1. Breast Lumps
Presented by :-
Divya Divakaran
Foundation Year 2 Doctor

2. Contents Anatomy of Breast History taking Clinical examination
Specific considerations
Triple assessment
Diagnosis
Management
What about men?

3. Anatomy of Breast Introduction to breast :
Breasts (mammary glands) = modified sweat glands

4. The breast is composed of glandular, ductal, connective, and adipose tissue. The mammary glands are modified sweat gland and are composed of lobules, each drained by a lactiferous duct.  Each lactiferous duct independently drains on the nipple. Areola surrounds nipple
In men, little fat is present in the breast, and the glandular system normally does not develop. 

5. Lie in superficial fascia anterior to deep fascia of pec. major
BOUNDARIES :-
Bounded by the clavicle superiorly
Infra-mammary fold inferiorly
The sternum medially
Lateral border of the latissimus muscle laterally 

6. Coopers ligament
The glands are firmly attached to the skin by connective tissue structures known as Cooper's ligaments or suspensory ligaments. Coopers ligament help maintain the structural integrity. They are named for Astley Cooper, who first described them in It is these ligaments which pull on the skin, creating the characterisctic dimpling (or peau d'orange) associated with malignancy

7. Four Quadrants of the Breast
Upper outer (superolateral) quadrant
Upper inner (superomedial) quadrant
Lower outer (inferolateral) quadrant
Lower inner (inferomedial) quadrant

8. The French term peau d'orange means skin of an orange
Advaned malignancy leads to infiltration and shortening of Cooper’s ligament
Leads to irregular dimpling
of skin or retraction of nipple

9. Arteries : Predominatly Internal mammary, lateral thoracic, thoracoacromial, posterior intercostal
Veins : Mainly Axillary (subclavian, intercostal, internal thoracic)
Lymphatics : Axillary, parasternal, inferior phrenic nodes
Nerves : 4th-6th intercostal nerves

10. The lymphatic drainage of the breast deserves special attention, due to its role in the metastasis of cancer cells.  The majority of lymph (>75%), particularly from the lateral quadrants, drains to the axillary lymph nodes.  The remainder of lymph drains to either the parasternal nodes or the opposite breast  

11. History taking : The Lump
Onset : when was the lump first noticed
Location : which side - right or left
Single or multiple : how many ?
Unilateral or bilateral
Duration : since when did the pt notice the lump
Progression : Has it changed in size (ca)
Is there any pain : type, severity (painless in ca )
Association with menstrual cycle

12. Skin changes, nipple discharge or retraction
Axillary / supraclavicular swelling
Previous breast cancer
H/o trauma, SOB, bone pain, fever or weight loss

13. Risk factors Female sex, older age Family history of breast ca
Oral contraceptive pill / HRT
Cycles (early menarche or late menopause)
Pregnancy : lack of child bearing
Lack of breast feeding
Smoking, alcohol intake
High fat diet

14. Past medical history
Surgical history
Drug history
Allergies
Social history : support, activity level, smoking, alcohol, drugs

15. Examination Specific considerations : Chaperone must be present
Explain to them what the examination will entail and gain the patients consent

16. Examination
Inspection
Palpation
Auscultation

17. Inspection Inspect the patient in upright position
Make a general inspection of both breasts. Look for any asymmetry, scars, obvious lumps or nipple abnormalities (e.g. inversion or discharge)
You should also comment on any skin changes (peau d’orange, eczema).

18. Ask the patient to place her hands above her head and repeat the inspection
Look for any obvious mass

19. Palpation Start on the “normal” side first
Ask the patient to place her hand behind her head on the side you are examining
Systematically examine all areas of the breast with your hand laid flat on the breast. Start from outside and work towards the nipple. Imagine that the breast is a clock face and examine at each ‘hour’

21. LUMP : size, shape, position,consistency, surface,overlying skin
Don’t forget that the breast tissue extends towards the axilla in the ‘axillary tail’
Ensure you ask the patient if she experiences any pain during examination

22. Examine the other breast in the same manner
Ask the patient to squeeze both nipples

23. Lymph node examination
Examine both axillae for any enlarged lymph nodes
Whilst examining the patient’s axilla, you should fully support the weight of that arm with yours
Examine the axilla with your other hand

24. Ensuring that you feel all four walls (anterior, posterior, medial and lateral) as well as feeling into the apex of the axilla
Repeat this on the other
side
Palpate the supraclavicular
fossa on both sides to check
for lymphadenopathy
Finaly auscultate the chest

25. Triple assessment Clinical findings
Radiological findings (Mammography/ USS)
Biopsy : Histology/cytology
If there is any abnormality detected in the examination, or imaging, then biopsies are taken. This can be in the form of FNAC (Fine Needle Aspiration Cytology) or a core (Tru-Cut) biopsy.

