surgical anatomy of breast & management of advanced carcinoma breast
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Transcript of surgical anatomy of breast & management of advanced carcinoma breast
Presented by: Dr. Sk. Sabir Ahmed
Chairperson: Prof. Dr. Chikkannachari
The breast is a modified sweat gland.
The epithelium lining of the ducts & acini of the breast is develop from ectoderm & the supporting tissue develops from mesenchyme.
ectoderm
mesoderm
On each side of the ventral surface of young embryos, a thickened band of ectoderm develops(the milk ridge).
It extends obliquely from axilla to inguinal region. In human, the whole of these ridge atrophies,
excepting only small portion in each pectoral region from which breast arises.
Amastia: bilateral absence of breast tissue & nipple. When breast tissue is absent unilaterally, the pectoral muscle is often absent.(3)
Polymastia: more than one breast in one or both sides.(1)
Polythelia: supranumerary nipples are situated irregularly over the breast & not on milk ridge.(2)
The breast lies in the superficial fascia of the pectoral region.
foramen of langer
A small extension called the axillary tail(of Spence) pierces the deep fascia and lies in the axilla
In some normal subjects it can be palpable or seen premanstrually or during lactation.
A well developed axillary tail sometimes mistaken for mass of enlarge lymph nodes.
Vertically: it extends from the 2nd to 6th rib.
Horizontally: it extends from the lateral border of the sternum to the mid- axillary line.
The breast lies on the deep fascia (pectoral fascia) covering the pectoralis major.
pectoral fascia
pectoralis major
Still deeper there are parts of four muscles, namely pectoralis major, the serratus anterior, latissimus dorsi and external oblique muscle.
pectoralis major Serratus anterior latissimus dorsi external oblique
Located deep to pectoralis muscle, the pectoralis minor muscle is enclosed in clavipectoral fascia.
clavipectoral fascia
pecroralis minor axillary fascia
clavipectoral fascia extends laterally to fuse with axillary fascia
Breast is separated from pectoralis fascia by loose areolar tissue(retromammary space).
It is thin layer of loose areolar tissue that contains lymphatics & small vessels.
retromammary pectorali space minor clavipectoral fascia axillary fascia
Because of this loose tissue the normal breast can be moved freely over the pectoralis major
Surgical importence: during removal of breast the breast is separeted from pectoral muscle in plane of retromammary space.
Structure of the breast can be studied under following heading skin, parenchyma, & stroma.
Skin - nipple & - areola
4th IC space
Nipple : erectile structure, covered with thick pigmented skin(which increases during pregnancy)
It contains smooth muscle fiber arranged concentrically & longitudinally.
Near its apex lies orifices of lactiferous ducts.
Areola: epithelium of areola contains numerous modified sweat glands and sebacious glands.
These glands enlarge during pregnancy(Glands of Montogomery).
It contains involuntary muscles arranged in concentric rings as well as radially in subcutaneous tissue.
Parenchyma consist of 10 to 100 lobules, each loblues is cluster of alveoli, drained by lactiferous duct, which near its termination it dilate to form lactiferous sinus.
alveoli
lactiferous lactiferous sinus duct
Different portions of duct system are associated with different diseases.
Large duct- duct papilloma duct ectasia Smaller duct-(during development of
breast) - fibroadenoma -(during involution of breast) - cyst formation - sclerosing adenosis
It forms the supporting framework of the gland. It is partly fibrous & partly fatty
Fibrous part: “Ligament of Cooper”-hollow conical projection of fibrous tissue filled with breast tissue, the apices of cones firmly attached to superficial fascia & to the skin.
It anchor the skin & gland to the pectoral fascia. Fatty stroma forms the main bulk of the gland. It is
distributed all over the breast, except beneath the areola & nipple.
In cancer of the breast, the malignant cells may invade these ligaments & consequent contraction of these strands may cause dimpling of the skin.
If the underlying growth attached to the skin, it cannot be pinched up from the lump
If cancer cells grow along the ligament of cooper binding the breast to the pectoral fascia breast fixed to pectoralis major
It cannot then moved in the long axis of the muscle.
