Breast Disease Your Initial Visit to the Surgeon Breast Evaluation Physical Examination Mammography Breast Ultrasound Additional Breast Imaging Invasive Diagnostic Testing Breast Cyst Aspiration Fine Needle Aspiration (FNA) Core Needle Biopsy Mammotomy Stereotactic Breast Biopsy Open Excisional Biopsy Needle Localized Excisional Biopsy Breast Disease Benign Disease Fibrocystic Disease Simple Cysts Fibroadenoma Papillomas Treatment for Benign Disease Malignant (Cancerous) Lumps Stages of Breast Cancer Surgery for Malignant (Cancerous) Lumps Lumpectomy Sentinel Node Biopsy Axillary Node Dissection Mastectomy, Modified Mastectomy, Radical Risks and Complications of Surgery for Malignant Lumps Lymphedema of the Arm Which is the Procedure for You? Recovering from Breast Surgery Post Surgical Intervention What You Need to Know About the Treatment for Breast Cancer How to examine your breast
Your Initial Visit to the Surgeon
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If you wish to be seen for breast disease, please BRING ALL of your X-RAYS, MAMMOGRAMS, ULTRASOUNDS, ETC. with you to your office visit. We need to see the films at the time of your exam. If you havd had a biopsy elsewhere, please bring your pathology report.
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Your exam begins with a history of past, present and family history of breast disease. Your family history of breast disease is especially important.
Your mammogram films are reviewed as well as the interpreted reports of your films. Your ultrasound is likewise reviewed. If done in this office, it is viewed in real time. A physical examination is then performed.
The physician will correlate the information from your diagnostic tests and physical exam to give you an opinion as to your disease or lack of disease. We will discuss your options as to further treatment or further diagnostic testing. [back to the top]
Breast Evaluation
Physical Examination
This involves visual inspection and manual palpation of the skin, breast tissue and axilla to evaluate the lymph nodes. One breast is compared to the other breast.
It is our feeling that correlation of the physical exam with mammography is the mainstay of the breast exam and that ultrasound should be added as needed. It is through this yearyly comparison that you obtain your best results with screening. [back to the top]
Mammography
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A mammogram is an x-ray picture of the compressed breast which allows for the evaluation of the contrast of the different tissues in the breast. It is used to detect tumors and cysts and help differentiate benign (noncancerous) and malignant (cancerous) disease; however, it does have some limitations in that some cancers are not visualized with mammography.
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Screening mammograms are important for early breast cancer detection, even when you don't have symptoms. The American Cancer Society recommends mammogram screening every year for all women age 40 and older. The National Cancer Institute recommends mammogram screening every 1-2 years for women age 40 and older.
It is important to be able to compare your mammogram from year to year so the availability of your films is important.
It is important to us at the Surgical Group that we look at your films and compare them to your previous films. PLEASE BRING YOUR FILMS WITH YOU TO YOUR OFFICE VISIT. Normal mammogram of breast
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- lymph node
- fat
- pectoralis muscle
- blood vessel
- ductal structure
- nipple
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Ultrasound of the Breast
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| Ultrasound room |
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Breast ultrasound is an imaging technique for diagnosing breast disease. It uses painless and harmless, high frequency sound waves to form an image (sonogram). The sound waves pass through the breast and bounce back,or echo, from various tissues to form a picture of the internal structures. It is not invasive and involves no radiation.
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Some lesions that are not seen on mammogram are seen with ultrasound. However, ultrasound, as with mammography, does not visualize all lesions of the breast. The combination of the two modalities increase the accuracy of breast evaluation. [back to the top]
Additional Breast Imaging Thermography (Digital Infrared Thermal Imaging [DITI])
Thermography (or DITI) is a painless, noninvasive test without any exposure to radiation or compression techniques. It is based on detecting new blood vessels and chemical changes associated with tumor genesis and growth. ORIGINALLY, THIS TEST WAS THOUGHT TO BE VALID BUT HAS NOT PROVEN TO BE AN SENSITIVE STUDY. [back to the top] Magnetic Resonance Imaging (MRI)
While it is thought to be a new and upcoming modality, it is in its infancy and its role in evaluating the breast needs to be further defined. MRI at present is as accurate as mammography and ultrasound combined. [back to the top] PET Scan
This has not been defined to be helpful in the initial evaulation of the breast.
