Department of Surgery Ruijin Clinical Medical College Shanghai Jiao Tong University

Breast diseases Anatomy Physical Examination Acute Mastitis Cystic hyperplasia Breast Tumor Gynecomastia

Anatomy On pectoral fascia and musculature of the chest wallOn pectoral fascia and musculature of the chest wall Over upper anterior rib cage 2 nd or 3 rd to 6 thOver upper anterior rib cage 2 nd or 3 rd to 6 th Fat surroundingFat surrounding Skin envelopeSkin envelope Axillary tail of SpencerAxillary tail of Spencer

Anatomy glandular lobes lobules alveoli Small duct-major duct Nipple-areolar complex Cooper’s ligament (fibrous septa)

Anatomy Relation to pectoralis major muscle Level I Encompasses the LN lateral to lateral border of the pectoralis minor muscle; this subgroup contains most of the axillary nodes.

Anatomy Level II LN lying directly beneath the pectoralis minor muscle Level III Medial to the medial border of the pectoralis minor muscle and extending up to the apex of the axilla

lymph Pectoralis major → axillary → subclavicular → supra-clavicular Medial portion → intercostal lymphatic duct →para- mediastinum

Lymph Subcutaneous lymphatic communication left→right Lymphatic plexus on the rectal sheath →falciform ligament→liver

Important structures Intercostobrachial nerve a sensory nerve supplying the underarm skin Long thoracic nerve of Bell a motor nerve to the serratus anterior and subscapularis muscles Thoracodorsal nerve a motor nerve to the latissimus dorsi adjacent to its accompanying artery and veins

Physiology Anterior pituitary hormones (prolactin) Adrenal corticoid hormones (Estrogen) Sexual hormones (Progesterone) Insulin Thyroid hormone

Examination Inspection Overall inspection symmetry, size, shape, skin color, venous pattern, lump, local dimpling Nipple excoriation, inversion, discharge, edema and redness Skin redness, edema, Peau d’orange or pig-skin

Examination Palpation Gentle palpation, quadrant by quadrant Mass: number, size, consistency and mobility Lymph node: Central,pectoral,subscapular, subclavicular and supra-clavicular group

Examination palpation Character of the discharge is significant Milky, serous, or green-brown discharge Bloody discharge

Imaging Study Mammography Thermography Ultrasound Ductogram Magnetic Resonance (MR) Positron Emission Tomography (PET)

Evaluation of breast masses Biopsy : FNA( mm) Open biopsy Nipple discharge: serous,colorless Normal menstrual cycle, intraductal papilloma or early pregnancy Bloody intraductal papilloma or ductal ca. Yellowish galactocele or cystic hyperplasia Ductogram

Acute Mastitis Cause Lactic stasis Bacterial invasion (Staphylococcus aureus) Manifestation Swelling pain Painful mass with reddish skin General features: Chill, fever, ipsilateral LN enlargement, bacteriaemia Abscess formation

Treatment General Thermo therapy: 25% Magnesium sulfate Antibiotic therapy: Local and general administration Drainage: Prevention

Cystic hyperplasia Cause Hormonal imbalance Excessive estrogen production and deficient corpus luteinum activity

Cystic hyperplasia Clinical manifestation Pain or lump, nipple discharge (15%) Bilateral invlvement Inseparable from other grandular tissue Tense cyst no fluctuant Tenderness Cyst may appear rapidly and then maintain their size or shrink after next menstraual flow Most painful in pre-menstraual period: mastodynia

Cystic hyperplasia Diagnosis Pain or lump FNA Management Hormonal therapy FNA, open biopsy, mastectomy

Tumor Benign Fibroadenoma 75% Intraductal papiloma 20% Malignant Cacer 98% Sarcoma 2%

Fibroadenoma Cause Estrogen may play an important role in its pathogenesis

Fibroadenoma Manifestation Lump or mass Freely moveable, smooth, lobulated and independent from surroundings without fixation regardless the size. 75% solitary Found incidentally on BSE

Fibroadenoma Diagnosis Mammographic appearance of a degenerating firoadenoma displaying a characteristic pattern of dense, popcorn- like calcification Histological appearance of a typical firoadenoma

Fibroadenoma Treatment Excision continued growth and need to be certain of the diagnosis

Intraductal papilloma Woman of years old. 6%-8% malignant tendency. Forming from the epithelial linings of the main ducts.

