1
Q
What are the 4 quadrants of the breast?
A
Upper outer
Upper inner
Lower outer
Lower inner
2
Q
What areas should you palpate in a breast exam?
A
- 4 quadrants of the breast
- subareolar area
- tail of spence
- axilla
- supraclavicular nodes
3
Q
What is the tail of spence?
A
the extension between the breast + the axilla
4
Q
If you find a lump, what are the key features of assess and describe?
A
- location
- size
- shape: round, oval, irregular
- consistency: smooth, hard, firm, fluctuat
- margins: irregular, smooth
- mobile or fixed to skin or chest wall
- tenderness
- skin colour
- nipple discharge
5
Q
Basic breast anatomy
A
- mostly made of adipose
- areola surrounds the nipple
- ducts are behind the nipple, which go into lobules, this is where milk is produced
6
Q
Differentials for breast lumps
A
- breast tumour
- fibroadenoma
- fibrocystic breast changes
- breast cysts
- fat necrosis
- lipoma
- galactocele
- phyllodes tumour
- intraductal papilloma
- mammary duct ectasia
7
Q
Clinical features suggestive of breast cancer
A
- hard, irregular, painless or fixed lumps
- lumps can be tethered
- nipple retraction
- peau d’orange
- Paget’s disease of the nipple
8
Q
What is peau d’orange?
What causes it?
A
- dimpled appearance + oedema of the breast
- in inflammatory breast cancer
- blocked lymphatic drainage > oedema
- sweat ducts cause dimpling within the oedematous skin
9
Q
What is Paget’s disease of the nipple?
What can it indicate?
A
- erythematous, scaly rash of nipple region
- can be itchy, inflamed or ulcerated
- may indicate breast cancer
10
Q
Describe a breast lump in breast cancer
A
Hard
Fixed
Irregular
Painless
Tethered
11
Q
Two week wait guidelines for suspected breast cancer
A
- unexplained breast or axilla lump in pt >30
- unilateral nipple changes in patients >50
- skin changes suggestive of breast cancer
12
Q
When does NICE suggest non-urgent referral for unexplained breast lumps?
A
In pts under 30
13
Q
Where are patients referred to for 2 week wait for breast lumps?
A
One stop clinic
14
Q
What are fibroadenomas?
A
Benign tumours of stromal/epithelial breast duct tissue
15
Q
Demographic of fibroadenomas
A
Younger women 20-40
16
Q
Why are fibroadenomas more common in younger women + regress after menopause?
A
They respond to oestrogen + progesterone
17
Q
Examination findings of fibroadenomas
A
- painless
- smooth
- round
- well defined borders
- firm
- mobile
18
Q
Management of fibroadenomas
A
- reassurance
- left in situ with routine follow up appointments
- potential excision if >3cm or patient preference
19
Q
Why do fibrocystic breast changes occur?
A
- stroma, ducts + lobules of the breast respond to oestrogen + progesterone, becoming more fibrous (hard + irregular) + cystic
- this fluctuates with menstrual cycle
20
Q
Presenation of fibrocystic breast changes (fibroadenosis)
A
- in women of menstruating age
- breast lumpiness
- mastalgia
- fluctuation of breast size
21
Q
Management of fibrocystic breast changes
A
- exclude cancer
- supportive bras
- NSAIDs
- avoid caffeine
- apply heat to area
- hormonal treatments (e.g. tamoxifen, danazol) under specialist guidance
22
Q
What are breast cysts?
A
Benign, individual, fluid filled lumps
Has slightly increased risk of breast cancer
23
Q
Demographic of breast cysts
A
- women 30-50
- more in perimenopause period
24
Q
Examination findings of breast cysts
A
- smooth
- well-circumscribed
- mobile
- possibly fluctuate
25
Management of breast cysts
exclude cancer with imaging, aspiration or excision
26
What does fat necrosis cause in the breast?
A benign lump formed by localised degeneration + scarring of fat tissue
27
What triggers fat necrosis in the breast?
- localised trauma
- radiotherapy
- surgery
.
- cause fibrosis + necrosis of fat tissue
28
Examination findings of fat necrosis
- painless
- firm
- irregular
- fixed
- skin dimpling or nipple inversion
29
Does fat necrosis increase risk of breast cancer?
No
30
Management of fat necrosis
- similar exam findings to breast cancer so exclude breast cancer
- USS or mammogram can appear similar to breast cancer
- **histology by fine needle aspiration or core biopsy** needed for diagnosis + exclusion
- once excluded, left alone or excised if symptomatic
31
Diagnosis of fat necrosis in the breast
Histology
By core biopsy
32
What are lipomas?
Benign tumours of adipose tissue
33
Examination findings of lipomas
- soft
- painless
- mobile
- no skin changes
34
Management of lipomas
- reassurance
- possible excision
35
What are intraductal papillomas?
Benign breast lesions that grow within one of the duct > proliferation of epithelial cells
36
Presentation of intraductal papillomas
- clear or blood stained nipple discharge
- tenderness or pain
- palpable lump (most commonly in subareolar region)
37
Diagnosis of intraductal papillomas
- triple assessment
- ductography
38
What is a ductography?
Injecting contrast into abnormal duct + performing mammogram to visualise the duct
39
Management of intraductal papillomas
- **complete surgical excision**
- after excision, tissue is examined for atypical hyperplasia or cancer
40
What is mammary duct ectasia?
benign condition where there is dilatation of large ducts of the breasts > white,grey or green nipple discharge
41
Presentation of mammary duct ectasia
- perimenopausal women
- white, grey or green nipple discharge
- tenderness or pain
- nipple retraction or inversion
- breast lump
- pressure on lump can produce nipple discharge
42
Diagnosis of mammary duct ectasia
- triple assessment
- **microcalcifcations** on mammogram are key findings
- ductography
- nipple discharge cytology
43
What is a key finding on mammograms suuggestive of mammary duct ectasia?
Microcalcifications
44
What is a risk factor of mammary duct ectasia?
Smoking
45
Management of mammary duct ectasia
- reassurance after cancer excluded
- supportive bra + warm compress
- abx if infection suspected
- microdochectomy
46
What is a microdochectomy?
Surgical removal of lactiferous duct
47
Microdochectomy vs microdochotomy
- **microdochectomy**: surgical excision of lactiferous duct
- **microdochotomy**: incision of mammary duct without excision
48
What is a galactocele?
**Breast milk filled cysts** that occur when the lactiferous duct is blocked
49
Examination findings of galactocele
- firm
- mobile
- painless
- normally beneath the areola
50
Management of galactocele
- most resolve without treatment
- drainage with needle if needed
51
What is a phyllodes tumour?
- rare large + fast-growing fibroepithelial tumours
- can be benign, borderline or malignant
- most often in 40-50 year olds
52
Management of phyllodes tumour
- surgical removal of tumour + surrounding tissue (wide excision)
- chemotherapy if malignant
53
What does a breast triple assessment involve?
- **clinical assessment**: history + examination
- **imaging**: USS or mammogram
- **histology**: fine needle aspiration or core biopsy
.
- at each stage the suspicion for malignancy is graded
54
When do you use USS or mammogram during triple assessment?
- **USS**: in women <35 + men
- **mammogram**: women >35
55
What does a core biopsy provide vs fine needle aspiration?
- **core biopsy**: full histology
- **fine needle aspiration**: only cytology
56
What is the most common method for histology of breast lumps?
Core biopsy
Breast
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