Breast surgery

         BREAST MASSES

1. A cyst is a regular, firm or fluctuant, mobile mass that may be tender.
2. A fibroadenoma is smooth, firm, elongated, and mobile with discrete borders.
3. Fibrocystic changes are "lumpy-bumpy" breast tissue.
4. Carcinoma is an irregular, hard, painless mass.

·         DCIS is considered a preinvasive malignancy. It is treated surgically with lumpectomy or mastectomy, with or without radiation therapy, similar to how invasive breast cancer is treated.

By contrast, LCIS is viewed as a risk factor for the development of subsequent breast cancer and is generally not thought to be "cancer" per se. LCIS does not require surgery.

LCIS is best thought of as a precursor lesion that confers increased risk for eventual cancer. The magnitude of this risk appears to be in the range of seven- to ninefold over baseline risk. The chance of breast cancer is equal in both breasts, not just in the biopsied breast, and the type of cancer is not confined to a lobular histology. After a diagnosis of LCIS, patients are at increased risk for invasive and noninvasive ductal carcinoma in both breasts. Therefore, mirror-image biopsy as practiced in the past has little to offer. Since LCIS is purely noninvasive, nodal dissection is not required if mastectomy is chosen. There are no data on the use of breast radiation therapy for LCIS. Most surgical oncologists recommend close follow-up for patients who have LCIS only; the alternative surgical treatment that makes most sense is bilateral simple mastectomies, with or without reconstruction.

·         Nipple discharge is surgically significant when it is grossly bloody and when it appears at a single duct orifice on one nipple. Bloody discharge is usually due to a benign intraductal papilloma; however, intraductal carcinoma in the large ducts under the nipple can be the cause of bloody discharge, and pathologically the lesion is frequently a large papillary tumor that has become malignant. Paget's disease of the nipple is also due to intraductal carcinoma arising in subareolar ducts, but it rarely is associated with nipple discharge. Subareolar mastitis may produce nipple discharge, but it is purulent and not bloody. Inflammatory carcinoma is not associated with nipple discharge.

·         Intraductal carcinoma refers to a malignancy of ductal origin that remains enclosed within duct structures. This noninvasive proliferation can undergo central necrosis, which frequently calcifies to form the microcalcifications seen on mammography. The central necrosis within enlarged and back-to-back ductal structures resembles comedoes and gives rise to the term “comedocarcinoma,” now reserved for this histologic variety of intraductal carcinoma.

·         REDUCTION MAMMAPLASTY can be performed at any age. Because of the increased weight of the breast considerable shoulder and back pain, accompanied by excoriation of the skin in the inframammary area and the shoulders, can occur. Older women frequently seek relief from these problems, which can be resolved by a reduction mammaplasty. The reduction in breast volume is usually accomplished by moving the nipple and areola on a dermal pedicle flap. The flap can be based inferiorly, medially, superiorly, laterally, vertically, or horizontally. It is possible to remove up to 3000 gm. of breast tissue utilizing a pyramidal-based breast flap with an inferior dermal nipple-areola pedicle since the blood supply to the tissues is preserved by this technique. Breast reduction involving removal of more than 3000 gm. requires a breast amputation technique with immediate free nipple grafting.

·         METASTATIC DISEASE FOLLOWING PRIMARY THERAPY FOR BREAST CANCER can recur at any time. However, of those who relapse, 50% to 70% do within two years and over 85% relapse within five years. More than 70% of recurrences are distant, but anywhere from 10% to 30% of recurrences are local. Bone and lung are the most common initial sites of distant relapse (50% and 25%), respectively. A breast-conserving procedure can be associated with a local tumor recurrence rate. The rate of local recurrence falls from 40% to 10% if postoperative radiation therapy is given to the entire breast. Despite potentially curative resection, at least 20% of node-negative and 60% of node-positive breast cancer patients have recurrence of their disease at some time after surgery.

·         There are four inherited syndromes associated with the development of breast cancer.

