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🏥 BREAST SURGERY - Complete Notes & Viva Questions

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SECTION 1: ANATOMY OF THE BREAST

Surgical Anatomy (High-Yield)

• Medial: Internal mammary (thoracic) artery - major supply (60%)
• Lateral: Lateral thoracic artery and thoracoacromial artery
• Perforating branches of intercostal arteries (2nd-6th)

• Axillary nodes - drain 75-97% of breast lymph
• Internal mammary nodes - drain medial breast, important in staging
• Supraclavicular nodes - involved in advanced disease (N3)

• Level I: Lateral to pectoralis minor (lower axilla)
• Level II: Behind pectoralis minor (mid-axilla) - includes Rotter's nodes
• Level III: Medial to pectoralis minor (apex of axilla)

• Long thoracic nerve (C5,6,7) - serratus anterior - injury causes winged scapula
• Thoracodorsal nerve (C6,7,8) - latissimus dorsi - injury causes weakness in arm adduction
• Medial and lateral pectoral nerves - pectoralis major/minor
• Intercostobrachial nerve (T2) - sensation to medial arm - often divided in ALND

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SECTION 2: PHYSIOLOGY OF THE BREAST

• Estrogen: ductal development
• Progesterone: lobular development and epithelial differentiation
• Prolactin: lactogenesis (primary stimulus in late pregnancy)
• GnRH from hypothalamus → FSH/LH from pituitary → estrogen/progesterone from ovaries

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SECTION 3: BENIGN BREAST DISEASES

ANDI (Aberrations of Normal Development and Involution)

Fibroadenoma

• Most common benign breast tumor in young women (<30 years)
• Mobile, rubbery, non-tender, well-defined - "breast mouse"
• Estrogen-dependent, may enlarge in pregnancy
• Histology: proliferating epithelial and stromal components
• Management: Reassurance if <3 cm, U/S guided excision if >3 cm or enlarging

Breast Abscess

• Lactational (puerperal) - most common, S. aureus, subareolar
• Non-lactational - periductal mastitis, often anaerobes/mixed flora
• Treatment: I&D (most common abscess) or needle aspiration for early/small abscess + antibiotics

Fibrocystic Disease

• Most common benign breast condition overall
• Includes: cysts, fibrosis, adenosis, ductal hyperplasia
• Cyclical mastalgia, multiple bilateral nodularity
• Risk of malignancy depends on histology:
  • Nonproliferative: no increased risk
  • Proliferative without atypia (hyperplasia): 1.5-2x risk
  • Atypical ductal/lobular hyperplasia (ADH/ALH): 4-5x risk
  • LCIS: 10x risk (bilateral)

Duct Ectasia / Periductal Mastitis

• Duct ectasia: dilatation of ducts with periductal inflammation
• Green/dark discharge, nipple retraction
• Management: Hadfield's operation (total duct excision)

Mondor's Disease

• Thrombophlebitis of superficial veins of the breast/chest wall
• Self-limiting; treat with NSAIDs

Gynecomastia

• Benign proliferation of male breast glandular tissue
• Physiological: neonatal, pubertal, elderly
• Pathological causes: hypogonadism, hyperthyroidism, liver cirrhosis, drugs (spironolactone, cimetidine, digoxin, cannabis, anabolic steroids)
• Treatment: treat cause; surgical subcutaneous mastectomy if cosmetically significant

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SECTION 4: RISK FACTORS FOR BREAST CANCER

Non-modifiable Risk Factors

BRCA Genes

• BRCA1: chromosome 17q21; breast + ovarian cancer risk; associated with triple-negative cancers
• BRCA2: chromosome 13q12; breast (male + female) + ovarian; Fanconi anaemia pathway
• BRCA mutation carriers: prophylactic bilateral mastectomy reduces risk by ~95%

Gail Model

• Used for risk assessment to determine if chemoprevention is indicated
• Variables: age, menarche, age at first live birth, family history, prior biopsies, race

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SECTION 5: HISTOPATHOLOGY OF BREAST CANCER

In Situ Carcinomas

• Malignant cells within ducts, basement membrane intact
• Most common finding on screening mammography (microcalcifications)
• Subtypes: comedo (necrosis, high grade - worst prognosis), cribriform, micropapillary, solid
• Treatment: lumpectomy + radiation; or mastectomy if extensive; sentinel node biopsy NOT routine
• If comedo-type DCIS: high risk of invasion and recurrence

