Presented at AWS General Hospital under supervision of dr. P.M.T. Mangalindung O. SpB

4. • Shift work (night shifts)

5. Results: Breast cancer risk was increased among subjects who frequently did not
sleep during the period of the night when melatonin levels are typically at their
highest (OR = 1.14 for each night per week; 95% CI = 1.01 to 1.28).
Conclusion:The results of this study provide evidence that indicators of exposure
to light at night may be associated with the risk of developing breast cancer

6. Statistically significant associations were observed between breast cancer and
work durations of ≥5 years with ≥6 consecutive night shifts, with the highest risk
observed for progesterone receptor–positive tumors (odds ratio = 2.4, 95%
confidence interval: 1.3, 4.3; P-trend = 0.01)

12. inflammatory carcinoma

13. Inspection of the breast in the upright position with the patient’s arms to the side (A), in the air (B), and hands on hips (C).
(From Bland KI, Copeland EM III.The breast, 3rd ed. Philadelphia:WB Saunders,2004.)

14. Examination of the cervical (A), supraclavicular (B), and axillary nodes (C). (From Bland KI, Copeland EM III.The breast, 3rd
ed. Philadelphia:WB Saunders, 2004.)

18. older than 40 years

19. axillary lymph node metastases

20. A, Stellate mass in the breast.
The combination of a density
with spiculated borders and
distortion of surrounding breast
architecture suggests a
malignancy
B, Clustered
microcalcifications. Fine,
pleomorphic,
and linear calcifications that
cluster together suggest the
diagnosis of ductal carcinoma
in situ
C, Ultrasound image of breast cancer.
The mass is solid, contains internal
echoes, and displays an irregular border.
Most malignant lesions are taller than
they are wide

21. D, Ultrasound image of a simple cyst.
By ultrasound, the cyst is round with smooth borders,
there is a paucity of internal sound echoes, and there is
increased through-transmission of sound, with enhanced
posterior echoes
E, Breast MRI showing gadolinium enhancement of
a breast cancer.
Rapid and intense gadolinium enhancement
reflects increased tumor vascularity. Lesion contour
and size may also be assessed by MRI .

23. PrimaryTumor (T)
TX Primary tumor cannot be assessed
T0 No evidence of primary tumor
Tis Carcinoma in situ
Tis (DCIS ) Ductal carcinoma in situ
Tis (LCIS ) Lobular carcinoma in situ
Tis (Paget’s) Paget’s disease of the nipple not associated with invasive carcinoma or carcinoma in situ (DCIS and/or LCIS ) in the
underlying breast parenchyma.
T1 Tumor ≤20 mm in greatest dimension
T1mi Tumor ≤1 mm in greatest dimension
T1a Tumor >1 mm but ≤5 mm in greatest dimension
T1b Tumor >5 mm but ≤10 mm in greatest dimension
T1c Tumor >10 mm but ≤20 mm in greatest dimension
T2 Tumor >20 mm but ≤50 mm in greatest dimension
T3 Tumor >50 mm in greatest dimension
T4 Tumor of any size with direct extension to the chest wall and/or to the skin
T4a Extension to the chest wall, not including only pectoralis muscle adherence or invasion
T4b Ulceration and/or ipsilateral satellite nodules and/or edema of the skin
T4c BothT4a andT4b
T4d Inflammatory carcinoma

24. Regional Lymph Nodes (N)
pNX Regional lymph nodes cannot be assessed
pN0 No regional lymph node metastasis
pN0(i−) No regional lymph node metastasis histologically, negative IH C
pN0(i+) Malignant cells in regional lymph node(s) no greater than 0.2 mm
pN0(mol−) No regional lymph node metastasis histologically, negative molecular findings (IHC)
pN0(mol+) Positive molecular findings (RT -PCR), but no metastasis detected by histology or IHC
pN1 Micrometastases; or metastases in one to three axillary nodes; and/or in internal mammary nodes with metastases detected by sentinel
lymph node biopsy but not clinically detected
pN1mi Micrometastases (>0.2 mm and/or >200 cells but none >2.0 mm)
pN1a Metastases in one to three axillary nodes; at least one metastasis >2.0 mm
pN1b Metastases in internal mammary nodes with micrometastasis or macrometastases detected by sentinel lymph node biopsy (not
clinically detected)
pN1c Metastases in one to three axillary nodes and in internal mammary nodes with micrometastases or macrometastases detected by
sentinel lymph node biopsy but not clinically detected
pN2 Metastases in four to nine axillary nodes; or in clinically detected internal mammary lymph nodes in the absence of axillary lymph node
metastases
pN2a Metastases in four to nine axillary nodes (at least one tumor deposit >2.0 mm)
pN2b Metastases in clinically detected internal mammary lymph nodes in the absence of axillary lymph node metastases
pN3 Metastases in ten or more axillary nodes; or in infraclavicular (level III axillary nodes); or in clinically detected ipsilateral internal
mammary lymph nodes in the presence of one or more positive level I, II axillary nodes; or in more than three axillary lymph nodes and
internal mammary lymph nodes, with micrometastases or macrometastases detected by sentinel lymph node biopsy but not clinically
detected; or in ipsilateral supraclavicular lymph nodes

25. Distant Metastases (M)
M0 No clinical or radiographic evidence of distant metastases
cM0(i+) No clinical or radiographic evidence of distant metastases, but deposits of molecularly or
microscopically detected tumor cells in circulating blood, bone marrow, or other nonregional nodal
tissue that are no larger than 0.2 mm in a patient without symptoms or signs of metastases
M1 Distant detectable metastases as determined by classic clinical and radiographic means and/or
histologically proven larger than 0.2 mm

