Lumps In The Breast

Front 1

Causes of breast lumps

Back 1

mammart dysplasia 32%

fibroadenoma 23%

cancer 22%

cysts 10%

breast abscess/periareolar inflammation 2%

Front 2

Genetic predispositions to breast cancer

Back 2

BRCA1 and BRCA2

Front 3

Dx a new lump

Back 3

75% of lumps are not cancer but need an aspiration biopsy

TRIPLE TEST

Front 4

The triple test

Back 4

1. clinical examination

2. imaging (mammogram and U/S)

3. FNA +/- core biopsy

Front 5

Most common cancer in women is ___________ affecting 1 in ____ in AUS

Back 5

breast

1 in 11

Front 6

the incidence of breast cancer with age

Back 6

increases steadily after 30 till 60

1/3 premenopausal 2/3 postmenopausal

a dominant breast lump in an older women shoeld be regarded as malignant

Front 7

History for a breast lump

Back 7

family hx breast cancer

patients past hx (trauma, previous breast pain, details about pregnancies (lactation such as mastitis, nipple problems and milk retention)

Front 8

Red flags for lumps

Back 8

- hard and irregular lump

- skin dimpling and puckering

- skin oedema ('peau d'orange")

- nipple discharge

- nipple distortion

- nipple eczema

Front 9

Bloodstained nipple discharge

Back 9

— intraduct papilloma (commonest)

— intraduct carcinoma

— mammary dysplasia

Front 10

Green-grey nipple discharge

Back 10

— mammary dysplasia

— mammary duct ectasia

Front 11

Yellow nipple discharge

Back 11

— mammary dysplasia

— intraduct carcinoma (serous)

— breast abscess (pus)

Front 12

MIlky white discharge

Back 12

— lactation cysts

— lactation

— hyperprolactinaemia

— drugs (e.g. chlorpromazine)

Front 13

Pagets disease of the nipple

Back 13

- ecezema of the nipple (dry scabby red rash, then ulceration, due to underlying malignancy)

- middle aged and elderly women

Front 14

DDx Pagets to eczema

Back 14

pagets is unilateral, in older patients, with possible discharge, not pruritic, no pustules, deformity of the nipple, possible palpable lump

Front 15

Ideal time to exam a breast

Back 15

ideally 4 days after the end of a period

Front 16

Method for a breast exam

Back 16

1 Inspection: sitting—patient seated upright on side of couch in good light, arms by sides, facing the doctor, undressed to waist.

a Note:

• asymmetry of breasts or a visible lump

• localised discolouration of the skin

• nipples:

— for retraction or ulceration

— for variations in the level (e.g. elevation on one side)

— or discharge (e.g. blood-stained, clear, yellow)

• skin attachment or tethering → dimpling of skin (accentuate this sign by asking patient to raise her arms above her head)

• appearance of small nodules of growth

• visible veins (if unilateral they suggest a cancer)

• peau d’orange due to dermal oedema

b Raise arms above the head (renders variations in nipple level and skin tethering more obvious).

Hands are pressed on the hips to contract

pectoralis major to note if there is a deep

attachment of the lump.

2 Examination of lymph glands in sitting position:

patient with hands on hips. Examine axillary and supraclavicular glands from behind and front.

Note: The draining lymphatic nodes are in the axillae, supraclavicular fossae and internal mammary chain.

3 Palpation:

a Patient still seated: palpate breast with fl at of hand and then palpate the bulk of the breast between both hands.

b In supine position:

• patient lies supine on couch with arms above head

• turn body (slight rotation) towards midline so

breasts ‘sit’ as flat as possible on chest wall

Method

• Use the pulps of the fingers rather than the tips with the hand laid flat on the breast.

• Move the hand in slow circular movements.

• Examine up and down the breast in vertical strips beginning from the axillary tail (see Fig. 92.3).