• Incidental finding; marker of bilateral breast cancer risk
• Not a true precursor lesion (unlike DCIS)
• No surgical excision required; consider chemoprevention (tamoxifen)

Invasive Carcinomas (Foote & Stewart Classification)

Paget's Disease of the Nipple

• Eczematous rash of nipple - starts at nipple (unlike eczema which starts at areola)
• Associated with underlying DCIS or invasive cancer in >95%
• Pathognomonic: Paget cells (large, pale, vacuolated cells) in rete pegs of epidermis
• CEA and EMA positive; S100 negative (helps distinguish from melanoma)
• Treatment: lumpectomy of nipple-areolar complex + radiation, or mastectomy

Inflammatory Breast Cancer

• Not a histological type but a clinical diagnosis
• Peau d'orange skin, warmth, erythema, rapid onset - mimics mastitis
• No discrete mass; dermal lymphatic invasion
• T4d by staging; locally advanced disease
• Treatment: Neoadjuvant chemotherapy FIRST, then modified radical mastectomy + radiation (NOT BCT)
• Worst prognosis of all breast cancers

Phyllodes Tumor (Cystosarcoma Phyllodes)

• Fibroepithelial tumor; classified benign/borderline/malignant
• Rapid growth, large, leaf-like appearance on cut section
• Stroma monoclonal (unlike fibroadenoma - can be polyclonal)
• Spreads haematogenously (NOT to lymph nodes)
• Treatment: Wide local excision with 1 cm margins (NOT simple enucleation); mastectomy if large
• Axillary dissection is NOT recommended (lymph node spread is extremely rare)

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SECTION 6: STAGING (TNM - AJCC)

TNM Classification

• T1: ≤2 cm
• T2: 2-5 cm
• T3: >5 cm
• T4a: Chest wall fixation; T4b: skin involvement (peau d'orange/ulceration); T4c: both; T4d: inflammatory

• N0: No regional node metastasis
• N1: Movable ipsilateral axillary nodes (Level I, II)
• N2: Fixed/matted axillary nodes OR clinical internal mammary nodes
• N3: Infraclavicular, supraclavicular, or extensive internal mammary involvement

Stage Groupings

• Stage 0: DCIS/LCIS
• Stage I: T1N0M0
• Stage II: T1N1 or T2N0/N1 or T3N0
• Stage III: T3N1 or T4 any N or any T N2/N3
• Stage IV: Any T, Any N, M1

Biomarkers

• ER/PR positive: Respond to endocrine therapy (tamoxifen, aromatase inhibitors)
• HER2 positive: Respond to trastuzumab (Herceptin)
• Triple negative (ER-, PR-, HER2-): Worst prognosis; chemo only; associated with BRCA1
• Oncotype DX (21-gene recurrence score): Guides chemotherapy decision in ER+/HER2- early cancer

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SECTION 7: DIAGNOSIS

Triple Assessment (Gold Standard)

1. Clinical examination
2. Imaging - Mammography ± Ultrasound ± MRI
3. Histology/Cytology - Core needle biopsy (preferred) or FNA

Imaging

• Mammography: Best screening tool for women ≥40; looks for microcalcifications, spiculated mass, asymmetric density
• Ultrasound: Best for young women (<35), evaluates cystic vs solid, guides biopsy
• MRI: Most sensitive (not most specific); used for BRCA carriers screening, multicentric/multilocal disease, implants, neoadjuvant response assessment
• Radiological grading: BI-RADS 0-6 (BI-RADS 4-5 = biopsy recommended; BI-RADS 6 = known malignancy)

Biopsy Types

• FNA (fine needle aspiration): Cytology only; cannot assess invasion; quick; 22G needle
• Core needle biopsy (Tru-Cut, 14G): Preferred - gives histology, can assess invasion, ER/PR/HER2
• Vacuum-assisted biopsy (8-10G): Multiple samples; for microcalcifications
• Excisional biopsy: Reserved for discordant triple assessment; needle-localized for non-palpable

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SECTION 8: SURGICAL TREATMENT

