Breast Surgery

Breast Pain (Mastalgia)

Breast pain is a frequent complaint women report to their physicians. It is rarely a sign of cancer. In fact, it is usually a sign of properly functioning breast tissue. Breast pain can be divided into three categories:

• Cyclic

• Noncyclic

• Chest wall pain

Cyclic pain is the most common type of breast pain. It usually occurs in women in their 30s or of child-bearing age. Both breasts may be affected. More often than not, one side is worse than the other. The most common area of tenderness is the upper outer quadrant of the breast near the armpit. The pain usually begins the week before your period starts and goes away after your period stops. Symptoms may worsen around the time of menopause. They usually resolve completely after menopause.

Noncyclic pain is the second most common form of mastalgia. It occurs in approximately 25% of patients. It is most common in women in their 40's and is almost always in one breast. The pain is usually sharp and shooting, but is of a shorter duration than cyclic pain. The pain does not fluctuate with the menstrual cycle, but comes and goes randomly.

Noncyclic pain is probably related to the natural aging changes that occur in the breast as a woman moves beyond the child-bearing years. Hormone fluctuations become less cyclic or regular causing similar changes in the breast. It may be associated with normal underlying fibrocystic breast tissue, breast cysts, fibroadenomas (benign breast mass-see below), or a breast infection. Non-cancerous cysts can often be aspirated or drained with a small needle. Generally this pain will resolve on its own. Abscesses or infections can be managed with antibiotics or drainage as necessary (see above). As with cyclic breast pain, avoiding substances like caffeine that may sensitize breast tissue to hormonal fluctuations and using anti-inflammatories may lessen the breast pain experienced.

Chest Wall Pain

Musculosleletal disorders of the chest wall may cause referred pain (pain that is felt in a location other than where it originates). Sometimes, the referred location may be perceived in the breast. Some of these disorders include costochondritis, arthritis, boney disease of the rib, and pinched nerve from a bulging or ruptured vertebral disc.

Nipple Discharge

Nipple discharge is the spontaneous release of secretions through the nipple. It is a normal function of the female breast in child-bearing years (puberty through menopause).

Nipple discharge can be:

• Clear (serous)

• Milky or cloudy

• Green or yellow

• Bloody (pink or red)

• Brown or black

In non-breast feeding women, normal discharge is bilateral (both breasts), from multiple ducts, and can be manually expressed. Abnormal discharge is often unilateral (one breast), from a single duct, and is released spontaneously or intermittently.

Breast Infection

Breast infections are divided into two categories: those that occur during pregnancy and breast feeding versus bacterial infections that occur outside of pregnancy.

During breast feeding and pregnancy, infections are often attempted to be resolved with antibiotic therapy. If this fails, incision and drainage may be required. While this offers the quickest recovery, breast feeding may need to be ceased on the involved side to allow the wound to heal. Non-surgical drainage of a breast abscess is usually ineffective.

When an abscess occurs outside of pregnancy, incision and drainage is the most expedient way of curing an abscess if a short course of antibiotics is unsuccessful. This also allows for a biopsy to be obtained to exclude an underlying breast cancer.

Breast Mass or Lumps

Approximately 90% of palpable breast masses (masses that can be felt) are benign and are not cancer. The most common cause of a breast mass is fibrocystic or normal tissue. The next most common causes are cysts and fibroadenomas.

Self breast exam is the most common manner in which a breast mass is identified. A new or changing palpable mass should be further evaluated by a physician. Breast masses are categorized as being solid or cystic.

Solid Masses

Most solid masses are nodules or lumpy areas composed of fibrocystic tissue. Fibrocystic tissue is a normal type of breast tissue that is very dense. The normal breast is composed of dense fibrocystic tissue and fat marbled together in a fairly irregular pattern that causes a nodular or lumpy pattern.

Different women have varying amounts of fibrocystic tissue. Fibrocystic tissue can become engorged with hormonal fluctuations, causing one or more of the nodular/lumpy areas to enlarge and become more obvious. This engorgement can also cause breast pain, usually cyclic, which also fluctuates with the menstrual cycle. Generally the nodular area will regress when the hormone levels decrease, after the menstrual period stops. If a solid lump does not regress over one or two menstrual cycles, a needle biopsy is usually recommended to definitively identify the mass.