• Systematically cover the six areas of the breast (see Fig. 92.4):

— the four quadrants

— the axillary tail

— the region deep to the nipple and areola

4 If a suspicious lump is present, inspect liver, lungs and spine.

5 Inspect the bra. Note possible pressure on breast tissue from underwiring of the bra, usually on the upper outer quadrant.

Note:

• Forty to fifty per cent of cancers occur in the upper outer quadrant

Front 17

assessing a solitary lump

Back 17

• position (breast quadrant and proximity to nipple)

• size and shape

• consistency (fi rm, hard, cystic, soft)

• tenderness

• mobility and fi xation

• attachment to skin or underlying muscle

Front 18

Positive signs on mammogram

Back 18

irregular infiltrating mass

focal spotty microcalcification

Front 19

Mammorgram uses

Back 19

• established benefit for women over 50 years

• possible benefit for women in their 40s

• follow-up in those with breast cancer, as 6% develop in the opposite breast

• localisation of the lesion for fine-needle aspiration

Front 20

Breast ulrasound

Back 20

elucidate an area of breast density

and is the best method of defining benign breast disease, especially with cystic changes. It is generally most useful in women less than 35 years old

Front 21

Breast ultrasound useful for

Back 21

• pregnant and lactating breast

• differentiating between fluid-filled cysts and solid mass

• palpable masses at periphery of breast tissue (not screened by mammography)

• for more accurate localisation of lump during fineneedle aspiration

Front 22

Very young women—12 to 25 years

LUMP

Back 22

Infl amed cysts or ducts, usually close to areola

Fibroadenomata, often giant

Hormonal thickening, not uncommon

Malignancy rare

Investigations:

• mammography contraindicated

• ultrasound helpful

Front 23

Young women—26 to 35 years

Back 23

Classic fibroadenomata

Mammary dysplasia with or without discharge

Cysts uncommon

Malignancy uncommon

Investigations:

• mammography: breasts often very dense

• ultrasound often diagnostic

Front 24

Women—36 to 50 years (premenopausal)

Back 24

Cysts

Mammary dysplasia, discharges, duct papillomas

Malignancy common

Fibroadenomata occur but cannot assume

Infl ammatory processes not uncommon

Investigations:

• mammography useful

• ultrasound useful

Front 25

Women—over 50 years (postmenopausal)

Back 25

Any new discrete mass—malignant until proven

otherwise

Any new thickening—regard with suspicion

Infl ammatory lesions—probably duct ectasia

(follow to resolution)

Cysts unlikely

Investigations:

• mammography usually diagnostic

• ultrasound may be useful

Front 26

Women over 50 years on hormones

Back 26

Any new mass—regard with suspicion

Cysts may occur—usually asymptomatic

Hormonal change not uncommon

Investigations:

• mammography usually diagnostic but breast

may become more dense

• ultrasound may be useful

Front 27

Oestrogen receptors in breast tissue

Back 27

unocmmon normally but found in 2/3 of breast cancers, and are a good prognostic indicator

Front 28

Method of aspiration and needle biopsy

Back 28

1 Use an aqueous skin preparation without local anaesthesia.

2 Use a 23 gauge needle and 5 mL sterile syringe.

3 Identify the mass accurately and fix it by placing three fingers of the non-dominant hand firmly on the three sides of the mass

4 Introduce the needle directly into the area of the swelling. Once in subcutaneous tissue, apply gentle suction as the needle is being advanced. If a cyst is involved it can be felt to ‘give’ suddenly.

5 If fluid is obtained (usually yellowish-green), aspirate as much as possible.

6 If no fluid is obtained, try to get a core of cells from several areas of the lump in the bore of the needle.

7 Make several passes through the lump at different angles, without exit from the skin and maintain suction.

8 Release suction before exit from the skin to keep cells in the needle (not in the syringe).

9 After withdrawal, remove syringe from needle, fill with 2 mL of air, reattach needle and produce a fine spray on one or two prepared slides.

