Breast Examination - PowerPoint Presentation

Slide1

Breast Examination

Robert Collins

GPVTS1Slide2

Topics

Breast history

Examination

Investigations

Breast conditions

Benign / Malignant

TreatmentSlide3

History

Presenting complaint is v important

Lump

;

always ask how long been present

Relation to menstrual cycle

Does its size vary? Is it getting larger?

Pain;

Is it cyclical? Is the lump painful?Slide4

Nipple discharge;

ascertain

Colour, Quantity, pattern, frequency

Age

of patient; cancers are uncommon <30yrs, but

fibroadenomas

are

Ask if noticed any;

Nipple retraction

Breast distortion

Metastatic related symptoms

Previous breast disease

Was it investigated / treatedSlide5

Family history

Genetics; 5-10% are inherited dominantly

They have early onset & associated with other tumours e.g. Bowel, ovarian.

BRCA1 (chromosome 17q21)

BRCA2 (chromosome 13q24)

P53 gene chromosome 17

Medications

; HRT, pill

Gynae

/ Obstetric

Hx

;

Menarche, menses

Parity? When? After 30 increases risk

Breast fed? Slide6

Examination

Introduce yourself to patient

Undress to waist, sit on couch at 45 degrees

Maintain patient dignity e.g. Bed sheet

Assess in following positions

Patient’s hands behind their head (accentuate lumps, asymmetry, tethering)

Pushing against their hips (accentuate lumps attached to

pectoralis

muscle)

Patient leaning over side of bed (accentuate abnormalities in large breasts)

Exam good breast first, then the ‘diseased’ breastSlide7

Inspection

6

S

’s

S

ite

S

ize

S

hape

S

ymmetry

overlying

S

kin

associated

S

cars

Fungation

; comment on presence of

fungating

carcinoma (check

inframammory

fold)

Asymmetry

; carcinoma may be present in higher breast

Tethering

; due to infiltration of ligaments of

Astley

-Cooper

Peau

d’orange

; micro-oedema

Lymphoedema

; may indicate lymphatic infiltration by carcinoma or previous surgery with LN removal

ErythemaSlide8

Nipple signs; 6

D

’s

Paget’s

D

isease

D

epression

D

eviation

D

ischarge Displacement DestructionSlide9

Palpation

Ask about pain and if patient has a lump.

Examine good breast first then diseased breast

Patient puts hand behind head on exam side

Check for temperature change

Use following with lumps;

Surface

Edge

Consistency (hard, firm, soft)

Fixity to skin

and underlying structuresFluctuancePulsatility and

expansilityTransilluminabilityReducibilitySlide10

Palpate using

palmar

surfaces of index, middle & ring fingers of both hands, sweeping down clock face positions.

N.B.

Most carcinomas present in upper, outer quadrantSlide11

Remember;

Inframammary

fold

Axillary

tail of Spence

Nipple discharge (explain important to check for discharge, gain permission, gain permission)Slide12

Axillary

lymphadenopathy

Support their arm with your corresponding arm

e.g. Patients right arm with you right arm and palpate with your left hand

Examine anterior, posterior, medial and lateral walls in addition to the apex

Medial

wall (

seratus

anterior)Lateral wall (body of humerus)Anterior wall (

pectoralis major)Posterior wall (latisimus

dorsi)Apices (arch of armpit – high in the head of the humerus)Slide13

Cervical and

supraclavicular

lymphadenopathy

Always cover the patient when examination complete and thank the patient.

For completion

;

Respiratory exam

; ?

mets

Abdomen exam

; palpate liver (if hepatomegaly think mets)Spinal exam; tenderness ? Mets

Encourage self exam; encourage patient to regularly monitor their breasts using simple examination infront of a mirrorTriple Assessment; If lump detected continue to thisSlide14

Triple Assessment

Clinical Examination

Imaging; Mammogram (false negative rate 10% / USS (in <40yr)Slide15

3. Tissue Sampling;

FNAC (cytology exam of aspirate, can have 95% sensitivity)

Core Biopsy

- Open BiopsySlide16

Breast Disease

Classify as benign or malignant

Benign aetiology classified as Aberrations of normal development and involution (ANDI)

Peak Age (years)

15-25

Development

Fibroadenoma

& excessive Breast

development

25-40

Cyclical

Hormonal

Cyclical

nodularity

& mastalgia

35-55

Involution Lobular:

Ductal

:

Epithelial:

Cyst

Duct

ectasia

&

periductal

mastitis

Hyperplasia & fibrosisSlide17

What is a

fibroadenoma

?