Fibroadenomas can also cause a solid mass in the breast. They are non-cancerous islands or clumps of dense breast tissue that grow separately from the surrounding breast tissue. Fibroadenomas are stimulated to grow by estrogen. Elevated levels, as seen with puberty, pregnancy, or hormone supplements, can cause them to grow rapidly.

Fibroadenomas can grow rapidly when the estrogen source is decreased or stopped. Usually in middle-aged, non-pregnant women, masses grow more slowly and are seen only with mammography. A needle biopsy should be done to verify the diagnosis. At this point, the woman can decide whether she wants the mass excised or not. If the fibroadenoma is not excised it should be followed over time and excision considered if sudden or rapid growth occurs.

Other, more rare, causes of solid masses include phylloides tumor, breast cancer, and metastatic cancer.

Cystic Masses

Benign cysts are the most common cause of a cystic mass in the breast. These occur normally in the breast and vary in size from a few millimeters to several centimeters. They may appear quickly and are often tender. They usually vary with your period.

Cysts develop from the involution (remodeling or regression) of breast tissue. This process occurs throughout the reproductive years. After menopause (ending of the menstrual cycle), this process usually ceases. A benign or simple cyst does not need to be drained; this is done for symptomatic relief or if one is unsure of the diagnosis.

Complex cysts (part solid and part liquid) and cysts that have bloody fluid within them require further biopsy to rule out breast cancer. Only one percent of breast cysts are cancerous.

Abscesses are also fluid-filled masses that can occur in the breast. Usually an abscess will have obvious signs of infection including redness, swelling, warmth and pain. An abscess may drain spontaneously or may need treatment including drainage via needle or incision.

Abnormal Mammogram

It is recommended that patients have mammogram studies performed annually beginning when they are 40. A mammogram before age 40 is of limited use because a woman’s breast tissue is generally too dense for the mammogram to identify a significant amount of detail. Around age 40, the breasts begin to thin out and become less dense in appearance. This process allows for more detail to be seen with mammography. Because of this dynamic change, it is important to perform mammography annually to follow any changes that occur over time.

Abnormal mammographic findings are benign 85-90% of the time. Most abnormalities are normally occuring masses and calcifications. Other abnormalities include changing masses, asymmetry, architectural distortion, skin changes, and axillary lymph node enlargement.

An abnormality identified on a screening mammogram usually prompts additional mammographic views to specifically examine the area of concern more closely. An ultrasound or MRI may be recommended to further examine the area of concern. If the abnormality is deemed to be most likely benign (not a cancer) with the additional studies, no biopsy is indicated. If further studies show a persistent abnormality, then a tissue sampling procedure (biopsy) is recommended to be sure that it is not a cancer.

Most abnormalities seem on mammography cannot be felt by touch. Therefore tissue sampling or biopsies are often guided by the use of diagnostic imaging (i.e. mammogram, ultrasound, or MRI). The most minimally invasive technique is always the preferred method often using a needle to collect the tissue sample. Occasionally an open biopsy through an incision, is necessary to properly sample the area of concern.

Breast Cancer

Most breast cancers are discovered with a routine mammogram, but can also be discovered by a palpable mass, bloody nipple discharge, abnormal skin changes or breast pain (rarely). Breast cancer, when identified early, is very treatable and often curable. The earlier a breast cancer is discovered, the greater the chance to catch it at an earlier stage and to provide more effective treatment.

Once a breast cancer has been diagnosed, the first step is to determine the treatment plan. Usually breast cancer surgery is planned initially and involves the complete removal of the breast cancer with a clear or negative margin around the cancer. There are two options to achieve this goal: lumpectomy (partial mastectomy) and mastectomy. Usually, an arm pit lymph node is removed as well (the draining tissue of the breast). This is what constitutes surgical staging.

Breast Conservation (Lumpectomy, Partial Mastectomy)

A lumpectomy involves removing the breast cancer mass and a margin of normal tissue around it. This is achieved through an incision on the breast with maintaining the majority of the normal breast appearance. Specifically, the nipple and areola are not removed. Often, the cancer is localized by the radiologist immediately prior to your surgery. They may use mammography or ultrasound to place a wire marker into the breast so that the surgeon knows where to operate. The wire and the cancer are removed during the lumpectomy.