26. ANATOMIC STA GE PROGNOSTICGROUP
0 Tis N0 M0
IA T1 N0 M0
IB T0
T1
N1mi
N1mi
M0
M0
IIA T0
T1
T2
N1
N1
N0
M0
M0
M0
IIB T2
T3
N1
N0
M0
M0
IIIA T0
T1
T2
T3
T3
N2
N2
N2
N1
N2
M0
M0
M0
M0
M0
IIIB T4
T4
T4
N0
N1
N2
M0
M0
M0
IIIC AnyT N3 M0
IV AnyT Any N M1

29. The Halsted radical mastectomy involved removing the breast with the overlying skin, the pectoralis major and minor
muscles, and the level I, II, and III axillary lymph nodes. (From Bland KI, Copeland EM III.The Breast, 3rd ed. Philadelphia:
WB Saunders, 2004.)

30. The classic Stewart elliptical
mastectomy incision.
The medial aspect is at the
lateral edge of the sternum
and the lateral aspect overlies
the latissimus dorsi muscle.
(From Bland KI, Copeland EM
III.The breast, 3rd ed.
Philadelphia:WB Saunders,
2004.)

31. The classic Orr oblique elliptical
mastectomy incision. (From Bland KI,
Copeland EM III.The breast, 3rd ed.
Philadelphia: WB Saunders, 2004.)

36. Total mastectomy with and without axillary dissection.
A, Skin incisions are generally transverse and surround the central breast and nipple-areolar complex.
B, Skin flaps are raised sharply to separate the gland from the overlying skin and then the gland from the underlying
muscle. Simple mastectomy divides the breast from the axillary contents and stops at the clavipectoral fascia.
C, In modified radical mastectomy, dissection continues into the axilla and generally extends up to the axillary vein, with
removal of level I and II nodes. Division of a branch of the axillary vein is shown, with separation of the node-bearing
axillary fat from the axillary vein at the superior aspect of the dissection.

39. Breast-conserving surgery.
A, Incisions to remove malignant tumors are placed directly over the tumor, without tunneling. A transverse incision in the low
axillary region is used for sentinel node biopsy or axillary dissection.The axillary dissection is identical to the
procedure for a modified radical mastectomy.The boundaries of the operation are the axillary vein superiorly, the latissimus
dorsi muscle laterally, and the chest wall medially.The inferior dissection enters the tail of Spence (the axillary tail of the
breast). Inset, Excision cavity of the lumpectomy.
B, In sentinel node biopsy, a similar transverse incision is made, which may be located by percutaneous mapping with the
gamma probe if radiolabeled colloid is used. It is extended through the clavipectoral fascia and the true axilla is entered.The
sentinel node is located by its staining with dye, radioactivity, or both, and dissected free as a single specimen

49. • Surgical Reconstruction

50. Type Advantages Disadvantages
Implant One stage procedure, minimal
prolongation, hospitalization, or
recovery.
Low cost.
Poor symmetry if skin removed or in
large ptotic breasts.
Capsular contracture, leakage,
rupture possible.
Tissue expander Short operative time.
Hospitalization, recovery not
prolonged.
Low cost.
Multiple physician visits postop. Poor
symmetry large or ptotic breasts.
Capsular contracture, leakage
rupture possible.
Latissimus dorsi flap Very low risk of flap loss.
Natural contour with autogenous
tissue.
Donor site scar.
Usually requires an implant.
Moderate prolongation
hospitalization and recovery.

51. Type Advantages Disadvantages
Transverse rectus abdominous
myocutaneous (TRAM) flap
Natural contour. Good match for
large or ptotic breasts.
Abdominoplasty.
Donor site scar.
Fat necrosis, flap loss possible.
Abdominal wall weakness plus
hernia.
Significant prolongation
hospitalization plus recovery.
Deep inferior epigastric perforator
(DIEP) flap
Natural contour.
Muscle sparing.
Abdominoplasty.
Donor site scar.
Need for microsurgeon.
Flap loss possible.
Moderate prolongation
hospitalization plus recovery.
Superior gluteal artery perforator
flap
Natural contour.
Alternative donor site.
Donor site scar.
Need for microsurgeon.
Flap loss possible.
Moderate prolongation
hospitalization plus recovery.

57. Patients are marked preoperatively in the standing position for anatomic landmarks as well as the proposed
DIEP flap procedure. Slight adjustments to the suprapubic marking can be made during surgery to assure a
tension-free closure of the abdomen

58. Isolation of the DIEP flap on the selected perforators proceeds
under loupe magnification, and begins by opening the anterior
rectus sheath around each perforator. A very small cuff of the
fascia can be harvested along with each perforator, as shown
here, but routinely, no fascia is harvested.
The rectus abdominis muscle is split along the direction
of its fibers during DIEP flap harvest. All small side
branches originating from the selected perforators or
the deep inferior epigastric vessels are carefully ligated
and divided as the dissection proceeds.

59. End-to-end microanastomoses are fashioned between the deep inferior epigastric vessels and either the
thoracodorsal or internal mammary recipient vessels. Once perfusion is re-established, the DIEP flap is
debulked, contoured, and inset. Areas of the skin island underlying the native mastectomy flaps are
deepithelialized in situ.

69. Atlas of Breast Surgery
DeVita, Hellman, and Rosenberg’s
Cancer: Principles & Practice of Oncology
Greenfield’s Surgery: Scientific Principles & Practice
Mastery of Surgery
Netter’s Surgical Anatomy and Approaches
SabistonTextbook of
Surgery