Breast-Conserving Surgery (BCS) / Lumpectomy

• Also called: lumpectomy, wide local excision, segmental mastectomy, partial mastectomy, tylectomy
• Standard treatment for Stage I and II breast cancer
• Equivalent survival to mastectomy (proven in 6 RCTs including Milan trial, NSABP B-06)
• Requires adjuvant whole-breast radiation
• Margin: "No tumor on ink" (SSO/ASTRO consensus) = adequate margin for IDC
• Absolute contraindications to BCT:
  • Inflammatory breast cancer
  • Multicentric disease (2 or more quadrants)
  • Prior radiation to chest wall
  • Inability to achieve clear margins
  • Patient preference for mastectomy
  • Active collagen vascular disease (relative)
  • First/second trimester pregnancy (relative - can do in 3rd trimester)

Mastectomy Types

Axillary Management

• Standard of care for clinically node-negative breast cancer
• First described by Cabanas (1977, penile cancer); adopted for breast by Giuliano (1994)
• Technique: Blue dye (isosulfan blue/patent blue) ± radiocolloid (Tc-99m sulfur colloid) injected peritumorally
• False-negative rate: 0-11%
• ACOSOG Z-0011 trial: In patients with 1-2 positive sentinel nodes undergoing BCT + whole-breast radiation, completion ALND is NOT required (no survival difference)

• Level I and II nodes routinely removed (standard: ≥10 nodes)
• Indications: >2 positive sentinel nodes, inflammatory breast cancer, clinically positive nodes not responding to neoadjuvant therapy
• Complications: lymphedema (most common), seroma, nerve injury (long thoracic, thoracodorsal, intercostobrachial), shoulder stiffness

Breast Reconstruction

• Immediate vs Delayed: Immediate preferred for most; delayed if post-mastectomy radiation needed
• Implant-based (more common): tissue expander → permanent implant
• Autologous flaps:
  • TRAM flap (transverse rectus abdominis myocutaneous) - most common autologous
  • DIEP flap (deep inferior epigastric perforator) - less donor-site morbidity
  • Latissimus dorsi flap - used when TRAM not available
• WHCRA (1998): Requires insurance coverage for breast reconstruction

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SECTION 9: ADJUVANT THERAPY

Radiation

• After BCS: Whole-breast irradiation (standard) or accelerated partial breast irradiation (APBI) in selected cases
• After mastectomy: Postmastectomy radiation (PMRT) indicated for T3/T4, ≥4 positive nodes, positive margins

Chemotherapy Regimens

Endocrine Therapy

• ER/PR positive pre-menopausal: Tamoxifen 5-10 years (SERM; also blocks endometrium - risk of endometrial cancer)
• Post-menopausal: Aromatase inhibitors (anastrozole, letrozole, exemestane) - more effective than tamoxifen
• Ovarian suppression: GnRH agonists (goserelin) for pre-menopausal high-risk

Targeted Therapy

• Trastuzumab (Herceptin): Anti-HER2 monoclonal antibody; reduces recurrence by 50% in HER2+ disease
• Pertuzumab: Anti-HER2 (different epitope); used with trastuzumab in neoadjuvant/adjuvant setting
• CDK4/6 inhibitors (palbociclib, ribociclib, abemaciclib): For metastatic ER+/HER2- disease

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SECTION 10: SPECIAL SITUATIONS

Male Breast Cancer

• <1% of all breast cancers; peak incidence: 6th decade
• Risk factors: Klinefelter's syndrome (XXY), radiation, estrogen therapy, cryptorchidism, gynecomastia (20%)

• 85% invasive ductal carcinoma; ~80% ER positive

• Treatment: Modified radical mastectomy (standard); SLNB feasible
• Adjuvant tamoxifen for ER-positive

Breast Cancer in Pregnancy

• Most common cancer in pregnancy; most common breast cancer in pregnancy is invasive ductal
• Mammography safe after 1st trimester (with shielding); USS preferred
• Surgery in all trimesters
• Chemotherapy in 2nd/3rd trimester (avoid in 1st)
• Radiation and endocrine therapy DEFERRED until after delivery

Locally Advanced Breast Cancer (LABC)

• Stage III disease
• Treatment sequence: Neoadjuvant chemotherapy → Surgery (MRM + ALND) → Radiation → Endocrine therapy
• pCR (pathologic complete response) after neoadjuvant = best prognostic marker

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SECTION 11: PROGNOSIS

• Localized (Stage I/II): 98.6%
• Regional (Stage III): 84.4%
• Distant (Stage IV): 24.3%
• Overall 5-year survival: ~89%

• Large tumor size, positive axillary nodes, high grade, ER/PR negative, HER2 overexpression, triple-negative, lymphovascular invasion, young age (<35)

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🔴 HIGH-YIELD VIVA QUESTIONS & ANSWERS

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Fibroadenoma. Differential: phyllodes tumor (older, larger, rapid growth), cyst, lipoma, hamartoma.

