Notes on breast surgery for medical finals.

1. Breast Surgery
Christiane Riedinger, September 2014
Resources: Path notes, Surgical Talk, Lecture Notes in Clin Surgery

2. TOC
● Clinical Assessment
● Pathology
● Management

3. Clinical Assessment

4. History
● Symptoms of breast disease
○ Pain
■ Cyclical? => Bilat. can depend on diet (caffeine)
Drug Mx: change contraceptive method,
danazol, tamoxifen, LHRH analogues
■ Non-cyclical? => Abscess, CA, Tietze’s syndrome*,
Herpes Zoster and other chest wall lesions.
○ Discharge
■ Clear Intraductal papilloma (benign)
■ Milky Galactorrhoea
■ Purulent Abscess
■ Multi-coloured Duct ectasia (inflammatory)
■ Blood Intraductal papilloma, CA, Paget’s
○ Lump

5. Breast Tumours: How to describe a lump
● she cuts the fish 3x + PER
○ site, size, surface
○ colour, contour, consistency, compressability/fluctuancy
○ tenderness, temperature, transillumination
○ fluid-filled, fixed (tethering vs. fixation, depth), fields (lymphatic drainage)
○ pulsatile (e.g. aneurysm)
○ expansile
○ reducible/relation to skin, muscle, other structures (hernia/breast lesion)
● Difference between tethering (lesion near fibrous septum or ligaments of Astley
Cooper, evident upon elevation of the arms or tension of pec major - dimpling) and
fixation (tumour attached to muscle and skin? implies more advanced disease)
● ??????

6. Breast Examination (1)
● Ask about pain
● Be ruthless but polite in terms of exposure for inspection
● General observation
○ General appearance - cachexia, pallor, SOB
○ Signs of previous surgery - wide local excision, mastectomy, reconstruction
○ Signs of infection
○ Nipples
■ Discharge, e.g. lactation, blood (duct ectasia, intraductal papilloma)
■ Rash (e.g. in Paget’s, DCIS underlying nipple, peau d’orange)
■ Inversion/retraction of nipples
■ Accessory nipples (usually below breast), accessory breast tissue (usually in axilla)
○ Supraclavicular area and axilla - swollen, nodes, veins, muscle wasting
● Continue with patient sitting at 45*
● Inspect breasts
○ Ask if pain when moving arms
○ Watch breasts as arms behind head – T4 skin, Astley Cooper* => Tethering?
arms behind back – T4 chest wall pec. major => Fixation?
○ = check for invading masses of stage T4
○ Ask about discharge and ask patient to demonstrate it

7. Breast Examination (2)
● Continue with patient lying flat with hands behind the head
● Cover patient and expose body parts needed
● Check inframammary fold with back of hand
○ Say: “I am now examining under the breast”
○ Most common finding: intertrigo – chronic thrush under breast
● Palpate 5 areas of the breast and axilla and nodes
○ Upper outer quadrant + axilla (most common site of lesions)
Hold pt’s R arm with your R arm then palpate axilla with the other hand. Ask patient to lift arm up, place
hand in axilla, lift arm down to rest on yours, then roll fingers down axilla 4 times. Examine the left axilla
with the left hand and vice versa. If you feel a lump, feel if it is fixed or not.
○ Upper inner quadrant
○ Lower inner quadrant
○ Lower outer quadrant
○ Areolar complex
○ Palpate normal breast first
■ During palpation don’t lift up hand
■ Move all around breast
○ Lymph nodes: Axillary (already done), infraclavicular, supraclavicular, neck
● Cover patient

8. Breast Examination (3)
● PRESENTATION
○ To complete my examination, I’d like to
■ Send off potential discharge for cytology
■ Palpate the liver and ausculate the chest for suspected mestastases
■ Perform a triple assessment
■ Clinical Hx and Ex => done
■ Radiological Mammography and US +/- MRI
■ Pathological Fine needle aspiration => cytology and core biopsy
■ MRI if younger patient or discrepancy between clinical assessment and
mammography or when planning breast conserving surgery
○ This lady has a non-tender/tender Xcm lump in the X quadrant of the X breast. It has a XX
surface and a XX edge, is mobile/immobile and not/attached to XX. There are XXX
palpable in the axilla, continue description as above. There are XXX nodes palpable in the
supraclavicular fossa / other sites. My differential diagnosis is XXXX based on the age of
the patient, the most likely diagnosis is XXXX.

