Surgery chapters
Breast: triple assessment, benign disease, breast cancer staging and treatment
Breast anatomy and lymph drainage, triple assessment of a breast lump, benign conditions (fibroadenoma, cysts, mastitis, duct ectasia, phyllodes), breast cancer risk, pathology, staging and treatment.
In 30 seconds
- Every breast lump gets triple assessment: clinical examination + imaging (ultrasound under 35-40, mammography over 35-40) + tissue (core biopsy preferred).
- Benign: fibroadenoma (young, mobile "breast mouse"), cysts, lactational abscess (S. aureus), duct ectasia, intraduct papilloma (commonest cause of bloody single-duct discharge).
- Cancer: commonest invasive ductal, upper outer quadrant, spreads first to axillary nodes; treat with breast-conserving surgery + radiotherapy or mastectomy, plus sentinel node biopsy for a clinically negative axilla, and systemic therapy by receptor status (ER: tamoxifen/AI; HER2: trastuzumab).
On this page
Overview
Breast lumps are one of the commonest surgical referrals. PGET questions test the triple assessment, the common benign conditions, the spread and staging of breast cancer, and choosing the right operation and systemic treatment.
Breast and thyroid carry the most MCQs within Breast and Endocrine, so learn both well.
Surgical anatomy
- The breast lies over the 2nd to 6th ribs, from the sternal edge to the anterior axillary line, with the axillary tail (of Spence) reaching into the axilla. Breast tissue extends wider than the visible mound, which matters at mastectomy.
- Suspended by Cooper's ligaments; their involvement by cancer causes skin dimpling.
- Lymph drainage: about 85% to the axillary nodes, the rest mainly to the internal mammary nodes (especially from medial and deep parts).
Axillary node levels (relative to pectoralis minor)
| Level | Position |
|---|---|
| I | Lateral to (below) pectoralis minor |
| II | Behind pectoralis minor (includes interpectoral Rotter's nodes) |
| III | Medial to (above) pectoralis minor, up to the apex |
- Nerves to protect in axillary surgery: long thoracic nerve (serratus anterior; injury causes winged scapula) and thoracodorsal nerve (latissimus dorsi). The intercostobrachial nerve is often divided, causing numbness of the inner upper arm.
Triple assessment
| Part | What it involves |
|---|---|
| 1. Clinical | History and examination of both breasts, axillae and supraclavicular fossae |
| 2. Imaging | Ultrasound in younger women (dense breasts, roughly under 35-40); mammography (plus ultrasound) in older women |
| 3. Pathology | Core needle biopsy (preferred: gives histology, invasion and receptor status) or FNAC |
- Each part is scored 1 (normal) to 5 (malignant).
- When all three agree, the diagnosis is accurate in nearly every case. If any part is suspicious, do not reassure; get more tissue.
- MRI: lobular cancer (often multifocal), implants, very dense breasts, high-risk screening.
High-yield
Core biopsy beats FNAC because it shows whether a cancer is invasive and gives ER/PR and HER2 status before surgery.
Congenital and developmental
- Accessory nipples (polythelia) lie along the milk line (axilla to groin).
- Amazia (absent breast) is rare; Poland syndrome is absence of the breast with the pectoral muscle.
Benign breast disease
Aberrations of normal development and involution (ANDI)
| Stage of life | "Normal" process | Aberration |
|---|---|---|
| Development (15-25 years) | Lobule formation | Fibroadenoma |
| Cyclical change (25-40) | Monthly hormonal change | Cyclical mastalgia, nodularity |
| Involution (35-55) | Lobular involution | Cysts, sclerosing adenosis, duct ectasia |
Benign lumps and conditions
| Condition | Typical patient and findings | Management |
|---|---|---|
| Fibroadenoma | 15-25 years; smooth, firm, rubbery, very mobile ("breast mouse"), usually 2-3 cm | Confirm with triple assessment (biopsy if over 25 or any atypical feature); leave alone or excise if large, growing or patient wishes |
| Giant fibroadenoma | Adolescents; over 5 cm, grows fast | Enucleation |
| Phyllodes tumour | Usually over 40; large, fast-growing, bosselated, still mobile; may ulcerate skin | Wide excision with a clear margin (recurs locally if shelled out); malignant forms spread by blood |
| Breast cyst | 35-55, sudden smooth lump | Aspirate; biopsy if fluid is bloody, lump remains, or recurs |
| Fat necrosis | After trauma (often seatbelt), may be hard and tethered, mimics cancer | Triple assessment to exclude cancer |
| Galactocele | Milk-filled cyst dating from lactation | Aspiration |
| Mondor's disease | Thrombophlebitis of a superficial vein of the breast; tender cord | Reassurance and NSAIDs; settles |
Exam trap
A phyllodes tumour looks like a large fibroadenoma, but it needs wide excision, not enucleation.
