causes redness, swelling and

pain, but breast infections usually develop during breast-feeding.

 With an infection, you're likely to have a fever, which is unusual

(but not unheard of) in inflammatory breast cancer
Inflammatory breast
cancer
Inflammatory breast
cancer
Treatment for inflammatory breast cancer starts
with chemotherapy, followed by surgery and
radiation therapy.

This combined-treatment approach has improved

the outlook for women with inflammatory breast
cancer.

About half the women diagnosed with the

condition survive five or more years, and nearly
one-third are alive 20 years after diagnosis.
Anatomy
Fibroadenoma

Benign neoplasm of the breast

Dominant feature is abundant fibrous tissue
Fibroadenoma
Signs
Site- any part of the breast
Overlying skin- normal
Not tender lump
Shape- Spherical/ovoid
Size-1-3 cm.
Surface-Smooth and bosselated
Margin- Distinct edge
Composition- hard- firm rubber
Relation- Highly mobile
No lymphadenopathies
Fibroadenoma
Lumpectomy
Acute breast abscess
Entry site:
 lactiferous ducts- more common
Blood stream
Symptoms, signs,
treatment
Dull ache- throbbing pain-tender area
Signs of acute inflammation
GA- malaise, night sweats, rigors
Treatment-” ubi pus ibi evacuat”- incision and
drainage
Breast abscess
Paget’s disease
Intraduct carcinoma in the nipple, spreading
into the skin of the nipple
The appearance- skin eczema
Nipple is destroyed leaving an ulceration
Cancer spreads into the breast
Gynecomastia
Increased size of the breast in men
Drugs: estrogens, diuretics, digitalis, anti-H2
R
Testicular atrophy- hormonal abnormality
Hormone-secreting testicular tumor
Gynecomastia