9. Breast Examination (4)
● Note main DD has 4 choices (Mannequin does not have inflammatory lesion and 2 lumps to palpate, the benign diagnosis depends on age of
patient)
○ Fibrocystic lesion
■ Women >30-40
■ Changes with cycle
○ Benign neoplasm, e.g. fibroadenoma
■ Women <30-40
■ Changes with cycle
○ Malignant lesion: Peau d’orange, nipple retraction, tethering, fixation, change in breast size, ulceration, Paget’s
■ Painless lump
■ More likely in upper outer quadrant?
○ Inflammatory lesion
■ Usually painful
● DD of breast discharge
○ Ask if spontaneous or on squeezing
○ Orange watery fluid from single duct Intraductal papilloma
○ Bright red blood from single duct Papilloma or malignancy
○ White or green discharge from multiple ducts Benign
○ Bilateral milky discharge Galactorrhoea
● Note on axillary nodes
○ 25% of palpable node will not contain metastases
○ 25% of nodes containing metastases are not palpable

10. Aids to DD
● Have 4 main options for lump (note for exam: mannequin does not have
inflammatory option, has 1 palpable benign or malignant lump. Need to distinguish 2
benign conditions by age of the patient)
○ Benign fibroCYSTIC lesion in older women, terminal ducts undergo
apoptosis and terminal lobuloaveolar unit produces fluid => cyst
■ Change with cycle
■ Most likely if >>30y and up to menopause
○ Benign FIBROADENOMA = STROMA, “breast mice”
■ Change with cycle
■ Most likely if <~30y!!! Young!!!
○ MALIGNANT tumour
■ Painless lump
○ INFLAMMATORY lesion
■ PAINFUL, potential purulent discharge

11. Pathology

12. Breast Tumours: Risk factors
● Age
● Gender - only 15% of breast CA patients have other risk factors
● Inherited trait
● Oe exposure: early menarche, late menopause, no children, children at age of >35y
● OCP (risk returns back to normal)
● HRT (beyond the age of 55), risk returns to normal 5y post stopping, combined Oe/P
HRT is worse than Oe only
● Previous benign breast disease: atypical epithelial hyperplasia (fibrocystic lesion)
● Obesity, alcohol intake, NOT smoking!?! (Acc. to surgical talk)
● Radiation exposure, esp. post lymphoma (mantle radiotherapy)

13. Breast Tumours: Overview
● While listing the different pathological types of tumours, think of the
different tissues it can originate from
○ Types of breast tissue epithelium (duct vs. lobule)
○ Fibroblasts (stroma)
○ Types of skin epithelium (keratinocytes vs. glands etc..)

14. Benign Breast Tumours/Lesions
● General: Lipoma, sebaceous cyst, hamartoma, sarcoma (rare), 2* mets
● Fibrocystic >>35, perimenopausal, remodelling of breast tissue causing fluid entrapment
○ Non-proliferating cystic changes => cyclical, ASPIRATION AND CYTOLOGY
○ Proliferating:
■ Epithelial hypertrophy
■ Sclerosing adenosis =>
● Inflammatory
○ Mastitis (lactating) => ABX, ABSCESS ASPIRATION AND IV ABX, BREASTFEEDING
CONTINUATION
○ Non-lactating: piercings => periductal mastitis, fungal in immunosuppressed,
granulomatous in sarcoidosis or TB, infective in T2DM, RA => TREAT UNDERLYING
CAUSE AND CAUSATIVE AGENT
● Benign
○ Fibroadenoma <<35 (Breast mice) => EXCISION OR NO Rx
○ Phylloides: WLE OR MASTECOMY AS 15% MALIGNANT
○ Intraductal papilloma => EXCISION OR NO Rx