Invasive Diagnostic Tests
If needed, an ULTRASOUND GUIDED BIOPSY may be required. Sometimes, this can be done on the same day; however, most of the time this requires that you come in within the week for the test. The biopsy can usually give you a histological diagnosis.
Surgical procedures are based on the histological findings, the physician's opinion and a detailed discussion with you the patient.
Different types of biopsy needles
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- spring loaded core biopsy needle
- fine aspiration (FNA) needle
- 25 guage needle used to deliver anesthesia to tissue
- 18 guage aspiration needle
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Breast Cyst Aspiration
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NOTE: the needle is the straight white line seen on the ultrasound image. |
A needle is used to aspirate the fulid from the cyst. Ultrasound is used to guide the aspiration and confirm the reduction of the fluid from the cyst.
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| Syringe with aspirated fluid from cyst |
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The fluid usually is not submitted for pathologic examination as it usually contians only non-diagnostic debris material.
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Fine Needle Biopsy How is the Fine Nedle Biopsy (FNA) performed?
Your skin will be cleaned with alcohol. You may be given a small injection of a numbing medicine, lidocaine, just under the skin with a small needle. This will numb your skin but can sting for a second while it is injected.
A fine, thin, needle attached to a syringe is used to collect a sample of breast tissue. This syringe allows the doctor to place some vacuum pressure into the needle to obtain a good sample. With the other hand, the doctor may gently pinch your breast to hold the lump steady for sampling. In order to get a good sample, the doctor will move the needle in and out of the lump a number of times. The needle is only in your breast for about 10 seconds and the pain is minimal. (There are not very many nerves inside the breast under the skin, so you shouldn't feel very much.) The breast tissue samples are usually put on slides and submitted to the pathologist for examination.
The FNA takes a smaller amount of tissue and is more difficult to make a diagnosis. [back to the top]
Core Needle Biopsy
The procedure is performed in the same manner as a FNA with the addition of a small skin nick to allow for the larger needle.
A core biopsy uses a larger, spring loaded needle to obtain a larger piece of tissue. This larger piece of tissue enables the patholigst to make a more informed diagnosis.
The spring loaded needle makes a noise when the needle is inserted into the tissue.
[back to the top] Complications of a Needle Biospy
Mammotomy
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| Mammatome Machine |
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This is a system that takes multiple core biopsies of the breast lesion with a simple puncture aided by a suction or negative pressure apparatus to increase the amount of tissue in the sample. In some cases, an entire benign lesion can be removed.
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The skin is cleaned and anesthetized. A nick is made in the skin and the needle is introduced into the lesion.
The advantage is multiple biopsies removing larger amounts of tissue.
The scar is 2-4 mm in size and minimally invasive. [back to the top]
Stereotactic Breast Biopsy
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| Mammotome Machine with the Stereotactic Table |
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This is a system that takes multiple core biopsies of the breast lesion with a simple puncture aided by a suction or negative pressure apparatus to increase the amount of tissue in the sample. In some cases, an entire benign lesion can be removed. This is used in conjunction with ultrasound guidance or stereotactic guidance.
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Stereotactic Breast Biopsy Machine |
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This is an x-ray guided method to localize the breast lesion utilizing computerized triangulation of the lesion to calculate a three dimensional position of the lesion. This can utilize any of the above mentioned biopsy techniques but usually utilizes the mammotome. This technique is used to biopsy non-palpable mammographic lesions especially those difficult to localize on routine mammogram.
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Stereotactic Biopsy Newsletter [back to the top]
Open Excisional Biopsy
This is a surgical procedure where an incision is used to remove the abnormality. Most of these consist of a procedure performed in the hospital, usually under general anesthesia, with removal of the lesion in question.
