FUNCTIONAL ANATOMY OF THE BREAST

LOBULUS 15-20 lobes major lactiferous duct (2-4mm)

sinus orificium in the ampulla of the nipple (0,40,7mm) ligaments of Cooper structural support Kuadran atas lateral mengandung lbh banyak jaringan mammae drpd bgn lainnya. Perdarahan :
a. mammaria interna; a. intercostalis posterior; a. axillaris

cabang toraks atas, torax lateral dan pectoral dari a.

thoracoacromial

Vena dan limf mengikuti jalan arteri dengan drainase vena ke

ketiak

 vertebral venous plexus of Batson vertebrae

melebar dari dasar tengkorak ke sacrum way for metas to vertebrae, skull, pelvic bones, and central nervous system. Lateral cutaneous branches of the third sixth intercostal nerves lateral mammary branches dan anterolateral chest wall. second intercostal nerve intercostobrachial nerve visualized during surgical dissection of the axilla loss of sensation over the medial aspect of the upper arm.

VVP batson

 Lymph drainage of the axilla not well demarcated - variation in the position of the axillary lymph nodes.
The 6 axillary lymph node groups
(1) the axillary vein group (lateral); (2) the external mammary group (anterior or pectoral); (3) the scapular group (posterior or subscapular); (4) the central group; (5) the subclavicular group (apical); and (6) the interpectoral group (Rotters).

 Lymph nodes located lateral/ below the lower border

of the pectoralis minor muscle level I lymph nodes, which : lateral , anterior, and posterior groups. superficial or deep to the pectoralis minor muscle level II lymph nodes : central and interpectoral groups. medial/above the upper border of the pectoralis minor muscle level III lymph nodes : subclavicular group. The axillary lymph nodes receive more than 75 percent of the lymph drainage from the breast.

PHYSIOLOGY OF THE BREAST

estrogen, progesterone, prolactin, oxytocin, thyroid hormone,

cortisol, and growth hormone. Estrogen, progesterone, and prolactin trophic effects normal breast development and function. ESTROGEN initiates DUCTAL DEVELOPMENT, PROGESTERONE DIFFERENTIATION OF EPITHELIUM and for LOBULAR DEVELOPMENT. PROLACTIN LACTOGENESIS in late pregnancy and the postpartum period UPregulates hormone receptors and stimulates epithelial development. gonadotropin-releasing hormone (GnRH) from the hypothalamus gonadotropins luteinizing hormone (LH) and folliclestimulating hormone (FSH) from the basophilic cells of the anterior pituitary estrogen and progesterone from the ovaries. Positive and negative feedback effects of circulating estrogen and progesterone regulate the secretion of LH, FSH, and GnRH.

GYNAECOMASTEA
Gynecomastia enlarged breast in the male.

Physiologic gynecomastia three phases of life: the

neonatal period, adolescence, and senescence. an excess of circulating estrogens in relation to circulating testosterone : Neonatal gynecomastia placental estrogens neonatal breast tissues Adolescence estradiol relative to testosterone, Senescence circulating testosterone level falls relative hyperestrinism

 Gynecomastia the ductal structures of the male

breast enlarge, elongate, and branch with a concomitant increase in epithelium.

Puberty UNILATERAL (ages 12 and 15 years). senescent gynecomastia BILATERAL NONOBESE MALE AT LEAST 2 CM IN DIAMETER

MUST BE PRESENT BEFORE A DIAGNOSIS OF GYNECOMASTIA IS MADE.

INFECTIOUS AND INFLAMMATORY DISORDERS OF THE BREAST

BACTERIAL INFECTION. Staphylococcus aureus and Streptococcus species point tenderness, erythema, and hyperthermia related to lactation subcutaneous, subareolar, interlobular (periductal), and retromammary abscesses (unicentric or multicentric) operative drainage of fluctuant areas. Preoperative ultrasonography BEST :
circumareolar incisions incisions paralleling Langer lines.

streptococcal infections local wound care, including warm

compresses, and intravenous antibiotics (penicillins or cephalosporins). Breast infections may be chronicrecurrent abscess formation cultures

HIDRADENITIS SUPPURATIVA
At nipple-areola complex or axilla

FROM : accessory areolar glands of Montgomery the axillary sebaceous glands. Antibiotic therapy with incision and drainage of

fluctuant areas and may necessitate coverage with advancement flaps or split-thickness skin grafts.

