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148. Yu RS, Zhang SZ, Hua JM. Imaging findings of splenic hamartoma. World J Gastroenterol

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149. Mackenzie RK, Youngson GG, Mahomed AA. Laparoscopic decapsulation of congenital splenic cysts:

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150. Atmatzidis K, Papaziogas B, Mirelis C, et al. Splenectomy versus spleen- preserving surgery for

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151. Manouras AJ, Nikolaou CC, Katergiannakis VA, et al. Spleen-sparing surgical treatment for

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152. Alonso Cohen MA, Galera MJ, Ruiz M, et al. Splenic abscess. World J Surg 1990;14(4):513–516;

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154. Robinson SL, Saxe JM, Lucas CE, et al. Splenic abscess associated with endocarditis. Surgery

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155. Misawa T, Yoshida K, Shiba H. Wandering spleen with chronic torsion. Am J Surg 2008;195(4):504–

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156. Haj M, Bickel A, Weiss M, et al. Laparoscopic splenopexy of a wandering spleen. J Laparoendosc

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157. Corcione F, Caiazzo P, Cuccurullo D, et al. Laparoscopic splenectomy for the treatment of

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158. Nelson EW, Mone MC. Splenectomy in high-risk patients with splenomegaly. Am J Surg

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159. Letoquart JP, La Gamma A, Kunin N, et al. Splenectomy for splenomegaly exceeding 1000 grams:

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160. Petroianu A, da Silva RG, Simal CJ, et al. Late postoperative follow-up of patients submitted to

subtotal splenectomy. Am Surg 1997;63(8):735–740.

161. Targarona EM, Espert JJ, Balagué C, et al. Splenomegaly should not be considered a

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162. Rescorla FJ, West KW, Engum SA, et al. Laparoscopic splenic procedures in children: Experience in

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164. Kercher KW, Matthews BD, Walsh RM, et al. Laparoscopic splenectomy for massive splenomegaly.

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177. Lutwick LI. Life threatening infections in the asplenic or hyposplenic individual. Curr Clin Top Infect

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182. Thomsen RW, Schoonen WM, Farkas DK, et al. Risk for hospital contact with infection in patients

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183. Kyaw MH, Holmes EM, Toolis F, et al. Evaluation of severe infection and survival after

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583.

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SECTION K: SURGICAL ENDOCRINOLOGY

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Chapter 74

Breast Disease

Thanh U. Barbie and William E. Gillanders

Key Points

1 Any clinically suspicious mass, even in the absence of an imaging abnormality, needs to be biopsied

as up to 15% of breast cancers are mammographically occult.

2 Core needle biopsy is the preferred strategy for breast cancer diagnosis. Core needle biopsy is less

invasive and less expensive than excisional biopsy and facilitates definitive breast cancer treatment

planning.

3 The upgrade of lobular neoplasias diagnosed on core biopsy at time of surgical excision to

malignancy is 1% to 3% and as such surgical excisional biopsy is no longer indicated.

4 All expert groups in North America agree that screening mammography should be performed in

women 50 years of age and older. However, differences exist about whether screening should be

performed between ages 40 and 49.

5 Surgical options for the treatment of DCIS include breast-conserving surgery as a component of

breast conservation therapy (partial mastectomy and postoperative radiation therapy) or simple

mastectomy.

6 Sentinel lymph node biopsy has replaced axillary lymph node dissection for axillary staging, and the

therapeutic impact of axillary lymph node dissection may be limited to specific subsets of breast

cancer patients.

7 Local regional management of invasive breast cancer consists of breast conservation therapy (partial

mastectomy with radiation therapy) or mastectomy, noting that the choice in locoregional

management does not typically impact the recommendation for adjuvant medical therapy.

8 Among patients undergoing partial mastectomy, performing cavity shaving halved the rates of

positive margins and reexcision.

9 A negative surgical margin for invasive breast cancer is now defined as no tumor at the ink margin.

Given the potential for gaps between lesions in DCIS, a negative surgical margin is still defined as

≥2 mm, understanding that this practice may evolve pending more study results.

10 Nipple sparing mastectomy is a safe option for BRCA mutation carriers, with no local regional

recurrences at up to 37 months of follow up.

11 Axillary radiation therapy may result in less morbidity than axillary lymph node dissection in

patients with early stage breast cancer with clinically negative axillary examinations who have ≤2

positive sentinel lymph nodes.

ANATOMY

Surgical Anatomy of the Breast

The boundaries of the mature adult breast are the second rib superiorly, the sixth rib inferiorly, the

sternal edge medially, and the midaxillary line laterally. Breast tissue also extends into the axilla.

Posteriorly, the breast lies on top of portions of the deep investing fasciae of the pectoralis major

muscle, the serratus anterior muscle, the external abdominal oblique muscles, and the upper extent of

the rectus sheath (Fig. 74-1). The breast is composed of skin, subcutaneous tissue, and breast

parenchyma. The skin overlying the breast is thin and contains hair follicles, sebaceous glands, and

exocrine sweat glands. The subcutaneous tissue is composed of fat, vasculature supplying the skin,

lymphatics, and nerves. The breast parenchyma consists of parenchymal components and stroma.