If cancer cells grow along the ligament of cooper binding the breast to the pectoral fascia breast fixed to pectoralis major
It cannot then moved in the long axis of the muscle.
internal thoracic art.(br. of subclavian art)
axillary supirior thoracic artery artery acromiothoracic artery lateral thoracic artery
branches from intercostal artery
Venous drainage: the superficial veins radiate from breast & are characterized by their proximity to skin.
They are accompanied by lymphatics & drain to axillary, internal mammary & intercostal vessels.
Phlebitis of one of these superficial veins feel like a cord immediately beneath the skin. The condition produces no discoloration & may be tensed like bowstring by putting traction on it (Mondor’s disease).
Nerve supply: the secreting tissue is supplied by sympathetic nerves(2nd-6th intercostal nerves). The overlying skin is supplied by the ant & lat branches of 4th, 5th & 6th intercostal nerves.
The breast drains mainly to the axillary nodes, of which there are 5 sets
axillary vein apical axillary nodes lat ax.nodes pectoralis minor interpectoral nodes(Rotters) anterior axillary nodes
post ax.nodes lat thoracic v. central axilary nodes subscapular vein internal mammary
chain
Anterior set: situation- along the lateral thoracic vein under anterior axillary fold.
They lie manly on 3rd r
The axillary tail of Spence is in close contact with these nodes & therefore , cancer involving this process may be misdiagnosed as enlarged node with an apparently healthy breast.
Anterior axillary nodes may be involved, by continuity of the tissue
Central set: Situation- in the fat of upper part of axilla. Intercostobrachial nerve passes outwards amongst these
nodes
Intercostobrachial nerve
Enlargement of these nodes(in cancer) by pressure on the nerve, cause pain in the distribution of the nerve along the inner border of the arm.
Apical set(infraclavicular nodes): situation- bounded below by 1st intercostal space, behind by axillary vein,
in front by the costocoracoid membrane.
They are of great importance because they receive one vessel directly from upper part of the breast & ultimately most of the lymph from the breast
A single trunk leaves the apical group on each side of the subclavian trunk, & enters the junction of jugular & subclavian vein
or may join the thoracic duct on the left.
Level 1: lateral to lateral border of pectoralis minor
Level 3(apical groups)
Level 2 (central groups)
Level 1 (lateral groups)
Level 2: central axillary nodes located under pectoralis minor muscle.
Level 3: subclavicular nodes medial to pectoralis minor muscle. It is difficult to visualised & remove unless pectoralis muscles are sacrifised or divided.
Axillary lymph nodes are enclosed by layers of fascia which resembles tent lying on its side
Axillary lymph nodes are enclosed by layers of fascia which resembles tent lying on its side
Anterior wall: pectoralis minor & clavipectoral fascia
Posterior wall: subscapularis muscle lying on the scapula
Medial wall: deep fascia covering chest wall, upper ribs, intercostal & serratus ant muscle.
surgical importance:
n. to serratus ant.
lies here
Apex : points upwards &
medially where layers of
fascia comes into contact
with
each other.
Base : points downwards & laterally & it is
open
Surgical importance : Block dissection
of axillary lymph nodes should excise the
‘tent’intact
Lymphatic of the overlying skin: These drains the integuments over the breast, but not the skin of the
areola & nipple. They pass in a radial direction & end in the surrounding nodes. Lymphatics from outer side- goes to axillary nodes Skin of the upper part – supraclavicular nodes & certain of the vessels may
end in cephalic nodes(which lies along with cephalic vein in deltopectoral groove)
Skin of the inner part of the breast- goes to internal mammary nodes. Lymphatics of the skin over the breast communicates across midline &
unilateral disease may become bilateral by these roote.