This results in a scar on the breast. The entire lesion is removed with some surrounding tissue. This procedure is often the final procedure and/or lumpectomy if the lesion is found to be a small cancer. [back to the top]
Needle Localized Excisional Biospy
This is an open excisional breast biopsy to remove a lesion that is localized with a needle or wire. This is done preoperatively with mammogram, ultrasound or stereotactic unit. This allows the placement of a wire at the site of the lesion so that it can be excised surgically. The specimen is then confirmed with postoperative imaging xrays to confirm that the lesion has been removed.
Breast Disease
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| Normal Breast |
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The normal breast consists of glandular tissue which responds to hormones and consists of tissue radiating out of the nipple, similary to multiple bunches of grapes with their stems exiting the nipple. The grapes change size and configuration depending on age and hormones. The disease process is usually in the distribution of one group of the grapes.
Fibrocystic disease is a benign disease involving all or most of the bunches of grapes.
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Breast disease is usually divided into two categories:
- Benign Disease
- Malignant Disease
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Benign Disease
BENIGN DISEASE is usually divided into several categories: [back to the top]
Fibrocystic Disease
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fibrocystic disease |
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* The most common cause of breast lumps in women age 35-50.
* Is responsible for 80% of all breast operations performed.
* The condition, which is not actually a disease, is probably caused by the mammary glands, ducts and fibrous tissue reacting to abnormal hormone levels. As a result, pockets of fluids, or cysts, form.
* Tenderness and lump size commonly incerase during the week prior to menstruation.
* Usually disappears with menopause.
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Simple Cysts
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| Simple cyst |
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There is no significant increase in fibrous tissue.
Tenderness and lump size often fluctuate with the menstrual cycle.
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| Ultrasound picture of multiple simple cysts. |
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Fibroadenoma
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fibroadenoma |
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* A single solid tumor, composed of fibrous and glandular tissue
* Most frequently occurs in women between 18 and 35
* Usually movable when felt
* Most all breast tumors in women under age 25 are fibroadenomas
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| Fibroadenoma |
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Papillomas
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papilloma |
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* A small wart like growth in the lining of a mammary duct near the nipple
* Can produce a clear or bloody discharge from the nipple
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Treatment for Benign Disease
BENIGN DISEASE of the breast does not always require histological confirmation and can usually be followed with routine diagnostic studies and physical examination.
Some BENIGN DISEASE require histological confirmation utilizing needle aspiration and/or core biopsy.
Some lesions may be removed completely with the use of a mammatome machine.
For larger areas of concern, an excisional biopsy with conservative conservation of the breast may be recommended to confirm the diagnosis and completely remove the lesion. Follow-up is usually yearly after confirmation that this is benign disease.
Excisional biopsy usually excises the lesion and some surrounding normal breast tissue. [back to the top Risks and Complications of Surgery for Benign Disease
- infection
- blood clot (hematoma)
- failure to obtain an accurate diagnosis
- disfiguring scar
- failure to locate and remove the abnormality
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| Scar 5 weeks after breast biopsy for benign disease. |
NOTE: Since a portion of the breast is removed, the repair is complicated by closing this space with sutures. You will feel a raised area at the skin line which will be red and/or raised for a while. This ridge and color should resolve over time.
Likewise, a lump may be felt at the scar site from suturing the breast tissue together. This should resolve over the next 6-12 months. [back to the top]
Malignant Lumps (Cancerous Lumps) Malignant Lumps
- usually single, hard and painless
- develop most often in mammary ducts or glands
- commonly found in the upper, outer portion of the breast, but may occur anywhere in the breast
- unlike benign lumps, cancerous lumps continue to grow and in time spread beyond the breast
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The round circle is compressing a smaller portion of the breast which better accentuates the stallate ("star-like") lesion. This is characteristic of cancer of the breast.
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Ultrasound of cancer of the breast.
NOTE: the darker area is irregular and darker than the surrounding breast tissue which is characteristic of a cancer. [back to the top]
Stages of Breast Cancer
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Stage 1: Cancer up to 2 cm (4/5 in) has grown in one breast. No other tissues are affected.
