ABDOMEN & MAMMA

• Presentation of breast disease

  • Age-related
  • Breast lump
  • Pain
  • Discharge
  • Nipple
  • Breast enlargement
• Inactive mammary gland histology

  • 15 to 20 irregular lobes
  • Lobular units contain secretory acini or alveoli
  • Dense CT and adipose tissue separate the lobes
  • Lactiferous sinus - stratified and a double layer of cuboidal epithelium
  • Duct system - columnar and a single layer of epithelium
• Proliferative lesions of breasts (fibrocystic change)

  • Adenosis (glandular proliferation)
  • Epithelial hyperplasia
  • Apocrine metaplasia
  • Fibrosis
  • Blue domed cysts
• Possible reasons for painful breasts

  • Cyclical and non-cyclical pain
  • Duct ectasia (pain behind nipple)
  • Fat necrosis
  • Cysts
  • Infections: Puerperal Mastitis; Breast Abscess
• Prolactin reflex


  1. Milk producing reflex

  2. Prolactin stimulates the mammary glands to produce milk (lactation)

  3. Increased levels: Physiologic - breastfeeding, sleep; Pharmacologic - dopamine antagonists (Metoclopramide)

  4. Decreased levels: Physiologic - infrequent stimulation, breast engorgement, stress, bulimia; Pharmacologic - dopamine, estrogens (contraceptive pill)
• Oxytocin reflex


  1. Let down reflex

  2. Oxytocin acts at the mammary glands, causing milk to be 'let down' into sub-areolar sinuses, from where it can be excreted via the nipple

  3. Increased levels: Physiologic - suckling

  4. Decreased levels: Physiologic - unfavourable effects on higher centres (stress; anxiety; emotional tiredness; sickness; pain); Pharmacologic - catecholamines
• Breast venous drainage


  • Superficial v.'s are accompanied by lymph vessels
  • Deep v.'s pass to the axillary anterior and posterior intercostal v.'s
• Breast lymph drainage


  • Lymph from mammary gland drain directly or indirectly via 7 groups of lymph nodes: apical (subclavian), central, anterior (pectoral), posterior (subscapular), lateral (humeral), interpectoral (Rotter's), parasternal
• The venous and lymphatic drainage are of clinical importance because metastasis can occur along this route
• TNM staging of the breast (APPLIES TO ANUS AS WELL)
• Pharmacologic: catecholamines
• Venous drainage


  1. Superficial v.'s are accompanied by lymph vessels

  2. Deep v.'s pass to the axillary anterior and posterior intercostal v.'s
• Lymph drainage


  Lymph from mammary gland drain directly or indirectly via 7 groups of lymph nodes: apical (subclavian), central, anterior (pectoral), posterior (subscapular), lateral (humeral), interpectoral (Rotter's), parasternal

  
• Clinical importance


  • The venous and lymphatic drainage are of clinical importance because metastasis can occur along this route
• TNM staging of the breast (APPLIES TO ANUS AS WELL)


  • Primary Tumor (T): TX, T0, Tis, T1-T4
  • Regional Lymph Nodes (N): NX, N0, N1-N3
  • Distant Metastasis (M): MX, M0, M1

  
• For example, breast cancer classified as T3 N2 M0 refers to a large tumor that has spread outside the breast to nearby lymph nodes but not to other parts of the body. Prostate cancer T2 N0 M0 means that the tumor is located only in the prostate and has not spread to the lymph nodes or any other part of the body.

  
• Pathological features of prognostic importance in carcinoma of the breast

  • Size of the tumour (<2cm = better prognosis)
  • Any lymph node involvement
  • Histological type and grade
  • Proliferation rate
  • Presence of increased oncogene expression
  • Presence of E and P receptors (best prognosis is E -ve and P +ve)

  
• Breast conservation therapy


  1. Lumpectomy (removal of the lump around +/- 2cm region from the lump)

  2. Sentinel lymph node biopsy or block dissection (2 lymph nodes)

  3. Radiotherapy

  4. Possibly chemotherapy as adjuvant therapy
• Indications for mastectomy


  • Radical mastectomy: Generally, breast cancer with international clinical stage at 0, I, II period and some of III period patients without contraindications
  • Extended radical mastectomy: Removal of parasternal (internal mammary blood vessels) the lymph nodes during the radical mastectomy
  • Modified radical mastectomy: For the patients with the early stage of I and II stage
  • Simple mastectomy: In situ breast cancer, Small breast cancer or eczema-like lesions confined to the nipple, The elderly and infirm are not suitable for radical surgery, Locally lesions at the late stage, as a part of the comprehensive treatments
  • Partial excision: For early breast cancer without lymph node metastasis
• Contraindications for mastectomy are not provided in the latest study material.
• Radical mastectomy


