Treatment

• fluid resuscitation, NG tube decompression

• surgery: enterolithotomy and removal of stone, inspect small and large bowel for additional proximal

stones

• may close fistula surgically or manage expectantly (can resolve spontaneously)

• cholecystectomy is generally not performed

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GS59 General and Thoracic Surgery Toronto Xotes 2023

Carcinoma of the Gallbladder

Risk Factors

• chronic symptomatic gallstones (70% of eases), old age, female, gallbladder polvps, porcelain

gallbladder, chronic infection (Salmonella, Helicobacter), primary sclerosing cholangitis, and

abnormal pancreaticobiliary duct junction

Clinical Features

• majority are adenocarcinoma

• may be incidental finding on elective cholecystectomy (~1% of open cholecystectomies OR 0.1% in

laparoscopic cholecystectomies)

• many patients are asymptomatic until late

• local: non-specific RUQ pain ± palpable RUQ mass

• Courvoisier’s gallbladdersign:enlarged gallbladder and painless jaundice due to obstruction of CBD,

suggestive of gallbladder or pancreatic malignancy'

• systemic: jaundice (50%) due to invasion of CBD or compression of CBD by pericholedochal nodes,

anorexia, N/V,weight loss, and malaise

• early local extension to liver, peritoneum, may extend to stomach, duodenum

• early metastasis common to lung, pleura,liver bone

Investigations

• U/S:mural thickening, calcification, loss of interface between gallbladder and liver, and fixed mass

• endoscopic U/S (BUS): good for distinguishing carcinomas from other diagnosessuch as, polyps,

staging, allowssampling of bile for cytology

• abdominal CT: polypoid mass, mural thickening,liver invasion, nodal involvement,and distant

metastases

• MRI/MRCP: good for distinguishing benign and malignant polyps

Treatment

• if carcinoma of the gallbladder is suspected preoperativcly, an open cholecystectomy should be

considered to avoid tumourseeding of the peritoneal cavity

• confined to mucosa (rare): cholecystectomy

• beyond mucosa: cholecystectomy, en bloc wedge resection of 3-5 cm underlying liver, and dissection

of hepatoduodenal lymph nodes

Prognosis

• poor 5 yrsurvival (20%) as gallbladder carcinoma is often detected late

• better outcomes when detected incidentally following cholecystectomy

Cholangiocarcinoma

Definition

• malignancy of the epithelial cells of extra- or intrahepatic bile ducts

Risk Factors

• ages 50-70, gallstones, UC, primary sclerosing cholangitis, choledochal cyst, Clonorchissinensis

infection (liver fluke), chronic intrahepatic stones (hepatolithiasis), genetic disorders (Lynch

syndrome, Cl;

, multiple biliary papillomatosis, BARI tumour predisposition syndrome)

Clinical Features

• majority are adenocarcinomas

• gradual signs of biliary obstruction:jaundice, pruritus, dark urine, and pale stools

• anorexia, weight loss, RUQ pain,Courvoisicr’ssign (if CBD obstructed), hepatomegaly

• early metastases are uncommon, but commonly tumour grows into portal vein or hepatic artery,

peritoneum, lungs, pleura, liver

• Klatskin tumour: cholangiocarcinoma located at bifurcation of CHD

Obstructive jaundice Is the most

common presenting symptom for

cholangiocarcinoma

Investigations

• Ll'

T'

sshow obstructive picture, carbohydrate antigen 19-9 (CA 19-9),CEA may be elevated

• U/S,CT:bile ducts usually dilated, but not necessarily

• ERCP or PTC:to determine resectability,for biopsies

• CXR,bone scan:for metastatic w orkup

Treatment

• if resectable:biliary drainage and wide excision margin

• intrahepatic lesions:liver resection after clear discussion at multidisciplinary tumour boards and

prognosis understood

upper third lesions:duct resection + Roux-en-Y hepaticojejunostomy, ± liver resection

middle third lesions (uncommon):duct resection + Roux-en-Y hepaticojejunostomy

lower third lesions:Whipple procedure

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GS60 General and Thoracic Surgery Toronto Notes 2023

•unresectablc lesions:stent or choledochojejunostomy (surgical bypass)