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Stage 2 |
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Stage 2. Cancer is less than 5 cm and may have spread to nearby axillary lymph nodes.
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| Stage 3 |
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Stage 3. Cancer is larger than 5 cm and usually has spread to the axillary lymph nodes.
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Stage 4 |
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Stage 4. From one breast, cancer has spread to other parts of the body: bones, liver or lungs.
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Surgery for Malignant (Cancerous) Lumps
Surgery for cancer of the breast requires understanding the anatomy of the breast and is dependent on the size, location, type of cancer and lymphatic drainage. Anatomy of breast
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Illustration by Elise Burrows, published by Romaine Pierson Pubs, Inc. A Surgical Rounds Anatomical Chart
For a MALIGNANCY, there are several options available:
Lumpectomy
- The procedure removes the tumor and a margin surrounding healthy tissue with conservation of breast tissue; sometimes a partial mastectomy is needed
- The lesion is usually less than 1 inch in size
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Sentinel Node Biopsy
- The sentinel node is the first node to receive lymph drainage from the breast.
- Biopsy of this node is done using a marker to identify the lymph chain which is a radioisotope and a blue dye.
Sentinel Node Biopsy Newsletter [back to the top]
Axillary Node Dissection
- Removal of the lymph nodes in the axilla
- Used both for treatment and to learn the possible extent of tumor growth
- Procedure performed when there are positive sentinal nodes
- Procedure performed when there are palpable lymph nodes in the axilla
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Mastectomy, modified
- Requires removal of the entire breast
- This procedure is done for large agressive tumors
- In the past, this was the most commonly performed breast cancer operation
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Risks and Complications of Surgery for Malignant Lumps
- infection
- blood clot (hematoma)
- disfiguring scar
- fluid collection in the axilla (arm pit)
- numbness to arm
- swelling of arm on the side of surgery (LYMPHEDEMA)
- damage to nerves of arm or chest wall, resulting in pain, numbness, weakness
- local recurrence of cancer
- complication of irradiation
- all of the tumor may not be removed with a lumpectomy and may require further operative procedure
- blue dye tattoo at site of injection lasts 6 months or more
- allergic reaction to blue dye
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Lymphedema of the Arm Lymphedema of the Arm [back to the top] Preoperative Chemotherapy and/or Radiation
This has not proven to be beneficial in the majority of cancers of the breast and is usually limited to the patient with advanced disease.
It is used to decrease the amount of tumor burden prior to surgery. [back to the top]
What is the Procedure for You?
We, your surgeons, and you will decide on what procedure you need. This depends on a lot of factors which we will discuss together, consisting of:
- the size and location of your tumor
- the mammogram picture
- the ultrasound picture
- the pathology
- the latest available techniques
- your self portrait--what you see of your image
Results Lumpectomy
- You usually have lost some volume of breast compared to the other side.
- You will have a scar on your breast.
- You may have a slight indention.
- Sensation is usually changed.
- You will have follow-up mammograms of this breast as prior to your surgery.
Radiation
- causes some skin and texture changes
- the above improves with age
- some describe their "radiated" breast as "younger"
Mastectomy, Modified
- There is no breast remaining, only fatty tissue overlaying the muscle.
- You are perceived as normal with a bra, prosthesis and clothes on.
Mastectomy, Radical
- Historical only
- Not done anymore
- The entire breast and muscle is removed
- Sometimes required a skin graft
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NOTE: This patient is greater than 40 years postoperative radical mastectomy without any evidence of recurrent disease. [back to the top]
Recovering from Breast Surgery
- You may or may not have a drain.
- If you have a drain, you will shown how to measure and record the amount of drainage.
- You may wear a bra.
- If you have had a mastectomy, you should do the exercises that Reach to Recovery will show you.
Post Mastectomy or Lumpectomy with Axillary Dissection
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You will probably have a clear drainge tube that will empty into a bulb. Drainage will flow into the bulb and be collected in the bulb.
