Comprehensive Study Notes on Breast Units, Breast Diseases, and Surgical Oncology

Clinic Structure and the Breast Unit at UCK

• Clinical Department: Klinika Chirurgii Onkologicznej, Transplantacyjnej i Ogólnej (KCHOTO) at the Gdański Uniwersytet Medyczny (GUMed).

• Leadership:

  • Lekarz kierujący: prof. J. Kobiela.

  • Zastępca kierownika: prof. M. Proczko-Stepaniak.

• Departmental Units and Leaders:

  • ACS Unit (Chirurgia przypadków ostrych): Focused on acute surgery, led by dr J. Bigda.

  • HB&P Units (Chirurgia wątroby i dróg żółciowych oraz chirurgia trzustki): Focused on liver, bile duct, and pancreatic surgery, led by prof. J. Zieliński.

  • UGI Unit (Chirurgia górnego odcinka przewodu pokarmowego): Focused on the upper gastrointestinal tract, led by prof. J. Kobiela.

  • LGI Unit (Chirurgia dolnego odcinka przewodu pokarmowego): Focused on the lower gastrointestinal tract, led by dr M. Śledziński.

  • Endocrinology Unit (Chirurgia Endokrynologiczna): Focused on thyroid and adrenal surgery, led by dr K. Drucis.

  • BSSM Unit (Chirurgia piersi, mięsaków i czerniaków): Focused on the surgery of the breast, sarcomas, and melanomas, led by prof. S. Hac.

• Specific Breast Unit Contact: Dr. Marcin Ekman, Oncology Surgery Outpatient Clinic (Poradnia Chirurgii Onkologicznej), Mondays $14.00-18.00$ at CMI, 3rd floor, room 9 or 12. Phone: $665\,486\,820$.

Mastitis: Inflammation of Breast Tissue

• Definition: Mastitis is an inflammation of the breast tissue that may involve an infection. It results in breast pain, swelling, warmth, and redness. Systemic symptoms such as fever and chills may also occur.

• Affected Population: Most commonly affects breastfeeding women (lactation mastitis), but can occur in non-breastfeeding women and men.

• Primary Causes:

  • Trapped Milk: If the breast does not empty completely, a milk duct can become clogged, leading to infection.

  • Bacteria: Surface bacteria or bacteria from the baby's mouth enter the milk ducts via skin cracks or nipple openings. Stagnant milk provides a breeding ground for these bacteria.

• Risk Factors:

  • Previous history of mastitis.

  • Sore or cracked nipples.

  • Tight-fitting bras or external pressure (seat belts, heavy bags) restricting milk flow.

  • Improper nursing technique.

  • Stress, fatigue, and poor nutrition.

  • Smoking.

• Prevention Strategies:

  • Fully drain milk from the breasts during feeding.

  • Allow the baby to completely empty one breast before switching to the second.

  • Vary breastfeeding positions.

  • Ensure proper latching.

  • Engage in smoking cessation if applicable.

Management and Treatment of Mastitis

• Swelling Reduction: Use ice packs or frozen vegetables while lying on the back to drain fluid into lymph nodes. Heat should NOT be applied.

• Pharmacotherapy: Use over-the-counter nonsteroidal anti-inflammatory drugs (NSAIDs) such as ibuprofen or naproxen to reduce pain and inflammation.

• Lymphatic Drainage: Gentle, light pressure (described as "petting a cat") directed toward the lymph nodes above the collarbones and in the armpit. This is lighter than a standard massage.

• Reverse Pressure Softening (RPS): A massage technique to reduce swelling in the areola and nipple to assist with latching. Two fingertips are placed at the base of the nipple, pressure is applied, and fingers are dragged away from the nipple at various angles.

• Support: Wear a supportive but non-tight-fitting bra.

• Contraindications (DO NOT):

  • Aggressively massage the breast.

  • Use massaging devices.

  • Soak the breast in any substance.

  • Apply heat.

Breast Abscess

• Definition: A painful collection of pus forming in the breast, typically located just under the skin.

• Etiology: Usually caused by a bacterial infection and often occurs as a complication of mastitis.

• Risk Factors for Progression:

  • Excessive "observation time" (delaying treatment).

