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Breast Surgery
For cancer

Worldwide, there are approximately 1 million new cases annually. Breast cancer is the most frequently diagnosed cancer in women in the United States accounting for 175,000 new cases and 43,300 deaths in 1999. Breast cancer accounts for approximately 30 percent of all cancer diagnosed and approximately 16 percent of all cancer deaths in American women. In the USA, the incidence of breast cancer increases with age, and a woman's lifetime risk of developing breast cancer are estimated at 1 in 8.

Breast cancer surgery at the beginning of the twentieth century was one procedure, Radical Mastectomy (removal of the entire breast, underlying chest muscle and lymph nodes in the axilla). In the 1970's, it became apparent that the same results could be obtained with Modified Radical Mastectomy (entire breast and axillary lymph nodes removed). In the 1980's, breast conservation surgery evolved when it became apparent that the same results or better could be obtained with lumpectomy (limited breast removal), axillary dissection and radiation to remainder of the breast. Today, clinical trials involving sentinel node biopsy are being carried out on breast cancer patients to determine if axillary dissection is necessary in all breast cancer patients.

Anatomy

  • Each breast is composed of fifteen to twenty lobes. Each lobe has a single lactiferous (milk) duct, which opens in a depression at the tip of the nipple (Figure 1)
  • The ducts are parallel to one another in the nipple but then diverge toward the periphery of the gland. Distally the ducts divide and end in a spherical alveolus (Figure 2). A number of alveoli open into a common duct and constitute a lobule. All the lobules draining through the same duct make up a lobe
  • Each alveolus (gland) and duct are composed of a single layer of epithelial cells that lay against a basement membrane
  • The stroma is the connective tissue that holds the ducts and lobes together
  • Lymph channels within the breast spread outward from the nipple along the major lactiferous ducts and along draining veins to beds of lymph nodes. The major beds (regional nodes) are the external mammary group, axillary vein group, and central axillary group (Figure 3). Scapular and subclavicular nodes drain into the axillary nodes. Lymphatics also drain directly into the internal mammary chain
Figure 1 - Anatomy of the breast in a cross-section through the nipple. ©R. WallsFigure 2 - Diagram of the microscopic structure of breast tissue. Each lobule is composed of several alveoli that drain into a common duct. ©R. Walls
Figure 3 - Lymph channels and beds of lymph nodes (labeled in green) that drain the breast. ©R. Walls