Breast tissue is located within the superficial fascia of the anterior thoracic wall and consists of 15 to

20 lobes of glandular tissue that are divided by connective tissue with adipose tissue filling the space

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between the lobes (Fig. 74-2). Each lobe is composed of 20 to 40 lobules, which are themselves

composed of 10 to 100 alveoli. Each lobe ends in a lactiferous duct that dilates into lactiferous sinuses,

which then open through constricted orifices into the nipple. The suspensory ligaments of Cooper are

fibrous connective bands that extend from the deep fascia to connect to the dermis, providing the breast

with both support and mobility. There is significant variation in breast size with the average

nonlactating breast weighing between 150 and 225 g, whereas the lactating breast may exceed 500 g.1

The left breast is commonly slightly larger than the right.2 The upper outer quadrant of the breast

contains more breast parenchyma and is the most frequent site of both benign and malignant breast

diseases.

The skin of the nipple and the areola is highly pigmented and somewhat wrinkled, composed of

stratified squamous epithelium. Deep to the nipple and the areola are bundles of smooth muscle fibers

that are arranged radially, circumferentially, and longitudinally, allowing for erection of the nipple

from stimuli. Along the margin of the areola are sebaceous glands and sweat glands. Accessory glands

known as Montgomery glands have nodular elevations (tubercles of Morgagni) that open onto the

surface of the areola. The nipple and the areola are highly innervated, with the nipple containing

numerous free sensory nerve endings and Meissner’s corpuscles, whereas the areola contains both

Ruffini-like endings and Krause-end bulbs.3 The sensory innervation of the breast is mainly the lateral

and anterior cutaneous branches of the second through sixth intercostal nerves. There is also a small

region of skin over the upper portion of the breast that is supplied by the anterior or medial branches of

the supraclavicular nerve that arises from the cervical plexus.

The arterial blood supply to the breast consists of the internal mammary artery (perforating

branches), the posterior intercostal artery (lateral branches), and several branches of the axillary artery

including the superior thoracic artery, the lateral thoracic artery, and the pectoral branches of the

thoracoacromial artery. The breast’s venous system parallels its arterial system, consisting of the

internal mammary veins, the posterior intercostal veins, and the axillary vein tributaries.4

Figure 74-1. The adult female breast. The upper and medial portions of the breast rest on the pectoralis major muscle, and the

inferolateral portion rests on the serratus anterior.

Lymphatic Drainage

The lymphatic flow from the breast is unidirectional through thin-walled, valveless vessels that are

interconnected through three groups. The primary group of lymphatic vessels comes from within the

gland in the interlobular spaces and along the lactiferous ducts. The lymphatic vessels that drain the

skin, nipple/areola, and the central portion of the gland constitute the subareolar plexus. The third

plexus is on the deep surface of the breast and communicates with small vessels in the deep fascia

underlying the breast. More than 75% of the lymph from the breast passes to the axillary lymph nodes,

whereas the remainder passes to parasternal nodes. The flow of lymph to either the axillary or the

parasternal nodes is independent of the quadrant from where the lymph originated.5 Occasionally,

lymph flow can be found outside of these three interconnected plexuses, occurring along the lateral

cutaneous branches of the posterior intercostal arteries, within the rectus sheath or subperitoneal plexus

by following branches of the intercostal and musculophrenic vessels, or directly to subclavicular or

apical nodes.6

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Figure 74-2. The breast consists of 15 to 20 lobes of glandular tissue. Within each lobe, the lobules are composed of branched

tubuloalveolar glands. Each lobule ends in a lactiferous duct. These ducts dilate into lactiferous sinuses beneath the nipple.

Figure 74-3. The axillary lymph nodes are divided into three levels by the pectoralis minor muscle. The level I nodes are inferior

and lateral to the pectoralis minor, the level II nodes are below the axillary vein and behind the pectoralis minor, and the level III

nodes are medial to the muscle against the chest wall.

The axilla is a pyramidal compartment between the upper extremity and the thoracic walls, which can

be thought of as consisting of four walls, an apex, and a base. The anterior wall consists of the

pectoralis major/minor and its associated fasciae. The subscapularis muscle, teres major muscle,

latissimus dorsi muscle, and associated tendons form the posterior wall. The medial wall consists of the

serratus anterior muscle and associated intercostal muscles of the upper four or five ribs. A thin strip of

the humerus and the bicipital groove, which is between the insertion of the muscles of the anterior and

posterior walls, forms the lateral wall. The apex is an aperture that extends into the posterior triangle of

the neck through the cervicoaxillary canal, which is bounded by the clavicle anteriorly, the scapula

posteriorly, and the first rib medially. The base of the axilla is the axillary fascia and the skin.6

The axillary lymph nodes have traditionally been divided into three levels, corresponding to their

location relative to the pectoralis minor (Fig. 74-3). Level 1 nodes (external mammary, axillary vein,

and scapular lymph node groups) are inferior and lateral to the pectoralis minor; level 2 nodes (central

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