Ashli’s Surgery Notes

THE BREAST
EMBRYOLOGY
During the fourth week of gestation, paired ectodermal thickenings termed mammary ridges or milk lines
develop on the ventral surface of the embryo and extend in a curvilinear fashion convex towards the
midline from the axillae to the medial thigh. This is the first morphological evidence of the mammary
gland development.
In normal human development, these ridges disappear except at the level of the fourth intercostal space on
the anterior thorax, where the mammary gland subsequently develops.
During the 5th week of gestation, the remnant of the mammary ridge ectoderm begins to proliferate and is
termed the PRIMARY MAMMARY BUD.
During the 7th week, the primary mammary bud subsequently begins growth downward as a solid
diverticulum into the underlying dermis.
By the 10th week, the primary bud begins to branch.
By the 12th week, secondary buds are yielded, which eventually develop into the mammary lobules of the
adult breast.
During the remainder of gestation, the buds continue lengthening and branching.
During the 20th week, small lumina devlop within the buds that coalesce and elongate to form
LACTIFEROUS DUCTS. The canalization of the mammary buds with the formation of lactiferous ducts
if induced by placental hormones entering the fetal circulation. These hormones include: progesterone,
GH, insulin-like growth factor, estrogen, prolactin, adrenal corticoids, triiodothyronine.
At term approximately, 15-20 lobes of glandular tissue have formed, each containing a lactiferous duct.
Support of the breast comes from both the skin envelope and the fibrous suspensory ligament of Astley
Cooper that anchor the breast to the pectoralis major fascia.
The lactiferous ducts drain into retroareolar ampullae that converge into a depressed pit in the overlying
skin. Each of the 15-20 lobes of the mammary glands has an ampulla with an orifice opening into the
mammary pit. It is stimulated by inward growth of the ectoderm, the mesoderm surrounding the area
proliferated creating the nipple with circular and longitudinally oriented smooth muscle fibres. The
surrounding areola is formed by the ectoderm during the fifth month of gestation. The areola also contains
other epidermal glands, including Montgomery (sebaceous glans that serve to lubricate the areola).

During pregnancy, alveoli bud off and form smaller ducts and the organ usually enlarges; and
more so in preparation for lactation. When lactation ceases, there is involution of secretory tissue.
After menopause progressive atropy of lobes and ducts take place.
 Ashli’s Surgery Notes

ANATOMY
Also known as the mammary gland, it lies in the subcutaneous tissue (superficial fascia) of the anterior
thoracic wall.
The protuberant part of the human breast is generally described as overlying the second to the sixth ribs
and extending from the lateral border of the sternum to the anterior axillary line. Actually, a thin layer of
mammary tissue extends considerably further, from the clavicle above to the seventh or eighth ribs below
and from the midline to the edge of the latissimus dorsi posteriorly. This clinical relevance of this is when
you perform a radical mastectomy, the aim of which is to remove the whole breast. Inferior to the breasts
lie four muscles: pectoralis major, serratus anterior, rectus abdominis and the external oblique.
The axillary tail of spence of the breast is of surgical importance, extends up medial wall of axilla. In
some normal subjects it is palpable and, in a few, it can be seen premenstrually or during lactation. A
well-developed axillary tail is sometimes mistaken for a mass of enlarged lymph nodes or a lipoma.
There are 15-20 lobes of the mammary gland.
The lobule is the basic structural unit of the mammary gland. The number and size of the lobules vary
enormously: they are most numerous in young women. From 10 to over 100 lobules empty via ductules
into a lactiferous duct, of which there are 15–20, each draining a lobe of the breast, converging in a radial
direction to open individually on the tip of the nipple. Each lactiferous duct is lined with a spiral
arrangement of contractile myoepithelial cells and is provided with a terminal ampulla, a reservoir for
milk or abnormal discharges.
LOBES—LOBULES---DUCTULES----LACTIFEROUS DUCT
The nipple is covered by thick skin with corrugations. Near its apex lie the orifices of the lactiferous
ducts. The nipple contains smooth muscle fibres arranged concentrically and longitudinally; thus, it is an
erectile structure, which points outwards.
The areola contains involuntary muscle arranged in concentric rings as well as radially in the
subcutaneous tissue. The areolar epithelium contains numerous sweat glands and sebaceous glands, the
latter of which enlarge during pregnancy and serve to lubricate the nipple during lactation (Montgomery’s
tubercles).
The ligaments of Cooper are hollow conical projections of fibrous tissue filled with breast tissue; the
apices of the cones are attached firmly to the superficial fascia and thereby to the skin overlying the
breast.
CONNECTS SUPERFICIAL FASCIA TO SKIN—SO CAN TELL YOU IF A MASS IS
ATTACHED TO THE SKIN ITSELF
These ligaments account for the dimpling of the skin overlying a carcinoma. There is superficial fascia
behind the breast (upward continuation of the membranous layer of superficial abdominal fascia of
Scarpa) is condensed to form a posterior capsule. Strands of fibrous tissue (forming the Suspensory
ligaments of Cooper) connect the dermis of the overlying skin to the ducts of the breast and its fascia.
They help to maintain the protuberance of the young breast; with the atrophy of age, they allow the breast
to become pendulous, and when contracted by the fibrosis associated with certain carcinomas of the
breast they cause dimpling over the skin. They also cause pitting of the edematous skin that results from
malignant involvement of dermal lymphatics (an appearance of peau d’orange). Between the capsule and
the fascia over pectoralis major is the loose connective tissue of the retromammary space.
 Ashli’s Surgery Notes