Clinical examination + Imaging (mammography/USS) + Tissue diagnosis (core biopsy/FNA). All three must be concordant; if discordant → excisional biopsy.

Suspicious abnormality - biopsy should be considered (malignancy risk 2-95%). BI-RADS 5 = highly suggestive of malignancy (>95% risk). BI-RADS 6 = known malignancy.

Eczematous rash of nipple associated with underlying DCIS/invasive cancer. Starts at nipple (eczema starts at areola), unilateral, does NOT respond to topical steroids. Paget cells are large vacuolated cells, CEA/EMA positive. S100 negative.

Long thoracic nerve (nerve of Bell, C5-7). It runs along the chest wall and can be injured during axillary dissection, causing paralysis of serratus anterior and winged scapula.

In patients with 1-2 positive sentinel nodes undergoing breast-conserving surgery + whole-breast radiation, completion ALND does NOT improve survival or local recurrence. Reduced morbidity by avoiding ALND in this group.

Inflammatory breast cancer, multicentric disease (>2 quadrants), prior chest wall radiation, inability to achieve clear margins, first/second trimester pregnancy.

"No tumor on ink" - this is the SSO/ASTRO consensus standard. Wider margins do NOT reduce local recurrence.

Removal of entire breast + pectoralis major + pectoralis minor + axillary lymph nodes (Level I-III). Largely obsolete - replaced by MRM (Modified Radical Mastectomy). Only performed when cancer directly invades the pectoralis major.

Patey's MRM: removes pectoralis minor (preserves pectoralis major). Scanlon's MRM: divides but does not remove pectoralis minor. Standard MRM preserves both pectoral muscles. Rotter's operation - preserves pec major and minor (Level II clearance through them).

Wide local excision with 1 cm clear margins. Mastectomy for large tumors or recurrence. NO axillary dissection because phyllodes spreads haematogenously, NOT via lymphatics.

Clinical diagnosis: rapid breast enlargement, peau d'orange, erythema, no discrete mass. Due to dermal lymphatic invasion. Staged T4d. Treatment: Neoadjuvant chemotherapy FIRST → Modified radical mastectomy (NOT BCT) → Radiation.

DCIS: true precursor, treated surgically (lumpectomy + radiation or mastectomy); SLNB not routine. LCIS: bilateral risk marker, not a true precursor; no surgery needed; chemoprevention with tamoxifen considered.

BRCA1 (chromosome 17q21) - breast + ovarian; BRCA2 (chromosome 13q12) - breast + ovarian + male breast. Other: TP53 (Li-Fraumeni), PTEN (Cowden), CDH1 (hereditary lobular), PALB2.

Prophylactic bilateral mastectomy (reduces risk by ~95%) ± bilateral salpingo-oophorectomy (reduces ovarian cancer risk and further reduces breast cancer risk by removing estrogen source). Annual MRI screening from age 25.

Bone (most common - osteolytic/blastic) > Lung > Liver > Brain > Adrenals. Bone mets: bisphosphonates (zoledronic acid) / denosumab for prevention of skeletal events.

Skin dimpling resembling orange peel. Caused by cutaneous lymphatic obstruction by tumor emboli causing lymphedema of the skin with tethering by Cooper's ligaments at sweat gland orifices.

Primarily to axillary nodes; also internal mammary nodes (for central/medial breast including nipple).

High nuclear grade, central necrosis, calcification. Highest risk of local recurrence after BCT and highest risk of progression to invasive carcinoma.

Tamoxifen: SERM, used in pre- and post-menopausal women; 5-10 years; risk of endometrial cancer and DVT. Aromatase inhibitors (anastrozole, letrozole, exemestane): only post-menopausal (or with ovarian suppression); more effective; risk of osteoporosis and arthralgia.

Thrombophlebitis of superficial breast/chest wall veins. Presents as tender cord running from breast to axilla. Self-limiting; NSAIDs.

