General info on the anatomic structure
The breasts or Mammary Glands are two subcutaneous organs located on the chest both in men and women. Being the primary organ for lactation or milk production, these organs are well developed in women as compared to men. The most pronounced structure in the breast is the nipple-areolar complex located usually at the centre of the breast. It is from this structure where the milk produced is extruded.
Each breast consists of multiple subsections called lobes, the lobes are further subdivided into smaller sections called lobules. These lobules have tiny endings where milk is produced. From each lobule arises a duct which coalesces with other similar ducts to form lactiferous ducts. They converge at the nipple where the milk is finally extruded. The breast characteristically has no muscle but a lot of fat is interspersed between these lobules.
The consistency of the breast varys based on the age and the body composition of the female. Younger and slimmer women tend to have firmer and smaller breasts as compared to older or more obese women. The menstrual cycle also has some effect on the consistency of the breast.
An important adjunct to the breast is the axilla, which for many purposes is the guardian or gatekeeper for the breast. The axilla or armpit region has a rich supply of lymph nodes which drain the breast and the arm on the same side. Most diseases of the breast such as cancers or infections manifest in the axilla as well.
Lymphatic drainage of the organ is an important aspect one must understand when discussing breast cancer. Lymphatics are basically tubular structures similar to blood vessels, only that they do not transport blood but a colourless fluid known as lymph. Many cancers spread via this route leading to what we call metastasis. These lymphatics are intermittently checked by special organs known as lymph nodes. These organs are the first stations where the cancer cells lodge after separating from the primary site.
In breast cancer, 3 areas of lymph nodes are of interest.
- The axillary group of lymph nodes, as explained above.
- The internal mammary group of lymph nodes, these are located in the chest wall towards the inner side of the chest.
- The supraclavicular group of lymph nodes, these are located in the lower part of the neck just above the collar bone.
- The most common sign of some pathology of the breast is the presence of a lump in the breast. This is usually detected incidentally by the patient (Men can also have it), while touching the breast for some other reason or while undergoing an examination. Most of these lumps are painless and very innocuous. The risk of the lump being a cancer is directly proportional to the age and the family history of the patient. Lumps are usually benign in girls below 30 years and the risk of cancer increases where a majority of lumps detected are cancerous in women above 60.
- Nipple discharge is also a common complaint in cancer patients, this is characteristically from one breast only and can vary from watery to milky to bloody. Having a blood stained discharge for one side is usually an ominous sign.
- Swelling in the axilla is also a common symptom, this usually is as a result of the cancer spreading to the axillary nodes.
- Ulceration in the breast, usually seen in those cancers which are located close to the skin or nipple areolar complex. Ulceration usually signifies a more advanced stage of the cancer.
- Other signs and symptoms are those of advanced disease such as bone pain due to spread to the bone. The most common site is the spine and backache can be a common symptom for these patients. Also present are other symptoms like coughing and expectoration of blood, signifying spread to the lungs, abdominal pain and liver enlargement signifying liver spread and convulsions or stroke signifying brain metastasis.
- Family history is the most important risk factor in breast cancer. There is ample evidence of a genetic linkage towards breast cancer. Most at risk are those people who have a direct 1st degree relative with breast cancer such as the mother or a sister. These people need to be extra aware.
- Excess estrogen exposure, such as women who achieved an early menarche, late menopause, childless women above 35, women giving a late childbirth, usage of hormone replacement therapy, etc.
- Radiation exposure during early years of life.
- Contrary to popular belief, alcohol and tobacco have not been associated with breast cancer.
Early diagnosis and treatment is the cornerstone towards success in breast cancer. Getting checked up by the doctor at regular intervals is key.
- Breast self examination is a simple and effective technique for the early detection of breast cancer. All women above the age of 18 should be educated about breast cancer and about breast self examination. All women above 25 should actively do self examination every month just after their periods are complete.
