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292
Nerve Anatomy Innervation Injury Surgical anatomy
S. C. Wimann et al.
Lies within a
neurovascular
bundle that
Medial pectoral
nerve
Lateral pectoral
nerve
Intercostobrachial
nerve (lateral
cutaneous branch
of second
intercostal nerve)
wraps around
the lateral
border of the
pectoralis
minor muscle
Pierces the
clavipectoral
fascia to reach
the deep
surface of
pectoral
muscles
Most superior
nerve that runs
just below
axillary vein
Radiological Findings
Pectoral major
and minor
Pectoral major Atrophy,
Sensation to
medial arm and
axilla
Inability to
elevate the
shoulder
areolar
asymmetry,
and
weakness of
pectoralis
major
muscle
Numbness
to medial
arm and
axilla
The pectoral neurovascular bundle is a useful
landmark because it indicates the position of
the axillary vein, which is superior and
posterior to the bundle
Risk of injury when level 3 nodes dissection
Most common nerve injured with axillary
dissection
Can transect without serious consequences
Preservation of the most superior nerve
maintains sensation to the posterior aspect of the
upper part of the arm without compromising the
axillary dissection
Pathology Ultrasound ndings Radiology
Hypoechoic smooth oval masses with
regular borders
Benign lesions
Well- circumscribed shape
No color Doppler signal inside the
lesion
Transversely-oriented ultrasound image of the left
breast at the 2:00 position, 11cm from the nipple,
demonstrates an 8mm hypoechoic well-circumscribed
nodule (arrow), consistent with a broadenoma
10 Breast andOncology
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Pathology Ultrasound ndings Radiology
Malignant lesions Hypoechoic irregular masses that are
taller than wider
Posterior acoustic shadowing
Color doppler signal inside the lesion
Transversely-oriented ultrasound of the left breast
demonstrates an ill-dened, taller than wider
hypoechoic mass (arrow) with posterior shadowing
(star)
Breast abscess Hypoechoic collection, multiloculated
No vascularity within collection
Acoustic enhancement due to uid
content
Echogenic vascular rim
293
Targeted ultrasound of the left breast demonstrates a
complex uid collection (arrow) with an echogenic
rim, peripheral vascularity, and posterior acoustic
enhancement, consistent with an abscess
Benign Inammatory Breast Disease
Non-lactational mastitis: periductal mastitis
Characteristics Inammatory condition of the subareolar ducts
Most commonly presents in smokers (Damage to ducts from toxins in cigarette smoke and local
hypoxia)
Presents with periareolar inammation ➔ secondary infection ➔ duct damage and rupture with
abscess formation➔ recurrent periductal abscess ➔ stula formation
Central abscesses ➔ due to periductal mastitis
Peripheral abscesses ➔ associated with underlying disease states such as diabetes, rheumatoid
arthritis, steroid treatment, and trauma
Periductal mastitis is usually a chronic problem
294
Non-lactational mastitis: periductal mastitis
Management Case Management
S. C. Wimann et al.
Uncomplicated case of
mastitis (without an
abscess)
Complicated cases of
mastitis (with abscess):
Empiric antibiotics for periductal mastitis
Amoxicillin-clavulanate or dicloxacillin
If anaerobes suspected ➔ cephalexin + metronidazole
If high risk for MRSA ➔ trimethoprim-sulfamethoxazole or doxycycline
Reasons for uncomplicated mastitis that did not resolve in 2weeks
Antibiotics is not sensitive
Symptomatic management (NSAIDs and cold compresses)➔
resolves within 4–6weeks
If the skin overlying abscess is intact➔ ultrasound- guided serial
aspirations + antibiotics
Repeat aspiration until mastitis resolves
If the skin has thinned ➔ small incision for drainage
Recurrent infections ➔ chronic skin changes (scarring and
nipple retraction) ➔ duct excision
➔culture of milk or purulent drainage to guide antibiotic therapy
➔MRSA as possible pathogen
➔less frequent pathogens streptococcus pyogenes, E. coli,
Bacteroides, and coagulase- negative staphylococci
➔recurrent breast abscess ➔ increased incidence of mixed ora
and anaerobic infection
It has become complicated
Presence of malignancy
➔aspiration vs incision and drainage
➔biopsy to rule out malignancy
Non-lactational mastitis: granulomatous mastitis
Rare, benign inammatory disease of unknown etiology
Characteristics
Linked to Rheumatoid arthritis and autoimmune disease
Diagnosis
Management
Prevalent in nonwhite and childbearing age
Present as multiple simultaneous areas of peripheral inammation with abscesses and overlying
skin inammation and ulceration
If granulomas are present ➔ rule out tuberculosis or sarcoidosis ➔core needle biopsy
(CNB)➔ send for gram stain, bacterial and fungal cultures, acid-fast bacilli stain and