Mastalgia
- Cyclical (worse before periods) or non-cyclical. Reassure after excluding cancer; a well-fitting bra and simple analgesia.
- Few cancers present with pain alone.
Breast infection
| Type | Features | Organism | Treatment |
|---|---|---|---|
| Lactational mastitis/abscess | Breastfeeding mother; red, hot, tender segment; fluctuation is a late sign | Staphylococcus aureus (often penicillin-resistant) | Early: flucloxacillin (or co-amoxiclav), keep feeding or expressing. Abscess: repeated (ultrasound-guided) aspiration with antibiotics, or incision and drainage if skin is thin or pus does not clear |
| Non-lactational (periductal) abscess | Smokers; around the areola; may form a mammary duct fistula | Mixed, including anaerobes | Antibiotics with anaerobic cover, aspiration; excise the diseased duct for recurrence |
- Antibiotics alone in the presence of undrained pus can leave a hard sterile mass called an antibioma.
High-yield
A pointing, fluctuant lactational abscess needs drainage (aspiration or incision), not antibiotics alone.
Duct ectasia and periductal mastitis
- Dilated subareolar ducts with thick discharge (green, cream or black), slit-like nipple retraction, and in smokers periductal inflammation, abscess and fistula.
Nipple problems
Nipple discharge
| Discharge | Likely cause |
|---|---|
| Bloody, single duct | Intraduct papilloma (commonest); DCIS or carcinoma must be excluded |
| Green, black or cheesy, multiple ducts | Duct ectasia |
| Milky, both sides | Lactation, galactorrhoea (prolactinoma, drugs) |
| Clear or serous | Physiological, papilloma, ANDI |
- Worrying features: blood, single duct, spontaneous, age over 50, associated lump.
- Treatment of a bloody single-duct discharge: imaging and microdochectomy (removal of the single duct); total duct excision (Hadfield) for multiduct ectasia.
Nipple retraction
- Slit-like (transverse): duct ectasia.
- Circumferential, recent, with a lump: carcinoma.
Paget's disease of the nipple
- Eczema-like red, scaly change that starts on the nipple and spreads to the areola; the nipple slowly erodes.
- Always means an underlying carcinoma (in situ or invasive). Histology shows large pale Paget cells in the epidermis.
- True eczema usually starts on the areola and spares the nipple, is often bilateral and itchy.
- Any persistent nipple eczema must be biopsied.
Gynaecomastia
- Enlargement of male breast tissue. Normal in neonates, puberty and old age.
- Causes: drugs (spironolactone, digoxin, cimetidine, oestrogens, anabolic steroids), cirrhosis, kidney failure, hyperthyroidism, Klinefelter syndrome, testicular tumours, leprosy.
- Treat the cause; surgery (subcutaneous mastectomy or liposuction) for persistent cases.
Breast cancer
Risk factors
- Female sex and age (rare before 20, rising steadily).
- Unopposed oestrogen exposure: early menarche, late menopause, nulliparity, first child late, not breastfeeding, combined HRT, obesity after menopause.
- Family history and genes: about 5% are due to a single gene. BRCA1 (chromosome 17q): breast and ovarian cancer. BRCA2 (13q): breast cancer including male breast cancer. p53 (Li-Fraumeni).
- Previous chest radiotherapy (e.g. mantle field for Hodgkin lymphoma), alcohol, atypical hyperplasia, previous breast cancer.
- Protective: early first pregnancy, breastfeeding, late menarche, early menopause.
Pathology
| Type | Points |
|---|---|
| DCIS | In situ; often microcalcification on mammogram; screen-detected; treated by excision (plus radiotherapy if high grade) or mastectomy if extensive |
| LCIS | A risk marker, often multifocal and bilateral |
| Invasive ductal (no special type) | Commonest |
| Invasive lobular | Up to about 15%; multifocal and bilateral, hard to see on mammography (use MRI) |
| Special types | Tubular, mucinous (colloid), medullary: better prognosis |
| Inflammatory carcinoma | Red, hot, swollen breast with peau d'orange; tumour cells block dermal lymphatics; can mimic an abscess; aggressive |
- Grade (I-III) from tubule formation, nuclear pleomorphism and mitoses.
