Breast Disease Management

OXFORD MEDICAL PUBLICATIONS
Breast Disease
Management
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Breast Disease Management: A Multidisciplinary Manual
James Harvey, Sue Down, Rachel Bright-Thomas, John Winstanley, and
Hugh Bishop
Breast Disease
Management
A Multidisciplinary Manual
James Harvey
Consultant Oncoplastic Breast Surgeon,
Nightingale Centre, UHSM, Manchester, UK
Sue Down
Consultant Oncoplastic Breast Surgeon, James Paget
Hospital, UK; Hon. Senior Lecturer, University of East
Anglia, UK
Rachel Bright-Thomas
Consultant Oncoplastic Breast Surgeon
Worcestershire Royal Hospital, UK
John Winstanley
Emeritus Consultant Surgeon, Royal Bolton Hospital,
UK; Hon. Consultant Surgeon, Royal Liverpool and
Broadgreen University Hospital, UK; Hon. Research
Fellow, Biological Sciences, Liverpool University, UK
Hugh Bishop
Emeritus Consultant Surgeon, Royal Bolton Hospital,
Bolton, UK
1
3
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v
Preface
As its name implies, this manual is intended to be of practical assistance to

those working in the breast industry. Advances in breast cancer are such
that it would be wrong for us to be dogmatic on fast-moving areas, such as
molecular biology or chemotherapy. Nevertheless, the process of breast
care has now evolved to be truly multidisciplinary.
This book is thus aimed at all members of the Multidisciplinary Team
(MDT), however peripheral their contribution. We hope it will provide
an introduction to all those medical professionals working in the field of
breast disease, such as:
• Foundation doctors attached to breast firms.
• Core Trainees (CT 1&2) and Specialty Trainees (ST) with no prior
knowledge or experience of breast firms.
• General practitioners with a breast interest.
• Specialist Breast Care Nurses.
• Medical students.
• Specialist breast radiographers.
• Breast physicians.
• Those who are responsible for purchasing or providing breast services.
In writing this book, we have concentrated on principles of care as they
apply at present. We have deliberately avoided detailed information about:
• Advanced or rarely performed surgical operations.
• Chemotherapy regimens, as these change with each new publication
or conference.
• Detailed issues of palliative care which are covered in b Oxford
Handbook of Palliative Care, 2e (2009). Watson et al. Oxford
University Press, Oxford, UK.
Whatever your discipline and whether or not you are embarking on a
career in breast disease or merely transiting during your training, we hope
you will find this book helpful in delivering excellent care to the patient
with breast disease.
Hugh Bishop
vi
Foreword
The past decade has seen some major advances in the management of
breast disease. Better imaging and diagnostics, improved surgical and radi-
otherapy techniques together with more targeted drug therapies should
lead to increased patient benefit. Good cooperation and communication
within and between increasingly large multi-disciplinary teams is vital, as
are management processes and systems that ensure the delivery of this
improved care.
This is not always easy to achieve and can be a source of frustration to
healthcare professionals and patients alike leading to sub-optimal care,
complaints and litigation. Patients with benign breast disease, whilst spared
the trauma provoked by a life-threatening diagnosis, nevertheless have
problems that can be deeply distressing, embarrassing or painful. Some
have signs and symptoms that create huge anxiety and considerable fears
of a cancer diagnosis. Other patients may feel very well, will have no mani-
fest breast lump or abnormalities, but may receive a sinister diagnosis
following routine mammographic screening.
Whatever the aetiology and eventual diagnosis all patients need to be
treated respectfully and sensitively by a multidisciplinary team contributing
to management decisions from their own areas of expertise. This is only
achievable with good teamwork, management experience and awareness
of the important contributions that relevant disciplines might make to
optimal decision-making.
The authors of this handbook have written a useful, pragmatic and
broad introduction to the management of breast disease, taking account
of some of the problems just mentioned and offering sensible, practical
suggestions. The factual content is refreshingly succinct, with an occasional
scintilla of humour and plenty of appropriate compassion. As such it avoids
the rather prosaic, cold, and abstract feel of many such introductory man-
uals where one might just as well be reading about the maintenance of a
piece of malfunctioning machinery rather than disease in a sensate being.
This text will be invaluable to anyone needing to acquire an overview
or to begin work in this challenging but immensely rewarding clinical field.
Professor Lesley Fallowfield
Sussex Health Outcomes Research & Education in Cancer (SHORE-C),
Brighton & Sussex Medical School
University of Sussex, Falmer, UK
August 2013
vii
Contents
Symbols and abbreviations ix
1 How to survive outpatient clinics

in breast disease 1
2 The National Health Service Breast
Screening Programme (NHSBSP) 7
3 Multidisciplinary working 19
4 Anatomy and physiology 25
5 Breast cancer—facts and figures 35
6 Breast assessment: making the diagnosis 41
7 Benign breast problems and their management 57
8 Surgical management of benign breast disease 81
9 Gynaecomastia 89
10 Invasive breast carcinoma: pathology
and prognosis 97
11 Non-invasive breast disease: DCIS,
lobular pathologies, and hyperplasias 109
12 Basic surgery for breast cancer and
the management of margins 115
13 Adjuvant therapy 123
14 Treatment-induced complications 133
15 Ward management 141
16 Breast reduction 153
17 Oncoplastic mastectomy incisions 163
18 Breast-conserving surgery: volume displacement 171
19 Breast reconstruction: volume replacement 177
20 Lipomodelling 187
viii CONTENTS
21 Nipple-areola reconstruction 193

22 Breast augmentation and symmetrization surgery 199
23 Recurrent breast cancer 207
24 Management of the high-risk patient 215
25 Research and audit 227
26 Complaints, mistakes, and how to
minimize problems 237
Index 245
ix
Symbols and
Abbreviations
° degree
£ pound sterling
& and
% per cent
> greater than
< less than
= equal to
± with or without
7 approximately
π pi
®
registered
™ trademark
ACE angiotensin-converting enzyme
ADH atypical ductal hyperplasia
ADRC adipose-derived regenerative cell
A&E Accident and Emergency
AI aromatase inhibitor
AJCC American Joint Committee on Cancer
ALH atypical lobular hyperplasia
ANC axillary node clearance
ANDI aberrations of normal development and involution
BCN breast care nurse
BCS breast-conserving surgery
BMI body mass index
CC cranio-caudal
cm centimetre
CT Core Trainee
CVA cerebrovascular accident
CXR chest X-ray
DCIS ductal carcinoma in situ
DEXA dual-energy X-ray absorptiometry
DIEP deep inferior epigastric perforators
DNA deoxyribonucleic acid
DVT deep vein thrombosis
EBCTCG Early Breast Cancer Trials Collaborative Group
x SYMBOLS AND ABBREVIATIONS
ECG electrocardiogram
e.g. exempli gratia (for example)
EGFR epidermal growth factor receptor
ER (o)estrogen receptor
ERP Enhanced Recovery Programme
FBC full blood count
FISH fluorescent in situ hybridization
FNA fine-needle aspiration
FNAC fine-needle aspiration cytology
FRCS Fellow of the Royal College of Surgeons
FY Foundation Year
g gram
GI gastrointestinal
GP general practitioner
GnRH gonadotropin-releasing hormone
G&S group and save
Gy gray
h hour
hCG human chorionic gonadotropin
HRT hormone replacement therapy
i.e. id est (that is)
IHC immunohistochemistry
IMF inframammary fold
IT information technology
IUCD intrauterine contraceptive device
IV intravenous
kg kilogram
LCIS lobular carcinoma in situ
LD latissimus dorsi
LH luteinizing hormone
LIN lobular intraepithelial neoplasia
LREC local research ethics committee
LVF left ventricular function
m metre
MDM multidisciplinary meeting
MDT multidisciplinary team
mg milligram
mGy milligray
mL millilitre
MLO mediolateral oblique
SYMBOLS AND ABBREVIATIONS xi
mm millimetre
MREC multicentre research ethics committee
MRI magnetic resonance imaging
MRSA Meticillin-resistant Staphylococcus aureus
MUGA multigated acquisition (scan)
NAC nipple-areola
NHS National Health Service
NHSBSP National Health Service Breast Screening Programme
NICE National Institute for Health and Care Excellence
NMBRA National Mastectomy and Breast Reconstruction Audit
NPI Nottingham Prognostic Index
NST no special type
OBCS oncoplastic breast-conserving surgery
OCP oral contraceptive pill
PCR polymerase chain reaction
PE pulmonary embolism
PRN pro re nata (as needed)
QA quality assurance
RCT randomized controlled trial
ROLL radioguided occult lesion localization
RR relative risk
RT-PCR reverse transcriptase-polymerase chain reaction
SIEP superficial inferior epigastric perforators
SIGN Scottish Intercollegiate Guidelines Network
SLN sentinel lymph node
SLNB sentinel lymph node biopsy
ST Specialty Trainee
TB tuberculosis
TDLU terminal duct lobular unit
TED thromboembolism deterrent
TNM tumour, node, metastasis
TRAM transverse rectus abdominis muscle
U&E urea and electrolytes
UK United Kingdom
U/S ultrasound
US United States
vs versus
WBRT whole breast radiotherapy
WHO World Health Organization
WLE wide local excision
Chapter 1 1
How to survive
outpatient clinics
in breast disease
Overview 2
Referral 3
The symptomatic breast clinic 4
Follow-up after breast cancer 6
2 CHAPTER 1 How to survive outpatient clinics
Overview
Welcome to breast disease, one of the most fascinating areas of clinical
medicine. To flourish in breast disease, it is vital to appreciate that it is a
high-volume specialty. Unless you remain disciplined, your patients will
suffer as a result of your inability to make a decision. Indecisiveness results
in patients drifting into ‘follow-up’ clinics, often with disastrous results.
Success in breast disease depends on the successful working of a cohe-
sive multidisciplinary team. This chapter looks at the patient’s journey and
where there is a potential danger to your patient.
REFERRAL 3
Referral
It is normal to be worried, even frightened, by discovering a potential
breast lump. Women naturally want the problem sorted and quickly. GPs
are realistic and accept that, at the present time, a well-organized symp-
tomatic breast clinic is the most efficient way to see, diagnose, and, more
often than not, reassure and discharge the patient (hence, the huge num-
ber of referrals).
In addition, clinicians should be realistic. There is a political dimen-
sion to breast disease. All women have two breasts and one vote. This is
reflected in the concern politicians demonstrate for breast cancer. There
is a Breast Cancer Committee of the House of Commons. The Breast
Cancer charities make a considerable contribution in terms of education,
funding research as well as lobbying.
Breast clinicians wish to see and reassure patients as quickly as possible.
To do this, it is not enough to examine a patient; breast patients require
imaging. The problem arises because of insufficient numbers of breast radi-
ologists. Not having a breast radiologist in the symptomatic clinic means
patients may have to return two, or even three, times, which is upsetting
to the patient as well as expensive and inefficient.
The referral letter
Beware that vital information on prescribed drugs or relevant history is
often missing.
The symptomatic breast clinic

It is important to recognize that the ratio of new symptomatic breast
patients to a patient with breast cancer is about 12–15:1. A great deal of
the work of a symptomatic breast clinic is thus reassuring the worried well.
Most patients will require a clinical examination, breast imaging, reassur-
ance, and, above all, discharge by the time the clinic has ended. Patients,
when they make an appointment, should be advised that attendance at a
breast clinic could take 3 hours.
Although some units are so pressed that patients are mammogrammed
first, it is better to allow the patient to be seen clinically first. It is courte-
ous to allow a patient to have an opportunity to explain their concerns. It
also saves the time and trouble of performing mammography on a woman
referred with a sebaceous cyst.
Furthermore, an initial history and examination allows the clinician
to alert the breast radiologist to areas of clinical concern or problems,
e.g. frozen shoulder. Most women in an NHS symptomatic breast clinic
will end up with a double assessment, i.e. clinical assessment and breast
imaging.
There is nothing to prevent a non-radiologist acquiring breast ultra-
sound (U/S) skills. There are courses and standards, but, at the present
time, breast U/S is still the preserve of the breast radiologist. Since the
best results are obtained when a biopsy is image-guided, then, in practice,
it will be the radiologist who will perform the core biopsy.
The rate-limiting step in a contemporary NHS breast clinic is how fast
the breast radiologist can comfortably work. This implies the clinician and
the radiologist must agree what is possible to achieve in a session.
Most women in a symptomatic breast clinic will not have breast can-
cer, which means there will be no breast care nurses present—there are
not enough of them anyway. This implies an adequate number of outpa-
tient staff to assist in helping 20 women to undress, dress, go for imaging,
undress, dress, wait, more imaging, undress, a needle biopsy, 5 minutes
pressure on the needle site, and dress again before departure. Whilst
some nurses will be required, a sensible lady with kindness and common
sense can make the patient’s experience much less distressing. We have
been privileged to work with some outstanding Health Care Assistants
with not a qualification to their name. Clinics should not habitually over-
run, as this is unfair on patients and low-paid staff and is also inefficient, e.g.
the last core biopsy specimen of the day goes missing because the labora-
tory has shut and the specimen was not properly signed in.
Managers may demand that patients are seen in order to meet a clini-
cally irrelevant target. It is of no help to the patient if, because of a lack
of a radiologist, the patient has to make two, or three, return visits in
order to have her breast imaging and core biopsy. Worse still, a relatively
unsupervised junior may then see the patient in a follow-up clinic. The
cost of this muddled process far outweighs the cost of doing it right first
time. Follow-up clinics containing patients with no clear diagnosis are a
rich source of delay in diagnosis. For this reason, there must be good
and documented reasons for a breast patient without breast cancer to
require a return visit. In practice, most review appointments often involve
THE SYMPTOMATIC BREAST CLINIC 5
a follow-up U/S, so arrange the appointment for when the patient, clini-
cian, and radiologist are all present.
The distinguished psycho-oncologist Lesley Fallowfield has published
evidence to suggest it is good practice for a patient without breast cancer
to be seen, processed, and discharged in one session.
The same is not true of a woman who does have breast cancer and
who will need adaptation time. The latter patient needs to leave the clinic
with a time and date for her next appointment, together with the contact
number for the breast care nurse. It is good practice for the clinician(s)
and breast radiologist to go through the clinic list at the end of the clinic
to ensure no obvious errors of omission have taken place.
Core biopsy
U/S-guided core biopsy is now the needling procedure of choice.
Fine-needle aspiration cytology (FNAC) has effectively been abandoned
for breast lesions and is best reserved for axillary node assessment.
The diagnostic multidisciplinary meeting (MDM)
All patients who have had a needling procedure require discussion at
an MDM. The diagnostic MDM should recommend the range of surgical
options that the patient can be offered. Patients should understand that a
multidisciplinary discussion of their problem is required before an opinion
can be given. It is poor practice to see a patient after a triple assessment if
they have not been discussed in an MDM.
Post-MDM appointment
The breast care nurse should always be present when a patient receives
the diagnosis of breast cancer. The patient needs time to come to terms
with her options, particularly reconstructive options, and frequently needs
more than one appointment before a decision is agreed.
Post-operative MDM
There is no point in discussing the patient, unless you have all the results.
Patients must be alerted to this. The multidisciplinary team (MDT) should
agree the adjuvant therapy programme to be offered. In addition, the
follow-up schedule and mammographic surveillance programme must be
agreed and documented. The intensity of follow-up will reflect the indi-
vidual’s inherent prognosis.
The post-operative consultation
Try to be truthful. Oncologists complain bitterly that, too often, surgeons
avoid spelling out the true prognosis or need for treatment. The result is
that the patient feels quite optimistic until the oncologist dashes this rosy
outlook. The effect is to damage the oncologist/patient relationship and is
devastating to the patient.
If necessary, make a list of the points you wish to convey, and remember
to ensure the breast care nurse is with you.
Follow-up after breast cancer

Originally designed to detect recurrence, which nowadays follow-up clin-
ics very seldom do. The emphasis has changed to encompassing issues of
bone health, sexual health, and the side effects of adjuvant therapy.
Practically any symptom can be a potential manifestation of metastatic
disease.
Assessing the post-operative, radiotherapized breast is not easy. Bear in
mind that repeated requests for follow-up appointments may imply a need
for psychological assistance.
In assessing symptomatic patients in a follow-up clinic, it is worth con-
sidering the patient’s original prognostic factors, such as whether she was
originally a symptomatic or screen-detected cancer, what her original NPI
score and HER2 status were, and whether or not there was lymphovas-
cular invasion.
Do not ignore life events, such as a husband’s recent death or a daugh-
ter’s divorce, which have been shown to be linked to the subsequent
development of metastatic breast cancer. Sometimes, questioning may
reveal the stress has been produced because a friend has developed
recurrence or died, and this event has not unsurprisingly resurrected the
patient’s level of anxiety.
Oncoplastic surgery is technically challenging and is part of its appeal to
surgical trainees. Nevertheless, there is much more to breast disease than
complex operations. It is vital that the patient undergoes the most appro-
priate operation for her as an individual. Thus, the process of consenting is
an important aspect of outpatient work. In addition, the considerable diag-
nostic load has to be handled accurately and sensitively. Finally, follow-up
and mammographic surveillance need to be set out for the patient on an
individual basis.
Welcome to breast disease.
Chapter 2 7
The National Health

Service Breast Screening
Programme (NHSBSP)
History 8
Organization of breast screening 10
Audit and quality control 12
The screening process 14
Controversies in breast screening 16
Future developments 17
Further reading 18
8 CHAPTER 2 The NHSBSP
History
The decision to fund an NHSBSP was taken following a report by
Professor Sir Patrick Forrest and is known as the Forrest Report. Forrest
reviewed all the evidence at that time, 1986, and concluded that mam-
mographic screening had the potential to reduce mortality from breast
cancer in the UK population. The greatest benefit was in older women.
It was not considered that younger women would derive any benefit. For
this reason, the NHSBSP set out to screen all women who were aged
between 50 and 65.
Principles of screening
The general principles of screening for any disease are that:
• The disease screened for represents an important health problem.
• It has a well-understood natural history.
• It has a recognizable early stage.
• There is a benefit from early treatment.
• There is a suitable test.
• It is acceptable to the population.
• There are adequate facilities to diagnose and treat the condition.
• Screening can be done at intervals to match the natural history.
• There is less harm than benefit.
Two measures are considered in this, which apply to any test—these are
the sensitivity and the specificity.
The sensitivity of a test is a measure of its ability to identify true posi-
tive cases. The specificity is the ability to identify true negative cases (see
Table 2.1).
Sensitivity = a/a + b
Specificity = d/c + d
Expressed as percentages, an ideal test has a high percentage for both sen-
sitivity and specificity. In breast cancer terms, the purpose of the screening
programme is not to diagnose cancers but to reduce mortality from breast
cancer in the population.
Statistics
At the present time, the screening programme screens 1.88 million
women a year and diagnoses 14,725 breast cancers per year (2010–11)
(see Further reading).
This work is carried out by:
• 80 breast screening units.
• Cost—£96 million/year.
• 73.4% of those invited for screening attend for their screen.
• 79.5% invasive cancers vs 20.5% DCIS.
• Rate of recall for further assessment—40 per 1,000 women screened.
• Rate of biopsy of the breast following further assessment—17 per
1,000 women screened.
• Rate of cancer detection is 7.8 cases per 1,000 women screened.
HISTORY 9
Table 2.1 Definition of the sensitivity and the specificity of a test

Patient with Patient without
breast cancer breast cancer
Test positive for True positive (a) False positive (c)
breast cancer
Test negative for False negative (b) True negative (d)
breast cancer
Organization of breast screening

Forrest proposed that a breast screening unit should serve a catchment
population of 500,000. Broadly, this ‘Forrest unit’ structure has persisted,
although there are now some very large units. The NHSBSP built on les-
sons learnt from earlier screening programmes. The most important was
an emphasis on quality assurance (QA—a new concept to many surgeons
in 1988!). Subsequently, the NHSBSP has developed a robust audit struc-
ture in order to improve the service. A senior NHS manager heads the
programme, and regional screening teams are assisted by regional QA
committees, consisting of all the disciplines participating in the programme
(see Fig. 2.1).
It is important to understand that the screening service is organization-
ally separate from a hospital breast unit. In many instances, it will be based
in a particular hospital’s breast unit so that, to all intents and purposes, it
will appear as one unit, but it will have a clerical staff that is separate from
the hospital’s clerical staff; in some instances, the radiographers will be
separate, and some of the radiologists may not do routine screening film
reading. Because of the large geographical areas involved, there will be, in
addition to a static screening unit, several mobile units, all administered by
the central unit. For that reason, not every hospital that treats breast can-
cer is a screening unit. From a technical point of view, women undergoing
screening are not called patients but clients. They only become patients
when they have either a cancer diagnosed or some other abnormality
requiring surgical intervention, commonly a core biopsy. At that point,
they become a patient and are referred to a surgeon. In many instances,
that will be an in-house referral to a surgeon working in the breast unit of
which the screening unit is a part. However, given the large areas covered
by screening units, it might be more convenient for patients to be treated
at a hospital more local to them, in which case a screening unit must
have an arrangement to repatriate local patients to a particular hospital.
Nevertheless, the hospital must demonstrate that its surgeons and radi-
ologists have the knowledge and facilities to carry out such procedures
as wire-guided biopsies, local excisions, and sentinel node biopsies. At
present, there is a distinction made between symptomatic and screening
breast units. It is recognized that the skills acquired in breast screening,
particularly in radiology, are of major benefit in symptomatic practice.
There is, therefore, a move to try to integrate the two services. Those
hospitals that do not have a screening programme must work to the same
standards of diagnostic stringency that screening units are required to
demonstrate.
ORGANIZATION OF BREAST SCREENING 11
National director of screening
Regional director of screening
Regional QA team (radiologist, surgeon, nurse, radiographer, clerical)
Individual Programme Director of screening and team
Fig. 2.1 The organizational structure of the NHSBSP.

Audit and quality control

The NHSBSP audit of screen-detected breast cancer made its first
attempt at collecting screening data in 1996. There have been consider-
able improvements in the quality of the data collected since then. With
the passage of time, the audit team, based at the West Midlands Cancer
Intelligence Unit, have been able to report 5-year survival rates and, quite
recently, 20-year survival rates for screen-detected cancers. The audit
results are presented annually at the annual meeting of the Association of
Breast Surgery (see Further reading).
In addition to this annual review at national level, there is local review,
which takes place every 3 years. This is done by the regional quality assur-
ance team. This consists of:
• The regional Director of Screening.
• The regional QA Surgeon.
• The regional QA Radiologist.
• The regional QA Pathologist.
• The regional QA Radiographer.
• The regional QA Breast Care Nurse.
• The regional QA Clerical Officer.
• The regional QA Physicist.
This team visits each of the screening units within the region once every
3 years and audits their performance against the screening guidelines; this
includes an assessment of the operation of the radiology equipment. The
purpose is to praise good practice and offer suggestions where they feel
performance could be enhanced. Many teams find the visits can be help-
ful. External support for improvements in a written report is less easy for
managers to ignore!
National screening committees for each
discipline–the BIG 18s
Each of the clinical disciplines—surgery, radiology, pathology, breast
care nurses, and radiographers—has a national committee, of which the
regional QA representative is a member. These became known as the BIG
18s because there were originally 18 screening regions. The national com-
mittees meet twice a year. Their function is to discuss issues affecting the
screening programmes and formulate policy. These groups oversee revi-
sion of the various guidelines for the disciplines, which is conducted on a
regular basis. For example, the national committee for pathology in breast
screening recently made a formal recommendation that core biopsy was
the needling procedure of choice in screen-detected lesions and that,
within the NHSBSP, fine-needle aspiration cytology should be abandoned.
AUDIT AND QUALITY CONTROL 13
The screening process

At the start of the programme, screening was targeted at the 50–65 year
old age group. However, this was extended to take the age limit up to
70, and the plan in the future is to extend the programme to include all
women from 47–73.
Women are screened by general practice lists once every 3 years.
A common misconception is that once a woman becomes 50, she will be
called for screening. This is not the case; she will only be called when her
practice is screened. For example, if a lady turns 50 six months after her
practice was screened, she will not be screened until the practice is next
screened in 3 years. The process is summarized in Fig. 2.2. After the upper
age limit of routine invitation for screening, a woman remains eligible for
screening every 3 years, however, the request has to be made by the
individual patient to the local screening unit.
• Patients are invited to be screened as a group from a general practice
triennially. The first invitation occurs between 50 and 53 years of age.
Any client who has had mammography within the previous 12 months
is advised not to undergo screening in this round.
• Two view (cranio-caudal and lateral-oblique) screening mammograms
are taken of each breast in a static or mobile screening unit. A patient
questionnaire is also completed, giving basic relevant history, which is
available to the mammogram readers.
• The majority of clients are returned to ‘routine recall’ in 3 years’
time—written confirmation is sent to the client.
• Those with a possible abnormality on their screening mammograms
(such as micro-calcification, mass, asymmetric density, distortion) or
those who have mentioned a significant new clinical problem on their
questionnaire are recalled to an assessment clinic.
The assessment procedure
This can involve the following stages:
• Further mammographic views—repeat standard views, coned
compression views, magnification views.
• Clinical examination.
• Ultrasound scanning.
If a radiological or clinical abnormality persists, a needle biopsy is undertaken.
• Ultrasound-guided biopsies. Possible for focal abnormalities visible on
ultrasound, e.g. mass or distortion and sometimes for micro-calcification.
• Mammographic, stereotactically guided biopsies. Done for
micro-calcification or for lesions not visible on ultrasound.
• Clinically guided biopsies can be undertaken for palpable lesions.
• Specimens are radiographed to check for the presence of
micro-calcification.
Biopsy procedures
All are done under local anaesthetic.
The multidisciplinary team meeting (MDT)
This has been another of the big benefits conferred on cancer manage-
ment in general from the breast screening process. It is a requirement of
THE SCREENING PROCESS 15
Initial mammogram
Abnormal—back to
Normal l discharge screening recall for
further assessment
Further
mammography
including
compression
views and U/S
Normal l discharge Abnormal—targeted

biopsy
Abnormal—
Normal l discharge management as
determined by MDM
Fig. 2.2 Flow of patients through the breast screening process to diagnosis.
the QA process that units have a regular meeting to discuss the results of
patients who are of concern. This usually comprises:
• Patients who have undergone biopsy.
• Patients whose mammograms require group discussion.
This meeting allows a group decision on how best to manage the prob-
lem identified. This usually results in a consistent standard of treatment
and avoids patients being subjected to idiosyncratic variability. As part of
the QA process, a representative of the QA usually attends one meet-
ing, unannounced, to write a report on the conduct of the meeting. As
with other MDT meetings, the proceedings must be recorded and a
register kept.
Controversies in breast screening

The 20-year survival data demonstrate an increase in survival in women
screened compared with those who failed to attend. The original remit
was to reduce death from breast cancer in the UK population. There is
some controversy about the true benefit of breast screening. The main
areas of concern are:
• The statistical benefit on survival has been overestimated.
• The programme identifies cancers which would never be
life-threatening.
• The process of screening is psychologically disturbing.
An independent review of breast screening was performed in October
2012 (see Further reading). Their conclusions, based on a meta-analysis of
the available data, were:
• NHSBSP leads to a 20% reduction in breast cancer mortality.
• One breast cancer death is prevented for every 250 women invited.
• 19% of cancers are overdiagnosed (i.e. would not have caused harm
to the patient if left alone) during the period that women are in the
screening programme.
• 11% of all breast cancers diagnosed in a woman’s lifetime constitute
overdiagnosis.
These figures give a spurious idea of the true accuracy of the data, which
have a large confidence interval.
The panel concluded that the NHSBSP confers significant benefit and
should continue.
Some of the cancers identified would not prove life-threatening, the
problem being that there is no means, at present, to identify those cancers
so that not treating a cancer, having found it, would be taking a consider-
able gamble. It is true that some women find the process worrying, but,
on balance, most people feel they would rather have that anxiety and be
diagnosed early rather than allow the tumour to reach a more advanced
stage. It is unlikely that the government will abandon the screening pro-
gramme in the immediate future.
FUTURE DEVELOPMENTS 17
Future developments
• Digital mammographic screening for all screening units.
• An age extension trial is currently underway of women aged 47–50
and 70–73 to determine whether screening is of benefit.
• Developing an audit of screen-detected non-invasive breast cancer.
This audit, called the Sloane Project, is now complete (see Further
reading), and over 11,000 women have been enrolled (November
2012). This is the largest prospective audit of non-invasive
screen-detected breast cancer to date.
Further reading
Further information on breast screening, including statistical data, can be found at: M http://www.
cancerscreening.nhs.uk/breastscreen/index.html
Independent review on breast cancer screening. Available at: M http://www.cancerresearchuk.org
Sloane project. Available at: M http://www.sloaneproject.co.uk
Chapter 3 19
Multidisciplinary working
Overview 20
The multidisciplinary team (MDT) 22
Team communication 24
Conclusion 24
20 CHAPTER 3 Multidisciplinary working
Overview
Patients with breast symptoms are managed by a multidisciplinary team
for their diagnosis and at all stages of their treatment. This implies mutual
respect for the various disciplines involved in the process.
OVERVIEW 21
The multidisciplinary team (MDT)

Components of the MDT
A modern breast MDT needs the following components:
• Surgeons.
• Radiologists.
• Pathologists.
• Oncologists.
• Breast care nurses.
• An MDT coordinator and adequate clerical support.
• Data manager.
• Trials nurses.
These are the fundamental components, however, it is important that the
team has links with other groups:-
• Plastics surgeons.
• Psychologists.
• Clinical geneticists.
It is important that the team has formally established mechanisms for
referral to groups, such as oncologists, or other centres that regularly
form part of the patient journey. It is also important to have a good cleri-
cal and administrative infrastructure to ensure that all parts of the process
happen. It is no use making good clinical decisions if clinic appointments
are not booked or the GP does not get letters! Equally, team meetings
need administrative support to ensure that all the films, notes, and pathol-
ogy reports are assembled together. There are now systems in place to
record the data and decisions made in real time online, e.g. Somerset
Health Informatics Database. The results are immediately available to
team members. It is wrong to discuss results if one component (e.g. Her-2
result) is missing. Failure to have all results present or to have representa-
tion from each of the fundamental disciplines can result in catastrophic
failure.
Functions of the MDT
The MDT has a number of functions:
• To plan and organize treatment for both benign and malignant breast
disease.
• To establish a cycle of audit and research.
• To act as a focus for undergraduate and postgraduate education in
breast diseases.
• To advise local healthcare providers on provision of services.
• To establish a trials portfolio.
• To determine operational policies and protocols.
How individual teams organize themselves is, in part, controlled by local
circumstances, but, in order to function well, all teams need:
• Operational policies so that everyone knows how to handle specific
situations.
• Regular meetings so that all patients undergoing diagnostic procedures
and surgery are discussed.
THE MULTIDISCIPLINARY TEAM (MDT) 23
• Regular meetings to discuss the way the unit functions on a day-to-day

basis, to review protocols as well as discuss complaints and errors.
• A written record of all decisions made by the MDT.
• An easily accessible database.
• Time to carry out all this.
• An MDM should be part of an individual’s job plan.
Most units will have a lead clinician. But if a team is going to function well,
it is vital that everyone involved feels valued for the contribution they
make, and that is why regular meetings are important to allow all those
involved to express their views, be it on clinical or organizational mat-
ters. When this does not happen, teams become dysfunctional and break
down, which ultimately leads to clinical errors.
Much of modern breast management is about process, and it is impor-
tant for the team that the process is recorded both clinically and from a
medico-legal point of view. Notes can get lost, and a record of what hap-
pened in the meeting held separately is supportive.
It is important that timetabling is such that all members can get to
meetings; if the oncologist cannot get to the meetings, they cease to be
multidisciplinary. It is also important that adequate time is allowed; fitting
meetings in between sandwiches at lunch time is often another recipe for
disaster in a busy unit.
Apart from clinical meetings, it is important that teams meet regularly
to look at operational matters. Working practices change, and what would
have been appropriate 2 years previously may not be now. Similarly,
changes in referral pattern may demand some re-organization of clinics.
Responses made on the spur of the moment often end up needing to be
revised. Equally important is audit and research (see Chapter 25). Audit
is a requirement of modern practice. It also provides a focus of interest
and avoids the danger of work becoming routine and the team becoming
bored. In addition, it is a means of making sure that the team is functioning
efficiently, which ultimately is in the best interests of patients.
Team communication
It is vital that team members, particularly those involved in clinical deci-
sions, make their opinions clear to their colleagues. Many clinical problems
arise because of a breakdown in this aspect of multidisciplinary working.
Those examining patients need to make their opinion clear about whether
lesions are sinister or not and if further imaging is needed should the
mammogram appear normal. Similarly, radiologists and pathologists need
to give a clear indication of their views on the nature of a lesion so that all
those involved have clear opinions to base their decisions on.
Conclusion
Multidisciplinary working is now established as an important component
of managing patients with breast problems. A functional MDT will have
patients who feel that their management is in safe hands, receiving consist-
ent explanations of their treatment, and the sense that the team knows
what is going on. This can only be achieved if everyone works as a team
member and not as an individual. Finally, good multidisciplinary working
results in fewer mistakes.
Chapter 4 25
Anatomy and physiology
The breast 26
The axilla 32
26 CHAPTER 4 Anatomy and physiology
The breast
Embryology and developmental variants
Breasts are modified sweat glands, developing from ventral mammary
ridges (the milk line) that run from the axilla to the inguinal region. Two
common problems are (see Chapter 7):
• Accessory nipples and breasts: remnants of the embryonic tissue can
remain anywhere along the milk line and be seen in adulthood as
accessory breasts (usually as a bulge in the axilla) or as nipples just
below the normal breast.
• Poland’s syndrome: covers a wide variety of developmental failures
of the chest wall and breasts, ranging from mild hypoplasia and
asymmetry of the breast to complete absence of the breast and
pectoral muscles with deformities of the rib cage and upper limb.
Anatomy
The huge variation in shape and size of the breast is related to the deposi-
tion of fat and stroma, but the anatomical landmarks are constant despite
the variation in size and shape of the breast.
Breasts are never completely symmetrical. The left breast is commonly
larger and more ptotic by a centimetre or two. The lack of symmetry can
be highlighted by chest wall asymmetry. In general, breasts share these
common features (see Figs 4.1 and 4.2):
• Modified sweat gland, comma-shaped with the tail extending towards
the axilla.
• The breast base lies on pectoralis major, serratus anterior, rectus
sheath.
• Overlies 2nd–6th ribs.
• Enveloped by the superficial fascia (Scarpas).
• Fibrous suspensory ligaments run through the breast, connecting skin
to the deep layer of the superficial fascia (Cooper’s ligaments).
• Rich lymphatic plexus (deep and superficial).
• Preferential lymphatic drainage toward the axilla (80%).
Structure
The adult female breast comprises both fatty and glandular tissue (see
Fig. 4.3).
• Lobes 15–20. Each lobe is made up of many lobules, at the end of
which are tiny bulb-like glands where milk is produced in response to
hormonal signals—the terminal duct lobular unit (TDLU).
• The male breast does not contain TDLU. The TDLU are the functional
part of the breast, and this is where most benign and malignant
pathology arises.
• Duct system. The ducts connect the lobes to the lactiferous sinuses
beneath the areola and 15–20 ducts ending on the nipple where the
epithelium of the duct changes to squamous epithelium.
• Nipple-areola complex (NAC): The nipple and areola contain smooth
muscle and modified sebaceous glands.
THE BREAST 27
Terminal Ductal Lobular Unit (TDLU)
Lobule
Ductules
(Acini)
Terminal duct
Segmental duct
Major duct
(Lactiferous duct)
Nipple
Areolus
Subcutaneous
fat
Lobe
Pectoralis major
Fig. 4.1 Cross-section of the female breast. Reproduced with permission from
'Training in Surgery : The essential curriculum for the MRCS', edited by Matthew
Gardiner, Neil Borley, copyright 2009 Oxford University Press.
It is supported and encased by fat and stroma.