Total duct excision (Hadfield's) - for duct ectasia/periductal mastitis. The major lactiferous ducts are excised from behind the nipple.

Node negative (localized): ~98%. Node positive (regional): ~84%. Each positive node reduces survival by approximately 6-7%. ≥4 nodes positive is a cutoff for post-mastectomy radiation.

ER-, PR-, HER2- cancer. Cannot use endocrine therapy or trastuzumab - chemotherapy is the only systemic option. Worst prognosis. Associated with BRCA1 mutations, young age, African-American women, high grade.

Patent blue V dye (isosulfan blue) + Tc-99m labelled sulfur colloid injected peritumorally or subdermally. First blue-stained or radioactive node removed = sentinel node. False-negative rate 5-10%.

Based on 3 features: tubule formation, nuclear pleomorphism, mitotic count. Each scored 1-3. Total 3-5 = Grade 1 (well); 6-7 = Grade 2 (moderate); 8-9 = Grade 3 (poorly differentiated/worst prognosis).

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KEY TABLES

Benign vs Malignant Breast Mass

Nipple Discharge - Significance

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🏥 BREAST - CLINICAL VIVA QUESTIONS (Complete)

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🔴 SCENARIO 1: PATIENT WITH A BREAST LUMP

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Start with a thorough history, then clinical examination, followed by investigations (Triple Assessment).

• Duration, size change, pain, skin changes
• Nipple retraction/discharge (color, unilateral/bilateral)
• Relation to menstrual cycle
• Age at menarche, parity, age at first birth, lactation history
• Family history of breast/ovarian cancer
• Use of OCP, HRT
• Previous breast biopsies/lumps

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Performed in 2 positions: sitting (upright) then supine.

• Compare bilateral breasts for size, shape, asymmetry
• Skin: dimpling, peau d'orange, erythema, ulceration, satellite nodules
• Nipple: symmetry, retraction (new vs old), eczematous change, discharge
• Arms raised: inspect lower breast
• Hands on hips + pectoral contraction: reveals tethering by deep tumors involving Cooper's ligaments

• Regional lymph nodes: axillary (support ipsilateral arm), supraclavicular, infraclavicular, cervical
• Note: size, consistency (soft/firm), mobility (mobile/matted/fixed), tenderness of nodes

• Palpate systematically - all 4 quadrants + axillary tail + subareolar region
• Describe lump: site (quadrant + relation to nipple), size, shape, surface, edge, consistency, tenderness, mobility/fixity (to skin, underlying muscle), transillumination

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Describe using the surgical sieve:

1. Site - quadrant (UOQ, UIQ, LOQ, LIQ, central), clock-face position, distance from nipple
2. Size - cm in 2 dimensions
3. Shape - round/oval/irregular
4. Surface - smooth/nodular/irregular
5. Edge - well-defined/ill-defined/spiculated
6. Consistency - soft/firm/hard/rubbery
7. Tenderness - tender/non-tender
8. Mobility - mobile in all directions / tethered to skin / fixed to chest wall
9. Skin over lump - dimpling, tethering, peau d'orange, ulceration
10. Nipple - retracted, normal, discharge
11. Regional lymph nodes - axillary, supraclavicular

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Tumor infiltration causes desmoplastic reaction - tumor cells secrete FGF, TGFα/β, VEGF → adjacent fibrocytes → fibroblasts → lay down collagen → Cooper's ligaments shorten → pull skin inward = dimpling/tethering/nipple retraction.

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Orange-peel appearance of breast skin due to obstruction of cutaneous lymphatics by tumor emboli → skin lymphedema with tethering at sweat gland orifices (held down by Cooper's ligaments). Clinically signifies locally advanced breast cancer (T4b). Also seen in inflammatory breast cancer (involves >1/3 of breast surface = T4d).

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Upper Outer Quadrant (UOQ) - 50% of TDLUs (terminal duct lobular units) are located here → 50% of breast cancers arise here. Also has the axillary tail of Spence.

