Breast Surgery. A Companion to Specialist Surgical Practice

Cover
Front Matter
Copyright
Evidence-based practice in surgery
Anatomy and physiology of the breast
	Normal breast development: embryology and physiology
		Embryology
			Clinical considerations
		Puberty
			Clinical considerations
		Pregnancy and lactation
			Clinical considerations
		Menopause
			Clinical considerations
	Breast anatomy
		Microscopic anatomy
			Clinical considerations
		Gross anatomy
			Breast shape/skin
			Clinical considerations
			Blood supply to the breast
			Clinical considerations
			Lymphatic drainage of the breast
			Clinical considerations
			Innervation of the breast, and nerves of the axilla
			Clinical considerations
Assessment of patient with breast symptoms
	Triple assessment
	Clinical evaluation
		Clinical history
		Clinical examination
		Lump
			Axillary lump
		Pain
		Discharge (Figs 2.4–2.6)
		Nipple retraction
		Change in breast shape
		Skin changes
		Gynaecomastia
	Radiological assessment
		Mammography
			Additional mammographic techniques
				Tomosynthesis
				Contrast-enhanced spectral mammography (CESM)
		Ultrasound
			Additional ultrasound techniques
				Automated whole breast ultrasound (ABUS)
		Magnetic resonance imaging
			MRI as a screening tool
		CT scanning
		Isotope bone scan
		Molecular imaging
		Radiation-induced cancers
	Image-guided breast intervention
		Techniques
			Fine-needle aspiration
			Core biopsy
			Vacuum-assisted diagnostic biopsy (VAB)
			Vacuum-assisted excision (VAE)
			INTACT device
		Guidance techniques for image-guided intervention
		Marker clip placements
		Number of samples
		Biopsy results
	Key references
Benign breast conditions
	Introduction
	Congenital abnormalities
	Aberrations of normal breast development and involution (ANDI)
		Aberrations of breast development
			Fibroadenomas
				Management
			Tubular and lactating adenomas
			Macromastia, so-called virginal or juvenile hypertrophy
		Aberrations in the early reproductive period
			Pain and nodularity
				Mastalgia
				Assessment
				Treatment
			Breast pain overview
		Aberrations of involution
			Palpable breast cysts
				Imaging
				Management
			Sclerotic/fibrotic lesions
			Duct ectasia
	Benign neoplasms and proliferations
		Epithelial hyperplasia
		Atypical hyperplasia on core needle biopsy
		Ductal papillomas
			Multiple intraductal papilloma syndrome
		Phyllodes tumours
		Lipomas
		Granular cell tumours
	Breast infections
		Neonatal infection
		Lactational infection
		Non-lactational infections
			Periareolar infection
				Treatment
			Mammary duct fistula
				Treatment
		Peripheral breast infection
			Granulomatous lobular mastitis
			Skin-associated infection
		Post-surgical infection
		Infection associated with breast implants
		Other infections and inflammatory conditions
	Other benign conditions seen in the breast
		Hamartoma
		Nipple adenoma
		Bloody nipple discharge in pregnancy
		Eczema of the nipple
		Raynaud’s disease of the nipple
			Jogger’s nipple
		Pseudoangiomatous stromal hyperplasia of the breast (PASH)
		Fibromatosis
		Montgomery's gland problems
		Fat necrosis
		Diabetic mastopathy
		Sclerosing lymphocytic lobulitis
		Haematomas
		Para-areola cysts
		Mondor's disease
		Morphoea
		Arteritis and aneurysm
		Sarcoidosis
		Keloids of the breast skin
		Factitial disease
	Nipple discharge
		Investigation
	Operations commonly performed in benign breast conditions
		Microdochectomy
		Total duct excision or division
	Common complications of cosmetic breast surgery
		Breast augmentation complications
			Capsular contraction
			Rippling/palpable implant edge
			Implant rupture
		Breast reduction problems
			Fat necrosis
			Inclusion cyst
	Key references
Breast pathology
	Introduction
	Macroscopic assessment of specimens
	Carcinoma in situ
	Invasive cancer
		Histological type
		Histological grade
		Tumour size
		Lymphovascular invasion (LVI)
		Lymph node status
		TNM staging
	Predictive biomarkers
		Oestrogen receptor
		HER2
		Triple-negative breast cancer
	Prognostication
	Other multiparameter tests for risk stratification
	Conclusion
	Key references
Epidemiology, risk factors and prevention strategies
	Risk factors for breast cancer
		Age, geography
		Age at menarche and menopause
		Age at first pregnancy
		Breast density
		Previous benign breast disease
		Diet and alcohol
		Weight and height
		Breastfeeding
		Exogenous hormones
		Physical activity
	Genetics
		Family history
		BRCA1 and 2 genes
		Other genes
	Risk assessment
	Prevention of breast cancer
		Therapeutic options
			Tamoxifen
			Raloxifene
			Lasofoxifene/Arzoxifene
			Aromatase inhibitors
				Adjuvant trials
				Prevention trials
		Other agents
		Surgical options
	Key references
Breast screening
	Introduction
		Single- versus double-view mammography
		Age extension of breast screening
	Controversies of breast screening
	NHS Breast Screening Programme (NHSBSP)
	Quality standards
		First stage of screening
		Second-stage screening