If a clear margin around the cancer is not achieved, a re-excision of the area may need to be performed at a later date. This involves reopening the same incision and shaving a margin of tissue in the area where the margin was not optimal. If a re-excisoin cannot achieve clear margins, a mastectomy may be the only option.

If a cancer is speckled throughout the entire breast, or if the mass is large relative to a small breast, mastectomy may be the best option in these cases. Women who are lumpectomy candidates may also choose mastectomy for personal reasons. Women who elect to have lumpectomy will generally require post-operative radiation treatment to the remaining breast tissue. Therefore, if a woman cannot have radiation, or chooses not to, mastectomy is the best option.

Breast Removal (Mastecomy)

A mastectomy involves removing the entire breast. This typically includes removal of the nipple and areola. It generally does not involve removing any muscle.

If a woman does not wish to have cosmetic breast reconstruction, the skin will lie flat on the chest wall upon completion.

If a woman elects breast reconstruction, she will most likely have a skin-sparing mastectomy, which removes the nipple, areola, and underlying breast tissue while preserving the majority of the skin. Immediate breast reconstruction is performed in the majority of our patients. It is done in conjunction with a plastic surgeon. You will meet meet with them prior to surgery to discuss the available reconstructive options. In certain cases, reconstruction may be delayed until a later date.

Sentinel Node Biopsy

Breast cancer surgery usually involves two parts: the removal of the breast cancer as outlined above and lymph node sampling. A lymph node is a gland that drains a surrounding bed of tissue. With respect to breast disease, the arm pit lymph nodes are the usual drainage channels. Historically, all of the lymph nodes were sampled in order to identify if a breast cancer has spread outside of the breast. This frequently resulted in permanent are swelling (lymphedema) or arm numbness or tingling.

Currently, sentinel node biopsy is used to determine if the cancer has spread outside of the breast. This is a minimally invasive way of sampling a few of the arm pit lymph nodes instead of removing all of them. This technique involves injecting the breast with a harmless amount of radioactive material that travels to the armpit (axilla) in the same manner as a breast cancer cell would. The lymph nodes in the axilla drain in a particular order. The sentinel node or nodes are the first lymph node(s) to drain the breast. The lymph nodes of the armpit/axilla are the gateway to the rest of the body, so a positive sentinel node indicates a higher risk of having metastatic disease.

Chemotherapy

Not all women with breast cancer are recommended chemotherapy. Chemotherapy is generally given to prevent distant or metastatic disease from developing in the future. After breast surgery, a woman will consult with a medical oncologist who will discuss the potential role that chemotherapy may play. If a patient elects to have chemotherapy, the medical oncologist will administer the treatment. The duration and type of chemotherapy depends upon the combination of drugs selected to treat an individual's particular cancer.

Radiation

Women who have had a lumpectomy, who have a cancer larger than 5 centimeters in diameter or who have more than four positive lymph nodes will usually be recommended to have radiation therapy following breast surgery. Radiation treats the remaining breast tissue and surrounding lymph nodes. The ultimate goal of radiation therapy is to prevent local recurrence.

Traditional radiation is given 5 days a week for five weeks. The daily treatments are non-invasive and side effects may include fatigue and skin irritation or blistering. Partial breast radiation is a relatively new field in which the radiation is delivered to a more focused part of the breast for a shorter duration of time. This method is best suited for small tumors. It is still considered investigational. A radiation oncologist will ultimately help you to decide what the best treatment will be for you.

Breast Cancer Navigator

Receiving a breast cancer diagnosis is always overwhelming, both emotionally and intellectually. There are a multitude of options regarding the type of surgery, chemotherapy, radiation, and coordination of these modalities. A nurse navigator is the best resource to support and guide an individual through this difficult process. A nurse navigator provides emotional support, medical information, and logistic assistance so that the journey through breast cancer treatment can be as efficient and comprehensive as possible. They are the tour guide on your journey so that you do not get lost or miss any important sites.