15. Malignant Breast Tumours
● DCIS
● DCIS near nipple = Paget’s disease
● DCIS subtype: comedone
● LCIS
● Invasive ductal NST
● Invasive ductal
○ Lobular
○ Medullary
○ Colloid/Mucinous
○ Tubular
○ Inflammatory
○ Cibriform
○ Micropapillary
○ Apocrine
○ Adenoid
○ Metaplastic
● Invasive LCIS

17. Breast Tumours: Organisation by site
● 50% upper outer
quadrant
● 20% central
● 4% bilateral 1* or >1 1*
lobular
carcinoma
invasive ductal carcinoma
mucinous carcinoma
medullary carcinoma
intraductal papillomaPaget’s,
DCIS
lipoma
sebaceous
cyst
stroma:
fibrocystic
fibroadenoma
phylloides

18. Breast Tumours: Genetic Changes
A HER2 -ve slow growing, responds to tamoxifen but not well to chemo
OeR +ve = luminal
B HER2 +ve double +ve, worse, often node involvement
basal-like HER2 -ve, triple -ve, highly aggressive, medullary, BRCA1/2 involved
OeR -ve PR -ve
HER2+ve HER2 +ve highly proliferative
● 10% genetic predisposition of which 30% BRCA1/2
● RECEPTORS
○ 30% HER2 upregulated (human epidermal GF = Y kinase) => worse prognosis
○ Oe R present/absent => if present better prognosis
● PROTEINS
○ Ras/Myc upregulated
○ pRb/p53 downregulated
● Classification according to receptor involvement:

19. Management

20. Screening of Breast Cancer
● 47-73 (after 70 voluntary)
● Every 3y
● 2 view mammogram looking for calcification
● Procedure
○ +ve (abnormal) => core biopsy
■ B1: Normal => return to screening (if biopsy from wrong area
rebiopsy)
■ B2: Benign => reassure, return to screening
■ B3: Uncertain malignant potential => excision
■ B4: Suspicion of malignancy => rebiopsy or excision
■ B5: Malignant => surgical excision (WLE or mastectomy)
● B5a - DCIS
● B5b - invasive
○ -ve (normal) => return to screening programme

21. Ix of Breast Disease
● Referral from GP or screening of suspicious lumps or mamogram findings:
● Triple assessment (diagnostic tests)
○ Clinical Hx and Ex
○ Radiological Mammography and US (useful for Ix of lesions already diagnosed,
not useful for ab initio identification, also US axilla)
○ Pathological Fine-needle aspiration FNA cytology and core biopsy
■ FNA: cystic lesion disappears on aspiration => diagnosis
■ Core biopsy only performed if suspicion of cancer after FNA
○ MRI if younger patient (high tissue density on mammobraphy) or discrepancy
between clinical assessment and mammography or when planning breast
conserving surgery
● Other Ix:
○ FBC (potential marrow involvement), LFTs, U&E/CA, CXR, Isotope bone scan,
liver US.

22. Ix of Breast Disease: Mammography
● Views
○ Mediolateral-oblique view MLO
○ Craniocaudal view CC
○ Lateromedial/mediolateral view?
● Result suspicious of cancer
○ White asymmetrical spiculated lesion containing microcalcification
○ DCIS: cluster of microcalcification
● Efficiency
○ Misses 7% of palpable cancers and 20% in pre-menopausal women
○ Lobular carcinoma not well detected
● ADD

23. Ix of Breast Disease: Staging
● Staging informs on state of progression and guides treatment
● Assessment for staging
○ Lymph node biopsy
○ CT for metastases
○ Bone scan for metastases
○ CXR for metastases
○ Liver US for metastases
○ Blood tests as before: FBC, LFTs, serum calcium, U&E
● TNM
○ Tx 1* cannot be assessed
○ T0 No evidence of 1*
○ Tis In situ
○ T1 <2cm
○ T2 2-5cm
○ T3 >5cm
○ T4 Chest wall or skin involvement
● Nx Lymph nodes cannot be assessed
e.g. if removed
● N0 no involvement
● N1 Movable axillary
● N2 Fixed axillary
● N3 Ipsilateral thoracic nodes
● Mx Cannot be assessed
● M0 No distant mets
● M1 Distant mets

