Breast Surgery

1. BREAST CANCER

Breast cancer is a malignant tumor. Appears in the cells of the mammary gland. Breast cancer often presents as a hard, irregular mass (breast lump). This is why it is so important to check your breasts every month. It is much more common in women and with a higher incidence after menopause.

Early diagnosis of breast cancer is essential as it increases the chances of a cure. It prevents cancer from spreading to other parts of the body, improving the prognosis.

That’s why all women should do a monthly self-examination.

A woman with breast cancer may have a lump or change in the shape of the breast, changes in the skin of the breast, or nipple discharge. The diagnosis is made through exploration by the doctor, clinical and family history and complementary diagnostic tests:

1. Mammography: the main breast exam. As it is very precise, it allows the doctor to know the approximate size, location and characteristics of a nodule just a few millimeters in size, when it cannot yet be felt on palpation.
2. Ultrasound: should always complement mammography. It informs whether the nodule is solid or contains liquid (cyst) and allows you to know the exact size of the nodule.
3. Aspiration cytology: with a fine needle and a syringe, a certain amount of liquid or a small portion of tissue from the nodule is aspirated for microscopic examination. This technique clarifies whether a breast lump is cancerous or not. It may be inconclusive in some cases.
4. Biopsy: procedure to take a sample of the suspected nodule (or even remove the entire nodule – excisional biopsy). The removed tissue is examined under a microscope by the Pathologist. This procedure allows us to confirm whether we are facing breast cancer. If the biopsy detects a malignant tumor, other laboratory tests are carried out on the tissue to obtain more data about the characteristics of the tumor.
5. Hormone receptors (estrogen and progesterone): If the biopsy allows the diagnosis of cancer, these laboratory tests reveal whether or not hormones can stimulate its growth. With this information, the doctor can decide whether or not it is advisable to include a treatment based on antagonists of those hormones in the therapeutic plan, that is, medications that counteract their effect. The tumor tissue sample is taken during the biopsy.
6. Exams (X-rays, blood tests, abdominal ultrasound, bone scintigraphy, computed tomography) must be ordered to check whether cancer is present in other organs of the body.

The breast cancer staging system (TNM) takes into account the size of the tumor, the involvement of lymph nodes in the armpit close to the breast and the presence or absence of distant metastases.

TYPES OF BREAST CANCER

Treatment and prognosis vary from patient to patient and depending on the type of tumor. Almost all malignant breast tumors originate from the ducts or lobules of the breast, which are glandular tissues. The two most common types are ductal carcinoma and lobular carcinoma.

• Ductal carcinoma “in situ”: it is the most common non-invasive breast tumor. Virtually all women with this disease can be cured. Mammography is the best method to diagnose breast cancer at this early stage.
• Lobular carcinoma “in situ”: although it is not a true cancer, some authors classify it as a non-invasive breast cancer. Many experts think that LCIS does not turn into an invasive carcinoma, but women with this neoplasm are at increased risk of developing invasive breast cancer.
• Invasive ductal carcinoma: this is the most common breast cancer. It originates in the ducts and invades neighboring tissues. At this stage it can spread through lymphatic vessels or blood, reaching other organs. About 80 percent of invasive (or invasive) breast cancers are ductal carcinomas.
• Invasive lobular carcinoma: originates in the milk-producing units, that is, in the lobes. Similar to the above, it can spread to other parts of the body. About ten percent of invasive breast cancers are lobular carcinomas.
• Inflammatory breast carcinoma: This is an aggressive but rare cancer.

There are also other rarer types of breast cancer, such as Medullary Carcinoma, Mucinous Carcinoma, Tubular Carcinoma and Malignant Phylloid Tumor, among others.

TREATMENT OF BREAST CANCER

The choice between the different treatment options depends on the stage of the disease, the type of tumor and the patient’s general health status. Depending on the needs of each patient, the Doctor may choose one or a combination of two or more treatments.

• Surgery: this is the most common initial treatment and the main local treatment. The breast tumor will be removed, as well as one or more lymph nodes in the armpit. These nodes filter the lymph that flows from the breast to other parts of the body and it is through them that cancer can spread. There are several types of surgery for breast cancer, which are indicated according to the evolutionary stage of the tumor, its location or the size of the breast.
• Tumorectomy: surgery that removes only the tumor. Then, radiation therapy is applied. Sometimes, underarm lymph nodes are removed as a preventative measure. It is applied to minimal tumors.
• Quadrantectomy: is the surgery that removes the tumor, a part of the normal tissue that surrounds it and the tissue that covers the breast below the tumor. It is, therefore, a treatment that preserves the breast. Radiotherapy is given after surgery.
• Simple or total mastectomy: this is surgery that removes only the breast. Sometimes, however, the nearest lymph nodes are also removed. It is applied in cases of diffuse tumor. The skin of the breast can be maintained, which will greatly assist plastic reconstruction.
• Modified radical mastectomy: this is surgery that removes the breast, the lymph nodes in the armpits and the tissue that covers the pectoral muscles.
• Radiotherapy: Radiation can be external or internal.
• Chemotherapy: is the use of drugs that act to destroy malignant cells.
• Hormone therapy: Treatment may include the use of drugs, which modify the way hormones act. Hormone therapy acts on cells throughout the body.
• Rehabilitation: comes to assist with treatment methods so that the patient has a better quality of life. It is done through medical support services (physiotherapy, psychology, etc.)

