Surgery E2: Breast

What muscles make up the breast?

Pectoralis major: lies beneath breast

Serratus anterior: lateral wall

Rectus abdominis: inferior border

External oblique: anterolateral wall

What provides blood supply to the breast?

anterior perforating intercostal arteries (60%)

lateral thoracic artery (30%)

posterior intercostal arteries (10%)

Where does the majority of breast lymph drain through?

axilla (75%), lymph drainage occurs first to a lower lymph node level and proceeds on to higher levels

What are the 4 nerves to be aware of during axillary dissection?

long thoracic, thoracodorsal, medial pectoral, lateral pectoral

What are the RF for breast cancer?

inc age, + FHx breast or ovarian CA, HRT, alcohol consumption, early menarche, late menopause, nulliparity, radiation exposure

What are sx of breast CA?

U/L spontaneous nipple discharge, noncyclic pain, firm fixed mass, complex findings on imaging, Peau d’orange

What is lobular carcinoma in situ (LCIS)?

RF for development of breast cancer, conforms to the outline of the normal lobule w/ expanded and filled acini

What is ductal carcinoma in situ (DCIS)?

pre-invasive form of ductal CA

What is infiltrating ductal carcinoma?

90% of invasive breast CA, tends to grow as a cohesive mass and appears as discrete abnormalities on mammogram

*Paget’s: skin involvement

What is infiltrating lobular carcinoma?

10% of breast CA, difficult to detect, tends to grow in a single file nature

What is tubular carcinoma?

usually low grade lesions, account for 1-2% breast CA

What is the workup for breast CA?

mammogram -MC screening

US -good at assessing size and consistency of lumps; used for guided needle biopsy

MRI -sensitive at describing abnormalities

Which BI-RADS risk score:

incomplete; needs additional imaging

0

Which BI-RADS risk score:

negative; symmetrical and no masses or suspicious calcifications

1

Which BI-RADS risk score:

benign; 0% probability of malignancy

2

Which BI-RADS risk score:

probably benign; < 2% probability of malignancy

3

Which BI-RADS risk score:

suspicious; 2-95% probability of malignancy

4

Which BI-RADS risk score:

high suggestive of malignancy

5

Which BI-RADS risk score:

known biopsy proven malignancy

6

What are MRIs good for ?

dense breasts, scar tissue, implants; used for local staging for DCIS and lobular cancer

*sensitivity & specificity may be greater than that of a mammogram

How is breast CA diagnosed?

fine needle aspiration FNA, core needle biopsy, stereotactic biopsy, US guided biopsy, excisional biopsy

How is breast CA staged?

TNM

What is the tx for breast CA?

surgery, radiation after lumpectomy, chemo or hormone therapy to decrease systemic recurrence

What are the surgical tx options for breast CA?

lumpectomy, simple mastectomy, modified radical, radial mastectomy

What is a lumpectomy?

excision of breast lump w/ a surrounding rim of normal breast tissue

What is a simple mastectomy?

removes breast tissue, nipple, areola, and skin, but not all of the lymph nodes

What is a modified radical mastectomy?

affected breast is removed as well as part of the axillary lymph system (levels 1 & 2), underlying muscle is preserved

What is a radical mastectomy?

affected breast, all lymphatic drainage and underlying pectoral muscles are removed

What are indications for a lumpectomy?

equivocal patho on biopsy, category 3 or 4 mass, DCIS or invasive breast CA that is amenable to breast conserving therapy based on the size

What lumpectomy incision is ideal for central lumps?

periareolar

What lumpectomy incision is ideal for peripheral lumps?

curvilinear

What are complications of a lumpectomy?

hematoma, infection, poor cosmesis, re-excision

What is a skin sparing mastectomy?

breast tissue, nipple and areola only removed

What is a nipple-sparing mastectomy?

option for early stage > 2cm away from nipple/areola

What are indications for a mastectomy?

advanced malignant tumors, Paget’s disease of the breast, multifocal or multicentric disease w/ chest wall involvement, inflammatory breast CA, hx lumpectomy w/ + margins, prophylactic for BRCA1, BRCA2, p53 carriers

What incision is used for a radical mastectomy?

elliptical

What are complications of a mastectomy?

seroma, hematoma, wound infection, skin flap breakdown or necrosis, lymphedema

What can be done intraoperatively to identify involved lymph nodes and help stage cancer?

lymphatic mapping and sentinel node biopsy

What nerve can be injured during axillary dissection resulting in weakening or paralysis of the serratus anterior mm?

long thoracic nerve

What are the sx of an injury to the long thoracic nerve?

“winged” scapula, limited ability to lift arm above head, scapula “pops” out when pt pushes against resistance

Breast surgery can cause an obstruction of lymph flow. What are sx of the resulting lymphedema?

usually progresses distal → proximal, pigmentation changes, ulceration, fibrosis → thick rough skin

What is primary lymphedema?

congenital absence or dec #s of lymphatics or obstruction of the thoracic duct

What is the secondary lymphedema?

from surgical removal of lymph nodes or from lymphatic destruction by radiation

What is the tx for lymphedema?

external pneumatic devices, elastic garments, exercise, diuretics, massage

What is the follow up protocol after tx of breast CA?

B/L mammograms 6 mos post completion of RT following lumpectomy; then yearly

C/L mammograms yearly after modified radical mastectomy

serial exams every 3-6 mos x 3 yrs, then annually

Do reconstructed breasts have natural sensations?

n, but offer cosmetic benefit

What are the options for breast reconstruction?

using tissue from back, belly, or buttocks → flap procedures

silicone implants

nipple and areola reconstruction

Which type of free flaps removes tissue from the lower abd to use for breast reconstruction?

Deep Inferior Epigastric Perforators (DIEP) -uses autologous tissue w/ perforators and blood vessels

Superficial Inferior Epigastric Artery (SIEA) -removes skin and fat

What are sx of fibroadenoma?

painless, unilateral, benign solid mass, highly mobile, firm-rubbery masses, typically shrink after menopause, MC 14-35 yo

What is the tx for fibroadenomas?

asx and small → observance and reassurance

lumpectomy or excisional biopsy, cryoablation

What must be done before a cryoablation for a fibroadenoma?

biopsy to confirm

What are sx of phyllodes tumor?

unilateral, firm, enlarging, painless, may stretch overlying skin and show distension of veins, 1-45 cm, continuum benign → malignant, 40-50 yo

*high recurrence rate and metastatic potential

What are Phyllodes tumors linked to?

Li-Fraumeni syndrome

What is the workup for a Phyllodes tumor?

mammogram: round lobulated dense mass

US: hypoechoic, partially circumscribed mass w/ post enhancement, inc vacularity

MRI: lobulated mass w/ hyperintense fluid

What is indicated if a cystic component is noted on US of a Phyllodes tumor?

typical of malignancy

What is the tx for Phyllodes tumor?

surgery → side local excision w/ > 1 cm margins

*large tumor = mastectomy