What causes peau d’orange?

A swollen or pitted surface overlying a carcinoma of the breast in which there is both stromal infiltration
and lymphatic obstruction with edema.
Analysis: this is caused by thromboemboli deposition within the lymphatic system from the malignancy
that causes dilation and blockage of drainage of lymphatic fluid and eventually leaking of fluid resulting
in an abnormal collection of fluid in the interstitium. This causes inflammation within that surrounding
region.
The lymphatics of the breast drain predominantly into the axillary and internal mammary lymph nodes.
The axillary nodes receive approximately 85 per cent of the drainage and are arranged in the following
groups:
•Lateral/Humeral, along the axillary vein
•Anterior, along the lateral thoracic vessels
•Posterior, along the subscapular vessels
•Central, embedded in fat in the centre of the axilla
•Interpectoral, a few nodes lying between the pectoralis major and minor muscles
•Apical, which lie above the level of the pectoralis minor tendon in continuity with the lateral nodes and
which receive the efferents of all the other groups.
Boundaries of the axilla: pyramidal in shape
Superior: outer border of first rib, superior border of scapula , posterior border of clavicle.
SURGICALLY: the extent of the axillary vein.
Floor/base: skin (visible surface over axilla)
Anterior: pectoralis major (lower border forms anterior axillary fold), pectoralis minor, subclavius
Posterior: subscapularis above and teres major and latissimus dorsi below (posterior axillary fold)
Medial: Serratus anterior and rib cage
Lateral: intertubercular sulcus
Contains: axillary vein and artery, brachial plexus, fat and lymph nodes
The apical nodes are also in continuity with the supraclavicular nodes and drain into the subclavian lymph
trunk, which enters the great veins directly or via the thoracic duct or jugular trunk. The sentinel node is
defined as the first lymph node draining the tumour-bearing area of the breast. The internal mammary
nodes are fewer in number. They lie along the internal mammary vessels deep to the plane of the costal
cartilages, drain the posterior third of the breast and are not routinely dissected although they were at one
time biopsied for staging.
Surgical Classification of the breast lymph nodes
Demarcated by the pectoralis minor muscle. Level one is any nodes inferior and lateral. Level two is any
nodes deep to pectoralis minor. Level three is any nodes superior and medial.
 Ashli’s Surgery Notes

Note: Male breast resembles rudimentary female breasts and has no lobules or alveoli. The small nipple
and areola lie over the fourth intercostal space.
Nerve Supply: mainly by branched of the 4th through 6th intercostal nerves, which convey sensation to the
skin of the breast and sympathetics to the blood vessel and smooth muscle cells in the overlying skin and
nipple.
Note: Although not intimately involved with the innervation of the breast, the long thoracic,
thorocodorsal and intercostobrachial nerve are important to visualize as they cross through the anatomic
spaces of the breast and axilla, and those important to consider during dissection.
Blood Supply:
Internal thoracic (mammary) arteries arising from subclavian artery
Lateral thoracic arteries (external mammary artery) arising from axillary artery
Thorocoacromial arteries arising from axillary artery
Posterior intercostal arteries arising from thoracic aorta
Venous Drainage:
Mainly by the Axillary vein
Also aided by: subclavian, intercostal, internal thoracic veins