		Higher-risk surveillance through NHSBSP
		Interval cancers
	Updates in breast screening
	Surgery for clinically occult breast lesions
		Guided excision
	Oncoplastic considerations for screen-detected lesions
Breast-conserving surgery: the balance between good cosmesis and local control
	Introduction
	Selection of patients for breast conservation
	Factors affecting local recurrence after breast-conserving surgery
		Patient-related factors
		Tumour-related factors
			Tumour phenotype
			Tumour size
			Tumour grade
			Histological type
			Lymphatic/vascular invasion
			Extensive in situ component
			Multiple tumours
		Treatment-related factors
	Breast-conserving surgery
		Special technical details: wide local excision
		Excising impalpable cancers
	Factors influencing cosmetic outcome after breast-conserving surgery
		Patient factors
		Tumour factors
			Location of tumour
		Surgical factors
			Re-excision and number of procedures
			Axillary surgery
			Postoperative complications
		Breast-conserving surgery after neoadjuvant therapy
		Radiotherapy
		Other treatment effects
		Treatment of poor cosmetic results after breast-conserving surgery
	Significance and treatment of local recurrence
	Key references
Oncoplastic breast-conserving surgery
	Introduction
	What about oncological outcomes?
	Selection of cases for oncoplastic breast-Łconserving surgery
	Causes of deformity after breast-conserving surgery
	Oncoplastic techniques in breast-conserving surgery
		Volume displacement or replacement?
			Volume displacement
			Volume replacement
		Timing of oncoplastic breast surgery
		Basic techniques in breast-Łconserving surgery
		Round block and tennis racket techniques
		Incisions
		Direct oncoplastic excisions with centralisation of NAC
		Direct oncoplastic excisions with removal of NAC
			Direct ellipses excisions
		Therapeutic mammaplasty
			Therapeutic reduction mammaplasty
			Therapeutic mastopexy
		Techniques of therapeutic mammaplasty by site of cancer
			Inferior pole tumours
			Medial and lateral tumours
			Tumours in the upper pole of the breast
			Tumours involving the NAC
		Volume replacement techniques
			Intercostal and lateral thoracic artery perforator flaps
		Planning a LICAP or LTAP flap
		Flap dissection
		Anterior intercostal artery perforator flaps (AIAP) and medial intercostal artery perforator (MICAP) flaps
		Thoracodorsal pedicle-based flaps
		Thoracodorsal artery perforator (TAP) flap (Fig. 8.21)
		Free flaps in breast-conserving surgery
		Omental flaps
	Case examples
		Case example 1
		Case example 2
		Case example 3
		Case example 4
		Case example 5
		Case example 6
		Case example 7
Mastectomy
	Introduction
	Completeness of mastectomy
	General considerations in planning a mastectomy
		Smoking
	Considerations for simple mastectomy
		Planning a simple mastectomy
		Technique
			Managing the potential dog ear
			Goldilocks mastectomy
			Bilateral simple mastectomy
			Undesirable scar patterns
	Radical mastectomy
	Considerations for mastectomy with immediate reconstruction
		Planning a mastectomy with reconstruction
			Tissue-based reconstruction
				Circumareolar
				Wise pattern
				Dome
				Lower vertical
			Implant reconstruction
				Nipple-sparing mastectomy
					Inframammary fold (IMF)
					Lower vertical
					Lateral lazy ‘S’
				Skin-sparing (removing nipple)
					Wise pattern
					Transvertical
					Short transverse
			Using a second incision for sentinel lymph node biopsy
			Undesirable scar patterns
		Technique
			Preoperative marking
			Practical considerations
				Lighting
				Retraction
				Identifying the ‘plane’
				Surgical tools
				Preserving the intercostal perforators
				Issues regarding posterior margin
				Inframammary fold
				The anterior fat over the shoulder
				A flat surface for simple mastectomy
				Wound closure
				Glue
				Over-dressing
			Flap necrosis
Management of the axilla
	Introduction
	Axillary node clearance
		Technique
		Complications
	Less invasive techniques for axillary staging
		Sentinel node biopsy technique
			Choice of dye
		Injection site
			Intraoperative evaluation
	Preoperative imaging and evaluation of lymph nodes
	Controversial situations
		Ductal carcinoma in situ (DCIS)
		Prophylactic Mastectomy
	Axillary dissection in node-positive patients vs radiotherapy
	Management of the axilla after neoadjuvant chemotherapy
	Management of patients presenting with axillary lymph node metastases and an unknown primary
	Conclusion
	Key references
Uncommon presentations of cancer affecting the breast
	Pregnancy-associated breast cancer
		Pathology
		Clinical presentation
		Diagnosis
		Treatment (Fig. 11.1)
			Local therapy
			Axillary staging
			Systemic therapy
			Locally advanced and inflammatory breast cancers
			Termination of and future pregnancy
		Prognosis
	Male breast cancer (Fig. 11.2)
		Pathology
		Clinical presentation
		Diagnosis
		Treatment
			Local therapy
			Adjuvant therapy
			Treatment of metastatic disease
		Prognosis
