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

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. 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. 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. 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.  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.  Parts of the Breast

7.  Histology

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.  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. 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. 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.  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. PATHOPHYSIOLOGY
 Breast abscess;
 Postpartum mastitis
 Benign mammary dysplasia
 Fibroadenoma
 Carcinoma
 Gynaecomastia

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. 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. 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. CLINICAL ASSESSMENT
 History
 Examination

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.  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.  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. 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.  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.  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.  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.  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.  Retracted Nipple

30. RADIOLOGICAL IMAGING
 Mammography
 Ultrasonography
 MRI

31. 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

33. 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

34. 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

35. BASELINE INVESTIGATIONS
 Full blood count
 Electrolytes, Urea and Creatinine
 Urinalysis
 Serum calcium
 Chest Xray
 ECG

36. 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

37. 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

38.  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

39. 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

40. 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

41. 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/