Breast Flashcards
Breat examination
Inspect: breast, and some + palpation: breast, and some + completeion
Expose pt. from waist up and start c¯ her sitting up
- Request a chaperone
- Ask pt. if they have noticed lump in breast: which breast?/point to the lump
Inspection
- Breast
- Positions
- Hands relaxed by sides
- Leaning forwards
- Hands behind head
- Hands pressing hips
- Shape: asymmetry, masses
- Skin
- Scars: periareolar, submammary
- Radiotherapy tattoos
- Eczema, erythema, ulceration
- Peau d’orange, dimpling
- Accessory nipples: look along the milk line
- Nipple: inversion, discharge, discolouration, destruction
- Positions
- Peripheral
- Axillae: LN dissection
- Arm: lymphoedema
- Abdomen / Suprapubic: DIEP or TRAM flap harvest
- Back: lat-dorsi flap harvest
Palpation
- Breast
- Pt. @ 45 with hand behind head, start c¯ normal breast
- Any pain or discharge?
- Palpate each breast quadrant, subareolar area and the axillary tail
- If lump found:
- SSS CCC TTTT FS
- Axillae
- Right axilla: hold pts. right arm with your right hand (and vice versa)
- Gently palpate axillary node:
- Apical
- Anterior
- Posterior
- Medial
- Lateral
- Supraclavicular and cervical nodes
- Lateral Chest Wall: Inflatable port sites for implants
Completion
- Spine: palpate / percuss for tenderness, masses
- Abdo: hepatomegaly
- Lungs: Percuss and auscultate lungs for signs of mets: e.g. effusion
Breast: Presentations
- Lump
- Breast pain
- Skin or nipple changes
- Mets
- Bones: bone pain, #s
- Lungs: dyspnoea
- Liver: abdo pain
- Brain: headache, seizures
RF for breast lumps
(BOOBYS)
OBESITY
- Bleeding: early menarche (<13), late menopause (>55)
- Oestrogen: OCP, HRT
- Other breast disease: previous Ca, DCIS, atypia
- Breast feeding: protective
- Young ‘un: first child >35yrs (↑ risk)
- Sister: FH of Ca breast
Radiology options in Breast lumps
- <35yrs: US
- >35yrs: US + mammography
- Oblique and craniocaudal
- MRI
- Multifocal disease
- Cosmetic implants
cytology options for breast lumps
- Solid lump: Tru-Cut biopsy
- Cystic lump: FNAC
- Reassure if clear fluid
- Send cytology if bloody fluid
- Core biopsy residual mass
- Core biopsy if +ve cytology
hormone receptor testing: OR/PR
and HER2
Investigations for breast lumps
Tripple assessment: Clinical: Hx and Ex + Radiology + Histology
- Radiology: US + Mammography + MRI
- Histology: Tru cut Bx + FNAC
Other:
- Bloods: LFTs + Bone profile + ESR + U&E +FBC
- Imaging for staging:
- CXR
- Liver US
- CT scan
- Breast MRI
- Bone scan + PET CT
- May need wire guided excision Bx
- LFT/bone profile may suggest malignancy*
- In oncology, a high ESR has been found to correlate with overall poor prognosis for various types ofcancer*
- and FBC+U&E pre chemo?/prognosis*
Commonest single breast lumps
(4)
- fibroadenoma
- cyst
- fat necrosis
- cancer
Features of a malignant breast lump
(6)
- Irregular, nodular surface
- Poorly defined edge
- Hard / scirrhous consistency
- Painless
- Fixation to skin or chest wall
- Nipple involvement
Classification of Malignant breast diseases (6)
- Ductal carcinoma NOS: c.70% of cancers
- Lobular carcinoma: 20% of cancers
- Other: mucinous
- Other: medullary
- Other: papillary
- Other: phylloides
Classification of benign breast lumps
Congenital (2)
Stromal (1)
Epithelial (3)
Inflammatory (4)
- Congenital
- Supernumerary nipples
- Hypoplasia
- Stromal Tumour: fibroadenomas
- Epithelial Lesions
- ANDI: fibroadenosis, cysts (abberation in normal development and involution)
- Papillomas
- Cystic disease
- Inflammatory Lesions
- Mastitis
- Abscess
- Fat necrosis
- Duct ectasia & periductal mastitis
Examination of Post-Mastectomy breast
Examination: Inspection + palpation + completion
Inspection
- Note asymmetry
- Describe scar
- Look at surrounding skin and axilla
- Evidence of radiotherapy
- Ask pt. to press her hips: pec major present
- Arm lymphoedema
Palpate
- Remaining breast
- Axilla
- Supraclavicular fossa
Completion
- Palpate / percuss spine for tenderness, masses
- Examine abdomen for hepatomegaly
- Percuss and auscultate lungs for signs of mets
Post Mastectomy breast history
Past 3/Present 4/future 2
What happened?
- Presentation
- Risk factors
- Surgery
How are things now?
- Post-op pain, anaesthetised skin (@ T1)
- Arm swelling
- Psych
- Symptoms of mets
What will happen in the future?
- Chemo and radiotherapy
- Reconstruction
Indications for mastectomy
- Modern oncological breast surgery involves breast conservation wherever possible.
