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Approach to a Patient with Breast Lump

Causes of breast lump, History taking, Examination, Investigations to diagnose breast lump

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Approach to a Patient with Breast Lump

  1. 1. APPROACH TO A PATIENT WITH BREAST LUMP PRESENTED By SALAMI ERNEST OSEMUDIAMEN To THE DEPARTMENT OF FAMILY MEDICINE, I.S.T.H, IRRUA
  2. 2. OUTLINE  Introduction  Anatomy & Physiology of the breast  Epidemiology  Pathophysiology  Etiologies/Differential diagnosis  Other Symptoms of Breast disease  Approach to the Patient – Triple Assessment  Baseline Investigations  Staging of Breast Cancer  Treatment  Conclusion  References
  3. 3. INTRODUCTION  A breast lump is a localized swelling, knot, bump, bulge or protuberance in the breast.  Breast lumps may appear in both sexes at all ages.  In women, it may be due to infection, trauma, fibroadenoma, cyst, fibrocystic conditions, or could even be due to a more serious medical condition such as cancer  The commonest cause of a breast lump in males is gynaecomastia  No breast lump should be dismissed as benign until it has been checked by a physician
  4. 4. ANATOMY & PHYSIOLOGY OF THE BREAST The breast (or mammary gland) is a modified apocrine sweat gland that is rudimentary in males but well developed in females. Anatomy Of The Female Breast  Surface Anatomy
  5. 5.  Position  2/3 rests on P. major  1/3 rests on Serratus anterior  Lower medial edge overlaps the Rectus sheath  Horizontal Extent: MAL laterally to the Sternal edge medially  Vertical Extent: 2nd-6th Ribs
  6. 6.  Parts of the Breast
  7. 7.  Histology
  8. 8. Arterial Supply  Internal thoracic artery  Lateral thoracic artery,  Thoracoacromial artery  Subscapular artery  Posterior intercostal artery  Venous Drainage:  Internal thoracic vein  Axillary vein  Azygos system of veins
  9. 9.  Lymphatic Drainage: By Quadrants;  UOQ + Upper part of LOQ  Axillary lymph nodes  UIQ + Upper part of LIQ  Parasternal lymph nodes  Lower part of LOQ + Lower part of LIQ  Abdominal nodes
  10. 10. Breast Physiology:  The breasts are poorly developed in males and females until puberty when pituitary and ovarian hormones influence the female breast development usually owing to accumulation of adipocytes  It produces breast milk that is essential for infant feeding  Milk let-down reflex is important for this
  11. 11. EPIDEMIOLOGY  Frequency  After skin cancer, breast cancer is the most commonly diagnosed cancer in women. It accounts for approximately 1 in 4 cancers diagnosed in women  Breast infections: 10-33% of lactating women  Lactating mastitis: 2-3% of lactating women  Breast abscess: 5-10% of women with mastitis  Mortality/Morbidity  1 in 28 women(3.6%) die of breast cancer  Increased morbidity may occur in breast abscess especially when it becomes recurrent, chronic, painful or scarring
  12. 12.  Race  Before age 40 – African women have a higher incidence  After age 40 – White women have a higher incidence  Sex  99% of breast cancers occur in females and 1% in males  Gynaecomastia is found exclusively in males  Age  Breast cancer – Ages 40 and above  Fubroadenoma – Ages 15-35  Breast infections – Ages 18-50  Benign mammary dysplasia – Ages 20-45  Access to Care
  13. 13. PATHOPHYSIOLOGY  Breast abscess;  Postpartum mastitis  Benign mammary dysplasia  Fibroadenoma  Carcinoma  Gynaecomastia
