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CHAPTER 6 Breast and endocrine surgery
242
Surgical treatment of breast cancer
Surgery is the mainstay of non-metastatic disease. Options for treatment
of the primary tumour are as follows.
Wide local excision
• To ensure clear margins.
• Commonest procedure.
• Breast-conserving, provided breast is adequate size and tumour
location appropriate (not central/retro-areolar).
• Usually combined with local radiotherapy to residual breast to reduce
risk of local recurrence.
Simple mastectomy
• Best local treatment and cosmetic result for large tumours (especially
in small breast), central location, late presentation with complications
• Also used for multifocal tumours or where there is evidence of
widespread in situ changes.
• Adjuvant breast radiotherapy is very rarely necessary.
• Performed with reconstruction at the same time or later stage
including:
Latissimus dorsi fl ap;•
TRAM fl ap;•
Prosthesis (see • b p. 618).
Surgical management of regional lymph nodes
Axillary node sampling
• Minimum of four nodes should be retrieved.
• Avoids complete disruption to axillary lymph drainage, reducing risk of
lymphoedema.
• Is inadequate for treatment of the axilla. If nodes are +ve, they require
adjuvant radiotherapy to axilla or axillary node clearance.
Axillary node clearance
• Optimizes diagnosis and treatment of axilla.
• Increases risk of lymphoedema greatly.
Sentinel node biopsy
• One or two nodes primarily draining tumour identifi ed by radioactive
tracer or dye injected around tumour and node(s).
• Identify positive nodes, then require a full axillary clearance.
• Avoids major axillary surgery where not necessary.
Surgery for metastatic disease
Surgery in metastatic disease is limited to procedures for symptomatic
control of local disease (e.g. mastectomy to remove fungating tumour).
Ductal carcinoma in situ (DCIS)
• Precancerous condition.
• Ten to fi fty per cent develop invasive ductal cancers.
SURGICAL TREATMENT OF BREAST CANCER
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• Mammograms show microcalcifi cation.
• Pathologically graded to low grade, intermediate grade, and high grade.
• DCIS is treated with wide local excision with clear margin.
• Mastectomy needed in larger breast lesions or multifocal disease.
• High grade DCIS treated by post-operative radiotherapy after wide
local excision.
• Axillary surgery is not needed as there is no potential for lymph node
metastasis.
243
CHAPTER 6 Breast and endocrine surgery
244
Breast cancer screening
Aims
• To identify asymptomatic (hopefully early) invasive breast cancer.
• To identify asymptomatic carcinoma in situ.
• Features looked for on screening mammography include: spiculated
calcifi cation; microcalcifi cation.
What is offered?
• Since 1988, population-based screening has been offered.
• Arranged regionally with centrally activated postal invitation.
• Starts age 50 and continues to age 70 (cover peak ages of incidence
of new diagnoses and excludes low risk younger women—‘prevents
psychological morbidity of screening the well’); plans to extend screening
age group from 47–74y.
• Two view (lateral and oblique) mammography of both breasts.
• Suspicious or malignant-looking lesions invited for clinical assessment
by standard triple assessment.
Results
• Seventy per cent of women offered it will accept screening (lowest
take-up in socio-economic groups and those diffi cult to contact, e.g.
rapidly changing addresses or no fi xed address).
• Ten per cent of invasive carcinoma is not radiologically detectable
(false negative rate).
• Risk of a false positive screening is approximately 25% over 10y of
screening.
• For every 1000 women screened over 10y, around 200 are recalled
because of an abnormal result.
Sixty (6%) will have at least one biopsy.•
Fifteen (1.5%) will have invasive cancer.•
Five (0.5%) will have DCIS.•
• Absolute reduction in cancer deaths due to screening over 10y are:
0.5 per 1000 at age 40.•
2 per 1000 at age 50.•
3 per 1000 at age 60.•
2 per 1000 at age 70.•
• Studies suggest up to a 30% reduction in mortality from screen-
detected early breast cancer.
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CHAPTER 6 Breast and endocrine surgery
246
Benign breast disease
Most benign breast conditions arise from pathology related to abnormalities of the normal development and involution of the breast (ANDI).
Other benign diseases are related to infection or trauma.
Fibroadenoma
Benign overgrowth of one lobule of the breast. Usually isolated, may be
multiple or giant, especially in Afro-Caribbeans. Commonest under age 30,
but may occur at any age up to menopause.