•chemotherapy ± radiotherapy

•role for transplantation in select patients with Klatskin tumours or NET with no evidence of

extrahepatic disease and relative stability

Prognosis

•overall 5 yrsurvival:localized 30%, regional 24%, distant 2%

Pancreas

Acute Pancreatitis

• see < i \troi iiternh >g\ , ti IS

GALLSTONE PANCREATITIS (45% of Acute Pancreatitis)

Pathogenesis

• obstruction of pancreatic duct by large orsmall gallstones and biliary sludge

• backup of pancreatic enzymes can cause autodigestion of the pancreas

Clinical Features (Pancreatitis of Any Etiology)

• pain (epigastric pain radiating to back), N/V,ileus, peritonealsigns, jaundice, and fever

• Inglefinger’

ssign: pain worse when supine, and better when sitting forward

• may have coexistent cholangitis or pancreatic necrosis

• Kanson'

s criteria for determining prognosis of acute pancreatitis (see sidebar)

• APACHE 11 score for determining prognosis of severe acute pancreatitis

• physical exam may show tachypnea,tachycardia, hypotension,abdominal distention and tenderness,

Cullen’ssign, and Grey Turner’ssign

Investigations

• lipase (most sensitive and specific), elevated amylase (higher than alcoholic pancreatitis), and

leukocytosis

• elevated ALT (>I50 1U/L), AST strongly suggest gallstone etiology of pancreatitis

• U/S may show multiple stones (may have passed spontaneously), and edematous pancreas

• CXK, AXR, and CT (if severe to evaluate for complications)

Ranson'

s Criteria

A.At admission

1. Ages >55yr

2. WBC >16*

tO’

/L

3. Glucose >11 mmol/L

4. LDH >3S0 IU/l

5.AST >250 IU/L

B. During initial 48 h

1. Hct drop >10%

2. BUN rise >1.8 mmol/l

3. Arterial POJ <60 mmHg

4.Base deficit >4 mmol/L

5.Calcium <2 mmol/L

6.Fluid sequestration >6 L

C. Interpretation

<3-severe pancreatitis unlikely (2%

mortality)

23- high mortality (218%)

Treatment

• supportive:e.g. NPO, hydration, analgesia, and early enteral nutrition

• antibiotics are not indicated for initial diagnosis.This is reserved for clear signs of infection on

imaging

• stone often passes spontaneously (

—90%); usually no surgical management in uncomplicated acute

pancreatitis

• cholecystectomy during same admission (25-60% recurrence if no surgery)

. may need urgent ERCP + sphincterotomy if CBD stone impacted or cholangitis

• surgical indications in acute pancreatitis (rare):

drain placement and debridement for necrotizing pancreatitis if refractory to medical

management, if septic,or in 1CU without other sources of sepsis

Complications

• local complications

acute lluid collections

walled-off pancreatic fluid collection/pseudocyst (>4 wk old)

abscess/infection, necrosis

• systemic complications

splenic/mesenteric/portal vessel thrombosis

pancreatic ascites/pancreatic pleural effusion

DM (b/c pancreatic & insulin insufficiency)

ARDS/sepsis/multiorgan failure

coagulopathy/DIC

severe hypocalcemia ri

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GS61 General and Thoracic Surgery Toronto Notes 2023

Chronic Pancreatitis

• SCC (

iastroenUToIouv. (i50

Surgical Treatment

• treatment is generally medical

• indications for surgery

failure of medical treatment

debilitating abdominal pain

• pseudocyst complications: persistence, hemorrhage, infection, and rupture

CBD obstruction (e.g.strictures) and duodenal obstruction

• pancreatic fistula, variceal hemorrhage secondary to splenic vein obstruction

• rule out pancreatic cancer (present in 15% of chronic pancreatitis treated surgically)

anatomical abnormality causing recurrent pancreatitis

preoperative CT and/or ERCP are mandatory to delineate anatomy

• minimally invasive options

endoscopic pancreatic duct decompression: less effective than surgery’

extracorporeal shockwave lithotripsy: if pancreatic ductstones

celiac plexus block:lasting benefit in 30% patients, less effective in those <45 yr or with prior

pancreatic surgery

• surgical options

drainage procedures:only effective if ductalsystem is dilated

Puestow procedure (lateral pancreaticojejunostomy):improves pain in 80% of patients

pancreatectomy:best option in absence of dilated duct

Whipple procedure (pancreaticoduodenectomy): proximal disease

distal pancreatectomy ± Koux-en-Y pancreaticojejunostomy: distal disease

total pancreatectomy: refractory disease

• islet cells autotransplantation can be used to control insulin-related morbidity

denervation of celiac ganglion and splanchnic nerves

WALLED-OFF PANCREATIC FLUID COLLECTIONS (PSEUDOCYSTS)