• The stroma and fat (subcutaneous adipose tissue) that cover the lobes
give the breast its size and shape.
• TDLUs lie scattered throughout the breast, mainly in the lateral half
and especially the upper outer quadrant of the breast. This is why
most breast pathology occurs in the lateral half of the breast. The
medial half is mainly stromal and fatty tissue. It is the TDLU that gives
the breast its dense appearance on mammography and lumpy feeling
on palpation.
Site of cancers
• 50%: upper outer quadrant.
• 20%: upper inner quadrant.
• 20% lower outer quadrant.
• 10% lower inner quadrant.
Breast development, physiology, and endocrinology
Initial growth of breast buds occurs at puberty under the influence of oes-
trogen and progesterone. Oestrogen induces duct sprouting, and proges-
terone causes differentiation of the terminal lobular ducts to form lobules
and the TDLU. Fifty percent of women have a 10% difference between
their breast volumes, 25% of women have a 25% difference in the volume
of their breasts. Throughout subsequent menstrual cycles, there are cycli-
cal changes affecting the TDLU, which give rise to cyclical symptoms, such
as pain and nodularity.
Blood and nerve supply
The breast is supplied by the internal mammary, anterior intercostal, and
lateral thoracic arteries and their accompanying veins (see Figs 4.2 and
4.4). The nerve supply to the breast is primarily via intercostal sensory
fibres (see Fig. 4.5).
Lymphatic drainage of the breast
Breast tissue lymphatics drain centripetally to a subareolar plexus and,
from there, to the axillary nodes (see Fig. 4.6). Some of the deeper breast
parenchyma also flows to a retromammary plexus and, from there, to the
internal mammary chain. There are lymphatic connections to the opposite
breast and abdomen.
Lymphatic flow through the axilla
Lymphatic flow through the axilla is orderly and tends to flow from the
lower to higher levels, eventually draining into the neck. However, differ-
ent groups of axillary nodes will preferentially drain different areas of the
breast, arm, and chest. However, there is huge variability, especially in the
presence of malignant nodal disease, which may obstruct, and so alter
lymphatic flow and drainage patterns.
THE BREAST 29
Second internal
mammary perforator
Internal mammary
External perforator
mammary artery
Anterolateral Anteromedial
intercostal perforator intercostal perforator
Fig. 4.2 Surface anatomy and blood supply of the breast. The breast overlies
the 2nd–6th ribs, pectoralis major superiorly, and serratus anterior inferiorly. The
blood supply is from branches of the lateral thoracic (external mammary), internal
thoracic, and intercostal perforator arteries.
Lobule
Terminal Terminal duct
lobular unit
duct
Nipple
Major
subareolar
breast duct
Fig. 4.3 Structure of breast tissue. The terminal duct lobular units are glands that
open into the ducts of the breast, running towards the nipple. The ducts open into
lactiferous sinuses behind the nipple before exiting via 15–20 ducts onto the nipple
surface.
(A) Axillary artery

Thoracoacromial artery
Subclavian artery
Internal
mammary
artery
Thoracodorsal Internal
artery mammary
perforator
External mammary
artery
Anteromedial
Anterolateral intercostal
intercostal perforator
perforators
(B) Pectoralis Internal

major muscle mammary
Anteromedial perforator
Internal
intercostal mammary
perforators artery
Anterolateral
intercostal
perforator
Intercostal
artery
Fig. 4.4 Frontal view (A) and transverse view (B) of the right breast from
below, demonstrating the blood supply of the breast. The breast is supplied by
(A) branches of the subclavian and axillary arteries and (B) by perforating arteries
from the intercostal vessels.
THE BREAST 31
Intercostobrachial nerve
Cervical plexus
3 Anteromedial
3
Anterolateral 4 intercostal
4
intercostal 5 nerves
5
nerves 6
Fig. 4.5 Nerve supply of the breast. Primarily, branches of the intercostal nerves
supply the breast; some additional sensation is supplied via the lower branches of
the cervical plexus.
Supraclavicular
lymph nodes
Lymph
nodes near
ribs and
sternum
Axillary
lymph
nodes
Fig. 4.6 Lymphatic drainage of the breast. The majority of the breast drains via
the subareolar plexus to the axillary nodes. Medial areas can preferentially drain to
the internal mammary chain.
The axilla
Anatomy
Is a pyramidal shape, with the base being formed by the hair-bearing area
of axilla. The nodes often lie much deeper in the axilla than is commonly
appreciated.
Axillary nodes lie in five distinct anatomical groups within the axil-
lary fat/space: anterior (pectoral) apical, central, lateral, and posterior
(subscapular).
From the surgical or functional perspective, these anatomically separate
groups are described as lying in levels 1–3 (see Fig. 4.7). These levels run
caudal to cranial, defined by the lateral border of pectoralis minor.
• Level 1: lateral to pectoralis minor.
• Level 2: deep to pectoralis minor.
• Level 3: medial to pectoralis minor.
The number of axillary nodes is variable, depending on body habitus. The
central, anterior, and posterior groups account for the vast majority of
nodes. As the level of dissection increases, the number of nodes harvested
decreases: level 1 may contain approximately 10–15 nodes, with only 3 or
4 found in level 3.
It is worth noting that the number of nodes removed at surgery may
not be reflected in pathology reports. The pathology node count depends
on both the surgeon’s ability in dissecting the axilla meticulously and the
pathologist’s ability to dissect out the nodes within the specimen.
The sentinel lymph node (SLN)
The sentinel lymph node (SLN) is the node to which tumour cells from
a primary cancer first drain. Consequently, the SLN is not an anatomical
entity. The SLN for breast lymphatic drainage tends to (80%) lie in the
lower axilla below the level of the intercostobrachial nerve. However, it
can be found almost anywhere: the lateral chest wall, internal mammary
chain, intra-mammary tissue, or sub-pectoral space.
The axillary SLN(s) is often termed a first-level, first-order, or
first-echelon node. The term 'first level' is best avoided, as it does
not relate to the anatomical/surgical term level I and is confusing. The
second-order or echelon nodes receive their breast lymphatic drainage
from the first-order nodes so they do not receive direct lymphatic drain-
age from the cancer. However, there is variability in axillary drainage pat-
terns, especially in the presence of malignant disease, which may obstruct
lymphatic channels and alter flow patterns. If the first-echelon SLN(s) is
obstructed with tumour, the lymphatic flow from the breast may then
drain towards the second-echelon nodes and, as such, appear to ‘skip’ the
cancerous first-echelon or true SLN(s). The second-echelon nodes, which
may be cancer-free, are then mistaken for the true SLN. This may result in
a falsely negative axillary staging.
In malignant disease, the sentinel lymph node has been shown to accu-
rately predict the nodal status of the rest of the nodal basin. For example,
if the axillary SLN is cancer-free, the rest of the axillary nodes will be
cancer-free. If the SLN contains cancer, there is a 50% likelihood of further
cancer in other axillary nodes.
THE AXILLA 33
Lymphnode
levels
Pectoralis minor
Internal
III mammary
II modes
I
Axillary
vein
Pectoralis
major
Breast
Fig. 4.7 Levels of the axillary lymph nodes. Axillary lymph nodes lie lateral to
pectoralis minor (level I), deep to the muscle belly (level II), or medial to the
muscle (level III). Reproduced with permission from Chaudry MA and Winslet MC,
'The Oxford Specialist Handbook of Surgical Oncology', copyright 2009, Oxford
University Press.
Chapter 5 35
Breast cancer—facts
and figures
Epidemiology 36
Risk factors for developing breast cancer 38
Communicating risk 40
Further reading 40
36 CHAPTER 5 Breast cancer—facts and figures
Epidemiology
Incidence and geographic variation
According to the WHO, more than 1.2 million women worldwide are
diagnosed with breast cancer each year, making it responsible for 22%
of female cancers and 10% of all cancers. Incidence rates are greatest
in the developed world but vary, even within Europe (see Fig. 5.1).
Interestingly, migrants acquire the risk of their host country within two
generations.
In Britain, the incidence of breast cancer has increased by 46% over
the last 20 years. This is mirrored by a similar rise internationally (0.5%
annually), but it is rising particularly fast in China and Eastern Asia (3–4%
annually) where, historically, the incidence has been low. If non-melanoma
skin cancer is excluded, breast cancer is now the most common cancer
diagnosed in the UK (over 40,000 new cases in 2000), with over 100 new
diagnoses each day.
Prevalence
Given the high incidence and good survival, the prevalence is high, with
over 172,000 women in the UK having had a diagnosis of breast cancer.
Belgium
Denmark
France (Metropolitan)
The Netherlands
Ireland
UK
Finland
Italy
Luxembourg
Germany
Sweden
EU-27
Malta
Czech Republic
Cyprus
Slovenia
Austria
Spain
Portugal
Hungary
Bulgaria
Slovakia
Estonia
Poland
Latvia
Lithuania
Romania
Greece
0 30 60 90 120 150
Rate per 100,000
Fig. 5.1 European age-standardized incidence rates of breast cancer. Figure
courtesy of Cancer Research UK EU 27 countries, 2008. Accessed Sept
2012. M http://info.cancerresearchuk.org/cancerstats/types/breast/incidence/
uk-breast-cancer-incidence-statistics#world
EPIDEMIOLOGY 37
Survival
Survival is intimately linked to stage at diagnosis, but overall breast
cancer-specific survival rates have steadily improved over the last 30 years
(see Fig. 5.2).
• The 5-year survival rate for all women diagnosed with breast cancer in
England and Wales is now >77%.
• Considering only screen-detected breast cancers, this rises to >95%
because screen-detected cancers have a better survival outcome
than symptomatic cancers, even when adjusted for tumour stage
(see Further reading).
These good survival figures are likely to be due to a combination of
factors, including uptake of breast screening, increasing specialization of
care, and the use of tamoxifen and chemotherapy.
Survival is also affected by socio-economic status, with a statistically
significant deprivation gap of >5% in 5-year survival between the top and
bottom groups. This appears to be due to greater co-morbidity in socially
deprived individuals rather than a difference in the standard of care.
100
90
80
70
Relative Survival
60
50
40
30
20
10
0
1971– 1976– 1981– 1986– 1991– 1996– 2001– 2007**
1975* 1980* 1985* 1990 1995 2000 2003
Fig. 5.2 Age-standardized 10-year relative survival rates, females, England and
Wales 1971–1995 and predicted 2007, England 1996–2003. Figure courtesy of
Cancer Research. Accessed Sept 2012. M http://info.cancerresearchuk.org/
cancerstats/types/breast/survival/
Risk factors for developing

breast cancer
The four main risk factors are gender, age, a previous history of breast
cancer, or a significant family history. Then, there are a host of lower risk
factors which can be assessed. These will be discussed briefly.
Gender
Ninety-nine percent of cases are in women, in whom the lifetime risk is
1 in 9. However, men are not immune, and there are approximately 250
new cases of male breast cancer in the UK each year.
Age
Over 80% of cases occur in women over 50 years of age. It is rare under
30 but is the commonest cancer diagnosed in women under 35. The great-
est rate of rise in incidence is just prior to the menopause, reflecting a
hormonal association (see Fig. 5.3).
Previous history of breast cancer
Having had a previous breast cancer, the chance of developing a second
breast primary is two to six times that of the general population risk of
developing a first breast cancer.
Family history/genetic predisposition
Having one affected first-degree relative (mother or sister) doubles an
individual’s background risk of breast cancer, and a stronger family history
Female Rates Female Cases

7,500 500
Average Number of Cases per Year
6,000 400
Rate per 100,000
4,500 300
3,000 200
1,500 100
0 0
0 to 04
05 to 09
10 to 14
15 to 19
20 to 24
25 to 29
30 to 34
35 to 39
40 to 44
45 to 49
50 to 54
55 to 59
60 to 64
65 to 69
70 to 74
75 to 79
80 to 84
85+
Age at Diagnosis
Fig. 5.3 Average number of new cases per year and age-specific incidence
rates in females in the UK, 2008–2010. Figure courtesy of Cancer Research UK.
Accessed Sept 2012. M http://info.cancerresearchuk.org/cancerstats/types/breast/
incidence/#age
RISK FACTORS FOR DEVELOPING BREAST CANCER 39
increases risk still further. Women likely to be at increased risk of breast

cancer should have their family history assessed to see if they would
benefit from additional breast screening, possibly with genetic testing
(see Further reading for NICE family history guidance and Chapter 24).
Reproductive/hormonal factors
The greater the period of unopposed oestrogen exposure (or number of
menstrual cycles), the higher the risk of breast cancer. However, individu-
ally, these give small increases in relative risk rather than any individual
factor being of great importance in its own right. Thus, risk is increased by:
• Lower age at menarche.
• Greater age at menopause.
• Greater age at first child.
• Nulliparity.
• Absence of, or reduced, period spent breastfeeding.
• Use of the oral contraceptive pill. Relative risk (RR) is increased to
1.24 during the period of use. Individual risk returns to baseline by
10 years after stopping.
• Use of hormone replacement therapy (HRT). The ‘Million Women’
study in 2003 showed an RR of 1.66 of developing breast cancer if a
current user of HRT (see Further reading). However, the risk fell off
dramatically in past users (1.01). When looking specifically at different
types of HRT, it was highest for combined HRT (2.00) but was still
increased with oestrogen-only compounds (1.3) and tibolone (1.45).
Given these risks and the recent demonstration that HRT is also linked
with an excess of stroke and venous thromboembolism, it is no longer
recommended as a prophylactic measure to prevent osteoporosis
or cardiovascular disease in all menopausal women. HRT should be
reserved as a treatment for those women whose quality of life is
affected by menopausal symptoms. Here, the risks and benefits can be
assessed on an individual basis.
Physical factors
• Post-menopausal obesity. Adipose tissue is a source of extra-gonadal
oestrogen production. Thus, there is an RR of 1.3 for a body mass
index (BMI) of >28kg/m2 compared with a BMI of <20kg/m2).
Premenopausal obesity does not have the same effect, possibly
because it is often linked to an increased number of anovulatory
cycles.
• Height. Taller women have an increased risk; the reason is unclear.
Lifestyle factors
• Diet. High levels of saturated animal fats may slightly increase risk.
• Alcohol. There is an association between alcohol intake and breast
cancer.
• Physical activity. A few hours of vigorous exercise per week reduces
risk (RR 0.7). It is unclear whether this is related to a drop in BMI or a
direct alteration in hormonal levels.
• Socio-economic status is directly related to breast cancer incidence.
This may simply reflect better early nutrition and delayed childbearing
in the upper socio-economic groups.
Table 5.1 Risk of subsequent breast cancer associated with benign

breast disease
Benign change Relative risk of later breast cancer
Proliferative breast change (florid, 1.5x
usual-type hyperplasia), sclerosing
adenosis, multiple papillomas
Atypical ductal hyperplasia 4x
Lobular carcinoma in situ 10x
Breast factors
• Mammographic density. Denser breasts are associated with an
increased risk of breast cancer (2–6-fold) and are harder to screen
mammographically.
• Benign breast change. Some benign breast conditions are associated
with an increased risk of subsequent breast cancer (see Table 5.1).
• Previous ionizing radiation to the chest. Clinically important in women
previously treated for Hodgkin’s lymphoma with mantle irradiation.
One in 3 to 1 in 7 will later develop a breast cancer.
Communicating risk
Risks are not additive. The single greatest risk factor is predominant; this
is frequently family history.
It is also often important for women to know that the baseline risk of
10–12% is for women who live to be 85 years old, and, actually, the risk
of a women aged 30–50 years is only 1 in 1,000/year, which equates to a
2% aggregate risk. Even doubling this with various inherited or acquired
risk factors still gives an absolute risk in this age group of only 4%, which is
much less than many women realize.
Risk assessment and management for higher risk women are discussed
in Chapter 24.
Further reading
Nagtegaal I, Allgood P, Duffy S, et al. (2011). Prognosis and pathology of screen-detected carcino-
mas: how different are they? Cancer 117, 1360–8.
Beral Y; Million Women Study Collaborators (2003). Breast cancer and hormone-replacement
therapy in the Million Women Study. Lancet 362, 419–27.
Beral V, Bull D, Reeves G; Million Women Study Collaborators (2005). Endometrial cancer and
hormone-replacement therapy in the Million Women study. Lancet 365, 1543–51.
Sweetland S, Beral V, Balkwill A, et al. (2012). Venous thromboembolism risk in relation to use
of different types of post-menopausal hormone therapy in a large prospective study. J Thromb
Haemost [Epub ahead of print].
The NHS Breast Screening Programme. Available at: M http://www.cancerscreening.nhs.uk/
breastscreen/
NICE guidance. Available at: M http://www.nice.org.uk/
Familial breast cancer guidance. Available at: M http://www.nice.org.uk/CG41
The Association of Breast Surgery. Available at: M http://www.associationofbreastsurgery.org.uk/
Chapter 6 41
Breast assessment:
making the diagnosis
Breast clinics 42
Targets and quality assurance 43
Primary care referrals 44
Triple assessment 46
Clinical assessment 48
Breast imaging 50
Pathology 54
Miscellaneous investigations 56
Further reading 56
42 CHAPTER 6 Breast assessment: making the diagnosis
Breast clinics
Patients referred to a breast clinic should have their clinical and imag-
ing investigations performed in one visit. This allows the vast majority of
symptomatic referrals to be clinically assessed, imaged, reassured, and dis-
charged in one visit. Patients requiring a core biopsy will need a return
clinic visit, at which the breast care nurse can, if necessary, be scheduled
to be present. Patients having a core biopsy should be advised that their
triple assessment results will be discussed in an MDM prior to their next
visit. In order to improve the experience for patients, many units have set
up clinics for specific issues:
• Young women clinics (<35 years) where there is a low risk of cancer.
These clinics will invariably need U/S support.
• Breast pain clinics, focusing on education and coping strategies.
• Family history/high risk clinics centred on risk assessment, genetic
counselling, and, occasionally, genetic analysis.
• In addition, most units allow rapid access appointments for women
with recurrent problems (e.g. breast cysts and breast abscesses). These
appointments are generally accessed through the breast care nurse.
TARGETS AND QUALITY ASSURANCE 43
Targets and quality assurance

Patients seen within the NHS need to be managed in accordance with the
latest NHS diagnostic and treatment targets and the ABS and NHSBSP
symptomatic and screen-detected cancer assessment guidelines and QA
standards. So patients need to be seen and treated within certain time
frames. It is important that the time frames set can change, as they are
often dictated by outside influences rather than clinical need. The underly-
ing feature is to try to reduce the period of anxiety that a patient goes
through, having found a worrying sign or symptom in the breast.
Common targets include:
• >93% of symptomatic patients should be seen within 2 weeks of
referral date from the GP.
• >96% of patients diagnosed with breast cancer should have treatment
within 32 days.
• >85% of patients should have treatment within 2 months (64 days) of
referral from the GP.
Primary care referrals

Patients with breast symptoms account for 15% of GP consultations.
Breast cancer is the common fear. Breast cancer is not an immediately
life-threatening disease, so urgent referral and treatment is unlikely to
influence the outcome; nevertheless, prompt diagnosis and treatment can
do much to alleviate anxiety.
Over the last 10 years, the focus has been on prioritizing breast referrals
into urgent (symptoms/signs suggestive of cancer—to be seen within 2
weeks) and non-urgent (wait up to 13 weeks). However, breast cancer can
present with any breast symptom or sign. Prioritization using this system
resulted in 30% of cancers being referred through the non-urgent route; in
addition, women in the non-urgent group suffered anxiety until they were
told their breasts were healthy. Consequently, the referral emphasis has
changed to rapid assessment for all breast patients: this alleviates anxi-
ety for all and reduces the wait for diagnosis and treatment if a cancer is
detected.
Referral guidelines
These are a useful way of providing GPs and practice nurses with a quick
and ready guidance on breast symptoms and when to refer. The guidelines
can also be an educational tool for patients, as many patients can be reas-
sured their symptoms and signs are not suggestive of cancer, even if a
formal breast assessment is recommended. See Further reading at the end
of this chapter for a link to referral guidelines.
The following is an example of a referral guideline for GPs.
Referral criteria for rapid diagnostic symptomatic
breast clinic
• <5% of breast cancers occur in women under 40 years.
• <35 years ‘whose symptoms/signs are highly suggestive of breast
cancer’.
Signs of breast cancer
• Lump with dimpling/ulceration.
• Nipple retraction (new), distortion, ulceration (unilateral).
• Others: change in skin contour, peau d’orange, dimpling, and fungation.
Lumps
Please do not needle a lump with no recent/proven history of cysts.
• Discrete lump: lumps in post-menopausal women are cancers until
proven otherwise.
• Asymmetrical, discrete, nodularity: that persists and does not change
with cycle.
• Post-menopausal abscess/infection: refer for urgent treatment and
investigation.
Nipple discharge
Multiduct or multicoloured discharge is innocent duct ectasia.
• Any post-menopausal discharge.
PRIMARY CARE REFERRALS 45
• Bloodstained (85% of bloody nipple discharge is benign, e.g. intraduct

papilloma).
• Persistent: single duct discharge, especially if watery.
• Excessive: discharge sufficient to stain clothes (i.e. socially
embarrassing).
• ‘Eczema’: Paget's ulcerates the nipple, then the areola. Eczema usually
affects the areola only.
Pain
Less than 5% of breast cancers present with pain and no lump.
• If associated with a lump (usually benign breast changes or cyst).
• Intractable (first, try reassurance, well-supporting bra, dietary and
lifestyle changes).
• Unilateral, persistent (>3 months) pain in post-menopausal women.
Women who can be managed by GP/practice nurse
• Starting HRT: mammography is not indicated.
• The majority of women under 30 years: especially with cyclical,
tender, lumpy breasts or symmetrical nodularity, with no focal or
discrete abnormality.
• The majority of breast pain: explain hormonal nature, but exclude
musculoskeletal causes.
• Most nipple discharge: especially if multiduct/multicoloured.
• Most family history: asymptomatic women with average risk.
• Simple lactational sepsis that responds to antibiotics.
Common symptoms and signs
The common presenting symptoms seen in the breast clinic are:
• Discrete lumps.
• Lumpiness.
• Pain both cyclical and non-cyclical.
• Nipple discharge.
• Skin/nipple changes.
Patients may present with one, or a combination, of these. Pain accompa-
nied by lumpiness, or what is perceived as a lump, is probably the most
frequent presentation in clinic. Although most ladies attending fear they
have breast cancer, the reality is that only about one patient in 10–15
attending a standard breast clinic will have breast cancer.
Triple assessment
This consists of:
• Clinical history and examination of the breast.
• Breast imaging.
• Pathological assessment of a biopsy.
Tips for the trainee
Triple assessment is the mainstay of breast assessment, minimizing the
chance of missing a breast cancer and allowing treatment planning for
those cancers that are identified. Each unit will have its own protocols
for breast triple assessment; ask if these are available, and, at your first
clinic, ask if you can sit in and watch someone senior do the first few
assessments.
Try to follow a patient through the whole process of triple assessment
in order to see it from the patient’s perspective; see the rest of the unit,
and introduce yourself to the whole team.
Triple assessment scores

In order to bring some objectivity to triple assessment, each modality is
scored 1 to 5, outlined as follows:
• P—palpability (clinical assessment).
• M—mammography.
• U—U/S.
• B—biopsy.
• C—cytology.
where:
1 = normal appearance.
2 = consistent with a benign lesion.
3 = atypical or indeterminate appearance, probably benign.
4 = suspicious of malignancy.
5 = consistent with malignancy.
NOTE: a score of 1 may also indicate inadequate assessment so needs to be interpreted with
caution. For example, this may occur if a needle does not hit its target.
TRIPLE ASSESSMENT 47
The importance of concordance

Not all cancers present as discrete lumps or with classical clinical or
radiological features; this is increasingly so, as women become more
breast aware and present with early-stage disease. Similarly, not all
cancers are visualized on mammography, so the appropriate use of
all three modalities, together with agreement (concordance) between
the scores, will reduce, but not eliminate, the chance of missing a
cancer. The cancer most commonly ‘missed’ is lobular; clinical and
radiological signs can be subtle.
The most common cause of a delay (and subsequent litigation) in
breast cancer diagnosis is failure to use triple assessment properly
or failure to recognize non-concordance. This is usually due to poor
departmental procedures rather than poor individual competence.
No definitive cancer treatment should be undertaken, unless at
least two of the three triple assessment modalities are positive for
cancer, one of which must be a pathological assessment, usually core
biopsy. A false positive diagnosis of breast cancer is rare, but, when it
occurs, it can result in devastating consequences for the patient and
her family. To avoid this catastrophe, stick to the defined diagnostic
pathway.
Clinical assessment
• Introduce yourself; explain your status; make the patient feel at ease.
• Right at the beginning, explain that their case will be discussed with a
senior doctor and they may be reviewed by that doctor.
• Sit down at the patient’s level; make eye contact.
• Take a history with the patient clothed or appropriately covered.
• Do so in a calm and confident manner.
• If a patient requests a female or a male doctor, try to accommodate
this without feeling offended.
The history
This needs to cover the presenting complaint and risk factors for breast
cancer (see Chapter 24) or breast sepsis, along with general health issues
that may affect treatment of the underlying problem.
• Age.
• Lump: size, shape, when it appeared, how it was noted, any change.
• Nipple discharge: unilateral/bilateral, single duct/multiduct,
spontaneous or on stimulation, colour (watery, yellow, green, brown,
purulent, bloodstained, blood), pregnancy/breastfeeding.
• Pain: onset, site, severity, relieving and exacerbating factors, cyclical/not.
• Relationship of symptoms to the menstrual cycle: regularity of menses
and any oral contraceptive pill (OCP) or HRT taken, intrauterine
contraceptive device (IUCD) in situ.
• Previous breast cancer, visits to breast clinic, or breast surgery.
• Previous breast imaging: location, dates, and results.
• Risk factors for breast cancer (see Chapter 24): family history, alcohol,
weight.
• Hormonal history: menarche, children, breastfeeding, menopause,
HRT/hormonal contraception.
• General health and co-morbidities; smoking is important in breast
sepsis (see Chapter 7).
The examination
• Always have a chaperone, regardless of your gender.
• The room and your hands must be warm.
• Explain what you are going to do and why (verbal consent).
• Examine in a consistent manner. There are many breast examination
techniques. Develop your own after seeing a few.
• Ask the patient to sit on the side of the couch, facing you, and expose
their whole torso, displacing hair or jewellery.
• Ask her to point to the area she is concerned about: the patient’s use
of hand and fingers will give you a clue as to whether it is a focal or
generalized problem. It is not uncommon for patients to admit that
they are no longer able to identify it.
Note: a lump is different to each patient. Any asymmetrical area should
be taken seriously and should be imaged; the overlying tissue may mask a
small lump deep within a dense breast, and lobular cancers can often feel
diffuse. Younger, more glandular breasts generally feel more ‘nodular’ than
older atrophic breasts, which contain a higher percentage of fat. Almost
CLINICAL ASSESSMENT 49
any type of breast change could indicate an underlying cancer, although

the majority of women in the clinic will actually have benign breast change.
• LOOK for asymmetry, visible lumps, and skin dimpling or peau
d’orange. Inspect the nipple-areola complex (NAC).
• LOOK for skin dimpling or distortion, as the patient slowly raises
both hands above the head (to see the whole of the breast) and then
lowers the hands and places them on the hips and presses down (to
look for muscle fixation when the pectoralis muscle contracts). Look
at the nipples for inversion, retraction, or eczematous change. Look
at the arms to exclude lymphoedema in advanced or recurrent breast
cancer.
• Lay the patient supine at 30° with a pillow under her head and hands
tucked under the head.
• Examine the asymptomatic breast first to gain some idea of the normal
texture of the breast. Then, examine the symptomatic side. A common
technique is to imagine the breast as a clock and work your way
around the clock face from 12 to 12, examining the breast from the
outer margin towards the nipple as you go. Do not forget the axillary
tail and the NAC.
• FEEL with the flat of the fingers.
• Note the site, size, shape, consistency, surface, and fixation of
any lumps.
• Check the axillae and infra- and supraclavicular fossae for enlarged
lymph nodes (and note their size, texture, etc.).
• If the patient has noted nipple discharge, ask her to demonstrate
it. Note whether it is from one or multiple ducts, the colour, any
associated nipple changes, and dipstick for the presence of blood. It
is sometimes helpful if you are having difficulty feeling a lump to ask
the patient to find it, sometimes they have something very small, but,
on other occasions, they are surprised to find that they can no longer
feel it!
Record-keeping
• Always record examination findings with a drawing, and score your
clinical impression P 1–5.
• Mark the site of patient’s concern.
• There are standard ways of illustrating your findings.
• Describe the size of the lesion and its position relative to the clock
face of the breast and the distance in cm from the NAC.
Initial discussion
Patients may seek reassurance, but this is often not possible until the his-
tology is available and the triple assessment has been discussed in the
MDM. Be honest; if you are not sure, say so. Explain to the patient what
the next steps will be and how they will hear the results of any further
investigations; this means that, before the patient leaves the clinic, they will
have been given an appointment for receiving the results.
Breast imaging
The majority of women attending a diagnostic breast clinic will be offered
at least one imaging modality, as clinical examination is a poor discrimina-
tor of breast pathology, especially in the dense premenopausal breast.
Mammography and U/S are the mainstays of imaging, but the use of mag-
netic resonance imaging (MRI) and other imaging modalities is increasing.
Results are scored as outlined previously, using M for mammography and
U for U/S scores. Increasingly, both mammography and U/S are used in
conjunction, as a proportion of cancers not visible on mammograms will
be visible on U/S. If a patient has a clinical lump or asymmetric finding, but
a normal mammogram, it is wise to do an U/S as well. It is unlikely that a
cancer will be missed with this approach.
Indications for imaging

Guidance on indications for breast imaging has recently changed.
Throughout this book, we will be using the Royal College of Radiology
Breast Group guidelines (see Further reading).
Check local protocols, which may vary, particularly over age, but consider
the following:
• All women >40 years with any symptom, other than pain alone, are
offered bilateral mammography to screen both breasts, ideally with
targeted U/S (focused on the symptomatic area).
• Women <40 years with the same indications are offered just
targeted U/S.
Request forms must state relevant history, side and site of lesion, and clini-
cal impression, with a diagram.
Mammography
This is the gold standard of breast imaging due to its relatively high sensi-
tivity (95% for symptomatic cancers) and specificity compared to clinical
examination or U/S. Two views are normally taken, mediolateral oblique
(MLO) and cranio-caudal (CC). The total radiation dose is approximately
1mGy (see Fig. 6.1).
Advantages
• ‘Screening’ of patients attending the breast clinic with a variety of
symptoms as outlined (to identify micro-calcifications and small occult
cancers).
• Mandatory prior to conservative breast surgery to exclude a second
clinically occult cancer in either breast.
• To accurately localize a small or impalpable cancer for excision.
Disadvantages
• Requires breast compression between two plates, which can be
uncomfortable.
• Less sensitive in women under age of 40 due to increased background
breast density.
BREAST IMAGING 51
Fig. 6.1 Mediolateral oblique mammogram showing malignant micro-calcification,

characteristic of ductal carcinoma in situ. Reproduced with permission from 'The
Oxford Textbook of Medicine' 5th edn., edited by David A. Warrell, Timothy
M. Cox, John D. Firth, copyright 2010 Oxford University Press.
Ultrasound (U/S)
High-frequency sound waves are directed through the breast, and reflec-
tions from different tissue components are detected and turned into
images (see Fig. 6.2). The specificity of distinguishing a cyst from a solid
lesion is almost 100%, and an experienced operator can be both sensitive
and specific.
Advantages
• Useful for all palpable lumps and usually the sole imaging technique for
women less than 40 years.
• Forms part of the preoperative assessment of the axilla in ladies with
breast cancer (any abnormal nodes have FNA or core under U/S
guidance).
• No radiation.
• Not uncomfortable.
• Allows accurate sizing of lesions (at first visit and after neoadjuvant
chemotherapy or hormonal therapy; see Chapter 13).
• Can distinguish discrete lumps from areas of nodularity in
young women.
• The majority of core biopsies are performed under U/S guidance.
If a breast cancer is detected, simultaneously U/S the axilla and use U/S to
guide FNAC of any enlarged axillary lymph nodes. This may allow most
appropriate use of axillary clearance and sentinel lymph node techniques.
Fig. 6.2 Ultrasound scan showing the characteristic appearance of an invasive

cancer with micro-calcification. Reproduced with permission from 'The Oxford
Textbook of Medicine' 5th edn., edited by David A. Warrell, Timothy M. Cox,
John D. Firth, copyright 2010 Oxford University Press.
Disadvantages
• Operator-dependent.
• Not useful to visualize micro-calcifications.
• Poor ‘screening tool’, less sensitive than mammography.
• Less easy for subsequent radiologists to comment on images, as it is a
‘live image’ and user-dependent.
MRI
Based on the nuclear spin of molecules when subjected to a strong mag-
netic field. Useful to image the augmented breast, to assess multifocality
(particularly in lobular cancers), or in screening of young women with a
strong family history of breast cancer. However, specificity is low; cost is
high, and availability may be limited, so check local protocols.
BREAST IMAGING 53
Pathology
• In general, random needling of a generally lumpy area should be
avoided. Histopathology should be reserved for a discrete solid lesion
on clinical examination and/or imaging, as, with imaging, there will
often be local protocols.
• Pathology request forms must state relevant history, side and site of
lesion, and clinical impression, usually with a diagram.
• Results are scored C1–5 for cytology and B1–B5a/b for histopathology.
B5a denotes in situ carcinoma; B5b denotes an invasive carcinoma, and
B5c a carcinoma with microinvasion.
• Because histopathology can report on the architecture of the lesion
as well as cellular appearance, core biopsy has now replaced FNAC.
Simple cysts, which have a typical appearance on U/S, do not need
to be aspirated, unless they are uncomfortable. If they are aspirated,
clear fluid does not need to be sent to pathology. However, bloody
aspirates can be sent to exclude a necrotic cancer with cystic
degeneration or an intracystic carcinoma or papilloma. Similarly,
any residual lump left after cyst aspiration should be subjected to
histological analysis.
Fine-needle aspiration cytology (FNAC)
Advantages
• Quick and easy to perform.
• Results available in about 30 minutes (for one-stop clinic).
• Samples a large area.
Disadvantages
• Information is limited to benign or malignant. Cannot distinguish DCIS
from invasive cancer.
• Results are dependent upon the operator doing the FNAC and the
cytologist interpreting it.
• Not useful in assessing micro-calcification.
Wide-bore needle (core) biopsy
Advantages
• Gives information on morphology, grade, hormone receptor status,
Her-2 status which helps in treatment planning.
• Biopsies are larger than FNAC, so more of the lesion is sampled.
Disadvantages
• More bruising.
• Results take longer (24 to 48 hours).
Punch biopsy
Used to biopsy skin lesions, e.g. to differentiate eczema from Paget’s dis-
ease of the nipple and to diagnose or exclude malignancy in skin nodules.
Once again, this takes 24 to 48 hours for the histology result.
PATHOLOGY 55
Nipple discharge dipstick and cytology

Fluid expressed from the nipple can be dipsticked for the presence of
blood and can be smeared onto a slide and sent for cytology. Rarely useful
to identify pathological discharge containing blood cells or malignant cells.
Open/surgical biopsy
Rarely needed to make a diagnosis since over 95% of cancers are confirmed
preoperatively using triple assessment. Only used when repeat biopsy is
not possible or unlikely to be helpful (usually for small screen-detected
lesions). Generally involves wire-guided techniques. Microdochectomy
and central duct excision procedures for bloody or troublesome nipple
discharge also fall into this category.
Miscellaneous investigations
These depend upon the mode of presentation of the patient.
• Blood tests
• May be useful in the investigation of gynaecomastia (see Chapter 9).
• Microbiology
• Try to get a culture from any breast sepsis prior to commencing
antibiotics.
• Staging investigations
• Locally advanced breast cancers or patients with symptoms that
raise the question of metastatic disease may require bone scan and
CT chest, abdomen, and pelvis.
At the end of the consultation, it should be possible either to reassure
the patient that their problem is benign or to warn them of the possibility
of a cancer.
If tissue has been taken for pathology, all the results—clinical, radiologi-
cal, and imaging—should be discussed at the diagnostic MDT at which a
plan of management can be formulated. Avoid making spur-of-the minute
decisions at the end of clinic, as this often leads to disaster and mistakes
being made.
Further reading
National GP guidelines and breast screening guidelines. Available at: M http://www.cancerscreen-
ing.nhs.uk/breastscreen/publications
Willett AM, Michell JM, Lee MJR (2010). Best practice diagnostic guidelines for patients present-
ing with breast symptoms. Available at: M http://www.associationofbreastsurgery.org.uk/
publications-guidelines/guidelines.aspx
The Royal College of Radiology Breast Group guidelines. Available at: M http://www.rcrbreast-
group.com/Documents/BBCDiagnosticGuidelines.pdf
Surgical guidelines for the management of breast cancer. Association of Breast Surgery at BASO,
2009. EJSO S1–22. Available at: M http://www.ejso.com
NICE guidance management of early and locally advanced breast cancer (2009). Available at: M
http://www.nice.org.uk/nicemedia/pdf/CG80NICEGuideline.pdf
Chapter 7 57
Benign breast problems

and their management
Overview 58
Congenital problems 59
Breast development and involution 60
Fibroadenoma 62
Breast cysts 64
Other common benign breast lumps 66
Duct ectasia and periductal mastitis 68
Breast infections: mastitis and abscesses 70
Granulomatous mastitis 72
Radial scar and complex sclerosing lesions 74
Breast pain (mastalgia) 76
Nipple discharge 78
Further reading 80
58 CHAPTER 7 Benign breast problems and management
Overview
Benign breast disease forms the bulk of outpatient diagnostic referrals in
breast clinics. It encompasses a diverse range of problems, ranging from
congenital abnormalities, physiological aberrations, and infections. Few, if
any, are associated with any serious risk of disease; nevertheless, they
cause immense anxiety because, in the perception of many women, any
breast symptom is synonymous with cancer. Their management requires
explanation and reassurance to dispel patients’ fears.
Guidance on indications for breast imaging has recently changed.

