Breast Surgery Flashcards
(39 cards)
The Breasts - Gross Anatomy
The breasts consist of glandular and supporting fibrous tissue embedded within a fatty matrix.
They lie over the 2nd-6th ribs between the sternum and mid axillary line - the lateral continuation is called the axillary tail. The areola is the pigmented area around the nipple where lactiferous ducts emerge.
Divide the breast into 4 quadrants – lower outer and inner, upper outer and inner and tail of Spence.
Parts of the Breast
- Parenchyma – lactiferous ducts give rise to 15-20 gland lobules of milk secreting alveoli arranged in clusters. Lactiferous sinus – dilated portion of each duct where droplet of milk accumulates in lactation.
- Sebaceous glands – these secrete an oily substance to protect the nipple and the areola.
- Suspensory ligaments – these attach the mammary glands to the dermis and help to support gland lobules.
Breasts - Blood, Lymph and Nodes
- Blood supply - from medial mammary branches of the internal thoracic, lateral mammary branches of the lateral thoracic branch of the axillary artery and cutaneous branches of intercostal arteries.
- Lymph drainage – passes to subareolar plexus from which >75% drains to axillary lymph nodes and the remainder to the parasternal lymph nodes.
- Nerve supply – from the anterior and lateral cutaneous branches of the 4th-6th intercostal nerves.
Examination - General Inspection
- If the presenting complaint is a lump ask the patient to show you where it is.
- Ask patient to sit on the side of the bed with their arms on their thighs to relax the pectoral muscles.
- Ask the patient to press firmly on her hips to contract and relax pectoral muscles - repeat inspection.
- Also inspect with hands straight above head and leaning forward so that skin dimpling is exacerbated.
- Assess asymmetry, local swelling or skin changes of the breast and nipple changes or discharge
Inspection - Skin Changes
- Skin dimpling – the skin remains mobile over the malignancy.
- Indrawing of the skin – the skin is fixed to the malignancy.
- Lymphoedema – the skin is swollen between the hair follicles and looks like the peel of an orange = peau d’orange. This is caused by infection and often accompanied by erythema, warmth and tenderness. Investigate for malignancy any infection that does not respond to one course of antibiotics.
- Eczema of the nipple and areola – this may be part of a generalised skin disorder, due to Paget’s disease (only affects nipple) or invasion of epidermis by an intraductal malignancy.
Inspection - Nipple Changes
- Nipple inversion – retraction of the nipple is common – if benign it is usually symmetrical and slit like or if malignant it is usually asymmetrical, distorting or nipple pulled to the side.
- Nipple discharge – it may be clear, yellow, white or green in colour. Investigate persistent single duct discharge or blood stained discharge to exclude ductal ectasia, periductal mastitis, intraductal papilloma or intraductal malignancy.
- Galactorrhoea – a milky discharge from multiple ducts in both breasts due to hyperprolactinaemia. There is often hyperplasia of Montgomery’s tubercles – small rounded projections that cover the areola.
Gynaecomastia
Enlargement of the male breasts that often occurs in pubertal boys. In chronic liver disease gynaecomastia is caused by high levels of circulating oestrogens.
Examination - Palpation
- Ask to lie down (with one pillow) with the hand of the side of the breast to be examined above head – palpate the breast systematically and examine the axillary tail between your thumb and forefinger.
- Palpate or ask the patient to palpate the nipple and observe for any discharge – note the colour and consistency. You can test the nipple discharge for blood using urine testing sticks.
- Ask the patient to sit up – palpate regional LN while you support the full weight of her arm at the wrist – palpate axillary, supraclavicular and cervical nodes (warn patient before palpating the axilla).
Lumps - SPACE
- Size – should be accurately measured with a ruler to detect significant changes over time.
- Position – which quadrant of the breast tissue or the tail of Spence is the lump located in.
- Attachments – lymphatic obstruction causes skin fixation with fine dimpling at openings of hair follicles - peau d’orange. Also fixation to underlying muscles may occur in breast cancer - determine whether fixed by asking the patient to place her hands on her hips and contract and relax the pectoral muscles – if it is attached the lump will move as the muscle contracts
- Consistency – may vary from soft to stony hard – hard swelling are often malignant or calcified.
