OHCEPS - The Breast

Question 1

Anatomic location of the breast?

Answer 1

Extend from the 2nd to the 6th ribs and transversely from the lateral border of the sternum to the midaxillary line.

Question 2

Lymphatic drainage of the breast?

Answer 2

Medial –> To the internal mammary nodes.

Central/Lateral –> To the axillary lymph nodes which are arranged into 5 groups.

Question 3

Normal breast changes - Puberty?

Answer 3

During adolescence, estrogen promotes the development of the mammary ducts and distribution of fatty tissue while progesterone induces alveolar growth.

Question 4

Normal breast changes - The menstrual cycle?

Answer 4

Towards the 2nd half of the menstrual cycle, after ovulation, the breasts often become tender and swollen.
They return to their “resting” state after menstruation.

Question 5

Normal breast changes - Pregnancy?

Answer 5

High levels of placental estrogen, progesterone, and prolactin promote mammary growth in preparation for milk production.

Question 6

Normal breast changes - Postnatal?

Answer 6

The sharply declining levels of estrogen and progesterone permit prolactin to stimulate the alveoli and milk produced. Suckling stimuli incr. secretion of prolactin as well as releasing oxytocin which stimulates myoepithelial cells to contract.

Question 7

Normal breast changes - Menopause?

Answer 7

The breasts become softer, more homogenous and undergo involutional changes including a decr. in size, atrophy of secretory portions, and some atrophy of the ducts.

Question 8

Important symptoms - First steps?

Answer 8

1. Establish a menstrual history.
2. Determine date of last period of menstruation
3. It is important to note that pre-existing disease in the breast is likely to become more noticeable during the 2nd half of the menstrual cycle - lumps often get bigger or become more easily palpable.

Question 9

Important symptoms - Breast pain (mastalgia)?

Answer 9

Establish everything as for any pain. Also ask:

1. Unilateral/Bilateral?
2. Heat/Redness at the site?
3. Other visible skin changes?
4. Pain is cyclical/constant - and is it related to menstruation?
5. Is there a history of any previous similar episodes?
6. Breastfeeding?
7. Any hormonal therapy?

Question 10

MCC of mastalgia in premenopausal women?

Answer 10

Hormone-dependent change. Other benign causes include mastitis and abscesses.

Question 11

What percentage of breast cancers present with mastalgia as the sole symptom?

Answer 11

1/100

Question 12

Important causes of nipple discharge?

Answer 12

1. Ductal ectasia
2. Papilloma
3. Carcinoma

Question 13

Nipple discharge - What to ask about?

Answer 13

1. Discharge is true milk or some other substance?
2. Discharge color (clear, white, yellow, blood-stained?)
3. Spontaneous/Non spontaneous discharge?
4. Bilateral/Unilateral?
5. Any changes in the appearance of the nipple or areola?
6. Mastalgia?
7. Any breast lumps?
8. Periareola abscesses or fistulae indicating periductal mastitis.

Question 14

Periductal mastitis - features?

Answer 14

1. This is closely linked to smoking in young women. Periductal mastitis is also associated with hydradenitis suppuritiva.
2. Ask about abscess elsewhere eg axilla and groins.
3. Symptoms are recurrent.

Question 15

How to take a menstrual history?

Answer 15

1. Age of first menses
2. Usual time between menstruations
3. Usual duration of menstruation
4. Usual quantity of menstruation
5. Age of menopause (if applicable)
6. Number of pregnancies
7. Previous history of breast-feeding
8. The date of the beginning of the last menstrual period

Question 16

Breast lumps - Important to establish what?

Answer 16

1. When the lump was first noticed?
2. Whether the lump has remained the same size or enlarged?
3. Whether the size of the lump changes according to the menstrual cycle.
4. Is there any pain?
5. Any local skin changes?
6. Is there a history of breast lumps - previous biopsies, diagnoses, operations.
7. Full system enquiry –> Loss of weight, appetite, fatigue + metastatic spread (dyspnea, bone pain etc).

Question 17

Breast lumps - Age?

Answer 17

A good clue as to the likely diagnosis of a lump is the age of the patient:
20-30 –> Fibroadenomas
30-50 –> Cysts
>50 –> Cancer

Question 18

The male breast - Gynecomastia?

Answer 18

1. Enlargement of the male breast tissue which should not normally be palpable –> There is an incr. in the ductal and connective tissue.
2. Common occurrence in adolescents and the elderly. Also in obese due to increased adipose tissue.

Question 19

Important drugs causing gynecomastia?