Mondors disease
thrombophlebitis superficial veins of the anterior

chest wall and breast. string phlebitis, presenting as a tender, cordlike structure, acute pain in the lateral aspect of the breast or the anterior chestwall. A tender, firm cord is found to follow the distribution of one of the major superficial veins. biopsy is indicated. Therapy :
antiinflammatory medications and warm compresses that

are applied along the symptomatic vein. Restriction of motion of the ipsilateral extremity and shoulder and brassiere support of the breast are important. The process usually resolves within 46 weeks. refractory to therapy excision of the involved vein segment

COMMON BENIGN DISORDERS AND DISEASES OF THE BREAST

ABERRATIONS OF NORMAL DEVELOPMENT AND INVOLUTION (ANDI) (1) related to the normal processes of reproductive life and to involution; (2) ranges from normal to disorder to disease; and (3) all aspects of the breast condition, including pathogenesis and the degree of abnormality.

Reproductive Years:
FIBROADENOMAS age 1525 years. Fibroadenomas

usually grow to 1 OR 2 CM in diameter stable/ larger size. <1 CM : NORMAL. 3CM : DISORDERS. >3CM : GIANT FAM/ DISEASE. multiple fibroadenomas (MORE THAN 5 LESIONS IN ONE BREAST) uncommon/disease.

MASIVE stromal hyperplasia (gigantomastia) is seen.

Nipple inversion
Mammary duct fistulas

Later Reproductive Years:

Cyclical mastalgia and nodularity premenstrual

enlargement normal. Cyclical mastalgia and severe painful nodularity persists >1 week of the menstrual cycle disorder. bilateral bloody nipple discharge. biopsy fibrocystic changes, cystic mastopathy, chronic cystic disease, chronic cystic mastitis, Schimmelbusch disease, mazoplasia, Cooper disease, Reclus disease, and fibroadenomatosis.

Treatment of Selected Benign Breast Disorders and Diseases

Cysts: needle biopsy,
a 10-mL syringe aspirated is not bloodstained to dryness

cytologic examination If the mass is solid tissue specimen is obtained. cystic fluid is bloodstained 2 mL of fluid cytology. then imaged with ultrasound any solid area on the cyst wall is biopsied by needle. cysts with dark fluid occult blood test or microscopy examination eliminate any doubt. The two cardinal rules of safe cyst aspiration :
(1) the mass must disappear completely after aspiration, and (2) the fluid must not be bloodstained. If either of these conditions is not met, then ultrasound, needle

biopsy, and perhaps excisional biopsy are recommended.

Treatment of Selected Benign Breast Disorders and Diseases

FIBROADENOMAS
Removal of all fibroadenomas solitary fibroadenomas in young women are frequently

removed most fibroadenomas self-limiting more conservative approach is reasonable. Careful ultrasound examination + core-needle biopsy concerning the biopsy results excision of the fibroadenoma may be avoided.

Treatment of Selected Benign Breast Disorders and Diseases

Sclerosing Disorders
its mimicry of cancer. Mammography+ gross pathologic examination (biopsi

eksisi exclude cancer. stereoscopic biopsynot possible to differentiate these lesions

Treatment of Selected Benign Breast Disorders and Diseases Periductal Mastitis:

Painful and tender masses behind the nipple-areola complex

aspirated with a 21-gauge needle attached to a 10-mL syringe Any fluid obtained cytology + culture METRONIDAZOLE AND DICLOXACILLIN while awaiting the results of culture but when there is considerable pus present surgical A subareolar abscess unilocular associated with a single duct system. Preoperative ultrasound childbearing age simple drainage is preferred, Recurrent abscess with fistula fistulectomy / major duct excision, localized periareolar abscess recurs at the previous site and a fistula is present fistulectomy

Treatment of Selected Benign Breast Disorders and Diseases

sepsis or when more than one fistula is present total duct

excision is the preferred fistula Antibiotic

Nipple Inversion:
congenital nipple inversion occurs secondary to duct

ectasia. Because nipple inversion is a result of shortening of the subareolar ducts a complete division of these ducts is necessary for permanent correction of the disorder.

 MULTI-STAGE CARCINOGENESIS. Carcinogenesis : three

major steps : Initiation, promotion and progression. Initiation irreversible, tumor promotion requires chronic exposure to a tumor promoter. Progression the final stage of neoplastic transformation, involves the growth of a tumor with invasive and metastatic potential.

BREAST CANCER
RISK FACTOR CUMMULATIVE AND INTERACT ONE ANOTHER Increased exposure to ESTROGEN : early menarche, nulliparity, and late menopause, are associated with increased risk. longer lactation period decrease the total number of menstrual cycles protective. The terminal differentiation of breast epithelium associated with a full-term pregnancy protective. So older age at first live birth increased risk of breast cancer.

