Surgical Semiotics of the Mammary Gland

Principles of Breast Surgical Pathology

• Any lesion of the breast should be considered potentially malignant until proven otherwise. This approach emphasizes the importance of thorough examinations and diagnostics.

• Essential to exclude malignant lesions through various clinical and pathological assessments.

• Historical Context: Breast diseases were recorded by the Egyptians as early as 1600 years before Christ, showcasing the long-standing recognition of breast health. Prominent figures such as Hippocrates and Galen contributed to the documentation of breast cancer, laying the groundwork for modern understandings of the disease.

General Information

• The Renaissance era brought significant advancements in clinical understanding of breast pathology, as well as a systematic approach to surgical techniques.

• Key developments in surgical techniques:

  • 1894: Halsted introduced the first radical mastectomy, a groundbreaking procedure that significantly reduced tumor recurrence rates by completely removing the breast tissue and affected lymph nodes.

  • Pattey: Modified mastectomy that involved the removal of a portion of the pectoralis muscle, which includes Rotter's lymph nodes and the axillary region, allowing for a more comprehensive treatment of cancer spread.

  • Madden: Focused on mastectomy with specific attention to axillary involvement, improving outcomes for patients with involved lymphatic pathways.

  • Lumpectomy: A less invasive option that involves the removal of the tumor along with some surrounding healthy tissue; sentinel node biopsy is often performed alongside to check for possible cancer spread.

• Advances in the 20th century include the introduction of radiotherapy, chemotherapy, hormonal therapies (utilizing agents such as estrogen receptor antagonists like Tamoxifen), and targeted treatments like monoclonal antibodies for HER2 positive breast cancer patients.

• BRCA-1 Gene: Identified as crucial for familial breast cancer, leading to genetic testing and preventive measures for those at high risk.

• Changes in therapeutic concepts have been influenced by social factors such as the introduction of birth control, which has affected reproductive health patterns and cancer incidence over the past 30 years.

Anatomy of the Breast

• The breast is anatomically composed of glandular lobules, which are the functional units containing alveoli responsible for milk production.

• Contains up to 20 excretory channels, which transport milk from the lobules to the nipple.

• Composed of both glandular and fatty tissues, contributing to the breast's overall structure and appearance.

• Blood Supply:

  • Medial and Central: Supplied predominantly by the internal mammary artery, which travels along the sternum.

  • Lateral: Cornered by the lateral thoracic artery, ensuring adequate perfusion of breast tissues.

Key Anatomical Structures

Anterior View

• Key structures when examining the breast include:

  • Pectoralis major muscle: Forms the main muscle structure beneath the breast and plays a role in surgical approaches.

  • Axillary tail: An extension of breast tissue into the axilla, important for understanding lymphatic drainage.

  • Nipple and Areola: Central structures whose abnormalities can be indicators of underlying pathology.

  • Suspensory ligaments (Cooper's ligaments): Provide structural support to the breast tissue, crucial in maintaining breast shape and position, with potential implications during surgical procedures.

  • Glandular tissue: Responsible for milk production and channeling; sensitive to hormonal changes.

Lymphatic Drainage of the Breast

• Major drainage pathways include:

  • The lateral and superior parts of the breast primarily drain into the axilla, where axillary lymph nodes play a key role in cancer metastasis.

  • Medial parts of the breast drain parasternally, contributing to the need for comprehensive lymphatic evaluation in breast cancer assessments.

• Important lymph nodes include:

  • Apical and Central Axillary Nodes: Critical in assessing cancer spread and staging.

  • Lateral thoracic arteries that may also harbor lymphatic channels related to breast cancer.

  • Areas surrounding the pectoralis major muscle can also serve as sites for metastasis.

Clinical Considerations

Anamnesis (Patient History)

• Symptomatic presentations when evaluating breast health may include:

  • Local pain or discomfort associated with underlying lesions.

  • Tumors detected by self-palpation, along with signs such as nipple discharge (e.g., blood or fluid).

• Collecting a comprehensive and detailed patient history is paramount:

  • Previous breast diseases documented, along with treatments or interventions performed.

  • Family history of breast cancer, noting hereditary patterns.

  • Patient's age, particularly regarding changes in risk factors noted in cohorts under 30 or over 30.

  • Menstrual cycle regularity, childbirth history, and previous radiation histories which may influence breast health.