  • Abruptly stopping breastfeeding.

  • History of previous breast abscesses.

Breast Cancer Epidemiology and Risk Factors

• Definition: A malignant tumor arising from breast cells that develops locally and metastasizes to lymph nodes and internal organs (lungs, liver, bones, brain).

• Statistics:

  • Most common malignancy in women, accounting for $23 \%$ of all cancer cases and $14 \%$ of cancer deaths in women.

  • Global: $1.5$ million annual diagnoses; $400,000$ annual deaths.

  • Poland (2020): $17,511$ new cases (incidence $50.0 / 100,000$) and $6,956$ deaths (mortality $14.7 / 100,000$).

  • Men: Approximately $150$ cases per year in Poland.

• Risk Factors:

  • Gender/Age: Female gender and increasing age.

  • Genetics: $5 \%$ to $10 \%$ of cases are hereditary.

  • Reproductive: Early menarche and late menopause.

  • Hormonal: Oral contraception and hormone replacement therapy (HRT).

  • History: Previous breast cancer (triples risk in the other breast), ovarian cancer, or endometrial cancer.

  • Pathology: Benign changes like atypical ductal hyperplasia (ADH) or atypical lobular hyperplasia (ALH).

  • Tissue Density: Dense glandular tissue increases risk.

  • Environment: Ionizing radiation and lifestyle factors.

Symptoms and Clinical Types of Breast Cancer

• Primary Symptoms: Often asymptomatic for a long time. Early signs include:

  • Irregular lump or thickening.

  • "Grasping" or pulling of the skin when raising hands.

  • Changes in size, shape, or outline of the breast.

  • Sudden nipple retraction (developing over weeks).

  • Skin dimpling, redness, or stiffening.

  • Upper limb swelling.

• Major Histological Types:

  • Ductal Carcinoma In Situ (DCIS): Non-invasive abnormal cells.

  • Invasive Ductal Carcinoma (IDC): The most common invasive type.

  • Invasive Lobular Carcinoma (ILC): Second most common invasive type.

  • Inflammatory Breast Cancer (IBC): Rare, aggressive, blocks lymph vessels causing an inflamed appearance.

  • Paget's Disease: Rare form affecting the nipple and areola.

• Rare Types: Phyllodes tumors, Angiosarcoma (originating in blood vessels).

Molecular Subtypes and Staging

• Receptor Status Subtypes:

  • HR+/HER2-: Most common ($73 \%$ of cases).

  • HR-/HER2-: Triple Negative ($13 \%$ of cases).

  • HR+/HER2+: Triple Positive ($10 \%$ of cases).

  • HR-/HER2+: ($5 \%$ of cases).

• TNM Staging Classification:

  • T (Tumour):

  • $T1 \le 2\,cm$ in greatest dimension.

  • $T2 > 2\,cm \text{ but } \le 5\,cm$.

  • $T3 > 5\,cm$.

  • $T4$: Any size with direct extension to chest wall/skin.

  • N (Lymph Node):

  • $N0$: No regional node cancer.

  • $N1$: Regional movable metastasis.

  • $N2$: Non-movable regional metastases.

  • $N3$: Internal mammary lymph node involvement.

  • M (Metastasis):

  • $M0$: No distant metastases.

  • $M1$: Distant metastases present.

• Stage and Survival (5-Year Rate):

  • Stage 0: Very small, inside glands ($100 \%$ survival).

  • Stage 1: $< 2\,cm$, no lymph involvement ($100 \%$ survival).

  • Stage 2: $2-5\,cm$, affected lymph nodes ($87 \%$ survival).

  • Stage 3: $> 5\,cm$, muscle/skin involved ($61 \%$ survival).

  • Stage 4: Any size, spread to distant organs ($20 \%$ survival).

Diagnostics and BI-RADS Scale

• Diagnostic Pathway: Patient history, physical exam, and imaging.

• Imaging Modalities:

  • Mammography (MMG).

  • Ultrasonography (USG) of breast and axillary lymph nodes.

  • Magnetic Resonance Mammography (MR) or Contrast-Enhanced Spectral Mammography (CESM) for ambiguous results.