Answer 19

1. Estrogen receptor binders
2. Digoxin
3. Marijuana
4. Spironolactone
5. Cimetidine
6. Hormone treatment for prostate cancer

Question 20

Gynecomastia - What else to examine?

Answer 20

Signs of:

1. Hypopituitarism
2. Chronic liver disease
3. Thyrotoxicosis
4. Examination of the genitalia

Question 21

Breast cancer in male?

Answer 21

1. 100:1 female/male
2. Appearance and pathology similar to female.
3. MC presentation is a hard, painless lump fixed to the skin or chest wall followed by nipple discharge.

Question 22

Risk factors for breast cancer in females?

Answer 22

1. Advancing age
2. Breast cancer in a 1st degree relative
3. BRCA genes
4. Previous cancer in the other breast
5. Early menarche (55yr)
6. Nulliparity
7. No previous breastfeeding
8. Previous radiotherapy - eg mantle radiotherapy for Hodgkin’s.
9. Oral contraceptive pill or HRT

Question 23

Some causes of breast lumps?

Answer 23

1. Cyst
2. Fibroadenoma
3. Carcinoma
4. Fat necrosis
5. Hamartoma
6. Lipoma
7. Epidermoid cyst
8. Cystosarcoma

Question 24

Inspection of the breast - General inspection?

Answer 24

Stand in front of the patient and observe both breasts, noting:

1. Size
2. Symmetry
3. Contour
4. Colour
5. Scars
6. Venous pattern on the skin
7. Any dimpling or tethering of the skin
8. Ulceration
9. Skin texture: eg any visible nodularity

Question 25

Nipples - Note:

Answer 25

1. Symmetry 2. Everted, flat, inverted 3. Scale --> may indicate eczema or Paget's disease of the breast 4. Associated with any discharge 5. If abnormalities present, make sure to ask if these are a recent or a long-standing appearance 6. Make note of additional nipples along the mammary line.

Question 26

Single duct discharge indicates?

Answer 26

Papilloma or cancer.

Question 27

Multiple duct discharge at the nipple suggests?

Answer 27

Duct ectasia

Question 28

Inspection of the breast - Axillae?

Answer 28

1. Ask the patient to place her hands on her head and repeat the inspection process. 2. Pay particular attention to any symmetry or dimpling that is now evident. 3. Examine the axillae for masses or color image.

Question 29

Inspection of the breast - Maneuvers?

Answer 29

Finally, dimpling or fixation can be further accentuated by asking the patient to: 1. Lean forward while sitting 2. Rest her hands on her hips 3. Press her hands against her hips ("pectoral contraction maneuver").

Question 30

Palpation of the breast - Before you start?

Answer 30

1. Palpation of the breast should be performed with the patient lying supine on the couch. 2. INITIALLY, the patient should have her hands by her sides. 3. Examination of the UPPER-OUTER quadrant is best performed with the hand on the side to be examined placed behind her head.

Question 31

Palpation - What must be asked first?

Answer 31

1. Ask the patient if there is any pain or tenderness - examine that area last. 2. Also ask her to tell you if you cause any pain during the examination. 3. You should begin the examination on the asymptomatic side, allowing you to determine the texture of the normal breast first. 4. Ask the patient to point out any areas of tenderness and come to these last.

Question 32

Palpation of the breast - Steps?

Answer 32

1. Should be performed by keeping the hand flat and gently rolling the substance of the breast against the underlying chest wall. 2. Most breasts feel "lumpy" if pinched. 3. Proceed in a systematic way to ensure that the whole breast is examined. 4. Do not forget to examine the axillary tail of Spence stretching from the upper-outer quadrant to the axilla.

Question 33

Palpation of the breast - Lumps?

Answer 33

1. If you feel a lump, describe it (position, color, shape, size, tenderness etc). 2. Next ascertain its relations to the overlying skin and underlying muscle. 3. You must decide whether you are feeling a lump or a lumpy area.

Question 34

Lumps - Tethering?

Answer 34

1. A lump may be described as tethered to the skin if it can be moved independently of the skin for a limited distance but pulls on the skin if moved further. 2. Tethering implies that an underlying lesion has infiltrated Cooper's ligament which pass from the skin through the subcutaneous fat. 3. Tethering may involve the skin itself with cancers or abscesses.

Question 35

Lumps - Tethering - Inspection?

Answer 35

On inspection at rest, there may be puckering of the skin surface (as if being pulled from within) or there may be no visible abnormality.

Question 36

Lumps - Tethering - How to demonstrate?