Pathology

  • Most breast masses are benign (non-cancerous)
  • Malignancies are divided into invasive and non-invasive tumors. This differentiation is based upon whether the basement membrane is intact (noninvasive) or broken through with tumor cells penetrating underlying tissues (invasive or infiltrating)
  • Cell growth that extends into the duct or lobule lumen and does not penetrate the basement membrane is defined as in situ or intraductal (noninvasive). The terms noninvasive, ductal carcinoma in situ (DCIS), intraductal carcinoma, and lobular carcinoma in situ (LCIS) imply intactness of the basement membrane (Figure 4)
Figure 4 - Degrees of malignancy from intraductal carcinoma to metastasis by way of lymph channels and blood. ©R. Walls
  • The fact that cell growth extends through the basement membrane is a critical issue because the lymphatics and blood vessels are in the areas beyond the basement membrane. Tumor cells can thus enter the lymphatics and spread to regional nodes or enter blood vessels and spread to distant sites
  • Benign breast masses:
    • Cysts - fluid collections that are hormonal in nature and rarely malignant
    • Fibroadenoma - solid, benign tumors of stromal tissue origin that may be multiple and bilateral (in both breasts) and are frequent in younger age groups
    • Fibrocystic mass - a combination of cystic and connective tissue changes, not a true tumor
    • Abscess - localized collection of pus, frequently associated with breast feeding
  • Common noninvasive breast tumors:
    1. Lobular Carcinoma In Situ:
    • Benign and considered "a marker" not a true neoplasm
    • Has tendency to be bilateral
    • There is risk of developing into an invasive tumor in either breast. If invasive, the tumor is usually invasive duct cell rather than invasive lobular
    1. Ductal Carcinoma In Situ:
    • Most common type, 20 to 30% of screening breast malignancies
    • Malignant with multiple subtypes (solid, micropapillary, papillary, cribiform, comedo)
    • Often presents with microcalcification (very small calcifications) on mammography
    • Frequent in younger age group
    • Multicentric (in more than one lobe), multifocal (more than one place in a lobe) and usually unilateral (in one breast)
    • Significant risk to develop into invasive duct cell tumor over time
  • Common invasive breast tumors (malignant):
    1. Invasive (infiltrating) duct cell carcinoma
    • Most common tumor, 80 - 85% of invasive breast tumors
    • Usually a single mass (1/1000 cases will have multiple tumors)
    • Frequently associated with DCIS
    1. Invasive lobular carcinoma
    • Second most common invasive tumor, 10 - 15% of invasive tumors
    • May involve breast diffusely an often does not show up on mammogram
    • Less common invasive duct cell tumors are medullary, papillary, mucinous, tubular, adenoid cystic and inflammatory
  • Less common solid tumors:
    1. Cystosarcoma phyllodes
    • Bad term because it implies malignancy and many of these are not malignant
    • Unusual tumor of connective tissue origin and often large
    • Suspicious for malignancy if it recurs
    1. Carcinosarcoma - has both epithelial and stromal malignant changes
    2. Angiosarcoma (blood vessels) - rare and malignant
    3. Lymphoma - breast lymph node origin and malignant

History and Exam

  • History, clinical exam, and ultra sound examination will identify the majority of benign cystic and inflammatory breast masses. Many breast masses will not be felt by the patient or examiner, nor will they show up on mammography or ultrasound exam.
  • A history may uncover risk factors.
    1. Important events are age at menarche (first period) and menopause
    2. Number of pregnancies and age at time of pregnancies
    3. Breast feeding
    4. X-ray exposure
    5. Previous breast surgery
    6. History of breast cancer
    7. Hysterectomy or oophorectomy (removal of ovaries)
    8. Hormone replacement therapy
    9. Family history of breast cancer and previous diagnostic studies
    10. Diet, alcohol, exercise and hormone medication have a smaller but measurable influence
  • Particularly important is the family history of first degree relatives (mother, daughters and sisters) and ages if breast cancer was present. Most cases of breast cancer are sporadic but approximately 5 percent are due to specific inherited mutations in the BRCA1 and BRCA2 tumor suppressor genes. (See Genetics of Breast Cancer)
  • Previous breast biopsy reports are important regarding presence of proliferative (cellular overgrowth) changes (i.e, sclerosing adenosis, papillomatosis, hyperplasia, atypical hyperplasia). These are benign diagnoses but they carry an increased risk of developing breast cancer. There appears to be a continuum of disease progression from proliferative changes to atypical hyperplasia to carcinoma in situ to invasive disease
  • The patient's description of self examination (See Breast Self Exam) such as presence of mass, pain, nipple discharge (especially bloody), enlarged lymph nodes, skin changes regarding breast and nipple and awareness of asymmetrical breast changes are important.
  • Breast and axillary (armpit) examinations are carried out in both upright and supine (lying) positions, Axillary and supraclavicular (above the collar bone) exam is better performed with the patient upright and breast exam is better performed with the patient supine (both should be done in each position)
    1. Upright inspection will detect breast asymmetry (common), skin dimpling (especially with arms raised), nipple retraction or inversion, excoriation, crusting of nipple, redness, presence of varicosities and previous surgeries
    2. Supine examination allows the examiner to begin the exam at a specific site and compress the breast tissue against the chest wall around the entire breast as if following the hands of a clock
    3. Nipple, axillary and supraclavicular exams are performed in both positions