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🔴 SCENARIO 2: INVESTIGATING A BREAST LUMP

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Triple Assessment - the gold standard (PPV approaches 100% when all 3 are concordant):

1. Clinical examination
2. Imaging: Mammography (≥35 yrs) / Ultrasound (<35 yrs or dense breasts); MRI if indicated
3. Tissue sampling: Core needle biopsy (preferred) or FNA

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Ultrasound preferred:

• Young women (<35 years, dense breast tissue)
• Differentiating cyst vs solid lump
• Guiding biopsy (USS-guided core biopsy)
• Pregnant/lactating women
• Evaluating axillary lymph nodes

MRI indications:

• Screening BRCA mutation carriers (annual MRI from age 25)
• Assessing response to neoadjuvant chemotherapy
• Suspected multicentric/multifocal disease
• Breast implant assessment
• Occult primary breast cancer (positive axillary nodes, no mammographic lesion)
• Discordant triple assessment

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Core needle biopsy (14G Tru-Cut) is preferred because:

• Gives histology (not just cytology like FNA)
• Can determine invasion (in situ vs invasive)
• Provides ER, PR, HER2 status for treatment planning
• Allows surgeon and patient to plan surgery before theatre
• FNA gives cytology only - cannot assess basement membrane

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• For palpable cysts (aspirate and assess if bloody; re-examine if cyst refills)
• When rapid on-site cytology is available and core unavailable
• For axillary lymph node assessment (USS-guided FNA)
• As part of triple assessment when other modalities suggest benign

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🔴 SCENARIO 3: NIPPLE DISCHARGE

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Blood-stained, unilateral, single-duct discharge is significant - must exclude malignancy.

1. Intraductal papilloma (most common - 50%) - benign
2. Ductal ectasia/periductal mastitis
3. DCIS - must rule out
4. Invasive carcinoma

1. Triple assessment (examination + mammogram + USS)
2. Ductoscopy / galactography (ductogram) to localise the bleeding duct
3. If no lesion found on imaging + single duct discharge → microdochectomy (excision of the discharging duct)
4. If DCIS/cancer found → treat accordingly

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Microdochectomy: Excision of a single duct - for unilateral, single-duct, persistent discharge to exclude/treat intraductal papilloma.

Total duct excision (Hadfield's operation): Excision of all major subareolar ducts behind the nipple - for duct ectasia, periductal mastitis, or bilateral/multi-duct discharge. Nipple is everted during the procedure.

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🔴 SCENARIO 4: BREAST ABSCESS

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Lactational (puerperal) breast abscess - most common type.

1. USS to confirm abscess and assess size/depth
2. Antibiotics (Flucloxacillin/Co-amoxiclav) for early cellulitis/mastitis
3. Needle aspiration (USS-guided) - first-line for small abscesses (<3 cm); repeat as needed
4. Incision and Drainage (I&D) - for large/loculated/failed aspiration; radial incision (to avoid ducts); avoid periareolar incision; break loculations with finger
5. Continue breastfeeding (or regular expression of milk) - reduces risk of recurrence; milk safe for baby

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Non-lactational (periductal mastitis):

• Occurs in smokers, overweight women, young non-pregnant women
• Subareolar location
• Mixed organisms - anaerobes + Staph/Strep
• Can lead to mammary duct fistula (Zuska's disease/subareolar fistula) - track between duct and skin
• Treatment: antibiotics (Metronidazole + Flucloxacillin) + USS-guided aspiration or I&D; for recurrent: excision of fistula tract
• Stop smoking - smoking causes squamous metaplasia of lactiferous ducts → obstruction → secondary infection

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Radial incision - to avoid dividing the lactiferous ducts. Periareolar incision can be used for subareolar abscesses. Avoid transverse incisions in the breast.

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🔴 SCENARIO 5: POSTMASTECTOMY COMPLICATIONS

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• Bleeding/haematoma
• Wound infection, seroma (most common early complication)

• Seroma (most common overall complication of ALND) - treat by aspiration

• Lymphedema (most important/common late complication) - arm swelling; risk ~20-30%
• Winged scapula - long thoracic nerve injury → serratus anterior paralysis
• Weakness in arm adduction/extension - thoracodorsal nerve injury → latissimus dorsi paralysis
• Numbness/paraesthesia of inner arm - intercostobrachial nerve (T2) - often deliberately divided
• Shoulder stiffness - frozen shoulder
• Cording (axillary web syndrome)
• Winging of scapula

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Lymphedema (secondary) due to disruption of axillary lymphatics.

