Surgery.Breast

1) Clinical examination
2) Radiological assessment - mammo, USS
3) Pathological assessment - FNAC, core biopsy

1) Fibroadenoma
2) Fibrocystic change
3) Mastitis
4) Carcinoma (ductal/lobular)
5) Fat necrosis
6) Cyst (galactocele)
7) Abscess
8) Radial scar
9) Lipoma
10) Hamartoma

1) Firm/hard
2) Painless
3) >1cm (50% in upper outer quadrant)
4) Fixed (muscle invasion)

1) Tethering
2) Dimpling or retraction
3) Discoloration
4) Peau d'orange
5) Ulceration

1) Nipple retraction or inversion
2) Nipple discharge - blood stained
3) Nipple deviation, displacement, or depression
4) Paget's disease

- Unilateral
- Eczematous rash
- Red, encrusted & oozy skin
- Nipple ulceration and destruction due to squamous epith. infiltration by malignant cells
- Often an underlying lump

- Hot oedematous & red breast
- Does not settle with ABs
- Poor prognosis
- Assoc w/ widespread permeation of sub-dermal lymphatics

- Axillary (Level 1,2,3 medially) - 75%
- Parasternal / internal mammary
- Supraclavicular

Bone (Pain, #)
Liver (hepatomegaly, jaundice)
Lung (SOB)

Mastectomy:

1) Modified radical (Patey) mastectomy (most common):
- Breast + Nipple
- Axillary LN 1,2
- Pec minor partial

2) Simple mastectomy
- Breast + nipple

3) Radical (Halsted) mastectomy (male BrCa)
- Breast + Nipple
- All axillary LNs
- Pectoralis muscles

Breast conservation surgery (lumpectomy, segmental mastectomy)
- Standard procedure for smaller tumours (stage I, II)
- Tumor excision w/ 1cm margin + axillary clearance
- 2nd excision may be necessary if histo shows insufficient margins
- Increased risk of relapse, give XRT
- Better cosmetic result and less psych impact

Seroma
Bleeding - hematoma
Infection
Scarring & deformity
Necrosis - skin flap or nipple
Phantom breast syndrome

When?
- Non-palpable lesion detected on radiology
- Needle localisation biopsy

What?
- Targeted surgical removal
- Under USS or mammographic guidance
- Mammogram is taken with hookwire in-situ pre-operatively
- Excision is performed
- Radiology performed on hookwire specimin post-op to ensure good radiological margins

To ensure the lesion has been excised with good radiological margins.

Pectoral - Outer 2/3 of breast, upper 1/2 of trunk ANTERIORLY

Subscapular - Axillary tail, upper 1/2 of trunk POSTERIORLY

Lateral - upper limb

Central - receive pectoral, subscapular, lateral

Apical - receive central

Apical --> Subclavian --> supraclavicular --> throracic duct on R lymphatic trunk

- Stage tumour for prognosis
- Level 1: lower border of pec minor
- Level 2: upper border of pec minor
- Level 3: apex of axilla

- Axillary sampling = level 1
- Full axillary clearance
- Sentinel node biopsy = remove sentinal LN (primary draining node; ID w/ blue dye or technetium) - If sentinel node (+), remove remaining axillary LNs

- Bleeding
- Infection
- Lymphoedema
- Seroma
- Limitation of shoulder movement
- Nerve damage (thoracodorsal nerve=lat dorsi; long throacic nerve=winged scapula; intercosto-brachial nerve=chest wall)

- Stimulate nerves to identify (don't paralyse pt during op)
- Avoid intercostobrachial nerve in axilla
- Axillary drains to prevent seroma

Superficial:
- Abscess
- Sebacious cyst
- Lipoma

Deep
- Axillary artery aneurysm
- Breast lump in axillary tail

Lymphadenopathy
- Infection
- Metastases
- Lymphoma

1) Arm, breast, chest wall, abdominal wall
2) Surrounding LNs (cervical, supraclavicular, inguinal)
3) Hepatosplenomegaly (lymphoma, mets)
4) Circulation (Axillary art. aneurysm)

Inflammatory Cancer

- Hot, red, oedematous & red breast
- does not settle on antibiotics
- Poor prognosis
- Assoc w/ widespread permation of subdermal lymphatics

- Cellulitis
- Mastitis
- Abscess
- Paget's disease of the nipple
- Eczema

1) BrCa adjuvant - esp. ER+ tumours in post-menopausal women
2) Decrease risk of BrCa in high risk women (50% RR)
- Metastatic male BrCa

1) Anti-estrogen
2) Mixed agonist-antagonist effect (- breast, + lipids, endometrium, bone)
3) Inhibit estrogen-stimulated growth on Ca

- Decrease risk of MI
- Decrease osteoporosis

20-40 mg OD PO, 5y

- Menopausal Sx (nausea, hot flushes,vaginal dryness, irregular periods)
- DVT/PE
- Endometrial Ca
- Cataract
- Retinopathy