Risk assessment. The longer a woman lives without cancer, the lower her risk of developing breast cancer. 50 years 11 percent lifetime risk of developing beast cancer, 70 years 7 percent lifetime. Risk management. When to use postmenopausal hormone replacement therapy; mammography screening; when to use tamoxifen to prevent breast cancer; and when to perform prophylactic mastectomy to prevent breast cancer. Postmenopausal hormone replacement therapy reduces the risk of coronary artery disease and osteoporosis by 50 percent, but increases the risk of breast cancer by approximately 30 percent.

 Routine use of screening mammography i women

age >=50 years in women younger than age 50 years for several reasons: (1) breast density is greater (2) more false-positive tests (3) youngerwomen are less likely to have breast cancer on a population basis screening mammography 40 and 49 years

 Tamoxifen reduced the incidence of breast cancer by

49 percent. only recommende for women who have a Gail relative risk Side Effect : deep venous thrombosis occurs, pulmonary emboli, endometrial cancer, Cataract surgery

NATURAL HISTORY :

The longest surviving patient died in the NINETEENTH year after diagnosis.

HISTOPATHOLOGY OF BREAST CANCER

Carcinoma in situ.
whether or not they invade through the basement

membrane. the accurate diagnosis of in situ cancer multiple microscopy sections to exclude invasion. Lobular carcinoma in situ (LCIS), which distinguished it from ductal carcinoma in situ (DCIS). Multicentricity multifocality

Lobular Carcinoma In Situ:

originates from the terminal duct lobular units only female breast. Distention and distortion of the terminal duct lobular units

by cancer cells, maintain a normal nuclear-to-cytoplasmic ratio incidental finding. 4447 years Invasive breast cancer develops in 2535 percent of women with LCIS. Invasive lobular cancer may develop in either breast

Ductal Carcinoma In Situ

female breast

5 percent of male breast cancers.

intraductal carcinoma proliferation of the epithelium that lines the minor breast

ducts. risk for invasive breast cancer is increased nearly 5-fold in women with DCIS. The invasive cancers are observed in the ipsilateral breast, usually in the same quadrant as the DCIS that was originally detected, suggesting that DCIS is an anatomic precursor of invasive ductal carcinoma.

Invasive breast carcinoma

Lobular or ductal Eighty percent of invasive breast cancers are described

as invasive ductal carcinoma of no special type (NST). These cancers generally have a worse prognosis than special-type cancers.

Foote and Stewart classification for invasive breast cancer:

I. Paget disease of the nipple II. Invasive ductal carcinoma

A. Adenocarcinoma with productive fibrosis (scirrhous,

simplex, no special type (NST)) 80 percent B. Medullary carcinoma 4 percent C. Mucinous (colloid) carcinoma 2 percent D. Papillary carcinoma 2 percent E. Tubular carcinoma (and invasive cribriform carcinoma (ICC)) 2 percent III. Invasive lobular carcinoma 10 percent IV. Rare cancers (adenoid cystic, squamous cell, apocrine)

Paget disease
a chronic, eczematous eruption of the nipple, subtle,

but may progress to an ulcerated, weeping lesion. Associated with extensive DCIS and an invasive cancer. A palpable mass may or may not be present. Pathognomonic large, pale, vacuolated cells (Paget cells) in the rete pegs of the epithelium. lumpectomy, mastectomy, or modified radical mastectomy

(scirrhous,simplex, NST)
macroscopic or microscopic axillary lymph node

metastases perimenopausal or postmenopausal fifth to sixth solitary, firm mass. It has poorly defined margins and its cut surfaces show a central stellate configuration with chalky white or yellow streaks extending into surrounding breast tissues.

DIAGNOSING BREAST CANCER

(1) breast enlargement or asymmetry; (2) nipple changes, retraction, or discharge;

(3) ulceration or erythema of the skin of the breast;

(4) an axillary mass; (5) musculoskeletal discomfort.

Breast pain benign disease.

physical examination and mammography ultrasound examination and biopsy are used to avoid a delay

in diagnosis.