Throughout this book, we will be using the Royal College of Radiology
Breast Group guidelines (see Further reading).
CONGENITAL PROBLEMS 59
Congenital problems
These encompass a variety of problems that result in an abnormal appear-
ance in the external appearance of the breast.
Athelia
This is the complete absence of the nipple and is usually unilateral.
Polythelia
This refers to accessory or supernumerary nipples which occur along the
milk (mid-clavicular) line. Incidence is 1–2%. These are associated with
accessory breast tissue and renal anomalies. Supernumerary breasts are
defined as accessory structures that produce milk. Most occur in the
axillo-pectoral region and are generally noticed in the second to third
pregnancy. Local excision is usually curative but should not be performed
whilst women are still lactating due to risk of fistula formation. Malignancy
has occasionally been reported in accessory nipples.
Amastia
This is a congenital absence of breast tissue, but the nipple is still present.
Hypoplasia of one or both breasts is a more common finding and is associ-
ated with mitral valve prolapse.
Poland’s syndrome
Occurring at an incidence of approximately 1:7,000 to 1:100,000, this syn-
drome describes an absence/underdevelopment of the pectoralis muscle,
cutaneous ipsilateral syndactyly, and hypoplasia of the breast. All three
features need not be present for a diagnosis of Poland’s syndrome. The
cause is unknown but may result from an interruption to the embryonic
blood supply of the subclavian region.
Other associated signs: brachydactyly, renal anomalies, liver/biliary tract
anomalies, dextrocardia, radial/ulnar agenesis, and upper limb asymmetry.
Management of congenital disorders
Accessory nipples can usually be excised without major cosmetic insult.
Other congenital abnormalities present a much greater aesthetic chal-
lenge. A wide variety of surgical techniques may need to be employed
as staged procedures. They are best managed by a reconstructive team.
Breast development and involution

Breast development and involution occurs throughout life.
• Breast development: occurs in both sexes from about the age of 10.
Initially, this development may be asymmetrical. Beware of any surgery
on a developing breast, as this can significantly damage the breast bud
with consequent long-term deformity.
• Menstruation: the breast undergoes regular changes associated with
the menstrual cycle.
• Pregnancy and lactation: causes lobuloalveolar growth and milk
production.
• Involution: this process begins from age 30 in nulliparous women. Fat
replaces breast tissue, and lobular stroma is replaced by fibrous tissue.
Aberrations of normal development and
involution (ANDI)
This describes a group of conditions that are so common they should be
considered as normal variations of these physiological processes; however,
their symptoms and signs frequently cause anxiety and result in referral for
reassurance, if nothing else. They are seen throughout life, starting with
menarche, going through early adult life and menstruation to older age
and menopause. The classification describes the various changes seen in
the breast at those times which result in perceived symptoms and signs.
• Breast development: juvenile hypertrophy, accessory breast tissue, and
fibroadenoma.
• Menstruation: fibroadenoma, cyclical nodularity, localized benign
nodularity.
• Involution: breast cyst, fibrocystic change, sclerosing lesions (radial scar
and complex sclerosing lesions), duct ectasia.
Diagnosis
• Up to 70% of patients referred to a breast clinic will complain of a
lump or lumpiness.
• Fig. 7.1 demonstrates the frequency of common breast lumps with
increasing age.
• Clinical assessment, followed by radiological and pathological
assessment as required, will result in the diagnosis of these common
breast lumps.
BREAST DEVELOPMENT AND INVOLUTION 61
Carcinoma
Localised benign
nodularity
Fibroadenoma
Frequency
Cyst
20 30 40 50 60
Age (years)
Fig. 7.1 The frequency and age at presentation of the most common breast lumps.
Fibroadenoma
Fibroadenomas are not benign breast tumours but should be considered
as an abnormality of normal development. Fibroadenomas develop from a
whole breast lobule and contain a combination of proliferating epithelium
and connective tissue.
Presentation
Usually present during the period of breast lobule development and,
therefore, are commonest during the late teens and early twenties (see
Fig. 7.1). The patient will notice a rubbery, discrete, often mobile lump
within the breast which gives rise to the description of these as a ‘breast
mouse’. Diagnosis of a fibroadenoma should be approached with caution
in a woman who is peri- or post-menopausal. Most common presenta-
tion is with a painless symptomatic breast lump or as an incidental finding
during breast imaging.
Differential diagnosis
Fibroadenomas contain stroma of low cellularity and regular cytology.
Phyllodes tumours are a mesenchymal variant and have a spectrum of
stromal cellularity and varying degrees of atypia.
Natural history
Patients under 40 can be advised that the majority of fibroadenomas
remain static in size; approximately 10% will enlarge, and one-third will
get smaller or resolve over a 2-year period. Although malignancy can very
rarely develop within a fibroadenoma, they should not be seen as hav-
ing any malignant tendency, and this should be stressed to the patient.
Pregnancy can occasionally result in rapid growth.
Assessment
Clinical assessment of a fibroadenoma will reveal a well-defined and firm,
but not hard, lesion that is mobile within the breast. All lumps require clin-
ical assessment and imaging. Imaging: if woman <40 years, use ultrasound
alone, if >40 years mammography and ultrasound. Ultrasound-guided core
biopsy should be performed on all lumps, unless the following criteria are
all met:
• Patient under 25 years of age.
• Ultrasound reveals benign features of a fibroadenoma (smooth,
well-defined outline, ellipsoid shape, fewer than four gentle
lobulations).
• No significant family history of breast cancer.
Management
Simple reassurance is sufficient for the vast majority of patients. Surgical
excision in the form of enucleation can be performed for large (>4cm) or
enlarging fibroadenomas, or if there is any histological concern from the
triple assessment. Surgical excision should be performed, using either a
peri-areolar or an inframammary subglandular approach to minimize vis-
ible scarring. Vacuum-assisted excision under ultrasound control is now
becoming the method of choice for smaller lesions when the patient
requests removal.
FIBROADENOMA 63
Giant fibroadenomas
Defined as fibroadenomas over 5cm in diameter or 500g in weight. Giant
fibroadenomas have a bimodal presentation, peaking in adolescence
and peri-menopausally. More frequent in Asian and African populations.
Treatment is with local excision/enucleation, using an inframammary
approach. These can sometimes be drug-induced by anti-epileptic drugs,
such as phenytoin and ciclosporin.
Phyllodes tumour
Phyllodes tumours are less common than fibroadenomas (ratio 1:50), and
their aetiology is unknown. These tumours represent a spectrum from
benign lesions (common) through to malignant sarcomas which rarely
metastasize. In contrast to fibroadenomas, phyllodes tumours should be
excised with a surrounding margin of normal breast tissue in a similar fash-
ion to a carcinoma. Approximately 20% of these lesions will recur locally
within the breast, requiring further wide local excision. It is important to
discuss these lesions preoperatively in the MDM.
Breast cysts
Breast cysts affect approximately 7% of peri-menopausal women and can
rarely be found in men. Breast involution occurs in the peri-menopausal
period, as female hormone levels begin to fall, coinciding with the produc-
tion of breast cysts. Breast cysts account for 15% of all breast lumps and
affect women aged 40–60 (see Fig. 7.1). Women taking hormone replace-
ment therapy (HRT) may develop breast cysts well after their natural
menopause.
Presentation
Cysts may be found symptomatically by the patient as a hard lump or
incidentally through the screening programme. Patients commonly have
multiple cysts affecting both breasts. Examination will reveal a mobile
lump, extremely well-defined and smooth, at times slightly compressible in
nature. They often enlarge very rapidly during the menstrual cycle, causing
great alarm. It is common for patients to say that they appeared overnight.
Differential diagnosis
• Galactocele (encapsulated collection of milk within the obstructed
duct of a lactating breast).
• Liquefied haematoma.
• Carcinoma.
• Oil cyst secondary to fat necrosis.
Management
All suspected cysts should have clinical and imaging assessment, no matter
how many times the patient has previously presented with breast cysts.
Imaging
Women over 40 should have mammography and ultrasound performed.
Women under age 40 should have ultrasound alone. Ultrasound should
demonstrate a thin-walled, well-defined fluid-filled lesion. Ultrasound fea-
tures suggestive of a risk of malignancy include a thickened wall, thick
internal septations, mixed solid and fluid composition, and an imaging clas-
sification of indeterminate.
Pathological assessment
• Complex/radiologically indeterminate cysts should be core-biopsied
and results discussed in a multidisciplinary breast team meeting.
• Simple symptomatic cysts should be aspirated to dryness under
ultrasound control. Green/brown/black serous fluid can be discarded.
Bloodstained discharge is a risk factor for an intracystic cancer and
requires cytology.
• Asymptomatic cysts with no suspicious clinical or radiological features
do not require aspiration or pathological assessment; this includes the
majority of screen-detected cysts.
BREAST CYSTS 65
Treatment
Women with simple cysts can be reassured but should be forewarned
about the risk of developing further cysts in the future. Simple cysts that
recur can be repeatedly aspirated and do not have an increased risk of
cancer, provided there are no suspicious features on imaging. Breast cysts
are not a risk factor for cancer; however, as both breast cancers and breast
cysts are common in this age group, each new subsequent lump should be
assessed in a one-stop breast clinic. Women taking HRT should be advised
that stopping treatment might prevent subsequent cyst development.
Complex cysts should have core biopsy performed. If this is
non-diagnostic, a surgical diagnostic excision biopsy should be undertaken.
Other common benign breast lumps

Hamartoma
This is a disorganized overgrowth of normal breast tissue; one element of
the breast tissue will usually predominate. These are benign lumps but can
grow progressively. Hamartomas do not have distinctive histopathological
features, hence diagnosis requires correlation between clinical, radiologi-
cal, and pathological findings (see Further reading).
Presentation
Symptomatic, soft to firm, well-defined mass. The initial clinical diagnosis
is usually of a fibroadenoma.
Management
Ultrasound (plus mammography if >40 years of age), along with clinical
correlation, can safely diagnose the majority of hamartomas. Clinically (P2)
and radiologically benign (U2 and M1/2) lesions do not require biopsy. If
any doubt exists about the nature of the lesion or if there is any clinical/
radiological discrepancy, an ultrasound-guided core biopsy should be
performed. Hamartomas cannot be diagnosed from a pathological speci-
men; multidisciplinary team correlation is essential.
Surgery
Excision of these benign lesions should be offered for symptomatic
patients. Excision should be performed with a cosmetic inframammary
or peri-areolar incision. A narrow margin should be taken, although local
recurrence is rare.
Fat necrosis
Fat necrosis is a partial necrosis of adipose tissue with an associated
inflammatory response.
Causes
Trauma (from minor knocks to the breast to a seat belt-induced injury),
surgery, radiotherapy, mammography, iatrogenic injections to breast
(e.g. patent blue).
Presentation
Initially presents with a firm, tender lump within the breast, often mimick-
ing a carcinoma and often with a history of trauma and extensive bruis-
ing. May be associated with an inflammatory response, causing a red,
hot, oedematous breast, sometimes associated with nipple retraction.
Subsequent scarring within the breast may cause parenchymal distortion.
Over time, the acute inflammatory response will settle, and fat begins to
liquefy and the lump softens and resolves. Superficial fat necrosis following
surgery may present with fatty discharge from the wound.
Imaging
Fat necrosis can also simulate a carcinoma radiologically. Ultrasound (and
mammography if >40 years of age), together with a clinical picture, will
diagnose the majority of fat necrosis lesions. If any doubt exists about
the nature of the lesion or if there is any clinical/radiological discrepancy,
OTHER COMMON BENIGN BREAST LUMPS 67
an ultrasound-guided core biopsy should be performed. The core biopsy

appearance can also be equivocal (B3/B4), requiring repeat core or occa-
sionally open biopsy.
Treatment
It is vital to exclude carcinoma. Having done that, no specific treatment is
required other than reassurance of the benign nature of the lesion. Lesions
resolve with time but may leave residual fibrous scarring.
Mondor’s syndrome
Mondor’s syndrome is a superficial thrombophlebitic process in the sub-
cutaneous veins of the thoraco-abdominal wall.
Presentation
The syndrome presents as a superficial, cord-like thrombophlebitis.
Commonly affects the superior epigastric, thoracoepigastric, and lateral
thoracic veins as far inferiorly as the umbilicus. Associated findings are
pain, erythema, pruritus, and rarely fever. Occasionally associated with
breast malignancy. Mammography should be performed for women
over 40.
Causation
Primarily induced by trauma, including breast surgery, physical activity,
breast infection, pendulous breasts, and rarely breast cancer.
Natural history
The palpable thrombophlebitis is a self-limiting condition, resolving in 2
weeks to 6 months. The pain of the acute inflammatory reaction subsides
within 10 days.
Management
Reassurance, rest, breast support, and analgesia form the mainstay of
treatment. Oral or topical non-steroidal anti-inflammatories are helpful in
the acute inflammatory phase.
Duct ectasia and periductal mastitis

Duct ectasia is part of normal breast ageing and is common towards the
menopause. Periductal mastitis is the inflammatory condition which may
complicate this and may go on to form a subareolar abscess. However,
periductal mastitis can be seen in younger women before ectasia has devel-
oped and, in these circumstances, is frequently associated with smoking.
Clinical features
• Nipple discharge: clear/coloured, thick/thin, occasionally bloodstained.
• Breast abscesses: commonly peri-areolar.
• Inflammatory breast mass: often chronic.
• Nipple retraction.
• Mammary duct fistula: associated with recurrent abscesses and nipple
inversion.
• Mastalgia.
• Eczema: associated with chronic nipple discharge.
Pathology
Duct ectasia is characterized by dilated ducts, extending 2–3cm behind the
nipple. Periductal inflammation causes shortening and retraction of the
ducts; this may be associated with abscess formation.
Microbiology
Some masses demonstrate no bacterial growth. Common organisms
found are a mixture of aerobes and anaerobes (Staphylococcus epidermidis
and aureus, Peptostreptococci, Bacteroides, Proteus).
Causation
Clinical syndrome may be related, in some women, to obstructed ducts
or pre-existing nipple inversion. Smokers are more likely to have severe
disease with fistula formation, anaerobic growth, and abscess formation.
Assessment
All breast masses require triple assessment to establish diagnosis.
Ultrasound will demonstrate dilated ducts associated with duct ectasia.
Microbiological assessment of any fluid aspirated may guide treatment.
Management
• Non-painful mass: observe initially, as it may resolve.
• Painful mass: microbiological assessment. Treat with broad-spectrum
antibiotics, e.g. co-amoxiclav, NOT flucloxacillin.
• Abscess: repeated ultrasound-guided aspirations and broad-spectrum
antibiotics. Open drainage if fistulating through skin.
Surgery
• Excision biopsy: for retro-areolar mass not responding to antibiotics.
• Correction of nipple inversion: can result in a worsening of cosmesis.
Patient must be aware of risk of nipple necrosis, loss of sensation,
inability to breastfeed, and recurrence of the inversion.
DUCT ECTASIA AND PERIDUCTAL MASTITIS 69
• Fistula surgery: fistulectomy can be performed in a young patient

with a single tract. Older patients and those with complex disease
or purulent discharge require total duct excision. The wound can be
closed by primary or secondary intention.
Recurrent infection following surgery can be caused by: persistent abscess
cavity, persistent proximal or distal ducts, nipple inversion, early preg-
nancy, factitial disease, or contralateral disease. Recurrent problems are
common in smokers.
Breast infections: mastitis

and abscesses
Mastitis is defined as an infection of the breast parenchyma whereas an
abscess is a localized collection of pus within the parenchyma, usually sur-
rounded by an area of mastitis.
Aetiology
Breast abscesses commonly occur in two distinct age groups (see Table 7.1).
• Lactational: affects 3% lactating women, 80% in the first month
post-partum. Almost exclusively skin-derived infection arising from
cracking of the nipple. Can be reduced with good nipple hygiene and
skin care.
• Non-lactational: secondary to periductal mastitis/duct ectasia, age
35–55, more common in smokers. Commonest site is subareolar.
Breast infections can be caused by atypical infections, especially in an
immunocompromised patient; these include Mycobacterium tuberculosis,
fungi, filariasis, hydatid, Pseudomonas, or mumps.
Presentation
Examination reveals a red, hot, swollen, indurated, and tender breast. Due
to the density and engorgement of a lactational breast, it can be difficult to
clinically determine the presence of an abscess within an area of mastitis.
Ultrasound demonstrates the presence of any underlying abscess cavity.
Management
• Antibiotics.
• Drainage: ultrasound-guided aspiration of an abscess cavity should be
performed under local anaesthetic. Serial ultrasound-guided aspirations
will be required over several weeks. Surgical drainage is only used
for abscesses that have breached overlying necrotic skin (see Further
reading). Surgical drainage should be avoided because it may leave
unsightly scars and increase the risk of subsequent fistula formation.
This latter complication is more common with abscesses related to
periductal mastitis than lactation.
• Lactational abscess: women must be reassured to continue to
breastfeed or to express milk to avoid an engorged breast full of milk
which makes an excellent culture broth. The S. aureus contaminated
milk will not harm their baby.
• Non-lactational abscess: these infections are persistent and can be
difficult to clear, especially if the patient continues to smoke. Offer
Stop Smoking support.
BREAST INFECTIONS: MASTITIS AND ABSCESSES 71
Table 7.1 A demonstration of the two common types of breast

abscess: lactational and non-lactational
Lactational Non-lactational
Common S. aureus, S. epidermidis Mixed aerobic/
organisms anaerobic (Bacteroides,
S. aureus, S. epidermidis,
Peptostreptococcus)
First-line antibiotic Flucloxacillin Co-amoxiclav
Penicillin allergy Erythromycin Erythromycin
The aetiology and flora of the infections must be appreciated to instigate the appropriate
antibiotic therapy.
Granulomatous mastitis
Granulomatous mastitis is a rare, benign, inflammatory condition of the
breast, often without an obvious cause.
Aetiology
Multiple aetiologies have been suggested, including tuberculosis (TB),
sarcoidosis, foreign body reaction, and parasitic infections. In the majority
of cases, no cause is found.
Epidemiology
Most common in third and fourth decades of life and is associated with
recent pregnancy and lactation. Uncommon in nulliparous women.
Presentation
A breast mass is the most common clinical finding. The mass may pen-
etrate the skin to form an ulcer or fistula, pucker the skin, or be teth-
ered to underlying muscle. Parenchymal and nipple distortion, and axillary
lymphadenopathy may be present; these findings may suggest a breast
carcinoma.
A full history of infectious diseases/contacts should be taken, including
TB contacts. Associated with autoimmune disease, including Wegener’s
granulomatosis, erythema nodosum, and polyarteritis nodosa.
Most patients with breast infections will be smokers. The presence of an
apparently infectious lesion in a non-smoker should alert the clinician to
the possibility that this might be granulomatous mastitis.
Imaging
Mammographic findings include focal asymmetric density and parenchy-
mal distortion. Ultrasound examination may reveal focal, homogeneous
enhancing masses and abscess formation.
Diagnosis
Differentiating granulomatous mastitis from carcinoma can be difficult and
may require ultrasound-guided biopsy of the lesion. Further pathological
assessment may be required using vacuum-assisted or, rarely, open biopsy.
Further investigation
Microbiological assessment is essential of any abscess fluid and of biopsies
taken of the mass. Prolonged TB culture and PCR analysis may be helpful.
Corynebacterium may be isolated.
Treatment
Granulomatous mastitis probably represents a spectrum of diseases, caus-
ing a similar clinical and pathological picture. Multiple treatments may be
required for clinical cure. Optimal treatment is controversial. Discussion
at the MDM is important, and getting a second MDM opinion may be
helpful. Many patients with an obviously ‘infected’ breast will become con-
cerned if ‘nothing’ appears to be done.
Note that patients need careful explanation of the benefits of observa-
tion. In the majority of patients, masterly inactivity and open access to the
GRANULOMATOUS MASTITIS 73
clinic when they are concerned is often the best option; however, if active
treatment is undertaken, the following options exist.
• Anti-microbials: in the presence of a proven infection, prolonged
anti-microbial treatment (2–6 weeks) is required.
• Wide excision: wide local excision, with margins clear of inflammatory
tissue, may give long-term cure but often at the expense of cosmesis.
This is a very controversial approach; some would advise avoiding
surgery at all costs.
• Steroid treatment: prednisolone 10–30mg/day for up to 8 weeks
has been used prior to surgery and after excision. Prolonged use of
steroids may help prevent multiple deforming operations.
• Immunosuppression: weekly low-dose oral methotrexate has shown
benefit in a small number of cases resistant to steroid therapy.
Complications
Major complications include recurrence and fistula formation which is
often the result of premature surgery. Recurrence rates are up to 50%
following surgical excision/steroid therapy. Excision of the recurrence and
further steroid treatment may be needed. The mastitis is characterized by
long-term resolution, often over several years.
Radial scar and complex

sclerosing lesions
Definition
Radial scar and complex sclerosing lesions represent areas of benign myoep-
ithelial proliferation with or without micro-calcification. Histologically, they
are characterized by a fibroelastic core with entrapped ducts and sur-
rounded by radiating ducts and lobules. Sclerosing lesions <1cm in diam-
eter are termed radial scars and those >1cm complex sclerosing lesions.
Presentation
Sclerosing lesions are asymptomatic and are detected on mammography,
most commonly as part of the National Health Service Breast Screening
Programme. The detection of these lesions has increased dramatically
since the introduction of population-based mammographic screening, with
an incidence of one in every 500 women screened. Clinical examination
may occasionally reveal a mass lesion.
Imaging
Sclerosing lesions require careful assessment because, radiologically, they
can mimic carcinoma. Common features on mammography include:
• The presence of a central radiolucency.
• Radiating long spicules.
• Radiolucent linear structures parallel to spicules.
• Absence of a mass lesion or skin changes.
• Varying appearance in different projections.
Pathological assessment
All sclerosing lesions require careful pathological assessment to exclude
a malignancy. This can be achieved using multiple core biopsies or
vacuum-assisted sampling mammotome. If diagnostic doubt remains fol-
lowing radiologically guided biopsy, an open diagnostic biopsy should be
performed.
Management
Sclerosing lesions alone are entirely benign and do not increase future
breast cancer risk. Sclerosing lesions can harbour atypical hyperplasia and
ductal carcinoma in situ. Due to the risk of an associated atypical lesion,
sclerosing lesions should either undergo a diagnostic excision biopsy or,
following benign biopsies, should undergo mammographic surveillance.
RADIAL SCAR AND COMPLEX SCLEROSING LESIONS 75
Breast pain (mastalgia)

Breast pain is the commonest presenting symptom in the breast clinic,
affecting up to 50% of patients. Patients present with pain alone or a pain-
ful lumpiness.
History
Association with the menstrual cycle differentiates breast pain into cycli-
cal and non-cyclical. True breast pain must be differentiated from pain
referred from the chest wall or other organs. Typically, true breast pain
increases in the days prior to menstruation and subsides once menstrua-
tion has started. Daily breast pain charts are useful for confirming to both
the patient and the health professional the nature and timing of the symp-
toms. A thorough history of the nature of pain, causative or related fac-
tors, hormonal medication, and other musculoskeletal conditions will help
to exclude non-breast conditions.
Examination
Routine breast and axillary examination should be performed. The chest
wall adjacent to the lateral fold of the breast should also be carefully
examined with the patient lying on their side. Focal musculoskeletal ten-
derness in this region commonly causes referred breast pain. Examination
of chest wall, abdomen, shoulders, and spine may identify other potential
causes of non-cyclical breast pain requiring further evaluation.
Causation
Cyclical mastalgia
• Commonest type of mastalgia.
• Can be focal or global breast pain, unilateral or bilateral.
Non-cyclical mastalgia
• Chest wall causes: localized musculoskeletal tenderness, Tietze’s
syndrome (costochondritis).
• Focal point tenderness within breast.
• Diffuse breast tenderness.
• Non-breast causes: spondylosis, gallstones, lung disease, exogenous
oestrogens, thoracic outlet syndrome.
Imaging
Imaging is only required where there is associated or incidental, focal
clinical signs in the breast (localized tenderness, nodularity, swelling, or a
lump). The majority of patients will not require any form of imaging.
Management
Information
All patients should receive verbal information and reassurance about the
nature of the pain. Patients should be given a written information leaflet.
This forms the mainstay of treatment. The risks and benefits of the few
therapeutic options should be explained.
BREAST PAIN (MASTALGIA) 77
Chest wall pain

Musculoskeletal tenderness requires rest and reassurance. Topical or oral
anti-inflammatories may provide some relief.
Localized chest wall tenderness
Oral anti-inflammatories. Depot injection of methylprednisolone 40mg and
local anaesthetic, repeated as necessary at 6 weeks, provides long-lasting
analgesia in 60% of patients.
True breast pain
• Supportive soft, non-underwired bra, particularly useful for pain at
night. Bra fitting should be offered within the breast clinic.
• Topical anti-inflammatory application, e.g. ibuprofen gel.
• Endocrine treatments (rarely used): danazol 200mg once per day given
in the luteal phase (day 15–25 of cycle) has a response rate of 70% in
cyclical and 30% in non-cyclical mastalgia. Significant side effects include
weight gain, acne, and hirsutism. Tamoxifen 10mg given in the luteal
phase gives long-term pain relief in up to 70% of women. Tamoxifen is,
however, unlicensed for breast pain.
• Antidepressants: selective serotonin reuptake inhibitors have limited
benefit in some patients.
Nipple discharge
History
Establish the duration, frequency, volume, and colour of nipple discharge.
Does it occur spontaneously or only on squeezing; whether bilateral; and
whether there are any other associated breast symptoms, particularly a
lump or inflammation.
Clinical features
Breast examination should detail nipple inversion and eczematous changes.
Asking the patient to express the discharge will determine if it is single or
multiple ducts, colour, and the presence of blood. Urinalysis sticks are
a useful guide to the presence of blood. Cytology of the discharge is of
limited clinical value. Twenty percent of men with nipple discharge have
breast cancer.
Features of nipple discharge associated with
malignancy
Associated recent nipple inversion, unilateral nipple eczema or nipple
change, bloodstained discharge (especially from solitary duct).
Investigation
Bilateral mammography in those over 40. Ultrasound if single-duct dis-
charge or if any palpable abnormality. Punch biopsy for unexplained nipple
eczema or ulceration. Serum prolactin in patients with persistent milky
discharge.
Causes of nipple discharge
• Multiduct clear galactorrhoea: mechanical stimulation, post-lactational,
stress, menopause, menarche, drugs (dopamine blockers, methyldopa,
oral contraceptives, metoclopramide), pituitary tumours, bronchogenic
carcinoma, hypothyroidism, renal failure.
• Single-duct clear discharge: papilloma.
• Multicoloured discharge: duct ectasia, cysts.
• Bloodstained discharge: duct ectasia, DCIS, invasive carcinoma,
pregnancy, papilloma.
Smokers are more likely to have severe disease with fistula formation,
anaerobic growth, and abscess formation.
Treatment
• Reassurance and advice to not express the discharge is the mainstay of
treatment for women with benign multiduct discharge.
• Microdochectomy: for persistent single-duct discharge, whether clear
or bloody. Also perform if papilloma present on ultrasound.
• Total duct excision: bloodstained discharge in woman over 45. Patient
choice due to persistent multiduct discharge. Nipple eczema secondary
to persistent discharge.
NIPPLE DISCHARGE 79
Solitary papilloma
Peak incidence at age 45. Occurs within 5cm of nipple and are generally
2–3mm in diameter. Fifty percent present with bloody/clear discharge;
50% have a palpable lump; 8% contain neoplasia.
Multiple duct papillomas
Less likely to cause discharge. Present with bilateral peripheral lumps.
Increased risk of breast carcinoma. Increased risk can be managed with
surveillance (little evidence of best way to perform this) or risk-reducing
surgery.
Further reading
Tse G, Law BK, Ma TK, et al. (2002). Hamartoma of the breast: a clinicopathological review. J Clin
Pathol 55, 951–4.
Ocal K, Dag A, Turkmenoglu O, Kara T, Seyit H, Konica K (2010). Granulomatous mastitis: clinical,
pathological features and management. Breast J 16,176–82.
Kim J, Tymms KE, Buckingham JM (2003). Methotrexate in the management of granulomatous
mastitis. ANZ J Surg 73, 247–9.
Mansel R, Webster D, Sweetland H (2009). Hughes, Mansel & Webster’s Benign disorders and
diseases of the breast, 3e. Saunders Ltd, Philadelphia.
Dixon J (1992). Outpatient treatment of non-lactational breast abscesses. Br J Surg 79, 56–7
Wallis MG, Devakumar R, Hosie KB, James KA, Bishop HM (1993). Complex sclerosing lesions
(radial scars) of the breast can be palpable. Clin Radiol 48, 319–20.
Breast Pain Chart at Breast Cancer Care. Available at: M http://www.breastcancercare.org.uk/
upload/pdf/breast_pain_chart.pdf
The Royal College of Radiology Breast Group guidelines. Available at: M http://www.rcrbreast-
group.com/Documents/BBCDiagnosticGuidelines.pdf
Chapter 8 81
Surgical management of
benign breast disease
Breast abscess 82
Operations on the nipple/major ducts 84
Excision of fibroadenoma/benign breast lump 86
Excision of accessory breast tissue 87
Further reading 87
82 CHAPTER 8 Surgical management of benign disease
Breast abscess
See also Chapter 7.
• Requires adequate drainage.
• Delay can lead to breast tissue and skin loss, poor cosmetic result and
impede breastfeeding.
• Normally managed by aspiration (ideally under U/S guidance) in the
A&E or outpatient setting. Only a small number require formal incision
and drainage.
• After aspiration/drainage, consider admission and intravenous
antibiotics in systemically unwell women, particularly those on
chemotherapy or other immunosuppressive drugs, or those with
extensive cellulitis.
• Following complete aspiration or drainage, the patient can be
discharged but should return to the breast clinic within 48 hours for
review, as many need repeat aspiration and/or further evaluation in
non-lactational abscesses to exclude an underlying breast cancer.
There is a danger at weekends and public holidays that there will
be inappropriately long intervals between aspirations, so suitable
arrangement must be made.
If the skin is intact, and the patient consents
• Treat with simple aspiration.
• Apply EMLA® cream to the skin. Going through non-indurated skin is
less painful.
• Using a 19G needle, aspirate the abscess, ideally under U/S guidance if
an U/S machine, or a friendly radiologist, is available.
• The needle should be inserted parallel to the chest wall to avoid the
small chance of a pneumothorax.
• An appropriate volume of 1% lidocaine, or similar local anaesthetic,
can be infiltrated into the abscess and the abscess aspirated, with a
‘washing’ in and out of the local anaesthetic.
• Send a sample of the pus to microbiology.
• Commence appropriate antibiotics, as outlined in Chapter 7.
• Do not insert a needle blindly into a breast with an implant. If you
think there is an abscess here, it is possible that the implant will
need to be removed to eradicate the infection. Discuss U/S-guided
aspiration with a breast radiologist.
If the overlying skin is necrotic or aspiration fails
• Formal incision and drainage under general anaesthesia.
• Remember that drainage will be gravitational when the patient sits or
stands. Occasionally, this requires drainage through the inframammary
crease.
• Clean the skin with povidone-iodine or chlorhexidine.
• Necrotic skin should be removed with a blade or scissors and a good
pair of forceps.
• Locules should be broken down gently, and the cavity should be
washed out with saline.
BREAST ABSCESS 83
• Send a sample of pus to microbiology and the wall to histopathology.

• The wound can be left open (not sutured) to improve drainage.
• Packing can be minimal (a small wick of Kaltostat®) to reduce
discomfort.
• Commence appropriate antibiotics if any residual cellulitis.
Operations on the
nipple/major ducts
Microdochectomy
This is the removal of a single duct from the breast, usually performed for
single-duct discharge.
Planning
Mark patient standing up (side, intended scar, and possibly duct involved).
Positioning
Supine with arm by side or abducted to 90°.
Scar/incision
Peri-areolar. Avoid going more than halfway around the areola to maintain
nipple viability.
Technique
• Identify affected duct on table by gently squeezing nipple.
• Place lacrimal probe into duct.
• Circumareolar incision with size 15 blade on a Baron’s handle.
• Excise affected duct from back of nipple for a length of >2cm. Take a
margin of a few mm around the probe (removing the probe with the
specimen).
• Mark nipple end with a suture for orientation, and send specimen to
pathology.
• Haemostasis.
• Local anaesthetic infiltration.
• Closure with 3-0 Monocryl® (interrupted dermal sutures and a running
subcuticular stitch) and Steri-stripTM or glue.
• Same-day discharge.
Total duct excision (Hadfield’s operation)
Performed for troublesome nipple discharge from multiple or unidentified
ducts or nipple inversion associated with duct ectasia.
Planning/positioning/scar/incision
As for microdochectomy.
Technique
• Lift up NAC with skin hooks, and disconnect nipple from major ducts.
• Be careful not to buttonhole the skin when doing this.
• Excise major ducts from back of nipple for a length of >2cm (a square
of tissue).
• Mark nipple end with a suture for orientation, and send specimen to
pathology.
• Haemostasis: be cautious in the use of diathermy.
• Close defect with 2-0 Vicryl® (undyed).
• A 3-0 Prolene™ purse string under nipple may help reduce/correct
nipple inversion (not too tight to maintain blood supply to the nipple).
OPERATIONS ON THE NIPPLE/MAJOR DUCTS 85

Complications
See Table 8.1.
Post-operative care
Sutures are dissolvable. Steri-stripTM can be removed at 10 days.
Post-operative review can be arranged to discuss results and check wound
at 2–3 weeks.
Excision of mammillary fistula
A mammillary fistula (normally at the areolar margin) is the end result of
complicated periductal mastitis. It can be excised along with the associated
diseased duct passing up to the nipple. However, the risk of recurrence of
the fistula is high (up to 50%).
Planning
Mark patient standing up (side, intended scar, and possibly duct involved).
Positioning
Scar/incision
Peri-areolar excising fistula is the best cosmetic way.
Technique
• Place lacrimal probe into fistula.
• Excise fistula; clean out any associated abscess cavity and associated
duct passing up to the nipple.
• Send specimen to pathology.
• Haemostasis.
subcuticular stitch) and Steri-stripTM or glue. If skin is very indurated,
interrupted 3-0 Prolene™ sutures, which need to be removed at
7–10 days, may excite less tissue reaction.
Table 8.1 Common local complications of nipple surgery to include as

part of the consent process
Haematoma Loss of part of nipple
Infection Puckering of nipple
Asymmetry Residual lump
Loss of sensation Inversion of nipple
Excision of fibroadenoma/benign
breast lump
Techniques vary from the use of a vacuum-assisted biopsy device (mam-
motome) for lesions less than 20mm to a more traditional surgical excision.
Planning
Mark patient standing up (side, intended incision, and position and size
of lump).
Positioning
Supine with arm by side.
Scars/incisions
Peri-areolar, inframammary crease, the lateral aspect of the breast, or
Langer’s Lines.
Technique
• Incise skin, and elevate skin flap towards the lump until you have
reached it. Do this in the plane between the subcutaneous fat and the
true breast tissue.
• Try to ‘fix’ the lump with a finger, gently with an Allis forceps, or with a
suture.
• Dissect it from the surrounding breast tissue with scalpel, scissors, or
diathermy. Common mistake: if there is no clear margin around the lesion
you are excising, you have not reached the fibroadenoma yet, go deeper!
• No need for ‘margin’ of normal breast tissue; can be shelled out intact.
• Ensure haemostasis.
Complications
See Table 8.2.
Post-operative care
Sutures are dissolvable. Steri-stripTM can be removed at 10 days. No rou-
tine follow-up is required or a single review to discuss results if there is
any concern.
Table 8.2 Common local complications of breast surgery to include as

part of the consent process
Haematoma (residual lump felt by patient) Loss of volume
Infection Asymmetry
Seroma Scars
Missed lesion (a palpable area of breast tissue Recurrence
is removed and not the index lesion)
EXCISION OF ACCESSORY BREAST TISSUE 87
Excision of accessory breast tissue

Normally in the axilla but can be below the breast.
Planning
Mark patient standing up (side, intended incision, and position and size
of lump).
Scars/incisions
In skin crease.
Positioning
Supine with arm abducted to 60°.
Technique
• Incise skin, and elevate skin flap beyond the tissue to be excised. Do
this in the plane between the subcutaneous fat and the breast tissue.
• Remove accessory breast tissue with scalpel, scissors, or diathermy.
• Ensure haemostasis.
Complications
See Table 8.2.
Post-operative care
Sutures are dissolvable. Steri-stripTM can be removed at 10 days. Follow-up
at 6 weeks to assess aesthetic result.
Further reading
Novell JR, Baker D, Goddard N (2013). Kirk’s general surgical operations, 6e. Elsevier, Philadelphia.
Fitzgerald O'Connor I, Urdang M (2008). Handbook for surgical cross-cover. Oxford University Press,
Oxford.
Chapter 9 89
Gynaecomastia
Overview 90
Role of primary care 91
Causes of gynaecomastia 92
Management 93
Excision 94
90 CHAPTER 9 Gynaecomastia
Overview
Changing nutritional and social habits may explain the reason why there
has been a dramatic increase in referrals to breast clinics because of
enlargement of the male breast. Gynaecomastia is a benign prolifera-
tion of glandular breast tissue, causing enlargement of the male breast.
Pseudogynaecomastia has a similar appearance but is due to excess adi-
pose tissue, not glandular tissue. Patients may have a combination of both.
Gynaecomastia affects 60% of males at puberty. The incidence increases
in advanced age.
ROLE OF PRIMARY CARE 91
Role of primary care

Many gynaecomastia referrals are due to concern about possible signifi-
cant underlying disease (see Fig. 9.1). GPs should be encouraged to screen
out any serious systemic disease prior to referral. In the absence of an
obvious clinical underlying cause, GPs should perform:
• Renal, liver, and thyroid function blood tests, and a chest X-ray (CXR).
If there is still no clinical underlying cause, perform:
• Endocrine testing: these four markers will screen for any underlying
endocrine abnormality:
• Human chorionic gonadotropin (hCG).
• Luteinizing hormone (LH).
• Testosterone.
• Estradiol.
If any of these blood tests are abnormal, the patient should be referred
to an endocrinologist first. When the blood tests are within the normal
range, surgical referral is appropriate for patients who would like to dis-
cuss treatment options.
History
A standard breast history should be taken. In addition, it is important to
record all prescribed drugs. Enquiries must be made of all recreational or
illicit drug use, including cannabis, anabolic steroids, and alcohol. It may be
tactful to begin this line of enquiry by asking about sporting prowess, gym
membership, or even bodybuilding.
Examination
If the blood tests have excluded systemic disease, then the physical exami-
nation can be restricted to the breast, axilla, and cervical lymph nodes.
Conventional teaching is that the testicles are examined (most commonly
in the FRCS exam!). In practice, few contemporary breast surgeons exam-
ine the patient’s testicles. If the blood tests have excluded systemic illness,
then this part of the examination becomes superfluous.
Male breast cancer is rare (7300 new cases a year in the UK). This rep-
resents about 1% of all causes of male breast enlargement seen in second-
ary care. In practice, male breast cancer often has a ‘woody’ texture on
examination, and there is often nipple distortion.
Causes of gynaecomastia
• Idiopathic: the most frequent.
• Physiological: gynaecomastia can occur in neonates, at puberty, and
in old age as a result of non-pathological fluctuations in steroid sex
hormones.
• Conditions resulting in decreased androgens: primary testicular failure,
Klinefelter’s syndrome, testicular feminization, bilateral testicular
torsion/cryptorchidism, orchitis, renal failure, hyperprolactinaemia.
• Conditions resulting in increased oestrogens: testicular tumours, lung
carcinoma, liver disease, thyrotoxicosis, adrenal disease.
• Drug-induced: a large group, particularly in elderly men. Any drug
that affects steroid metabolism in the liver might be responsible for
gynaecomastia. These include:
• Hormones: anti-androgens, oestrogen antagonists, treatments
particularly associated with carcinoma of the prostate.
• Cardiovascular: spironolactone, digoxin, ACE inhibitors,
amiodarone, verapamil.
• Gastrointestinal: ranitidine, cimetidine, omeprazole.
• Others: tricyclic antidepressants, metronidazole, diazepam,
metoclopramide, phenytoin, theophylline.
• Recreational/illicit drugs: cannabis, anabolic steroids, alcohol.
MANAGEMENT 93
Management
Imaging
Mammography and/or ultrasound (U/S) should only be performed in men
with suspicious or unexplained unilateral breast enlargement. U/S can
be used to differentiate between true glandular gynaecomastia and fatty
pseudogynaecomastia.
Bloods
A biochemical profile should only be performed in men with true gynae-
comastia and should include renal and liver function tests. The four blood
tests mentioned earlier (see Fig. 9.1) (hCG, LH, testosterone, and estra-
diol) will highlight any endocrine abnormality. If any of these are abnormal,
further discussion with an endocrinologist is required. Ideally, these four
blood tests should have been arranged prior to referral.
Measure serum hCG, LH, testosterone (T) and estradiol (E)
Normal Raised hCG Low LH+ Raised LH+ Raised LH+ Raised E+
low T Raised T low T low LH
Testicular Measure Measure Primary Testicular

ultrasound prolactin thyroid hypogonadism ultrasound
Idiopathic function
gynaecomastia
Normal Raised Normal
Normal prolactin prolactin Normal
thyroid Testicular
Testicular function tumour
Possible
tumour Hyperthyroidism
prolactin Possible
secreting adrenal
Investigate for
tumour neoplasm
extragonadal germ
Androgen
cell tumour
Secondary resistance
hypogonadism
Fig. 9.1 Investigation of a patient with bilateral gynaecomastia.