Most common benign neoplasm.

Fibroepithelial

tumour, composed of glandular tissue &

stroma

.

Peak onset 15-25yrs.

Painless, smooth, firm, rubbery lump, highly mobile.

Approx 10% resolve spontaneously within 1yr

What are breast cysts?Fluid-filled, distended & involuted

lobules. Present as smooth lumps. Maybe painfulPeak age onset 35-55yr.FNA may relieve symptoms and can be analysedSlide18

What are cyclical

nodularity

&

mastalgia

?

Affect pre-menopausal females & are hormonal dependent.

Cyclical breast changes occur, result lumps (

nodularity

) & pain (

mastalgia

) related to menstrual cycle.

Treatment options classified as;

Conservative

MedicalSurgicalReassurance

Evening primrose oil

Mastectomy (for treatment resistant severe

mastalgia

)

Firm supporting

bra

Analgesia

Evening primrose oil

OCP

Danazol

Bromocriptin

TamoxifenSlide19

What is duct

ectasia

?

Involution & dilatation of

subareolar

ducts

Clinical features; nipple inversion, nipple discharge (may be cheese / blood stained),

subareolar

mass,

mastalgia

.

What is periductal mastitis?

Inflammation, often due to infection of subareolar ducts.May present like duct ectasiaPus discharge from nipple &

mastalgiaSlide20

What is epithelial hyperplasia?

Increase no. of epithelial lining cells of the terminal lobular unit.

Atypical

dyplasia

increased risk of progression to carcinoma.

What is fat necrosis?

Often after trauma to fatty breast

tisssue

e.g. Surgery / breastfeeding.

Inflammation, fibrosis & calcification may occur

Can be similar to carcinoma

Most cases resolve spontaneoulySlide21

Classification of breast tumours

Benign

Pre-Malignant /

in situ

Malignant / Invasive

Fibroadenoma

Ductal

carcinoma

in situ

Invasive

Ductal

Carcinoma (80% of invasive)

Intraductal PapillomaLobular carcinoma in situ

Invasive

Lobular Carcinoma (10% invasive)

Lipoma

Invasive

Medullary

,

Mucinous

, Tubular & Papillary Carcinomas (10% invasive)Slide22

Breast Cancer

Incidence 1:11

Age; rare <30yr

Risk factors;

Early menarche, late menopause

1

st

child >30yr

FHx

in 1

st

degree relativeHx of breast feedingPrev breat

caRadiation exposureExogenous hormonesHigh intake of saturated fats, alcoholSlide23

Staging of cancer

Bloods; FBC, LFTs, U&Es, ALP, Ca2+, ESR

CXR

2

nd

line investigation; Liver USS, bone scan, CT-scan,

axillary

node staging

Clinical staging – TMN

Tis

(no tumour palpable) CIS / Paget’s

T1 < 2cm. No skin fixationT2 2-5cm. Skin distortionT3 5-10cm. Ulceration + pectoral fixation

T4 >10cm. Chest wall extension, skin involved.N0 No nodesN1 Ipsilateral mobile nodes

N2 Ipsilateral fixed nodesN3 Internal mammary nodesM0 no

metsM1 Mets in liver, lung, boneSlide24

Treatment

Surgical

;

WLE plus DXT (need 1cm excision margin)

Mastectomy

Axillary

sampling (removal of lower

axillary

nodes)

Axillary

clearance (removal of contents below the level of the

axillary vein)Level 1 = below

pec minorLevel 2 = behind pec minorLevel 3 = above

pec minor (full clearance)SLNBSlide25

Systemic treatment

Can be adjuvant or neo-adjuvant

Radiotherapy

Breast and chest wall

Axilla

Palliation (e.g. For bony tenderness)

Chemotherapy

Recurrent disease

<70yr with > 1 +

ive

axillary

nodeVery large tumoursSlide26

3. Endocrine therapy and

Tamoxifen

Tamoxifen

in ER +

ive

females

Up to 15% of ER –

ive

females also respond

Beneficial in pre- and postmenopausal women, not effective in ER –

ive

premenopausalsIncreased risk of endometrial carcinomaAromatase enzyme inhibitor =

Anastrazole (Arimidex)For post-menopausal women ER +ive