1.       The Li-Fraumeni syndrome has an autosomal dominant mode of inheritance. The syndrome is attributed to mutations in the p53 tumor suppressor gene, a gene that codes for a protein that serves as a G1-S checkpoint regulator of the cell cycle.

2.       More recently, a mutation has been characterized on the short arm of chromosome 2 in a gene associated with DNA repair. Predisposition to a wide range of malignancies, including breast and colon cancer is associated with abnormalities at this locus.

3.       The most exciting development in inherited susceptibility to breast cancer relate to the identification and cloning of the BRCA 1 gene, which was initially localized on the long arm of chromosome 17 by linkage analysis. Germline abnormalities in BRCA a may be responsible for as many as 5% of all breast cancers in the United States. The gene is characterized by autosomal dominant inheritance with a high degree of penetrance. Almost 60% of women inheriting the gene will develop breast cancer by age 50, and a lifelong risk approaches 85%.

4.       Another breast cancer susceptibility gene, dubbed BRCA 2, has been localized by linkage analysis to a small region of chromosome 13q12-13. BRCA 2 apparently confers the high-risk of early onset female breast cancer. Similar to BRCA 1, the lifetime breast cancer risk approaches 90% in carriers of this gene.

·         Mastodynia patients should be advised to eliminate caffeine beverages for a period of 2 to 3 months to determine if there has been improvement in their symptoms. In addition to caffeine abstention, patients should be urged to stop smoking because nicotine is purported to worsen mastodynia. A number of medications have been advocated for the treatment of mastodynia. Unfortunately, because of the subjective nature of the disease and its propensity to be better tolerated by patients with reassurance, the exact method of most of these interventions is unclear. Vitamin E has been touted as beneficial, however, clinical data do not support the use of this or other vitamins for this condition. The use of hormonal agents to treat mastodynia has been more extensively treated. Danazol, a weak antigen, is the most effective drug available for treatment of mastodynia related to fibrocystic disease. Unfortunately, Danazol’s androgenic side effects are troublesome enough to restrict its use to the most problematic cases of mastodynia. Other hormonal agents have been investigated for the management of mastodynia. In young women, oral contraceptives have a variable effect on mastodynia. A trial and error search for optimal preparations may be necessary as the effect of oral contraceptives is dependent on the formulation of the pill.

·          Cystosarcoma phyllodes is a tumor arising in the mesenchymal tissue of the breast. The tumors usually present as a painless breast mass. Phyllodes tumor is most commonly encountered in women age 30–40 years of age but can occur at any age, even before puberty. The differentiation of a benign from a malignant phyllodes tumor may be difficult. About one-fourth of all phyllodes tumors are histologically malignant, but only a fraction of these patients actually develop metastatic disease. The optimum treatment for benign or malignant phyllodes tumor is wide excision with a margin of normal breast tissue. The margin must be histologically free of involvement because even benign lesions can recur after incomplete excision. If this can be done leaving an adequate cosmetic appearance, mastectomy is not necessary. Total mastectomy is reserved for large lesions in small-breasted women or recurrences after previous local excision that is not amenable to repeat local excision. Axillary lymph node dissection is not performed in the absence of biopsy-proven nodal involvement, even for malignant phyllodes tumors, because axillary metastases are uncommon.

·         Sclerosing adenosis is a histologic subtype of fibrocystic change that is not associated with an increased risk of cancer development. It is, however, one of the benign breast processes most likely to be confused radiologically and histologically with cancer. Most commonly, it is detected on routine mammography as cluster microcalcifications without an associated palpable mass. In these cases, needle localization and excision are required to establish a diagnosis. Sclerosing adenosis microscopically is characterized by interlobular fibrosis and proliferation of small ductules. If the fibrous component is particularly intense, the orientation of lobules and epithelial cells may be lost, mimicking carcinoma. Differentiating sclerosing adenosis from cancer on frozen-section examination can be particularly difficult and should not be attempted.