Breast surgery

Breast Surgery

1. BREAST SURGERY Faisal Azmi

2. Introduction Situation and deep relations Structure Blood supply Lymphatic drainage

3. Situation and deep relations Lies in superficial fascia of the pectoral region (except for tail) Axillary tail of Spence pierces the deep fascia & lies in the deep fascia Extent Vertically; 2 nd to 6 th ribs Horizontally; lateral border of sternum to the mid-axillary line Deep relations Pectoral fascia: the deep fascia which the breast lies on Muscles which lies deeper to the breast Pectoralis major Serratus anterior External oblique Retro mammary space: loose areolar tissue which separates the breast from the pectoral fascia

4. The skin Nipple Conical projection Just below the centre of the breast At the level of 4 th intercostals space Pierced by 15 to 20 lactiferous ducts Contains circular smooth muscles : make the nipple stiff Contains longitudinal smooth muscles : make the nipple flatten Has few modified sweat & sebaceous glands Rich in nerve supply Has many sensory end organs at the termination of nerve fibres Devoid of hair

5. The parenchyma glandular tissue 15 to 20 lobes each lobe is a cluster of alveoli drained by a lactiferous duct lactiferous ducts converge towards the nipple & open on it each duct has a dilation called a lactiferous sinus near its termination

6. The stroma Fibrous stroma Supporting framework of the gland Forms septa known as the suspensory ligaments of Cooper Anchor the skin to the pectoral fascia Fatty stroma Main bulk of the gland Distributed all over the breast; except beneath the areola & nipple

7. Blood supply Arterial supply : arteries converge on the breast & are distributed from the anterior surface; the posterior surface is relatively avascular Internal thoracic artery : through its perforating branches Some branches of axillary artery; Lateral thoracic artery Superior thoracic artery Acromiothoracic artery ( thoracoacromial artery) Lateral branches of the posterior intercostal arteries

8. Venous drainage : veins follow arteries; first converge towards the base of the nipple & form an anastomotic venous circle, from where veins run in superficial & deep sets The superficial veins drain into; Internal thoracic vein Superficial veins of the lower part of the neck The deep veins drain into; Internal thoracic vein Axillary vein posterior intercostal veins

9. Nerve supply Anterior & lateral cutaneous branches of the 4 th to 6 th intercostal nerves Convey sensory fibres to the skin Convey autonomic fibres to smooth muscle & to blood vessels Nerves do not control the secretion of milk (controlled by prolactin hormone)

10. Breast Anterior Posterior Central Lateral Apical Supraclavicular Posterior intercostal Parasternal Axillary 75% 20% 5% Bergs level Lateral and below the P.M(PAL) Behind the P.M (Central) Above and medial to P.M

11. FibroAdenoma Duct Ectasia Duct Papilloma Phylloides Tumour Breast Abscess Benign Breast Diseases

12. Fibroadenoma Simplex Young women Rubbery firm, smooth, very mobile mass Mostly a clinical diagnosis Early years after Menarche 16-25 years Overall incidence is highest in 30s and 40s Lobular in origin / Mostly remain static 1-3cm in size increase over 1-5 years Most common in left breast and upper outer quadrants.

13. Giant Fibroadenoma 30 % of all Fibroadenoma Greater than 6 cm Differential diagnosis with Phyllodes Tumor Confirmed via histology 4% are reported in pregnancy and lactating adenomas. Women on HRT has increased incidence.

14. Investigations Triple assesment Mammography Age above 35 Typical solitary lesion, Stippled calcification ( Popcorn Appearance)

15. Managment Overall Conservative. Reassurance Offer exicision i f >3cm / rapid increase Symptomatic Patients choice, patients satisfaction. Surgical- If within 3cm of nipple, periareolar incision. Alternative- Laser Ablation, Cryosurgery Hormonal- Tamoxifen . Not favored due to unwanted side effects.

16. Benign Duct Papilloma Discrete Duct papilloma- common Multiple duct papillomas -rare Discrete Papilloma  2-3mm diameter, grows along the length of duct, no pre malignant potential. Either observe or excise. Multiple Papilloma Involve peripheral ductules , premalignant potential, complete excision with healthy margins.