	Paget’s disease of the breast (Fig. 11.3)
		Diagnosis
		Treatment (Table 11.1)
		Prognosis
	Other breast malignancies
		Melanoma of the breast
		Primary breast lymphoma (Fig. 11.4)
		Angiosarcoma of the breast (Fig. 11.5)
		Metastasis to the breast (Fig. 11.6)
	Key references
The genetics of breast cancer, risk-reducing surgery and prevention
	Genetic predisposition
	BRCA probability models
	Genetic counselling and Łgenetic testing
	Current management strategies for BRCA1/2 mutation carriers
		Therapeutic surgery for breast cancer in BRCA1/2 mutation carriers
		Risk-reduction strategies for women with a BRCA1 or BRCA2 mutation
		Risk-reduction mastectomy for BRCA mutation carriers
			Techniques of NAC-sparing mastectomy
			Management of breast asymmetry after risk-reduction mastectomy
			Breast reconstruction in BRCA1/2 mutation carriers
			Role of sentinel lymph node biopsy in risk-reduction surgery
			Psychosocial aspects of risk-reduction mastectomy
		Bilateral risk-reducing salpingo-oophorectomy
		Use of chemopreventive agents
			Selective oestrogen-receptor modulators (SERM)
			Aromatase inhibitors
	Management of individuals with mutation in less common and moderate penetrance genes
		Variance of unknown significance (VUS)
	Summary
	Key references
Breast reconstruction
	Introduction
	Timing
		Immediate breast reconstruction
			Advantages
			Disadvantages
		Delayed breast reconstruction
			Advantages
			Disadvantages
	Contraindications
	Techniques
		Non-autologous reconstruction
			Indications
			Contraindications
			Surgical techniques
			Complications
			The silicone issue
			Breast implant-related anaplastic large-cell lymphoma (ALCL)
		Autologous breast reconstruction
			Background
			Latissimus dorsi (LD) flap reconstruction
				Indications
				Contraindications
				Flap options
				Preoperative planning
				Surgical technique
				Complications
			Breast reconstruction with lower abdominal tissue
				Indications
				Contraindications
				Surgical techniques
					Pedicled transverse rectus abdominis musculocutaneous (TRAM) flap
					Free transverse rectus abdominis musculocutaneous (TRAM) flap
					Deep inferior epigastric artery perforator (DIEP) flap
					Superficial inferior epigastric artery (SIEA) flap
				Techniques
				Complications
			Superior and inferior gluteal artery perforator (SGAP/IGAP) flaps
			Transverse upper gracilis (TUG) flap
			Profunda artery perforator (PAP) flap
			Alternative free flap donor sites
			Role of autologous fat grafting in breast reconstruction
			Staged nipple-sparing mastectomy and immediate reconstruction following mastopexy
	Finishing touches
		Surgery to the reconstructed breast
		Surgery to the contralateral breast
		Surgery to the flap donor site
		Nipple–areola reconstruction
		Complications of breast reconstruction
		Local recurrence
	Summary
	Key references
Treatment of ductal carcinoma in situ
	Background
	Risk factors, natural history, pathology and receptors
		Risk factors
		Natural history
		Stem cells
		Pathology
			Classification and features
			Lobular intraepithelial neoplasia (LIN)
		Receptors and markers
	Presentation, investigation and diagnosis
		Presentation
		Investigation and diagnosis
			Stereotactic core biopsy and vacuum-assisted biopsy
			Localisation-guided biopsy
			Other diagnostic procedures
				Ductoscopy
				Magnetic resonance imaging (MRI)
	Treatment: mastectomy versus breast-conserving surgery
		Mastectomy
		Breast-conserving surgery
		Axillary staging
	Recurrence: rates and predictors
		Assessment of excision margins
		High-grade/comedo tumours
		Histological type and tumour architecture
		Age at diagnosis
		Tumour size and palpability
		Predictive scoring systems for recurrence after conservation surgery
		Markers of recurrence
	Adjuvant therapy
		Radiotherapy
		Endocrine therapy
	Follow-up and prognosis
	Management of recurrence
		In situ recurrence
		Invasive recurrence
	DCIS of the male breast
	The future
		Ongoing DCIS trials
		UK National DCIS audit (Sloane Project)
		DCIS stem cell therapy
		Optimising treatment
	Key references
The role of adjuvant systemic therapy in patients with operable breast cancer
	Introduction
	Adjuvant endocrine therapy
		Endocrine therapy in premenopausal women
			Tamoxifen
		Endocrine therapy in postmenopausal women
			Aromatase inhibitors: first-line therapy
			Comparative toxicities of first-line aromatase inhibitors and tamoxifen
			Sequential therapy with aromatase inhibitors after tamoxifen
			Extended adjuvant therapy with aromatase inhibitors: beyond 5 years
			Other aromatase inhibitor issues
	Adjuvant chemotherapy
		Identifying which patients will benefit from adjuvant chemotherapy
			Age
			Preserving ovarian function in premenopausal women
			Nodal status
			ER status
			Molecular markers
			Gene expression assays
		Chemotherapy schedules
			Anthracycline-based chemotherapy
				Dose of anthracyclines
				Anthracyclines and HER2-positive disease
			Taxanes
				Which taxane and which schedule?