Intraductal papilloma Nodule at the areola margin. Pressure at that point reproduces the bloody discharge. Surgical excision (involved duct or radical resection if it is proved malignant by frozen section)

Breast Cancer Every 12 minutes a woman in America dies of breast cancer

CHANGES IN BREAST CANCER SURGERY, 1972–1986 “LESS CAN BE BETTER” Patients Undergoing Procedure (%) BreastRadical YearConservationMastectomy 1972~40~ <1

Breast cancer for women Cancer No.1or 2 for Death No.5 Shanghai Morbidity: in /100,000 in /100,000

Etiology Estrogen as an important factor in pathogenesis Estron(E1) and estradiol (E2) : carcinogenic Estriol (E3) : non-carcinogenic Other various factors

Etiology Cumulative risk of developing invasive beast cancer after a biopsy for benign breast disease Women with proliferative disease with atypia are at significantly increased risk for developing invasive breast cancer

Etiology Age-specific incidence curves for breast cancer The curve rises sharply after 30 years of age and continues to climb thereafter

Demographic factor Age more than 30 yrs Female gender (130:1 female/male ratio) Greatly increased risk Known carrier of breast cancer susceptibility gene Strong family history—2 or more first-degree relatives with bilateral or premenopausal breast cancer Atypical ductal or lobular hyperplasia or lobular carcinoma in situ Ductal carcinoma in situ, risk limited to ipslateral breast

Pathological procedure Tumor size Hormone receptor status Status of excision margins Histologic type

Pathological classification Type 1 Non-metastasizing Inarticulate carcinoma Type 2 Rarely metastasizing1.Pure extracellular mucinous or colloid Ca. 2.Medullary Ca. with lymphocyte infiltration 3.Well-differentiated adenocarcinomas Type 3 Moderately 1. Adenocarcinoma metastasizing2.Intraductal Ca.with stromal invasion 3.Any other Ca. not specifically classified in other groups Type 4 Highly metastasizing1.Undifferentiated Ca. 2.Any tumor that definitely invades blood vessels

Metastasis Metastasis routes Direct invasion Skin, fascia, muscle Lymphatic metastasis of 4 routes Distant metastasizes Lung, bone, liver, adrenal glands, brain, ovarian

Lymphatic metastasis Pectoralis major LN→ipslateral axillary LN→subclavicular →supra-clavicular →thoracic duct →venous stream Internal mammary nodes (para- sternal)→supra-clavicular lN

Clinical manifestation Early manifestation is solid, painless mass, which is hard, not smooth, unmovable, usually found accidentally. Rapidly developing carcinoma invades surrounding tissue, changes the contour of the breast: Skin traction Nipple traction Peau d’orange or pig-skin Chest wall fixation.

Inflammatory carcinoma An acute onset of redness, pain and swelling of the breast due to lymphatic blockade and lymphangitis. Skin,surface veins and the axiallary nodes are involved. Poor prognosis and treatment is usually inadequate to control the disease.

Inflammatory Carcinoma

Paget’s Disease An unique form of breast cancer Weeping eczematous lesion of the nipple followed a sub-areolar mass develop beneath the nipple in most cases. Skin is merely involved and the prognosis is better.

