Lumps, swellings, mass presentations

Question 1

What is the triple test for a breast lump?

Answer 1

1. medical history and clinical breast examination
2. imaging – mammography and/or ultrasound
3. non-excisional biopsy – core biopsy and/or fine needle
   aspiration (FNA) cytology.

Question 2

Apart from a breast lump itself, what are other concerning features for breast cancer?

Answer 2

Thickening or ridge
Breast or nipple asymmetry
Skin changes; dimpling or redness
Nipple changes
Nipple discharge
unilateral breast pain

Question 3

What to gather on history for a breast lump?

Answer 3

Site

Duration

Changes since first noticed

Relationship to menstrual cycle

Red flag features (in previous slide)

Question 4

What positions should the patient adopt whilst examining the breast?

Answer 4

On inspection
hands by side
arms raised above head
hands on hips leaning forward

On palpation
Seating or standing
Laying flat (or 45d) with ipsilateral hand behind head

Question 5

Nipple Discharge

What are red flag features and what should investigation consist of?

Answer 5

Unilateral, spontaneous, bloody or serous discharge from a
single duct raises the possibility of cancer.

Imaging for nipple discharge should include
mammography and ultrasound.

Question 6

What is a lymphadenopathy?

Answer 6

Lymph nodes that have an abnormal size > 1cm or consistency

Further more lymph nodes >0.5cm in any of these regions: popliteal, supraclavicular, iliac or epitrochlear regions are considered abnormal .

Question 7

What are causes of lymphadenopathy ?

MIAMI pneumonic can be used

Answer 7

Malignancy (kaposi sarcoma, leukemia, lymphoma, skin cancer, metastases)

Infections (wide variety: fungal, bacterial, viral, granuomatous), don’t forget HIV, TB

Autoimmune (Sjorgens, RA, Dermatomyositis, Still disease, SLE)

Miscellaneous: Kawasaki disease, sarcoidosis

Iatrogenic (medication, serum sickness)

Question 8

Which lymphadenopathy is low risk of being a neoplasm?

Answer 8

In adults and children, lymphadenopathy lasting less than two weeks or greater than 12 months without change in size has a low likelihood of being neoplastic

Question 9

What are important aspects on physical exam to cover when someone has an enlarged lymph node/s?

Answer 9

1. Overall height and weight (and tracking - more so for children)
2. Complete lymphatic exam - considering areas of drainage - cervical/head/neck, axilla, epitrochlear, inguinal
3. Skin examination - to identify possible lesions that have metastasized
4. Abdominal exam especially for splenomegaly which can be associated with EBV, leukemia, lymphoma or sarcoidosis.

Question 10

What are risk factors for malignancy when a person has lymphadenopathy?

Answer 10

Male sex
> 40
Duration greater than 4-6 weeks (of lymphadenopathy)
Generalised lymphadenopathy (2 or more non contiguous areas)
Supraclavicular location
Systemic signs: fevers, weight loss
Caucasian

Question 11

When should you image, and what imaging?

What about a biopsy?

Answer 11

If not considered malignant, you can monitor for 4 weeks

If malignant or unsure after 4 weeks then…

For cervical lymphadenopathy
<14 yo use U/S
>14 year old use CT

For lymphadenopathy anywhere else it’ll depend on the person and location, but any of
U/S, CT, MRI

In any one that meets the high risk for malignancy category (previous question), a FNA or core biopsy may be warranted.

Question 12

What are two main risk factors for head and neck cancer in adults ?

Answer 12

1. Smoking
2. HPV positive oral infection (for HPV positive oropharyngeal cancer)

Also
alcohol use
age > 40
previous head and neck malignancy
past history of head and neck cutaneous lesions

Question 13

Red flag features of neck masses?

(5)

Answer 13

A recent voice change

Odynophagia
Dysphagia

Persistent for > 2 weeks

Epsilateral otalgia, nasal obstruction or epistaxis

unexplained weight loss of lack of appetite.

Question 14

What features of the neck mass do you need to characterise on examination?

Answer 14

1. mobility of the neck mass (fixed masses are more likely to be malignant)
2. size (>1.5 cm is more likely to be malignant)
3. firmness
4. overlying skin ulceration.

Question 15

First line investigations for neck mass?

Answer 15

CT with contrast
and FNA

U/S is not recommended as first line as it is operator dependent
MRI is great for soft tissue evaluation but the wait time is not worth it when CT contrast can do the job.
PET scan can be useful with good sensitivity and specificity but isn’t widely available.

Question 16

Malignancy is the biggest concern regarding a neck mass.

What other things can you consider, and what can you order to check this?

Answer 16

Thyroid enlargements - TFTs, thyroid U/S

Infection- FBC and CRP and specific serology: EBV, CMV, TB

Lymphoma- FBC (elevated WCC)

Hypoparathyroid adenoma - Thyroid U/S, PTH serology

Autoimmune diseases- ESR, ANA