10 Fix to one slide (in Cytofix or similar) and allow one to air dry, and forward to a reputable pathology laboratory to be examined by a skilled cytologist.

Front 29

patient with breast lump <35 IX

Back 29

ultrasound

Front 30

patient with breast lump presents >35yr Ix?

Back 30

mammogram and US

Front 31

If lump is cystic

Back 31

aspirate

Front 32

if lump is solid

Back 32

Fine needle biopsy

Front 33

Suscpious features

Back 33

excisional biopsy

Front 34

Indications for biospy or excision of a lump

Back 34

• The cyst fl uid is bloodstained.

• The lump does not disappear completely with

aspiration.

• The swelling recurs within 1 month.

Front 35

Types of breast cancer

Back 35

90% invasive duct carcinoma

the rest are lobular carcinoma, papillary, medullary, colloid

Front 36

Breast cancer RF

Back 36

age (>40 years), Caucasian race, pre-existing benign breast lumps, alcohol, HRT >5 years, personal history of breast cancer, family history in a fi rst-degree relative (raises risk about threefold), nulliparity, late menopause (after 53), obesity, childless until after 30 years of age, early menarche, ionising radiation exposure.

Front 37

Familial breast cancer

- genetic inheritance pattern

Back 37

- 5% of all breast ca

- most are Autosomal dominate

Front 38

Main 3 presentations of breast Ca

Back 38

• the vast majority present with a local breast lump

• ductal carcinoma in situ

• some present with metastatic disease

Front 39

Of those who present with local disease, approximately ______% will develop metastatic disease.

Back 39

50

Front 40

Mx of breast Ca

Back 40

- immediate referal to surgeon

- staging: FBC, LFTs, sentiel nose, bone scan

Front 41

Single most powerful prognostic and reccurrence feature in breast ca is __________

Back 41

sentiel node

OTHERS: size, histolgy, grading, node, receptor status

Front 42

What is Ductal carcinoma in situ?

Back 42

DCIS is a non-invasive abnormal proliferation of milk duct epithelial cells within the ductal–lobular system and is a precursor lesion for invasive breast cancer.

Front 43

Mx of DCIS

Back 43

Management decisions are challenging, with options being total mastectomy or breast-conserving therapy with or without radiotherapy

Front 44

DCIS Outcomes

Back 44

excellent outcome with low local recurrence rates and a survival of at least 98%.

Front 45

Local therapy

Back 45

Tumour excision followed by whole breast irradiation

was the most preferred local therapy for most women

with stage I or II cancer.

Front 46

Total vs breast conserving therapy

- survival

- and preference

Back 46

- Total mastectomy and breast-conservation surgery had an equivalent effect on survival.

- Total mastectomy is preferred for a large tumour, multifocal disease, previous irradiation and extensive tumour on mammography.

Front 47

Recommendations for radiotherapy post-mastectomy

Back 47

— tumours >4 cm in diameter

— axillary node involvement of >3 nodes

— the presence of positive or close tumour margins

Front 48

Chemotherapy

Back 48

• Cytotoxic chemotherapy has an important place in management. Newer regimens containing anthracyclines (e.g. epirubicin) and a taxane (e.g. docetaxel) have largely replaced the traditional CMF (cyclophosphamide, methotrexate and fl uorouracil) regimen.

• Adjuvant hormonal therapy by the anti-oestrogen agent tamoxifen 20 mg (o) daily, which is a specific modulating agent, is widely used and is most suitable in postmenopausal women.