- Edge – may be well delineated or ill defined, regular or irregular and sharp or rounded.
Lumps - SPIT
- Surface and shape – may be smooth or irregular on palpation.
- Pulsations, thrills and bruits – arterial and highly vascularised swelling may be pulsatile.
- Inflammation – redness, tenderness and warmth – lipomas and skin metastases are painless.
- Transillumination – cystic swellings light up if the fluid is translucent and skin is not too thick.
Examination - Mets and Triple Assessment
- Metastases – palpate the liver for hepatomegaly and percuss the spine for bone metastases.
- Triple assessment – the clinical assessment, mammography (or US) and fine needle aspiration cytology.
Mastitis
Breast infections are uncommon but can occur during lactation where the organism (often staph aureus) gains access via cracks or fissures in the nipple or areola.
Without antibiotic therapy mastitis is followed by an abscess which may require surgical drainage.
Fat Necrosis
Local inflammation occurs following breast trauma.
Necrotic adipose tissue causes infiltration of inflammatory cells and leads to fibrosis producing a hard, irregular breast lump.
Ductal Ectasia
A completely benign condition where there is inflammation and dilation of the large ducts of the breast.
It usually presents with nipple discharge (this can be green, brown or can contain blood) but can also cause breast pain, a mass or nipple retraction.
Cytology of the nipple discharge will show proteinaceous material and inflammatory cells.
Fibrocystic Changes
Alterations in breast tissue (fibrosis, adenosis, cysts, epitheliosis and papillomatosis) which reflect normal albeit exaggerated responses to hormones.
It is very common and presents with generalised breast lumpiness which can show cyclical variation.
Fibroadenoma
A benign fibroepithelial neoplasm (growth) that commonly presents in young women aged between 20-30 years.
It presents as a small circumscribed mobile breast lump that is treated by ‘shelling out’ which is curative.
This is also known as a ‘breast mouse’.
Phyllodes Tumour
A potentially aggressive fibroepithelial neoplasm that usually presents as an enlarging mass in women over the age of 50 years.
The majority of these are benign but others may behave more aggressively. Some of these may arise in pre-existing fibroadenomas.
Intraductal Papilloma
Lesions of the mammary duct epithelium that may be solitary or multiple and usually occur in women aged between 40-60 years.
Solitary or central lesions are located in the larger lactiferous ducts near the nipple and often present with a watery orange or blood stained nipple discharge.
Peripheral lesions usually arise within small terminal ducts and can be clinically silent if they are small.
Malignant change is rare but carcinoma with papillary architecture is sometimes seen. Excision of the affected ducts will be curative.
Breast Ca - Epidemiology
Affects 1 in 10 women with 20,000 new cases per year in the UK – this is rising!
Breast Ca - Pathology
- Ductal carcinoma in situ (more common than lobular) is premalignant and causes microcalcification on mammography – 20-30% develop invasive malignancy in 10 years.
- Invasive ductal carcinoma is most common and accounts for 70% of cases whereas invasive lobular carcinoma accounts for 10-15% of malignancies.
- Medullary tumours (5%) affect younger patients whereas colloid tumours (2%) affect older patients.
Breast Ca - Risk Factors
Related to family history, age and uninterrupted oestrogen exposure – nulliparity, 1st pregnancy >30 years, early menarche, late menopause, HRT (million women study – small increase in risk), obesity, no breast feeding, oral contraceptive pill (when used for >4 years before the first pregnancy), previous breast malignancy or BRCA genes (40-80% risk).
Breast Ca - Presentation
With a lump, nipple discharge or inversion or skin changes e.g. peau d’orange.
Breast Ca - Triple Assessment
Performed for all lumps – clinical examination, ultrasound for <35 years or mammography and ultrasound for >35 year olds and histology (FNA) or cytology (core biopsy).
Ultrasound and Mammography
- Ultrasound – not useful screening tool for malignancy but excellent for detecting cysts.
- Mammogram – warn the patient it could be painful – the breast is compressed between 2 plates. The upper plate is made of clear Perspex and the one below contains the x-ray plate. Malignancy is characteristically a white asymmetrical speculate lesion containing micro-calcification.
- Mammography misses 7% of cancers but this rises to 12% in premenopausal women (dense breast tissue) – this is often lobular carcinoma.