Excision
For the majority of men, treatment should begin with an explanation of
any underlying cause and, if appropriate, a review of prescribed medica-
tion. Patients with pubertal gynaecomastia should be reassured, avoid-
ing surgical intervention, if possible. Gynaecomastia has been treated
with tamoxifen in the short term, but the evidence base for this is small.
Surgery can result in a poor aesthetic outcome and should be approached
with caution. Surgical options include those shown in Table 9.1.
Planning
The patient should be standing. Mark the side, inframammary fold, current
and desired nipple heights and areola size, intended scars, and extent of
resection.
Positioning
Scars/incisions
Peri-areolar, inframammary crease, or at the lateral aspect of the breast.
Technique
Liposuction
Liposuction is particularly useful in pseudogynaecomastia where the bulk
of the tissue to be resected is fat. Glandular breasts are best resected with
open surgery or U/S liposuction techniques.
Surgical excision
• Local anaesthetic infiltration (with adrenaline, may help haemostasis)
pre- or post-excision.
• Aim to avoid nipple necrosis or concavity (dinner plating) by not
leaving skin and subcutaneous tissue too thin and graduating to edges
of excision.
Complications
See Table 9.2.
As this surgery is associated with a high incidence of post-operative
haematoma, many patients return to the ward with a drain in situ or a
compression garment is applied, and they are observed overnight.
Post-operative care
Sutures are dissolvable. Steri-stripTM can be removed at 7 days. Post-operative
review can be arranged to check aesthetic result at 2–3 months.
There are two primary reasons for poor surgical results; in a thin man
with primary glandular enlargement, excision can result in a defect that
EXCISION 95
may cause the nipple to sink into the chest wall post-operatively so that
the patient exchanges a lump for a concavity.
Conversely, in the patient with fatty enlargement that produces a
pseudobreast with ptosis, it is possible to perform liposuction. This may
result in there being excessive quantities of redundant skin left behind
with an equally poor aesthetic outcome. The complex, and often difficult,
decisions required in gynaecomastia surgery demand a multidisciplinary
approach with an experienced plastic surgeon.
Patients with gynaecomastia, even when their expectations are realistic,
require adequate time and explanation in order to fully understand their
options.
Table 9.1 Surgical options for gynaecomastia

Type of surgery Advantages Disadvantages
Excision of tissue Good for removing dense Scarring and deformity,
glandular tissue including nipple scarring
to underlying chest wall
Liposuction Quick. Minimal Cannot always remove
scarring. Good for dense glandular tissue
pseudogynaecomastia
Breast/skin reduction Removes redundant skin Extensive, visible scarring
in large, ptotic breasts
Table 9.2 Common local complications of gynaecomastia surgery to

include as part of the consent process
Haematoma Loss of part of nipple
Infection Puckering of nipple down to muscle
Asymmetry Residual lump
Loss of sensation Inversion of nipple
Chapter 10 97
Invasive breast
carcinoma: pathology
and prognosis
Overview 98
Determining tumour grade 100
Molecular factors 101
Breast cancer staging 102
Prognostic tools in breast cancer 104
Molecular classification of breast cancers and their
clinical applications 106
Further reading 107
98 CHAPTER 10 Invasive breast carcinoma
Overview
The definition of an invasive breast cancer is one in which the basement
membrane of breast ducts and lobules has been breached, allowing the
malignant cells to access the surrounding stroma which contains both
blood and lymphatic vessels, potentially leading to more widespread dis-
semination. This contrasts with in situ disease in which the basement mem-
brane remains intact, imprisoning the malignant cells (see Chapter 11). For
that reason, by definition, in situ disease does not metastasize.
Broadly speaking, breast cancers arise from the two major breast unit
structures, the ducts and lobules. Therefore, they can be divided into inva-
sive ductal carcinomas which make up about 85% of cancers and invasive
lobular carcinomas which account for 10–15% of carcinomas. In addition,
there is a small group of special type carcinomas—they arise from spe-
cialized parts of these units. They are far less common, tend to be seen
in screen-detected tumours, and are associated with a better prognosis.
Infiltrating ductal carcinoma: carcinoma of no special

type (NST)
Carcinoma of NST (previously known as ductal carcinoma) is the com-
monest morphological type (>50% of invasive cancers). Traditionally,
these present symptomatically as a hard, irregular, well-defined lump.
Infiltrating lobular carcinoma

Infiltrating lobular carcinoma is the second commonest morphological
type (10–15%) of invasive carcinomas. Lobular carcinomas are more com-
monly multicentric and traditionally associated with a bilateral presenta-
tion, although, in reality, the majority affect only one side. The diffuse
infiltrating pattern of lobular carcinoma leads to a clinical presentation
of diffuse thickening, rather than a defined lump, and, frequently, they
are mammographically occult, only being visible on ultrasound. For that
reason, patients presenting with an asymmetric thickening and a normal
mammogram should have an ultrasound. Lobular carcinomas are often the
subject of delay in diagnosis. Because of their diffuse nature, assessment of
their size is often best made using ultrasound and MRI. Most MDTs would
recommend an MRI in all women considering conservation surgery, fol-
lowing a core biopsy revealing invasive lobular carcinoma. This can change
surgical management in up to 28% of cases.
Special types
These are more frequently seen in screening than symptomatic practice.
Tubular carcinoma
Accounts for 15% in screened and 2% in symptomatic. They are seen as a
spiculate mass on a mammogram.
OVERVIEW 99
Medullary
These account for about 3% of cancers, often associated with BRCA gene
mutations. Clinically, they present as a soft lump.
Mucinous carcinomas
These are rare (<1% of invasive carcinomas) and have a well-defined
gelatinous appearance. Histologically, tumours consist of epithelial cells
within lakes of mucin.
Determining tumour grade

Although it is traditional to histologically type tumours, in practice, an
assessment of histological grade is of far more value. The system cur-
rently used is that developed by Elston, based on Bloom and Richardson’s
original scheme. This assesses three aspects of the tumour:
• Tubule formation.
• Nuclear polymorphism.
• Mitotic count.
A numerical scoring system of 1–3 is used for each factor; collation of the
three scores gives an overall tumour grade (see Table 10.1).
Other histological factors
There are two other factors, based on basic histopathology, which can
contribute to the overall prognosis:
• Lymphovascular invasion and tumour vascularity.
• Extranodal spread in lymph nodes.
Several studies have shown that the presence of tumour cells in vessels,
both lymph and blood, is associated with a poorer prognosis for both
local and distant recurrence. The density of new vessel growth is also
prognostic, although the difficulties in assessing this mean that, in contrast
to invasion, it is not routinely reported on pathology reports.
Extranodal spread of tumour in the axilla is, in addition, associated with
a poorer overall prognosis.
Table 10.1 The Bloom and Richardson grading system for breast
cancers is based upon an additive score of tubule formation, nuclear
polymorphism, and mitotic count
Grade Differentiation Score
1 Well differentiated 3–5
2 Moderately differentiated 6–7
3 Poorly differentiated 8–9
Reprinted by permission from Macmillan Publishers Ltd on behalf of Cancer Research
UK: British Journal of Cancer. 11(3): 359–377, 'Histological Grading and Prognosis in Breast
Cancer', H. J. G. Bloom and W. W. Richardson, copyright 1957.
MOLECULAR FACTORS 101
Molecular factors
Increasingly, molecular factors are being used to assist in prognosis and
predict response to treatment. Two particular targets have been identi-
fied: the oestrogen receptor and the HER-2 receptor.
Oestrogen receptor status

Since Beatson’s observation in 1896 that oophorectomy led to tempo-
rary control in some breast cancers, endocrine manipulation has been
an essential component of breast cancer management. Laboratory-based
technologies can now identify which tumours exhibit strong oestro-
gen receptor expression. The degree of oestrogen receptor expres-
sion in a tumour predicts an individual’s response to endocrine therapy.
Immunohistochemistry uses monoclonal antibodies to stain nuclear oes-
trogen receptors. The Allred scoring system collates the two scores for
the proportion of positive cells (0–5) and the staining intensity (0–3).
A combined score of 0–2 is negative, and a score of 3–8 is considered
positive.
Her-2/neu expression
Her1–4 are members of the epidermal growth factor receptor (EGFR)
family. The Her-2/neu receptor is expressed on approximately 20% of
invasive breast cancers and has a negative impact on patient survival (See
Further reading). Immunohistochemistry using monoclonal antibodies
to Her-2/neu is used as the primary screen to stain paraffin-embedded
tumour tissue. A score of 0–1+ is considered negative, 2+ is equivocal,
and a score of 3+ is positive. When a score of 2+ is present, further
testing is required using FISH (fluorescent in situ hybridization) or D-dish
(dual-colour dual-hapten in-situ hybridization). FISH is semi-quantitative
and directly measures the number of Her-2/neu genes. Patients whose
tumours overexpress Her-2 have a poorer prognosis but are candidates
for treatment with receptor blockers, such as trastuzumab or lapatanib.
Both these receptors are now used in the routine assessment of breast
cancers histologically.
Breast cancer staging

The American Joint Committee on Cancer (AJCC) staging for breast
cancer is based upon the TNM (tumour, nodes, metastases) system. The
components are shown in Table 10.2.
BREAST CANCER STAGING 103
Table 10.2 AJCC staging for breast cancer

Tumour (T)
T0 No evidence of primary tumour
Tis In situ carcinoma
T1 <20mm diameter
T2 20–50mm diameter
T3 >50mm diameter
T4 T4a—extension to the chest wall, not including only pectoralis
major adherence/invasion
T4b—ulceration/ipsilateral satellite nodules/peau d’orange
T4c—both T4a and T4b
T4d—inflammatory carcinoma
Nodes (N) (p—pathology)
N0 No evidence of lymph node metastases
pN0 (i+) Malignant cells in regional lymph node(s) <0.2mm, detected by
IHC
pN0 Positive molecular findings (RT-PCR), but no regional lymph
(mol+) node metastases detected by IHC or histology
pN1 (mi) Micrometastases (0.2–2mm) to ipsilateral level I/II axillary
lymph node
pN1a Metastases in 1–3 axillary lymph nodes
pN1b Metastases to internal mammary lymph nodes, not clinically
detected
pN1c Both pN1a and pN1b
N2 Metastases in ipsilateral level I/II axillary nodes that are fixed
or matted, or in clinically detected ipsilateral internal mammary
lymph nodes in the absence of involved axillary nodes
N3 Metastases in ipsilateral level III axillary nodes, or in those
with clinically involved internal mammary lymph nodes and
axillary lymph node metastases, or metastases in the ipsilateral
supraclavicular lymph nodes.
Metastases (M)
cM0(i+) Deposits of microscopically circulating tumour cells in blood
or bone marrow but no clinical or radiological evidence of
metastases
M1 Distant detectable metastases >0.2m
Reproduced from AJCC: Breast. In: Edge SB, Byrd DR, Compton CC, eds. AJCC Cancer
Staging Manual. 7th ed. New York, NY: Springer, 2010, used with permission of Springer
Science and Business Media LLC and the American Joint Committee on Cancer (AJCC).
Prognostic tools in breast cancer

Prognosis in breast cancer depends on time-dependent factors, inherent
tumour characteristics, and the response to treatment. Accurate survival
estimates and the likely benefit of adjuvant therapy are key pieces of infor-
mation for patients with early breast cancer. In the UK, the most widely
used system is the Nottingham Prognostic Index.
Nottingham Prognostic Index (NPI)
NPI is a validated and reproducible prognostic tool and is based upon
three factors:
NPI = [tumour size (cm) x 0.2] + [lymph node stage (1: node negative;
2: 1–3 nodes positive; 3: >3 nodes positive)] + [grade (1–3)]
NPI provides accurate prognostic information and is easy to calculate,

based upon three factors that are part of the breast cancer histopathol-
ogy minimum data set (see Table 10.3). There is a suggestion that, within
each prognostic group, screening cancers tend to have a better prognosis.
‘Adjuvant! Online’
‘Adjuvant! Online’ is a decision-making tool that not only gives prognostic
information, but also provides projections of the benefit of adjuvant therapy.
Entering a minimum data set of age, co-morbidity, ER status, grade, size,
and number of positive nodes will give the clinician a prediction of 10-year
survival. ‘Adjuvant! Online’ will also give a prediction of the absolute ben-
efit of hormonal therapy, chemotherapy, and combined therapy.
Limitations of ‘Adjuvant! Online’
‘Adjuvant! Online’ is based upon the American SEER database; it is for
unicentric/unifocal invasive breast carcinomas only and assumes that all
patients undergoing breast-conserving surgery will receive adjuvant radio-
therapy. At present, ‘Adjuvant! Online’ does not give prognostic informa-
tion for Her-2-positive patients, a big disadvantage.
‘Predict’
‘Predict’ is a validated prognostic and treatment benefit tool, based upon
UK cancer registry data taken from the Eastern cancer registration and
information centre. It has very similar predictive performance to ‘Adjuvant!
Online’. ‘Predict’ is also restricted for use on unifocal invasive breast car-
cinomas and offers prognostic information for Her-2-positive patients
and treatment benefit for those offered trastuzumab. ‘Predict’ includes
mode of cancer detection (screen-detected or symptomatic) as one of
the input parameters; this is important as stage for stage, screen-detected
cancers have a survival advantage over their symptomatic breast cancer
counterparts.
PROGNOSTIC TOOLS IN BREAST CANCER 105
Table 10.3 Nottingham Prognostic Index allows us to place patients

into a prognostic group with a known and validated 10-year survival
NPI score 10-year survival (%)
Excellent prognostic group <2.4 96
Good prognostic group 2.4–<3.4 93
Moderate prognostic group 1 3.4–<4.4 82
Moderate prognostic group 2 4.4–<5.4 75
Poor prognostic group 5.4–<6.4 53
Very poor prognostic group >6.4 39
Reprinted by permission from Macmillan Publishers Ltd on behalf of Cancer Research UK:
Br J Cancer 56: 489-492, 'Confirmation of a prognostic index in primary breast cancer',
JH Todd, C Dowle, MR Williams, CW Elston, IO Ellis, CP Hinton, RW Blamey and JL Haybittle,
copyright 1987.
Molecular classification of
breast cancers and their
clinical applications
NPI, ‘Adjuvant! Online’, and ‘Predict’ are all predictive/prognostic models
that are based on population data and, therefore, do not apply to a spe-
cific individual. Several methods are emerging for assessing an individual’s
future risk of disease and response to treatment, although they are not
currently widely used in the UK. These individualized assessment systems
include the following.
Oncotype DX
Assesses the expression of 16 cancer genes and five ‘housekeeping’
(control) genes within an individual’s paraffin-embedded cancer tissue.
Oncotype DX is only applicable in ER-positive, Her-2-negative tumours
and calculates a recurrence score (between 0–100). Patients with a:
• Low recurrence score (1–17): have low risk of cancer recurrence but
also respond well to hormonal therapy and have little benefit with
chemotherapy.
• High recurrence score (31–100): have a high risk of recurrence and
gain a great benefit from chemotherapy.
• For patients with a moderate recurrence score (18–30), it is unclear
whether there is a benefit from chemotherapy. The TAILORx ((Trial
Assigning Individualized Options for Treatment (Rx)) trial has been
designed to help define the role of chemotherapy, particularly in
patients with a moderate recurrence score.
• NICE is likely to approve the use of Oncotype DX for Intermediate
risk (as per NPI/Predict), ER positive, node negative patients. Results
of the initial consultation are in Further reading.
Mammaprint
Mammaprint analyses a gene signature of 70 breast cancer-related genes
and places patients in a high- or low-risk recurrence group. Access to the
test may be limited, as the analysis must be performed on fresh/frozen tis-
sue in the Netherlands. Mammaprint is able to define the benefit of adju-
vant chemotherapy for a given patient’s cancer. Mammaprint can be used
for cancers up to 5cm in size, ER-positive or -negative, and node-positive
or -negative. Mammaprint is costly (>£2,500) and has not yet been vali-
dated on a UK population.
FURTHER READING 107
Further reading
Mann RM, Hoogeveen, YL, Blickman JG, Boetes C (2008). MRI compared to conventional diagnos-
tic work-up in the detection and evaluation of invasive lobular carcinoma of the breast: a review
of existing literature. Breast Cancer Res Treat 107, 1–14.
Slamon DJ, Clark GM, Wong SG, et al. (1987). Human breast cancer: correlation of relapse and
survival with amplification of the Her-2/neu oncogene Science 235, 177–82.
Tovey S, Brown S, Doughty J, Mallon E (2009). Poor survival outcomes in Her-2 positive patients
with low-grade, node negative tumours. Br J Cancer 100, 680–3.
Moja L, Tagliabue L, Balduzzi S, et al. (2012). Trastuzumab containing regimens for early breast
cancer. Cochrane Database Syst Rev 4, CD006243.
Barr LC, Baum M (1992). Time to abandon TNM staging of breast cancer. Lancet 339, 915–17.
Adjuvant! Online. Available at: M http://www.adjuvantonline.com
The PREDICT tool. Available at: M http://www.predict.nhs.uk
Gene expression profiling and expanded immunohistochemistry tests to guide the use of adjuvant
chemotherapy in early breast cancer management - MammaPrint, Oncotype DX, IHC4 and
Mammostrat: diagnostics consultation document 3 (PDF version) available at: M http://guidance.
nice.org.uk/DT/4/Consultation3/DraftGuidance/pdf/English
Chapter 11 109
Non-invasive breast
disease: DCIS, lobular
pathologies, and
hyperplasias
Overview 110
Atypical ductal hyperplasia 111
Ductal carcinoma in situ 112
Lobular intraepithelial neoplasia (LIN) 114
Further reading 114
110 CHAPTER 11 Non-invasive breast disease
Overview
The introduction of the NHS Breast Screening Programme has resulted in
a large increase in the proportion of cases of pre-malignant breast disease.
Improved pathological methods also detect non-invasive breast disease in
a significant number of patients.
Definition
• Also known as in situ breast disease.
• Malignant cells remain within ducts/lobules (see Fig. 11.1).
• Do NOT invade the basement membrane.
Types
• Atypical ductal hyperplasia (ADH).
• Ductal carcinoma in situ (DCIS).
• Atypical lobular hyperplasia (ALH).
• Lobular carcinoma in situ (LCIS) (can be known as lobular in situ
neoplasia [LIN]).
Non-invasive breast pathologies are a spectrum of disease. Atypical ductal
hyperplasia has the same pathological features as DCIS, but usually it
is only an increase in the quantity seen on pathology that will upgrade
the diagnosis to DCIS. Due to the lack of longtitudinal studies of DCIS,
the natural history of low- and intermediate-grade DCIS is uncertain.
High-grade DCIS will develop into an invasive cancer; the time lag before
this occurs, however, is also uncertain. Much of the debate about the
benefit of the NHSBSP revolves around ‘overdiagnosis’ of breast cancers;
the majority of these overdiagnoses are likely to be non-invasive breast
cancers, the future prognosis of which we are currently unable to predict.
Basement
Epithelium Cancer cells
membrane
a) Normal duct b) DCIS c) Invasive

carcinoma
Fig. 11.1 Carcinoma sequence for breast cancer. a) Normal duct with epithelial
lining. b) DCIS. Tumour has grown within the duct but does not penetrate the
basement membrane. Tumour cells in the centre lose vascular supply (black cells in
figure), become necrotic, and calcify. Micro-calcification is visible on mammography.
c) Invasive carcinoma—tumour cells have grown and invaded into the lumen and
out through the duct wall and basement membrane. They now have an increased
potential to metastasize.
ATYPICAL DUCTAL HYPERPLASIA 111
Atypical ductal hyperplasia

• Abnormal cells within breast ducts.
• Involves <2 ducts or is <2–3mm in size.
• Possible precursor to low-grade DCIS.
Diagnosis
• Visible on mammograms if associated with micro-calcification.
• May be incidental finding after excision biopsy.
Prognosis
• 25% risk of developing invasive disease.
• Risk increased in presence of DCIS.
Treatment
• If diagnosed on core biopsy, requires excision biopsy, as it is often
adjacent to in situ or invasive cancer.
• If incidental finding in association with invasive disease, no further
treatment is necessary.
Follow-up
• Regular mammographic surveillance should be discussed.
• High-risk patients may benefit from chemoprevention (not licensed
in UK).
Ductal carcinoma in situ

• Accounts for 720% of screen-detected breast tumours in UK.
• Abnormal proliferation of cells within milk ducts.
• 90% of cases are impalpable and asymptomatic.
• 10% of cases are associated with symptoms—mass, nipple discharge,
Paget’s disease.
Diagnosis
• 70–80% of cases associated with micro-calcification—visible on
mammograms (see Fig. 11.1).
• As impalpable, requires stereotactic-guided biopsy.
• Marker clip should be inserted at time of biopsy.
• Presence of micro-calcifications should be confirmed in cores.
Pathology
• Graded by cytological features: low, intermediate, and high grade
(observer-dependent).
• Low/intermediate grade may arise from ADH/LIN due to loss of 16q.
• High grade exhibits 17p loss and has no known precursor.
• High-grade DCIS associated with increased Her-2 and decreased ER
expression.
• Architectural subtypes: papillary, micropapillary, solid, comedo,
cribriform.
• Majority of screen-detected DCIS is high-grade (760%).
Prognosis
• Risk of developing invasive breast cancer unknown.
• Up to 33% future breast cancer risk for low-grade DCIS.
Treatment
• In general, if <4cm area of DCIS: image-guided wide local excision.
• Up to 30% of cases may require re-excision (NICE guidelines, 2mm
margin).
• >4cm or multifocal disease: mastectomy 9 reconstruction.
• Axillary surgery is not currently recommended for simple cases of
DCIS alone.
• Sentinel node biopsy is indicated if performing a mastectomy for DCIS
or if there is an associated mass.
Recurrence risk
• Following breast-conserving surgery only, 25% risk of recurrent disease
(either DCIS or invasive).
• Important risk factors: <1mm margins, high grade, comedo necrosis,
poorly differentiated, age <40 years.
• USC/Van Nuys prognostic index scores, DCIS grade, margin status,
tumour size, and patient age to predict local recurrence and suggest
treatment options (see Table 11.1). It is rarely used in clinical practice
but does demonstrate risk factors associated with local recurrence.
DUCTAL CARCINOMA IN SITU 113
Adjuvant treatment
• Radiotherapy: reduces ipsilateral recurrence but no survival advantage.
Recommended for high-grade DCIS.
• Endocrine therapy: reduces local recurrence in ER-positive cases and
may reduce contralateral cancer incidence. Tamoxifen recommended
if <50 years. Current IBIS II trial comparing tamoxifen and aromatase
inhibitor.
Follow-up
• Following breast-conserving surgery, annual mammography is
recommended.
Table 11.1 USC/Van Nuys prognostic index

Score 1 2 3
DCIS grade Low/int, no necrosis Low/int, with necrosis High 9
necrosis
Margin (mm) >10 1–9 <1
Size (mm) <15 16–40 >41
Age (y) >61 40–60 <39
Score Local recurrence risk Suggested treatment Score
4–6 1% Local excision, no 4–6
radiotherapy
7–9 20% Local excision and 7–9
radiotherapy
10–12 50% Mastectomy 10–12
Reproduced with permission from Cancer, 1996 Jun 1;77(11):2267-74, 'A prognostic index
for ductal carcinoma in situ of the breast', Silverstein MJ, Lagios MD, Craig PH et al., with
permission from John Wiley and Sons.
Lobular intraepithelial
neoplasia (LIN)
• Includes atypical lobular hyperplasia (ALH) (part of lobule affected)
and LCIS (whole lobule affected).
• Not a pre-malignant condition, but a marker of breast cancer risk.
• Abnormal cells within breast lobules.
Diagnosis
• 90% of cases detected in pre-menopausal women.
• Not usually visible on mammograms.
• Incidental finding on biopsy or surgical excision.
• 50% have multifocal disease.
• 30% have bilateral disease.
• 50% have a family history of breast cancer.
Prognosis
• 25% risk of developing invasive disease.
• Risk increased if family history of breast cancer and in presence of
ADH or DCIS.
• Pleomorphic phenotype may be associated with poorer prognosis.
Treatment
• If diagnosed on core biopsy, requires excision biopsy.
• If incidental finding in association with invasive disease, no further
treatment is necessary.
• No indication for radiotherapy or chemotherapy.
Follow-up
• Increased surveillance (MRI may be optimal, as disease not visible on
mammograms).
• Chemoprevention with tamoxifen or raloxifene (not currently licensed
in the UK).
• Young or high-risk patients may opt for risk-reducing mastectomy.
Further reading
Silverstein MJ, Buchanan C (2003). Ductal carcinoma in situ: USC/Van Nuys Prognostic Index and
the impact of margin status. Breast 12, 457–71.
Julien JP, Bijker N, Fentiman IS, et al. (2000). Radiotherapy in breast-conserving treatment for ductal
carcinoma in situ: first results of the EORTC randomised phase III trial 10853. EORTC Breast
Cancer Cooperative Group and EORTC Radiotherapy Group. Lancet 355, 528–33.
Fisher ER, Dignam J, Tan-Chiu E, et al. (1999). Pathologic findings from the National Surgical
Adjuvant Breast Project (NSABP) eight-year update of Protocol B-17: intraductal carcinoma.
Cancer 86, 429–38.
Fisher B, Dignam J, Wolmark N, et al. (1999). Tamoxifen in treatment of intraductal breast
cancer: National Surgical Adjuvant Breast and Bowel Project B-24 randomised controlled trial.
Lancet 353, 1993–2000.
Houghton J, George WD, Cuzick J, et al. (2003). Radiotherapy and tamoxifen in women with com-
pletely excised ductal carcinoma in situ of the breast in the UK, Australia, and New Zealand: ran-
domized controlled trial. Lancet 362, 95–102.
Chapter 12 115
Basic surgery for

breast cancer and the
management of margins
Surgical considerations 116

Management of margins 118
Breast-conserving surgery 119
Simple mastectomy 120
Sentinel lymph node biopsy 120
Axillary lymph node clearance 120
Further reading 122
116 CHAPTER 12 Basic surgery and margin management
Surgical considerations
The results of the triple assessment should be discussed with the patient
by the operating surgeon, accompanied by a breast care nurse (BCN). It is
important that all the relevant treatment options agreed by the MDT are
explained, and the patient should be given time to make a fully informed
choice about their treatment. Information leaflets should be provided
along with a contact number for the BCN.
Preoperative assessment
All patients should undergo formal preoperative assessment prior to their
definitive surgery. The aim is to identify any significant co-morbidities and
to address any concerns which the patient may have about their opera-
tion. If there is any doubt about the fitness of the patient for a particular
procedure, it should be discussed with the anaesthetist doing the case
prior to admission.
Consent for the operation should be sought by a member of the surgical
team who is capable of performing the procedure and should include all
significant and common risks associated with the procedure.
Surgical options
Each patient’s body shape is unique, and the challenge is to match sound
oncological excision with the best aesthetic outcome. In addition, the
patient’s general health and psychological make-up may modify the sur-
gical options. In general, once more than 20% of the breast has been
excised, a significant defect will be created. In practice, this means that, for
most patients, the options are:
• Wide local excision.
• Wide local excision and therapeutic mammoplasty.
• Mastectomy.
• Mastectomy and reconstruction.
Tumours <2cm in diameter, or those with a favourable tumour-to-breast
volume ratio, are suitable for wide local excision (WLE). Tumours involv-
ing the nipple may require mastectomy, although central WLE is also
acceptable, depending on patient choice. All WLE cases for invasive can-
cer require a course of post-operative radiotherapy. The possible need
for re-excision to obtain clear margins should be discussed, particularly if
non-invasive disease has been found to be mixed with invasive on biopsy.
Mastectomy is usually required for those cancers where the
tumour-to-breast volume ratio is adverse. In these cases, the options for
reconstruction need to be considered. Oncoplastic techniques and spe-
cific procedures are discussed in Chapters 18 and 19, but the oncological
principles detailed here are still applicable.
In invasive cancer, preoperative ultrasound and biopsy of axillary nodes
will have indicated whether there is axillary disease present. If no abnor-
mal lymph nodes are detected in cases of invasive cancer, a sentinel lymph
node biopsy (SLNB) is performed. Involved axillary lymph nodes mandate
SURGICAL CONSIDERATIONS 117
an axillary lymph node clearance (ANC). In DCIS which is to be managed

by WLE, there is no indication for axillary surgery. The exception to this is
when imaging is highly suggestive of a focus of invasive disease (e.g. visible
mass on ultrasound or mammography, larger area of disease, high-grade
disease); in this situation, a sentinel node biopsy at the time of WLE can
be offered. If mastectomy is required for extensive or multifocal DCIS, a
sentinel node biopsy is appropriate.
Management of margins
There are no high-quality randomized data to determine what an accept-
able post-operative margin is that does not require further tissue excision
(see Further reading). Principles in assessing margin adequacy include:
• Increasing the width of an acceptable post-operative pathological
margin around a tumour is weakly associated with lower odds of local
recurrence.
• Cavity shaves (taking radial cavity shaves at the time of cancer surgery)
can decrease the need for re-excision surgery.
• A radial margin involved with tumour should be re-excised. Any
margin around an invasive cancer may be adequate; a larger margin
may be preferable in DCIS.
• Anterior/posterior margins involved with tumour may not need
re-excision, as often these cannot be surgically improved upon.
Adjuvant radiotherapy has a role in many of these patients to decrease
the risk of local recurrence.
• Individual units must know their local recurrence rate, as this
determines if their margin management is of an adequate standard.
Local policy will dictate margin size.
BREAST-CONSERVING SURGERY 119
Breast-conserving surgery
Indications
• Patient choice.
• Small tumour-to-breast volume.
In practice, most early breast cancers, particularly screen-detected cancers
up to 2cm in size, are suitable for conservation. However, a patient with
E cup size breasts and a 4cm tumour may be suitable for conservation.
Preoperative preparation
• Impalpable tumours require image-guided localization.
• Methods include wire placement, ultrasound marking, or radioguided
occult lesion localization (ROLL).
• Palpable tumours should be marked preoperatively by the surgeon.
• If, at the time of marking, there is doubt in the surgeon’s mind about
location of the tumour, even in symptomatic cases, preoperative image
guidance is appropriate.
• It is courteous to confirm the timing of localization with the radiologist
who will also have a busy schedule.
Simple mastectomy
Indications
• Locally advanced tumours, including inflammatory cancers.
• Large tumour-to-breast volume ratio.
• Central tumours involving nipple, although this is not mandatory.
• Recurrent breast cancer.
• Multifocal or widespread DCIS.
Sentinel lymph node biopsy

Indications
• In invasive cancer when the preoperative ultrasound assessment 9
FNA has shown the axillary nodes to be apparently normal.
• When performing mastectomy for DCIS.
• Prior to immediate breast reconstruction in patients at risk of needing
adjuvant radiotherapy (see Chapter 19).
• Sentinel node biopsy does carry a minimal risk of arm morbidity,
including lymphoedema, a stiff arm, and numbness (see Further
reading).
Axillary lymph node clearance

Indications
• Involved axillary lymph nodes in the presence of invasive disease on
preoperative ultrasound and biopsy.
• Positive SLNB (this is the subject of much current debate—see Box
12.1 and Further reading).
• Loco-regional disease recurrence.
AXILLARY LYMPH NODE CLEARANCE 121
Box 12.1 Current opinion—management of a positive

sentinel node biopsy
• Options for axillary treatment following a positive sentinel node
biopsy are:
• Axillary clearance.
• Axillary radiotherapy.
• Whole breast radiotherapy (WBRT)—following breast
conservation surgery.
• This is a fast-moving area of contention; guidance, the evidence base,
and practice are rapidly changing.
• Historically, all patients received axillary clearance following the
identification of a positive sentinel node.
• Arguments in favour of axillary clearance:
• Surgery removes all involved nodes and, therefore, reduces
burden of disease.
• It reduces the risk of axillary recurrent disease.
• It generally avoids the need for axillary radiotherapy.
• Some patients may be at higher risk of axillary recurrent disease
and, therefore, show a survival advantage following ANC. We
are, as yet, unable to identify this group preoperatively.
• ANC accurately stages the axilla and can change adjuvant
treatment. Those with four, or more, involved nodes will be given
chest wall, axillary, and supraclavicular radiotherapy.
• Arguments against routine axillary clearance following identification
of a positive sentinel node:
• The majority of patients undergoing ANC will have no
further positive nodes identified. The operation is, therefore,
overtreatment for the majority.
• If no ANC is performed, local recurrence after a positive SNB is
rare.
• ANC does not confer a survival advantage following SNB in
post-menopausal women requiring whole breast irradiation (WBRT).
• Radiation to the axilla reduces the risk of local recurrence and
reduces the risk of lymphoedema compared to ANC, but it does
increase the incidence of a stiff arm.
Currently, an approach for SNB-positive women may be:
• Pre-menopausal: little available evidence. Likely to be a higher risk
group—ANC.
• Post-menopausal women:
• Following WLE: low-risk T1/T2 tumours—WBRT.
• Following WLE: high-risk tumours (T3/4, Her-2-positive)—ANC.
• Following mastectomy—ANC.
Further reading
Mansel RE, Fallowfield L, Kissin M, et al. (2006). Randomized multicenter trial of sentinel node
biopsy versus standard axillary treatment in operable breast cancer: the ALMANAC. J Natl
Cancer Inst 98, 599–609.
Giuliano AE, Hunt KK, Ballman KV, et al. (2011). Axillary dissection vs no axillary dissection in
women with invasive breast cancer and sentinel node metastasis: a randomized clinical trial.
JAMA 305, 569–75.
Setton J, Cody H, Tan L, et al. (2012). Radiation field design and regional control in sentinel lymph
node-positive breast cancer patients with omission of axillary dissection. Cancer 118, 1994–2003.
Giuliano AE, Morrow M, Duggal S, Julian TB (2012). Should ACOSOG Z0011 change practice with
respect to axillary lymph node dissection for a positive sentinel lymph node biopsy in breast
cancer? Clin Exp Metastasis 29, 687–92.
Houssami N, Macaskill P, Marinovich M, et al. (2010). Meta-analysis of the impact of surgical
margins on local recurrence in women with early –stage invasive breast cancer treated with
breast-conserving surgery. Eur J Cancer 46, 3219–32.
Morrow M, Harris J, Schnitt S (2012). Surgical margins in lumpectomy for breast cancer—bigger is
not better. N Engl J Med 367, 79–82.
Chapter 13 123
Adjuvant therapy
Benefits of adjuvant therapy 124

Indications for adjuvant chemotherapy 128
Chemotherapy regimens 130
Biological modifiers: Her-2/neu and adjuvant trastuzumab
(Herceptin®) 131
Further reading 132
124 CHAPTER 13 Adjuvant therapy
Benefits of adjuvant therapy