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how to milk the drainage tube |
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It may be necessary to milk the drainage tube if the drainage from the tube doesn't flow freely or if the tube becomes stopped up.
Hold the tube firmly in one hand, close to the area where it exits from the skin, pinch the tube firmly. (HAND IN PICUTURE ON LEFT) Using the other hand, pinch the tubing and pull on the tube towards the direction of the bulb reservoir. (HAND IN PICTURE ON RIGHT) This is called MILKING the tube and should unclog the tubing to allow for better drainage.
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| measuring and empyting the bulb reservoir |
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You will have to open the bulb, using the tab at the top of the bulb. This will allow air to fill the bulb and the drainage will settle in the bottom of the bulb.
Read the amount of drainage in the bulb, using the measurements listed on the bulb. (This does not have to be a precise measurement)
Squeeze the bulb in one hand while closing the tab in the top of the bulb. This will reprime and collapse the bulb, which in turn, will cause any fluid collected to drain into the bulb.
Record the amount of drainage that was in the bulb.
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Post Surgical Intervention
- You are treated by a team consisting of your medical physician, your surgeon, the pathologist, an oncologist and a support group.
- We refer all patients with a malignancy to an oncologist for evaluation as to whether chemotherapy and/or radiation is needed.
- Treatment is dependent on several factors that the oncologist will discuss with you-- size of tumor, nodal status, hormonal response of the tumor and other levels such as ER, PR, Her2/neu and Ki-67.
- While we don't do breast reconstruction, we are available to recommend plastic surgeons who do reconstructive breast surgery.
- There is a support group in the area called Reach to Recovery. This group is made up of women who have had previous mastectomies. They volunteer their time and visit women who have had recent mastectomies to talk to them about exercise, prosthesis, hairpieces, etc.
- We offer yearly follow-up breast exams to those that wish to continue to have their breast disease followed.
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What You Need to Know About the Treatment of Breast Cancer
The Louisiana State Board of Medical Examiners and developed by the Department of Health and Hospitals in consultation with the Louisiana Cancer and Lung Trust Fund Board published a document “What you need to know about the treatment of breast cancer", March 2000 according to LSA-R.S. 40:1300.153 Breast Cancer Document Chemotherapy
We utilize 2 groups of oncologists in New Iberia who we consider to be up to date with the latest techniques.
Chemotherapy may require a venous access port, or mediport, to give your medication and draw blood without puncturing a vein in your hand or arm.
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| mediport |
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A venous access port, or mediport, is a plastic port placed under the skin and has a silastic catheter placed in a large vein in the ches.
This is put in under local anesthesia in the operating room so that the catheter can be located with x-ray and fluoroscopy at the time of surgery.
NOTE: Your oncologist will tell when to remove our mediport. This is done in our office as an outpatient and usually takes about 30 minutes.
Please call our office to set up an appointment for your mediport to be removed when the time arises.
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Access Catheter Document Radiation
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- The surgical lumpectomy scar is at the 10:00 position of the left breast.
- The surgical scar for the sentinel node biopsy is in the axilla.
- The blue smudge at the nipple is the dye injected for the sentinel biopsy.
- The mark-o-lot marking is used to direct the radiation beam for your postoperative radiation treatment.
We utilize Oncologics, Inc. in New Iberia, who we consider to be up-to-date with current technology and equipment. Breast Reconstruction
We feel that reconstruction is a personal choice. We will offer you recommendations of surgeons who perform this procedure.
In the picture below, this patient had a right modified mastectomy, chest wall and axillary radiation as well as chemotheraphy.
The following year, she had a reconstruction of her breast on the right and a reduction of the left breast.
We are proud of our practice and 26 years of experience and our results in treating breast disease.
We offer you up-to-date therapies, innovative diagnostic modalities and keep up-to-date with the latest technology through journal articles and meetings.
How to examine your breast Click to download Adobe Acrobat Reader from the Adobe Website Reach to Recovery Susan Komen Breast Cancer Foundation [back to the top] |
