 The breast lies between the subdermal layer of

adipose tissue and the superficial pectoral

fascia
 The breast parenchyma  Fibrous 
suspensory ligaments of Cooper  Hold in
Position
 Retromammary space  contains lymphatics
and small vessels.
 The axillary nodes are typically described as
three anatomic levels defined by their
relationship to the pectoralis minor muscle.
 Level I nodes are located lateral to the lateral
border of the pectoralis minor muscle.
 Level II nodes are located posterior to the
pectoralis minor muscle.
 Level III nodes include the subclavicular
nodes medial to the pectoralis minor muscle.
 Lymph flow 75% is directed into
the axillary lymph nodes
 Lymph group between pectoralis
mayor musle and pectoralis minor
musle named interpectoral group
or Rotter’s nodes.
 Breast cancer stage is determined prior to any treatment with physical
examination and imaging studies (clinical staging) and on definitive surgical
treatment by pathologic examination of the primary tumor and regional lymph
nodes (pathologic staging).
 Staging is performed to group patients into risk categories that define prognosis
and guide treatment recommendations for patients with a similar prognosis.
 Breast cancer is classified with the TNM classification system, which groups
patients into four stage groupings based on the size of the primary tumor (T),
status of the regional lymph nodes (N), and presence or absence of distant
metastasis (M). The most widely used system is that of the American Joint
Committee on Cancer (AJCC).
Excisional biopsy implies complete removal of a breast lesion with a margin of normal-
appearing breast tissue. In the past, surgeons would obtain prior consent from the
patient allowing mastectomy if the initial biopsy results confirmed cancer.
 Sentinel lymph node (SLN) dissection is primarily used to assess the
regional lymph nodes in women with early breast cancers who are
clinically node negative by physical examination and imaging studies.
This method also is accurate in women with larger tumors (T3 N0), but
nearly 75% of these women will prove to have axillary lymph node
metastases on histologic examination
Breast-Conserving Surgery
Technical aspects Excision of the primary tumor with preservation of the
breast has been referred to by many terms, including lumpectomy, partial
mastectomy, segmental mastectomy, segmentectomy, tylectomy, and wide local
excision. Breast-conserving surgery removes the malignancy with a
surrounding rim of grossly normal breast parenchyma. For many women
with stage I or II breast cancer, breast-conserving therapy (BCT) is
preferable to total mastectomy because BCT produces survival rates
equivalent to those after total mastectomy while preserving the breast.
Indications Certain tumors still require mastectomy, including those that are large
relative to breast size, those with extensive calcifications on mammography, tumors for
which clear margins cannot be obtained on wide local excision, and patients with
contraindications to breast irradiation. Tis to T3 cancers
 Technical Details

A total (simple) mastectomy without skin sparing removes all breast tissue, the
nipple-areola complex, and skin.

An extended simple mastectomy removes all breast tissue, the nipple-areola

complex, skin, and the level I axillary lymph nodes.
 A modified radical (‘Patey’) mastectomy removes all breast tissue, the
nipple-areola complex, skin, and the levels I, II and III axillary lymph
nodes: the pectoralis minor which was divided and removed by Patey
may be simply divided, giving improved access to level III nodes, and
then left in-situ or occasionally the axillary clearance can be performed
without dividing pectoralis minor.
 The Halsted radical mastectomy removes all breast tissue and skin, the
nipple-areola complex, the pectoralis major and pectoralis minor
muscles, and the level I, II, and III axillary lymph nodes.