Front 49

Adjunct agents available for treatment include

Back 49

• anti-oestrogens: tamoxifen, toremifene

• aromatase inhibitors: anastrozole, letrozole,

exemestane

• monoclonal antibodies: trastuzumab (Herceptin)

• progesterones (e.g. medroxyprogesterone acetate)

Front 50

Mammary dysplasia clinical features

Back 50

• Most common in women between 30 and 50 years

• Hormone-related (between menarche and menopause)

• Pain and tenderness and swelling

• Premenstrual discomfort or pain and increased swelling

• Fluctuation in the size of the mass

• Usually settles after the period

• Unilateral or bilateral

• Nodularity ± a discrete mass

• Ache may extend down inner aspect of upper arm

• Nipple discharge may occur (various colours, mainly green–grey)

• Most cysts are premenopausal (fi nal 5 years before menopause)

Front 51

Examination of a mammry dysplastic breast

Back 51

Look for lumpiness in one or both breasts, usually upper outer quadrant.

Front 52

Managment of mammary dysplasia

Back 52

• Consider mammography if diffuse lumpiness is present in patient >40 years.

• Perform needle biopsy if a discrete lump is present and aspirate palpable cysts.

• Reassure patient that there is no cancer.

• Give medication to alleviate mastalgia.

• Use analgesics as necessary.

• Surgically remove undiagnosed mass lesions.

Front 53

Breast cyst age

Back 53

• Common in women aged 40–50 years

(perimenopausal)

• Rare under 30 years

Front 54

Breast cyst cancer risk

Back 54

1 in 1000

Front 55

Breast cyst examination

Back 55

Look for a discrete mass, firm, relatively

mobile, that is rarely fluctuant.

Front 56

Dx of breast cyst

Back 56

• Mammography

• Ultrasound (investigation of choice)

• Cytology of aspirate

Front 57

Adjuvant tx in breast cancer

Back 57

Front 58

Lactation cysts (galactoceles)

What are they?

their size?

how are they treated?

Back 58

• These milk-containing cysts arise during pregnancy and present postpartum with similar signs to perimenopausal cysts.

• They vary from 1–5 cm in diameter.

• Treat by aspiration: fl uid may be clear or milky.

Front 59

Fibroadenoma

- clinically

Back 59

• A discrete, asymptomatic lump

• Usually in 20s (range: second to sixth decade,

commonly 15–35 years)

• Firm, smooth and mobile (the ‘breast mouse’)

• Usually rounded

• Usually in upper outer quadrant

• They double in size about every 12 months7

Front 60

Fibroadenoma Mx

Back 60

Ultrasound and fine-needle aspiration or core biopsy with cytology is recommended plus mammography in older women. If needle aspiration or core biopsy is negative the patient can be reassured. The lump may be

left in those in the late teens but as a rule it is removed to be certain of the diagnosis in all patients.

Front 61

Phyllodes tumour

Back 61

These are giant fi broadenoma-like tumours that are usually benign but 25% are malignant and metastasise. They are completely excised with a rim of normal breast tissue.

Front 62

Fat necrosis

Back 62

Fat necrosis is usually the end result of a large bruise or trauma that may be subtle, such as protracted breastfeeding. The mass that results is often accompanied by skin or nipple retraction and thus closely resembles cancer. If untreated it usually disappears but the diagnosis can only be made on excision biopsy.

Front 63

Duct papillomas

Back 63

These are benign hyperplastic lesions within large mammary ducts and are not premalignant (nor usually palpable). They present with nipple bleeding or a bloodstained discharge and must be differentiated from infiltrating carcinoma. Mammography and ductography are usually of limited value. The involved duct and affected breast segment should be excised.

Front 64

Mammary duct ectasia

Back 64

In this benign condition a whole breast quadrant may be indurated and tender. The larger breast ducts are dilated. The lump is usually located near the margin of the areola and is a fi rm or hard, tender, poorly defined swelling. There may be a toothpastelike nipple discharge. It is a troublesome condition with a tendency to repeated episodes of periareolar inflammation with recurrent abscesses and fistula formation. Many cases settle but often surgical intervention is necessary to make the diagnosis. The condition is most common in the decade around the menopause.