• localized fluid collections rich in pancreatic enzymes, with a non-epithelialized wall consisting of

fibrous and granulation tissue

• complication of chronic and/or acute pancreatitis

• up to 40% resolve spontaneously

• cyst wall must be mature prior to drainage (4-6 wk)

• pseudoaneurysm an absolute contraindication to endoscopic drainage, must embolize first

Pseudocyst Management

• if asymptomatic:expectant management

• if symptomatic: choice of drainage procedure depends on location of fluid collection

endoscopic drainage: transmural vs. transpapillary (pseudoaneurysm an absolute

contraindication, must embolize first)

surgical drainage: cystogastrostomy vs. cystoduodenostomy vs. cystojejunostomy

percutaneous catheter drainage

resection

if draining,attempt to biopsy cyst wall to rule out cystadenocarcinoma

The hallmark of chronic pancreatitis is

epigastric pain radiating to the back

Total Panutattctuay and Islet

Autotransplantation:A Decade Nationwide

Analysis

World J transplant 2016.6|T):233’238

Purpose:to investigate outcomes and predictors

of in-hosprtal mortmAty and mortality alter total

pancreatectomy (TP) and islet autotransplantation.

Results:A total of 923 patients underwent IAT after

pancreatectomy during 2002-2012.Tire most common

indication of surgery was chronic pancreatitis

!( 6%|followed try acute pancreatitis(12%). Overall

morlality and morhdity ol patients weie 0% and

57.8 %. respectively. Post surgical hypolnsulioemia

was reported m 42.3% of patients.Indicating that

57.1% of patients were insulin independent during

hospitalization.Predictors of in-hospital morbidity

were obesity.fluid and electrolyte disorders,alcohol

use,and weight loss.

Conclusion:Total pancreatectomy islet

autotransplantaboo isa safe procedure with no

mortality, acceptable morbidity, and achieved high

rale of early insul>n independence.Obesity is the most

significant predictor of in-hospital morbidity.

Pancreatic Cancer

Epidemiology

• 4th most common cause of cancer-related mortality in both men and women in Canada

• M:F=1.3:1, average ages:50-70

Risk Factors

• increased age

• smoking: 2-5x increased risk, most dearly established risk factor

• high fat/low fibre diets

• heavy alcohol use

• obesity

• DM, chronic pancreatitis

• partial gastrectomy

• cholecystectomy

• chemicals: p-naphthylamine, benzidine

• African descent

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GS62 General and Thoracic Surgery Toronto Notes 2023

Clinical Features

• the most common presenting symptoms are abdominal pain, jaundice, and weight loss

• head of the pancreas (70%)

pancreatic head tumours typically present with jaundice, steatorrhea, and weight loss

other features include anorexia, dark urine, hepatomegaly, cachexia, Courvoisier’s sign, recent

onset DM

• body or tail of pancreas (30%)

tendsto present later and usually inoperable (80% are unresectable at diagnosis)

• weight loss, vague mid-epigastric pain

• <10% jaundiced

Trousseau's Sign

Spontaneous peripheral venous

thrombosis, often associated with

pancreatic and other cancers

Vague abdominal pain with weight loss

Z jaundice in a patient over SO yr is

pancreatic cancer until proven otherwise

Investigations

• serum chemistry is non-specific, LFTs may show obstructive jaundice (elevated ALP and bilirubin)

• CA 19-9 most useful serum marker of pancreatic cancer

• U/S,CT (also evaluates metastasis and resectability) ± LRC.P, MR1, EUS Courvoisier'

s Sign

Palpable, nontender, distended

gallbladder due to CBD obstruction.