• Complex Decongestive Therapy (CDT) = gold standard
  • Manual Lymphatic Drainage (MLD) by physiotherapist
  • Multi-layer compression bandaging
  • Specific exercises
  • Skin care
• Compression sleeve (long-term)
• Avoid: blood pressure cuffs, venipuncture, infections in affected arm
• Surgical options: lymphovenous anastomosis, vascularized lymph node transfer (selected cases)

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Collection of lymphatic fluid/serous fluid under the mastectomy skin flap. Most common complication after mastectomy and ALND.

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🔴 SCENARIO 6: LOCALLY ADVANCED / INFLAMMATORY BREAST CANCER

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Inflammatory Breast Cancer (IBC) - T4d; Stage IIIB minimum.

• Clinical diagnosis (NOT histological type)
• Due to dermal lymphatic invasion by tumor emboli
• No discrete palpable mass in ~50%
• Must differentiate from mastitis (IBC does NOT respond to antibiotics)

1. Neoadjuvant chemotherapy (NACT) FIRST (anthracycline + taxane based)
2. Modified Radical Mastectomy (BCT/lumpectomy is CONTRAINDICATED)
3. Post-mastectomy radiation (mandatory)
4. Targeted therapy if HER2+; endocrine therapy if ER+

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1. Locally Advanced Breast Cancer (T3, T4 / N2, N3) - to downsize tumor
2. To convert inoperable → operable disease
3. To downsize tumor and enable BCS in cases initially requiring mastectomy
4. HER2-positive tumors (>5 mm)
5. Triple-negative breast cancer (TNBC)
6. Premenopausal women with high-risk features
7. Axillary node metastasis (to assess treatment response)
8. Inflammatory breast cancer (mandatory before surgery)

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🔴 SCENARIO 7: CLINICAL VIVA - SPOT DIAGNOSIS

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Carcinoma of the breast - T4b (skin involvement), N2 (fixed/matted nodes). Locally advanced breast cancer.

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Fibroadenoma - the "breast mouse" (extremely mobile). Triple assessment → USS (solid, benign features). If <3 cm with concordant benign triple assessment → reassurance + 6-month follow-up.

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Fibrocystic disease / ANDI. Management: reassurance, evening primrose oil (GLA), danazol/bromocriptine in severe cases; cycle-mapped follow-up.

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Phyllodes tumor (cystosarcoma phyllodes). Triple assessment → Core biopsy. Treatment: Wide local excision with 1 cm clear margins (NOT enucleation). Large tumors → simple mastectomy. No axillary clearance needed.

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Male breast carcinoma. Treatment: Modified radical mastectomy + SLNB. ~80% ER+; adjuvant tamoxifen.

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Paget's disease of the nipple. Nipple biopsy → Paget cells (large, pale, vacuolated), CEA+, EMA+. Underlying DCIS/invasive cancer must be excluded with mammogram + MRI.

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🔴 SCENARIO 8: MASTECTOMY CLINICAL VIVA

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1. Position: Supine, arm extended on arm board
2. Incision: Transverse elliptical incision encompassing nipple-areolar complex and biopsy scar (Stewart's transverse incision - cosmetically superior); or oblique Halsted-type incision
3. Raise skin flaps (superior + inferior) - 5-8 mm of subcutaneous fat left on flap
4. Mastectomy: Dissect breast from pectoralis major fascia (preserve both pectoral muscles)
5. Axillary dissection: Identify and preserve:
   • Long thoracic nerve (medially, on chest wall)
   • Thoracodorsal nerve (laterally, on latissimus dorsi)
   • Thoracodorsal vessels
   • Medial/lateral pectoral nerves
   • Axillary vein (superior boundary)
6. Remove specimen (breast + axillary contents Level I & II)
7. Drains: 2 closed suction drains (axillary + mastectomy flap)
8. Closure

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• Superiorly (roof): Axillary vein
• Medially: Chest wall (serratus anterior) and long thoracic nerve
• Laterally: Latissimus dorsi and thoracodorsal nerve
• Anteriorly: Pectoralis major/minor
• Inferiorly: Axillary tail of breast (tail of Spence)

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Based on ACOSOG Z-0011 trial criteria: If the patient has 1-2 positive sentinel nodes + BCS + whole-breast radiation planned → NO completion ALND needed (no survival difference, less morbidity).

ALND is still indicated if: >2 positive sentinel nodes, mastectomy, clinically positive nodes, neoadjuvant chemotherapy setting (ALLIANCE trial - some centres).

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🔴 COMMON SHORT NOTES / ONE-LINERS

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