17. Duct Ectasia Dilatation of the ducts Leads to stagnation and accumulation of discharge May cause ulceration If Blood discharge- Duct excision Mx Microdochetomy Had Field operation( in case of multiple)

18. Duct Exicision

19. Breast Abscess

20. BREAST CANCER

21. CLINICAL ASSESSMENT Clinical assessment History Clinical Examination General Survey Local Examination of Breast Systemic Examination Inspection Palpation

22. MAJOR POINTS TO BE NOTED: Age L ump in breast : Mode of onset, duration, rate of growth Pain Breast or axillary changes Nipple: Retraction, Discharge Past history: H/O irradiation, cancers Personal history: Marital status, menstrual history Family history HISTORY TAKING

23. POSITIONS: Arms by her side Arms straight up in the air Hands on her hips (with and without pectoral muscle contraction) Arms extended forward in a sitting position leaning forward Semi recumbent position with head raised by 45° INSPECTION

24. MAJOR POINTS TO BE NOTED: Breast : Symmetry, Size, Shape, Edema ( peau d’ orange ), Any visible lump or fungation Skin : Retraction, Erythema, Ulceration Nipple : Retraction, Erythema, Ulceration, Discharge INSPECTION

25. In sitting, semi-recumbent and recumbent position Examination of all quadrants of the breast, along with the axillary tail Done with the pads of the middle 3 fingers; avoid grasping and pinching motion PALPATION OF BREAST

26. POINTS TO BE NOTED IN CASE OF BREAST LUMP: Temperature Tenderness Number Situation Size Shape Surface Consistency Margin Mobility or fixity of lump Fixity to skin, breast tissue, pectoral muscle and fascia, chest wall PALPATION OF BREAST

27. Assessment of axillary lymphadenopathy Patient’s arm is supported on the non examining arm of examiner to maintain relaxation Examination with pads of middle 3 fingers in a circular motion PALPATION OF AXILLA

28. INVESTIGATION OF BREAST CARCINOMA

29. TO CONFIRM THE DIAGNOSIS: Imaging Mammography USG MRI Biopsy FNAC Trucut biopsy INVESTIGATIONS

30. TNM staging Stage Tumor Node Metastasis Stage 0   Tis N0 M0 Stage I   T1 N0 M0 Stage IIA   T0 N1 M0   T1 N1 M0   T2 N0 M0 Stage IIB   T2 N1 M0   T3 N0 M0 Stage IIIA   T0 N2 M0   T1 N2 M0   T2 N2 M0   T3 N1 M0   T3 N2 M0 Stage IIIB   T4 N0 M0   T4 N1 M0   T4 N2 M0 Stage IIIC   Any T N3 M0 Stage IV   Any T Any N M1

31. BREAST CARCINOMA: PATHOLOGICAL CLASSIFICATION

32. Breast Carcinoma Carcinoma in situ Invasive Carcinoma Ductal Carcinoma in situ Lobular Carcinoma in situ Paget’s disease of the nipple Invasive ductal carcinoma Medullary carcinoma Mucinous (colloid) carcinoma Papillary carcinoma Tubular carcinoma Invasive lobular carcinoma Rare cancers (adenoid cystic, squamous cell, apocrine )

33. Ma s t ec t o m y

34. Ope r a ti v e p r oc e du r e s - Ma s t ec t o m y Simp l e ma s t ec t o m y . Mod i f ied r adi c al ma s t ec t o m y . B r ea s t c onse r v i n g su r g er y .

35. T o t a l o r s i m p l e m a s t e c t o m y : R e m o v al o f the e n ti r e b r ea s t ti ssue, No d i ssect i o n o f lymph node s o r r em o v al o f m usc le. Som e times adjace n t lymph node s a r e r em o v ed al ong with the b r ea s t ti s s ue.

36. P r e -ope r a ti v e mana g eme n t T ri p le a ssess m e n t. M e t a s t a ti c w or k up. R ou t i n e b l o o d i n v e s t i g a t i ons. P r e - ane s th e ti c e v al u a ti o n. C o n t r o l o f m ed i c al c ond i t i on s li k e d iab e t es and h yper t ens ion. Counse li n g and wri t t e n i n f orm ed c onse n t. P arts p r epa r a t i o n- nec k t o mid thi g h i nclud i n g pe lvic r egi o n , a x i l la and arm.

37. Ope r a ti v e p r oc e du r e Ane s the s ia Gene r al ane s thesia. P osit i on Th e p a tie n t is placed in sup i n e po s itio n with the ar m abduc t ed < 90 deg r e e . Sandbag or f o l de d sheet is placed und e r the tho r a x and sho u l der of a f f ec t ed side.