Present in 33% of patients with

pancreatic carcinoma. The distended

gallbladder could not be due to acute

cholecystitis orstone disease because

the gallbladder would actually be

scarred and smaller, not larger

Pathology

• ductal adenocarcinoma: most common type (75-80%); exocrine pancreas

• intraductal papillary mucinous neoplasm (1PMN )

• other: pancreatic NETs (non-functional, insulinoma, gastrinoma, VIPoma, glucagonoma,

somatostatinoma), mucinous cystic neoplasm (MCN), acinar cell carcinoma

• see Surgical tndocrinology, ( IS7I for functional pancreatic NETs

Treatment

• resectable (10-20% of pancreatic cancer)

• no involvement of liver, peritoneum, or vasculature (hepatic artery, SMA, SM V, portal vein, 1VC,

aorta), no distant metastasis

Whipple procedure (pancreaticoduodenectomy) for cure <5% mortality

distal pancreatectomy ± splenectomy, lymphadenectomy if carcinoma of midbody and tail of

pancreas

adjuvant chemotherapy recommended (gemcitabinc i capecitabine, 5-I U/leucovorin)

• locally advanced, borderline resectable

tumours that abut the SMA, SM V, portal vein, hepatic artery, or celiac artery

• locally advanced, non-resectable (palliative -> relieve pain,obstruction)

• encasement of major vascularstructuresincluding arteries

most body/tail tumours are not resectable (due to late presentation)

• relieve biliary/duodenal obstruction with endoscopic stenting or double bypass procedure

(choledochoenterostomy i gastroenterostomy)

• palliative chemotherapy (gemcitabine + nab- paclitaxel, EOLEIRINOX) ± radiotherapy

Prognosis

• most important poor prognostic indicators are lymph node status, margin status,size >3 cm,

perineural invasion (invasion of tumour into microscopic nerves of pancreas)

• overall 5 yr survival for all patients with pancreas cancer is 1%; following surgical resection 5 yr

survival is 20%

• median survival for unresectable disease:3-6 mo if metastatic, 8-12 mo if locally advanced at

presentation

Steps of a Whipple Resection

(Pancreaticoduodenectomy)

1. Assessment of metastatic disease (all

peritonealsurfaces)

2. Mobilization of the hepatic flexure of

the colon

3. Mobilization of the duodenum

(Kochcr maneuver) and head of the

pancreas

4. Identification of the superior

mesenteric vein and mobilization of

the pancreatic neck

5. Mobilization of the stomach:

dissection of the hepatoduodenal

ligament and cholecystectomy

6. Division of the stomach, proximal

jejunum, and CBD

7. Transection of the pancreatic neck

and dissection of the uncinate

processfrom the retroperitoneum

8. Restoration of gastrointestinal

continuity:construction of

a pancreaticojejunostomy,

hepaticojejunostomy,

gastrojejunostomy using a

neoduodenum

Remove

. CBD

• Gallbladder

• Duodenum

• Pancreatic head

• Distal stomach (sometimes)

Table 27. TNM Classification System for Exocrine Tumours of the Pancreas (AJCC 8th edition)

Primary Tumour (T) Regional Lymph Nodes (N) Distant Metastasis (M)

TX Primary tumour cannot be assessed

TO No evidence ol primary tumour

Tis Carcinoma in situ

NX Regional lymph nodes cannot be assessed

NO No regional lymph node metastasis

N1 Metastasis in one to three regional lymph nodes

M0 No distant metastasis

Ml Distant metastasis

Oncological Benefits of Neoadjuvant

Chemoradiation with Gemcitabine vs. Upfront

S urgery in Patients with Borderline Resectable

Pancreatic Cancer:t Prospective, Randomised,

Open-label.Mullicenler Phase 2/3 Trial

Ann Surg 2018:268:215-222

Purpose: lo deter— r e whether neoadjinant

treatment increasessurvival in patients with

borderline resectable pancreatic cancer(BRPC).

Methods:A total of SO patients were randomized to

neoadjuvant gemutabine-based chemoradiotherapy

or upfront surgery.

Results:Ihe 2 yr survival rate|2YSR|and median

survival of patientstieated with ncoadiuvant

chemoradiation wassignificantly improved (40.7%

2YSR. 21mo median suivival) compared to upfront

surgery (26.1% 2YSR.12 mo median survival).Ihe RO

resection rate was also significantly increased in the

neoadjuvant chemoradiation group.

Conclusion: Neoadjuvant chemoradiation provides

survival and surgical benefits in patients with BRPC.

