Surgery Clinical Demonstration: Breast

Question 1

History taking

Answer 1

1. Pain
2. Mass
   - Size
   - Comes and goes (menstrual)
   - Shape
   - Tenderness
   - Consistency
   - Mobility
3. Nipple
   - Retraction
   - Colour
   - Eczematous changes
4. Discharge
   - Bloody, Colourless, Purulent discharge (abscess formation), Milky (lactation)
   - Spontaneous / Expression
5. Skin
   - Peau d’orange
6. Menarche, Menstrual period, Menopause
7. Pregnancy
8. Breastfeeding history
9. Contraceptive
   - COC takes 10 years to wear off
10. Constitutional symptoms
    - LN: Cervical, Virchow’s
    - Bone (Bony tenderness)
    - Liver (Hepatomegaly)
    - Lungs (Pleural effusion)
11. Family history

Question 2

Commonest breast complaints and investigations

Answer 2

1. Lump
   - Duration
   - Change size?
   - Painful / Tender
2. Pain (***Mastodynia)
   - Site (just lump / whole breast / bilateral)
   - Effect of menstrural cycle on pain
3. Nipple
   - Spontaneous / Expression discharge
   - Colour / Nature of discharge
   - Unilateral / Bilateral nipples
   - Crack / Eczema
   - Distortion e.g. Retraction
4. Hormone related history
   - Age at menarche
   - Menstrual pattern
   - Age at menopause
   - Contraceptives / HRT
   - Pregnancy
   - Breast feeding
5. Family history
   - Breast cancer
6. Medication
   - Traditional / Alternative medicines

Question 3

Physical examination of breasts

Answer 3

1. Inspection (Expose clavicle to upper abdomen)
   - Stand in front of patient
   - **Sit up patient
   - **At rest (hands on side) —> **Arms above head —> **叉腰 —> ***Lean forward

Arms above head: Inframammary folds
叉腰: Tense pectoralis —> see if mass move with pectoralis (attached)
Lean forward: Make breast pendulous —> accentuate puckering of skin

—> Surgical scars (Axillary skin folds, Peri-areolar region, Infra-mammary folds)
——> Breast reconstruction (Donor site scar)
—> Symmetry
—> Visible lump
—> Nipple retraction
—> Tethering / attachment to skin
—> Colour change
—> Ulceration
—> Peau d’orange (Skin edema due to blockage of lymph)
—> Inframammary folds

2. Palpation (finger pads)
   - Breast + Nipple (4 Quadrants) (Radially outward)
   —> ***Site of lump (左右breast, lateral vs medial, o’clock, distance from nipple)
   —> Size
   —> Shape (oval / spherical)
   —> Surface (regular / irregular)
   —> Edge (regular / irregular)
   —> Tenderness (look at patient’s facial expression)
   —> Consistency (soft / firm / hard)
   —> Attachment to skin
   —> Attachment to pectoral fascia / muscle (put hands on hips, push down to tense pectorals, test mobility of lump) (叉腰 —> 如果旭 —> lump is attached)

• LN
  —> Axilla (4 groups: anterior, posterior, medial, lateral, apex)
  —> Supra-clavicular fossa

Summary

1. Breast mass
2. Palpable LN
3. Clinically suspicious / non-suspicious
   - If proven malignant, it is clinically (T-stage) tumour
   - ulcerative / fungating: T4

Question 4

Other examinations

Answer 4

Complete examination by

1. Demonstrate nipple discharge (ask patient to do it herself)
   - Single (may be malignant) / Multiple ductal discharge
   - Unilateral / Bilateral
2. Hepatomegaly (Palpate abdomen)
3. Pleural effusion (Auscultation chest)
4. Bony tenderness (Examine spine)

Triple assessment
1. Clinical

2. Radiological
   - Mammography
   - USG
   - MRI
3. Pathological
   - FNAC
   - Core-cut biopsy

Question 5

Summary of PE

Answer 5

1. Right / Left breast mass
2. Axillary LN
3. ***Clinically suspicious / non-suspicious
4. ***Clinically stage ? tumour (if proven malignant)

Question 6

Inflammatory breast cancer

Answer 6

• Very aggressive breast cancer
• ***T4 disease by default

DDx:

1. Mastitis
2. Abscess

Question 7

Paget’s disease

Answer 7

• Eczema on ***only nipple but not skin
• Malignancy within same breast
• Malignant epithelial cells (Paget cells) infiltrate + proliferate in epidermis
  —> thickening of nipple + areolar skin

(Nipple is part of breast)
(Areola is part of skin)

Question 8

Ultrasound vs Mammogram

Answer 8

Depends on age
Young: Denser breast tissue —> Ultrasound
Old: Less dense breast tissue —> Mammogram (X-ray can penetrate)

USG:

• High frequency probe: superficial structure
• Look for: Suspicious masses + Enlarged LN

MRI:

• not 1st line
• unless ***discordant between pathology report / imaging report
• ***many false negative results
• for ***high risk patients (BRCA1/2)
• for patients with implants

Question 9

Mammogram interpretation

Answer 9

Describe

1. Name
2. Date
3. View: CC (Craniocaudal) / MLO (Medial Lateral Oblique)
4. Place 2 sides of breasts side by side

Describe:

1. Symmetry
2. Skin thickness
3. Parenchyma density
4. Obvious mass density
5. ***Calcification
6. Axillary LN

Signs:
1. Breast cancer: Clusters of ***pleomorphic microcalcifications

Question 10

Types of biopsy

Answer 10

1. FNAC
2. Core biopsy
   - Free hand
   - **Stereotactic (Mammogram) guided
   - **Ultrasound guided
   - ***MRI guided
3. Incisional biopsy (part of tumour)
   - if ulcerative / fungating
   - take from ***edge of ulcer because rapidly-growing area
4. Excisional biopsy (whole tumour)