Breast SurgeryBreast SurgeryMr. Walid A. SamraMr. Walid A. Samra

Breast anatomy Breast anatomy

Breast development Breast development Up until the onset of puberty, the Up until the onset of puberty, the

breasts are much the same in the breasts are much the same in the male and female and their internal male and female and their internal structure is similar – a collection of structure is similar – a collection of ducts emptying into the nipple. ducts emptying into the nipple.

the breast responds to the release of the breast responds to the release of female sex hormones Oestrogen and female sex hormones Oestrogen and progesterone. The breast is fully progesterone. The breast is fully formed, typically by the age of 15. formed, typically by the age of 15.

Hormones Affecting the BreastHormones Affecting the Breast

Oestrogen & Oestrogen & ProgesteroneProgesterone

Oestrogen : Oestrogen : Stimulates the formation of additional ducts, Stimulates the formation of additional ducts,

the elongation of existing ducts and the elongation of existing ducts and formation of a system of milk secreting formation of a system of milk secreting glands glands

Is associated with an increase in volume and Is associated with an increase in volume and elasticity of connective tissue, deposition of elasticity of connective tissue, deposition of adipose tissue and increased vascularity.adipose tissue and increased vascularity.

Progesterone: stimulates lobule formation. Progesterone: stimulates lobule formation.

Blood and lymphatic Blood and lymphatic systems systems

Breast cancer Breast cancer epidemiology epidemiology

Breast cancer was recognized by the Ancient Breast cancer was recognized by the Ancient Egyptians as long ago as 1600 BC.Egyptians as long ago as 1600 BC.

affecting as many as one in eight women affecting as many as one in eight women during their lifetime.during their lifetime.

diagnosed in over one million women diagnosed in over one million women worldwide and is the cause of death in over worldwide and is the cause of death in over 400,000 women.400,000 women.

It is known that incidence rates for breast It is known that incidence rates for breast cancer increase rapidly during the fourth cancer increase rapidly during the fourth decade of life and continue to increase decade of life and continue to increase thereafter, but more slowly in the fifth, sixth thereafter, but more slowly in the fifth, sixth and seventh decades.and seventh decades.

Breast Cancer Risk Breast Cancer Risk Factors Factors

The aetiology of the majority of The aetiology of the majority of breast cancers is multifactorial, breast cancers is multifactorial, including both genetic and including both genetic and environmental factorsenvironmental factors

Hormonal factors Hormonal factors Family history Family history Dietary factors and the Dietary factors and the

development of breast cancerdevelopment of breast cancer.. Environmental factors and the Environmental factors and the

development of breast cancerdevelopment of breast cancer

Breast cancer diagnosisBreast cancer diagnosis

Physical examination Physical examination

Mammography Mammography

Physical examinationPhysical examination Inspection : Inspection : Have the patient sit at end of exam table and relax arms to Have the patient sit at end of exam table and relax arms to

her side.her side.Look for: Look for: Approximate symmetry Approximate symmetry

Dimpling or retraction of skin Dimpling or retraction of skin Swelling or discoloration Swelling or discoloration Orange peel effect on skin Orange peel effect on skin Position of nipple or Nipple retraction Position of nipple or Nipple retraction

Palpation.Palpation.

MammographyMammography

To confirm the diagnosis To confirm the diagnosis Fine needle aspiration (FNA)Fine needle aspiration (FNA)

Core needle biopsyCore needle biopsy Excision biopsyExcision biopsy

Additional screening procedures are undertaken to Additional screening procedures are undertaken to ensure correct management of the patient most ensure correct management of the patient most

valuable tests are a chest X-ray, full blood count, valuable tests are a chest X-ray, full blood count, simple assessment of liver function, bone scan and simple assessment of liver function, bone scan and abdominal (hepatic) ultrasonography, CT, MRI. PET abdominal (hepatic) ultrasonography, CT, MRI. PET

scan.scan.

Breast Cancer Breast Cancer stagingstaging

The TNM staging The TNM staging T0 No tumourTISIn situ (non-invasive)diseaseT0 No tumourTISIn situ (non-invasive)disease T1 Tumour less than 2cm in diameterT1 Tumour less than 2cm in diameter T2 Tumour 2–5cm in diameterT2 Tumour 2–5cm in diameter T3 Tumour greater than 5cmT3 Tumour greater than 5cm T4 Tumour of any size with direct extension to the chest T4 Tumour of any size with direct extension to the chest

wall or skinwall or skin

N0 No palpable node involvementN0 No palpable node involvement N1 Mobile ipsilateral nodesN1 Mobile ipsilateral nodes N2 Fixed ipsilateral nodesN2 Fixed ipsilateral nodes N3 Supraclavicular or infraclavicular nodes or oedema of N3 Supraclavicular or infraclavicular nodes or oedema of

the armthe arm

M0 No distant metastasesM0 No distant metastases M1 Distant MetastasesM1 Distant Metastases

Breast cancer grading Breast cancer grading Grade1 (well differentiated)tumours Grade1 (well differentiated)tumours

with formed glands and only slight with formed glands and only slight anaplasia.anaplasia.