Answer 36

1. Move the lump from side to side and look for skin dimpling at the extremes of movement. 2. Ask the patient to lean forwards while sitting. 3. Ask the patient to raise her arms above the head.

Question 37

Lumps - Skin fixation?

Answer 37

1. This is caused by direct, continuous infiltration of the skin by the underlying disease. 2. The lump and the skin overlying it cannot be moved independently. 3. It is on a continuum with skin tethering. 4. It may be associated with some changes of skin texture.

Question 38

The relation of the lump to a muscle?

Answer 38

1. The lump may be tethered or fixed to the underlying muscle (eg pectoralis major). 2. Lumps that are attached to the underlying muscle can be moved to some degree if the muscle is relaxed but are less mobile if the muscle is tensed.

Question 39

How to examine the relation of a lump to the muscle?

Answer 39

1. Ask the patient to rest her hand on her hip with the arm relaxed. 2. Hold the lump between your thumb and forefingers and estimate its mobility by moving it in 2 planes at right angles to each other (up/down, left/right). 3. Ask the patient to press her hand against her hip causing contraction of pectoralis major. Repeat the mobility exercise.

Question 40

Lumps - Immobile lump?

Answer 40

If a lump is immobile in all situations, it may have spread to involve the bony chest wall (eg in the upper half of the breast or axilla).

Question 41

Palpation of the breast - Nipple?

Answer 41

1. If the patient complains of nipple discharge, ask her to gently squeeze and express any discharge, noting color, presence of blood, smell. 2. Milky, serous, or green-brown discharges are almost always benign. 3. A bloody discharge may indicate neoplasia (papilloma or cancer).

Question 42

Examination of the lymph nodes?

Answer 42

1. Support the patient's arm. 2. When examining the right axilla, abduct the patient's right arm gently and support it at the wrist with your right hand while examining the axilla with your left hand. 3. Examine the main sets of axillary nodes, including: a. Central b. Lateral c. Medial (pectoral) d. Infraclavicular e. Supraclavicular f. Apical 4. Remember also to palpate for lymph nodes in the lower deep cervical lymph chain at the same time as the supraclavicular nodes.

Question 43

Examining beyond the breast - Rest of the body?

Answer 43

If cancer is suspected, is worth performing a full general examination keeping in mind the common sites of metastasis of breast cancer. --> Examine especially --> Lungs, liver, skin, skeleton, CNS.

Question 44

Important presentation - Fibroadenoma?

Answer 44

1. Painless 2. Solid 3. Mobile 4. Well-circumscribed rounded breast mass 5. Smooth, bosselated surface and rubbery consistency. 6. May be multiple and bilateral with no axillary lymphadenopathy. 7. Large fibroadenomas may be found in teens.

Question 45

Important presenting patterns - Breast abscess?

Answer 45

1. Mainly during the childbearing years and are often associated with trauma to the nipple during breast feeding. 2. Present with a painful, spherical lump with surrounding edema. 3. Often shows additional signs of inflammation (hot, red). 4. Patients may have constitutional symptoms --> malaise, night sweats, hot flushes and rigors.

Question 46

Important presenting patterns - Recurrent and chronic breast abscesses?

Answer 46

Most of them occur in association with duct ectasia or periductal mastitis. --> Associated periductal fibrosis can often led to nipple retraction.

Question 47

Important presenting patterns - Abnormal nipple and areola?

Answer 47

1. Diseases of the nipple are important because they must be differentiated from malignancy and cause concern to the patients. 2. Unilateral retraction or distortion of a nipple is a common sign of breast carcinoma - as is blood-stained nipple discharge (papilloma or carcinoma. 3. Unilateral red, crusted and scaling areola suggests an underlying carcinoma (Paget's disease of the breast) or, more commonly, eczema --> Ask the patient if she has eczema at other sites and examine appropriately.

Question 48

Important presenting patterns - Breast cancer - Presenting symptoms related to the primary lesion?

Answer 48

1. Palpable mass 2. Pain (1% of cancers presents with mastalgia only) 3. Nipple discharge, retraction, or rash. 4. Dimpling of the breast tissue 5. Local edema

Question 49

Important presenting patterns - Breast cancer - Presenting symptoms related to the effects of secondary spread?

Answer 49

1. Arm swelling (lymphatic or venous obstruction) 2. Backache (skeletal infiltration) 3. Malaise 4. Loss of weight 5. Dyspnea 6. Cough 7. Nodule in skin 8. Jaundice 9. Mental changes 10. Fits/Seizures 11. Symptoms of hypercalcemia (thirst)

Question 50

What are the mammary glands?

Answer 50

Highly developed apocrine sweat glands.