The use of adjuvant therapy following surgery in patients with breast can-
cer has been a significant factor in the reduction in breast cancer mortality
seen in Western countries over the last 20 years. The aim of adjuvant
therapy is to prevent or delay recurrence by treating residual micrometa-
static disease with both systemic and local treatments following surgery.
There are four modalities of adjuvant therapy commonly used:
• Radiotherapy (local treatment).
• Hormone manipulation (systemic treatment).
• Chemotherapy (systemic treatment).
• Biological modifiers (systemic treatment).
Radiotherapy
The prime role of radiotherapy (DXT) is in treating residual disease in
the breast and chest wall and sometimes the axilla. Its use after breast
conservation significantly reduces local recurrence.
The common situations in which radiotherapy is employed are:
• Following wide local excision (WLE) for invasive cancer, almost
invariably.
• Following wide local excision for some cases of DCIS.
• Following mastectomy in high-risk cases.
• Occasionally to the axilla following a positive axillary sampling or SNB.
The commonest indication is following a WLE for invasive cancer once
the margins are clear. In these circumstances, whole breast radiotherapy
is the rule, and not employing it would be difficult to justify, except in
rare circumstances. Precise protocols may vary between centres, but the
usual dose is 20Gy spread over 3 weeks. The dose is delivered to the
whole breast, often with a tumour bed boost. The IMPORT trial is cur-
rently investigating more tumour bed-targeted therapy which is why the
insertion of titanium clips at surgery is now becoming standard protocol in
some centres in order to facilitate targeting.
Radiotherapy following WLE for DCIS is more controversial and more
subject to local variations in practice. Whilst some regard it as a substitute
for inadequate surgery, other centres employ it routinely for all but very
small, areas of low-grade DCIS, using prognostic factors as a guide. It is not
suitable for widespread multifocal disease.
Use after mastectomy to the chest wall, axilla, and supraclavicular
regions is frequently recommended for:
• Large tumours (>5cm).
• Close or involved margins.
• 4+ node-positive tumours.
• Lymphovascular invasion.
The PRIME study is currently comparing the value of radiotherapy in
apparently less aggressive tumours following mastectomy with the more
established indication (see Further reading).
Axillary radiotherapy is the most controversial. It is contraindicated in
patients who have undergone axillary node clearance. However, it has been
advocated for patients who have undergone an axillary node sampling who
BENEFITS OF ADJUVANT THERAPY 125
are found to have involved nodes (see Chapter 12). With the introduction
of sentinel node biopsy, this procedure is becoming less common; however,
the AMAROS study is assessing the benefits of radiotherapy, as opposed to
salvage clearance, for patients who have involved sentinel nodes. This trial
shows equivalence in cancer outcomes between the two cohorts.
Hormonal manipulation
The use of hormonal manipulation in breast cancer dates back to the late
19th century when Beatson observed the beneficial effects of oophorec-
tomy in locally advanced breast cancer. Despite Beatson’s observation,
adjuvant endocrine therapy only became widespread with the introduc-
tion of tamoxifen in the 1980s. Clinical trials showed a clear survival ben-
efit for those patients receiving tamoxifen. It took some years for clinicians
to fully recognize that hormonal therapy was not indicated in women
whose tumours are ER-negative.
The mechanisms available for hormone manipulation now are:
• Hormone blockade at cellular level.
• Pharmacological disruption of hormone production.
• Oophorectomy.
As a therapy, it is only of benefit and its use is confined to oestrogen
receptor-positive tumours.
Hormone blockade
The classic drug associated with this was tamoxifen, which, for many years,
was the mainstay of hormonal adjuvant treatment. It had both oestrogen
agonist and antagonist properties. In bone, it behaved as an oestrogen
whereas, in the breast, its properties were antagonistic. It remains in com-
mon use for pre-menopausal women and has recently been replaced in
post-menopausal women by aromatase inhibitors.
Pharmacological disruption of hormone production
Despite its effects when first used, it was recognized that some patients
seemed resistant to blockade with tamoxifen, which led to a search for
means of blocking oestrogen production. The prime sources of oestrogen
are the ovaries in pre-menopausal women and the adrenals and periph-
eral fat in post-menopausal women. Originally, oophorectomy, adrenal-
ectomy, and hypophysectomy were used as therapeutic manoeuvres in
the treatment of recurrence. These were obviously very invasive and not
ideal as adjuvant treatment. It was recognized that two mechanisms could
be targeted pharmacologically to disrupt production. In post-menopausal
women, most oestrogen comes from peripheral aromatization of testos-
terone, which can now be blocked using a new generation of aromatase
inhibitors which block this step. Three drugs are in common use: anas-
trozole, exemestane, and letrozole. Of these, the ATAC study demon-
strated a significant improvement in disease-free interval with the use of
anastrozole compared to tamoxifen, and similar advantages were seen
in the Big 1-98 study with letrozole. Consequently, these two drugs are
used, according to local preference, as the first-line hormone manipulation
in post-menopausal ER-positive patients. Exemestane has been used as a
cross-over drug; patients who have already had 2 years of treatment with
tamoxifen are swapped over for a further 3 years of exemestane treatment.
In pre-menopausal women, oestrogen comes from the ovary so that aro-

matase inhibitors confer no benefit, as they do not block this ovarian oes-
trogen production. Tamoxifen directly blocks oestrogen receptors in the
cancer cell, therefore, blocking all oestrogen stimulation, no matter what
the site of production. Tamoxifen is the first-line drug in pre-menopausal
women. Alternatively, chemical or surgical oophorectomy can be used as
an adjuvant hormonal treatment. Goserelin is a gonadotropin-releasing
hormone (GnRH) which, when given at a continuous dose, inhibits both
oestrogen and testosterone production. It is given as a depot injection
every 3 months for 2 years and abolishes ovarian oestrogen production. Its
great advantage over surgical oophorectomy is that it is potentially revers-
ible. In practice, relatively few tumours in pre-menopausal women are
receptor-positive so that hormone manipulation in the pre-menopausal is
less common. When it is used, a frequent regimen is goserelin for 2 years
(in combination with 6 months of chemotherapy), followed by tamoxifen.
Chemotherapy
Not all patients benefit from chemotherapy in the adjuvant setting, with
the benefit depending on the individual patient’s risk. Data on these ben-
efits are available from the Early Breast Cancer Trials Collaborative Group
(EBCTCG) which reviews and updates results from relevant randomized
trials every 5 years. A total of 28,000 patients have been entered into
studies looking at adjuvant chemotherapy vs no chemotherapy, and over-
all there is a 10% survival benefit seen at 15 years for patients receiving
chemotherapy. Younger women (<50 years) have a greater reduction
in their risk of recurrence with chemotherapy than women between 50
and 70 years (30% vs 12%). Patients with both ER-positive and -negative
tumours gain a similar proportional benefit with chemotherapy; however,
the absolute gain is greater in patients with ER-poor tumours.
BENEFITS OF ADJUVANT THERAPY 127
Indications for adjuvant

chemotherapy
The decision to recommend adjuvant chemotherapy is made with the
patient by discussing the potential benefits of treatment and weighing
these against the treatment-related toxicities. Thus, accurate assess-
ment of an individual’s risk of loco-regional recurrence and mortality is
important in order to gauge the true risk/benefit ratio. Prognostic tools
have been developed to give an estimation of breast cancer mortality,
based on combinations of known prognostic factors (see Chapter 10),
such as:
• Tumour size.
• Histological grade.
• Nodal involvement.
• Oestrogen/progesterone receptor status.
• Patient age.
• Her-2/neu status (see Biological modifiers in this chapter).
• Lymphovascular invasion.
A number of groups have produced consensus guidelines identify-
ing risk groups and recommending treatment strategies. The European
International Consensus Panel Guidelines (2005) are summarized (see
Table 13.1 and Further reading):
Risk category
Low risk
Node-negative and:
• Tumour <2cm, and
• Grade 1, and
• No lymphovascular invasion, and
• Her2 gene not overexpressed,
• Age >35 years.
Intermediate risk
Node-negative and at least one of:
• Tumour >2cm, or
• Grade 2–3, or
• Presence of lymphovascular invasion, or
• Her-2 gene overexpressed, or
• Age <35 years,
• Node-positive (1–3) and Her-2 gene not overexpressed.
High risk
• Node-positive (1–3 nodes) and Her-2 overexpressed.
• Node-positive (4, or more, involved nodes).
In addition to this approach, the Nottingham Prognostic Index (NPI) can
be used to stratify patients according to risk of death. More recently,
computer-generated models, such as Adjuvant! Online and ‘Predict’,
have been used to compare the relative benefits of the various adjuvant
regimes as an aid to decision-making (see Prognostic tools in breast cancer
in Chapter 10).
INDICATIONS FOR ADJUVANT CHEMOTHERAPY 129
Table 13.1 Summary of the European guidelines for prescribing

adjuvant treatment
Risk category Endocrine responsive Endocrine non-responsive
Low ET or nil Nil
Intermediate ET or CT + ET CT
High CT + ET CT
ET, endocrine therapy; CT, chemotherapy.
Chemotherapy regimens
A large number of regimens have been used that can be divided broadly
into those containing anthracyclines and those that do not. Older regi-
mens commonly did not include anthracyclines, which have been shown to
confer a 5% survival advantage at 10 years. Treatment is commonly given
three weekly for 4–6 months. Anthracyclines are associated with both a
dose-dependent and idiosyncratic risk of cardiac impairment.
Taxane-containing regimes
Multiple studies have looked at the benefit of adding a taxane to
anthracycline-based regimes. There is significant heterogeneity between
the trials in terms of regimens used, duration of treatment, and patient
population studied. Although the addition of a taxane has not shown a sur-
vival benefit in all trials, there is evidence of benefit, particularly in patients
with node-positive disease, and taxane therapy should be considered for
this patient group (see Further reading).
Side effects of chemotherapy
Although the treatment of chemotherapy-related toxicities has improved,
both potential acute and long-term side effects need to be discussed with
the patient and form part of the decision-making process (see Following
systemic therapies in Chapter 14).
• Nausea and vomiting.
• Sore mouth—ulcers/infection.
• Fatigue.
• Hair loss.
• Menopausal symptoms and premature menopause.
• Sexual difficulties.
• Diarrhoea.
• Neutropenia.
• Bleeding.
• Nail disorders.
• Limb oedema.
• Weight loss/gain.
• Depression/anxiety.
• Cardiac impairment (especially with anthracyclines).
• Infections.
BIOLOGICAL MODIFIERS 131
Biological modifiers: Her-2/neu and

adjuvant trastuzumab (Herceptin®)
Her-2/neu (human epidermal growth factor receptor 2) is a cell surface
tyrosine kinase receptor-like molecule, which is involved in signal trans-
duction pathways regulating cell growth and differentiation. Eighteen to
20% of breast cancers overexpress this protein, and this overexpression is
also associated with a poorer prognosis. Tumours are classified as over-
expressing Her-2 if they score 3+ on immunohistochemical staining or are
positive on fluorescent in situ hybridization (FISH).
Trastuzumab is a humanized murine monoclonal antibody to the Her-2/
neu protein. A number of large US and multinational trials have looked
at the use of trastuzumab in the adjuvant setting. Patients enrolled in
these studies were either node-positive or high-risk node-negative, and
all received adjuvant chemotherapy. After a short follow-up, the results
of these studies have shown a similar significant improvement in both
disease-free and overall survival. Treatment with trastuzumab does carry
a risk of cardiac toxicity, with up to 4% risk of a significant reduction in
left ventricular function. This has been seen with a follow-up of 2–3 years,
and the long-term effects on the heart are unknown. Lapatinib is an oral
tyrosine kinase inhibitor that has not yet been approved by NICE out-
side the context of clinical trials. Lapatinib shows promise in combination
with trastuzumab and in the context of metastatic disease (see Further
reading).
Further advances
With greater understanding of the molecular processes involved in cancer,
it is proving possible to pinpoint specific molecules with pivotal functions
in cell growth and division which can be targeted pharmacologically. As
yet, many of these drugs are in early development, although some are
making their way through to early phase 1 trials. If successful, it is likely
that the next 10 years will see a major revolution in much more per-
sonalized and targeted therapy for breast cancer that might even render
surgery redundant!
Further reading
Goldhirsch A, Wood WC, Coates AS, et al. (2011). Strategies for subtypes—dealing with the
diversity of breast cancer: highlights of the St. Gallen International Expert Consensus on the
Primary Therapy of Early Breast Cancer 2011. Ann Oncol 22, 1736–47.
Goldhirsch A, Glick JH, Gelber RD, et al. (2005). Meeting highlights: international expert consensus
on the primary therapy of early breast cancer 2005. Ann Oncol 16, 1569–83.
Prescott RJ, Kunkler IH, Williams LJ, et al. (2007). A randomised controlled trial of post-operative
radiotherapy following breast-conserving surgery in a minimum-risk older population. The
PRIME trial. Health Technol Assess 11, 1–149.
Cuzick J, Sestak I, Baum M, et al. (2010). Effect of anastrozole and tamoxifen as adjuvant treatment
for early stage breast cancer: 10 year analysis of the ATAC trial. Lancet Oncol 11, 1135–41.
Coates AS, Keshaviah A, Thurlimann B, et al. (2007). Five years of letrozole compared with tamox-
ifen as initial adjuvant therapy for postmenopausal women with endocrine responsive early
breast cancer: update of study BIG 1-98. J Clin Oncol 25, 486–92.
Early Breast Cancer Trials Collaborative Group (EBCTCG) (2005). Effects of chemotherapy and
hormonal therapy for early breast cancer on recurrence and 15-year survival: an overview of the
randomized trials. Lancet 365, 1687–717.
Early Breast Cancer Trials Collaborative Group (EBCTCG) (2011). Effect of radiotherapy after
breast-conserving surgery on 10 year recurrence and 15-year breast cancer death: meta-analysis
of individual patient data for 10,801 women in 17 randomised trails. Lancet 378, 1707–16.
Early Breast Cancer Trials Collaborative Group (EBCTCG) (2012). Comparisons between different
polychemotherapy regimens for early breast cancer: meta-analysis of long-term outcome among
100,000 women in 123 randomised trials. Lancet 379, 432–44.
Blackwell KL, Burstein HJ, Storniolo AM, et al. (2010). Randomized study of lapatinib alone or in
combination with trastuzumab in women with ErbB2-positive, trastuzumab-refractory meta-
static breast cancer. J Clin Oncol 28, 1124–30.
The ALTTO trial. Available at: M http://www.alttotrials.com
Chapter 14 133
Treatment-induced
complications
Following surgery 134

Following radiotherapy 136
Following systemic therapies 138
Further reading 140
134 CHAPTER 14 Treatment-induced complications
Following surgery
Post-operative complications can be split into those specific to the opera-
tion concerned and the general complications of surgery. Only the former
will be covered in any detail here.
Risk factors for complications
• Smoking.
• Obesity.
• Diabetes.
• Prior breast or chest wall radiotherapy.
• Connective tissue disorders.
Immediate complications
Haemorrhage/excessive blood in drains. Assess need for circulatory
support, and have blood available if bleeding copiously. Ensure good
intravenous (IV) access, and arrange urgent return to theatre to stop the
bleeding. Blood does not need to be cross-matched prior to a mastectomy.
Early complications (within 24 hours)
• Haematoma: bruising or discoloration of the skin over a tense
swollen wound. A result of reactionary haemorrhage. Small bleeding
vessels thrombose, as the pressure from the haematoma rises, but,
if left untreated, a haematoma will be a source of discomfort and
potential infection and will impede wound healing. Once the patient
is adequately resuscitated, FBC, clotting, and G&S should be obtained,
and the patient should return to theatre for evacuation of haematoma
and to try and identify the bleeding point. In general, it is better to
evacuate a haematoma than to hope it will ‘resolve’ with time.
Of note: excessive bleeding is often associated with minimal blood in

the drains (as the drains clot off). If you even think about the need for
evacuation, DO IT! Ensure this strategy is clearly handed over to any
subsequent shifts.
• Necrosis/breakdown of wound edges: a small area of simple wound

breakdown can be cleaned up and occasionally re-sutured if the edges
are healthy.
Following reconstructive or plastic surgery
• The viability of skin flaps, the nipple, and the transposed flaps can
all be threatened by undue pressure on the flap, venous congestion,
hypotension, or arterial insufficiency. These complications are the
highest risk of modern oncoplastic surgery; as such, wards and units
carrying out this type of surgery need good training in recognizing
potential problems. There need to be well-established protocols for
the post-operative care of patients. When complications do occur, it
is important to enlist the help of other specialists, such as wound care
nurses and plastic surgeons.
FOLLOWING SURGERY 135
• Accurate handover of the status of free flaps should occur at the end
of each shift. This ensures awareness of the patients requiring careful
observation overnight and continuity of care.
• Myocutaneous flap failure: a cold flap (white with arterial insufficiency/
purple with venous congestion) with poor capillary return is a cause
for alarm. Consider urgent return to theatre to avoid flap loss. Free
flaps are less robust than pedicled (LD or TRAM) flaps.
• Skin flap necrosis: this occurs with a thin or devascularized mastectomy
flap, more commonly on the side of an axillary clearance where the
lateral blood supply to the breast has been interrupted. Exclude
haematoma; optimize perfusion, and excise frankly necrotic skin before
secondary repair or inserting a skin graft or flap to close any defect.
• Nipple congestion/discoloration: may need some sutures removed or
leeches applied to decrease tension. Discuss with a senior first.
• Sloughing of abdominal wounds or umbilical necrosis after TRAM/
DIEP, secondary to extensive tissue undermining and tension on
wound closure. Associated sepsis needs antibiotic treatment.
Late/long-term complications
• Wound/breast infection: any collection should be aspirated/drained
and appropriate antibiotics commenced. If an implant is in situ, it may
ultimately need to be removed to eradicate the infection.
• Seroma: a collection of lymphatic/tissue fluid arising in the breast or
axilla following removal of the drains. Almost universal after axillary
surgery. Does not need draining unless tense and uncomfortable, as
aspiration carries a small risk of introducing infection.
• Anaesthesia of the armpit and/or paraesthesia of the inner aspect
of the arm after axillary dissection. Due to damage to the second
intercostobrachial nerve. Common (up to 80% of women) and not
alarming. It may improve gradually for up to 2 years.
• Stiff or frozen shoulder after axillary surgery. This may be prevented
by early exercise and physiotherapy.
• Arm lymphoedema occurs in 5–50% of women following axillary surgery
as a result of disruption to the afferent lymphatics and the venous
drainage of the limb. Active management of this, including referral to
specialist lymphoedema services, is important to minimize long-term
morbidity. Treatment includes manual lymphatic drainage, massage, arm
elevation, and compression garments. It is often noticed following minor
trauma to the arm. Therefore, women are advised to avoid having blood
taken, injections, or even blood pressure monitored on the operated
arm. Patients should protect their affected arm by wearing gloves while
doing gardening or activities likely to break the skin.
• Breast lymphoedema is less common but often seen in the medial
quadrant of the breast following radiotherapy, infection, haematoma,
or large seroma.
• Poor cosmetic result.
Following reconstructive or plastic surgery
• Donor site morbidity after flap surgery. This is often forgotten about;
however, tethering following latissimus dorsi and dog ears after TRAM
flaps are not uncommon and may need secondary surgery to improve
the situation.
Following radiotherapy
With modern machinery, increased fractionation, better planning of radio-
therapy, and the use of tangential fields, the incidence of post-radiotherapy
complications is decreasing. Some of the rarer complications only pre-
sent long after the treatment has ended, but the benefits of radiotherapy
(decreased local recurrence and a smaller increase in survival) are gener-
ally felt to outweigh the risks.
Systemic effects
• Loss of appetite and nausea are uncommon. Fatigue may occur (usually
with prior chemotherapy).
Local effects
Short-term
• Skin: reduced basal cell turnover with ongoing epidermal shedding
gives rise to epidermal thinning and occasionally progresses to moist
desquamation. Erythema occurs when blood vessels become leaky,
and some people develop pruritus. These effects settle within 2
weeks (skin turnover time), but hyperpigmentation (from melanocyte
stimulation) can last for several months. Good skin care may help.
• Breast: aches and pains within the breast (often mild) can begin with
treatment but continue afterwards.
• Shoulder: temporary shoulder restriction is common, possibly due
to inflammation or atrophy of the pectoral and rotator cuff muscles.
Physiotherapy helps to minimize this effect.
• Oesophagus: occasional oesophagitis with treatment to the central
area of the chest.
Long-term
• Skin: damage to endothelial cells and connective tissue gives rise
to telangiectasia, and tissues heal poorly with subsequent surgery.
Cutaneous radionecrosis is now rare.
• Breast: fibrosis produces a smaller, harder breast that does not alter
with time like the contralateral breast. This can give a deteriorating
cosmetic result. Irradiation of a reconstructed breast may significantly
affect its long-term appearance.
• Arm lymphoedema: occurs following fibrosis and damage to
lymphatics and veins. Management of the axilla with radiotherapy alone
has a similar risk of arm lymphoedema to that of a standard axillary
dissection (5%). Adding radiotherapy to a fully dissected axilla should
be avoided, unless there is a high risk of axillary recurrence (e.g. with
extensive extracapsular tumour deposition), as the risk of subsequent
arm lymphoedema is up to 40%.
• Breast lymphoedema: generally on the medial aspect of the breast and
is less common.
• Chest wall: rib pain and occasional rib fracture (<2%) may occur.
Osteoradionecrosis is now rare but can arise in patients treated many
years ago.
FOLLOWING RADIOTHERAPY 137
• Lung: radiation pneumonitis, presenting with a dry cough or shortness

of breath is rare (0.5%) with breast or chest wall radiotherapy alone
but increases if the axilla or supraclavicular fossa (SCF) are also
irradiated. It often settles spontaneously.
• Heart: with the use of modern tangential fields, only a small part of the
left anterior descending coronary artery is included in the radiotherapy
field for left-sided breast cancers, so the risks of cardiac damage
are low.
• Brachial plexus: damage to the brachial plexus, causing tingling,
numbness, pain, weakness or even paralysis, is uncommon and usually
occurs as a result of overlapping fields and high treatment doses.
• Sarcomas: radiation-induced bone or soft tissue sarcomas are rare.
Following systemic therapies

Hormonal manipulation
There are some side effects common to all treatments (although not all
women experience all of these effects) and some which are treatment-specific.
Adverse effects common to all treatments
• Hot flushes and sweats.
• Fatigue and mood disturbance.
• Fluid retention, weight gain, and bloating.
• Vaginal discharge, itching, or dryness.
• Irregular periods or amenorrhoea in pre-menopausal women.
• Flare reaction and possible hypercalcaemia with bony metastases.
• Headache, arthralgia, rash, and/or nausea are less common.
Associated with tamoxifen
• Increased risk of endometrial cancer (absolute risk of 0.2%, i.e. a
doubling of baseline risk with 5 years of treatment).
• Increased risk of thromboembolic events, deep vein thrombosis
(DVT), pulmonary embolism (PE), and cerebrovascular accidents
(CVA) (2%).
• Visual disturbance due to cataracts, corneal changes, and rare cases of
retinopathy (<1%).
• Thrombocytopenia, leucopenia, liver enzyme changes.
• Contraindicated if pregnant or breastfeeding.
Associated with aromatase inhibitors (AIs)
Although the AIs have a similar adverse effect profile to tamoxifen as out-
lined, the recent ATAC trial has shown a statistically significant reduction
in vaginal discharge, vaginal bleeding, ischaemic cerebrovascular events,
and thromboembolic events in patients taking the non-steroidal aro-
matase inhibitor anastrozole, as opposed to tamoxifen, whilst, conversely,
these women appear to be statistically more likely to develop fractures or
musculoskeletal disorders (see Further reading for adverse events associ-
ated with taximofen and anastrozole.). The size of any long-term clinical
difference is awaited.
• All the AIs can cause some gastrointestinal (GI) symptoms (diarrhoea
or constipation).
• Anastrozole can lead to increased total cholesterol levels.
• All patients starting an AI need a baseline DEXA scan to assess bone
density and the need for adjuvant bone health therapy (see Further
Reading).
Associated with oophorectomy (surgical or medical with goserelin)
• Infertility (may be temporary with goserelin).
• Loss of bone mineral density.
Chemotherapy
Neutropenic sepsis is a real and significant danger to patients on chemo-
therapy. Therefore, it is important they and their GP are aware of the
potential symptoms and how to access prompt medical assessment.
FOLLOWING SYSTEMIC THERAPIES 139
Short-term toxicities
Depends on the dose and drug combination used.
• Fatigue and lethargy (80%).
• Nausea and vomiting, eased by anti-emetics.
• Alopecia, reduced risk with use of ‘cold cap’.
• Diarrhoea.
• Weight gain (50%) often aggravated by steroids.
• Myelosuppression.
• Infection.
• Mucositis.
• Neuropathy, especially with taxanes.
• Cardiac arrhythmias, cardiac failure with anthracyclines.
• Thromboembolism.
• Allergic reactions with taxanes.
Long-term toxicities
These are less common.
• Premature ovarian failure: the risk increases with age (>60% over age
40), with menopausal symptoms, accelerated loss of bone mineral
density, and infertility in up to 40%.
• Myelodysplasia/leukaemia: rare (1%).
• Cardiomyopathy: with high doses of anthracyclines or anthracyclines in
combination with trastuzumab.
Signal transduction inhibitors (trastuzumab/Herceptin®)
Transient adverse effects/most common with first treatment
• Flu-like symptoms, fever, chills (40% at first treatment).
• Nausea.
• Diarrhoea.
• Less frequently headache, dizziness, rash, vomiting, or breathlessness.
Serious adverse effects
• Ventricular dysfunction, congestive cardiac failure (5%). Especially
when used in combination with anthracyclines or cyclophosphamide.
Left ventricular function (LVF) should be evaluated with echo/MUGA
prior to and during treatment, and discontinue with any significant
drop in LVF.
• Hypersensitivity reactions, including anaphylaxis, infusion reactions, and
pulmonary events (especially in metastatic lung disease). Stop drug if
significant dyspnoea or hypotension occurs.
Further reading
NICE Guidelines. Available at: M http://www.nice.org.uk/nicemedia/pdf/CG80NICEGuideline.pdf.
NMBRA. Available at: M http://webarchive.nationalarchives.gov.uk/20120802111034/http://
www.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/audit-reports/
mastectomy-and-breast-reconstruction
For adverse events associated with taximofen and anastrozole, see: Budzar AU (2004). Data from
the arimidex, tamoxifen, alone or in combination (ATAC) trial: implications for use of aromatase
inhibitors in 2003. Clin Cancer Res 10, 355S–61S.
Chapter 15 141
Ward management
Enhanced recovery 142

Preoperative assessment 144
Preoperative preparations for theatre 146
Post-operative care 148
Physiotherapy 150
Cancer pain and its management 151
Further reading 152
142 CHAPTER 15 Ward management
Enhanced recovery
The Enhanced Recovery Programme (ERP) is a joint Department of
Health and NHS Improvement Programme initiative, which aims to
improve patient outcomes after surgery by facilitating recovery. The ERP
was initially introduced for colorectal surgery and has since been adopted
by other surgical specialties, including breast surgery.
The main elements of the ERP are:
• Preoperative preparation.
• Reduced operative stress.
• Structured pain relief.
• Early mobilization.
The target is to reduce length of stay and maximize the use of resources
available.
The implementation of an ERP requires good staff communication,
as this is a multidisciplinary process involving GPs, pre-assessment clinic
nurses, ward staff, theatre staff, anaesthetists, surgeons, dietitians, and
physiotherapists. A key period is the preoperative phase, ensuring that
patient health is maximized prior to surgery (e.g. stopping smoking, reduc-
ing alcohol intake) and that adequate information is given about the opera-
tion and recovery period, allowing patients to understand the concept of
enhanced recovery.
Pain management is also an important area, which requires optimi-
zation following breast surgery, as it delays mobilization and discharge
(see Post-operative care). The UK National Mastectomy and Breast
Reconstruction Audit demonstrated that, following mastectomy, 6.2% of
patients reported severe post-operative pain and that this increased fol-
lowing breast reconstruction. The use of an analgesic ladder, avoidance of
opiate-based analgesia, and specific regional anaesthetic techniques, such
as paravertebral blocks, should improve patient outcomes. Avoiding the
use of drains may also decrease pain and post-operative complications.
Early discharge
It is recommended that >80% of patients undergoing breast surgery should
be discharged within 24 hours of their procedure. Increased utilization of
day case procedures is generally preferred by patients and is associated
with a Best Practice Tariff.
NHS Improvement, in association with the Association of Breast
Surgery and British Association of Day Surgery, have produced a day case/
one night breast surgical pathway to facilitate this (see Further reading).
The pathway emphasizes the role of the GP in optimizing preoperative
health, the importance of comprehensive patient information both dur-
ing clinic appointments and at pre-assessment, admission on the day of
surgery with minimal starvation times, the use of appropriate anaesthesia
and analgesia, and the importance of post-operative information and care
following discharge.
Discharge planning should be undertaken at the pre-assessment visit to
ensure that there are no delays due to predictable social issues.
ENHANCED RECOVERY 143
Preoperative assessment
The aim is to:
• Quantify the severity of the primary disease and any co-morbidity.
• Decide on suitability for day surgical procedures.
• Optimize the patient prior to surgery.
• Obtain informed consent.
• Mark the patient for surgery.
In general, the presence of breast cancer or any other breast pathology
does not itself adversely affect the patient’s suitability for surgery, although
there are certain exceptions:
• Patients who have recently undergone chemotherapy (within 4 weeks)
may be neutropenic and at increased risk of post-operative infection.
An FBC is essential prior to surgery.
• Prior breast or chest wall radiotherapy increases the chance of
post-operative difficulties with wound healing.
• Metastatic breast cancer can cause hypercalcaemia or lung deposits,
which may make general anaesthesia risky. Serum calcium level and a
CXR should be checked if such metastatic disease is suspected.
Other coexisting medical conditions should be dealt with in the standard
fashion. Only age, diabetes, and drugs will be considered further.
Age
Although age itself is not an independent risk factor, it is often accompa-
nied by other health problems, with an increased peri-operative morbidity.
Thus, many units have a policy of leaving the axilla untouched in a patient
with breast cancer over the age of 80 with no clinical evidence of axillary
disease.
Diabetes
Breast surgery is classed as ‘minor’ surgery for diabetics in that they can
eat within 6 hours of the procedure.
• All patients should have BMs monitored at least four times on the day
of surgery and hourly if on a sliding scale.
• Assuming adequate control (BMs 4–14), two measurements on the
first day post-operatively are usually sufficient.
• Diabetics should be first on the operating list where possible.
• Patients on diet treatment (or metformin) only should fast as
required for surgery and avoid 5% glucose as fluid replacement
intra-operatively.
• Patients on other oral hypoglycaemic drugs should omit these tablets
on the morning of surgery. After recovery, they can have a light meal
and their normal oral hypoglycaemics.
• Insulin-dependent diabetics: omit morning insulin. Start insulin sliding
scale at least 2 hours prior to theatre. Restart normal insulin regimen
once eating and drinking.
PREOPERATIVE ASSESSMENT 145
Drugs
Tamoxifen is usually withheld prior to surgery to decrease the risk of
venous thromboembolism. Warfarin, clopidogrel, and aspirin should be
stopped prior to surgery. In high-risk patients (e.g. metallic heart valves
or recent coronary stenting), anticoagulation should be discussed with the
cardiology team and a treatment plan documented prior to surgery. Most
hospitals have an anticoagulant pathway for patients on long-term anti-
coagulation, whereby the anticoagulation team formulates a plan for the
patient covering the whole peri-operative period.
Preoperative investigations
• In benign disease in a young patient with no significant medical history,
‘routine’ tests are not needed. Unfortunately, these patients are rare.
• Afro-Caribbeans should be tested for sickle cell trait.
• Mediterraneans need to have thalassaemia excluded.
• FBC prior to all breast cancer procedures and G&S prior to
mastectomy/axillary clearance and all reconstructive procedures.
• Clotting studies in those on anticoagulants or with known liver
impairment.
• U&E on diabetics, patients with renal impairment, or those on drugs
causing electrolyte disturbance (e.g. diuretics, digoxin, steroids).
• CXR in those with a history suggestive of symptomatic
cardiorespiratory disease or possible lung metastases. Not required in
women <60 years with early-stage breast cancer.
• ECG in patients >50 years, diabetics >40 years, or patients with any
cardiac history.
Preoperative preparations for theatre

Thromboprophylaxis
There is an increased risk of DVT and PE in women with malignancy, espe-
cially those having long reconstructive operations. The risk is increased
in women on tamoxifen or those who have recently had chemotherapy.
Thus, all women with no contraindications should receive TED stockings,
with or without a low molecular weight heparin. Pneumatic compression
devices are routinely used in theatres, and the patients are encouraged to
be up and mobile as soon as possible after surgery.
Consent
The surgeon performing the operation, or an assistant who is familiar
with the procedure, should take consent. This issue has been extensively
covered elsewhere, so suffice it to say that decisions about the exact
nature of the breast, axillary, and reconstructive surgery to be undertaken
are often complex and should have been thoroughly discussed with the
patient prior to admission.
Marking the patient
This should be done by the surgeon on the ward.
• The side of the surgery (and indicate what operation is to be
performed).
• The site of incisions (drawn with patient standing in order to get scars
in a skin crease or inframammary crease).
• The borders of the breast (to prevent removal of excess tissue and
facilitate re-shaping).
• Skin excisions and flaps.
• Midline and contralateral breast (to allow symmetrization).
Antibiotic prophylaxis
The majority of patients undergoing breast surgery will benefit from
peri-operative prophylactic antibiotics. Local antibiotic policy based upon
local microbiological preferences and sensitivities should be adhered to.
Prophylaxis should be given against MRSA for those previously exposed
or currently colonized. Prolonged prophylaxis should be considered in
patients undergoing implant surgery.
Always go and see the patient yourself before the patient has been
anaesthetized. You should check the following:
• Is the lesion palpable with the patient lying as they would be on the
operating table? If not, should it be localized?
• Has the lesion grown? If yes, is the planned surgery, i.e.
breast-conserving, still possible?
• Does the patient understand what procedure they are about to
undergo?
• Does the patient agree with the site of the lesion?
PREOPERATIVE PREPARATIONS FOR THEATRE 147
• Consent and mark the patient. In some instances, this is best done
with the patient supine, in others (e.g. mastopexy) with the patient
sitting.
• Check that FNA, core biopsy, and routine blood results are in the
notes. Ensure mammograms are available. Blood has been grouped or
cross-matched, if necessary.
• Antibiotics, TED stockings, and heparin prophylaxis should be
prescribed as required by local policy.
Post-operative care
General measures
• Patients can generally eat, drink, and mobilize soon after surgery.
• Wounds can be washed in the shower from the first post-operative
day but should be dried gently and not left covered in damp dressings;
a hairdryer may be helpful.
• Pressure dressings should be removed in order to inspect the wound
on the first post-operative day. After this, clean, dry wounds can be
left open or a simple Mepore® dressing applied.
• A soft bra can be worn when comfortable.
• Drains are generally left in situ until draining less than 30–50mL
of serosanguinous fluid/day or at day 5 (whichever comes first).
However, many units are happy for patients to go home with their
drains, and the community nurses will monitor the drainage and
remove when ready.
• Physiotherapy should be initiated prior to discharge to encourage a
range of exercises to keep the arm and shoulder moving.
• Advice on arm and skin care after axillary surgery.
• Ensure patients have contact numbers for breast care nurse in case of
physical/emotional problems.
• Post-operative haemoglobin may be necessary, following
mastectomies, reconstructions, or major cosmetic procedures.
• Check wound for haematoma, flaps/nipples for evidence of necrosis.
• The breast care nurse should see the patient regarding the fitting of a
prosthesis.
• Arrange first post-operative follow-up.
Pain management
Pain control after breast surgery was assessed in the National Mastectomy
and Breast Reconstruction Audit (see Further reading). Significant levels of
post-operative pain were experienced, and conclusions of the audit were
that units should be auditing pain control and improving peri-operative
analgesia. Methods of pain control peri-operatively include:
Analgesia
• Paracetamol.
• Non-steroidal anti-inflammatory drugs.
• Oral opiates, e.g. codeine (these should always be given in conjunction
with aperients and anti-emetics).
• IV opiates, such as pethidine (short-acting) and morphine (long-acting),
with an anti-emetic.
Local anaesthetic
• Peri-operative injection to wound surfaces, including all raw surfaces.
• Peri-operative infiltration down a drain.
• Wound infiltration catheters.
• Blockade: paravertebral, intercostal, and interpleural blocks are used
for breast surgery.
POST-OPERATIVE CARE 149
Flap management
Patients having complex reconstructive procedures need careful observa-
tion of the flap for the first few hours/days.
• Ensure good oxygenation.
• Good analgesia to avoid hypertension.
• Keep the patient warm, gamgee on the flap, a warming blanket on the
patient.
• Obtain IV access, and keep well perfused with good urine output
(50mL/h)—catheters are useful following flap surgery.
• Avoid smoking.
• Abdominal wall flaps (TRAM/DIEP) require a period of bed rest, with
hip and knee flexion before mobilization.
Physiotherapy
Begins on day 1 post-operatively, with a respiratory assessment and the
teaching of breathing exercises to minimize the effects of anaesthesia and
shoulder exercises to restore movement and function to the arm as soon
as possible. After a full axillary clearance, physiotherapy can also reduce
the risk of lymphoedema. The exercises are repeated two to three times
daily for at least 6 weeks or until a full range of movement is regained.
(Additional physiotherapy during radiotherapy may minimize shoulder
stiffness). They include:
• Shoulder circling.
• Hair brushing.
• Back scratching.
• Arm bending.
• Arm lifts.
• Wall climbing.
• Back drying.
CANCER PAIN AND ITS MANAGEMENT 151
Cancer pain and its management

In general, breast cancer is not painful, unless it invades a nerve or due to
bulk compressing and pressure effects.
• Oral analgesics are the mainstay of pain relief in patients with cancer.
Strong opioids are safe and effective for moderate to severe pain.
• Analgesia should be taken regularly at prescribed times, rather than on
an as-needed (PRN) basis. PRN analgesics for chronic pain should be
reserved for breakthrough pain only.
• Radiotherapy plays a major role in the management of acute
cancer pain.
• The regular use of laxatives should be considered in conjunction
with the administration of analgesics, preferably before constipation
develops.
• Bisphosphonates have a role in the treatment and prevention of bone
pain in breast cancer.
• Non-steroidal anti-inflammatory drugs have a role in the treatment of
inflammatory or bone pain.
• Epidural, intrathecal, and intracerebroventricular opioids are often
effective in treating acute pain that is not controlled with conventional
treatment.
Further reading
NHS Institute for Innovation and Improvement: Quality and Service Improvement Tool. Available at:
M http://www.institute.nhs.uk/quality_and_service_improvement_tools/quality_and_service_
improvement_tools/enhanced_recovery_programme.html
NHS Enhanced Recovery Partnership. Available at: M http://www.improvement.nhs.uk/enhance-
drecovery2/Breast.aspx.
National Mastectomy and Breast Reconstruction Audit 2010. Available at: M http://
Arsalani-Zadeh R, ElFadl D, Yassin N, MacFie J (2011). Evidence-based review of enhancing postop-
erative recovery after breast surgery. Br J Surg 98, 181–96.
Breast Cancer Care. Available at: M http://www.breastcancercare.org.uk
NMBRA. Available at: M http://webarchive.nationalarchives.gov.uk/20120802111034/http://
NHS Improvement in association with the Association of Breast Surgery and British Association of
Day Surgery, a day case/one night breast surgical pathway (Dec 2011). Available at: M http://
www.improvement.nhs.uk/documents/DayCaseBreastSurgery.pdf
Chapter 16 153
Breast reduction
Breast reduction 154

Marking of a patient for Wise pattern breast reduction 158
Post-operative care 160
Further reading 161
154 CHAPTER 16 Breast reduction
Breast reduction
Basic principles
Breast reduction surgery is cosmetic surgery performed to decrease the
size of a breast. The majority of cases are performed bilaterally to reduce
the size of the breasts when their size causes significant symptoms for
the patient. Breast reduction surgery involves moving breast parenchyma
and nipples on pedicles carrying their blood supply. The principles of this
surgery will prepare a breast trainee for volume displacement techniques
in breast conservation and therapeutic mammaplasty (see Chapter 18).
Breast reduction is the basis of much of oncoplastic breast surgery. Breast
reduction surgery improves quality of life to a similar extent to that
observed in hip replacement surgery (see Further reading).
Common reasons for seeking breast reduction surgery include:
• Associated back/neck/shoulder pain caused by the breast weight.
• Unwanted attention due to the size of the cleavage.
• Difficulty with hygiene due to breast size/ptosis.
• Psychological impact of having large breasts.
• To aid symmetry following previous contralateral mastectomy/breast
reconstruction surgery.
• Massive breast hypertrophy during pregnancy.
The aims of breast reduction surgery include four core principles (see
Further reading):
• Excision of excess parenchyma: excess parenchyma must be removed
whilst leaving adequate breast tissue to maintain a suitable final breast
size for the patient’s body shape and to maintain bulk in the medial
cleavage region.
• Skin envelope reduction: when reducing breast bulk, it is usually
necessary to remove skin excess to reduce breast ptosis and to help
maintain breast shape long-term.
• Breast shaping: the final result must give good long-term breast shape,
with nipples placed at an appropriate height upon a well-projected
breast mound.
• Nipple complex blood and nerve supply: the nipple vascularity and
sensation are preserved by fashioning a pedicle of breast tissue large
enough to support nipple viability.
From the patient’s point of view, breast reduction surgery carries the
advantages of:
• Reduced breast bulk.
• Improved breast ptosis and shape.
Against this has to be weighed the disadvantages of:
• Scarring to the breast.
• Changes caused to breast appearance on mammography.
• Future ability to breastfeed may be prevented.
• Reduced nipple sensation/erotic sensation.
BREAST REDUCTION 155
All breast reconstruction surgery is potentially prone to complications,

but particular caution has to be exercised in the face of:
• Previous radiotherapy.
• Smokers/vascular disease/diabetics.
• Previous breast augmentation/breast reduction.
Preoperative discussion and assessment
Before accepting a patient for breast reduction, it is important to get a
clear picture of the patient’s motivations behind seeking surgery and their
expectations of the final result. Breast reduction surgery carries significant
risk of complications, which the patient must be made fully aware of. It
should not be seen as a simple cosmetic procedure. The most serious
potential complication is nipple and fat necrosis, which can result in com-
plete loss of the central breast tissue and significant breast deformity.
Therefore, the preoperative assessment of the patient needs to include
both the previous medical and social history. In particular, disorders associated
with problems in tissue perfusion and increased risk of infection, together with
smoking, heavy alcohol, or other social drug use, are relative contraindications
to surgery because of the potential disturbance to vascularity.
Physical assessment of the patient needs to include measurements of
the suprasternal to nipple distance and the nipple to inframammary fold
since it is these measurements that will be used in preoperative marking.
The breast needs assessing for any evidence of pathology and, in ladies
over 40, a mammogram should be obtained. Preoperative photographs
must be obtained.
Complications and consent issues
Patients must be made aware of the risks and complications, both at the
preoperative discussion and at the time consent is obtained. It is often
helpful to reiterate these in correspondence with the GP and the patient.
Reduction surgery is a happy hunting ground for medical negligence law-
yers and their expert witness henchmen, and they will seize on any slight
chink in the informed consent process to ensure a successful payout.
The important points to emphasize and include in the consent process are:
• The surgeon is unable to guarantee a cup size of the breast that will be
achieved post-operatively.
• Visible scars on the breast, which can become hypertrophic/keloid.
• Infection.
• Bleeding and possible return to theatre.
• Wound dehiscence (most commonly at the junction of the ‘T’).
• Fat necrosis (development of lumps requiring triple assessment or, if
the fat necrosis is superficial, it presents with oily discharge).
• Asymmetry.
• Numbness or occasionally hyperaesthesia of the nipple-areola
complex.
• Chronic pain.
• Partial, or total, loss of the nipple complex because of necrosis.
• Incomplete relief of symptoms, such as back pain.