Grade2 (moderately well Grade2 (moderately well differentiated)tumours with formed differentiated)tumours with formed glands and moderate anaplasiaglands and moderate anaplasia

Grade3 (poorly differentiated)tumours Grade3 (poorly differentiated)tumours with formed glands and marked with formed glands and marked anaplasia or with no glands at all.anaplasia or with no glands at all.

Pathology of breast Pathology of breast cancercancer

Malignant tumours may arise from any Malignant tumours may arise from any of the breast structures. Ductal of the breast structures. Ductal carcinomas are the most common, carcinomas are the most common, followed by lobular carcinomas and followed by lobular carcinomas and malignancies arising from other malignancies arising from other connective tissues. connective tissues.

The majority of breast cancers arise The majority of breast cancers arise from the epithelium lining of the from the epithelium lining of the lactiferous ducts and ductules, and are lactiferous ducts and ductules, and are consequently termed adenocarcinomas consequently termed adenocarcinomas

Ductal carcinoma in Ductal carcinoma in situ( DCIS)situ( DCIS)

It is considered that at present radiotherapy It is considered that at present radiotherapy and/or tamoxifen may be offered to patients with and/or tamoxifen may be offered to patients with DCIS as an adjuvant to surgery.DCIS as an adjuvant to surgery.

LCIS is usually multicentric and frequently LCIS is usually multicentric and frequently bilateral, and the disease is diagnosed more bilateral, and the disease is diagnosed more frequently in younger women (44–46 years). frequently in younger women (44–46 years).

The patient should make the choice between The patient should make the choice between careful observation and bilateral prophylactic careful observation and bilateral prophylactic mastectomy once they thoroughly understand the mastectomy once they thoroughly understand the risks and benefits of the two management options. risks and benefits of the two management options.

Lobular carcinoma in Lobular carcinoma in situ( LCIS)situ( LCIS)

MaManagement of early (stage I nagement of early (stage I and II) breast cancer.and II) breast cancer.

determining the best treatment plan has determining the best treatment plan has now become a collaboration between now become a collaboration between surgeons, pathologists, radiation surgeons, pathologists, radiation oncologists, reconstructive surgeons, oncologists, reconstructive surgeons, medical oncologists and most importantly medical oncologists and most importantly the patient. the patient.

The preferred treatment option for most The preferred treatment option for most women with Stage I/II disease is breast women with Stage I/II disease is breast conserving surgery, dissection of the conserving surgery, dissection of the axillary lymph nodes, followed by axillary lymph nodes, followed by radiation therapy. radiation therapy.

Neoadjuvant therapy Neoadjuvant therapy Neoadjuvant or primary medical therapy, Neoadjuvant or primary medical therapy,

is an approach which has become is an approach which has become increasingly used in the management of increasingly used in the management of early-stage, operable breast cancer, early-stage, operable breast cancer, whereby systemic therapy is whereby systemic therapy is administered prior to surgery in order to administered prior to surgery in order to shrink the tumour and allow more shrink the tumour and allow more breast-conserving types of surgery to be breast-conserving types of surgery to be undertaken or more complete excision of undertaken or more complete excision of very large tumours. very large tumours.

Adjuvant therapy Adjuvant therapy Systemic therapy (either Systemic therapy (either

chemotherapy, endocrine therapy, or chemotherapy, endocrine therapy, or both), as an adjuvant to surgery in both), as an adjuvant to surgery in patients with early breast cancer, is patients with early breast cancer, is used either to eliminate or to used either to eliminate or to prevent the growth of distant prevent the growth of distant metastases, and in so doing prolong metastases, and in so doing prolong disease-free survival and improve disease-free survival and improve overall survival.overall survival.

Management of stage III & Management of stage III & IV breast cancerIV breast cancer

Locally-advanced (Stage III) disease is Locally-advanced (Stage III) disease is rarely treated by surgery alone. rarely treated by surgery alone.

If the primary tumour responds If the primary tumour responds sufficiently to allow surgical sufficiently to allow surgical intervention, the patient can then be intervention, the patient can then be treated with surgery, usually modified treated with surgery, usually modified radical mastectomy, followed by further radical mastectomy, followed by further systemic therapy, either endocrine or systemic therapy, either endocrine or chemotherapy, depending upon the chemotherapy, depending upon the hormone receptor status of the tumour. hormone receptor status of the tumour.