		Duration of chemotherapy
		Dose density
	Trastuzumab (Herceptin)
		Chemotherapy and trastuzumab: concurrent or sequential?
		Small HER2-positive breast cancers
		Cardiotoxicity with trastuzumab
	Triple-negative breast cancer
	Bisphosphonates
	Emerging adjuvant therapy
	Conclusion
	Key references
Neoadjuvant therapy for breast cancer, including surgical considerations
	Introduction
	Landmark clinical trials evaluating neoadjuvant chemotherapy in operable breast cancer
	Response to neoadjuvant chemotherapy
	Influence of tumour molecular subtype on response to therapy
		Triple-negative breast cancer
		HER2-positive breast cancer
		Hormone receptor-positive breast cancer
	Imaging surveillance during neoadjuvant therapy
	Implications for local regional therapy following neoadjuvant therapy
		Management of the breast primary
	Management of the axilla (see also Chapter 10)
		Radiation therapy
	Future directions
	Summary
	Key references
Adjuvant radiotherapy for breast cancer
	Background and history
	Planning and treatment delivery
	Practicalities and treatment pathways
	Radiotherapy after breast-conserving surgery
		Invasive cancer
		Radiotherapy ‘boost’
		Ductal carcinoma in situ (DCIS)
		Partial breast radiotherapy after breast-conserving surgery
		Tailored radiotherapy
	Radiotherapy after mastectomy
		Radiotherapy and breast reconstruction
		Postmastectomy radiotherapy (PMRT) after neoadjuvant chemotherapy (NACT)
	Regional nodal irradiation
		Axillary radiotherapy
		Regional nodal radiotherapy
	Fractionation
	Toxicity
		Early toxicity
		Late toxicity
	Conclusion
	Acknowledgements
	Key references
Locally advanced breast cancer
	Definition
	Epidemiology
	Pathobiology and prognosis
	Work-up and staging
	Treatment
		Neoadjuvant chemotherapy
		Neoadjuvant hormonal therapy
		Surgery to the breast/skin coverage/reconstruction
		Axillary surgery
		Radiotherapy
	Problems specific to LABC
		Complex wounds
	Summary and conclusions
	Key reference
Metastatic breast cancer and palliative care
	Introduction
	Presentation and prognosis
	Staging
	Treatment
		Systemic therapy
		Endocrine therapy
			Premenopausal women
			Postmenopausal women
		Targeted therapies in HR-positive disease
		Chemotherapy
		Biological agents
			HER2-targeted therapy
			Bone supportive therapy
		Assessment of response
		Radiotherapy
	Management of specific sites of disease
		Primary tumour
		Oligometastatic disease
		Central nervous system metastases
		Bone metastases
		Malignant spinal cord compression
		Pleural effusions and ascites
		Other interventions
	Control of symptoms
		Pain relief
		Neuropathic pain
		Nausea and vomiting
		Constipation
	Care of the dying patient
	Key references
Psychosocial issues in breast cancer
	Introduction
	Delay in presentation
	Psychosocial issues with breast cancer surgery
		Decision-making
		Effects of type of surgery
		Impact of axillary surgery on quality of life
	Ductal carcinoma in situ
	Hormone therapy
	Exercise
	Conclusion
	Summary
Management of common breast emergencies and complications
	Postoperative complications
		Haematomas and postoperative bleeding
		Infection following surgery to the breast and axilla
		Infection around implant
		Seroma management
	Breast infection
		Puerperal mastitis/abscess (see also Chapter 3, Benign Breast Disease)
		Non-lactating abscess
		Skin-related infection