T1 Tumour

-:2 cm in greatest dimension

N2 Metastasis in four or more regional lymph

nodes

T 2 Tumour »2 cm and s4 cm in greatest

dimension

T3 Tumour >4 cm in greatest dimension

T4 Tumour involves celiac axis.SMA. or common

hepatic artery r -i

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GS63 General and Thoracic Surgery Toronto Notes 2023

Table 28. Staging and Treatment of Pancreatic Cancer

Stage Classification 5 Yr Survival Treatment

Tis,NO. MO

11, NO. MO

12, NO. MO

13,NO. MO

T1-3, N1. M0

11-3.N2.MO

14, any N,MO

anyI. anyN.M1

Surgical resection t chemotherapy

Same as above

Same as above

Same as above

Same as above

Borderline resectable, trial ol chemotherapy and radiation

0

IA m

IB 12%

IIA 7%

I IB 5%

III 3%

IV 1% Mon-resectable, palliative treatments

Lett and right hepatic ducts

ontmon hepatic

duct

Stomach

Liver

Gastrojejunostomy

Gallbladder

-Tail of pancreas

Cystic duct

Hepaticojejunostomy

CBD Pancreas

Ampulla of Vater Pancreatic duct Pancreaticojejunostomy

Duodenum

Jejunum

Resected portion

© Natalie Comiier 2015.after Caitlin O'Connell

Figure 26. Schematic of Whipple resection showing the resected components

Spleen

Splenic Trauma

Clinical Features

• most common intra-abdominal organ injury in blunt trauma (especially can occur in people with

splenomegaly)

• may have Kenr’s sign

- patients may be hemodynamically unstable with altered mentalstatus

• initial presentation may be masked by other injuries and contained ruptures may have few symptoms

Kehr’s Sign

Left shoulder pain due to diaphragmatic

irritation from splenic rupture, worsens

with inspiration

Investigations

• FAST'

(used in trauma with hemodynamically unstable patients)

• CT with oral or IV contrast (once stable or when l-

'

AST negative)

Treatment

• non-operative

in stable patients: extended bed rest with serial hematocrit levels, close monitoring for 3-5 d;

paediatric guidelinesfor days of bed rest is grade plus 1 (i.e. grade 3 splenic laceration requires 4

d of bed rest)

hemostatic control

• splenic artery embolization if patient stable and one of: active contrast extravasation,splenic

pseudoaneurysm, hemoperitoneum

• operative

hemodynamically unstable patients with positive FAST will undergo emergent operative surgical

exploration

• splenorrhaphy (suture of spleen) ± splenic wrapping with hemostatic mesh (if patient is

hemodynamically stable)

splenectomy if patient unstable or high-grade injury or ongoing bleeding with hemodynamic

instability

• packing the spleen with temporary abdominal closure and relook laparotomy in 48 h

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Splenectomy

Indications

• splenic trauma (most common reason for splenectomy), hereditary spherocytosis, primary

hypersplenism, chronic immune thrombocytopenic purpura (1TP),splenic vein thrombosis causing

esophageal varices,splenic abscess,thrombotic thrombocytopenic purpura (TI P), and sickle cell

disease

• does not benefit all thrombocytopenic states (e.g.infection, most malignancies involving the bone

marrow, drugs/toxins)

• probability of cure of IIP by splenectomy is 60-70%, maybe predicted by response to 1VIG

Indication of Splenectomy

SHIRTS

Splenic abscess/splenomegaly

Hereditary spherocytosis

Immune thrombocytopenic purpura

Rupture of spleen

Thrombotic thrombocytopenic purpura

Splenic vein thrombosis

Complications

• short-term

injury to surrounding structures(e.g. gastric wall, tail of pancreas) and their vascularsupply

postoperative thrombocytosis,leukocytosis

thrombosis of portal,splenic, or mesenteric veins

subphrenic abscess

• long-term

post-splenectomy sepsis (encapsulated organisms): 4% ofsplenectomized patients(highest risk

<16 yr)

splenosis:intra-abdominal “seeding"of splenic tissue during removal

increased risk of malignancy, DVT,and PH

• 50% mortality

Prophylaxis

• vaccinations, ideally 2 wk pre- or postoperative (pneumococcal, H. influenzae,and meningococcus)