38. Ope r a ti v e p r ocedu r e s- Simp l e Ma s t ec t o m y In d i c a ti ons: S t a g e I and s t a g e IIa c a r cinoma La r g e c an c e r s th a t pe r s i s t a f t er adju v a n t the r a p y Mu lt i f o c al o r mu l tice n tr i c CIS. Inci sion: Ho r i z o n t al e l l i pti c al i nc i s io n is m ar k ed s o as t o i nc l ud e the e n ti r e a r eo l ar c ompl e x. S h ou ld b e 1 - 2 cm a w a y f r o m the tumor ma r gi ns. Sk in spar i n g i nci s i o n - if b r ea s t r e c on s tructi o n is planned T w o sk i n edg e s shoul d b e o f equ i v al e n t len g th Type of Incision ….....

39. Simple Ma s t ec t o m y-p r oc e du r e Ski n i nc i s i o n is de ep e ne d with el e c t r o - c au t e r y . A p lane b e t w een b r ea s t f a t a n d t he subc u t aneous f a t, s een as w h i t e f i b r ous p lane. D is sec t i o n is c arried in this p lane and f la p s a r e r ai s ed i n f eri o rly and super i or l y . Ideally t h i c kness of the f lap sh o u ld b e 7 - 10mm.

40. Simple Ma s t ec t o m y - p r ocedu r e E x t e n t o f dissection: Sup e ri or ly till cl a vicle, L a t e r ally till P .majo r l a t e r al bo r der Medially t o the st er na l bo r de r , and I n f er ior ly till i n f r a - mam m a r y f old B r ea s t t i ss u e al on g wi t h the pec t o r al f ascia ( c o n t r o v e r s ia l ) is dissec t ed f r o m the P .ma j o r .

41. Simple Ma s t ec t o m y-p r oc e du r e Ca r e mu s t b e t a k en t o li g a t e p er f o r a ti n g b r anches o f l a t e r al tho r aci c and a n t eri o r i n t e r c o s t al v esse l s . W oun d i rri g a t ed wi t h s t eri l e w a t er t o c r en a t e (shr i v el o r shr i nk) c ance r ou s cell s . Subcu t ane ou s ti s s u e is cl o s ed us i n g 00 a b sorbab l e i n t errup t ed sutu r es . S k in cl o se d us i n g 00 no n-a b sorbab l e m a t t r ess sutu r es o r us i ng s t aples.

42. M odi f i e d Ra d i c a l M a s t e c t o m y ( M R M ) : R em o v al of b r ea s t ti s su e and a xi ll a r y l ymph n odes. No r em o v al of p e c t o r al musc l e . • 3 Modification Patey’s Modified Radical Mastectomy: Pectoralis major muscle is preserved and Pectoralis minor removed + level III Scanlon’s Modified Radical Mastectomy: Pectoralis minor muscle is divided but not removed + Level III Auchincloss ’ Modified Radical Mastectomy: Pectoralis minor is retraced but not divided + Level 1, Level II Cleared but Level III are left Auchincloss ’ Modified Radical Mastectomy is widely practiced nowadays.

43. Ope ra ti v e p r oced u r e s - Modified r adi c al Ma st ec t o m y Ind i c a ti ons: E arly b r e a s t cancer (mo s t c om m o nly d one) R esidua l la r g e c ance r s th a t p e r si s t a f t er a dju v a n t the r a p y Mult i f o c al or mu l tice n tric d ise a s e. In c i s io n: Ob li qu e ell i p ti c al i nc is i o n angled t ow a r ds ax i l l a. S houl d i nc l ud e the e nti r e a r eo l ar c omp l e x and p r e v i ous s c a r s, if p r ese nt. Shoul d b e 1 - 2cm a w a y f r o m the tum o r ma r g ins. T w o sk in e d g es s houl d b e of equ i v ale n t len g th

44. M o dified r adi c al M a s t ec t o m y -p r ocedu r e P r ocedu r e till app r oach i ng a xi ll a is sam e as s imp l e ma s t ec t o m y . E x t e n t of d issecti o n : S u periorl y t i ll cl a v i cle, L at e r al l y ti l l a n t er i o r ma r gin of l a ti s s i mus do r s i . Medial l y t o the s t ernal bo r de r , and I n f er i orl y t i ll the c o s t al ma r gin nea r the i nse rt i o n o f the r ectus she a th.

45. M o dified r adi c al M a s t ec t o m y -p r ocedu r e Th e spec im e n i s r e t r ac t ed u p w a r d s and l a t e r al l y t o e xpose P .m i no r . Th e d i ssect i o n i s c o n ti nue d t o a x i ll a r y l y mph node clea r ance. Ca r e mu s t b e t a k en no t t o i nju r e medial pec t o r al ne r v e and v esse ls. Th e a x illa r y i n v e s ti n g f ascia is i nc i se d t o e xpos e the a x illa r y g r ou p o f l y mph nodes.