Examination
Inspection: arms by her side arms straight up in the air, hands on her hips (with and without pectoral muscle contraction). Symmetry, size, and shape, edema (peau dorange), nipple or skin retraction, and erythema. arms extended forward leans forward skin retraction. Palpated. Supine best examine all quadrants

from the sternum latissimus dorsi muscle clavicle inferiorly to the upper rectus sheath. palmar aspects of the fingers avoiding a grasping or pinching motion.

 gentle palpation, all three levels of possible axillary

lymphadenopathy : location, size, consistency, shape, mobility, fixation IMAGING TECHNIQUES Mammography: craniocaudal (CC) view and the mediolateral oblique (MLO) view. The MLO view images the greatest volume of breast tissue, including the upper outer quadrant and the axillary tail of Spence. CC view provides better visualization of the medial aspect of the breast and permits greater breast compression.

 Specific mammography features that suggest a diagnosis

of a breast cancer
solid mass with or without stellate features, asymmetric thickening of breast tissues, clustered microcalcifications. fine, stippled calcium in and around a suspicious lesion is microcalcifications important sign of cancer in

younger women

normal-risk women age 20 years or olderbreast exam

at least every 3 years. At age 40 years, breast exams should yearly

Xeromammography: Ultrasonography: breast cysts : well circumscribed, smooth margins and an echofree center. Benign breast : smooth contours, round or oval shapes, weak internal echoes, and well-defined anterior and posterior margins. Breast cancer : irregular walls, smooth margins with acoustic enhancement

BREAST BIOPSY
Nonpalpable Lesions Image-guided breast mammography, ultrasound or stereotactic localization,

and fine-needle aspiration (FNA) biopsy almost 100 % accurate in the diagnosis of breast cancer.
Core-needle biopsy is accepted as an alternative to open

biopsy for nonpalpable breast lesions.

Palpable Lesion FNA biopsy of a palpable breast

BREAST CANCER PROGNOSIS

Breast cancer staging. Mammography, chest radiograph, and intraoperative

findings (primary cancer size, chest wall invasion)

TNM (tumor, nodes, and metastasis) system. The American Joint Committee on Cancer (AJCC) has

modified the TNM system for breast cancer. The single most important predictor of 10- and 20-year survival rates in breast cancer is : THE NUMBER OF AXILLARY LYMPH NODES INVOLVED WITH METASTATIC DISEASE.

OVERVIEW OF BREAST CANCER

THERAPY
In situ breast cancer (stage 0).
Both LCIS and DCIS may be difficult to distinguish from

atypical hyperplasia or from cancers with early invasion.

lumpectomy and radiation Adjuvant tamoxifen therapy is considered for all DCIS

patients.

Early invasive breast cancer (stage I, IIa, or IIb).

lumpectomy with radiation therapy

Advanced locoregional regional breast cancer (stage IIIa or IIIb).

surgery + radiation therapy + chemotherapy

Internal mammary lymph nodes

There is no need for internal mammary lymph node

radiation therapy in women who are at increased risk for occult involvement who show no signs of internal mammary lymph node involvement. (cancers involving the medial aspect of the breast, axillary lymph node involvement), chemotherapy + radiation therapy are used in the treatment of grossly involved internal mammary lymph nodes.

Distant metastases (stage IV).

Hormonal therapies

cytotoxic chemotherapy
Surgical treatment, such as brain metastases; pleural

effusion; pericardial effusion; biliary obstruction; ureteral obstruction; impending or existing pathologic fracture of a long bone; spinal cord compression; and painful bone or soft tissue metastases. Bisphosphonates

Locoregional recurrence
separated into two groups: those having had mastectomy Those having had lumpectomy. Chemotherapy + antiestrogen + adjuvant radiation

SURGICAL TECHNIQUES IN BREAST CANCER THERAPY

Excisional biopsy with needle localization removal of a breast lesion with a margin of normal-appearing breast tissue. Sentinel lymph node biopsy

Breast Conservation Breast conservation involves resection of the primary breast cancer with a margin of normal-appearing breast tissue, adjuvant radiation therapy, and assessment of axillary lymph node status.
Mastectomy and axillary dissection. A skin-sparing mastectomy removes all breast tissue, the nippleareola complex, and only 1 cm of skin aroundexcised scars.

Reconstruction of the breast and chest wall. The goals of reconstructive surgery following a mastectomy for breast cancer arewound closure and breast reconstruction, which is either immediate or delayed.

NONSURGICAL BREAST CANCER THERAPIES

Radiation therapy
Chemotherapy Adjuvant Chemotherapy: Adjuvant chemotherapy is of

minimal benefit to node-negative women with cancers 0.5 cm or less in size and is not recommended.

 Antiestrogen therapy.

 Anti-HER-2/neu antibody therapy.