• Breast reduction causes mammographic changes to the breast, which
may require further assessment following breast screening.
• Interference with ability to breastfeed in the future.
• Relapse with the breast increasing in size again, particularly with
weight gain.
Photographs should be taken before and after surgery, and any preopera-
tive asymmetry should be pointed out to the patient.
Patients should be shown photographs, with a range of outcomes expe-
rienced following breast reduction surgery.
Operative techniques
Patients must be aware of all the options available, including having no
surgery or attempting weight loss to reduce breast bulk.
The techniques available should be discussed with the patient, includ-
ing Wise pattern (inverted T), vertical pattern, peri-areolar scarring, and
breast liposuction.
Several techniques exist, of which the commonest in use is probably
the Wise pattern approach. It is important to match the most appropriate
procedure to the patient, not the patient to the procedure that you are
familiar with.
• Wise pattern: the most commonly used skin pattern with predictable
results and immediately good breast shape in most patients. The Wise
pattern deals well with skin excess and ptosis. It can be used with any
pedicle.
• Vertical pattern: this results in a peri-areolar scar with a lower vertical
extension. Vertical scar reductions eliminate the horizontal scar of the
inverted T techniques. Approximately 10–20% of patients will require
scar revision to eliminate a dog ear at the inferior end of the scar.
Revision often requires a short horizontal scar. These are best used for
smaller reductions on young women with good quality skin. Long-term
results are excellent, but the optimal shape is not achieved for
approximately 3 months. Lejour, Hall–Findlay, and Lassus techniques
are variations of the vertical reduction, which utilize superior or
superomedial pedicles.
• Peri-areolar: the round block reduction (Benelli) limits scars to a
peri-areolar scar. It can be used selectively for young patients and
is best performed in those requiring small reductions. A superior
pedicle is most commonly used, and a non-absorbable suture is used
subcutaneously to try to stop the areola from enlarging over time.
Initially, the peri-areolar skin will be ruffled, but this usually settles
over the following months. Patients must be aware that a proportion
of patients will need revisional surgery with conversion to a vertical/
Wise pattern technique.
BREAST REDUCTION 157
• Breast liposuction: removes bulk from the breast but does not address
ptosis or skin redundancy. It is of limited use in older women who
have predominantly fatty breasts. Liposuction has the advantage
of removing mass without significant scars. The most common
complication of breast liposuction is haematoma formation (1–3%).
• Free nipple graft: it is useful for patients with enormous breasts that
would end up with a pedicle that is too long. It is a good technique in
older women who may have a diminished microvasculature. It is easy
to perform and gives additional flexibility in shaping the breast because
the pedicle does not need preserving as in most other techniques.
The major drawback is that the nipple appearance may be poor and is
without sensation.
Marking of a patient for Wise pattern

breast reduction
There are many different ways to mark patients for breast reduction. The
Wise pattern is easily followed, can be replicated, and gives consistently
good aesthetic results (see Fig. 16.1). It is vital that the surgeon performing
the operation marks the patient. The patient must be standing or sitting
on the side of the bed; trying to mark the patient on their back or asleep
in theatre will result in complete disaster. The indefensible complication is
if the final position of the nipple is too high and coming out of the bra, so
it is recommended to follow these steps:
1 L>R 4 L>R
2 D D
6x x
a) 1 cm
b) 5
3 A
c) d)
L R L>R
D D
7 x x
B x B’ 9
x C’ C
x 8 10+11 x
Fig. 16.1 Marking of a Wise pattern breast reduction. a) 1. Any preoperative

breast asymmetry is marked on the patient. 2. Desired final cup size (not guaranteed,
just a guide) is marked. 3. Midline is marked, including suprasternal notch. b) 4. With
a tape measure around the neck, the breast meridian is drawn. 5. Level of the
inframammary fold (IMF) is marked on the midline. 6. One cm above the IMF, the
new nipple site is marked on the line of the breast meridian. c) 7. Outline of new
areola is marked. 8. Lift the breast, and push laterally; mark a plumb line between
the medial edge of the marked areola (B) and the midpoint of the inframammary
fold (A). d) 9. Lift the breast, and push medially; mark a plumb line between the
lateral edge of the marked areola (C) and the midpoint of the inframammary fold
(A). 10, 11. Place a thumb midway between points A + B (and A + C); fold the
breast until these two points are touching. Where the crease of skin folding meets
the inframammary fold is the medial and lateral (respectively) extents of the Wise
pattern incisions. Mark the inframammary fold, and join B to B’ and C to C’.
MARKING OF A PATIENT FOR WISE PATTERN BREAST REDUCTION 159
1. With the patient standing, assess the patient’s breast size. If one breast
is larger and needs more reduction, write this on the patient’s sternum.
2. Write the patient’s aim for final cup size over sternum.
3. Mark suprasternal notch and midline along sternum and down to
umbilicus.
4. Put a tape measure around the patient’s neck, so it falls over the
current nipple site. Draw breast meridian along the tape measure
through the current nipple and down the breast to cross the
inframammary fold.
5. Place a finger in the inframammary fold, and translate this level
across to the midline and make a mark on the midline. Put fingers in
the inframammary fold and thumb on the anterior surface of breast
(Pitanguy’s point), and mark this point on the midline. This should
correspond with your first mark.
6. The centre of the new nipple site should be 1–3cm above this height.
One cm above this mark, draw the new nipple height on the breast
meridian bilaterally. Measure from the suprasternal notch to the new
nipple height. This distance should NEVER be less than 21cm and
only less than 23cm in a very small-framed woman. Ensure bilateral
measurements are the same.
7. Draw the new areola margin around the new nipple site. If your nipple
marker is 4cm in diameter, this areola margin needs to be 2 x π x
radius = 12.5cm in length. Check the length of this ellipse with a tape
measure. Alternatively, use a template to draw this elliptical shape.
8. Place a thumb just medial to the nipple, and move the breast gently
upwards and laterally so that the redundant skin is taken up and
the ptosis is removed. Draw a line vertically down from the medial
areolar edge towards the intercept of the breast meridian with the
inframammary fold (point A). Put a mark 5.5cm down this line (point B).
9. Place a thumb just lateral to the nipple, and move the breast gently
upwards and medially so that the redundant skin is taken up and
the ptosis is removed. Draw a line vertically down from the lateral
areolar edge towards the intercept of the breast meridian with the
inframammary fold (point A). Put a mark at 5.5cm down this line
(point C).
10. Place a thumb halfway between point B and the inframammary
fold. Using your fingers, fold the breast over so that point B comes
and rests over point A. There will now be a crease in the skin that
extends to the medial aspect of the inframammary fold. Mark this
most medial point of the skin incision (B’). Let go of the breast, and
draw a straight line from point B to B’.
11. Place a thumb halfway between point C and point A. Using your
fingers, fold the breast over so that point C comes and rests over
point A. There will now be a crease in the skin that extends to the
lateral aspect of the inframammary fold. Mark this point (C’). Let
go of the breast, and draw a straight line from point C to C’. Mark
the inframammary fold from point B’ to C’. Points B’ and C’ should
not meet in the middle and should be at least 3cm apart to avoid
synmastia.
12. Stand back, and ensure markings are symmetrical.
Post-operative care
Patients will usually have a drain placed post-reduction surgery. This drain
does not avoid bleeding problems, but does allow earlier detection of a
bleed, and avoids the pedicle being compressed by an expanding haema-
toma before the patient is returned to the operating theatre. The drain
can be safely removed the day following surgery. Patients are advised to
wear a soft sports bra, day and night for the first 4 weeks after surgery, and
to moisturize their scars on a daily basis once healed.
The commonest immediate complication is a haematoma, which invari-
ably needs evacuating. It is important to treat signs of infection early, as
failure to do so can encourage fat necrosis in the pedicle which then
causes nipple necrosis.
FURTHER READING 161
Further reading
Jones GE, ed (2010). Bostwick’s plastic and reconstructive breast surgery, 3e. Quality Medical
Publishing, St Louis.
Spear SL, Willey SC, Robb GL, Hammond DC, Nahabedian MY, eds (2010). Surgery of the
breast: principles and art, 3e. Lippincott Williams & Wilkins, Philadelphia.
Chapter 17 163
Oncoplastic mastectomy
incisions
Overview 164
Skin-sparing mastectomy incisions 166
Nipple-sparing mastectomy techniques 168
Further reading 169
164 CHAPTER 17 Oncoplastic mastectomy incisions
Overview
The best cosmesis following mastectomy is achieved by maintaining the
original skin envelope of the breast, including the nipple. Not all patients
are oncologically suitable for a skin-sparing or nipple-sparing mastectomy.
Preoperative planning is essential for all patients having a mastectomy so
that the optimum aesthetic outcome can be achieved in either an immedi-
ate or a delayed reconstructive setting.
Simple mastectomy incisions
Simple mastectomy incisions should be designed to maximize the cos-
metic outcome should a patient choose to have a reconstruction in the
delayed setting. In designing the incision, we should attempt to:
• Keep the scar as low on the breast as possible, so it is not visible.
• Ensure that skin in the décolleté/cleavage region is intact and the
medial end of the scar is low.
• If possible, maintain the inframammary fold and its attachments. In
a ptotic breast, the upper flap can be sutured at the level of the
inframammary fold (see Fig. 17.1). This ensures that, in a delayed
reconstruction, the skin paddle from an autologous reconstruction
is hidden in the inferior pole of the breast, and the visible part of the
breast is native skin.
OVERVIEW 165
a) b)
Fig. 17.1 Maintaining the inframammary fold during simple mastectomy. a) In the
ptotic breast, the upper flap is marked as low as possible, just above the nipple
(incisions marked with a dashed line). The lower skin incision is made at the level of
the inframammary fold, care being taken to maintain the attachments of the fascial
layers at this level. b) The upper flap is brought down following the mastectomy
and sutured at the level of the inframammary fold.
Skin-sparing mastectomy incisions

Skin-sparing mastectomies are performed in patients who will undergo
immediate breast reconstruction. The nipple in these patients is removed.
The four main types, as described by Carlson in 1997, are shown in
Table 17.1 and Fig. 17.2.
A further good choice for many women who are not deemed suitable
for immediate breast reconstruction or who choose to have a delayed
procedure is to conserve breast skin and the inframammary fold (see
Fig. 17.2). This preserves upper chest wall skin and allows insertion of a
delayed autologous skin paddle into the inferior aspect of the new breast,
giving a better cosmetic result.
Table 17.1 Common incision types used for skin-sparing

mastectomies
Type Incision
I Peri-areolar incision (with or without a lateral extension)—this
incision can be closed with a purse string suture, or a paddle from an
autologous flap can be inset into this space.
II A peri-areolar incision, incorporating skin over superficial tumours or
an adjacent biopsy/wide local excision scar on the breast.
III A peri-areolar incision—the skin overlying superficial tumours or
previous surgery sites is removed without excising the intervening skin.
IV The nipple-areola complex is removed, using an inverted T or Wise
pattern reduction scar.
This classification includes incisions required in patients following a previous attempt at breast-
conserving surgery.
SKIN-SPARING MASTECTOMY INCISIONS 167
a) b)
c) d)
Fig. 17.2 Skin-sparing mastectomy incisions. a) Type I incision—peri-areolar,

with or without a lateral extension. b) Type II incision—to include the nipple and a
previous lumpectomy scar. c) Type III incisions—both the nipple and lumpectomy
scars are excised separately. d) Type IV Wise pattern incision.
Nipple-sparing mastectomy
techniques
Nipple-sparing mastectomy is becoming increasingly common for immedi-
ate breast reconstructions and is an excellent choice for women undergo-
ing prophylactic mastectomy. Patients undergoing mastectomy for breast
cancer can also be offered nipple-sparing mastectomy; however, they
must be informed of the slightly increased risk of local recurrence. Spear
et al. have recommended that certain breast cancers may be amenable to
nipple-sparing surgery if they meet specific oncological criteria:
• Tumour size 3cm or less.
• Tumour at least 2cm from nipple.
• Not multicentric.
• Clinically negative lymph nodes.
Incisions used for nipple-sparing mastectomy include:
• A peri-areolar incision (with or without a lateral extension).
• A lateral radial incision.
• An inframammary incision.
• A reduction pattern incision.
The safety of nipple-sparing mastectomy may be increased by obtaining
nipple shaves at the time of surgery or by taking core biopsies from behind
the nipple prior to the mastectomy.
Specific risks of skin-sparing or nipple-sparing
mastectomy
• Flap necrosis: the longer flaps used in this surgery will cause an
increased risk of skin flap necrosis. This risk is highest if using reduction
pattern surgery. Careful planning of skin incision type is essential in
all patients, particularly those already at higher risk of necrosis (prior
radiotherapy, smokers, vascular disease, diabetics). Leaving skin bridges
(type III skin-sparing mastectomy) may not be advisable in this cohort
of high-risk patients.
• Higher risk of locally recurrent disease: the more skin and nipple that
is spared, potentially the more breast tissue will be left behind. This
will put patients at higher risk of locally recurrent disease or, in the
prophylactic setting, of developing a primary breast cancer.
• Partial or total nipple necrosis if the nipple is being spared.
• Loss of sensation: this occurs to the breast skin envelope and also to
the nipple if spared.
FURTHER READING 169
Further reading
Rainsbury D, Willett A (2012). Oncoplastic breast reconstruction—Guidelines for Best Practice
ABS/BAPRAS Nov 2012. Available at: M http://www.associationofbreastsurgery.org.uk/
media/23851/final_oncoplastic_guidelines_for_use.pdf
Carlson GW, Bostwick J 3rd, Styblo TM, et al. (1997). Skin-sparing mastectomy. Oncologic and
reconstructive consideration. Ann Surg 225, 570–5.
Hannan C, Spear S, Seiboth L, Al-Attar A (2010). Nipple sparing mastectomy: A review on indica-
tions, techniques and safety. Plast Reconstr Surg 126, 25.
National Mastectomy and Breast Reconstruction Audits. Available at: M http://www.
ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/audit-reports/
Chapter 18 171
Breast-conserving
surgery: volume
displacement
Overview 172
Oncoplastic breast-conserving surgery (OBCS) 173
Classification of OBCS 174
Further reading 176
172 CHAPTER 18 Breast-conserving surgery
Overview
Breast-conserving surgery (BCS), combined with radiotherapy, has equiva-
lent survival rates to mastectomy. The goal is to conserve breast shape
whilst removing an adequate volume of tissue.
When >20% of breast volume is excised during wide local excision,
there is a higher risk of developing deformity of the breast. This can be dis-
tressing for the patient and may require multiple operations in an attempt
to restore normal breast form.
Classification of post-WLE deformities

Deformities can be classified for descriptive purposes, although how they
are managed must be based on individual assessment.
• Grade 1: loss of volume—requires local flap or lipomodelling.
• Grade 2: loss of volume and ptosis—requires contralateral
symmetrization.
• Grade 3: loss of shape—requires scar revision or local remodelling.
• Grade 4: loss of shape and volume—requires volume replacement.
• Grade 5: extensive fibrosis—requires mastectomy and reconstruction.
ONCOPLASTIC BREAST-CONSERVING SURGERY (OBCS) 173
Oncoplastic breast-conserving
surgery (OBCS)
The initial use of oncoplastic breast-conserving techniques will minimize
the risk of post-operative breast deformities and should be considered for
all resections >20% of breast volume. Tumours in the lower and medial
poles of the breast are particularly prone to post-operative deformity.
The principles of OBCS are the same as for standard WLE—to excise at
least a margin of normal tissue around the tumour, taking a full thickness
of tissue from the level of skin down to pectoralis fascia. The cavity should
be clipped to facilitate radiotherapy prior to remodelling.
Patient factors are important in deciding on the appropriate technique.
All patients should be counselled about the risks of poor scarring and
post-operative breast asymmetry. Contralateral symmetrization may be
required, either immediately or as a second-stage procedure following
completion of adjuvant treatment.
Techniques fall into two broad groups:
• Volume displacement—local breast tissue is mobilized to fill the defect
and may form part of a breast reduction procedure.
• Volume replacement (see Chapter 19)—new tissue is brought in, often
in the form of a myocutaneous flap.
Smoking, diabetes, and high BMI increase the risk of complications, espe-
cially wound infections and delayed healing. These patients should be
counselled appropriately prior to surgery.
Advantages of OBCS
• No difference in oncological outcome compared to standard WLE.
• Allows larger volume of tissue to be excised.
• Improved cosmetic result.
Disadvantages of OBCS
• Re-excision may be difficult, as original margins not easily identified.
• Increased risk of complications, e.g. fat necrosis.
• Delayed healing will delay adjuvant therapy.
Classification of OBCS
Level 1 techniques:
• Local glandular remodelling.
• Up to 20% volume excision.
• Dual-plane undermining required—glandular breasts only.
Level 2 techniques:
• Mammaplasty techniques.
• 20–50% volume excision, with or without skin excision.
• Single-plane undermining—suitable for fatty and glandular breasts.
Level 1 OBCS techniques
• Mark patient preoperatively in standing position.
• Position patient on operating table to allow an upright position during
surgery.
• Drape patient with both breasts exposed.
• Make sufficient skin incision to allow extensive glandular mobilization.
• Undermine skin in mastectomy plane beyond tumour site.
• If necessary, transect nipple ducts, leaving 1cm tissue on underside of
NAC to facilitate repositioning.
• Excise full-thickness fusiform wedge of breast tissue, including tumour
orientated along breast ray.
• Orientate specimen for pathologist.
• Mark cavity with metal clips.
• Mobilize surrounding breast tissue from pectoralis fascia to create
local glandular flaps, and approximate to fill defect.
• If necessary, de-epithelialize crescent of peri-areolar skin opposite
excision to re-centre NAC.
Level 2 OBCS techniques

Choice of technique depends on tumour location, but all are variations on
basic mammaplasty procedures and allow extensive volume excision along
with overlying skin. Appropriate options are summarized in Table 18.1.
The use of level 2 techniques requires specialist training and is based
on breast reduction procedures. Details of each procedure will not be
covered here but can be found in any good oncoplastic textbook.
• Mark patient preoperatively in standing position.
• Position patient on operating table to allow upright position during
surgery.
• Drape patient, with both breasts exposed.
• Incise skin pattern to dermis.
• De-epithelialize nipple pedicle if necessary.
• Perform full-thickness wedge excision of breast tissue, including
tumour with overlying skin.
• Mobilize surrounding breast tissue from pectoralis fascia.
• Approximate glandular flaps, and inset nipple pedicle.
• Use of drain is optional.
• Perform contralateral symmetrization if required.
CLASSIFICATION OF OBCS 175
Table 18.1 Level 2 techniques for OBCS

Position of tumour Suggested procedure
Lower pole Superior pedicle mammaplasty/Vertical mammaplasty
Upper pole Inferior pedicle mammaplasty/Round block technique
Medial pole Medial mammaplasty
Lateral pole Lateral mammaplasty
Central Wise pattern mammaplasty including NAC, Vertical
mammaplasty including NAC
Further reading
Clough KB, Kaufman GJ, Nos C, Buccimazza I, Sarfati IM (2010). Improving breast cancer sur-
gery: a classification and quadrant per quadrant atlas for oncoplastic surgery. Ann Surg Oncol
17, 1375–91.
Fitoussi A, Berry MG, Couturaud B, Salmon RJ (2009). Oncoplastic and reconstructive surgery for
breast cancer. Springer, London.
Iwuchukwu OC, Harvey JR, Dordea M, et al. The role of therapeutic mammaplasty in breast cancer
surgery—a review. Surg Oncol 21, 133–41.
Baildam A (2002). Oncoplastic surgery of the breast. Br J Surg 89, 532–3.
Chapter 19 177
Breast reconstruction:
volume replacement
Overview 178
Implant-based reconstruction and acellular dermal
matrices 180
Latissimus dorsi (LD) reconstruction 182
Abdominal flap reconstruction 184
Further reading 186
178 CHAPTER 19 Breast reconstruction
Overview
Volume replacement should be considered in the setting of:
• Immediate or delayed breast reconstruction after mastectomy.
• >20% of breast volume resected as part of breast-conserving surgery.
• Resection of central, medial, or lower pole tumours likely to cause
significant deformity.
Common types of volume replacement
• Implant-based reconstruction.
• Autologous flap reconstruction (e.g. latissimus dorsi, abdominal, or
gluteal flap).
• Lipomodelling.
Selection of volume replacement technique
The key to successful volume replacement and patient satisfaction is the
clinical decision-making process. Clinician, patient, family, and breast care
nurses should be involved in the decision-making process. Patients must
be aware:
• Reconstructive surgery is a choice, unlike their cancer surgery.
• It involves risk of complications and prolonged recovery.
• That the complications of reconstructive surgery may delay adjuvant
therapies.
• Of all the options available for reconstruction (even if they are not
available in your hospital).
• What is involved in each reconstructive option to aid informed
decision-making.
• That reconstructive surgery usually involves several operations and
multiple clinic visits.
• A reconstructed breast will not be the same as their natural breast.
This process will take multiple visits to achieve understanding and agree-
ment. Specialist nurses are the backbone of this discussion and should
be giving patients written information, photographs of a range of recon-
structions with a range of outcomes (from good through to those having
peri-operative complications), and, if time permits, a meeting with patients
who have undergone breast reconstruction.
History-taking
A full medical history should be taken from all patients. Important informa-
tion includes:
• Previous adjuvant treatment (especially radiotherapy and its dosage).
• Smoking history.
• Current weight and BMI, and stability of current weight (large
variations in weight will rapidly change the appearance of the
reconstructed vs the non-reconstructed breast).
• Which breast does the patient prefer?
• What does patient want to achieve from breast reconstruction?
• Social history of current job and hobbies (especially sport).
• Family circumstances (e.g. is the patient a carer for young children?).
OVERVIEW 179
Clinical examination
Clinical examination should incorporate:
• Recording of BMI.
• Assessment breast shape, including height/width/projection and ptosis.
• Examination of the presence/absence of pectoralis major and
latissimus dorsi.
• Assessment of breast/chest wall skin quality and any radiation changes.
• Examination of the abdominal pannus for amount and quality of tissue.
• Examination for abdominal wall hernias or weakness.
Implant-based reconstruction and

acellular dermal matrices
Basic principles
A permanent implant or expander is placed in a subpectoral pocket, which
covers the superior and medial aspects of the implant. The more tissue
covering an implant, the more natural it will feel.
The inferior and lateral aspects of the implant are more difficult to
cover. The main options to cover this area include:
• Skin-only coverage (implant may, therefore, be palpable/visible).
• Creating a total submuscular pocket by also lifting serratus anterior.
• Inserting an acellular dermal matrix (e.g. Strattice™) or mesh.
• Using a dermal flap as part of a skin-reducing (e.g. Wise pattern)
mastectomy.
• Lifting an abdominal fascial flap, including rectus abdominis and
external oblique fascia.
Advantages
• Short operation and recovery. Full recovery takes weeks, not months.
• Gives good results, particularly in small, non-ptotic breasts.
• The use of expander implants gives adjustability.
• Good for patients unwilling to undergo autologous flap reconstruction.
Disadvantages
• Post-operative adjuvant radiotherapy often results in poor cosmesis.
• Risk of implant infection.
• Further revisional operations are usually required.
• Multiple clinic visits are needed for expansion.
• Lack of ptosis—patient may be asymmetrical compared with the
contralateral side.
• Cost of acellular dermal matrices.
• Does not provide extra skin often needed in the delayed setting.
• Is not suitable for partial breast reconstruction.
• Long-term development of capsular contracture.
Contraindications
• Sepsis.
• If post-operative radiotherapy is likely (a relative contraindication).
• Thin, damaged, or irradiated skin (a relative contraindication).
Consent
The consent discussion should include discussion about the potential
adverse outcomes of implant-based reconstruction, including;
• Likely need for revisional surgery in the future.
• Capsular contracture (the risk increases with time).
• Implant infection and subsequent risk of implant removal.
• Implant extrusion (particular risk after radiotherapy).
• Implant leakage or deflation of an expander implant.
• Rotation of implant (or filler port of an expander implant).
IMPLANT-BASED RECONSTRUCTION 181
• Visible or palpable rippling of an implant.

• Thinning of overlying tissues with time.
• Chronic pain.
• Seroma and ‘sloshing’ of implant.
• Wound breakdown/necrosis.
In the past, concerns have been raised that systemic diseases are associ-
ated with breast implants. There is no evidence for this phenomenon, and
most major manufacturers do not recommend routine replacement of
implants after 5/10 years.
Outcomes
The findings of the fourth National Mastectomy and Breast Reconstruction
Audit (NMBRA) are extremely useful for informing patients of likely
outcomes and to compare the results of the different reconstruction
options (see Further reading). Approximately 70% of immediate and 85%
of delayed implant reconstruction patients are satisfied or very satis-
fied with the amount of rippling of their implant that can be seen or felt.
Approximately 7% of implant-based reconstructions have a post-operative
infection requiring removal.
Latissimus dorsi (LD) reconstruction

Basic principles
The LD reconstruction is a pedicled, autologous flap supplied by the
thoracodorsal artery (see Fig. 19.1). The size of the overlying skin pad-
dle and the amount of subcutaneous fat and muscle that is harvested will
depend on the surgeon’s requirements.
Types of LD reconstruction
• Extended LD flap: harvesting the maximal amount of LD muscle
and fat underlying Scarpa’s fascia to create a purely autologous
reconstruction.
• LD and implant: the LD flap is used for coverage of an implant. This
approach gives the soft feel of autologous tissue with the added
volume of an implant. The implant can be totally covered by LD
anteriorly or the implant pocket is created by lifting pectoralis major
anteriorly and covering the lower pole with the LD flap.
Trapezius
muscle
Axillary
artery
Teres
major
Thoracodorsal artery
(enters latissimus
dorsi 10cm below axillary
artery)
Lower border
of scapular
Flap swung anteriorly

through subcutaneous
tunnel in the axilla
Line of resection of
latissimus muscle,
(showing types of
overlying skin paddles
possible)
Iliac creat
Fig. 19.1 Latissimus dorsi flap. Reproduced with permission from Chaudry MA
and Winslet MC, 'The Oxford Specialist Handbook of Surgical Oncology', copyright
2009, Oxford University Press.
LATISSIMUS DORSI (LD) RECONSTRUCTION 183
Advantages
• Relatively radioresistant, especially if there is no implant present.
• Good aesthetic result, even in mildly ptotic breasts.
• Use of expander implant gives adjustability.
• Robust flap with a low failure rate.
• Can be used selectively in smokers.
Disadvantages
• Removes LD function on the ipsilateral side (may affect shoulder/back/
neck function).
• Donor site morbidity.
• Skin paddle is often a different colour to the chest wall skin, giving a
patch appearance.
• Longer operation and recovery than implant-based reconstruction. Full
recovery takes 1–3 months.
• If an implant is used, revisional surgery is likely.
Contraindications
• Previous damage to thoracodorsal pedicle.
• Active hobbies or lifestyle where weakness of LD would be a problem
(e.g. sportswomen [climbers/rowers/dancers] or carers).
• Patients with pre-existing back or neck conditions.
• Severe co-morbidity—because LD flap reconstruction involves a
prolonged operation and recovery.
Consent
The consent process should include discussion about the potential
adverse outcomes of implant-based reconstruction if an implant is being
used, as discussed in the previous section. Specifically, patients undergoing
LD reconstruction should be warned about the risks of:
• Flap failure (rare).
• Donor site morbidity, including skin necrosis/breakdown and seromas.
• Chronic pain (especially from donor site).
• Weakness of back/shoulder muscles—particularly noticeable when
picking up heavy bags/taking items from a high shelf/getting up out of a
bath or off the floor.
• Scarring on back and around the inset skin paddle.
• Future risk of hernias (lumbar hernias).
Outcomes
See Further reading—NMBRA.
• 1.2% partial and 0.2% total flap loss.
• 9.5% risk of donor site complications (7.5% of patients require
post-operative drainage of a seroma or haematoma).
• 10–15% of women are bothered by the appearance of their donor
site scar.
• 712% of women suffer shoulder or back pain most, or all, of the time
following surgery.
• 720% of women have difficulty lifting and carrying heavy objects.
• Scores for emotional, sexual, and physical well-being as well as breast
appearance are higher than those of implant-based reconstruction.
Abdominal flap reconstruction

Basic principles
The abdominal flap reconstruction is an autologous flap supplied by one
of the epigastric arteries (see Fig. 19.2) that can be taken as a pedicled flap
or as a free flap requiring microsurgical anastomosis. Skin and subcutane-
ous fat are harvested from the lower abdomen, using a tranverse ellipse of
resection similar to that used for an abdominoplasty procedure.
Axillary Subclavian
artery artery
Internal
Subscapular mammary
artery artery
Thoracodorsal
artery
Superior
epigastric
artery
TRAM
FLAP
Deep
inferior
III I II IV
epigastric
artery
Safe zones
Fig. 19.2 Basic TRAM/DIEP anatomy. Safe zones I and II are the zones with the
best blood supply following abdominal flap surgery. Zones III and IV often need to
be sacrificed early during the operation due to their poor viability. Reproduced with
permission from Chaudry MA and Winslet MC, 'The Oxford Specialist Handbook
of Surgical Oncology', copyright 2009, Oxford University Press.
ABDOMINAL FLAP RECONSTRUCTION 185
Types of abdominal flap reconstruction