Lymphatic Drainage:
75% passes to axillary lymph nodes, mainly to the anterior nodes along lateral thoracic vessels although
drainage to central or apical nodes are possible.
The remainder drains to either parasternal nodes along the internal thoracic artery or the opposite breast
(medial quadrants) or the inferior phrenic nodes (lower quadrants)
With the exception of the nipple and areola, the lymph from the skin of the breast drains into the axially,
inferior deep cervical, infraclavicular and parasternal nodes (depending on the location of the vessel).
Ashli’s Surgery Notes
 Ashli’s Surgery Notes

HISTORY OF BREAST DISEASE

- Age
Young women will only very rarely have cancer, but over the age of 70, most breast lumps turn
out to be malignant.

- Menstrual Pattern
What is the menstrual pattern? (regularity, duration and quantity of bleeding)
Breast symptoms which alter with menstrual cycle are highly likely to be associated with benign
disease.
Age of menarche, women who reach menarch younger than 11 years have a 20% increased risk
of breast carcinoma. Late menopause also increases risk (time period exposed to hormones)

- Previous pregnancies
How many children have you had?
Age of First Live Birth, women who experience a first full term pregnancy at ages younger than
20 years have half the risk of nulliparous s women over the age of 35 at their first birth. It is
hypothesized that pregnancy results in terminal differentiation of milk producing luminal cells,
removing them from potential pool of cancer precursors. Not a strong risk factor for African
American women.

Were they breast-fed, if so for how long?

Parity and breast-feeding reduce the incidence of breast cancer: a mother of five who fed all her
children is less likely to have breast cancer than a nulliparous woman of the same age.

- Family History
First-Degree Relatives with Breast Cancer, risk increases with number of affected relatives
especially if cancer occurred at young age. 13% of women with breast cancer have one affected
first degree relative, only 1% have two or more.
Most family risk is probably due to interaction of low-risk susceptibility genes and nongenetic
factors. The BCRA1 or BRCA2 genes.

- Atypical Hyperplasia
A history of previous biopsies, especially if revealing atypical hyperplasia, increases risk of
invasive carcinoma.

- Race/Ethnicity
Non-hispanic white women have the highest rates of breast cancer.

- Medication (Drug History)

Is the patient taking drugs containing female sex hormones? (Estrogen Exposure)
Oral contraceptives commonly reduce the severity of cyclical changes in the breasts. Hormone
replacement therapy taken by menopausal and post-menopausal patients extends the age at which
they are likely to suffer from benign conditions such as breast cysts; progesterone increases risk
further.
 Ashli’s Surgery Notes

- Breast Density
This is correlated with young age and hormone exposure, and clusters in families. May be related
to less complete involution of tubules at the end of each menstrual cycle, which in turn may
increase the number of cells that are potentially susceptible to neoplastic transformation. Also
makes detection on mammogram more difficult.

- Radiation Exposure
Radiation to the chest, whether due to cancer therapy, atomic bomb exposure, or nuclear
accidents result in higher rate of breast cancer. The risk if greatest with exposure at young ages
and with high radiation doses.

- Carcinoma of the Contralateral Breast or Endometrium

Approximately 1% of women with breast cancer develop a second contralateral breast carcinoma
per year.

- Geographic influence
Incidence in USA and Europe are 4-7 times higher than in other countries.

- Diet
Caffeine may decrease the risk.
Moderate of heavy alcohol consumption increases the risk.

- Obesity
Decreased risk in obese women younger than 40 as a result of anovulatory cycles and lower
progesterone levels late in the cycle.
Postmenopausal obese women has increased risk.

- Exercise
Decreased risk greatest in premenopausal women, women who are not obese and women who
have had full term pregnancies.

- Breastfeeding
Longer breast fed reduces risk

- Environmental toxins
Organochlorine pesticides have estrogenic effects on humans.

- Tobacco
Associated with development of periductal mastitis.