Tests
Radiological Studies

  • Film-screen mammography
    1. Typically two views of each breast are imaged on X-ray film
    2. Does not always demonstrate solid or cystic masses
    3. Better images are obtained in post memopausal breast
    4. A spiculated irregular mass is suspicious of malignancy (Figure 5)
Figure5 - Mammogram showing a tumor. Courtesy C. Yutzy, MD
  • Digital mammography
    1. A newer test in which the image is stored electronically on disk and the image is able to be manipulated to enhance certain structures
    2. Has a similar sensitivity as film-screen mammography
    3. Does not always demonstrate solid masses
  • Ultrasound
    1. Excellent study to identify cystic masses
    2. Usually demonstrates solid masses but not always
    3. Good study for patients less than 30 years of age
  • Magnetic Resonance Imaging - indications for breast use are still being developed
  • Computed Tomography
    1. Has only a limited ability to identify small structures
    2. May require the injection of an X-ray contrast medium
  • Adjuvant Studies - Some patients will require various tests done before surgery to identify possible metastatic disease: chest x-rays, CAT Scans, radioisotope bone scans, X-ray survey of the bones and/or studies of liver function

Breast Biopsy Techniques

  • Fine Needle Aspiration (FNA)
    1. Performed with fine needle and suction technique usually on a palpable (can be felt) mass or with ultra sound guidance for a non-palpable mass
    2. A mammogram is frequently obtained before aspiration to evaluate the entire breast in the event of hematoma (blood clot) forming after aspiration and delaying subsequent mammogram
    3. If fluid is aspirated and is clear and the mass completely disappears, only a follow up breast exam is needed. Clear fluid is not routinely submitted for cytology (cell examination)
    4. If the fluid is bloody, then it is sent for cytology
    5. If the mass is solid, then multiple passes are made into the mass and the needle biopsy is sent for cytology. If cytology is indeterminate, suspicious or positive then additional tissue is needed to confirm either with core biopsy or surgical biopsy
  • Core Biopsy - excellent diagnostic procedure
    1. The procedure is carried out either by stereotactic needle biopsy with computer assistance and mammography, or (often simpler) ultrasound guided needle biopsy of solid masses
    2. Small solid cylinders of tissue are removed from solid masses or suspicious areas (e.g. microcalcifications)

Indications

  • All solid masses, suspicious areas and suspicious microcalcification must have a tissue diagnosis. All efforts are expended to make a tissue diagnosis before going to the operating room. The goal is to do a definitive procedure with one trip to the operating room
  • The type of surgery will be dictated by the biopsy report, which will include the type of tumor and degree of malignancy as determined by the pathologist, as well as the presence of DCIS or LCIS and most importantly the patient's preference