- Molecular groups: luminal A and B (ER positive), HER2-positive, and triple negative (ER, PR and HER2 negative; common with BRCA1; poor prognosis).
Spread and presentation
- Commonest site: upper outer quadrant (most breast tissue lies there).
- Lump: hard, irregular, painless, may be tethered to skin or fixed to muscle.
- Skin signs: dimpling, peau d'orange (skin oedema from blocked lymphatics, hair follicles stay tethered), ulceration, cancer-en-cuirasse (spread around the chest wall).
- Lymphatic spread: axillary nodes first; internal mammary nodes for medial and deep tumours; supraclavicular or opposite-side nodes mean advanced disease.
- Blood spread: bone (lumbar spine commonest, then femur, thoracic spine, ribs, skull; mostly osteolytic), lung, pleura, liver, brain.
Staging (TNM, simplified)
| Category | Meaning |
|---|---|
| T1 | 2 cm or less |
| T2 | More than 2 cm up to 5 cm |
| T3 | More than 5 cm |
| T4 | Any size with direct spread to chest wall (4a) or skin (ulcer, satellite nodules, peau d'orange: 4b), both (4c), or inflammatory cancer (4d) |
| N1 | Mobile ipsilateral level I-II axillary nodes |
| N2 | Fixed or matted axillary nodes, or internal mammary nodes alone |
| N3 | Infraclavicular, supraclavicular, or internal mammary plus axillary nodes |
| M1 | Distant metastasis |
- Early breast cancer: T1-2, N0-1. Locally advanced: T3-4 or N2-3. Metastatic: M1.
- Small tumours (under 2 cm) with a clinically and ultrasonically negative axilla need little more than clinical staging. Larger or node-positive tumours need CT of chest, abdomen and pelvis and a bone scan.
Prognosis
- Best predictors: axillary node status (the single most important), tumour size and grade; also ER/PR, HER2, lymphovascular invasion, age.
- Nottingham Prognostic Index (NPI) = (0.2 × size in cm) + node score + grade. Node score: 1 = no nodes, 2 = 1-3 nodes, 3 = 4 or more nodes.
Worked example: Nottingham Prognostic Index
Tumour 2.5 cm, grade 2, two positive axillary nodes (node score 2)
NPI = (0.2 × 2.5) + 2 + 2 = 0.5 + 2 + 2 = 4.5 → moderate prognostic group
Exam trap
In NPI, the node score is 1, 2 or 3 (not the actual number of nodes), and the size is multiplied by 0.2.
Treatment of early breast cancer
All cases are planned by a multidisciplinary team.
Surgery to the breast
| Operation | Use |
|---|---|
| Breast-conserving surgery (wide local excision) + whole-breast radiotherapy | Tumour small in relation to the breast; survival is the same as mastectomy |
| Mastectomy (simple or with reconstruction) | Large tumour for breast size, central tumour under the nipple, multifocal disease, recurrence after conservation, patient choice, radiotherapy contraindicated |
| Modified radical (Patey) mastectomy | Breast plus full axillary clearance, preserving pectoralis major |
| Halsted radical mastectomy | Also removed both pectoral muscles; abandoned (morbidity without survival gain) |
- Wide local excision without radiotherapy has an unacceptably high local recurrence rate (except special cases).
- An involved margin needs re-excision (or mastectomy) before radiotherapy.
Surgery to the axilla
- Clinically and ultrasound-negative axilla: sentinel lymph node biopsy (SLNB). Blue dye and/or a radioisotope are injected near the tumour or areola; the first node(s) to take up the marker (blue and "hot") are removed and examined. If clear, no further axillary surgery.
- Proven node-positive axilla (on ultrasound-guided biopsy): axillary clearance (or axillary radiotherapy in selected cases).
- Do not combine axillary clearance with axillary radiotherapy: this sharply raises the risk of arm lymphoedema.
High-yield
The sentinel node is the first draining node, not the largest, hardest or nearest. Removing only this node avoids most of the morbidity of axillary clearance.
High-yield
Arm lymphoedema is commonest after axillary clearance (as in modified radical mastectomy), especially when combined with axillary radiotherapy.