Lymphatics of the parenchyma of the breast:
2nd leading cause of death
2nd most common cancer
Incidence increases with age
All women are at risk
Breast Cancer Facts
Stage 0: Tis N o M o
Tis = carcinoma in situ
N o= no reginal lymph node metastasis M o= no distant
metastasis
Stage 1: T1 N o M o
T 1 = tumor 2cm or less
in greatest dimension
Stage 2a: To N1 Mo N1=
metastasis to ipsilateral
ax. Nodes T1 N1 Mo mobile
T2 N o Mo T2= tumor>2cm
but <5cm in greatest dimention
Stage 2b:
T2 N1 Mo
T3 N o Mo T3= tumor size
> 5cm in greatest dimention
Stage 3a N2a =met to ipsilat axillary node , fixed or matted
N2b= met to ipsilat int mammary node in absence of ax. node
T o N2 M o
T1 N2 Mo
T2 N2 Mo
T3 N1 Mo
T3 N2 Mo
Stage 3b
T4a= extension to chest wall
T4b= edema(Peaud’ Orange),
T4c= both T4a& T4b
T4d= inflammatory carcinoma
T4 No Mo
T4 N1 Mo
T4 N2 Mo
T4 N2 Mo
Stage 3 c N3a= met to ipsilat infraclavicular LN
N3b= ipsilatInternal mammary& axillary LN
N3c= ipsilat supraclavicular LN
Any T
N3
Mo
Stage 4 : Any T any N + M1 M1= distant metastasis
Patient with locally advanced breast cancer include – large primary tumors(>5cm)
- tumor involving the chest wall
- skin involvement
- ulceration or satellite skin nodule
- inflammatory carcinoma
- bulky or fixed axillary node
- internal mammary or
supraclavicular node involvement
blood vessel or lymph vessel invasion
- HER 2/neu overexpression
- negative hormone receptor status
Such cancer span stages 2b, 3a & 3b disease.
Central to treatment is the concept that disease has advanced on the chest wall or regional lymph node with no evidence of distant metastasis.
Such patients are recognized to be at significant risk for development of subsequent metastasis & treatment must address the risk of both local & systemic relaps.
Till 1970s surgery alone provided poor local control, with relapses rate
- 30 – 50% mortality rate - 70% Similar results are reported when
radiotherapy was the sole modality of treatment.
Current management includes - surgery - radiotherapy - systemic therapy
Simple or total mastectomy: removal of all breast tissue, nipple
areola complex, & skin
Extended simple mastectomy:
removal of all breast tissue, nipple areola complex, & skin + level 1 axillary lymph node
Modified radical mastectomy:
removal of all breast tissue, nipple areola complex, & skin + level 1 & level 2 axillary lymph nodes.
Modified radical mastectomy:
removal of all breast tissue, nipple areola complex, & skin + level 1 & level 2 axillary lymph nodes.
Administration of systemic chemotherapy or hormonal therapy result in reduction of tumor size in 50 to 80% of the patients with locally advanced breast carcinoma
Preoperative or neoadjuvant therapy can convert
Inoperable tumor that require can shrink
Tumor mastectomy large tumor
Operable one to eligible for to allow more
lumpectomy cosmetic lumpectomy
C M F regimen C – cyclophosphamide M – methotrexate F – 5 flurouracil FAC regimen F – 5 flurouracil A – adriamycin(doxorubicin) C – cyclophosphamide AC regimen A – adriamycin C - cyclophosphamide
Trastuzumab : is a humanized murine (Herceptin) monoclonal antibody
raised against erb B2, HER 2 surface receptor Laptinib : a dual inhibitor of both - EGFR - HER 2
Beatson , a surgeon in glasgow cancer hospital was the first to demonstrate that BL oophorectomy can lead to metastatic breast cancer.
Huggins, reemphesized oophorectomy & demonstrated the effectiveness of adrenalectomy in treatment of metastatic breast cancer.
But endocrine ablation therapy has been replaced by antiestrogen therapy.
Tamoxifen(estrogen agonist-antagonist) is the first line treatment of estrogen
sensitive breast cancer.
Class Common examples
Clinical use
Selective estrogen receptor modulator(SERMS)
Tamoxifen, Raloxifen,Toremifen
Adjuvant therapy for metasttic disease
Aromatase inhibitors(AIs)
AnastrazoleLetrozoleExemestane
Adjuvant therapy for metasttic disease
Pure antiestrogenLutinizing hormone- releasing hormone(LHRH)
FluvistrantGoserelinLeuprolide
-2nd line therapy for metastatic disease-Adjuvant therapy for metasttic disease
Progestational agents
Megestrol 2nd line therapy for metastatic disease
Androgens Fluoxymesterone 3rd line therapy for metastatic disease
High dose estrogens
Diethylstilbestrol 3rd line therapy for metastatic disease