Background Info

Presentations of Breast Disease

  • Lump
  • Pain – Rare in breast cancer
  • Asymmetry – Change in breast size – particularly related to the menstrual cycle
  • Change in breast feature
  • Change in Nipple
  • May present to clinic due to strong FH of breast disease
 

Breast lumps

 
Lump
Description
Feels like…
 
 
 
C
O
M
M
O
N
Fibroadenoma
  • Normal breast tissue that has become fibrous
  • Painless
  • Typically present at age 15-35
  • 1/3 will stay the same
  • 1/3 will grow bigger
  • 1/3 will go away
  • Do Not become cancerous, or increase the risk of breast cancer
Firm and lumpy – large lobules. Moves easily. Can be 1-5cm
Cyst
  • Presentation typically at age 35-45
  • Fluid filled sac, filled with serous or sebaceous fluid. The fluid (and therefore the lump) can be any colour
  • May be more suspicious if blood is present
Very smooth, spherical / elliptical.  Again size varies greatly.
Carcinoma
  • Can present at any age, but more common in old age
  • Any woman >50 with a breast lump is cancer until proven otherwise
Rock hard and irregular and lumpy. Tethered, immobile. Puckering of the skin. Peau d’orange, nipple changes.
 
 
R
A
R
E
Periductal Mastits
Fat Necrosis
Galactocoele
Abscess
Not from breast tissue – e.g.
Lipoma
sebaceous cyst
 
 
 

Examination

A few important points:
  • Get a CHAPERONE!
  • Careful of your terminology – try to use phrases like ‘I will examine the left breast now’ and not things like ‘I will have a feel of the breast now’
 

Explanation

Explain what you are going to do. Say you would like to examine and have a look at the breasts, and also to check the lymph nodes in the neck and axilla. Ask the patient to go behind the curtain and take their clothes off to uncover the breasts. Usually a shawl is provided so that the patient can then cover themselves up. Once the patient is ready, then join them behind the curtain.
 
As usual, we can follow the Inspection, palpation, percussion, auscultation pattern – however, for a breast exam, we need only actually do Inspection and Palpation.
 

Inspection

Ask the patient to sit upright, on the side of the bed. You need to expose both breasts at the same time to be able to compare!
 
With the patients hands by her sides, ask the patient to life up their shawl, and look for:
Nipple changes – discharge, blood, inverted nipple, areolar changes
Skin changes:
  • Peau d’orange – ‘orange peel skin’ – part of the skin of the breast may have a texture like orange peel. This is often a sign of cancer.
  • Tethering – a dimple in the skin often indicates an underlying mass (usually cancer) pulling on the skin
  • Rash / redness

Any visible lumps
Check symmetry

  • Breasts are not usually completely symmetrical. If there is a gross abnormality, you can always ask the patient when she first noticed, and if it has been there very long.

Now ask the patient to put her hands on her hips and squeeze inwards – this tenses the pectoral muscles, and can bring out any lumps or abnormalities
Now ask the patient to put her hands behind her head –similar to the above, can allow you to see lumps and other abnormalities that may not have been visible before. Also allows you to look into the axilla.

Any other abnormalities

  • Don’t forget to look right along the tail of the breast up into the axilla.
  • Don’t forget to look under the breast. You may need to life up the breast to see properly into the skin fold underneath
 

Palpation

Ask the patient to lie back on the bed. The headrest should be at 180’, or as low as is comfortable for the patient. Now allow the patient to cover up one breast with the shawl, and palpate one breast at a time.
Ask if she has any breast pain.
  • You should have a system. Some doctors will divide the breast into quadrants, and check each quadrant individually, but a better way is to image the breast like a clockface and move round clockwise. You can then also note any abnormalities by their relation to the clockface, e.g.: A 1-2cm, hard lump, tethered to the skin at 4’o’clock in the left breast.’
  • Technique – you should NOT your fingertips or your palms, instead, use the ‘pad’ of your fingers, basically, the part of the finger under the middle phalange, and the DIP. Use several finger at once, and start at the outside of the breast and move inwards toward the nipple.
  • If you find a lump, continue the rest of the examination of the particular breast, and then come back to it at the end, and fully analyse it then. Norma breast tissue can be a bit lumpy, especially in the ‘tail’ of the breast (12 to 3 o’clock region). Some doctors describe it as like feeling for a marble in a bag of rice!
  • Remember to feel behind the nipple – tell the patient what you are about to do before you do it!
  • Repeat for the other breast
  • Some doctors then recommend you repeat the examination with the patient sitting. Different position can expose lumps that you didn’t previously feel.
 

Lymph node exam

Check the supraclavicular lymph nodes
Check the lymph nodes of the axilla
  • Support the weight of the woman’s arm, with your own, and ask her to relax.
  • It may feel uncomfortable, but shouldn’t be painful
  • Not palpate for lymph nodes in the axilla. Make sure you feel all the four sides of the axilla
  • Palpable lymph nodes can again be normal – e.g. with general arm trauma / cuts / bruises, but in these cases, the inflamed nodes should subside within a couple of months. They may of course also be a sign of breast pathology (e.g. cancer)
 

Presenting findings

If you find a lump, you need to be able to describe:
  • Size
  • Location
  • Shape
  • Surface
  • Texture
  • Mobility
 

Triple assessment and grading of the lump

All breast lumps should undergo Triple assessment procedure, which includes:
  • Examination
  • Fine need aspiration (Cytology)
  • Imaging (can be Mammography – if patient >35 , USS if patient <35, or MRI if USS/mammogram is not definitaive)
  • Any patient referred to hospital for a breast problem will have a triple assessment to try to find the underlying cause.
 
Grading of the triple assessment

Examination

  • E1 – Normal (no lump)
  • E2 – Benign lump
  • E3 – A lump
  • E4 – A suspicious lump
  • E5 – Probable cancer

Cytology

  • C1 – inadequate sample
  • C2 –Benign
  • C3 – Atypical features, but still likely benign
  • C4 –Atypical features, probably malignant
  • C5 –Malignant

Imaging (<35 USS [breast tissue too dense for mamm.], >35 Mammogram)

  • M1 / U1 – Normal
  • M2 / U2 –benign
  • M3 / U3 –Probably benign
  • M4 / U4 –Probably malignant
  • M5 / U5 –Malignant
 
Quadruple assessment
This term is sometimes used in place of Triple assessment, and describes an assessment involving both ultrasound and mammography – i.e. the imaging techniques are not grouped together.
 
For more info, please see the notes on Breast cancer and Breast lumps

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