- Mental attitude
Patients often fearful of consequences of breast lumps and hide their symptoms with an
impressive degree of self-delusion.
EXAMINATION OF BREAST DISEASE
1. Introduce Self
 Ashli’s Surgery Notes

2. Expose Adequately
Top half of trunk
3. Inquire about pain
4. Position
Fully undress patient to the waist, ensure upper body is raised at 45 degree angle to the legs. Ask
patient to face you.
Note: patients sometimes say their lump can only be felt when they adopt a certain posture,
examine them in this position as well.
5. Inspection
Examiner: stand or sit directly infront of the patient, inspect both breasts for the following
features:

Size

Symmetry:
It is quite normal for there to be difference between sides

Scars
Previous biopsy
Previous surgery

Skin:
Puckering
Peau d’orange - carcinoma
Nodules
Discolouration
Ulceration

The nipples and areolae:

- Colour of areolae and nipples- changes with age and pregnancy as there is darkening
- Nipple Retraction
Make note of if areolae is inverted or everted. The nipple may be inverted. Is this bilateral, and
does it display the transverse slit pattern seen in duct ectasia? There may be evidence of fluid
leaking from the nipple, or there may be eczematous skin changes as in Paget's disease.
- Cracked Nipple
- Nipple Discharge

Duplication:
Ectopic breast tissue
Accessory nipples

Ask patient to slowly raise her arms her head:

 Ashli’s Surgery Notes

Suspensory ligaments of cooper attaches superficial fascia to skin, so if a mass in attached to the
skin it will be pronounced upon raising the hands. When relaxed the ligament of cooper are more
widely spaced, when tensed (hands above head), they become taut.

Skin changes may become more apparent, particularly tethering to a carcinoma. Exposure of the
underside of the breasts in an obese patient with large breasts may reveal intertrigo(irritant
dermatitis).

Ask patient to press her hands against her hip to tense the pectoral muscles:
May reveal a previously invisible swelling.
Mass attached to muscle is more predominant in this position

Axillae, arms and supraclavicular fossae:

Grossly enlarged lymph glands may be visible, and distended veins or arm lymphedema may be
obvious

6. Palpation

Ask patient to lay flat and put their hand behind their head, to expose breast and axilla.

Use the flat of fingers and not with the palm of the hand (fingers are far more sensitive). Use both
hard, one to stabilize and other to palpate

Feel normal side first

Feel axillary tail (lies over anterior axillary fold)

If a lump is felt:

Ascertain:
Site
Use quadrants or clock face

Colour

Tenderness

A cyst commonly presents with pain and tenderness

Temperature
Due to inflammatory process

Shape
Regularly
Irregularly
 Ashli’s Surgery Notes

Carcinoma may grow into any shape, in early stages roughly spherical
Fibroadenomata usually spherical or ovoid, sometimes lobulated
Cyst is usually spherical

Size
Length
Width
Depth

Cysts may be large and visible and may appear blue green through skin, there will never be
tethering or fixation to skin

Surface
Smooth- cystic swellings, fibroadenomata
Irregular (indistinct)- carcinoma
Lobular
Nodular

Edge
Well-circumscribed and regular- most benign swelling, fibroadenomata (definite)
Well-defined and irregular- malignant swellings
Diffuse and ill-defined- inflammatory swellings such as abscess of cellulitis
Diffuse and spherical - cyst
Slipping edge- subcutaneous lipoma

Consistence
Soft- lipoma
Firm
Firm rubber- fibroadenoma
Hard- carcinoma
Vairable- cyst

Mobility
In fibroadenoma ‘mobile mouse’

Composition
Carcinomas are solid, do not fluctuate, transilluminate or have a fluid thrill
Cysts are rarely possible to elicit fluctuation, transilluminaton or fluid thrill

Relations to skin:
Skin Fixation- if a lump cannot be moved without moving the skin it is said to be fixed. It has
spread into the skin and cannot be moved or separated from it
 Ashli’s Surgery Notes

Skin tethering- if a lump is pulled outside the arc the skin indents, it is tethered. This is more
deeply situated and, by distorting fibrous septa which separate lobules of the breast tissue (the
ligaments of Astley Cooper), puckers and pulls the skin inwards, but remains separate from the
skin and can be moved independently.

Fixation of lump to skin is almost diagnostic of a carcinoma. Fat necrosis also causes skin
fixation or pointing abscess.