26. Breast Cancer
Commonest Cancer among women in UK. About 48,000 women get breast cancer in Britain each year.
Breast cancer originates from breast tissue, most commonly from the inner lining of milk ducts (ductal ca )or the lobules that supply the ducts with milk (lobular ca)
Ductal Ca 90%, lobular Ca 10%

27. Increase in incidence with age
Associated with mutations in the breast cancer susceptibility genes BRCA1 or BRCA2
Risk factors : Smoking, alcohol, OCPs, HRT
C/F : painless lump, discharge, skin changes

28. Stages of breast ca
Common symptoms for breast cancer in both men and women are:
Swelling or redness in the skin on or around the breast area
A change in size or shape of one or both of the breast
A lump or mass in the breast or near the under arm
Changes in the appearance of nipple
Discharge of fluid other than milk out of the nipple

30. Types of breast Cancer
Breast cancer is often divided into non-invasive and invasive types
Non-invasive breast cancer is also known as cancer or carcinoma in situ. This cancer is found in the ducts of the breast and has not developed the ability to spread outside the breast. This form of cancer rarely shows as a lump in the breast and is usually found on a mammogram

31. Invasive cancer has the ability to spread outside the breast
Invasive ductal breast cancer accounts for about 80% of all cases of breast cancer

32. Spread
It is possible for breast cancer to spread to other parts of the body, usually through the lymph nodes or the bloodstream. If this happens, it is known metastatic breast cancer.
It metastasis to the lymph nodes, lungs, liver, bones etc

33. Treatment : Breast cancer is treated using a combination of surgery (lumpectomy or mastectomy), chemotherapy and radiotherapy
There is a good chance of recovery if it is detected in its early stages.

34. Fibroadenoma
Fibroadenoma of the breast is a benign tumor composed of two elements : epithelium and stroma
Fibroadenomas are called breast mouse owing to their high mobility in the breast
Painless, firm and mobile
In young women of child bearing
year

35. Hormone-dependent and frequently regress after menopause
Investigation : needle biopsy
Treatment : surgical excison

36. Benign breast conditions
Mastalgia : cyclical and non cyclical
Cyclical mastalgia : painful nodularity associated with ovulation, hyperplasia secondary to E2
Non cyclical mastalgia : trauma, mastitis, shingles, diurectics

37. Mastitis Inflammation of breast tissue Staph aureus is the main
organism
2-10% in lactating women at 2-4 weeks post partum
Treated with antibiotics
90% cured, 10% abscess formation (drainage)

38. Duct ectasia Blockage of the lactiferous duct
The duct widening is commonly believed to be a result of secretory stasis (stagnant colostrum) or subject to hormonal interactions or non specific

39. pre-menopausal age
Mimic breast cancer, noncyclic breast pain
Clinical features : pain, nipple retraction or nipple discharge
Self limiting and not indicated for surgery

40. Pappiloma Benign lesion Types: central and peripheral
Central type: single solitary lesion develops near nipple, seen nearing menopause
Peripheral type : multiple papillomas in the periphery of breast seen in young women
C/F: Bloody nipple discharge, masses are too small to be palpated

41. Higher risk of malignant change
Investigation : galactogram +/- biopsy, not shown in mammograpghy due to small size
Excision is sometimes performed (benign)

42. Men !!!
Less than 1%
Peak incidence at 60yrs
Worst prognosis

43. Men
Gynaecomastia : steroids, hormonal therapy, spiranolactone, CCB, testicular tumours, pituitary tumours, obesity and in elderly

44. Summary History Think risk factors Likely diagnosis
Practise examination

45. Any Questions ?