46. M o dified r adi c al M a s t ec t o m y -p r ocedu r e Th e i nt er- pe c t o r al ( R o t t er) g r ou p o f lym p h n o de s a r e r e m o v ed. The n d i s s ec t i o n c an b e d o n e either f r om medial t o l a t e r al o r vi s e - v e r s a . Th e l o o s e l a t e r al a r eo l a r ti ssu e in a x illa r y sp a ce is d i s s ec t ed t o e xpo se the a x illa r y v ei n. Th e i n v e s ti n g l a y er o f a x i l la r y v esse l s is c u t, the tri b u t aries a r e t r an s f i x ed a n d c ut. D is sec t i o n is c arried ou t l a t e r ally in c l udin g l a t e r al g rp ( l e v el I) of lymph n o des.

47. M o dified r adi c al M a s t ec t o m y -p r ocedu r e Th e l e v el II l y mph node s b e t w een superi o r trun k of i n t e r c o s t ob r anch i al bundle and a xil l a r y v ein a r e r em o v ed. Th e ce n t r al grp o f l y mph node s a r e r em o v ed c a r e ful l y se pa r a ti ng f r o m a xil l a r y v e i n and its tri bu t ari es. Wh i le dis s ect in g mediall y , lon g tho r aci c ne r v e is en c ou n t e r ed, wh i ch li e s a nt eri o r t o t h e su b s c apu l ar musc l e. Th e dis s ect io n c arried out a nt eri o r and medial t o lon g tho r aci c ne r v e and the s pec imen del i v e r ed.

48. M o dified r adi c al M a s t ec t o m y -p r ocedu r e Ca r e mu s t b e t a k en whi l e d i s secti ng i n a xi ll a r y a r ea t o p r ese r v e, Medial and l at e r al pe c t o r al ne r v e. Lon g tho r acic v es s e l s and ne r v e Ne r v e t o l a ti s s i m us do r s i . Axi l lary v e i n. W oun d irri g a t ed with st er ile wa t er t o shri nk / c r en a t e c ance r ous c e lls. 2 d r ai ns , 1 be l o w and o ther ab o v e P .majo r a r e se c u r ed. Sub c u t ane ous ti ssu e is close d usi ng 00 a b so rbab l e i n t er ru p t ed sutu r es. Sk in close d usi ng 00 non - a bso rbab l e m a t t r ess sutu r es or usi ng st apl e s.

49. P o s t -ope r a ti v e c a r e W o u n d e x ami ne d o n p o s t -o p d a y 3. D r ain c an b e r em o v ed when it is < 30ml. A n y c o l lect io n is t o b e aspi r a t ed under ase p tic p r e c auti ons. S t apl e s c an b e r em o v ed af t er 1 d a y s. Arm m o v eme n ts st ar t ed i n the 1 s t w e e k.. Acti v e sho u l der and upp e r limb e x e r ci se s a r e st ar t ed f r o m 2 w e e k s

50. Other T ypes o f ma st ec t o m y 3. Hal st ed ’ s Radi c al Ma s t ec t o ŵ y: Mo s t e x t ens i v e type. • B r ea s t ti ssue , a x i l la r y lym p h n o de s and p e c t o r al m u sc les a r e r e m o v ed. D i s ad v a n t a g es: Bad s c a r s and u nac c e p t able de f orm i t y . R ed uce d r ange o f mob i l i ty o f s hou l d er

51. T ypes o f ma st ec t o m y 4. Su b cu t aneous m a s t ec t o m y: S imple ma s t ec t o m y sp a ri n g n i pp le. • Ra r ely done , as a la r g e amou n t of b r ea s t ti ssu e is l e f t in s itu. Skin s p aring ma s t e c t o m y: T o t al / s i mp l e ma s t ec t o m y or m od if i ed r adi c al ma s t ec t o m y w i th p r es e r v a ti o n o f as much as b r ea s t sk i n as poss i b le neede d f o r b r ea s t r e c on s tructi on. Lo c al r ecur r ence is ac c e p t able, - 3%. B r ea s t conse r ving su rg e r y: Wi d e l o c al e x ci si on/Lumpec t o m y Qua d r a n t ec t o m y .

52. Bre a st conser v ing surgery Ind ica tio ns: S t a g e ( C IS), S t a g e I, S t a g e I I a b r ea s t Si ngle lesi on . c a r cinoma. M e thod: Wi d e l o c al e x ci si on/Lumpec t o m y or Qua d r a n t ec t o m y + a xi ll a r y l ymph n o de cl e a r ance + r adio t he r a p y .