• BI-RADS (Breast Imaging-Reporting and Data System):

  • Category 1: Negative (Routine screening; $0 \%$ cancer likelihood).

  • Category 2: Benign (Routine screening; $0 \%$ cancer likelihood).

  • Category 3: Probably Benign ($6$-month follow-up; $\le 2 \%$ cancer likelihood).

  • Category 4: Suspicious (Requires tissue diagnosis; $2 \%$ to $95 \%$ likelihood). Subdivided into 4a (low), 4b (moderate), and 4c (high suspicion).

  • Category 5: Highly Suggestive of Malignancy (Requires tissue diagnosis; $\ge 95 \%$ likelihood).

  • Category 6: Known biopsy-proven (Surgical excision).

• Biopsy Types:

  • Core Needle Biopsy: Basis of current diagnosis; assesses histological type, malignancy degree, and markers (ER, PgR, HER2, Ki67).

  • Fine Needle Aspiration (FNA): Used primarily to assess suspicious regional lymph nodes.

  • Mammotome Biopsy: Used for very small suspicious lesions.

  • Nipple Mucus Examination: Assessing cells in discharge.

Breast Cancer Treatment and Surgery

• Treatment Categories:

  • Local: Surgery and Radiotherapy.

  • Systemic: Chemotherapy, targeted therapy, immunotherapy, hormone therapy.

  • Timing: Preoperative (neoadjuvant), postoperative (adjuvant), or palliative.

  • Purpose: Radical (Stages I-III) or Palliative (Stage IV).

• Breast Conserving Therapy (BCT): Surgical removal of the tumor followed by breast irradiation.

  • BCT Contraindications: Multifocal cancer, previous radiation, extensive microcalcifications, collagenoses, inability to achieve R0 margins or good cosmetic effect, lack of consent, first/second trimester pregnancy, or local recurrence.

• Surgical Techniques:

  • Mastectomy procedures: Halsted, Patey, and Madden procedures.

  • Mammaplasty variations: Periareolar, Inferior pedicle, Omega, Lateral, Medial, Vertical, L-plasty, J-plasty, Inverted-T, and Inferior Mammary Fold plasty.

  • Advanced: Breast endoscopic single-site surgery for nipple-sparing mastectomy.

Paget’s Disease and Inflammatory Breast Cancer (IBC)

• Paget’s Disease:

  • Cancer of the milk ducts affecting the nipple/areola.

  • Accounts for $0.5$ to $5 \%$ of breast cancers.

  • Typical in women aged $60 \text{ to } 70$.

  • Symptoms: Redness, pimple-like lesions, irregular shape, tingling, itching, burning pain, and purulent or bloody discharge.

  • Advanced stage: Nipple retraction, ulceration, and destruction.

• Inflammatory Breast Cancer (IBC):

  • Rare and very aggressive.

  • Pathophysiology: Cancer cells block the lymphatic vessels of the breast skin.

  • Prognosis: Extremely poor.

Perioperative and Postoperative Care

• Pre-Surgery Checklist: Identification, informed consent for procedure and anesthesia, site marking, fasting status, jewelry/hair/denture removal, thrombosis prophylaxis, and antibiotic prophylaxis.

• Postoperative Instructions:

  • Wound Care: Regular sterile dressing changes; keep the wound clean and dry. Avoid excessive soaking.

  • Suture Removal: Typically at the Oncology Surgery Clinic (e.g., UCK CMI 3rd floor).

  • Scar Management: Start delicate massage and lubrication (e.g., Vaseline) after healing. Silicone patches and mobilization can be used after $3$ weeks; full remodeling takes up to $12$ months.

  • Medications:

  • Anticoagulation (e.g., Neoparin $0.4\,ml$ s.c. once daily).

  • Antiseptics (e.g., Betadine).

  • Analgesics: Paracetamol ($500-1000\,mg$ 3x/day) and Pyralgina ($500\,mg$ 3x/day); can be used together.

  • Follow-up: Histopathology results are typically ready in $3 \text{ to } 4$ weeks.

  • Warning Signs: Constant severe pain or fever above $38^{\circ}C$ requires immediate medical contact.

  • Rehabilitation: Postoperative physiotherapy is highly recommended.