• liberal use of penicillin especially in children <6 yr

Splenic Infarct

Pathophysiology

• splenic artery occlusion or oxygen-delivery insufficiency leading to parenchymal ischemia and

necrosis

• can occur in sickle cell disease, thromboembolism, myelofibrosis, CML, and hypercoagulable states

Clinical Features

• patient can be asymptomatic or can have LUQ pain (70%), N/V,fever, chills, and Kehr’ssign

Investigations

. CT with contrast;MRI

• peripheral blood smear abnormalities

Treatment

• non-operative:close follow-up, analgesia

• indicationsforsplenectomy: complicationssuch as rupture, abscess, persistent pseudocyst, bleeding,

orsepsis

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GS65General and Tlioracic Surgery TorontoNotes 2023

Breast

Apical

Deltopectoral

Internal jugular v.

Thoracic duct Lateral

Axillary a.

/

Lett bronchomediastinal

trunk

— Axillary v.

Subscapular a.

- Posterior

Levels of Axillary Lymph Nodes

LevelI:lateral to pectoralis minor

LevelII:deep to pectoralis minor

LevelIII:medial to pectoralis minor

(higher level of nodal involvement*

worse prognosis)

Interpectoral

Pectoralis minor m.

Pectoralis major m.

/

Central

7s

Anterior

v

—Lateral tlioracic a.

/

Internal thoracic

JL J

Level3 Level2 LevelI

Medial to Deep to Lateralto

pectoralis pectoralis pectoralis

minor minor

DDx for Breast Mass

Benign

Fibrocystic changes

Fibroepithelial lesions (fibroadenoma

most common: benign phyllodes)

Fat necrosis

Papilloma/papillomatosis

Galactocele

Duct ectasia

Ductal/lobular hyperplasia

Sclerosing adenosis

Lipoma

Neurofibroma

Granulomatous mastitis (e.g. TB.

granulomatosis with polyangiitis,

sarcoidosis)

Abscess

Silicone implant

Malignant

Breast cancer (likely invasive, DCIS

rarely forms a breast mass)

Malignant phyllodes

Angiosarcoma (rare)

1 rur © Merry Shiyu Wang 2012

Figure 27. Anatomy of the breast

Benign Breast Lesions

Three Categories

1. non-prolifcrative

2. proliferative without atypia

3. atypical hyperplasia

NON-PROLIFERATIVE LESIONS

• benign breast condition characterized by fibrous and cystic changes in the breast (fibrocystic changes/

disease)

• most common: breast cysts

• other lesions include papillary apocrine change, epithelial-related calcifications, and mild hyperplasia

of the usual type

• no increased risk of breast cancer

• age 30 to menopause (and after if hormone replacement therapy (HRT) used)

clinical features

• breast pain,focal areas of nodularity or cysts often in the upper outer quadrant, frequently

bilateral, mobile, varies with menstrual cycle, and nipple discharge (straw-like, brown, or green )

• treatment

» evaluation of breast mass(U/S, mammography as indicated) and reassurance

analgesia (e.g. ibuprofen, ASA)

• forsevere symptoms: DCF, danazol, bromocriptine

PROLIFERATIVE LESIONS - WITHOUT ATYPIA

Table 29. Proliferative Lesions - Without Atypia

Clinical Features Diagnosis Treatment Risk of Breast Cancer

Fibroadenoma Most common breast

tumour in women

<30 yr

Modules:lirm,rubbery,discrete,

well-circumscribed,non-tender,mobile.

Core or excisional biopsy Generally conservative serial observation Increased if complex,

sometimes required if concerned Consider excisionif size 2-3 cm and growing adjacent atypia or strong

on serial U/S (q6 mo x 2 yr is usual follow-up), family history olbreast

U/S and FNA alone cannot IIsymptomatic,formed alter age 35.patient cancer

differentiate fibroadenoma from preference or features on corebiopsy

suggestive of a phyllodes tumour

Surgical excision olinvolved duct to ensure

no atypia

hormone-dependent (unlike cysts),needle about malignancy

aspiration yields no fluid

phyllodes tumour

Solitary intraductal

benign polyp

Can presentas nipple discharge (most

common cause ol spontaneous,unilateral,

bloody nipple discharge ~ pathologic nipple

discharge),breast mass,nodule on U/S

Incidental finding on biopsy of

mammogiaphic abnormalities or breast

masses

Mass or mammogiaphic abnormality

Can harbour areas of

atypia or DCIS

Intraductal

Papilloma r T

L J

Usual Ductal

Hyperplasia

Increased number of

cells within the ductal

space

lobular lesion with

increased librous tissue

and glandular cells

Generally low-risk,slightly

increased if moderate or

florid hyperplasia

low-risk

None required

Sclerosing +

Adenosis

None required

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ATYPICAL HYPERPLASIA

• can involve ducts (atypical ductal hyperplasia) or lobules (atypical lobular hyperplasia )