  • Removes the breast, chest wall muscles, and lymph nodes under the arm (axillary lymph nodes) during the surgery
  • Adapted to the primary cancer with medial area and central area, especially with axillary lymph node metastasis in clinical examination

  
• Modified radical mastectomy


  • For patients with early stage I and II breast cancer
• Simple mastectomy


  • Indications: in situ breast cancer, small breast cancer or eczema-like lesions confined to the nipple, elderly and infirm patients not suitable for radical surgery, locally advanced lesions as part of comprehensive treatment

  
• Partial excision


  • For early breast cancer without lymph node metastasis, tumor diameter less than 4cm, no skin or chest muscle adhesions, axillary lymph nodes can be isolated but no adhesions with chest wall and vessels and nerve bundles, breast must be large enough to achieve satisfactory shape after surgery

  
• Indications for mastectomy instead of breast-conserving surgery

  • Women who have already had radiation therapy to the affected breast
  • Women with 2 or more areas of cancer in the same breast that are too far apart to be removed through 1 surgical incision, while keeping the appearance of the breast satisfactory
  • Women whose initial lumpectomy along with (one or more) re-excisions has not completely removed the cancer
  • Women with certain serious connective tissue diseases such as scleroderma, which make them especially sensitive to the side effects of radiation therapy
  • Pregnant women who would require radiation while still pregnant (risking harm to the child)
  • Women with a tumor larger than 5 cm (2 inches) that doesn't shrink very much with neoadjuvant chemotherapy
  • Women with a cancer that is large relative to her breast size
  • Women who have tested positive for a deleterious mutation on the BRCA1 or BRCA2 gene and opt for prophylactic removal of the breasts
  • Male breast cancer patients
• Systemic contraindications for mastectomy

  • Tumor distant metastasis
  • Frail and elderly cannot tolerate surgery
  • Generally poor and cachexia
  • Important organ dysfunction cannot tolerate surgery
• Localized disease contraindications for mastectomy

  • Orange peel-like skin, edema of the breast area of more than half of the breast
  • Satellite nodular breast skin
  • Violations of breast cancer chest wall
  • Parasternal lymph nodes of clinical examination enlargement and confirmed to be transferred
  • Ipsilateral upper extremity edema
  • Supraclavicular lymph node metastasis was confirmed by pathology
  • Inflammatory breast cancer
• Circumstances where both tumor ulceration and other factors are present

  • Tumor ulceration
  • Breast orange peel skin, like breast edema of the total area of 1/3 or less
  • Cancer with pectoralis major fixed
  • Maximum diameter of axillary lymph node more than 2.5cm
  • Axillary lymph adhesion to each other, or with nodes and skin, deep tissue

  
• Aim of plastic surgery in breast cancer

  To improve self-image and quality of life after mastectomy
• Breast reconstruction


  • Only for breast cancer patients with no evidence of systemic or local disease who are medically fit
  • Goals: volume, envelope, symmetry, nipple-areola complex
• Advantages of breast reconstruction

  • Improves self-image and quality of life
  • Procedures are safe and effective
  • No adverse effects on survival
  • Normal breast landmarks can be preserved
• Disadvantages of breast reconstruction

  • Prolonged operative time, risks involved and pain
  • Resistance against foreign objects – breast implants
  • Financial burden
  • Increased risk of local recurrence – inflammatory cancer
  • Post-op radiotherapy is required
• GORD (Gastro-Oesophageal Reflux Disease)


  • Symptoms: Heartburn, Acid in the mouth, Regurgitation, Asthma, Aspiration, Choking
  • Atypical symptoms: non-cardiac chest pain, asthma, dysphagia, H.pylori
• Causes of GORD


  • Hiatus hernia
  • Outlet obstruction
  • Zollinger-Ellison syndrome
  • Oesophageal motility problem
  • Destruction of the mucosa – NSAIDs

  
• Investigations for GORD


  • 24 hour pH monitoring (gold standard)
  • Upper GI endoscopy
• Increased risk of local recurrence

  Inflammatory cancer
• Discuss the clinical presentation of GORD (symptoms)
• Symptoms of GORD


  • Heartburn
  • Acid in the mouth
  • Regurgitation
  • Asthma
  • Aspiration
  • Choking
• Atypical symptoms of GORD

  • Non-cardiac chest pain
  • Asthma
  • Dysphagia
  • H.pylori

  
• Causes of GORD


  • Hiatus hernia
  • Outlet obstruction
  • Z-E syndrome
  • Oesophageal motility problem
  • Destruction of the mucosa - NSAID's