BREAST RECONSTRUCTION. IT IS DONE THROUGH ONCOPLASTIC SURGERY TECHNIQUES

1. Reconstruction with the rectus abdominis muscle (TRAM) flap,
2. DIEP flap (Deep perforating inferior epigastric artery free flap),
3. Flap of the latissimus dorsi muscle (GD) and the use of an expander, which is later replaced by a silicone prosthesis.
4. The patient’s own fat transplant is also being widely used in breast reconstruction (Lipofilling), as an adjuvant method to the previous methods or even alone, when the patient has not had the entire breast amputated (breast-conserving surgery). We are supporters of immediate breast reconstruction. Several studies seem to demonstrate a better quality of life for patients undergoing immediate surgery.
5. When the breast undergoes breast-conserving surgery, there are several oncoplastic surgery techniques to reconstruct the breast:
6. Inferior pedicle: for tumors located in the upper quadrants;
7. Superior pedicle: for tumors located in the lower quadrants;
8. Periareolar: targets tumors in any quadrants that can be approached by the periareolar incision.

Advantages: allows immediate or delayed partial breast reconstruction. It is ideal for patients with large breasts, who want breast reduction and have a relatively small tumor. It is performed in a similar way to cosmetic breast reduction. Generally, symmetrization of the healthy breast is performed in the same surgery.

In some cases of tumors very close to the areola, there is a need for reconstruction of the nipple-areola complex (CAM). It can be associated with the placement of silicone prostheses. Thus, the final result is similar to cosmetic surgery (except if the CAM is resected or incisions are made in atypical locations). All reconstruction can be done in a single surgical time, which varies from 90 to 120 minutes. When it is associated with symmetrization of the breast on the other side, the operative time is 180 minutes.

2. BREAST NODULES

Breast lumps can be benign or malignant. Malignant disease has already been seen in the previous chapter, benign diseases are discussed in the next chapter.

Nodules may be palpable or non-palpable. All must be studied by imaging (ultrasound, mammography and/or nuclear magnetic resonance).

Whenever there is doubt, a puncture aspiration biopsy should be performed.

3. BENIGN BREAST DISEASES

A. FIBROADENOMA

It is the most common benign breast tumor. It is dependent on hormonal influence, so it can increase during pregnancy and when taking contraceptives. The most common age for it to appear is between 15 and 30 years old.

Palpation presents clear, mobile edges in the thickness of the breast tissue. The usual size varies between 1 and 3 cm. Growth is slow. With the onset of menopause, they can reduce their size and even disappear. Sometimes, several fibroadenomas appear in one or both breasts (multiple fibroadenoma). Palpation reveals a hard, mobile tumor with well-defined contours.

Ultrasonography shows a well-defined nodule with no posterior band. It can be used to guide the aspiration puncture.

The relationship between fibroadenoma and cancer is minimal. Only around 100 cases of malignant degeneration of fibroadenomas have been described worldwide. Surgical treatment is the only valid one. The attitude of surveillance through exploration and ultrasound is also correct. Surgical excision must be carried out using completely aesthetic procedures, so as not to cause unsightly scars.

In newly appearing nodules, in older women or with risk factors for breast cancer, a biopsy is necessary before surgery.

B. PHYLLODES TUMOR

Called cellular intracanalicular fibroadenoma; is considered a variant of fibroadenoma with clinical characteristics of rapid growth and large size, and must be differentiated from sarcomas.

Approximately represents 1% of breast tumors. It has two peaks of appearance: before the age of 25 and after the age of 40.

It appears as a well-defined, unilateral, painless, mobile, rapidly growing mass that can affect the skin by compression, acquiring a large size, sometimes more than 10 cm. Histology demonstrates significant growth of epithelial and stromal tissues.

Apparently, it originates from the intralobular and periductal stroma, which is sensitive to hormonal action. It has a benign character defined by little cellular atypia and necrosis, with less than 5 mitoses per high-power field, and no infiltrative character in the periphery. It can metastasize to regional lymph nodes in case of malignancy. Whether benign or malignant, it is almost never multifocal. Depending on the marginal tumor, growth of the connective component, mitoses in the area of ​​greatest tumor activity, stromal cellularity and cellular atypia, the phyllodes tumor can be classified as benign, borderline and malignant.

The treatment is extended tumorectomy: resection with a margin of 1-2 cm to avoid recurrence. Intraoperative histological control of the surgical edges must be carried out, as, if they appear contaminated, they will also be excised.

If the remaining breast tissue is scarce, subcutaneous mastectomy with implant placement may be necessary.