Helping You Through the Breast Cancer Process

Boulder Community Hospital has a full time Breast Health Navigator available for your support during this often confusing and difficult time. It is often a challenge emotionally, socially and financially. Nanna Bo Christensen, RN, CBCN, is a trained oncology nurse who provides support, education and navigationregarding any breast health issues, including imaging procedures, surgery, radiation, chemotherapy and hormone therapy.

Nanna Bo is available to:

• Help organize the vast amounts of clinical information

• Ensure timely access to the care team i.e. physicians, psychosocial support, social worker, genetic counselor, etc.

• Work with the physician team to ensure patient understanding of clinical information and treatment choices

• Coach the patient though decisional conflicts and support informed medical decision making

• Coordinate and streamline access to the different tests and procedures

• Initiate discussion between the patient and their medical team regarding health and wellness during treatment i.e. exercise and nutrition

• Identify non medical resources and connect the patient to secondary navigators to ensure access to these needed services

• Provide support and resources well into the post treatment survivor-ship phase.

Please feel free to contact her at 720-854-7057 with any additional breast health needs or for possible financial needs regarding breast imaging procedures and/or treatment.

Male Breast Disease

The two most common forms of male breast disease are gynecomastia and male breast cancer.

Gynecomastia

Gynecomastia is a condition in which the male breast tissue swells and increases in size. This is often associated with breast tenderness and pain. Gynecomastia typically occurs in young men age 20-30 and also in older men after 60 years of age.

Gynecomastia occurs when there is an overproduction of estrogen (i.e, liver disease or thyroid disease), alcoholism, drug side effects, testicular tumors, or a reduction in the male hormone testosterone.

Workup may include mammography and ultrasonography. Similiar to workup for a women with a breast mass, a biopsy may be warranted to exculed a diagonsis of breast cancer. In some cases, men opt to undergo surgery to remove the affected breast tissue because of pain or embarrasing cosmetics.

Male Breast Cancer

Male breast cancer is cancer that forms in the breast tissue of men. Though breast cancer is most commonly thought of as a woman's disease, male breast cancer does occur in approxiately 1% of all newly diagnosed breast cancers. Male breast cancer is most common in older men though it can occur at any age. The surgical treatment options for male breast cancer usually involves complete removal of the breast (mastectomy) with sentinel lymph node sampling.

After Breast Surgery

• Breast conservation patients are usually performed as an outpatient (i.e., no inpatient hospital time).

• Mastectomy patients will usually spend 1-2 days in the hospital.

• After a mastectomy or complete axillary lymph node dissection, there will be a drain tube(s) at the site of your mastectomy or under your arm to collect residual fluid.

• You may experience some pain, swelling and tenderness at the mastectomy site

• You will be given pain medication for your pain.

• You will be able to resume normal activities, but should limit intense exercise or strain of upper extremities/ chest until your incisions have healed fully.

• If you have undergone a mastectomy, exercise your arm to restore its range of motion.

Continue your monthly self breast exams to check for any changes in your breast or chest wall. You will have regular diagnostic imaging performed to monitor progress after breast conservation therpay (lumpectomy). After a mastectomy, the removed side will not require any additional routine imaging studies. Follow up after surgery depends on your diagnoses as well as the type of surgery you have undergone.

The most comprehensive treatment for breast cancer requires involvement of multiple speciaties of care. It is our committment at Alpine Surgical to ensure you, as well as all parities involved in your care, are in constant communication and fully informed.

Why Choose Alpine Surgical for Your Breast Surgery:

• Reserved scheduling slots specifically for newly diagnosed cancers

• Our General Surgeons are active members of the Breast Committee at Boulder Community Hospital.

• We offer state-of-the-art diagnostic imaging technology in every exam room in office.

• Members of the American Society for Breast Surgeons.

Meet Dr. Richard Fox

This symbol designates surgeons who are Fellows of the American College of Surgeons. Surgeons who display this symbol are dedicated to the highest standards of patient care and continuing development of professional skills and competence.

Resource Links

American Cancer Society
Colorado Breast Cancer Resources Directory
Medline Plus
National Cancer Institute
National Institute of Health
Susan G. Komen for the Cure
Breast Surgeons.org