Radiotherapy
- After breast-conserving surgery: always (whole breast, often with a boost).
- After mastectomy (chest wall): large tumours, many positive nodes, involved margins.
Systemic (adjuvant) therapy
| Treatment | Who gets it | Notes |
|---|---|---|
| Tamoxifen (anti-oestrogen, 20 mg daily for at least 5 years) | ER-positive, mainly premenopausal | Risks: endometrial cancer, DVT/PE, hot flushes |
| Aromatase inhibitors (anastrozole, letrozole, exemestane) | ER-positive postmenopausal | Risk: osteoporosis, joint pains |
| Trastuzumab (Herceptin) | HER2-positive | Monitor heart function (cardiotoxicity) |
| Chemotherapy | Node-positive, high grade, triple negative, HER2-positive, young patients | Given before surgery (neoadjuvant) to shrink large or inflammatory cancers |
- Hormone therapy is only useful when the tumour is ER or PR positive.
Locally advanced and metastatic disease
- Locally advanced / inflammatory: neoadjuvant chemotherapy (or hormones) first, then surgery and radiotherapy.
- Metastatic: systemic therapy for control and palliation; bisphosphonates for bone disease; radiotherapy for painful bone deposits or spinal cord compression.
Screening
- Mammographic screening of women over 50 reduces breast cancer deaths. The UK programme screens women aged about 50-70 every 3 years.
- MRI screening for very high-risk women (BRCA carriers, Li-Fraumeni).
- Pakistan has no national population screening programme; awareness, self-examination and early clinical assessment are encouraged, and many women present at a late stage. Check current national guidance.
Male breast cancer
- Under 1% of breast cancers. Risk: BRCA2, Klinefelter, excess oestrogen, gynaecomastia.
- Usually invasive ductal, often ER-positive; treated with mastectomy (little breast tissue) and SLNB, then therapy as for women.
High-risk women
- Genetic counselling; earlier and MRI surveillance; risk-reducing mastectomy (with reconstruction) and salpingo-oophorectomy for BRCA carriers; tamoxifen or anastrozole for chemoprevention.
Exam focus
Expect: the components of triple assessment and core biopsy over FNAC, the first lymph node group involved (axillary), what the sentinel node is and when SLNB is used, the most common site and type of breast cancer, fibroadenoma versus phyllodes, lactational abscess (S. aureus, drainage), causes of nipple discharge, Paget's disease of the nipple, peau d'orange, T stage cut-offs (2 cm and 5 cm), NPI, indications for mastectomy versus breast conservation with radiotherapy, the operation with the highest lymphoedema risk, tamoxifen versus aromatase inhibitors and their side effects, trastuzumab for HER2, and BRCA genes.
Quick revision
- Triple assessment: clinical + imaging + core biopsy.
- 85% of lymph drains to axilla; SLNB = first draining node, for clinically negative axilla.
- Fibroadenoma: young, mobile; phyllodes: older, large, wide excision.
- Bloody single-duct discharge: intraduct papilloma (exclude cancer).
- Lactational abscess: S. aureus; aspirate or drain plus flucloxacillin.
- Paget's of the nipple: underlying cancer; biopsy any nipple eczema.
- T1 up to 2 cm, T2 2-5 cm, T3 over 5 cm, T4 skin or chest wall.
- Conservation + radiotherapy = mastectomy for survival.
- ER+ premenopausal: tamoxifen; postmenopausal: aromatase inhibitor; HER2+: trastuzumab.
Written by The House Job from standard references (Bailey & Love).
FAQ
What is triple assessment?
The combination of clinical examination, imaging (ultrasound and/or mammography) and tissue sampling (preferably core biopsy) used to diagnose any breast lump.
Which lymph node is removed in sentinel node biopsy?
The first node or nodes to receive lymph from the tumour, found by blue dye and a radioactive tracer; it is not chosen by size, hardness or distance.
Is breast-conserving surgery as safe as mastectomy?
Yes. Wide local excision followed by radiotherapy gives the same survival as mastectomy for suitable tumours, though local recurrence is slightly higher.
Why is tamoxifen not used in postmenopausal women as often as before?
Aromatase inhibitors work better after menopause, when most oestrogen comes from peripheral conversion by aromatase in fat.
What does peau d'orange mean?
Orange-peel skin caused by blocked dermal lymphatics and skin oedema over a breast cancer; it makes the tumour T4.