Procedures

  • Incisional Biopsy - a small portion of tumor (biopsy) is removed to make the diagnosis and the remainder is left behind. It is usually done in advanced inoperable situations
  • Excisional Biopsy - the mass is felt to be benign and is removed in its entirety. It is performed with a small circumareolar incision (incision along nipple complex) or incision over the mass, may require needle localization (Figure 6)
  • Lumpectomy
    1. The diagnosis of malignancy is usually made before the surgery
    2. The entire tumor plus a zone of surrounding normal tissue is removed (1-10 millimeters of normal tissue)
    3. For microcalcifications, the entire area plus a surrounding zone of normal tissue is removed
    4. The tumor may be palpable and not require ultrasound or needle localization. If not palpable then a fine wire or wires are placed near the tumor area under guidance with mammography (Figure 6) or ultrasound
    5. Microcalcifications require fine wire mammographic localization
    6. All wire localized specimens are tagged for orientation and a mammogram performed on the fresh tissue to see if the area in question is present with what appears to be adequate normal margins (Figure 7)
    7. Specimens that are not fine wire localized are tagged for orientation. All specimens are marked by the pathologist (usually with different colored dyes) to help accurately assess all tumor margins and determine the width of the tumor free zone
    8. The surgery is performed through small incisions over the site of the tumor or, if close to the nipple, circumareolar incisions may be used (Figure 8)
  • Sentinel Node Biopsy
    1. The sentinel node is the first node in the ipsilateral (same side) axilla to drain the tumor in the breast
    2. The sentinel node is located by injecting a blue dye or radioisotope into the breast tissue around the tumor or into the skin overlying the breast. The two methods may also be used together
    3. When a radioisotope is used a small incision is made in the axilla and a gamma probe is used to identify a hot spot which should represent the sentinel node. It is removed and checked for radioactivity. The axilla is again checked for background radiation and if the level did not fall sufficiently additional exploration is carried out to find the sentinel node
    4. When blue dye is used, it is followed in lymphatics until a blue lymph node can be identified and removed. Additional search is then made for more nodes
    5. There can be more than one sentinel node and most often more than one node is removed. Frequently the nodes will be both blue and hot. Radioisotope sensitivity is slightly greater than blue dye to date
    6. The sentinel node is then examined by the pathologist to see if tumor cells are present
    7. Clinical trials are under way to see if patients with negative sentinel nodes will require an axillary dissection. The standard today is to do axillary dissections in almost all invasive breast carcinoma. A new standard appears to be evolving but before it can be accepted the trials need to be completed
  • Axillary Dissection
    1. Axillary dissection is usually performed through a separate.) axillary incision
    2. Nodes that are lateral to the pectoralis minor muscle border (Level I nodes) and beneath the pectoralis minor muscle (Level II nodes) are routinely removed. (Level III nodes are medial to the pectoralis minor muscle)
  • Simple Mastectomy
    1. The entire breast including the nipple and much of the overlying skin is removed by incisions above and below nipple
    2. Axillary nodes are left intact
  • Skin Sparing Simple Mastectomy
    1. A smaller incision is made around the nipple complex with removal of the nipple and the entire breast
    2. Allows preservation of breast skin to enhance immediate reconstruction
  • Modified Radical Mastectomy - the entire breast and axillary nodes (Level I & II) are removed often through incisions above and below the nipple (Figure 9)
  • Radical Mastectomy - The entire breast, axillary nodes and pectoralis major muscle are removed. It is rarely performed today
  • Male breast cancers require a modified mastectomy
Figure 6 - Tumor localized by insertion of a fine needle. Courtesy C. Yutzy, MDFigure 7 - Tumor localization confirmed by mammography of the specimen. Courtesy C. Yutzy, MD
Figure 8 - Lumpectomy. Figure 9 - Modified radical mastectomy.

Post Operative Care

  • Most patients are discharged the day of surgery
  • The patient y may go home with a drain in the axilla or mastectomy site, which will be removed in the doctor's office in 2-5 days
  • Modified mastectomy or mastectomy with immediate reconstruction patients may require a few days in the hospital
  • Pain control is readily achieved with oral medications
  • Early ambulation (walking) is encouraged

Complications

  • Bleeding from the surgical site
  • Seroma - collection of fluid (lymph or serum) at the operative site
  • Wound infection
  • Possible skin slough at wound edges
  • Thrombophlebitis of the axillary vein
  • Numbness of the back of the upper arm usually due to sacrifice of a nerve to the skin (intercostal brachial cutaneous nerve)
  • Weakness of the latissimus dorsi or serratus anterior muscles due to compromise of the thoracodorsal or long thorasic nerves, rare
  • Arm edema (swelling) is common but usually mild
  • Limited range of motion of the shoulder. This occurs early after surgery, is limited and totally recoverable

Follow Up

  • Decision making after surgery will be based on the pathological and clinical staging (See Pathological Tumor Staging)
  • The patient may need radiation therapy, chemotherapy, endocrine therapy or chemoprevention
  • Follow up is life long with frequency dependent upon the pathology report and any associated recommended therapy
  • Follow up mammograms are extremely important along with clinical exams