Management of Management of advanced/metastatic breast advanced/metastatic breast

cancercancer The aim of treatment is palliative, to prolong The aim of treatment is palliative, to prolong

survival by disease remission or stabilisation, to survival by disease remission or stabilisation, to alleviate symptoms and improve quality of life.alleviate symptoms and improve quality of life.

Systemic therapy is the primary treatment, Systemic therapy is the primary treatment, using chemotherapy, endocrine therapy, or using chemotherapy, endocrine therapy, or both, depending upon the hormone both, depending upon the hormone responsiveness of the tumour. responsiveness of the tumour.

Surgery is occasionally used in conjunction with Surgery is occasionally used in conjunction with radiotherapy, chemotherapy and hormone radiotherapy, chemotherapy and hormone therapy to improve local control of fungating therapy to improve local control of fungating bulky cancers. bulky cancers.

Breast Cancer Surgery Breast Cancer Surgery

The type and extent of breast The type and extent of breast surgery to be selected is dependent surgery to be selected is dependent upon the size and stage of the upon the size and stage of the tumour.tumour.

Breast SuregryBreast Suregry

breast conserving breast conserving procedures procedures

Wide local excisionWide local excision Lumpectomy Lumpectomy

Quadrantectomy Quadrantectomy

Sentinel lymph node Sentinel lymph node biopsy biopsy

Mastectomy Mastectomy The major breast cancer The major breast cancer

treatment option is treatment option is mastectomy, with or without mastectomy, with or without breast reconstruction breast reconstruction

the form of mastectomy the form of mastectomy generally adopted is known generally adopted is known as modified radical as modified radical mastectomy or simple mastectomy or simple mastectomy, a technique that mastectomy, a technique that involves total removal of the involves total removal of the breast and dissection of the breast and dissection of the axilla, whilst preserving both axilla, whilst preserving both pectoral musclespectoral muscles

Complications following Complications following surgery surgery

Pain, Infection and recurrent or Pain, Infection and recurrent or persistent disease.persistent disease.

Arm swelling, sometimes called Arm swelling, sometimes called lymphoedema occurring in lymphoedema occurring in approximately 10% of cases following approximately 10% of cases following radical surgery and radiotherapy .radical surgery and radiotherapy .

Stiff or frozen shoulder.Stiff or frozen shoulder. depression and psychosexual disorders depression and psychosexual disorders

during the first year.during the first year.

Radiotherapy for breast Radiotherapy for breast cancercancer

Radiotherapy involves the use of ionising Radiotherapy involves the use of ionising radiation to damage actively dividing radiation to damage actively dividing cells. Since cancerous cells are dividing cells. Since cancerous cells are dividing more rapidly than most healthy tissues, more rapidly than most healthy tissues, cancerous cells tend to be killed first; cancerous cells tend to be killed first; however, the treatment is not specific however, the treatment is not specific

Radiotherapy can be used as primary Radiotherapy can be used as primary therapy in cases of inoperable (usually therapy in cases of inoperable (usually stage III) disease or when the patient stage III) disease or when the patient refuses or is unsuitable for surgery refuses or is unsuitable for surgery

Side effects of radiation Side effects of radiation therapy therapy

The procedure itself is painless, the immediate The procedure itself is painless, the immediate effects being swelling and heaviness in the effects being swelling and heaviness in the breast. The main side effects of radiotherapy breast. The main side effects of radiotherapy include fatigue, acute skin reactions maximal include fatigue, acute skin reactions maximal at 4-6 weeks, delayed healing and local at 4-6 weeks, delayed healing and local fibrosis, which may not be fully apparent until fibrosis, which may not be fully apparent until a year after therapy a year after therapy

Radiation therapy applied to the axillary lymph Radiation therapy applied to the axillary lymph nodes may also increase the risk of nodes may also increase the risk of lymphoedema in the arm. However, newer, lymphoedema in the arm. However, newer, more targeted and selective techniques have more targeted and selective techniques have reduced the incidence of side effects reduced the incidence of side effects associated with radiation therapy.associated with radiation therapy.

Cytotoxic chemotherapy for Cytotoxic chemotherapy for breast cancerbreast cancer

Cytotoxic Cytotoxic chemotherapeutic chemotherapeutic agents work by agents work by interfering with the interfering with the ability of cancerous ability of cancerous cells to divide cells to divide

Nearly all Nearly all chemotherapy chemotherapy treatment regimens treatment regimens used in breast cancer used in breast cancer involve two or more involve two or more agents used together agents used together The S phase - the point of action of

chemotherapeutic agents in the cell cycle

Side effects of cytotoxicsSide effects of cytotoxics

Endocrine therapy for Endocrine therapy for breast cancerbreast cancer

Endocrine therapy has become a major Endocrine therapy has become a major mode of treatment for all stages of mode of treatment for all stages of breast cancer.breast cancer.

