DIFFERENTIALS (AGE DEPENDENT)
Painless lump Painful lump
Elderly:
1. Carcinoma Younger:
2. Cyst
3. Fibroadenoma
4. Area of fibroadenosis (nodularity)
1. Area of fibroadenosis 2. Cyst
3. Abscess (usually in lactating women) 4. Fat necrosis (minor trauma)
5. Periductal mastitis
6. Galactocoele (lactating women) 7. Carcinoma (rare; ~10% & advanced)
HISTORY
1. History of lump - Site of the lump?
- Single or multiple?
- When & Why was it first noticed? (Pain, self-examination, etc)?
- Painful or painless?
- Overlying skin changes noted:
Erythema, warmth,
Dimpling (more prominent hair follicles 2o to dermal oedema from blocked lymphatics)
Swelling?
Any general asymmetry of the breasts noticed?
- Duration since first noticed
- Any increase in size from first noticed to now?
- Any changes in the nipple e.g. retraction
- Nipple discharge? If present, what is the colour and consistency?
- Any other lumps elsewhere – other breast? Axilla? Neck?
2. Oestrogen exposure history Increased risk:
- Age of menarche (early <12YO increased risk)
- Age of menopause if applicable? (>55YO increased risk) - Use of HRT (>5yrs) and/or Oestrogen based OCP?
Protective factors:
- How many children? (nulliparity increased risk) - Age at which first child was born (>30 years old)
- Whether patient breastfed her children, and if so, for how long 3. Other risk factors for cancer
- Family history of breast cancer or ovarian cancer in paternal (BRCA2) and maternal side (BRCA 1&2), especially if cancer occurs in:
first degree relative below the age of 40,
in bilateral breasts - Previous breast disease:
Treated cancer
Previous biopsy showing atypical ductal hyperplasia or LCIS - Exposure to ionising radiation (esp. RT for previous breast disease) - Daily Alcohol intake, especially before age of 30 (link has been shown) 4. Systemic review
- LOA, LOW (constitutional) - Fever (infective cause) - Bone pain, SOB (metastasis) PHYSICAL EXAMINATION Preliminaries (HELP)
- Hi: Introduce yourself & ask for permission to examine the breast
Always have a chaperone to accompany you if you are male - Expose patient adequately from the waist up with exposure of axillae - Lighting: good
- Position the patient at 45o or sitting position if a bed is not available Inspection
- General appearance
- Patient‘s hands relaxed at her sides – look for:
any asymmetry in the breast contours,
any obvious skin changes (peau d‘orange, erythema, puckering)
any scars of previous operation or procedure e.g. punch biopsy
- Ask patient to raise her arms (to accentuate any tethering to the skin dimpling)
- Ask the patient to contract the pectoralis major (push her hands against her hips) may reveal a previously unnoticeable lump
- Look for nipple changes (7 D‘s):
Discolouration
Discharge Depression (retraction)
Deviation
Displacement
Destruction
(Duplication – unlikely)
Palpation
- Patient should be lying down at 45 degrees to the horizontal with her hand tucked behind her head – this splays the breast out so it can be palpated properly
- Start with the normal side first!
- Ask for any pain before starting to palpate
- Use one hand to retract and stabilise the breast and palpate with the other - Palpate in a systematic manner e.g. quadrant by quadrant from centre outwards - Examine the entire breast including the axillary tail
- When the lump is located, check with the patient whether this is the same lump - Characterise the lump:
Site (which quadrant)
Tender or non-tender
Warmth of overlying skin
Size
Shape (hemispherical/ oval)
Surface (smooth or nodular/irregular)
Consistency (soft, firm, or hard)
Fluctuance
Margins (regular and smooth, or irregular and ill-defined)
Fixation to the skin – try to pick up the skin above the lump
Fixation to underlying muscle – ask patient to press her hands against her hips to contract the pectoralis major muscle, then try to move the lump in 2 perpendicular directions, then ask patient to relax and try to move the lump again - Continue to examine carefully for other lumps (multiple lumps are unlikely
malignant, usually fibroadenoma or fibroadenosis)
- Ask patient if she can show you the discharge by expressing it herself (NEVER squeeze the nipple yourself!); if patient cannot do it, then ask the chaperone to help Axillary lymph nodes
- Palpate the normal side first
- Rest the patient‘s right forearm on your right forearm and use your left hand to palpate the right axilla (vice versa for the left side)
Check list:
“I feel a lump in the upper outer quadrant of the Right breast. This lump is NOT WARM, and NON-TENDER, is hemispherical with poorly defined edges, measuring
___X___CM. It is firm in consistency with a irregularsurface and is NOT FLUCTUANT.
It is NOT FIXED to the SKIN ………….(ask her to contract the pect maj)…. ………….And NOT FIXED to the underlying muscle”
- Palpate gently, slowly, and systematically, covering the major groups of nodes:
anterior, posterior, medial, lateral, and apical
- If any lymph nodes are found to be enlarged, note the number of lymph nodes, their site, size, tenderness, consistency (firm, hard, matted), mobility
To complete the examination
- Examine the the supraclavicular LNs & cervical LNs - Examine the lungs for any pleural effusion
- Percuss the spine for bony tenderness
- Examine the abdomen looking for hepatomegaly FINDINGS FOR THE COMMON BREAST LUMPS
Type of lump Age Pain Surface Consistency Mobility
Cyst 30-55 Occ Smooth Soft to hard Not fixed
Nodularity 20-55 Occ Indistinct Mixed, fluctuant
Not fixed
Fibroadenoma 15-25 No Smooth, bosselated Rubbery Very mobile
Cancer 35+ No Irregular Stony hard May be tethered
or fixed
INVESTIGATIONS
“The evaluation of a breast lump is via the TRIPLE ASSESSMENT – (i) Clinical examination; (ii) Imaging; and (iii) Histology.”
