breast examination.pptx

Assessment of breast

1. Breast Examination GNM II YEAR UNIT -

2. Topics Assessment of breast History Physical examination Diagnostic tests

3. History Presenting complaint is very 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?

4. Nipple discharge- ascertain Colour, Quantity, pattern, frequency Age of patie nt- cancers are uncommon <30yrs, but fibroadenomas are Ask if noticed any; Nipple retraction Breast distortion Metastatic related symptoms Previous breast disease Was it investigated / treated

5. Family history - Genetics; 5-10% are inherited dominantly They have early onset & associated with other tumours e.g. Bowel, ovarian. Medications - HRT, oral pills Gynae / Obstetric History Menarche, menses Parity? When? After 30 increases risk Breast fed?

6. 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’ breast

7. Inspection 6 S ’s S ite S ize S hape S ymmetry overlying S kin associated S cars

8. Inspection 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 Erythema

9. Nipple signs; 6 D ’s Paget’s D isease D epression D eviation D ischarge D isplacement D estruction

10. 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 structures Fluctuance Pulsatility and expansility Transilluminability Reducibility

11. Palpate using palmar surfaces of index, middle & ring fingers of both hands, sweeping down clock wise positions. N.B. Most carcinomas present in upper, outer quadrant

12. Remember; Inframammary fold Axillary tail of Spence Nipple discharge (explain important to check for discharge - gain consent before doing)

13. 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 )

14. 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 mirro r Triple Assessment ; If lump detected continue to this

15. Triple Assessment Clinical Examination Imaging; Mammogram (false negative rate 10% / USS (in <40yr )

16. 3. Tissue Sampling; FNAC (cytology exam of aspirate, can have 95% sensitivity) Core Biopsy -Open Biopsy

17. 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 & fibrosis

18. 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 painful Peak age onset 35-55yr. FNA may relieve symptoms and can be analysed

19. 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 Medical Surgical Reassurance Evening primrose oil Mastectomy (for treatment resistant severe mastalgia ) Firm supporting bra Analgesia Evening primrose oil OCP Danazol Bromocriptin Tamoxifen

20. 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 ectasia Pus discharge from nipple & mastalgia

21. 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 spontaneouly

22. Classification of breast tumours Benign Pre-Malignant / in situ Malignant / Invasive Fibroadenoma Ductal carcinoma in situ Invasive Ductal Carcinoma (80% of invasive) Intraductal Papilloma Lobular carcinoma in situ Invasive Lobular Carcinoma (10% invasive) Lipoma Invasive Medullary , Mucinous , Tubular & Papillary Carcinomas (10% invasive)

23. Breast Cancer Incidence 1:11 Age; rare <30yr Risk factors; Early menarche, late menopause 1 st child >30yr FHx in 1 st degree relative Hx of breast feeding Prev breat ca Radiation exposure Exogenous hormones High intake of saturated fats, alcohol

24. 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 fixation T2 2-5cm. Skin distortion T3 5-10cm. Ulceration + pectoral fixation T4 >10cm. Chest wall extension, skin involved. N0 No nodes N1 Ipsilateral mobile nodes N2 Ipsilateral fixed nodes N3 Internal mammary nodes M0 no mets M1 Mets in liver, lung, bone

25. 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 minor Level 2 = behind pec minor Level 3 = above pec minor (full clearance) SLNB

26. 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 node Very large tumours

27. 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 premenopausals Increased risk of endometrial carcinoma Aromatase enzyme inhibitor = Anastrazole ( Arimidex ) For post-menopausal women ER + ive