- Mammography for all women is recommended after the age of 40. This should be done on a yearly basis till the age of 60. After 60 it is advised to do the mammography every 2 yearly.
- Those women with a known history of breast cancer in the family are usually advised screening earlier in life, this may begin even as early as 25 years of age. Due to their early age, MRIs are advised instead of mammography till the age of 35 or so.
Definition of the procedure
The mainstay of treatment in early breast cancer is surgery. This is seen in mainly 2 forms:-
- Breast conservative surgery:- in short also known as BCS is now the mainstay of treatment in breast cancer. This involves removal of the tumour completely in the breast with preservation of the uninvolved part of the breast. Latest standards of treatment are more in favor of breast conservation with reconstruction.
- Modified radical mastectomy:- this used to be the gold standard of treatment for breast cancer, where the entire breast was removed along with the axillary fat and lymph nodes. Now in advanced centers it has largely been replaced by BCS.
Different variations of the procedure
- Axillary dissection:- In most cases, the cancer from the breast spreads first to the lymph nodes in the pad of fat inside the armpit region. Thus any procedure for breast cancer always needs to address the axilla. Thus axillary dissection is removal of all the fat in the axilla, either along with the breast tissue as in modified radical mastectomy or as a separate sample when done in a breast conservation surgery.
- Sentinel lymph node biopsy:- early cases of breast cancer, it has been proven that axillary dissection may not be needed as the cancer may be still too rudimentary to spread. In such cases, the sentinel node is considered the first region of the axilla where the cancer is supposed to spread. Using modern imaging techniques, this node is acquired and tested, if positive, the entire axilla is cleared. If negative, the axilla is presumed safe and left untouched.
- Mammoplastic surgery:- here a cosmetic reconstruction of the breast is performed after breast conservative surgery. This not only removes the tumour but also results in a cosmetically appealing operated breast. Giving confidence to the Patient! Generally mammoplastic means usage of surrounding breast tissue to reconstruct the defect without any external plastic surgery.
- Pedicled flap reconstruction:- here tissue from a distal site is brought to fill the defect created. Pedicled means that it is still attached to the site of origin via some muscle or vessel. Common ones are the Lattisimus Dorsi Flap and the TRAM flap.
- Free Flap Reconstruction:- here the flap used is from a site which is distant from the site of origin. It is completely separated from the origin and fixed to the blood vessels of the site where it is implanted. The best example is the DIEP flap.
- Implant based reconstruction:- here implants are used to augment the reconstruction after surgery. They can be temporary in the form of expanders or permanent in the form of silicone implants.
- Lymphatic surgery:- many women complain of arm swelling after surgery. This is usually due to lymph blockade after an axillary clearance. Modern techniques use lymph nodes to remove this blockade and re-establish lymphatic flow in the arm. Lymphovenous anastomosis and lymph node implantation are some of the techniques used.
Risk of surgery
- Failure of flap:- advanced techniques always have the risk of failing due to the complexities involved. In advanced centres however, this risk is minimal; ranging from 2 to 5%.
- Bleeding, hematoma:- these are sometimes encountered in the immediate postoperative period
- Infection:- though rarely seen nowadays
- Arm swelling:- this is due to the axillary clearance as mentioned earlier. Occurs in approx 30% of women.
- Cancer recurrence:- thats why its called cancer, to show us we are humans after all!
Recovery and out look
This centre focuses on ensuring all our patients are properly cared for during and after treatment. Proper post treatment counseling, physiotherapy and check-ups ensure that recovery is achieved with the best quality of life. Breast cancer treatment is tedious with surgery, chemotherapy, radiation and hormonal therapy all forming a part of the treatment.
But take treatment properly and one can hope for a long and happy life!
Additional procedures required
Here CHEMOPORT surgery deserves a special mention. This is a special device created for administering chemotherapy instead of using the arm veins. This makes chemotherapy more palatable and easy to administer.