culture)
Check for Corynebacterium
Imaging: mammography and ultrasound (mastitis appears as a solid and irregular mass)
Self-limiting condition that resolves slowly (complete resolution in 5–20months)
If drained ➔ recurrence
Use of steroids is controversial
Surgery is not indicated (can cause are-ups of the condition)
Follow-up ultrasound
10 Breast andOncology
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Lactational mastitis
295
Characteristics
Presentation Present as cellulitis with fever, pain, redness, and swelling
Management
Caused by the proliferation of Staphylococcus aureus in poorly drained breast segments
Most common during the rst 4–6weeks of breastfeeding or during weaning
Reactive lymphadenopathy can also cause axillary pain and swelling
Continue breastfeeding or pumping➔ to drain the engorged segment
Culture breast milk
If symptoms do not improve in 48–72h ➔ ultrasound to rule out abscess
Avoid surgical intervention or needle aspiration in lactating women ➔ lead to milk stula
(usually resolves spontaneously➔ if it persists➔ cessation of breastfeeding)
Antibiotics for Lactational mastitis
Dicloxacillin or cephalexin
If high risk for MRSA ➔ trimethoprim-sulfamethoxazole or clindamycin
Severe infection ➔ vancomycin
Avoid tetracycline, chloramphenicol, and ciprooxacin in lactating women
Mondor’s disease
Supercial vein thrombophlebitis of breast
Thickened palpable cord in subcutaneous breast
Characteristics
Involves lateral thoracic, thoracoepigastric, and superior epigastric veins
Mondor’s disease is not a sign of hypercoagulable state
Diagnosis Diagnosis by physical exam
If concerned for malignancy ➔ order imaging
Mammogram: Beaded cord representing thrombosed vein
Management Warm compresses and NSAIDs
Resolves in 2–8weeks spontaneously
Nipple Discharge
Nipple discharge
Characteristics Most common cause is papilloma (50%)
Most nipple discharge is benign
Causes Lactation, physiologic discharge triggered by medications or hormonal changes, and pathologic
nipple discharge
Diagnosis
If nipple discharge + suspicious lesions ➔ Core needle biopsy (CNB)
5–15% of nipple discharge is associated with malignancy (Most commonly DCIS)
296
Nipple discharge
S. C. Wimann et al.
Discharge type Bloody Serous Green/yellow/brown
discharge
Management
Intraoperative
key steps
Breast Pain
Characteristics Most common
intraductal
papilloma
Management Excision of
ductal area
• Spontaneous discharge ➔ worrisome for cancer ➔ excisional biopsy of ductal area
• Nonspontaneous discharge ➔ needs excisional biopsy if bloody
• Women <30years + nipple discharge ➔ U/S
• Women >30years + nipple discharge ➔ diagnostic mammogram + U/S ➔ no ndings ➔
MRI or ductography ➔ no ndings ➔ duct excision
Localize the duct with lacrimal duct probe or via preoperative ductography
If the lesion cannot be localized ➔ complete subareolar duct excision
If the lesion can be localized ➔ resection is limited to the region of disease (to prevent
parenchymal disruption)
Worrisome for cancer
Especially if coming
from one duct or
spontaneous
Excisional biopsy of
ductal area
Most common due to
brocystic disease
(especially if cyclic and
nonspontaneous)
Reassure patient
Breast pain
Characteristics Upper outer quadrant most common location
Diagnosis History and breast exam
Bilateral mammogram
Treatment Reassurance is often an effective treatment for mastodynia
Evening primrose oil, vitamin E, and caffeine elimination ➔not been proven more benecial than
placebo in clinical studies
Tamoxifen➔
rst line therapy
Danazol, bromocriptine, and tamoxifen have been evaluated in randomized, controlled trials
10 Breast andOncology
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Fibroadenoma andPhyllodes Tumor
Fibroadenoma
Most common breast lesion in adolescents and young women
More common in African Americans than Caucasians
10–40% of broadenomas spontaneously regress (in adolescents)
10% are multiple
Tubular adenoma/lactating adenoma: Variant of broadenoma; have evidence of
secretory activity; do not occur in association with pregnancy or lactation; have more
lobular features
297
Characteristics
Variants Hamartoma, tubular adenoma, lactating adenoma, adenolipoma, juvenile broadenoma, and
Presentation Usually painless, slow growing, well circumscribed, rm, and rubbery
Diagnosis
Pathology Fibrous tissue compressing epithelial cells
Associated
syndromes
Management
Risk of malignancy <0.3% and exceedingly low in women <40years of age
No accurate way to grossly differentiate a giant broadenoma from a benign phyllodes
tumor
giant adenoma
Often grows to several centimeters in size then stops
Change in size with menstrual cycle and can enlarge in pregnancy