53. T ypes o f ma s t ec t o m y 7 . T o i l e t ma s t ec t o m y: Don e in fun g a tin g or ulce r a ti v e g r owths. P all i a ti v e s imple ma st e c t o m y .

54. Bre a st conser v ing surgery Ad v a n t a g es: Mai nt enance o f appea r an c e and fu ncti o n o f b r ea s t. D ise ase f r ee i nt e r v al is sam e as MRM. B e tt er qua l i ty of l i f e and p s y ch o l ogi c al ad v a n t a g e . Co n t r aind i c a ti ons: Mult i ce n tric tum o r . P os it i v e ma r g i ns af t er e x ci sion. S i z e > 4cm ( r el a ti v e). Ad v anced s t a g es. No as s e s s t o r adi atio n/ po o r p a tie n t c o m p l i ance. C/ I f or r adi atio n : S LE/ Rh e um a t o i d arthriti s / Scle r oderma/ p r egnan c y/ prio r che s t r adi a tion.

55. Brea s t cons e rv i ng surge r y -P r ocedur e • R eshap in g o f b r ea s t ti s s u e is done Inci s i o n- ci r cular/ r adial/ suba r eo l ar inc isi o n near t o the tum o r , about 3- 4cm. E x ci si o n of the c a r cinom a ti s s u e with a ma r gin of a tlaea s t 1cm of norma l b r ea s t ti s s u e t o g et a 2 - mm c ancer -f r ee ma r gi n. If tumor is s i tu a t ed superfic i a l ly then e x ci s io n of th a t part of sk i n. If tumor is deep then tumor is e x ci se d ti l l pe c t o r al i s maj o r . Depend i ng o n p o s t -su r gi c al d e f ect P r i m a r y cl osu r e or

56. Brea s t cons e rv i ng surge r y -Lumpecto m y Af t er sk in i n c i s i o n , subcu t ane o u s ti ssu e is deepene d us i n g e l ec t ric c au t e r y . • Skin with subcuticu l ar 3 - a bsorb able sutu r es. Wh i le d i s sect i n g the b r ea s t ti ssue , b e t t er t o us e s c al pe l. C a r e m u s t b e t a k en w h ile d i s s ec t i n g t o pa l p a t e the tu m o r , s o th a t e n ti r e le s i o n is e x ci sed . Spec i m en r adi o g r ap h y c an b e d o n e t o ch e ck f or c lear ma r gi ns. Hemocli p s a r e app l i e d al on g t h e ma r gi n s o f the ca vit y . W o un d cl o s ed in 2 l a y e r s: S ubcu t an e ous tissu e with i n t erru p t ed i n v er t ed 3 - a b sorbable sutu r e . 136

57. Brea s t cons e rv i ng surge r y -P r ocedur e Quad r a nt ec t o m y: Usua l ly don e f or lesi o n in t h e uppe r o u t er and i nne r l o w er quad r a n ts. Radial i n c i s i o n is t a k en. E n ti r e b r ea s t ti ssu e in t h a t quad r a n t is e x c ise d ti l l p e c t o r al f asc i a. W o un d cl o s ed in mu l t i p le l a y e r s: B r e a s t tis su e w i th i n t erru p t ed 3 - a b sorbable sutu r e. S ubcu t an e ous tissu e with i n t erru p t ed i n v er t ed 3 - a b sorbable sutu r e. Skin with subc ut icular 3 - a b sorbable sutu r e.

58. Brea s t cons e rv i ng surge r y Quad r a n t ec t o m y v / s Lu m pec t o m y . Lump e c t o m y has mo r e l o c al r ec ur r ence ri sk. Lumpec t o m y has be t t er c o s m e tic o u t c ome.

59. Brea s t cons e rv i ng surge r y Af t er BCS, r ad iothe r a p y is esse n t i al, otherw i se the lo c al r ecur r ence r a t e i s unaccep t ably h i gh W i thout r adi oth e r a p y , the lo c al r ecur r ence c an b e as h i gh as 40%

60. Breast reconstruction surgery The most common reason of breast reconstruction surgery, is for psychological well being. Reconstructive surgery post mastectomy can be either immediate or delayed. Immediate Skin sparing Better outcomes Delayed When immediate reconstruction is contraindicated. Other reconstructive options

61. Breast reconstruction surgery Types: Latissimus dorsi myocutaneous flap. Transverse rectus abdominus myocutaneous (TRAM) flap.

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