Imaging
1. Mammography
- Most sensitive of the proven breast imaging modalities
- Usually performed in asymptomatic older women (>40YO) [breast tissue in younger women is denser; more difficult to pick up abnormalities], but >35YO in symptomatic women
- Normally, 2 views are done:
craniocaudal (CC)
right /Left
70% tumours in lateral quadrant (upper)
mediolateral oblique (MLO)
captures the tail
right/ left
80% tumours in oblique milky way
- Additional specialised views: magnification and coned compression; done on request to help magnify areas of abnormality or help visualise breast better
- Abnormal features:
(a) Neo-density or asymmetric density (look for bilateral synchronous ca;
satellite lesion)
(b) Microcalcifications (<0.5mm in size)
- If calcifications >0.5mm macrocalcifications; >5/mm2 cluster - Sole feature of 33% of cancers detected on mammography
- Causes: DCIS, invasive cancer, fibrocystic disease, papilloma - Features of malignancy:
pleomorphic microcals,
heterogeneous appearance; segmental
closely grouped or arranged in a linear pattern (ductal distribution),
underlying density
- Features of Benign microcals: punctate, ―tea-cup‖ appearance (c) Spiculated mass or stellate lesionwith poor outline or comet sign
- 95% of spiculated masses on mammography are due to malignancy - Stellate lesion is a localised distortion of the breast parenchyma without
perceptible mass lesion – high chance of it being malignant
- Causes: Invasive cancer, radial scar (benign), fat necrosis, abscess, etc (d) Architectural disortion (of the contour), tent sign , nipple changes - Look at the axilla on the MLO view for any enlarged lymph nodes
2. Ultrasound
- Usually used as the 1st investigation in young patients (<35 years old) or pregnant, lactating patients; not the gold standard for screening
- Uses:
Guide procedures e.g. Biopsy, drainage of abscess, aspiration of cyst
Evaluates consistency (solid vs cystic) &margins
Localisation of lesion seen in only one mammographic projection
Evaluation of a palpable mass with a negative mammogram
Evaluation in mammographically-difficult areas e.g. chest wall, axilla All 3 must be
concordant for benign to have
>99% specificity to r/o malignancy
BI-RADS (Breast Imaging Reporting and Data System) classification Category 0: Need additional imaging evaluation
Category 1: Negative (nothing to comment on, 0.05% risk still present) Category 2: Benign
Category 3: Probably benign, short-term follow-up suggested (<0.2% risk) Category 4: Suspicious, biopsy should be considered (25-74% risk) Category 5: Highly suggestive of malignancy (75-99% risk)
Category 6: Known malignancy 70%
80%
- Pitalls:
Operator dependent, non-standardised techniques, poor resolution,
Unable to detect most microcalcifications - Features of malignancy:
Markedly hypoechoeic with + thick echogenic halo
Irregular edges; Destruction of surrounding structures
Hypoechoeic shadowing; Posterior acoustic shadowing
Taller than it is wide (fir-tree appearance; invasion of fascia)
High central vascularity 3. MRI of the breast
- Expensive, but Good soft tissue definition without radiation (>90% sensitivity) - Indications:
Occult lesions: Axillary LAD but Mammogram & US -ve
Suspicion of multifocal or bilateral malignancy (esp ILC)
Assessment of response to neoadjuvant chemotherapy
When planning for breast conservation surgery
Screening in high risk patient Histology
- Options available:
(a) Fine needle aspiration cytology (b) Core biopsy (Trucut/ mammotome) (c) Incisional or Excisional biopsy
- Mostly a choice between FNAC and core biopsy
FNAC is less invasive, less painful, smaller wound, does not require any local anaesthetic, but only cells are obtained with no histology cannot differentiate between in-situ cancer and invasive cancer, requires skilled cytopathologist
Core biopsy is more invasive, requires local anaesthetic, will result in a larger wound, more painful, risk of complications higher (because biopsy needle is a spring-loaded firing mechanism, improper angling may result in puncture of the lung or heart), but can obtain tissue specimen, can stain for ER/PR status better diagnostic value
- Guided by clinical palpation or radiologic guidance[ more accurate, not 100%]
US or Stereotactic guidance (stereotactic mammotome) MANAGEMENT
- If triple assessment suggests a benign lump (i.e. all 3 are concordant), follow up with physical examination for 1 year (q3-6mths) to ensure the lump is stable or regresses - If all 3 concordant for malignancy further staging and treatment
- If 1 or 2 of 3 aspects suggest malignancy further workup, excisional Bx?