- Typically WLE and SNB (sentinal nobe Bx)
- Mastectomy may be considered if
- Pt. preference
- Multifocal disease
- Large lump in small breast: e.g. >4cm
- Large area DCIS: e.g. >4cm
- Nipple involvement
Types of masectomy
(4)
- Simple mastectomy
- Removal of breast alone: commonest type
- Still need to Mx the axilla
Other types not performed as no survival benefit
- Modified radical: breast, pec minor, axilla
- Radical: breast, pec minor and major, axilla
- Extended radical: radical + internal mammary LNs
Post mastectomy breast
Pt preparation: physical and psychological
-
Physical
- Mark side prior to anaesthetic
- Explanation including use of suction drain to close cavity and ↓ risk of haematoma or seroma formation.
- There will be an anaesthetised patch of skin in the upper medial part of the arm
- Division of intercostobrachial nerve (T1)
-
Psychological
- Pts. should see breast care nurse pre-op
- Options for reconstruction should be discussed
Masectomy: post of drains?
Typically 2 drains: axilla and site of surgery
Left for 3-5d or until draining <50ml/d
Pts. can go home c¯ drains and district nurse support.
Breast reconstruction examination
Inspection: gen and flap vs implant
General
- Note asymmetry
- Arm lymphoedema
- Evidence of radiotherapy
- Evidence of axillary clearance / radiotherapy
Flap Reconstruction
- Scars extend over back or abdominal wall
- Recess on back where lat dorsi has been removed
- Ask pt. to lift head of bead (when lying supine) to see recess in the rectus muscle
Implant Reconstruction
- Rounder shape than normal breast
- Breast usually lies higher
- Becker implant may have palpable SC filling port in the axilla
Timing of breast reconstruction
- Immediate: single operation
- Delayed
- ↑ pt. decision time
- Avoidance of detrimental effects of adjuvant therapy
Techniques for breast reconstruction
Tissues expansion reconstruction with implants (becker’s=combined)
Autologous tissue reconstruction with myocutaneous flaps
Implants for breast reconstruction
Advantages and disadvantages
- Advantages:
- simpler techniques
- primary or delayed
- Disadvantages:
- cosmetic result not as good
- lies higher than other breast
- requires plenty of available skin
- Late complications:
- capsular contracture
- Implant leakage
- Infection requiring removal
- cosmetic result not as good
Myocutaneous flaps
Advantages and disadvantages
- AdvantagesL
- useful when little remaining skin or muscle
- good costmetic result
- Primary or delayed
- Disadvantages:
- blood loss ^
- Op time and complications ^
- Use of rectus impossible if pt has had abdo surgery
- late complications: flap necrosis and infections
Types of Myocutaneous Flap:
Latissimus Dorsi myocutaneous flap
- Pedicled: skin, fat, muscle and blood supply
- LD mobilised and tunnelled medially to form neo-breast
- Supplied by thoracodorsal A. via subscapular A.
- Often augmented c¯ an implant
Types of Myocutaneous Flap
Transverse Rectus Abdominis Myocutaneous (TRAM) Flap
- Pedicled: inf. epigastric A. Or free: attached to internal thoracic A
- No implant necessary and combined tummy tuck
- CI if poor circulation: smokers, obese, PVD, DM
- Risk of abdominal hernia
Types of Myocutaneous Flap
Deep Inferior Epigastric Perforator (DIEP) Flap
- Evolution of the TRAM flap
- Free: skin and fat only, no muscle
- Spares the rectus: ↓ pain and ↓ risk of hernia
- May not be possible if small perforators
Gynaecomastia
Examination
(Inspection/palpation/completion)
- *Inspect:** Unilateral or bilateral breast swelling
- Palpation:** Must feel *glandular tissue to differentiate from pseudogynaecomastia (fat).
- *Completion**
-
Look for cause
- External genitalia
- Thyroid examination
- Evidence of CLD
- Visual fields
- Take Hx
- Prescription and recreational drugs
Causes of gynaecomastia: 3 Ps
Potions
Physiological
Pathological
Potions
- Recreational
- Marijuana
- Diazepam
- Anabolic steroids
- Prescription
- Spiro
- Digoxin
- Captopril
- Verapamil
- Ranitidine
Physiological
- Especially at puberty where breast tissue may be unilaterally or bilaterally enlarged.
- Usually resolves by adulthood
Pathological
- ↓ androgen production: hypogonadism
- Hyperprolactinaemia
- Renal failure
- Testicular atrophy
- Post-orchitis
- Bilat torsion
- Klinefelter’s: XXY
- ↑ oestrogens
- ↑ production
- Sex-cord stromal tumours
- Lung Ca
- ↑ production
- ↑ peripheral aromatisation
- Chronic liver disease
- Thyrotoxicosis
Investigation of Gynaecomastia
- Testicular Ca: AFP, βhCG
- Hypogonadism: testosterone and LH levels
- Prolactinoma: PRL level
- TFTs
What is Gynaecomastia?
enlargement of a man’s breasts, which may be a result of physiological changes, drugs (recreational or pescription) or pathological changes (driven by hormonal imbalances)
Features of gynaecomastia suggestive of breast Ca
1% of breast Ca occurs in men
- Older age
- FH
- Unilateral gynaecomastia
- Firm or hard nodules w/i breast tissue
- Axillary LNs