  14. 14. ETIOLOGIES/DIFFERENTIAL DIAGNOSES  Benign  Fibroadenosis (Benign mammary dysplasia)  Fibroadenoma  Phylloides tumour  Breast cyst  Breast abscess  Mastitis  Fat necrosis  Lipoma  Intraductal papilloma  Malignant  Infiltrating ductal carcinoma  Infiltrating lobular carcinoma  In-situ ductal carcinoma  In-situ lobular carcinoma  Inflammatory carcinoma
  15. 15. OTHER SYMPTOMS OF BREAST DISEASE Apart from breast lump, there are other symptoms of breast pathology. These symptoms may also be associated with a breast lump in the same patient. They include:  Breast pain  Nipple discharge  Nipple/Areolar deformity e.g. nipple retraction  Metastatic features e.g. Paraplegia, Jaundice, Breathlessness
  16. 16. APPROACH TO THE PATIENT The gold standard for the evaluation of a breast lump is the Triple Assessment which consists of:  Clinical assessment  Imaging techniques  Tissue biopsy Its diagnostic accuracy approaches 100%
  17. 17. CLINICAL ASSESSMENT  History  Examination
  18. 18. HISTORY  Important Biodata  Sex  Age  Tribe/Race  Marital status  Common Presenting Complaints: Breast lump with/without  Nipple discharge  Nipple/Areolar deformity  Change in breast size  Metastatic features e.g. Paraplegia, Jaundice, Breathlessnes, etc
  19. 19.  History of Presenting Complaints  Symptom (Complaint) Analysis & Course  Breast lump  Breast pain  Change in breast size  Nipple discharge  Nipple retraction  History of Etiology (Cause)  New Growth  Genetic  Infection  Trauma  Tuberculosis  Drugs
  20. 20.  History of Complications  Weight loss  Aorexia  Bone pains, Low back pain, Pathological fractures  Dyspnoea  Cough with haemoptysis  Jaundice  Ulceration  Seizures  Headache  Paraplegia  History of Care  Other parts of the History
  21. 21. EXAMINATION  Breast Examination: Introduction & Consent, Chaperone, Exposure  Inspection: Done in the Sitting Position; Inspect for:  Breast;  Positioning  Symmetry, size, shape compared to the other breast  Visible mass, location  Skin over breast  Colour & texture  Dilated veins  Peau d’ orange, dimpling  Nodules  Ulceration  Fungating mass  Nipple  Retracted or destroyed  Symmetry; elevated or deviated  Number, size & shape  Surface; cracks or fissures, ulcer  Discharge; check under cloth
  22. 22.  Areola  Colour  Size  Surface  Texture  Scaliness  Fissures or cracks, ulceration  Arms: Odema  Axilla & Supraclavicular regions: Observe for  Fullness  Lymph node enlargement  Anterior chest wall  Nodules
  23. 23.  Palpation: Position is semi recumbent(45 degrees)  Breast lump: Site, Temperature, Tenderness, Shape, Size, Surface, Margin, Consistency, Fluctuancy, Fixity to Skin, Breast tissue, underlying Fascia/Muscle & Chest wall  Nipple & surrounding area:  For retracted nipple, try everting  Feel for any mass deep to the nipple  Press the breast segments & areola for nipple discharge; note nature & colour  Axillae & Supraclavicular fossae: Enlarged lymph nodes: Number, Size, Tenderness, Consistency, Fixity, Matting
  24. 24.  Systemic Examination  General examination: Cachexia, Jaundice, Pallor, Lymphadenopathy  Abdominal examination: Hepatomegaly, usually nodular  Chest examination: Dyspnoea, Added sounds, Signs of pleural effusion  Lumbar spine: Tenderness, Swelling & Depression  Bones: Tenderness in the ribs, sternum, pelvis, long bones  Interpretation  Benign masses  No skin changes  Smooth & mobile