• Features. Painless, mobile, discrete lump.
• Diagnosis. Ultrasound usually conclusive.
• Treatment. Excision if concern over diagnosis, cosmesis, or symptoms.
Cysts
Almost always benign, fi lled with green-yellow fl uid. Often associated with
fi brocystic disease (below).
• Features. Round, symmetrical lump(s); may be discrete or multiple.
Occasionally painful.
• Diagnosis. Aspiration—typical fl uid returned; residual mass or
recurrent cysts—mammography to exclude associated tumour.
• Treatment. Repeated aspiration; hormone manipulation occasionally
useful for multiple recurrent cysts.
Fibrocystic disease
Combination of localized fi brosis, infl ammation, cyst formation, and hormone-driven breast pain. Occurs almost exclusively between menarche
and menopause (15–55y).
• Features. Cyclical pain and swelling, ‘lumpy’ breasts, multiple breast
cysts.
• Diagnosis. Lumps usually require triple assessment (even once a
diagnosis of fi brocystic disease is made—any woman may develop a
carcinoma).
• Treatment. Reassurance, anti-infl ammatories, hormone or ‘cellular’
manipulation (e.g. G-linoleic acid/evening primrose oil, combined oral
contraceptive (COC) pill, cyst aspiration).
Breast infections
Lactational mastitis
Due to acute staphylococcal infection of mammary ducts. May degenerate
into an acute lactational abscess. Treat with oral antibiotics and (repeated)
aspiration if abscess occurs. No need to stop lactating.
Recurrent mastitis/mammary duct ectasia
Due to dilated, scarred, chronically infl amed subareolar mammary ducts.
Associated with smoking. Present with recurrent yellow-green nipple discharge or recurrent breast abscesses. Infection is usually mixed
anaerobic based. Treatment with metronidazole and drainage of acute
abscesses. Surgery is rarely necessary.
BENIGN BREAST DISEASE
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Traumatic fat necrosis
Post-traumatic disorder of breast tissue caused by the organization of
acute traumatic injury by:
• Fibrosis.
• Organized local haematoma.
• Occasionally calcifi cation.
Presents with new, painless or painful breast lump, often poorly defi ned.
History of trauma is often absent.
Diagnosis may be diffi cult even on triple assessment. Failure to resolve
or doubt about diagnosis after assessment is an indication for excision
biopsy.
247
CHAPTER 6 Breast and endocrine surgery
248
Acute breast pain
Causes and features
Breast origin
• Breast abscess. Acute severe, localized pain in the breast, associated
with swelling, redness, and sometimes purulent nipple discharge. Most
common in breastfeeding women. May be due to chronic mastitis/
mammary duct ectasia (see b p. 246)—occasionally recurrent.
• Mastitis. Recurrent intermittent breast pain with swelling, tenderness,
seropurulent nipple discharge. Most common in smokers; associated
with mammary duct ectasia (see b p. 246).
• Fibrocystic disease (see b p. 246). Usually recurrent or chronic
breast pain, but may be acute isolated episode. Often multifocal and
associated with tender vague swelling or ‘lumpiness’.
Non-breast origin
• Musculoskeletal. Often onset after exercise, coughing, or straining,
but not always. No associated breast symptoms. Pain usually sharp
and precipitated by movement or breathing. Often tender deep to
breast tissue and over other chest wall areas (e.g. costochondral
junctions in costochondritis (Tietze’s disease)). May be due to pleural
disease (post-pneumonic, post-pulmonary embolism, viral pleurodynia
(Bornholm’s disease)).
• Visceral. May be due to atypical angina or acute coronary syndrome.
• Skin pathology. Such as infected sebaceous cysts, cellulitis, skin abscess.
Emergency management
Establish a diagnosis
• Good inspection and careful history taking is usually all that is required.
• Imaging is rarely necessary and is often painful if the pathology is
primary breast. Mammography should be avoided due to the breast
compression required. Breast ultrasound may help, particularly in the
diagnosis of breast abscess.
• Consider specialist referral or opinion if PE, cardiac ischaemia, or
pneumonia suspected. CXR is simple, but often unhelpful.
Early treatment
• Give adequate analgesia. NSAIDs (diclofenac (Voltarol
100mg PR) are effective in most causes. Opiates may be necessary.
• Breast abscesses may be effectively aspirated for relief of pressure
symptoms under local anaesthetic. Formal incision and drainage is
often avoided, especially in lactational abscesses.