Front 65

Problems with breast prostheses

Back 65

- can still develop cancer and need palpation, fortunately most of the tissue is superfical and can be palpated but with difficulty at the axillary tail

- mammgrams are of limited use

- ultrasounds are helpful

Front 66

Lymphoedema of arm

Back 66

- complications of surgery (skin is tight and heavy)

- exclude DVT with doppler US

- skin changes can occur (cellulitis, abrasions..)

Front 67

Managment of lymphoedema

Back 67

• Encourage movement; elevation of the arm on a pillow at night; avoid slings

• Physiotherapy: a reduction phase with non-elasticised bandages then maintenance with graduated pressure support sleeves

• Elastic sleeves worn all day but not at night

• Lymphoedema massage at home

• Skin hygiene: regular use of non-perfumed emollients, prevention of infection and injury. Avoid sunburn and insect bites

• Avoid BP measurement, venesection and IV therapy in that arm

• Consider diuretics to relieve pressure

Front 68

Breast lumps in children

Neonatal enlargement

Back 68

Newborn babies of either sex can present with breast

hyperplasia and secretion of breast milk

This is due to transplacental passage of lactogenic hormones. The swelling usually lasts 7–10 days if left alone. Any attempts to manipulate the breasts to facilitate emptying will prolong the problem.

Front 69

Premature hyperplasia in children

Back 69

The usual presentation is the development of one breast

in girls commonly 7–9 years of age but sometimes

younger. The feature is a fi rm discoid lump 1–2 cm in

diameter, situated deep to the nipple. The same change

may follow in the other breast within 3–12 months.

Reassurance and explanation is the management and

biopsy must be avoided at all costs.

Front 70

Premature mamillary hyperplasia in a child do you biopsy?

Back 70

AVOID at all costs

Front 71

Screening mamograms

Back 71

50-70yrs (less dense tissue)

every 2 years

90% specificty

and those aged 40–49 who request it.

Front 72

Breast self examinations?

Controversial

Back 72

Breast self-examination is a controversial issue

and has no proven benefi t in reducing morbidity and mortality. The false positive rate is high, especially in those under 40 years. However, regular BSE is recommended for all women 35 years and over.

Front 73

Mx women at high risk of breast cancer

Back 73

Monthly breast self-examination

At least an annual consultation with GP—if aged 40

or older

Aspiration of cysts

Mammography, ultrasound and/or fi ne-needle biopsy

to diagnose any localised mass

Ultrasound alone for further assessment of young,

dense breasts

Regular screening mammography after 50 years of

age—every 2 years

Front 74

Lumos that require investigation and referral

Back 74

A stony, hard lump or area, regardless of size, history

or position

A new palpable ‘anything’ in a postmenopausal

woman

A persisting painless asymmetrical thickening

An enlarging mass—cyclic or not

A ‘slow-to-resolve’ or recurrent infl ammation

A bloodstained or serous nipple discharge

Skin dimpling, of even a minor degree, or retraction of

the nipple

A new thickening or mass in the vicinity of a scar

Front 75

Most common cause of a lump in a women over 50

Back 75

cancer

Front 76

Ezcema of the nipple

Back 76

Any eczematous rash appearing on the nipple or

areola indicates underlying breast cancer

Front 77

Disease that cant be distinguished clinically from breast Ca

Back 77

Mammary duct ectasia and fat necrosis can be

clinically indistinguishable from breast cancer

Front 78

__ out of 10 women with breast Ca dont have a stong family hx

Back 78

9

Front 79

OCP with breast cancer risk

Back 79

show not to alter the risk of breast Ca

Front 80

Things to never do

Back 80

• Never assume that a lump is due to trauma unless you have seen the bruising and can observe the lump decrease in size.

• Never assume a lesion is a cyst—prove it with

ultrasound or successful aspiration.

• Never ignore skin dimpling even if no underlying mass is palpable.

• Never ignore a woman’s insistence that an area of her breast is different or has changed