Current modes of endocrine Current modes of endocrine treatment:treatment:Oestrogen receptor blockade with antioestrogens (Tamoxifen)Oestrogen receptor blockade with antioestrogens (Tamoxifen)

Ovarian suppression (oophorectomy or radiotherapy) Ovarian suppression (oophorectomy or radiotherapy) LH-RH analogues LH-RH analogues Aromatase inhibitors Aromatase inhibitors Oestrogen receptor down-regulators Oestrogen receptor down-regulators Herceptin (trastuzumab)Herceptin (trastuzumab) HER-2-targeted antibody interacts HER-2-targeted antibody interacts with with human epidermal growth factor receptor (HER)2 human epidermal growth factor receptor (HER)2 mediated breast mediated breast cancer development. cancer development.

Anti-angiogenesisAnti-angiogenesis AngiogensisAngiogensis: :

development of new development of new blood vessels from blood vessels from existing vesselsexisting vessels

Anti-angiogenicsAnti-angiogenics prevent tumour vessel prevent tumour vessel formation formation

Early research with Early research with anti-angiogenics anti-angiogenics demonstrate tumour demonstrate tumour growth can be growth can be regressed or slowed regressed or slowed downdown

Tumour Angiogenesis

Formation of new tumour vasculature

TumourAngiogenic

factors

Molecular Targeting of Breast Molecular Targeting of Breast CancerCancer

Targeted therapy in cancerTargeted therapy in cancer Many more biologic processes understood at a Many more biologic processes understood at a

molecular level in the molecular level in the hosthost (the body’s response (the body’s response to the cancer) as well as those in the to the cancer) as well as those in the tumourtumour itselfitself

Growth factors

Tumourvasculature

Disseminatingtumour cells

InvasionCell cycle control

Proliferatingtumour cells

Angiogenesis

Signal transduction

Targeting tumour blood Targeting tumour blood supplysupply

Solid tumours e.g. Solid tumours e.g. breast cancer, breast cancer, survive by developing survive by developing their own blood their own blood supply (angiogenesis)supply (angiogenesis)

Therefore treatments Therefore treatments which inhibit tumour which inhibit tumour blood supply blood supply formulation and formulation and maintenance can kill maintenance can kill cancer cells and cancer cells and shrink tumoursshrink tumours

Gene TherapyGene Therapy Gene therapy is still experimentalGene therapy is still experimental Gene therapy aims to supply defective Gene therapy aims to supply defective

cells with healthy copies of missing or cells with healthy copies of missing or altered genes. altered genes.

If research proves successful, gene If research proves successful, gene therapy may be used in cancer and other therapy may be used in cancer and other types of diseasestypes of diseases

Breast ReconstructionBreast Reconstruction The most commonly used procedures are The most commonly used procedures are

those that involve breast implants. Many those that involve breast implants. Many women find that the improved body contour women find that the improved body contour helps with confidence, self-image and a feeling helps with confidence, self-image and a feeling of well-being. However, reconstruction of the of well-being. However, reconstruction of the nipple is not generally performed and the nipple is not generally performed and the overall cosmetic results do not compare with overall cosmetic results do not compare with the best results from radiotherapy or the best results from radiotherapy or chemotherapy. Surgical methods that employ chemotherapy. Surgical methods that employ myocutaneous flap reconstruction are more myocutaneous flap reconstruction are more successful, but these are more lengthy successful, but these are more lengthy procedures than simple insertion of a breast procedures than simple insertion of a breast prosthesis. prosthesis.

Breast reconstruction Breast reconstruction optionsoptions

Reconstruction using an Reconstruction using an implant implant of some of some kind kind

Tissue flapTissue flap reconstruction, in which  reconstruction, in which skin, muscle and fat from your back skin, muscle and fat from your back or abdomen (tummy) TRAM is or abdomen (tummy) TRAM is tunnelled through to the chest to tunnelled through to the chest to create a new breast. The skin, create a new breast. The skin, muscle and fat stays connected to muscle and fat stays connected to the area of the body from which it the area of the body from which it was taken was taken

Latissimus dorsi muscle Latissimus dorsi muscle flap flap

Free flapFree flap reconstruction, in which  reconstruction, in which skin and fat from your lower skin and fat from your lower abdomen, or occasionally buttock, is abdomen, or occasionally buttock, is grafted to the breast area. The skin grafted to the breast area. The skin and fat is completely removed from and fat is completely removed from the original area and a new blood the original area and a new blood supply is created for the new breast supply is created for the new breast tissue, using microsurgery.tissue, using microsurgery.