Normally, a lymphadenectomy is not necessary, because lymph node invasion does not exceed 2% of cases.

C. LIPOMA

Pure mesenchymal tumor. Others are hemangioma, leiomyoma, myofibroblastoma and granular cell tumor, which appear anywhere in the breast parenchyma.

It is a well-defined nodule, formed by fat cells and limited by a capsule. The size ranges from 2 to 10 cm. Palpation reveals a solitary nodule, well-defined, soft, mobile and not adherent to any structure. Treatment is surveillance or excision.

D. BREAST HAMARTONE / FIBROADENOLIPOMA

Well-defined and encapsulated nodular lesion that clinically resembles a fibroadenoma. It is uncommon and usually appears in the 4th and 5th decades of a woman’s life. Palpation demonstrates a tumor that is difficult to palpate as it has a similar consistency to breast tissue.

Ultrasonography identifies a well-defined, hypoechoic, solid mass with a posterior ultrasound shadow. The puncture biopsy identifies the components of normal breast tissue. Treatment is surveillance or excision.

E. ADENOMA

It is a benign tumor with a pure epithelial component. In clinical terms, it is similar to fibroadenoma, being an exclusively anatomopathological criterion (only seen in the analysis of the specimen) and very uncommon. Treatment is surgical.

F. DUCTAL ECTASIA

This expansion produces considerable disproportion of the collector ducts in relation to their neighbors. The cavity is occupied by lipid material and debris. It is characteristic of adulthood with a peak appearance between 40 and 60 years of age. It can manifest as a spontaneous and intermittent nipple effusion, usually greenish, flowing through one or several orifices. The woman presents with itching, tension and finally retraction of the nipple due to fibrosis of the conduit.

In the granuloma stage, a tumor is felt beneath the areola. Fibrosis and even distortion of nearby skin are seen. It can be confused with a carcinoma. Ultrasound may show dilation of the ducts. A mammogram doesn’t give much information. If the process is mild, it does not require treatment, if it is very symptomatic, the affected galactophoric ducts are removed.

G. LYMPHOCYTIC MASTITIS

It is associated with Hashimoto’s thyroiditis, diabetes mellitus, lumbar arthritis, collagen sclerosis, and evolutionary changes in the ducts. With lymphocytic foci of b cells.

H. SUBAREOLAR ABSCESS

The patient is usually a young woman, with recurrent episodes of abscesses in the subareolar region.

The lesion originates in the milk ducts under the nipple or in the ducts of the Montgomery glands that drain into the areola. Ultrasound may reveal subareolar fluid.

They do not respond to antibiotic therapy and usually require surgical treatment.

I. TUBERCULOSIS AND FUNGAL MASTITIS

The clinic progresses with tumors and swelling. There may be pain. Mammography does not provide information for diagnosis. Ultrasonography may show an area with less echogenicity. Harvesting for cultivation must be done. In rare cases it can coexist with cancer.

J. BREAST CYST

These are lumps filled with fluid from the breast, whose formation mechanism, natural history and pathogenesis are unknown.

Its relationship to cancer is unknown (its association is probably a coincidence).

They are more common in pre-perimenopausal women (40-50 years old), but can occur at any age. It is, however, rare before the age of 20 and exceptional menopause.

These are well-defined tumors and are diagnosed by ultrasound. Its treatment can be done by aspiration or excision (surgery).

• Simple cyst

A simple cyst is an expansion of the secondary and tertiary ducts, occupied by fluid of varying color. If it is a simple cyst, the contents will be aseptic fluid; if it is an abscess, the contents will be a purulent liquid and if it is a hematoma the contents will be blood.

They can be single or multiple and of varying sizes. They are characterized by being palpable when they are larger than one or more centimeters and can cause some pain, in relation to the ovarian cycle. They usually disappear after puncture-aspiration.

Ultrasonography gives us information: the image has a very well-defined oval or circular contour. The image is anechoic (appears as a dark spot on the ultrasound).

Aspiration is necessary for cytology of the liquid. Then the air is blown out. This allows a pneumorradiography to be performed immediately or within 2-3 weeks, which also serves as a treatment. This puncture cures 70 to 90% of cysts.

The mammogram shows a nodular, well-circumscribed tumor with a round or oval outline, homogeneous and well-defined. You may have a radiolucent peripheral halo that encompasses part or all of the lesion.

• Galactocel

Galactocele is a simple cyst containing liquid or thick milk produced by a dilation of a breast milk duct. Previous breastfeeding is associated with this problem and generally develops when it has been abruptly stopped.

It feels like a spherical, non-adherent, circumscribed and variable floating “puff” in which expression can cause milk to appear through the nipple.

The mammographic image presents rounded edges with homogeneous and dense content, very similar to simple cysts, but which never exceeds 60 mm. The ultrasound image shows a nodular and regular margin. Cytology material reveals the existence of milk.

It is not convenient to operate to avoid the formation of fistulas. The treatment of choice is puncture-aspiration and excision.