Mammography: Can have large, coarse calcications (popcorn lesions) from degeneration
In patients <40years conrm CNB to be consistent with broadenoma
In patients >40years old ➔ excisional biopsy to ensure diagnosis
Associated with Beckwith- Wiedemann syndrome, Maffucci syndrome, and Cowden
syndrome
Indications for surgical excision: Size > 3cm, symptomatic, or core biopsy demonstrating
cellularity or a rapid increase in size
Cryoablation is a safe and effective therapy for selected broadenomas
Phyllodes tumors
Exhibits hypercellularity within the stroma
Tumor will stain positive for vimentin and actin
Causes and Diagnosis
WHO classication of phyllodes tumor
Benign Borderline Malignant
Minimal cellularity and
atypia
Well circumscribed Zone of microscopic
Moderate cellularity and
atypia
invasion around tumor
Increased cellularity
Invasive margins
Sarcomatous appearance
298
Cancer cells
asive Breast
Phyllodes tumors
Wide excision with 1–2cm margin of normal breast tissue
Large tumors ➔ mastectomy may be required
Management
No axillary node (because it spreads hematogenously)
No role for chemotherapy or radiation or hormonal therapy
Gynecomastia
Gynecomastia
Characteristics Mostly occurs in neonatal, pubertal, and older men
Elevations of leptin and insulin-like growth factor-1in puberty ➔ pubertal gynecomastia
(resolves spontaneously within 6–24months)
Causes • Persistent pubertal disease
• Cirrhosis
• Malnutrition
• Hypogonadism, testicular and adrenal tumors, hyperthyroidism
• Chronic kidney disease and dialysis
S. C. Wimann et al.
• Antiandrogens or inhibitors of androgen synthesis: spironolactone, ketoconazole,
nasteride
• Hormones: anabolic steroids, androgens, estrogens, and growth hormones
• Antibiotics: metronidazole
• H2 blockers and proton pump inhibitors
• Cardiovascular drugs: ACE-I and CCB
• Psychoactive drugs (diazepam, haloperidol, tricyclic antidepressants, alcohol,
marijuana, amphetamines, and heroin)
Diagnosis Routine mammogram, ultrasound, and biopsy if unilateral
Management Discontinue cause if possible
First line: Tamoxifen ➔resolve 60–90%
Proliferative Breast Disease
Nonproliferative
- Fibrocystic changes
- Cysts
- Fibrosis
- Adenosis
- Lactational Adenomas
1.0
Ductal Hyperlasia
Proliferative
without atypia
- Epithelial hyperplasia
- Sclerosing Adenosis
- Radial scar
(Complex sclerosing adenosis)
- Papillomas
1.5 - 2.0
Atypical Hyperlasia
Proliferative
with atypi
- LCIS
- DCIS
8.0 - 10.0
DCIS
Relative Risk
of developing
Inv
cancer
10 Breast andOncology
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Proliferative breast disease
Fibrocystic disease • Many types: bromatosis, sclerosing adenosis, apocrine metaplasia, duct adenosis,
epithelial hyperplasia, ductal hyperplasia, and lobular hyperplasia
• Symptoms: breast pain, nipple discharge (yellow, green, or brown), lumpy breast tissue
that varies with hormonal cycle
• No cancer risk except (Atypical ductal or lobular hyperplasia)
Fat necrosis • Develop following trauma, breast surgery, or radiation
• Presents as a mass, with/without tenderness
• Mammography: architectural distortion, calcication (smooth and curvilinear described
as eggshell calcications or coarse), asymmetry, radiolucent lesion
• Histology: lipid-laden macrophages, saponication, and chronic inammatory change
• Mass associated with fat necrosis may not resolve with time
• Benign nding ➔ no need for follow-up
Sclerosing adenosis • Increased number of small terminal ductules
• May be confused with cancer
• Does not have malignant potential
• Mammogram: appears as microcalcications
• Pathology: Proliferation of stromal tissue
• No excision
Radial scar • A broelastic core that pulls and distorts the ducts and lobules
• Mammography: architectural distortion with a central lucency
• Histology: elongated ducts ➔ stellate architecture
• Differential diagnosis for mammographic architectural distortion: malignancy, tubular
carcinoma, radial scar, fat necrosis
• Radial scars identied on CNB are associated with malignancy up to 25 %
➔management is surgical excision
• Small, incidental radial scars diagnosed with vacuum-assisted CNB and concordant
with imaging ndings ➔ observe
299
Simple cysts • Do not need to be aspirated although this can be done so for symptomatic relief
• Bloody uid aspirate ➔ sent for cytology
• | If aspirated uid is bloody, the cyst continues to recur, or if there are other suspicious
associated ndings ➔ tissue sampling to rule out malignancy
Intraductal papilloma • Most common cause of bloody nipple discharge
• Usually, small, nonpalpable, and close to the nipple
• These lesions are benign ➔ get contrast ductogram to localize then needle localization
