DrE: Breast Flashcards
Breast examination: inspection
Start: pt exposed from waist upwards, lying @45, maintain dignity with bed sheet, chaperone, systematically: as per lump, features of breast disease, 2x positions, hand behind head (lumps/asymmetry/teathering), against hips (attachement to pectoralis), ?leaning forward over side of bed (large breast), good then diseased
Is there any pain?
- 6Ss of a lump: site, size, shape, surfact, symmetry, scars
- Fundation - of fungating carcinoma, inspect inframammary fold
- Asymmetry: carcinoma present in the higher breast
- Tethering - infilration of ligaments of Astley-cooper
- Peau d’orange - micro-oedema
- lymphoedema - lymphatic infiltration by carconoma/previous op with LN removal
- 6Ds of nipple signs:
- paget’s Disease
- Dishrage
- Depression
- Deviation
- Displacement
- Destruction
Breast examination: Palpation
- Temperature changes: back of hand
- Lump - SEC FFP TR - size, edges, consistency, fluctuance, fixity, pulsatile/expansile, transiluminates, reducible
- breast - palmar surface of index middle ring fingers of both hands, sweeping down clock face positions of good breast then disease, 2x positions. most carcinomas present in upper outer quadrant of the breast
- Inframammary fold - DON’T FORGET TO PALPATE
- Axillary tail of spence - DON’T FORGET TO PALPATE
- Nipple discharge - explain to pt it is important to test for discharge by gently squeezing the nipple
- Axillary lymphadenopathy - face pt, support arm with corresponding arm, free hand to palpate. Ant/post/medial/lateral walls + apex
- Supraclavicular lymphadenopathy
Breast examination: completion
- Surgical complications
- thoracic nerve of bell - winging of the scapular (trapezius)
- intercostobrachial nerve - loss of sensation in distribution of T2
- Respiratory examination ?metastasis
- Abdo examination ?metastasis
- Spinal examination ?metastasis
- Encourage pt in self examination in front of the mirror
- Tripple assessment
How would you classify disease of the breast?
- Benign v malignant
- In accordance with aberrations of normal development and involution (ANDI):
Introduced at international breast conference in Cardiff
- 15-25yrs - Development
- Aberration: fibroadenoma, excessive breast development
- 25-40yrs - Cyclical hormonal
- Cyclical nodularity & mastalgia
- 35-55yrs - Involution:
- lobular - cysts
- ductal - duct ectasia & periductal mastitis
- epithelial - hyperplasia & fibrosis
Malignancy is more plevalent in females >55yrs
What is fibroadenoma?
Most comon benign neoplasm in females
Fibroepithelial tumor composed of glandular tissue & stroma
Peak age of onset = 15-25yrs
Clinically = painless, smooth, firm & rubbery lump + highly mobile
10% resolve spontaneously within 1 yr
What is excessive breast development?
Excessiv enlargement of the breast due to glandular and stromal proliferation
minor degrees may be seen in infants due to the effect of maternal oestrogens
males = gynaecomastia
Causes:
- physiological: puberty, pregnancy
- pathological: hormone secreting Tx, hypogonadism, liver cirrhosis
- pharmacological: cimetidine, digoxin, spironolactone, THC
What are cyclical nodularity and mastalgia?
pre-menopausal females, hormone dependent, cyclical breast changes -> lumps (nodularity) and paid (mastalgia) assoc with menstrual cycle.
What are the treatment options for cyclical nodularity and mastalgia?
- Conservative:
- reasurance
- firm supporting bra
- evening primrose oli
- Medical:
- evening primrose oil
- analgesia
- OCP
- Danazol
- bromocriptin
- Tamoxifen
- surgical: sever resistant mastalgia
- mastectomy
What are breast cysts?
Fluid filled distened and involuted lobules
smooth lumps that can be painful
peak age c.35-55yrs
FNA can be diagnostic (microbiology/cytology) and therapeutic
What is duct ectasia?
Chr by involution and dilation of subareaolar ducts
Features: nipple inversion, nipple discharge (may be blood stained), subareolar mass & mastalgia
What is periductal mastitis?
inflammation, often assoc with infection, of subareolar ducts
present similarly to duct ectasia - subareolar mass, pus discharge from the nipple & mastalgia
Rx (if infection related) = antibiotics
what is epithelial hyperplasia?
chr histologically by increase in number of epithelial lining cells of terminal duct lobular unit
When atypical dysplasia is present there is an increased risk of progression to carcinoma
What is fat necrosis?
Occurs after trauma to fatty breast tissue e.g. during breastfeeding/surgery
Inflammation, fibrosis, calcification
Clinically - hard irregular lump ?tethered to skin ?assoc with axillary lymphadenopathy - Ddx = carcinoma
Resolves spontaneously
How would you classify breast tumours?
- Benign:
- fibroadenoma
- intraductal papilloma
- lipoma
- pre-malignant/in-situ:
- ductal carcinoma in situ
- lobular carcinoma in situ
- malignant/invasive
- invasive ductal carcinoma 80% of invasive
- invasive lobular carcinoma 10%
- invasive medullary, mucinous, tubular, papillary carcinoma 10%
What is paget’s disease of the nipple?
Eczematous nipple presentation that, when present, is almost always assoc with underlying carcinoma
2% of all carcinomas are assoc with paget’s disease
Clinically = nipple erythema, crusting, paraesthesia, pain