• Pedicled TRAM (transverse rectus abdomininis muscle) flap: the
viability of the skin and subcutaneous tissues is maintained by lifting
the whole length of the rectus abdominis (usually on the contralateral
side) based on the superior epigastric artery pedicle. The flap is then
rotated and tunnelled subcutaneously to fill the breast defect.
• Free TRAM flap/muscle-sparing free TRAM flap: these are both free
flaps based on the inferior epigastric artery, which runs into the rectus
abdominis. Variable amounts of the rectus abdominis muscle can be
preserved to maintain function.
• SIEP/DIEP flaps: these spare the abdominal muscle completely by
basing the skin and fat paddle upon either the superficial (SIEP)
or deep (DIEP) inferior epigastric artery. These are also free flaps
requiring microsurgical anastomosis.
Advantages
• Good aesthetic result, even in ptotic or large breasts.
• A large skin paddle and tissue volume is often available.
• Rarely any need for implants.
• Robust flap with a low failure rate.
• Purely autologous tissue and, therefore, more resistant to the effects
of radiotherapy than an implant-based reconstruction.
• The reconstruction ages well and often requires no revision so is a
good choice for motivated young women.
• Patients get a ‘tummy tuck’.
Disadvantages
• Long operation (up to 8 hours) and recovery (approximately
3 months).
• Significant donor site morbidity.
• Skin paddle is often a different colour to the chest wall skin.
• Risk of systemic complications due to the potential length of surgery.
• Large changes in the patient’s weight will affect native breast differently
to the reconstructed breast.
• Requires microsurgical skills to perform and requires the availability of
microsurgical emergency cover out of hours.
Contraindications
• Previous abdominal surgery compromising the vascular supply
(vascular contraindication).
• Significant back problems—if any of the muscle is to be harvested.
• Think carefully before performing in smokers or those with BMI over 30.
• Severe co-morbidity—because abdominal flap reconstruction involves
a prolonged operation and recovery.
Consent
Specifically, patients undergoing abdominal flap reconstruction should be
warned about the risks of:
• Flap failure or partial failure.
• Donor site morbidity, including skin necrosis/breakdown and seromas.
• Chronic pain (especially from donor site).
• Weakness of abdominal muscles—particularly noticeable when getting

up out of a bath or off the floor.
• Abdominal scarring.
• Future risk of abdominal hernias.
• Risk of infection if a prosthetic mesh is used to strengthen or repair
the abdominal musculature.
• Systemic complications, e.g. DVT/chest infection.
• Umbilical loss or stenosis.
• Risk of return to theatre in the immediate post-operative period
(712%).
Outcomes
See Further reading—NMBRA.
• 2% partial and 2% total flap loss.
• 715% local complication rate (5% have a donor site complication).
• 75–80% of women are satisfied with their abdominal appearance.
• 710% of women suffer abdominal bulging or tightness.
• 75% of women have difficulty sitting up due to abdominal muscle
weakness.
• Scores for emotional, sexual, and physical well-being as well as breast
appearance are higher than those of implant-based reconstruction or
LD-based reconstruction. Satisfaction levels are higher for free flaps
than for pedicle-based flaps.
Further reading
ABS/BAPRAS Nov 2012. Available at: M http://www.associationofbreastsurgery.org.uk/media/
23851/final_oncoplastic_guidelines_for_use.pdf
NMBRA. Available at: M http://webarchive.nationalarchives.gov.uk/20120802111034/
http://www.ic.nhs.uk/services/national-clinical-audit-support-programme-ncasp/audit-reports/
Chapter 20 187
Lipomodelling
Overview 188
Indications 189
Complications 190
Further reading 191
188 CHAPTER 20 Lipomodelling
Overview
Lipomodelling is a fast-evolving technique that harvests subcutaneous fat,
usually from the abdomen/flanks/thighs, and uses it for volume replace-
ment in the breast. Fat is harvested using liposuction, and then the fat
cells are separated from the tissue fluid/blood and oil that is also gathered
during liposuction. Separation is usually achieved by centrifugation, but
processes for washing the fat cells have also recently been developed. Fat
for injection can also be enriched with adipose-derived regenerative cells
(ADRCs), which may enhance graft take by maximizing vascularization of
the graft (see Further reading).
Fat injection (lipomodelling) into the breast will only be successful if
the fat is injected in small aliquots to an area with a good blood sup-
ply. Fat is injected in tunnels at different depths and angles to achieve
a 3-dimensional increase in volume, avoiding the formation of ‘fat lakes’
which will form fat necrosis/oil cysts over time.
Lipomodelling is dependent upon a suitable donor site but, if fat can
be harvested, lipomodelling allows the surgeon to contour the breast,
depending on the specific needs of the patient. Lipomodelling may need
to be repeated several times to reach the desired result; volume increases
over 150–200mL can rarely be achieved in one session.
INDICATIONS 189
Indications
Common uses of lipomodelling include:
• Correction of contour deformities (e.g. lack of upper, medial fullness)
after previous breast reconstruction or augmentation.
• To soften the contour at the edge of a breast implant.
• Filling of contour and volume deformities after previous
breast-conserving surgery.
• As a volume adjunct to a previous reconstruction (e.g. to increase
breast bulk after previous autologous reconstruction where the
surgeon/patient wishes to avoid an implant).
• As a method of delayed breast reconstruction (see Further reading).
• Breast augmentation (lipomodelling in this setting will only give limited
volume increase, often over several treatments).
• To provide soft tissue cover prior to breast augmentation or delayed
reconstruction.
Advantages
• Liposuction of fatty areas on abdomen/flanks/thighs is usually welcome.
• Quick to perform and gives a natural autologous feel.
Disadvantages
• There is a significant learning curve to master all its applications.
• Donor site can become cosmetically unsatisfactory if fat is not evenly
harvested.
• Theoretical risk of interference with mammographic screening causing
an increase in recurrence rates. However, there is currently no
evidence to demonstrate interference with mammographic screening
or a higher risk of local recurrence with this technique.
190 CHAPTER 20 Lipomodelling
Complications
Specifically, patients undergoing lipomodelling should be warned about
the risks of:
• Fat necrosis/oil cysts and, therefore, increased risk of diagnostic biopsy
after their next mammographic screening to ensure all mammographic
changes are benign. Possible risk of cancer recurrence.
• Donor site morbidity, including bruising, infection, visceral injury, and
lumpiness.
• Lipomodelling often needs repeating until the desired cosmetic result
is achieved.
FURTHER READING 191
Further reading
Lipomodelling guidelines for breast surgery Joint guidelines from the Association of Breast Surgery,
the British Association of Plastic, Reconstructive and Aesthetic Surgeons and the British
Association of Aesthetic Plastic Surgeons. Available at: M http://www.bapras.org.uk/download-
doc.asp?id=666
Breast reconstruction using lipomodelling after breast cancer treatment (IPG417). Available at: M
http://guidance.nice.org.uk/ipg417
Perez-Cano R, Vranckx, J, Lasso J, et al. (2012). Prospective trial of adipose-derived regenerative
cell (ADRC)—enriched fat grafting for partial mastectomy defects: the RESTORE-2 trial. Eur J
Surg Oncol 38, 382–9.
Chapter 21 193
Nipple-areola
reconstruction
Overview 194
Marking up 195
Techniques 196
Further reading 198
194 CHAPTER 21 Nipple-areola reconstruction
Overview
The common situations in which the need for nipple-areola reconstruc-
tion is encountered are:
• Following immediate/delayed flap reconstruction.
• After central wide local excision.
• Nipple loss following duct surgery or mastopexy/breast reduction.
General principles
Nipple reconstruction can be performed as part of a one-stage breast
reconstruction. However, the final position of the nipple may change in
the months following surgery, as the reconstructed breast assumes its final
position. Therefore, NAC reconstruction is usually performed as a delayed
procedure under local anaesthetic, 3–6 months following reconstruction.
The first stage is to re-create the nipple mound using either a local flap
or a graft. This is then tattooed 3 months later to symmetrize with the
contralateral NAC.
Consent and preoperative issues
Nipple reconstruction is not mandatory after breast reconstruction, and
some patients decide not to bother. However, it is important to give the
patient the options that are available. Before the final decision to recon-
struct, it may be helpful to give the patient an artificial nipple, which can be
custom-made so that the patient has some idea of the visual benefit. It can
also be helpful in final positioning if reconstruction is undertaken because,
if worn regularly in the lead up to surgery, the artificial nipple leaves a
mark which makes positioning much more accurate. If reconstruction is
undertaken, the patient should be made aware of the following possible
complications:
• Loss of nipple projection, requiring revision.
• Nipple necrosis and infection.
• Asymmetry (especially if performed as a one-stage procedure).
• Donor site morbidity (if graft is used).
• Poor scarring.
• Loss of tattoo pigment.
The patient needs to be warned that, because reconstructed nipples
nearly always shrink, it is often wise to make them a little too large to
allow for this atrophy. Beware also that much of the ‘new’ nipple is made
of subcutaneous fat so that a very thin patient with prominent nipples
may prove difficult to match, particularly if an implant reconstruction has
taken place, as the tissues may be very thin after expansion. Therefore, it is
important, as in all reconstructions, to match the patient to the technique.
MARKING UP 195
Marking up
The patient should be marked in the upright position prior to surgery. The
position of the new NAC should be marked to achieve close symmetry
with the contralateral side and should ideally be positioned on the site of
maximum projection of the breast.
Nipple position can either be determined using contralateral measure-
ments of NAC distance from the sternal notch, midline, and infra-mammary
fold, or an adhesive sticker, such as an ECG dot, may be used. When
marking the areola, a template of the contralateral side should be traced.
Techniques
Local flaps
Local flaps are designed to harvest skin and underlying fat in order to cre-
ate a nipple mound. When designing a flap, pre-existing scars should be
avoided, as this may compromise the blood supply. The general principle
is to aim to produce a mound with double the height of the opposite nip-
ple, as it will invariably lose projection with time.
Local flaps should not be closed under tension, as this leads to poor scar-
ring, which is difficult to camouflage by tattooing, and to flattening of the
mound. If necessary, a full-thickness skin graft can be used to aid closure.
If the flap site overlies an implant-based reconstruction, there may be
a lack of subcutaneous tissue to create projection. A strip of underlying
muscle may be raised with the skin or a filler, such as acellular dermal
matrix, used. Beware of damaging the underlying prosthesis.
There are many different techniques and modifications described using
locally designed flaps. The most common are described in the following
bullet points. C-V flap is the most commonly used; other methods of local
flap are very similar in principle to this. Following reconstruction, the site
should be covered with a non-adherent dressing, which avoids direct pres-
sure on the reconstructed mound.
C-V flap (see Fig. 21.1):
• Raise flap based on modified star design.
• Include subcutaneous fat deep to central flap.
• Wrap lateral wings around—one inferior and one superior.
• Central flap placed on top to create plateau.
• Close skin defects directly.
Skate flap (see Further reading):
• Raise flap based on semicircular design.
• Close deep tissue defect to create base for nipple.
• Lateral wings are opposed to create conical projection.
• Skin defect is closed directly.
Star flap (see Further reading):
• Raise flap based on triangular design.
• Oppose tips of all triangles to create mound.
• Close skin defects directly.
A major advantage of these flaps is that for, the most part, they can be
done under local anaesthesia as a day case/outpatient.
Grafts
Full-thickness skin grafts can be taken from various donor sites, including
the pigmented inner thigh/labia. However, due to potential donor site
morbidity, the need for general anaesthetic, and morbidity at the donor
site, these techniques have largely been superseded by local flaps and
tattooing. Redundant breast skin (e.g. as part of a Wise pattern breast pro-
cedure) can be used as a full thickness Wolfe graft to recreate an areola,
avoiding the need for tattooing.
TECHNIQUES 197
Reconstructed Incision
breast
Fibrofatty
tissue
C C
A B B
A
B
A
Fig. 21.1 Nipple reconstruction with a C-V flap. Reproduced with permission
from Chaudry MA and Winslet MC, 'The Oxford Specialist Handbook of Surgical
Oncology', copyright 2009, Oxford University Press.
If the contralateral nipple is a generous size, a free nipple graft may be

harvested and placed on a de-epithelialized dermal bed (see Fig. 21.2). The
two main techniques are to excise a distal wedge of the nipple, closed
with a purse string suture, or to take the inferior half of the nipple (pre-
ferred) which is closed directly. This is very useful where there is a dispar-
ity between nipple size and subcutaneous fat.
Tattooing
This should be performed under local anaesthetic, at least 2 months fol-
lowing nipple reconstruction. The goal is to match the size, shape, and
colour of the contralateral NAC. This can be done by creating a template
of the opposite nipple shape and by careful matching of pigment colours.
a) b)
Fig. 21.2 Nipple reconstruction with a composite graft. a) The contralateral

nipple is harvested by removing the inferior half of the nipple, full-thickness. b) The
lower edges of the nipple are sutured to the inferior edge of the raw area from
which the graft was harvested. This leaves a surprisingly normal-shaped nipple.
The graft is kept in saline and is sutured on the preferred site of the new nipple by
de-epithelializing the recipient site and suturing the graft down.
Tattooing is often performed by specialist nurses. Initially, the tattoo

will appear darker than the desired shade due to haemosiderin, but this
will settle within a couple of weeks. Tattoos often fade with time and may
require repeat attempts. If the contralateral NAC is pale, the patient may
wish to undergo bilateral tattooing to achieve symmetry.
Further reading
Chapter 22 199
Breast augmentation and

symmetrization surgery
Breast augmentation 200

Symmetrization surgery 204
Further reading 205
200 CHAPTER 22 Breast augmentation and symmetrization
Breast augmentation
Basic principles
Hypomastia may occur as a developmental or involutional process.
Developmental hypomastia can be unilateral or bilateral, or secondary to
a chest wall deformity. Hypomastia often results from breast involution in
post-partum women; this is exacerbated by breastfeeding and significant
weight loss. Inadequate breast volume can lead to a negative body image,
which may affect a patient’s quality of life.
Breast implant choice
Breast implant manufacture is constantly evolving and improving. The
major types of breast implant are:
Silicone implants
Silicone is made up of polymeric chains; the physical properties of the
silicone depend on both the chain length and the level of cross-linking
between the polymers. Increased cross-linking and longer chain length
results in higher viscosity and a formed stable gel (it maintains its shape
when sitting or lying). Modern implants are made up of two core parts:
• Shell: tough silicone shell with a textured surface; the textured surface
allows tissue adherence and ingrowth. The textured surface reduces
implant movement/rotation in its pocket and capsule formation.
• Filling: cohesive gels are solid, even when cut with a knife; this results
in less gel bleeding through the implant shell and less silicone leakage
should an implant shell fail. The cohesiveness of the gel will determine
the feel of the implant from soft through to firm.
Shape: implants are manufactured in a huge variety of sizes and in two
main shapes—anatomical or round.
• Round: round implants vary in base width and in projection. The
majority of breast augmentations have been performed with round
implants. They eliminate the risk of implant rotation present with
anatomical implants and are easier to insert. Round implants are
particularly good for women who want visible enhancement to the
medial cleavage area.
• Anatomical: anatomical implants provide a more naturally shaped
breast implant that is fuller in the lower pole than the upper pole.
Surgeons can choose an implant based upon its base width, height,
and projection.
Saline implants
Widely used in the US because silicone implants were banned by the FDA
during a period when it was thought that these implants caused autoim-
mune disease. Saline implants, if underfilled, tend to ripple and, if overfilled,
result in very firm implants. Used for transumbilical breast augmentation.
Polyurethane
Polyurethane-covered implants gain very good tissue adherence and are
increasingly being used for revision augmentations, particularly when rota-
tion of an implant caused the need for revisional surgery. These implants
BREAST AUGMENTATION 201
have a polyurethane shell covering a conventional silicone implant. The

polyurethane coating has a tendency to decrease capsule formation but
may also delaminate from the underlying implant over time. Little data are
available on the long-term outcomes of modern-generation polyurethane
implants (see Further reading).
Expanders
Breast tissue expanders are made up of a silicone shell and are expanded seri-
ally in their tissue pocket using saline. Expanders are temporary implants used
to create a pocket where tissues are tight and need stretching over time. The
devices can be round or anatomical and can have an integrated port (e.g.
Allergan 133 or Mentor Contour profile) or a filler port that is sited sub-
cutaneously, remote from the device. Expander implants (e.g. Allergan 150
range or Mentor ‘Becker’ devices) combine some silicone fill (for improved
contour and feel) with the flexibility of saline expansion. Expander implants
are designed as permanent implants not requiring exchange.
Incision choice
• Inframammary: the most commonly used incision, as it gives the
surgeon excellent views and control over pocket formation and
is suitable for both subglandular and subpectoral positioning. One
disadvantage is that, in patients with a short nipple-to-inframammary
fold (IMF) distance, it can be difficult to site the incision in what will be
the final IMF position (i.e. the scar has a tendency to ride up onto the
lower breast).
• Transaxillary: the transaxillary approach has the obvious advantage
of avoiding visible scars on the breast. It is used for submuscular
implant placement, but the incision site does make the surgery more
technically demanding. The implant pocket is either dissected bluntly
using a dissector (increased risk of bleeding) or more accurately using
endoscopic instruments or lighted retractors. This technique gives
good control of the final IMF position.
• Periareolar: this allows for an inconspicuous scar and good access
to the implant pocket through an inferior peri-areolar incision. It is
an excellent option for augmentation in women with small tuberous
breasts, as it flattens the breast shape, releases the lower pole
constriction associated with tuberous breasts, and eliminates any
areolar herniation. It is also useful when the IMF needs lowering.
However, peri-areolar incisions may decrease nipple sensation,
and cutting through breast ducts may result in increased bacterial
contamination of the implant (which has been associated with infection
and capsule formation).
• Transumbilical: this approach can be used to place saline-filled implants
only; the incision does not allow sufficient access for silicone implant
placement. Scarring is minimal, and little post-operative pain is reported.
Implant pocket location
Subglandular
Placement of the implant in the subglandular position will give optimal
results in patients with good soft tissue coverage (subclavicular soft tissue
pinch >2cm). The implant pocket is between the posterior aspect of the
breast parenchyma and the anterior fascia of the pectoralis major muscle.
Subfascial
An attempt to combine the benefits of subglandular and submuscular
techniques. The implant is placed under the anterior pectoralis fascia
which may result in less visible implant edges, rippling, and contracture
than subglandular placement. Not widely used.
Submuscular
Retropectoral placement increases soft tissue coverage over the implant,
giving a more natural feel, and reduces medial visibility and rippling of the
prosthesis. Disadvantages include increased post-operative pain, reduction
of pectoralis major function, and ‘animation’ (visible lateral movement) of
the implant when pectoralis major contracts.
Complications of breast augmentation
• Capsule formation: has a reported incidence of 1–30%
(see Table 22.1).
• Scars at site of insertion.
• Bleeding.
• Reduced nipple/breast sensation.
• Infection: which may result in explantation of the device.
• Interference with mammographic screening: silicone devices are extremely
dense on mammography and may mask some of the breast parenchyma.
• Unsatisfactory cosmetic result: outcome is very dependent on
managing the patient’s expectations and ensuring thorough patient
education and open discussion throughout the consultation process.
• Risk of revisional surgery in the future: either due to implant failure or
a change in the patient’s tissues over time.
• Palpability of the implant and rippling.
• Implant rotation: occurs in 72% of anatomical breast implant
augmentations.
• Leakage: silicone gel implants only leak when the shell has failed.
Expanders may deflate due to a leak from the injection port site.
Tissue planning process
See Further reading. Planning a breast augmentation must allow for both
the patient’s wishes and also the tissue characteristics. Planning a breast
augmentation should take account of the following five factors:
• Implant coverage/pocket planning.
• Implant size/volume.
• Implant type.
• Inframammary fold position.
• Incision.
This planning process must be conducted with the patient and can be
further enhanced using visual aids (photos, image capture and com-
puter planning technology, device catalogues, demonstrating a range
of prostheses, interactive digital education) to try to exhibit a likely
outcome range.
BREAST AUGMENTATION 203
Table 22.1 Baker classification of capsular firmness in augmented

breasts
Grade of capsule formation Clinical signs
I Soft breast, with no palpable implant
II (minimal firmness) Soft breast; the implant can be palpated but
is not visible.
III (moderate firmness) The implant can be palpated easily, and
distortion is visible.
IV (severe contracture) The breast is hard and tender, with marked
distortion.
Reproduced with permission from 'Classification of capsular contracture after prosthetic
breast reconstruction', Spear SL, Baker JL Jr., Plast Reconstr Surg. 1995 Oct;96(5):1119-23;
discussion 1124.
Beware—cases requiring specialist expertise

• Previous breast reduction or mastopexy.
• Secondary augmentation procedures.
• Chest wall deformities.
• Differential breast augmentation (non-symmetrical breasts requiring a
personalized operation for each side).
Post-operative care
Drains can be used to remove any blood from the implant pocket in the
first 24 hours after surgery. Careful haemostasis is key to breast augmen-
tation, as the presence of blood in the implant pocket may contribute to
capsule formation. Many surgeons use pressure garments or taping of the
breasts for several weeks in the post-operative period to minimize implant
movement and lateral drift of the implants.
Symmetrization surgery
Basic principles
Surgery, including breast conservation surgery, mastectomy, and mastec-
tomy with immediate reconstruction, can leave women with significant
size and shape discrepancies between their two breasts. Managing this mis-
match is challenging. During the consent process for any breast surgery,
women must be shown any pre-existing differences between the breasts
and warned that there will be a difference following treatment, the extent
of which is difficult to predict.
Options for managing asymmetry
• Reassurance and a frank discussion: reassurance that this is normal.
Many women, once they have explored all possible surgical options,
will opt for no further surgical symmetrization surgery. This involves
the lowest level of risk to the patient and her current aesthetic
appearance. Many patients do not want to have surgery or scars on
their unaffected and ‘normal’ breast.
• Volume deficit: volume can be enhanced with breast augmentation or
lipomodelling (see Chapter 20).
• Volume too large: breast reduction or liposuction.
• Ptosis: often a problem after contralateral implant-based
reconstruction. Mastopexy, or breast reduction, is mainstay of
treatment.
Timing of symmetrization surgery
When to perform symmetrization surgery is a personal decision. Generally,
it is performed either at the time of the index procedure (more challeng-
ing) or once the ipsilateral breast has completed treatment and its size
and shape have matured. Factors which influence decision-making include:
• Patient preference.
• Macromastia: patients with macromastia who are having a large
reduction in volume on one side will be lopsided if the contralateral
breast is not also reduced at the same time.
• Radiotherapy: radiotherapy has a relatively unpredictable effect upon
final breast volume and size. Performing synchronous bilateral surgery
may leave patients with asymmetry once radiotherapy is complete.
• Adjuvant chemo-/radiotherapy: patients at high risk of systemic disease
should not have their adjuvant chemotherapy delayed by cosmetic
contralateral surgery. Complications from contralateral surgery are
common and can delay the start of adjuvant treatments.
• Theatre capacity and the availability of a skilled surgeon to work
synchronously on the contralateral breast.
FURTHER READING 205
Further reading
de la Pena-Salcedo J, Soto-Miranda M, Lopez-Salguero J (2012). Back to the future: a 15 year experi-
ence with polyurethane foam-covered implants using the partial subfascial technique. Aesthetic
Plast Surg 36, 331–8.
Pompei S, Arelli F, Labardi, L, et al. (2001). Breast reconstruction with polyurethane implants: pre-
liminary report. Eur J Plast Surg Epub 21 June 2011.
Tebbetts JB, Adams WP (2005). Five critical decisions in breast augmentation. Using five measure-
ments in 5 minutes: the high five decision support process. Plast Reconstr Surg 116, 2005–16.
Chapter 23 207
Recurrent breast cancer
Overview 208
Management of recurrence 210
Management of skeletal metastases and palliative care 212
Locally advanced breast cancer 213
Further reading 214
208 CHAPTER 23 Recurrent breast cancer
Overview
Following initial treatment for breast cancer, the risk of recurrence is
the event that patients most dread. As a consequence, minor symptoms,
even if they are of no significance, can cause great anxiety. It is impor-
tant, therefore, that symptoms suspicious of a recurrence are promptly
investigated, so either the patient can be reassured or treatment initiated
without undue delay.
Recurrences can be:
• Local: either in a conserved breast or on the chest wall following
mastectomy.
• Locoregional: usually in the local draining lymph nodes of the axilla or
supraclavicular fossae.
• Systemic: arising at sites distant to the breast, the most common being
bone, lungs, liver, and brain.
Although these are the common sites, breast recurrences can occur
almost anywhere anatomically, including as an isolated skin metastasis.
It is also important to realize that local recurrence can be associated
with another asymptomatic systemic recurrence. Therefore, when a recur-
rence is diagnosed, it is important to make a general staging assessment of
the extent of disease before the MDT formulates a treatment plan, which
may involve treating both local and systemic recurrence. Management is
very much a multidisciplinary activity.
OVERVIEW 209
Management of recurrence
Local recurrence following breast conservation
This will either be found as a lump on clinical exam or, more commonly,
on mammography at follow-up. When this follows wide local excision
for invasive cancer, the only option is mastectomy. This is because if the
patient has already had radiotherapy, it cannot be repeated, and the recur-
rence suggests that the disease is more extensive than appeared initially
and is radioresistant; therefore, anything less runs the risk of another
recurrence at some point in the future. The possible exception to this is
when a patient, for some reason, has not had previous radiotherapy. In
these circumstances, if a patient was unwilling to consider mastectomy,
further wide local excision could be considered, this time combined with
radiotherapy; these situations will be rare though.
Local recurrence following mastectomy
This can vary in extent, from a single small nodule in a scar to a ‘field
change’ with multiple nodules of widespread recurrence throughout the
skin flaps. If radiotherapy had not been used originally, most cases will
require a course of radiotherapy to the chest wall. In addition, there may
be a case for surgical excision as well. With a very small area of local-
ized recurrence, this may be quite straightforward. However, if the area is
extensive, clearance may be difficult to achieve and might involve the use
of flaps to cover the defect. A full assessment and MDT discussion should
take place before embarking on any surgery.
Local nodal recurrence
These can occur despite axillary clearance. There is no single correct
treatment, and every case needs individual assessment and discussion.
The options include:
• Local surgery to debulk the nodes, followed by a further course of
systemic treatment, often chemotherapy.
• Systemic treatment on its own, using the nodes as a means of assessing
response to treatment.
• Radiotherapy: this can have a place for nodes, particularly those
difficult to access surgically in the supraclavicular fossa; however,
there can be significant morbidity with lymphoedema following this,
particularly if a node clearance has been performed.
Systemic recurrence
In addition to the physical symptoms produced, systemic recurrence can
be a source of major psychological morbidity since it is systemic recur-
rence that leads to death. It is important to appreciate that its presence
means that the cancer is no longer curable, and, even if this episode is
controlled, it will recur at some time in the future, unless the patient dies
of something else in the meantime. Nevertheless, with modern chemo-
therapy, biological modifiers, and hormone manipulation, significant con-
trol can be gained, and very worthwhile quality of life can be achieved. The
majority of patients get a good response to treatment of both their first
and second recurrences; thereafter, results become much less predictable.
MANAGEMENT OF RECURRENCE 211
The common sites for recurrence are:

• Bone.
• Liver.
• Lungs.
• Brain.
Management of the patient will involve:
• An assessment of disease extent.
• An assessment of the patient’s physical state and suitability for treatment.
• A pathological assessment of the tumour; suitability for treatment with
hormone therapy or biological modifiers, such as Herceptin®.
• A discussion with the patient and their relatives about treatment and
what it involves.
In the past, diagnosis of recurrence has often been by imaging alone; how-
ever, there is an increasing argument that, where possible, a biopsy is
obtained in order to reassess receptor status, as this may have changed
since the original diagnosis.
Most recurrences will be treated by systemic therapy, the general prin-
ciples of which are:
• Chemotherapy will produce a faster response than hormone
manipulation.
• Hormone receptor-positive tumours may respond to a change of
hormone therapy rather than automatically opting for chemotherapy.
• Hormone receptor-negative tumours will usually need a further course
of chemotherapy, often with taxanes.
• Patients with Her-2-positive tumours who did not receive trastuzumab
will benefit from that treatment.
Management of skeletal metastases

and palliative care
The skeleton is probably the commonest site of first systemic recurrence.
In the first instance, it may be the only site and often responds very well
to treatment. There are important aspects to remember in managing skel-
etal metastases (see Further reading). A thorough radiological assessment
and a low threshold for referral to an orthopaedic surgeon is important
because:
• There may be long bone metastases which are in danger of producing
a pathological fracture requiring stabilization.
• There may be vertebral body deposits that are in imminent danger of
producing cord compression.
In addition, a proportion of patients may present with hypercalcaemia
which requires emergency admission and treatment with:
• Intravenous rehydration.
• Intravenous bisphosphonates.
Outside these acute situations, management of bone metastases is
usually by:
• A course of systemic treatment usually dictated by receptor status.
• Local radiotherapy to painful metastases or those in danger of fracture.
• Oral bisphosphonates.
Role of surgery and radiotherapy in systemic
recurrence
Both these modalities have limited use in systemic recurrence. Surgery
may be used:
• To biopsy an accessible recurrence, if necessary.
• For isolated liver and brain metastases which may be suitable for
resection.
• To stabilize skeletal metastases.
Radiotherapy is primarily used in skeletal metastases, although it can be
used for brain metastases as well.
Role of palliative care
Palliative care techniques are a discipline in themselves, and it would be
pointless trying to cover them in this chapter (see b Oxford Handbook
of Palliative Care, 2e (2009). Watson et al. Oxford University Press,
Oxford, UK). It is important to remember that they are not applicable
solely at the end of life, and palliative care teams have much to offer in
helping in the physical management of problems related to recurrence. It
is well worthwhile arranging for patients with recurrence to make contact
with palliative care services in order to make an assessment of their likely
needs, both physical and psychological.
LOCALLY ADVANCED BREAST CANCER 213
Locally advanced breast cancer

There are two situations generally in which this occurs:
• As chest wall recurrence following previous surgery for breast cancer.
• As initial late presentation of primary disease.
In this latter case, it may well be associated with systemic disease so that,
in this situation, a full screen for systemic disease is important. It is also
important to realize that these patients may only present because their
family are distressed by the smell of a necrotic fungating tumour that the
patient has been hiding for some time and may have resulted in them
being socially isolated. Apart from considerations of tumour treatment,
they often need the care of specialist wound care services to gain control
of anaerobic infection, which makes the situation even more distressing.
There is no single correct management of the local problem, and it is
often harder to deal with if it is recurrence after treatment rather than
initial presentation. The general approach is to:
• Use systemic therapy to reduce tumour burden.
• Following a good response, embark on salvage surgery to debulk the
local disease and optimize local control.
• Use radiotherapy to consolidate control following surgery.
In some patients, even after systemic therapy, surgery is not possible, and,
in these circumstances, radiotherapy, if it has not already been used, may
be helpful.
Unfortunately, there is a small group of patients in whom neither physi-
cal nor pharmacological manipulation proves effective, and they need the
help of both the wound care and palliative care services.
Further reading
Breast cancer (early and locally advanced). Available at: M http://www.nice.org.uk/CG80.
Breast cancer (advanced). Available at: M http://www.nice.org.uk/CG81.
British Association of Surgical Oncology Guidelines (1999). The management of metastatic bone
disease in the United Kingdom. Eur J Surg Oncol 25, 3–23. Also available at: M http://www.
associationofbreastsurgery.org.uk/media/4505/the_management_of_metastatic_bone_disease_
in_the_united_kingdom.pdf.
Chapter 24 215
Management of the
high-risk patient
Overview 216
Genetic mutations 218
Determining breast cancer risk 220
Genetic testing 222
Management of the higher risk patient 224
Further reading 226
216 CHAPTER 24 Management of the high-risk patient
Overview
Breast cancer is common in the population, affecting approximately one
in every nine women. It is, therefore, extremely common for women to
volunteer that a family member has previously been affected by breast
cancer. With the help of NICE guidance (see Further reading), it is impor-
tant to stratify the level of individual risk. The majority of women can be
reassured that, despite their family history, they are not at an increased
risk of breast cancer. Those with a significant family history should be
offered appropriate early screening and genetic assessment, if applicable.
OVERVIEW 217
Genetic mutations
Breast cancer mutations can be:
• Somatic (non-inheritable), i.e. sporadic 90%: due to failure of DNA
repair mechanism of both copies of the gene. Sporadic mutations
are the most common cause of cancer. The likelihood of sporadic
mutations increases with age (see Fig. 24.1).
• Germline (inheritable), 5–10%: breast cancer germline mutations
demonstrate an autosomal dominant pattern, i.e. inherit one abnormal
copy and one normal copy from parents. Inheritance of two abnormal
copies is not compatible with life. Only when the DNA in the normal
copy mutates can cancer develop. This occurs at a younger age than
sporadic cancer, as only one copy of the DNA has to mutate.
It is likely there are many germline mutations which will confer a range
of breast cancer risk. So far, the genetic mutations identified have a high
lifetime risk (>40% and up to 80% for the BRCA genes) of cancer suscep-
tibility (high penetrance genes).
• The breast cancer susceptibility genes (BRCA1 and BRCA2) are
responsible for 2–5% of all breast cancers. Women carrying these
genes have a 55–80% lifetime chance of developing breast cancer. If
they have large enough families, these women often have three or four
affected members at a young age. Also linked with ovarian, bowel, and
prostate cancer. BRCA2 is associated with male breast cancer.
• Mutation in p53 (Li Fraumeni syndrome) causes early-onset breast
cancer, along with brain tumours, leukaemias, childhood sarcomas, and
adrenocortical carcinomas.
• Mutation in one of several mismatch repair genes is linked to breast
cancer as well as bowel (hereditary non-polyposis colorectal cancer),
endometrial, ovarian, pancreatic, and stomach cancers.
• Mutation in CHEK2 doubles the background risk of breast cancer and
appears to be involved in many families where two cases are identified.
• Mutations in PTEN (Cowden’s syndrome), STK11/LKB1 (Peutz–
Jeghers), and ATM (ataxia telangiectasia) are also occasionally a cause
of familial breast cancer.
However, each family needs to be assessed on its own merits, remem-
bering that the high incidence of breast cancer (1 in 9) means that many
women will have an affected relative merely by chance, rather than due
to a genetic abnormality. Indeed, over 85% of women with an affected
first-degree relative will never be affected themselves, and over 85% of
affected individuals have no significant family history.
GENETIC MUTATIONS 219
“sporadic” cancer
—common
CANCER
Key
Breast cell
Body cell Breast cell (tumour) Normal gene
CANCER
Mutated gene
germline mutation
cancer—rare
Fig. 24.1 The two-hit theory. Mutations in both copies of the genes must be
present for a cancer to develop. This can occur sporadically due to chance or one
mutated copy of the gene can be inherited as a germline mutation.
Determining breast cancer risk

Preliminary identification of families at higher risk comes from assessment
of the patient’s family history.
Need to:
• Take an accurate, extended family history. Definitions of relatives for
NICE guidance are:
• First-degree relative is mother, sister, or daughter.
• Second-degree relative is grandmother, aunt, or niece.
• Need both sides of family: paternal and maternal.
• Confirm histology of cancer diagnoses (including ovarian).
• Age at diagnosis.
Factors that predict for likely germline mutation and increased cancer
susceptibility:
• Number of breast cancer cases.
• Number of confirmed ovarian cancer cases.
• Any woman with both breast and ovarian primaries.
• Ages of diagnoses (generally, <50 is ‘young’).
• Any bilateral breast cancer.
• Any male breast cancer.
• Ashkenazi Jewish ancestry.
Assessment of other risk factors, including;
• Female sex.
• Increasing age.
• Oestrogen exposure: endogenous oestrogen, age at menarche and
menopause, number of full-term pregnancies, and age at first pregnancy.
Exogenous oestrogens, such as contraceptive hormones and HRT.
• Pathological high-risk factors, such as LCIS, ADH, multiple papillomas.
• Alcohol intake.
• Weight.
An easy way to accurately assess a patient’s risk is to use ‘risk assess-
ment software’, such as the IBIS risk evaluator (see Further reading). This
software assesses a patient’s individual risk and evaluates for age, BMI,
oestrogen exposure, previous high-risk pathology (e.g. ADH), and family
history. The software outputs a family tree and a 10-year and lifetime risk
of breast cancer for that individual.
NICE guidance—levels of breast cancer risk
Stratifying the level of risk into one of three categories not only gives
patients and clinicians knowledge of the future risk of breast cancer, but
also determines what screening and future management will be offered
(see Table 24.1).
High-risk: lifetime risk >30%
• Four breast cancers in family at any age; three <60; two < average age 50.
• One breast <50 (or two breast cancers <60) plus one ovarian cancer.
• Two ovarian cancers.
• One male breast cancer plus female breast cancer before 50 (or plus
two breast cancers <60).
DETERMINING BREAST CANCER RISK 221
Table 24.1 Summary of the NICE guidance as to 10-year and lifetime

risk of breast cancer for each risk category
Level of risk 10-year risk of Lifetime risk of Management
breast cancer breast cancer
At or near <3% <17% Refer back to primary
population risk care
Raised risk 3–8% 17–30% Managed in secondary
care (breast family
history clinic)
High >8% >30% Refer to tertiary care for
genetic assessment and
testing, if appropriate
Familial breast cancer M http://www.nice.org.uk/CG41.
Raised risk: lifetime risk between 17 and 30%