• Treatment: subareolar resection of the involved duct and papilloma
300
a
Proliferative disease with atypia
Pathology ADH ALH LCIS
S. C. Wimann et al.
Figure
Increased
4–5× 4–5× 8–12×
relative risk
of cancer
Signicance Risk indicators rather than precursor lesions
Pathology Proliferation of uniform
epithelial cells with
monomorphic round
nuclei lling part, but not
all, of the involved duct
Proliferation of
monomorphic
cells lling, but
not expanding
lobule
Normal lobule with distended acini
Multifocal and bilateral
Lacks E-cadherin expression
Incidence 4% in breast biopsies 0.5–3.8%
More frequent in young premenopausal females
Diagnosis CNB as the target lesion
on biopsy
Management
ADH, ALH, LCIS found on CNB ➔ wire or seed localization excisional breast biopsy (to exclude
Incidental nding
on breast biopsies
Incidental nding on breast biopsies
associated malignant lesion)
Upgraded to DCIS or invasive breast cancer in 10–20% of cases
If ADH, ALH, or classic LCIS is conrmed on excisional biopsy ➔ do not re-excise if there are
positive margins, except in the case of pleomorphic LCIS
Lobules
Duct
Normal
lobules
Lobular
Carcinom
in situ
If ADH is diagnosed on an excisional
biopsy➔ no additional surgery except: if
ADH is only present at the margin, if it is
bordering on reaching criteria for diagnosis
as DCIS at the margin, there is concern that
the imaging target was not completely excise
➔ re-excision
+Risk reduction therapy
Pleomorphic LCIS ➔ more aggressive ➔ treat with
surgical excision (negative margins); no radiation
needed
+Risk reduction therapy
10 Breast andOncology
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Ductal carcinoma in situ (DCIS)
Malignant cells of the ductal epithelium without invasion of basement membrane
DCIS progress from Papillary ➔ Cribiform ➔ Comedo
Comedo: Most aggressive subtype; notable for presence of central necrotic areas; large
pleomorphic nuclei; numerous mitotic gures; microcalcication; high risk for
multicentricity, microinvasion, and recurrence
301
Characteristics
Management
Women <40years present with high-grade DCIS
Increased recurrence risk: high grade, comedo type and lesions>2.5cm, positive margins,
younger age
Not palpable and presents as cluster of calcications on mammography
MRI can be used to determine the extent of the disease, evaluate tumor physiology, evaluate
for tumors in contralateral breast, and evaluate for multicentricity
MRI is associated with low specicity and high false positive rates in breast cancer
Lumpectomy (1cm margin)+radiation therapy (XRT)+risk reduction therapy
Breast conservative therapy (BCT) indications➔ lesion limited to one quadrant,
cosmetically acceptable results can be achieved
Mastectomy indications➔ multicentric DCIS, centrally located, large lesions
(immediate reconstruction can be done after mastectomy)
SLNB indications➔ lesions >4cm; comedo type palpable breast lesions; high-grade
disease; microinvasive disease; suspicious axillary lymph nodes, patient undergoing
mastectomy
Radiation Therapy indications➔ for all BCT (except patients with small foci of
low-grade disease that was resected with negative margins; patients with signicant
comorbidities; patients with advanced age) ➔ reduces the risk of local recurrence of both
invasive and noninvasive breast cancer, does not reduce the risk of disease recurrence in
contralateral breast and does not decrease overall or disease-specic mortality
Radiation is most effective when no identiable tumor is present at the margins
Hormone receptor therapy indications: ER-positive DCIS (tamoxifen for 5years) ➔
prevent ipsilateral recurrence and new breast cancer
Postoperative problem Management
Positive margin is present after partial
mastectomy
Positive margin is present and unable
to determine margin
Ipsilateral DCIS recurrence Unilateral mastectomy + SLNB
Re-excision
Re-excision of all 6 faces or total mastectomy
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