Paget’s disease

Diagnosis Self-examination 60% cancer discovered by patients Physical examination Mammography Asymmetry, skin thicking, irregular masses or architectural distortions

Staging Primary tumor (p) TX Primary tumor cannot be assessed T0 No evidence of primary tumor Tis Carcinoma in situ T1 Tumor 2 cm or less in greatest dimension T2 Tumor more than 2 cm but not more than 5 cm in greatest dimension T3 Tumor more than 5 cm in greatest dimension T4 Tumor of any size with direct extension into chest wall (not including pectoral muscles) or skin edema or skin ulceration or satellite skin nodules confined to the same breast or inflammatory carcinoma

Regional Lymph Node Involvement NXRegional lymph nodes cannot be assessed N0No regional lymph node involvement N1Metastasis to movable ipsilateral axillary lymph node(s) N2Metastasis to ipsilateral axillary lymph node(s) fixed to one another or to other structures N3Metastasis to ipsilateral internal mammary lymph nodes

Metastase

Distant Metastasis M X Presence of distant metastasis cannot be assessed M 0 No distant metastasis M 1 Distant metastasis present (including ipsilateral supraclavicular lymph nodes)

Staging Stage1T1-T2, N0, M0 Stage2T1-T2, N1, M0 Stage3 T1-T2, N2-N3, M0 or T3-T4, N0-N3, M0 Stage4Any combination of TN with M1

Breast cancer APPROXIMATE 5-YEAR BREAST CANCER SURVIVAL RATE BY AJCC STAGE Stage 5-year Survival Rate (% ) I90 II75 III50 IV15

Examination Ultrasound solid or cystic Needle aspiration solid or cystic Cytology excision biopsy Preferred method

Treatment Surgical procedures Curative or palliative Halsted radical mastectomy En bloc removal of breast, pectoralis muscle and axillary LN dissection (ALND) Extended radical mastectomy Plus mediastinal LNs (2,3,4 rib cartilage and intra-thoracal A and V, LN)

Surgery Modified radical mastectomy En bloc removal of breast and ALND Total mastectomy Breast conservation operation Lumpectomy, ALND and post-operative irradiation

Breast conservation operation Factors favoring breat-conserving therapy are as followings: Patient preference for breast conservation Tumor size and location Unifocal tumor Small or absent intraductal component of tumor Postlumpectomy breast anticipated Patient inability to tolerate general anesthesia

Breast Reconstruction A: Subpectoral prosthetic implant B: Pedicle transverse rectus abdominis myocutaneous (TRAM) flap

Adjuvant Therapy Radiotherapy Chemotherapy Endocrinotherapy Others

Radiotherapy Pre-or post-operative reduce local recurrence rate and dissemination at the time of mastectomy

Chemotherapy Breast cancer is considered relatively sensitive to chemotherapy. CMF: cyclophosphamide, methotrexate, and 5-fluorouracil Other active regimens : –CMFVP: CMF plus vincristine and prednisone –AC: Adriamycin plus cyclophosphamide –CAF: cyclophosphamide, Adriamycin, and 5- fluorouracil

Endocrinotherapy Both ER and PR at a level of at least 10 fmol/mg have the highest likelihood of response to hormonal intervention (60% to 70%). Hormonal interventions may be either ablative or additive.

Endocrinotherapy Tamoxifen is by far the most commonly used hormonal intervention for both adjuvant and advanced disease treatment because of its ease of administration and minimal toxicity.

Gynecomastia Gynecomastia is defined as palpable enlargement of the male breast. Clinically significant gynecomastia has been associated with use of a number of drugs as well as with other causes: Idiopathic Drug-induced

Gynecomastia In many cases of gynecomastia, no cause is found Pathologic causes of estrogen excess or testosterone deficiency are also associated with gynecomastia.

Treatment of gynecomastia Correction or elimination of the underlying cause, if any Reassuring the patient about the benignity of the condition. For most patients, particularly older males with bilateral disease, exclusion of malignancy is all that is required. Hormonal agents A subcutaneous mastectomy performed under local anesthesia.

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