When a tumour spreads along the fibrous septae of the breast it blocks the lymphatics which run
alongside them. This causes oedema of the overlying skin between the many small pits which
mark the openings of the hair follicles and sweat glands. The result is an orange-peel appearance
known as peau d'orange.

Relations to structures beneath the breast

If there is a deep-seated lump, ask patient to press her hand against her hip, thereby tensing the
pectoral muscles. If the lesion becomes less mobile, it is either fixed or tethered. The less
movement, the more likely it is to be fixed.

The nipple

Squeeze nipples in 2 directions

If there is nipple inversion, it may be possible to ever it by gently squeezing its base or by asking
the patient to do it for you. Nipple inversion that is easily everted is not an abnormality.

If the nipple will not evert, there is likely to be underlying disease. Unilateral inversion is more
significant than bilateral inversion.

If there is said to be discharge. It may be possible to express it by gently pressing the areola
around the base of the nipple and observing whether any fluid comes from one or many duct
orifices. The character of the fluid should be noted: red, white, creamy yellow or watery.
Endocrine causes of nipple discharge include ductal carcinoma-in-situ, duct papilloma and most
commonly duct ectasia.

1. Nipple Retraction
May occur at puberty or later in life. At puberty, also known as simple nipple inversion, unknown
cause. In about 25% of cases it is bilateral. May cause issues with breastfeeding and infection can
occur, especially during lactation because of retention of secretions.

Types:
a. Slit retraction
Seen in:
 Ashli’s Surgery Notes

Duct Ectasia (Plasma Cell Mastitis)- unknown aetiology; condition in which the
lacteriferous duct becomes blocked or clogged by inflammatory cells and debris. Most
common cause of greenish discharge (infection). Can mimic breast cancer. Disorder of peri-
or post-menopausal age.
MOST COMMON CAUSE OF NIPPLE INVERSION

Chronic Periductal Mastitis

b. Circumferential retraction
May indicate and carcinoma/ post surgical
Treatment: usually unnecessary and condition may spontaneously resolve during pregnancy and
lactation. Simple comestic surgery may help. Mechanical suction devices have been use to evert
the nipple with some effect.
2. Cracked nipple
May occur during lactation and be the main cause of acute infective mastitis. If this happens
during lactation, it should be rested for 24-48 hours and breast should be emptied with a breast
pump. Feeding should be resumed as soon as possible.

3. Papilloma of the nipple

Excised with a tiny disc of skin. OR base may be tied off and it will spontaneously fall off.

4. Retention cyst of a gland of Montgomery

These glands situated in areola and secretes sebum for lubrication. If blocked can form a
sebaceous cyst.

5. Eczema
RARE! Often bilateral. Usually associated with eczema elsewhere on the body. Treated with
0.5% hydrocortisone.

6. Paget’s Disease
Paget's disease of the nipple is caused by cancer cells migrating or spreading along the duct
system from a carcinoma situated deeply in the breast, which in the early stages is usually
confined to the epithelium (DCIS). The presence of carcinoma cells in the skin of the nipple
produces a clinical appearance similar to that of eczema. Patches of skin first become red and
then encrusted and oozy. The edges of these lesions are distinct, unlike eczema, and they do not
itch, although the patient may complain of abnormal sensations and prickling. In time the nipple
is destroyed, and replaced by a malignant ulcer. In the early stages of the disease there may be no
palpable abnormality in the breast, but ultimately the in-situ carcinoma becomes invasive and a
lump appears. Never forget that Paget's disease of the nipple always indicates an underlying
malignant process in the breast itself.

Has a linear spread. Investigated by skin biopsy if there is no palpable mass.

7. Discharges of Nipple:
Most common: DCIS, duct papilloma, duct ectasia (mainly)
 Ashli’s Surgery Notes

Discharge from surface:

Paget’s Disease
Skin Diseases (psoriasis, eczema)
Rarely (chancre)

Discharge from a single duct:

Blood stained: most commonly benign
Intraduct papilloma
Cysts
Intraduct carcinoma
Duct ectasia

Serous (any colour):

Fibrocystic Disease
Duct ectasia
Carcinoma

Discharge from more than one duct:

Blood stained: most commonly benign conditions

Carcinoma
Ectasia
Fibrocystic Disease

Purulent:
Infection

Black or Green:
Duct Ectasia

Serous: most commonly benign conditions

Duct Ectasia
Fibrocystic Disease
Carcinoma

Milk: galactorrhea
Lactation
Rare causes (hypothyroidism, pituitary adenoma—elevated prolactin levels, endocrine
anoculatory syndromes, patients taking OCP,tricyclic antidepressants, methyldopa,
phenothiazines)