• One first-degree relative breast <40.
• One first- plus one second-degree relative breast cancer any age.
• Two first-degree relatives breast cancer any age.
At or near population risk: lifetime risk <17%
• Non-significant family history.
Genetic testing
At present, genetic testing on the NHS is only offered to those with a 10%,
or greater, likelihood of detecting a mutation (not a 10% risk of develop-
ing breast cancer). This risk can be calculated using softwares, such as the
BOADICEA, BRCAPro, or IBIS evaluator.
Without gene testing, the highest predictable risk of carrying a gene or
getting breast cancer is 50%, i.e. a 1:2 chance of inheriting an abnormal
gene from either mother or father. If you carry that gene, then you have a
lifetime risk of breast cancer of 80%.
Note that usually testing is only offered if there is a live affected indi-
vidual with cancer who can be gene-tested, however new NICE guidance
now allows genetic testing on those with an affected relative who is una-
vailable for testing.
BRCA mutation testing is not 100% sensitive and has a significant false
negative rate. A positive test means you carry the gene, but a negative
test does not mean you do not carry the gene. Prior to testing, a risk
estimation is made of the likelihood and counselling offered, plus other
strategies, such as early screening, are discussed.
Those likely to be BRCA1/2-tested are:
• Three or more cases <60 (breast only).
• One breast case <50 and one ovarian case.
• Two ovarian cases.
• (Two breasts <50 is just on the borderline).
• Ashkenazi ancestry.
Take blood from a living, affected family member.
If a causative mutation in BRCA1/2 can be identified, then can offer
predictive testing to other family members.
GENETIC TESTING 223
Management of the higher

risk patient
Patients should have had their level of risk assessed. Patients at or near pop-
ulation risk should be reassured and discharged back to primary care. They
should be advised that, if their level of risk changes (i.e. another family mem-
ber is diagnosed with breast cancer), then they will need to be reassessed.
Screening
Early screening should be offered for those at raised or high risk of breast
cancer. This will take the form of mammographic screening or MRI screen-
ing or both (see Table 24.2). Those with TP53 mutations are very suscep-
tible to genetic damage caused by X-rays; these women should ONLY be
offered MRI screening. Screening of high-risk women should be performed
under the auspices of the NHSBSP, subject to the same QA standards
(see Chapter 2).
Prior to enrolment to a breast cancer surveillance programme and at
each subsequent change in the programme, women should be provided
with a documented plan that includes:
• Written patient information and discussion on mammography and MRI,
including the risks and benefits.
• A clear description of the methods and intervals.
• The reasons for any changes to the surveillance plan.
• Sources of support and further information (see Further reading—
NICE guidance).
Risk management
Those at raised risk of breast cancer can alter their level of future risk
by modifying their risk factors or by undergoing risk-reducing treatments.
Women at raised or high risk of breast cancer should be advised of
their risk factors for breast cancer and of the benefits of risk modification
(see Table 24.3).
Risk-reducing treatments
Risk reduction is a complex topic, and many patients are very emotive,
as many have personal experience of family members being treated for
breast cancer. All options for risk reduction, including surveillance only
and no treatment at all, should be discussed. A specialist clinical psycholo-
gist can be invaluable to the patient to clarify their thinking and values
prior to making a final decision.
Risk-reducing surgery
Risk-reducing surgery for the breast really means risk-reducing mas-
tectomy. The amount of breast tissue removed during the mastectomy
determines the level of risk reduction; the risk reduction is approxi-
mately 92–99%. Sparing the nipple inevitably leads to a better cosmetic
result but also leaves ductal tissue behind the nipple; patients should be
warned that this increases their level of future breast cancer by 2–5%.
All patients considering risk reduction surgery should have up-to-date
MANAGEMENT OF THE HIGHER RISK PATIENT 225
Table 24.2 NICE guidance for breast screening in higher risk women
Age Mammography MRI
(years)
20–29 Not available Only for those at exceptionally high
risk (annual risk >1%), e.g. TP53
carriers
30–39 Individualized screening Annual MRI for those at high risk
should be offered for (10-year risk >8%), including those
known mutation carriers known to be mutation carriers
40–49 For women with a raised Annual MRI for women:
or high risk of breast
>20% 10-year risk of breast cancer
cancer (10-year risk >3%)
>12% 10-year risk of breast cancer
with dense breast pattern on
mammography
Known high-risk mutation carriers
>50 3-yearly screening under Not available
the NHSBSP
Annual mammography
up to age 70 for those at
high risk
Familial breast cancer M http://www.nice.org.uk/CG41. 1.4.4 surveillance.
Table 24.3 Risk-modifying behaviours to reduce future risk of

breast cancer
Risk factor Risk-reducing behaviour
HRT Avoidance of HRT or keeping the treatment course as short
as possible
Hormonal Advise those over age of 35 of slightly increased risk of breast
contraception cancer. BRCA carriers taking hormones have an increased risk
of breast cancer but a reduction in their ovarian cancer risk
Breastfeeding Reduces future risk of breast cancer
Alcohol Excess alcohol consumption increases breast cancer risk but
also reduces cardiovascular risk at low levels of consumption
Smoking Stop-smoking advice
Weight and Women should be informed of the increased risk of breast
physical exercise cancer in overweight, post-menopausal women. Exercise will
help reduce risk
screening radiology and have seen a clinical psychologist prior to their

surgery being finalized.
Risk-reducing oophorectomy should be offered to those at high risk of
ovarian cancer (BRCA carriers). The risk of ovarian cancer in BRCA carri-
ers does not start until age 40 (BRCA 1) or 50 (BRCA 2); therefore, there
is no rush to remove the ovaries prior to these ages, as the health benefits
of the ovaries at a young age clearly outweigh the risks.
Following oophorectomy, a woman will be rendered post-menopausal,
and this will reduce her risk of future breast cancer by 50%. This risk
reduction alone may be enough, for some women, in eliminating the need
for breast surgery.
Endocrine prevention
Chemoprevention of breast cancers with 5 years of tamoxifen or ralox-
ifene is now licensed in the UK following a recent NICE consultation (see
Further reading). This is only offered to moderate and high risk women.
There is some evidence that tamoxifen, raloxifene, and anastrozole reduce
the incidence of ER-positive breast cancers; however, there is no survival
benefit (see Further reading).
Support services
All women should be given written information throughout their jour-
ney through primary, secondary, or tertiary care. This should detail their
level of risk, lifestyle advice, contact information, and a summary of the
discussions that have occurred. It is recommended that all patients with a
family history have access to nursing support (such as a breast care nurse)
and a clinical psychologist, preferably with a special interest in breast
cancer. Information should also be provided on local support groups.
These patients with a family history have complex problems that are best
dealt with by a specialist multidisciplinary team in an environment where
patients are given adequate time for discussion and contemplation.
Further reading
Familial breast cancer. Available at: M http://www.nice.org.uk/CG41
NICE. Available at: M http://www.nice.org.uk/CG164
Fisher B, Costantino JP, Wickerham DL, et al. (2005). Tamoxifen for the prevention of breast
cancer: current status of the National Surgical Adjuvant Breast and Bowel Project P-1 study.
J Natl Cancer Inst 97, 1652–62.
Vogel V, Constantino J, Wickerham D, et al. (2010). Update of the National Surgical Adjuvant
Breast and Bowel Project Study of Tamoxifen and Raloxifene (STAR) P-2 Trial: Preventing
breast cancer. Cancer Prev Res 3, 696–706.
Lostumbo L, Carbine N, Wallace J (2010). Prophylactic mastectomy for the prevention of breast
cancer. Cochrane Database Syst Rev 10, CD002748.
Chapter 25 227
Research and audit
Overview 228
Tools for research and audit 230
Clinical trials and levels of evidence 232
Conclusion 236
Further reading 236
228 CHAPTER 25 Research and audit
Overview
Within the NHS, breast surgeons have made enormous national contribu-
tions to audit and research. Demonstrating a continuing involvement with
audit is an important component of both appraisal and revalidation. This is
particularly so for breast surgeons, as participation in NHSBSP screening
audit is an important part of a screening unit’s inspection process. Aside
from this, in pure terms, knowledge of research methods and process is an
important part of training, even if you do not carry out any research your-
self. Often, the distinction between research and audit becomes blurred.
One way of seeing the difference is to regard research as finding out what
we should be doing and audit as seeing whether we are doing it. In other
words, audit is involved with looking at the way we work and how effec-
tive it is, which forms the first part of the audit loop. In this concept, we:
• Analyse and identify problems in what we do.
• Formulate and implement strategies to correct them.
• Re-analyse the situation to see whether the expected improvements
have occurred.
To audit effectively, a standard, against which to compare our perfor-
mance, is required. In contrast to this, research does not necessarily need
standards because this is the process whereby we extend our knowledge.
The audit process may raise questions which research can be used to
answer so that another way of looking at the differences between the two
is to say that audit raises the questions and research attempts to answer
them. To accomplish both of these activities, certain tools are needed,
without which the whole process can become pointless.
OVERVIEW 229
Tools for research and audit

Before embarking on either of these activities, it is important to look at
several issues if whatever you do is going to be effective.
Background literature or fact search
It is important to establish what is known already. Somebody else may have
answered what is a new question to you. Even if it has, you need to evaluate
how they have done it and whether their methods were sound and their
conclusions justified. Similarly, in audit, you need to know what standard
you are judging against and whether any exist. It is often wise to let some-
body completely independent look at the idea, as they will often point out
things that you have forgotten. For a pure research project, it will often be
impossible to go ahead without some form of external peer review.
What resources are needed?
It is almost impossible to carry out any project without resource, be it
patient records, specimens, laboratory support, IT facilities, access to a
good database, secretaries, or nurses. What you are going to do needs
mapping out and a shopping list produced to make it work. An important
component often forgotten in planning is time—you need to ask yourself
‘Do I, or the others involved, have the necessary time?’ Following from
that is the support and goodwill needed from other people. Scientific pro-
jects may need the help of either a university or research institute.
Do I have the resources?
Very simple audit projects may need very little resource and be easily
deliverable; however, as projects become complex, more is needed, and
most research projects need some form of funding. This will need costing
out and a decision made as to where the money is coming from.
Do I need statistical advice?
This may not be relevant for audit projects, but anything that compares
outcomes in a numerical way may need statistical analysis in order to have
validity. This needs to be built into the plan because it may influence the
numbers of specimens, patients, or events that are needed for the work
to be valid. For projects that require ethical approval, it may be impossible
to obtain without submitting a statistical analysis.
Research and ethics approval
This is an extremely important aspect to consider. An audit may not
require ethics approval; however, if there is doubt, advice should be taken
from the appropriate ethics committee. For anything that has, what could
be called, an element of research, a formal application must be made
for ethical approval to the ethics committee related to the institution
where the research is to be conducted. It must also be remembered that
research involving patients or specimens from patients requires patient
consent. For the application, details will be needed of:
• Rationale for the project.
• Methods to be employed.
TOOLS FOR RESEARCH AND AUDIT 231
• Numbers of patients or specimens required.

• Statistical basis for numbers.
• Who will be carrying out the project.
• Sample of information leaflets and consent.
• Details of how confidentiality will be maintained.
Most applications can now be completed online by accessing the research
ethics website.
Research and development committee
The Research and Development department will be interested in any
extra costs that may be incurred as a result of a research study. In many
units, funding for research must be found before the study can begin to
recruit. Close links with research and development and ethics committees
are very helpful and will help to speed up what can be a very lengthy and
convoluted paper process. Performing research requires long-term plan-
ning, persistence, and patience.
Disseminating information from research and audit
Having completed audit or research, you will want to communicate your
results to other people. Depending on the nature of the work, a variety
of forums exist:
• Local meetings.
• National meetings.
• International meetings.
• Journals.
In deciding which of these forums to use, you need to consider the group
that it will be of most interest to. Is it information mainly of interest to
a local audience or is it something that would be of interest nationally
or even internationally? Is it primarily clinical in basis or purely scientific?
Does it have broad interest within the breast community or to a spe-
cific clinical group, for instance, surgeons as opposed to radiologists? By
addressing these issues, you are much more likely to succeed in presenting
your work than by randomly submitting it.
Clinical trials and levels of evidence

Evidence-based medicine and management guidelines are based on levels
of evidence. It is important you have some basic understanding of these
(see Table 25.1).
Recommendations can subsequently be made about the direction of
clinical practice, based upon the available data (see Table 25.2).
Types of clinical trials
For information on the difference between the designs of clinical trials
and how to review the results of these trials, see Further reading (Young
and Solomon).
The purpose of a trial is to answer specific questions about the effects of

a treatment.
• Explanatory trials (phase I and II trials) evaluate the biological effects of
treatment on host and tumour in small numbers of subjects to guide
decisions about further research.
• Pragmatic trials (phase III and IV trials) evaluate the practical effects of
treatments.
The distinction is important because treatments which have desirable
biological effects (e.g. the ability to kill cancer cells and cause tumour
shrinkage) may not have desirable effects in practice (i.e. may not lead to
improvement in duration or quality of life). For example, many drugs with
strong anti-tumour effects are so toxic that patients are unable to tolerate
and derive benefit from them.
The evaluation of new cancer treatments usually involves progression
through a series of clinical trials.
Phase I trials
Evaluate relationship between dose and toxicity, and aim to establish a
maximum tolerable dose and schedule of administration.
Small numbers of patients are treated at successively higher doses until
the maximum acceptable degree of toxicity is reached. The maximum tol-
erable dose is defined as the maximum dose at which dose-limiting toxic-
ity occurs in less than one-third of patients tested. This design is based on
experience rather than data and is predicated on the assumption that the
maximum tolerable dose is also the most effective anticancer dose.
Phase II trials
Screen treatments for their anti-tumour effects to identify those worthy
of further evaluation.
They usually include highly selected patients, excluding those with
‘non-evaluable’ disease, and use tumour response rate as the primary
measure of outcome. Their sample size is calculated to distinguish active
from inactive drugs, according to whether the response rate is greater
or less than some arbitrary level, often 20%. The resulting sample size is
CLINICAL TRIALS AND LEVELS OF EVIDENCE 233
Table 25.1 Levels of evidence, as agreed by the Scottish Intercollegiate

Guidelines Network (SIGN) (see Further reading)
1++ High-quality meta-analyses, systematic reviews of RCTs, or RCTs with
a very low risk of bias
1+ Well-conducted meta-analyses, systematic reviews of RCTs, or RCTs
with little risk of bias
1– Meta-analyses, systematic reviews of RCTs, or RCTs with a high risk
of bias
2++ High-quality systematic reviews of case control or cohort
studies. High-quality case control or cohort studies with a very low
risk of confounding or bias and a high probability that the relationship
is causal
2+ Well-conducted case control or cohort studies with a low risk of
confounding or bias and a moderate probability that the relationship is
causal
2– Case control or cohort studies with a high risk of confounding or bias
and a significant risk that the relationship is not causal
3 Non-analytic studies, e.g. case reports, case series
4 Expert opinion
M http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html.
Table 25.2 SIGN grades of recommendation, based upon the levels of

available evidence
Grade of Recommendation
recommendation
A At least one meta-analysis, systematic review, or RCT
rated as 1++ and directly applicable to the target
population; or
A body of evidence consisting principally of studies rated
as 1+, directly applicable to the target population and
demonstrating overall consistency of results
B A body of evidence, including studies rated as 2++, directly
applicable to the target population and demonstrating
overall consistency of results; or
Extrapolated evidence from studies rated as 1++ or 1+
C A body of evidence, including studies rated as 2+, directly
applicable to the target population and demonstrating
overall consistency of results; or
Extrapolated evidence from studies rated as 2++
D Evidence level 3 or 4; or
Extrapolated evidence from studies rated as 2+
M http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html.
inadequate to provide a precise estimate of activity. For example, a phase

II trial with 24 patients and an observed response rate of 33% has a 95%
confidence interval of 16–55%. While tumour response rate is a reason-
able endpoint for assessing the anticancer activity of a drug, it is not an
adequate surrogate for patient benefit.
Phase II trials are suitable for guiding decisions about further research
but are not suitable for making or guiding decisions about patient manage-
ment. However, the literature is often confusing because phase II trials are
often reported and interpreted as if they do provide answers to questions
about patient management
Phase III trials
Determine the usefulness of treatments in patient management.
Questions about patient management tend to be comparative since
they involve choices between alternatives, i.e. an experimental vs the
current standard management. The current standard may include other
anticancer treatments or may be the best supportive care without specific
anticancer therapy. The aim of a phase III trial is to estimate the differ-
ence in outcomes associated with a difference in treatments, sometimes
referred to as the treatment effect.
Ideally, alternative treatments are compared by administering them to
groups of patients which are equivalent in all other respects. Randomized
controlled phase III trials are the best, and often only reliable, means of
determining the usefulness of treatments in patient management.
Phase IV
Monitor the effects of treatments which have been incorporated into clini-
cal practice.
Setting up clinical trials and studies
Clinical trials and studies are probably the commonest research activity
that clinicians working in breast units become involved with. The trials
and studies can involve all modalities of therapy, surgery, radiotherapy,
and medical oncology as well as related clinical areas. Clinical trials are
very carefully regulated; many relating to breast cancer are run by national
organizations or groups, rather than being purely drug company-sponsored,
and frequently involve multiple centres. The trial protocol will often have
received multicentre ethical approval (MREC), but it is still necessary for it
to be put before the hospitals local ethical committee (LREC). In order for
it to get through this process, it will be necessary to have:
• A local principle investigator.
• Adequate resource to run the trial.
• Sufficient numbers of whatever group of patients are being studied.
Integrated software (IRAS) is now universally available which streamlines
the application process in an online format (see Further reading). Modern
trials and studies require a very significant amount of documentation,
which must be carefully recorded. This begins with the consenting process
for entering patients into studies and continues throughout the course of
the study. Often, the whole process is helped by having trial nurses, who
can help with much of the routine day-to-day organization.
CLINICAL TRIALS AND LEVELS OF EVIDENCE 235
It is now expected that those involved with trials, both in organiza-

tion and entering patients, will have attended a course on Good Clinical
Practice in relation to trials. Failure to have attended such a course may
well prevent someone from becoming the principle investigator for a trial
locally.
Conclusion
Research and audit can seem daunting but can be made easier if you:
• Are well organized.
• Ask for help.
• Do background work thoroughly.
Further reading
Young J, Solomon, M (2009). How to critically appraise an article. Nat Clin Pract Gastroenterol
Hepatol 6, 82–91.
SIGN Guidelines. Available at: M http://www.sign.ac.uk/guidelines/fulltext/50/annexb.html.
IRAS Integrated Research Application System. Available at: M http://www.myresearchproject.org.uk.
Chapter 26 237
Complaints, mistakes,
and how to minimize
problems
Overview 238
How to prevent incidents 239
Where are you vulnerable? 240
The grid 242
238 CHAPTER 26 Complaints and mistakes
Overview
In a high-profile specialty where the patient and family are understandably
anxious, it is inevitable that, for whatever reason, the interaction between
the surgeon and the patient may occasionally not work well. In addition,
other members of the team, or the wider institution, may not fulfill the
patient’s expectations.
The consequence is a complaint. If the complaint is not handled well,
the consequence is litigation.
Principles of dealing with a complaint:
• Take all complaints seriously; they often have some basis.
• If a complaint is made, it may just be the tip of an iceberg problem.
• Respond rapidly to complaints; do not let them fester.
• Be prepared to swiftly offer an interview and an apology.
• There will be local guidelines, so stick to them and ensure all
documentation, including responses, are properly filed.
• Complaints often represent a failure of team working. There should be
regular meetings of the Breast Unit when complaints can be discussed
in a non-judgemental manner.
• Complaints represent an opportunity to make things better for the
patient and thus should be welcomed. So often, patients just want an
explanation and an apology. Therefore, acknowledge errors; apologize,
and respond rapidly.
HOW TO PREVENT INCIDENTS 239
How to prevent incidents

Never forget lawyers deal in paper. In civil law, the basis of proof is based
on the balance of probability. This means that, if, on the evidence, the
judge feels that it is 50.1% likely that something untoward happened as a
result of an action, that action will be deemed negligent. Write clear hand-
written or computer-generated notes, which are signed, timed, and dated.
• Poor notes = poor defence.
• No notes = no defence.
Delay in the diagnosis of breast cancer is the most frequent cause of litiga-
tion in breast disease.
Partly, this is because the most difficult decision in an outpatient breast
clinic is to decide whether the patient has a discrete lump or whether the
area of concern is merely an area of vague nodularity.
Therefore, what you write and, in particular, draw is of crucial impor-
tance when litigation starts 4 years later.
For example, consider the following scenario where the drawing of
the breast and the area is labelled ‘Lump’. Most experts and lawyers will
believe that the surgeon found a lump. The situation is exacerbated if
the clinician then fills it in to make it look solid. Most patients in a breast
clinic do not have a lump, so do not draw one. Patients have vague inde-
terminate areas of nodularity about which they are concerned. So try to
be accurate:
Write ‘Area of concern to the patient. No discrete lump.’
The issue in delay in diagnosis litigation is ‘did the surgeon believe the
patient had a lump or not?’ If the word lump is written, experts and law-
yers will believe there was a lump and will want to know why it was not
properly investigated or discussed.
All breast experts are familiar with the patient who thinks she has a lump
but, in fact, has a vaguely nodular/lumpy area. It is a common presentation.
Expectations of how a vaguely nodular area is investigated and not fol-
lowed up are different from where the word lump has been written.
Where are you vulnerable?

Poorly organized or staffed clinics
A diagnostic breast clinic involves clinical examination, probable mammog-
raphy, and an U/S plus a smaller number of new patients having a core
biopsy or cyst aspiration.
Thus, the lack of a breast radiologist or too many patients for that
breast radiologist will result in delays in processing patients, overcrowded
waiting rooms, and complaints.
Doctors and managers must work together to ensure a smooth and
seamless experience for the patient. Retail is detail. Think how much you
appreciate interminable waits and wearing backless gowns, and recognize
that these sorts of indignities start to irritate already anxious patients.
Is it a lump?
As already noted, you must state clearly whether that patient has a lump
or non-specific nodularity in the area of concern to the patient.
The pregnant breast
Many pregnant women develop concerns about possible sinister changes.
The availability of good-quality contemporary U/S of the breast has
done much to improve our ability to reassure this group of patients, and
there should be no hesitation to use U/S. Such patients should be offered
rapid, if not open, access to a diagnostic breast clinic if they have continu-
ing concerns during their pregnancy.
Sometimes, the cause is a fibroadenoma. It is usually possible to reas-
sure the patient and to then offer a clinical and an U/S review when they
have delivered and finished breastfeeding.
Implants
Less of a problem these days, as breast MRI is much more available.
Occasionally, a non-specialist breast radiologist may baulk at doing a core
biopsy for fear of damaging the implant. If this is the case, it is in the
patient’s best interests for her to be referred to a breast radiologist who
does have these skills. These patients must be discussed at an MDM.
Failure of multidisciplinary working
The failure for key members of the MDT to communicate effectively and
work cohesively is a frequent cause of a delay in diagnosis. MDTs must
have adequate clerical and administrative support.
WHERE ARE YOU VULNERABLE? 241
Oncoplastic surgery
It is vital that the patient has a realistic expectation of what can be
achieved together with the risks. Decisions and advice should be carefully
documented. It is good practice to copy clinic letters to the patient.
Decision-making in oncoplastic surgery may well require two, or more,
clinic visits. A list of all the complications related to a particular procedure
must be written down as they are discussed with the patient.
Clinical photographs are an important part of oncoplastic surgery.
Patients must have an opportunity to see photographs of both good and
bad results (see Further reading—ABS oncoplastic guidelines).
The grid
It is helpful to structure a diagnostic triple assessment by using the
following grid.
In breast disease, each modality is marked from 1 to 5. Thus, B2 = benign
core biopsy and M5 = mammogram reveals malignancy.
Thus, set a grid (see Table 26.1).
• Each score should be circled.
• If the scores are all 5, e.g. P5, M5, U5, B5, then, after discussion in
the MDM, the patient can confidently be diagnosed as having breast
cancer.
• If all the scores circled are 2, e.g. P2, M2, U2, B2, then the patient has a
benign problem.
• Beware the discordant triple assessment.
• A pattern of results, such as P3, M4, U3, B1, is discordant, and it is
essential that the reasons for this discordance are discussed at an
MDM, and an agreed plan to resolve this discordance must be agreed.
THE GRID 243
Table 26.1 A grid is useful for demonstrating concordance between

the different elements of assessment.
Abbreviation 1 2 3 4 5
Normal Benign Uncertain Suspicious Cancer
Clinical/ P 1 2 3 4 5
palpable
Mammogram M 1 2 3 4 5
Ultrasound U 1 2 3 4 5
Biopsy B 1 2 3 4 5
Circle the appropriate number for each element of the assessment. Non-concordance should
promote multidisciplinary discussion and reassessment.
245
Index
A duct ectasia 68
fat necrosis 66
chemotherapy 126, 128,
130, 138
abdominal flap fibroadenoma 62, 86 communicating risk 40
reconstruction 184–6 giant fibroadenoma 63 diet 39
aberrations of normal hamartoma 66 ductal carcinoma
development and infections 70, 71 in situ 110, 112
involution (ANDI) 60 mastalgia 76 epidemiology 36
abscesses 70, 71, 82 mastitis 68, 70, 72 family history 38
accessory breast tissue Mondor's syndrome 67 follow-up 6
excision 87 nipple discharge 78 gender 38
accessory breasts 26 phyllodes tumour 63 genetic factors 38, 218,
accessory nipples 26, 59 radial scar 74 219
acellular dermal sclerosing lesions 74 genetic testing 222
matrices 180 surgical management 81 geographic variation 36
adipose-derived BIG 18s 12 height 39
regenerative cells 188 biopsy 5, 14, 42, 54, 55, Her-2/neu 101, 131
‘Adjuvant! Online’ 104 120, 121 hormonal factors 39
adjuvant therapy 123 blood tests 56, 93 hormone replacement
alcohol intake 39 Bloom and Richardson therapy 39
Allred scoring system 101 grading 100 hormone therapy 125,
amastia 59 body mass index 39 138
American Joint Committee bone metastases 212 in situ (non-invasive)
on Cancer staging 102, brachial plexus damage disease 98, 109–14
103 137 incidence 36
anastrozole 125 BRCA1/2 218, 222, 225 infiltrating ductal 98
antibiotic prophylaxis 146 breast abscesses 70, 71, 82 infiltrating lobular 98
arm lymphoedema 135, 136 breast anatomy 26, 27, 29 invasive 98
armpit anaesthesia 135 breast assessment ionizing radiation 40
aromatase inhibitors 125, blood tests 56 lifestyle 39
138 clinical assessment 48–49 lobular intraepithelial
artificial nipples 194 imaging 50 neoplasia 114
ataxia telangiectasia 218 microbiology 56 locally advanced 213
athelia 59 pathology 54 mammographic density 40
ATM 218 staging investigation 56 managing higher risk
atypical ductal triple assessment 46, patients 224
hyperplasia 110, 111 242, 243 margin management 118
atypical lobular breast asymmetry 26, 204 mastectomy 116, 120
hyperplasia 114 breast augmentation 200 medullary 99
audit 12, 17, 23, 228, 230 breast cancer in men 38, 91
axilla 28, 32, 33 adjuvant therapy 123 molecular
axillary lymph node age 38 classification 106
clearance 120, 121 alcohol intake 39 molecular factors 101
axillary radiotherapy 124 aromatase inhibitors 125, mucinous 99
138 nipple discharge 78
atypical ductal obesity 39
B hyperplasia 110, 111 oestrogen receptor
Baker classification 203 axillary lymph node status 101
Benelli breast reduction 156 clearance 120, 121 oophorectomy 126, 138
benign breast disease 57 axillary radiotherapy 124 oral contraceptive use 39
aberrations of normal benign breast disease 40 pain management 151
development and breast-conserving palliative care 212
involution (ANDI) 60 surgery 119, 171 physical activity 39
abscesses 70, 71, 82 carcinoma of no special physical factors 39
breast cancer risk 40 type 98 post-operative
congenital disorders 59 carcinoma sequence 110 complications 134
cysts 64 chemoprevention 226 prevalence 36
246 INDEX
breast cancer (Cont’d) antibiotic prophylaxis 146 breast volume 28

previous history of breast avoiding mistakes breasts
cancer 38 in oncoplastic aberrations of normal
prognostic tools 104, 105 surgery 241 development and
radiotherapy 124, axillary lymph node involution (ANDI) 60
136 clearance 120, 121 accessory 26
recurrent 208, 210 benign breast lumps 86 blood supply 28, 29, 30
reproductive factors 39 breast abscess 82 development 28, 60
risk determination 220 breast augmentation 200 developmental variants 26
risk factors 38 breast cancer duct system 26
risk-reducing management 115 endocrinology 28
treatment 224 breast-conserving 119, fat 27
sentinel lymph node 171 hypoplasia 59
biopsy 120, 121 breast reconstruction 177 involution 60
site 28 breast reduction 153 lobes 26
skeletal metastases 212 common local lymphatic drainage 28, 31
socio-economic status 37, complications 86 milk line 26
39 consent 146, 155, 180, nerve supply 28,
staging 56, 102, 103 183, 185, 194 31
surgical management 115 diabetics 144 stroma 27
survival 37 drains 148, 160 terminal duct lobular
tamoxifen 125, 126, 138 early discharge 142 unit 26, 27
trastuzumab enhanced recovery 142
(Herceptin®) 131, 139 fibroadenoma 86
tubular 98 flap management 149 C
tumour grading 100 lipomodelling 187 C-V flap 196, 197
wide local excision 116, mammillary fistula 85 cancer pain 151
172 margin management 118 carcinoma of no special
breast clinics 4, 42, 240 marking patient 146, type 98
breast-conserving 158, 195 cardiac problems 137,
surgery 119, 171 mastectomy 116, 120, 139
breast cysts 64 163, 224 CHEK2 218
breast development 26, microdochectomy 78, 84 chemotherapy 126, 128,
28, 60 nipple-areola 130, 138
breast embryology 26 reconstruction 193 chest irradiation 40
breast examination 48 peri-operative drug chest wall pain 77
breast imaging 50, 93 management 145 clinical assessment 48–49
breast implants 180, 200, physiotherapy after 150 clinical trials 232
201, 240 post-operative care 148, communication
breast infections 70, 71 160, 203 breast cancer risk 40
post-operative 135 post-operative in multidisciplinary
breast liposuction 94, complications 134 teams 24
95, 157 post-operative results of research and
breast lumps 60 consultation 5 audit 231
excision of benign post-operative pain 142, complaints 238
lumps 86 148 complex sclerosing
frequency and age at preoperative lesions 74
presentation 61 assessment 116, concordance 47
recording in notes 239, 144, 155 congenital disorders 59
240 preoperative consent 146, 155, 180, 183,
referral guidelines 44 preparations 146 185, 194
breast lymphoedema 135, risk-reducing 224 Cooper's ligaments 26
136 sentinel lymph node core biopsy 5, 14, 42, 54
breast pain 45, 76 biopsy 120, 121 Cowden's syndrome 218
breast reconstruction 177 symmetrization 204 cysts 64
breast reduction 153 thromboprophylaxis 146
breast screening, see total duct excision 78,
NHS Breast Screening 84–85 D
Programme wide local excision 116 danazol 77
breast structure 26, 29 wound care 148 diabetes 144
breast surgery breast symmetry 26, 204 diet 39
accessory breast tissue 87 breast tissue expanders 201 discharge planning 142
INDEX 247
drains 148, 160

drug-induced
G invasive breast cancer 98
involution 60
gynaecomastia 92 genetic mutations 38, IRAS 234
ductal carcinoma 218, 219
in situ 110, 112 genetic testing 222
ducts 26 giant fibroadenoma 63 L
atypical ductal goserelin 126, 138 lactational abscess 70, 71
hyperplasia 110, 111 grade lapatinib 131
ductal carcinoma Bloom and Richardson latissimus dorsi
in situ 110, 112 grading 100 reconstruction 182
ectasia 68 grafts 196, 198 letrozole 125
microdochectomy 78, 84 granulomatous mastitis 72 levels of evidence 233
multiple duct gynaecomastia 89 Li Fraumeni syndrome
papilloma 79 blood tests 93 218
periductal mastitis 68 causes 92 life events 6
total duct excision 78, drug-induced 92 lifestyle 39
84–85 examination 91 lipomodelling 187
excision 94 liposuction 94, 95, 157
history-taking 91 literature search 230
E imaging 93 lobular carcinoma
Early Breast Cancer liposuction 94 in situ 114
Trials Collaborative management 93 lobular intraepithelial
Group 126 primary care 91 neoplasia 114
early discharge 142 locally advanced breast
eczema 45 cancer 213
embryology 26 H lumps, see breast lumps
Enhanced Recovery Hadfield's operation lung problems 137
Programme 142 84–5 lymphatic system 28, 31,
ethical issues 230, 234 haematoma 134 32, 33
evidence 233 hamartoma 66 axillary lymph node
examining patients 48, Health Care Assistants 4 clearance 120, 121
91 Her-2/neu 101, 131 sentinel lymph node
exemestane 125 Herceptin® 131, 139 biopsy 120, 121
expanders 201 history-taking 48, 91 lymphoedema 135, 136
Hodgkin's lymphoma 40
hormone replacement
F therapy 39 M
family history, breast cancer hormone therapy 125, magnetic resonance
risk 38 138 imaging 52
fat necrosis 66 hormones male breast cancer 38, 91
fibroadenoma 62, 86 breast cancer risk 39 MammaPrint 106
fine-needle aspiration breast development 28 mammillary fistula 85
cytology 5, 54 hypersensitivity 139 mammography 50, 51, 93
first-order (echelon) margin management 118
node 32 marking patients 146
flaps I nipple-areola
abdominal 184 IBIS risk evaluator 220 reconstruction 195
C-V 196, 197 imaging 50, 93 Wise pattern breast
complications 134 implants 180, 200, 201, reduction 158
latissimus dorsi 182 240 mastalgia 76
management 149 in situ (non-invasive) mastectomy 116, 120
nipple-areola disease 98, 109 incisions 163
reconstruction 196, incident prevention 239 risk-reducing 224
197 incisions mastitis 68, 70, 72–3
SIEP/DIEP 185 breast augmentation 201 medullary carcinoma 99
skate 196 mastectomy 163 metastases 212
star 196 infections 70, 71 microbiology 56
TRAM 185 post-operative 135 microdochectomy 78, 84
Forrest Report 8 infiltrating ductal milk line 26
free nipple graft 157, carcinoma 98 Million Women study 39
197, 198 infiltrating lobular Mondor's syndrome 67
frozen shoulder 135 carcinoma 98 MRI 52
248 INDEX
mucinous carcinoma 99
multidisciplinary teams 5,
oestrogen receptor
status 101
Q
14, 20, 22, 240 oncoplastic surgery quality assurance 43
multiple duct avoiding mistakes 241 quality control 12
papilloma 79 breast-conserving 119, 173
mastectomy incisions 163
Oncotype DX 106
R
N oophorectomy 126, 138, radial scar 74
national screening 225 radiation pneumonitis 137
committees 12 open biopsy 55 radiotherapy 124, 136
neutropenic sepsis 138 oral contraceptive pill 39 rapid access
NHS Breast Screening appointments 42
Programme 7 record-keeping 49, 239
audit 12, 17 P recurrent breast
controversies 16 p53 mutations 218, 224 cancer 208, 210
future developments 17 pain referral 3, 44
higher risk patients 224, breast pain 45, 76 referral letter 3
225 cancer pain 151 research 228, 230
historical background 8 post-operative 142, 148 research and development
national screening palliative care 212 committee 231
committees 12 papilloma 79
organization 10, 11 pathology 54
principles 8 peri-areolar breast S
quality control 12 reduction 156 saline implants 200
screening process 14 periductal mastitis 68 sarcoma 137
statistics 8 Peutz–Jeghers sclerosing lesions 74
NICE guidance syndrome 218 Scottish Intercollegiate
breast screening high risk phase I–IV trials 232 Guidelines Network 233
women 225 phyllodes tumour 63 screening, see NHS Breast
levels of breast cancer physical activity 39 Screening Programme
risk 220 physiotherapy 150 second-order (echelon)
nipple-areola complex 26 Poland's syndrome 26, 59 node 32
nipple-areola polythelia 59 sensitivity 8, 9
reconstruction 193 polyurethane-covered sentinel lymph node 32
nipple-sparing implants 200 sentinel lymph node
mastectomy 168 post-operative care 148, biopsy 120, 121
nipples 160, 203 seroma 135
accessory 26, 59 post-operative shoulder problems 135, 136
artificial 194 complications 134 SIEP/DIEP flaps 185
congenital absence 59 post-operative SIGN 233
discharge 44, 78 consultation 5 signs, common 45
discharge dipstick and post-operative pain 142, silicone implants 200
cytology 55 148 simple mastectomy 120
free nipple graft 157, ‘Predict’ 104 incisions 164, 165
197, 198 pregnancy 240 skate flap 196
post-operative premature ovarian skeletal metastases 212
congestion/ failure 139 skin flap complications 134;
discoloration 135 preoperative see also flaps
surgery 84–85 assessment 116, 144, skin grafts 196, 198
tattooing 197 155 skin-sparing
non-invasive (in situ) preoperative mastectomy 166,
disease 98, 109 preparations 146 167, 168
non-lactational abscess 70, primary care Sloane Project 17
71 gynaecomastia 91 smokers 70, 72, 78
notes 49, 239 referrals 44 socio-economic status 37,
Nottingham Prognostic progesterone 28 39
Index 104, 105 prognostic indicators solitary papilloma 79
breast cancer 104, 105 specificity 8, 9
DCIS 112, 113 staging
O pseudogynaecomastia 90 American Joint Committee
obesity 39 PTEN 218 on Cancer staging 102,
oestrogen 28 punch biopsy 54 103
INDEX 249
breast cancer staging 56, tattooing 197 USC/Van Nuys prognostic

102, 103 taxanes 130 index 112, 113
TNM staging 102, 103 terminal duct lobular
star flap 196 unit 26, 27
STK11/LKB1 218 thromboprophylaxis 146 V
subfascial implants 202 tissue expanders 201 vertical pattern breast
subglandular implants 201 TNM staging 102, 103 reduction 156
submuscular implants 202 total duct excision 78, 84–85 volume displacement 171
supernumerary breasts/ TRAM flaps 185 volume replacement 177
nipples 59 trastuzumab 131, 139
surgical biopsy 55 treatment targets 43
symmetrization surgery 204 triple assessment 46, W
symptoms, common 45 242, 243 wide-bore needle
tubular carcinoma 98 (core) biopsy 5, 14,
tumour grading 100 42, 54
T two-hit theory 219 wide local excision 116,
tamoxifen 172
adjuvant therapy 125, 126 Wise pattern breast
breast pain treatment 77 U reduction 156, 158
peri-operative 145 ultrasound 51, 93 wound care 148
side effects 138 ultrasound-guided core wound infection 135
targets 43 biopsy, see core biopsy

Breast Disease Management

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OXFORD MEDICAL PUBLICATIONS

As its name implies, this manual is intended to be of practical assistance to

Symbols and abbreviations ix

1 How to survive outpatient clinics

21 Nipple-areola reconstruction 193

The symptomatic breast clinic

Follow-up after breast cancer

The National Health

Table 2.1 Deﬁnition of the sensitivity and the speciﬁcity of a test

Organization of breast screening

National director of screening

Regional director of screening

Regional QA team (radiologist, surgeon, nurse, radiographer, clerical)

Individual Programme Director of screening and team

Fig. 2.1 The organizational structure of the NHSBSP.

Audit and quality control

The screening process

Normal l discharge Abnormal—targeted

Controversies in breast screening

The multidisciplinary team (MDT)

• Regular meetings to discuss the way the unit functions on a day-to-day

Anatomy and physiology

Terminal Ductal Lobular Unit (TDLU)

It is supported and encased by fat and stroma.

(A) Axillary artery

(B) Pectoralis Internal

Risk factors for developing

Female Rates Female Cases

increases risk still further. Women likely to be at increased risk of breast

Table 5.1 Risk of subsequent breast cancer associated with benign

Targets and quality assurance

Primary care referrals

• Bloodstained (85% of bloody nipple discharge is benign, e.g. intraduct

Triple assessment scores

The importance of concordance

any type of breast change could indicate an underlying cancer, although

Indications for imaging

Fig. 6.1 Mediolateral oblique mammogram showing malignant micro-calciﬁcation,

Fig. 6.2 Ultrasound scan showing the characteristic appearance of an invasive

Nipple discharge dipstick and cytology

Benign breast problems

Guidance on indications for breast imaging has recently changed.

Breast development and involution

Other common benign breast lumps

an ultrasound-guided core biopsy should be performed. The core biopsy

Duct ectasia and periductal mastitis

• Fistula surgery: ﬁstulectomy can be performed in a young patient

Breast infections: mastitis

Table 7.1 A demonstration of the two common types of breast

Radial scar and complex

Breast pain (mastalgia)

Chest wall pain

• Send a sample of pus to microbiology and the wall to histopathology.

• Local anaesthetic inﬁltration.

Table 8.1 Common local complications of nipple surgery to include as

Table 8.2 Common local complications of breast surgery to include as

Excision of accessory breast tissue

Role of primary care

Measure serum hCG, LH, testosterone (T) and estradiol (E)