• cells lose apical-basal orientation

• increased risk of breast cancer

• diagnosis: core or excisional biopsy

• treatment: complete resection, risk modification (avoid exogenous hormones), close follow-up

OTHER LESIONS

Fat Necrosis

• uncommon,result of trauma (may be minor, positive history in only 50%), after breastsurgery (i.e.

reduction)

• firm, ill-defined mass with skin or nipple retraction, ± tenderness, ± ecchymosis

• regressspontaneously, but complete imaging ± biopsy to rule out carcinoma

• oil cysts on mammography are pathognomonic for fat necrosis

Mammary Duct Ectasia

• obstruction of a subareolar duct (see Obstetrics. Mastitis, OB48)

Abscess

• lactational vs. non-lactational (periductal/subareolar) (see Obstetrics. Mastitis,UB48)

Breast Cancer

Epidemiology

• leading cancer diagnosis in women in North America, 2nd leading cause of cancer mortality in

women

• 1 in 8 (12.9% lifetime risk) women in Canada will be diagnosed with breast cancer in their lifetime

• I in 31 women in Canada will die from breast cancer

• all age relative survival is 87%

Female sex.followed by age. are the two

greatest risk factorsfor breast cancer

Risk Factors

• sex (99% female)

. age (83% >50 yr)

• personal history of breast cancer and/or prior breast biopsy (regardless of pathology)

• family history of breast cancer (greater risk if relative was first degree and premenopausal)

• estrogen exposure

nulliparity,first pregnancy >30 yr, menarche <12 yr,or menopause >55 yr

decreased risk with lactation, early menopause, and early childbirth

>5 yrHRTuse, >IOyrOCPuse

• high breast density

• radiation exposure (e.g. mantle radiation for Hodgkin’

s disease)

• BRCA1 and BKCA2 gene mutations

• alcohol use, obesity, and sedentary lifestyle

Male Breast Cancer (<1%)

• most commonly invasive ductal carcinoma

• often diagnosed at later stages

• stage-for-stage similar prognosis to breast cancer in females

• consider genetic testing: most often hormone receptor positive

Any palpable dominant breast mass

requiresfurther investigation

Breast Lymphatic Drainage:

Axillary lymph nodes

Internal mammary lymph nodes

lnfra-/supra-davicular lymph nodes

Investigations

• see margin for physical exam findings

• mammography

indications:screening guidelines(see f amily Medicine, l

'MT)

findings indicative of higher risk of malignancy

mass that is poorly defined,spiculated border

» microcalcifications

architectural distortion

interval mammographic changes

normal mammogram does not rule outsuspicion of cancer based on clinical findings

• other radiographic studies

U/S:differentiate between cystic and solid

• MR I : high sensitivity, low specificity. Use annual MRI and mammography for patients with 25%

lifetime risk of breast cancer

Digital Breast Tomosynthesis (DBT):improved lesion localization and characterization in

noncalcified lesions

• galactogram/ductogram (for nipple discharge): identifies lesions in ducts

metastatic workup indicated in Stage 11-1V disease:bone scan,abdominal U/S,CXR (or CT chest/

abdomen/pelvis), CT head (ifspecific neurological symptoms)

Physical Exam Findings in Breast

Cancer:

Lump/mass:Often firm, irregular, nonmobile,unilateral

Pain: Usually thought of as painless,

however pain may be present

with rapidly expanding tumours or

inflammatory cancer

Inflammation (and peau d’orange):

There are many benign causes of

inflammation, however inflammatory

cancer can presentsimilarly

Nipple or skin retractions/changes:

Nipple or skin retractions/changes:

Attachment of the tumour to skin/nipple

may cause retraction/distortion

Nipple discharge:Majority due to

benign causes, bloody spontaneous

discharge should be investigated for

malignancy

r T

LJ

+