NOT .. RARELY ASSOCIATED WITH MALIGNANCY

Treatment:
1. Occult blood test and cytology – exclude carcinoma
2. Operation to remove affected duct or ducts ( microdochetomy)
 Ashli’s Surgery Notes

3. Cone excision of major ducts

The axilla

Stand on patient’s right side

Take hold of her right elbow with your right hand and let her forearm rest on your right forearm.
Persuade her to allow you to hold the weight of her arm. (Patients always want to help by holding
their arm away from their side, but this tenses the muscles in the anterior and posterior axillary
folds and makes palpation of the lymph glands impossible.) Place your left hand flat against the
chest wall and feel for any glands that may lie in the central or medial aspects of the right axilla
by sweeping the tips of your fingers across and from the top to the base of the axilla to catch the
glands against the chest wall. To reach the apex of the axilla you will have to push the tips of
your fingers upwards and inwards. Explain to the patient that you must push firmly to examine
the axilla thoroughly and that this may cause discomfort. (Some patients find this ticklish!)

Next move your left hand anteriorly over the edge of the pectoralis minor muscle and downwards
into the axillary tail and behind the edge of the pectoralis major muscle. Turn your hand (or
change hands) to feel the subscapular glands on the posterior wall of the axilla, and finally feel
the lateral aspect of the axilla in case there are any brachial glands level with the neck of the
humerus.

To palpate the left axilla, lean across the patient, hold her left elbow with your left hand and use
your right hand to feel the axilla. If it is difficult to feel the axilla in this way, move round to her
left side.

Look to see if there is lymphedema

Finally, palpate the supraclavicular fossa and the neck (supraclavicular lymph nodes)

Record this of glands if felt:

Number
Size
Consistence – usually hard and discrete if its metastases

General Examination

Check arms for swellings or any neurological or vacular abnormalities

Palpate abdomen for: hepatomegaly, ascites, nodules in the pouch of douglas
 Ashli’s Surgery Notes

Examine lumbar spine for pain or any restricted movement: percussion, movements, straight-leg
raising, ankle jerks

The skeleton — especially the lumbar spine, causing back pain and reduced spinal movements,
and pathological fractures in long bones. There may even be paraplegia from cord compression.

The lungs — causing pleural effusions. Lung parenchymal involvement, in the form of diffuse
lymphatic involvement known as lymphangitis carcinomatosa, may cause severe dyspnoea.

The liver — making it palpable and causing jaundice and ascites.

The skin — producing multiple hard nodules within the skin. These are usually in the skin of the
breast containing the cancer, but may be seen in the neck, trunk and further away.

The brain — producing any variety of neurological symptoms and signs.

LIVER, LUNGS, BRAIN, BONE, SKIN (most common sites of metastases)

Triple Assessment

1. History and Examination

2. Diagnostic imaging by mammography and or ultrasound scanning
3. Cytology or Histology
Cytology looks at smears obtained by aspiration of a lump with a fine needle
Histology is based on biopsy specimens obtained with special core-cutting needles, often
with radiological guidance

INVESTIGATIONS:
1. Mammography
Sensitivity of investigation increases with age as the breast becomes less dense. Can be used for
screening.
2. Ultrasound
Useful in younger women with denser breasts in whom mammogram is difficult to interpret, and
in distinguishing cyst from solid lesions. Can be use to localize impalpable areas of breast
pathology. Not useful as a screening tool and remains operator dependent.

Ultrasound of axillary tissue is performed when a cancer is diagnosed and guided percutaneous
biopsy of any suspicious glands.

3. Magnetic Resonance Imaging

Useful when:
To distinguish scar from recurrence in women who have had previous breast conservation therapy
for cancer (inaccurate within 9 months of radiotherapy)
 Ashli’s Surgery Notes

Best imaging modality for breasts of women with implants

Screening tool in high risk women (Family Hx)

Less useful than U/S in management of axilla in both primary breast cancer and recurrent disease

4. Needle Biopsy/Cytology
5. Large-Needly Biopsy with Vacuum Systems
6. Triple Assessment