24. Why Stage and Grade
● Grade = biology/histology differentiation
● Stage = anatomy infiltration
● Prognosis guided by
○ grade (incl. node biopsies)
○ stage
i

25. Treatment Overview
● Management by MDT: surgeon, oncologist, nurse, radiologist, histopathologist, cytologist,
coordinator, +/- plastic surgery, genetics, palliative care
Breast care nurse from 1st visit for SUPPORT AND EDUCATION
● Medical
○ Tyrosine kinase inhibitors: HER2 antagonists Herceptin
○ Endocrine treatment: Oe antagonist Tamoxifen pre-menopausal, Arimidex post
● Surgical
○ Excision of the tumour
○ Surgery to axilla
○ +/- Breast reconstruction
● Radiological
● +/- Adjuvant therapy: hormonal, biological or chemotherapy, neo-adjuvant means prior to
surgery
● Know local policies and national guidelines
● Consider social circumstances of patient
● Breast care nurse from 1st visit for SUPPORT AND EDUCATION

26. Surgical Treatment of the 1* Tumour
● <4cm
○ Breast-conserving surgery: WLE wide local excision and radiotherapy
○ OR mastectomy
○ Depends on patient choice, 75% chose WLE
● For impalpable tumours
○ Stereotactic localisation under mammographic control
○ Needle is placed in place of microcalcification
○ Area surrounding the needle is excised
○ Excised area X-rayed to confirm it contains the calcifications
● If margins of local excision not clear, re-excision is required
● Treatment of axilla is not normally done in DCIS

27. Treatment of the Axilla
● Aim: Prevent cancer spread and establish prognosis (axillary nodes most important prognostic
indicator!)
● Procedures:
Sentinel lymph node biopsy SNL
1. Pre-op US with FNA
2. Sentinel node biopsy
● Pre-op intradermal injection of technetium and methylene blue into tumour / periareolar
● Wait 2h
● Find first axillary node draining the cancer, excise and examine.
● Find hot and blue nodes and excise just these
3. If sentinel node +ve for tumour => axillary clearance
Axillary sampling
1. Remove >4 nodes and analyse histologically, if any +ve then axillary clearance
● Grades of axillary clearance
○ Axillary sampling Lower part of axillary fatpad, obsolete
○ Level 1 Nodes up to axillary vein
○ Level 2 Nodes up to pec minor
○ Level 3 Nodes up to 1st rib
○ The more, the higher the risk of nerve damage and lymphoedema
● Do NOT perform radiotherapy to a cleared axilla => inc. risk of lymphoedema

28. Surgical Treatment of Breast CA
● Conservation surgery (usually <4cm)
○ Wide local excision WLE, removal of cylinder of breast tissue down to the pectoral muscle
○ Limited axillary surgery
○ Post-operative radiotherapy
● Total simple mastectomy (usually >4cm or too large in small breast or nipple)
○ Removal of breast tissue, nipple and areola +/- axillary surgery
● Skin sparing mastectomy
○ Circular incision around nipple and removal of breast tissue with nipple by diathermy excision
through incision, followed by insertion of drainage tubes +/- implants and closure
● Nipple sparing mastectomy with simultaneous reconstruction
● Nipple and areola sparing mastectomy
● Most radical treatment - but no increased survival
○ Radical mastectomy with axillary clearance
○ Post-operative radiotherapy (if >5cm or close to chest wall)
● +/- chemotherapy, endocrine and antibody therapy

29. Breast Reconstruction
● Immediate
● Delayed
○ If significant comorbidity
○ or post-operative radiotherapy
● Becker prosthesis
○ Prosthesis placed under the pectoralis muscle / implant with potential port
○ Simplest procedure
● Autologous reconstruction / tissue flaps, when skin replacement needed
○ Latissimus dorsi
○ DIEP
■ Deep inferior epigastric perforator (a, anastomosed onto inf. mammary a)
■ Only skin and fat flap
○ previously TRAB (now replaced by DIEP)
■ Transverse abdominus,
■ Muscle sacrificed