®
) 50mg PO or
ACUTE BREAST PAIN
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Defi nitive management
• Breast abscess. If lactational, oral antibiotics (including fl ucloxacillin
500mg tds) and aspirational drainage (often repeated several times on
a daily or alternate day basis). If associated with chronic mastitis, oral
antibiotics (to include metronidazole 400mg PO tds or co-amoxiclav
750mg tds PO).
• Fibrocystic disease. NSAIDS (e.g. ibuprofen 400mg prn), G-linoleic acid,
danazol, occasionally tamoxifen.
249
CHAPTER 6 Breast and endocrine surgery
250
Goitre
Key facts
• Goitre refers to an enlarged thyroid gland (from the Latin guttur,
meaning throat).
• For clinical practice, ‘enlargement’ is taken to mean a thyroid gland
that is easily visible or palpable with the neck in neutral position.
Pathological features
• Goitres result from follicular cell hyperplasia at one or multiple sites
within the thyroid gland.
• The mechanism is multifactorial—genetic, environmental, dietary,
endocrine, and other factors.
On the basis of clinical and pathological features, goitre can be subclassifi ed as follows.
• Epidemiology.
Endemic.•
Sporadic.•
Familial.•
• Morphology.
Diffuse.•
Nodular.•
Multinodular. —
Solitary nodules. —
• Thyroid function status.
Toxic.•
Non-toxic.•
• Location.
Cervical.•
Retrosternal.•
Intrathoracic.•
Clinical features
Sporadic nodular goitre
• Commonest surgical presentation of thyroid disease.
• Generally asymptomatic and usually present with a neck mass or
compressive symptoms.
• Present as a small, diffuse, or nodular goitre and is generally euthyroid.
Compressive symptoms
• More likely to occur in patients with a retrosternal extension (at the
thoracic inlet, the bony structures create a limited space that cannot
expand).
• Growth of the goitre may cause:
Dyspnoea (worse when lying fl at) due to tracheal displacement.•
Dysphagia due to oesophageal compression.•
Voice changes due to recurrent laryngeal nerve (RLN) pressure.•
GOITRE
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Distended neck veins, facial plethora, swelling, and stridor due to •
superior vena caval compression (worse with arms raised above
the head—‘Pemberton’s sign’).
Cosmesis May or may not be a signifi cant problem—varies widely.
Hyperthyroidism or hypothyroidism
• The vast majority of patients with goitre will be euthyroid.
• May be apparent clinically or biochemically (hyper = i free T
hypo = d free T
, i TSH).
4
, d TSH;
4
Diagnosis and investigations
• Thyroid function tests ((TFTs) for TSH and free T4). Usually normal,
especially outside endemic areas.
• CXR. Look for tracheal deviation and a retrosternal shadow.
• Thoracic CT. Used to defi ne the anatomy in patients with large
intrathoracic extension.
• Preoperative laryngoscopy. To assess the possibility of pre-existing RLN
palsy.
Treatment
Surgical treatment
• Indications include:
Relief of local compressive symptoms.•
Cosmetic deformity.•
Prevention of progressive thyroid enlargement.•
• Thyroid lobectomy is feasible if there is asymmetric enlargement with
only the one lobe creating the obstructive symptoms. This avoids the
need for long-term thyroxine replacement (important mainly in areas
where medical facilities are limited).
• Total thyroidectomy offers immediate improvement of obstructive
symptoms, minimal morbidity in experienced hands, less risk of
recurrent symptoms, particularly in large or retrosternal goitres.
Medical treatment
• Oral levothyroxine (
with iodine defi ciency or subclinical hypothyroidism (i.e. when a raised
TSH stimulates the enlargement of the thyroid gland).
• Radioactive iodine (
with a decrease in goitre volume up to 50% in 2y. Large (or repeated)
131
doses of
I are needed. Used for non-toxic goitres (more in Europe
). Used to reduce the size of goitres in patients
lT4
131
I). Induces a gradual destruction of thyroid tissue,
than UK or USA).
• The risks of radioactive iodine are:
Radiation thyroiditis (acute thyroid swelling can potentially be •
dangerous in patients with large substernal goitres).
Temporary thyrotoxicosis (due to rapid release of preformed •
hormones from the destroyed follicles).
Late hypothyroidism due to over-destruction of the gland.•
251
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