  25. 25.  Soft or firm in consistency  Well defined margins, fibroadenosis however, usually has ill defined edges  No associated lymphadenopathy  Malignant masses  Hard & immobile  May be fixed to surrounding structures  Poorly defined or irregular margins  Nipple retraction, skin dimpling & peau d’orange  Lymphadenopathy usually present, with hard or matted nodes  Infections e.g. mastitis  Signs of inflammation  Tender and firm enlarged lymph nodes  TB – lymph nodes may be matted
  26. 26.  Retracted Nipple
  27. 27. RADIOLOGICAL IMAGING  Mammography  Ultrasonography  MRI
  28. 28. MAMMOGRAPHY  Indications:  Screening – Every 1-2 years for women ages 50-69  Metastatic adenocarcinoma of unknown primary  Nipple discharge without palpable mass  Mammogram findings indicative of malignancy:  Stellate appearance & Spiculated border is pathogonomic of breast cancer  Microcalcifications, ill defined lesion border  Lobulation, Architectural distortion
  29. 29. ULTRASONOGRAPHY  Best initial test in women less than 35 years of age with breast lump  Performed primarily to differentiate cystic from solid lesions  Not diagnostic
  30. 30. HISTOLOGICAL/CYTOLOGICAL ANALYSIS The diagnosis of breast cancer depends on examination of tissues(histology) or cells(cytology) removed on biopsy Biopsy can be  Needle biopsy  Fine-needle aspiration biopsy  Core-needle biopsy  Open biopsy  Incisional biopsy  Excisional biopsy
  31. 31. BASELINE INVESTIGATIONS  Full blood count  Electrolytes, Urea and Creatinine  Urinalysis  Serum calcium  Chest Xray  ECG
  32. 32. INVESTIGATIONS FOR STAGING BREAST CANCER  Chest X-ray  Abdominopelvic ultrasound scan  Skeletal bone survey  Bone scan  LFT  Mammography of opposite breast  FNAC of contralateral axillary lymph nodes  CA 15-3/CEA
  33. 33. STAGING OF BREAST CANCER TNM Staging of Breast Cancer T – Primary Tumour  Tis: carcinoma in situ  T0: tumour not palpable  T1: tumour size less than 2cm diameter  T2: tumour size 2-5cm  T3: tumour size >5cm  T4: any size with skin and underlying tissue involvement  a – underlying muscle involved  b – skin involvement  c – both involved
  34. 34.  N – Regional Lymph Nodes  N0: no palpable ipsilateral axillary lymph nodes  N1: palpable discrete mobile axillary ipsilateral lymph nodes  N2: matted fixed ipsilateral axillary lymph nodes  N3: ipsilateral supraclavicular lymph nodes, lympoedema of ipsilateral arm  M – Distant Metastasis  M0: no evidence of metastasis  M1: distant metastasis present  Mx: indeterminate metastasis, need to do more investigations  T2N1M0 & below  Early dx  T3N2M1 & above  Late dx
  35. 35. TREATMENT  Benign lesion: Excision biopsy  Cyst: Excision biopsy  Abscess: Incision and drainage  Carcinoma  Local/Regional  Surgery  Radiotherapy  Systemic  Cytotoxic chemotherapy  Hormonal therapy  Immunotherapy  Hypercalcaemia due to tumour lysis syndrome  IV/Oral inorganic phosphate  Furosemide large doses  Adequate hydration
  36. 36. CONCLUSION Although, fortunately, most breast lumps usually turn out to be benign, a thorough assessment is necessary so as not to miss the diagnosis and subsequent treatment of a very serious medical condition most especially a carcinoma. Early detection of breast cancer is the key to cure, hence females are advised on self examination of their breasts at least once monthly in order to catch early any disease that may be springing up
  37. 37. REFERENCES  Browse’s Introduction to Symptoms & Signs of Surgical Dusease 5e:Kevin G Burnand et al  Clinical Surgery Tutorial Manual; Omoigiade Ernest Udefiagbon  Last’s Anatomy 12e; Chummy S. Sinnatamby  Principles & Practice of Surgery 4e; E.A. Badoe et al  www.medscape.com/

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