30. Chemotherapy
● Overall reduces the risk of (distal) recurrence by 20%
● Greatest success in young node + xx
● In each case, assess potential benefits against toxicity (RISK Management!)
● Combination more effective than single agent (single more palliative)
● Six cycles of cytotoxic chemo given 1/m for 6m
● FEC: 5-fluorouracil, epirubicin and cyclophosphamide
● Scoring of toxicity 0-4, 1 can still work, from 2 on cannot continue work
● Side-effects
○ Alopecia (can prevent with scalp cooling)
○ Mouth ulcers
○ Sterility
○ Myelosuppression
○ Extravasation: stop infusion don’t remove!
○ Lethargy
○ Nausea and vomiting
○ Teratogenicity
○ Specific to individual drugs

31. Radiotherapy
● Reduces (local) recurrence but not mortality
● Usually combined with WLE
● 50Gy external beam radiotherapy 5d/w for 3w
● Side-effects
○ Tiredness
○ Skin irritation (~sunburn) from ~week3
○ Shrinkage of the irradiated breast
● Reduces risk of recurrence from 30% to 5% in 10y

32. Adjuvant Therapy
● Improves survival by 5-10% over 10y
● Oe antagonists / endocrine therapy
○ Usually for 5y if OeR +ve, especially if nodal spread. +/- ovarian ablation
○ Also reduce risk of contralateral breast CA, recurrence, death rate, 5%/10% benefit if node
-ve/+ve at 10y
○ Side effects: menopausal-type symptoms (less so with arimidex)
○ Tamoxifen - actually a mixed agonist/antagonist = SERM selective OeR modulator
○ Arimidex = anastrozole - an aromatase inhibitor that blocks peripheral oe production in
fat tissues in post-menopausal women where ovaries no longer produce Oe
● Herceptin = Trastuzumab
○ HER2 antibody
○ 25% of breast CA HER2 +ve (i.e. with HER2 overexpression?)
○ Side-effects: cardiomyopathy and congestive cardiac failure
○ Given every 3w for 1y as long as no cardiac problems
○ 3-monthly echocardiograms to monitor (see NICE)
● Neo-adjuvant therapy***
○ Treat with endocrine and/or cytotoxic drugs prior to surgery to allow shrinkage of the
tumour, followed by radiotherapy post-operatively

33. Prognosis
● Predictive factors
○ Node involvement single best predictor of survival! Nr of nodes ~ p of distant
mets!
○ Also: size, grade (differentiation), Nottingham Prognostic Index (size, grade and
nodes), vascular invasion, hormone R, HER2 R, histo type.
● DCIS >90% 5y
● if recurrence 50% invasive
● <1% death risk
● <2cm 90% 5y
● node -ve 80% 5y
● 16 nodes 50% 5y
● distant mets 15% 5y, life expectancy 2-3y
● metastases to: (LCIS different: CSF, serosal surfaces, GI, ovaries, uterus, bone
marrow)

34. Advanced Disease
● Tumour >5cm initial Mx non-surgical: chemotherapy with subsequent surgery +/-
radiotherapy
● Sole radiotherapy only if unfit for surgery or very elderly +/- adjuvant
● Metastatic disease: systemic therapy = hormonal, chemotherapy for advanced
visceral disease
● Treatment of bone mets
○ Radiotherapy
○ Bisphosphonates
● Treatment of hypercalcaemia due to bone mets
○ Hydration with IV saline
○ Diuretics
○ Bisphosphonates (inhibit Ras farnesylation and osteoclast proliferation)
● Palliative care
○ Treat pain and other symptoms of advanced disease

35. Additional Info
https://www.adjuvantonline.com/index.jsp
● Treatment of discharge of the breast
○ Hadfield’s procedure: duct excision
○ Microdochectomy: removal of the duct by a probe passed into it