clinical - Breast discussion

BREAST

What is the commonest site of breast cancer? Upper outer quadrant

What are positions for breast examination?

Inspection: 45^o with hands beside →elevation hands (axilla & arm) → hand on waist (pect.maj. cont. for teethering)→ pt. elevate br. (for big breasts- usual in Egypt)

Palpation: 45^o with hands beside → hand on waist (for mass attach to pect.maj.)

How to palpate breast?

4 quadrants, areola, axillary tail, back breast

By flat of middle 3 fingers to screen for masses

if find mass → palpate by tip of fingers

How to manage case of breast swelling? Triple assessment

1-    clinical: history & examination

2-    radiological: <35 years → breast U/S

                           >35 years → mammography

3- Pathological: FNAC or trucut or excisional biopsy (if small)

What are finding in mammography indicating malignant mass?

 microcalcification & speculations (irregular swelling)

What are other investigations (investigation for malignancy)?

Abdominal U/S (for abdominal mts & Bone Scan (for bone scan)

How to treat breast cancer 2cm?

WLE (wide local excision) with 1 cm safety margin

+ axillary clearance or axillary L.N. sampling

+ radiotherapy of breast & axilla (if no clearance & sampling +ve)

How to manage treat breast cancer 6cm?

Radio & Chemotherapy (to downstage & ↓ size tumor)

What is diagnosis of breast case? Example

Mass in the Lt breast lower lateral quadrant, 2X2 cm,

ill defined edge, smooth surface, firm consistency, not teethered or fixed to skin or underlying muscle, axillary L.N.s not felt, 

→ case of breast mass for triple assessment

How to treat breast abscess?

Drainage by radial incision (to avoid interruption of lactating unit)

How to differentiate benign from malignant breast mass?

Triple assessment

1-    history: duration & age of pt.

2-    examination: consistency, relation to skin & ms

3-    pathological: FNAC

D.D. Breast mass?

Physiological: Fibroadenosis (ANDI)→ pain with menstruation

Tr.: fat necrosis

Inf.: abscess, mastitis

Neoplastic: Benign: Fibroadenoma (breast mouse), Duct papilloma, phylloides t.

                   Malig.: 1ry (ductal carcinoma or lobular carcinoma) or 2ry

OSCE advanced Qs

What are pathologies of nipple? 7D: Destruction, Depression, Deviation, Displacement, Discoloration, Discharge, Duplication

What is dimple, buckering, teethering, fixation?

Dimple= dip in skin, buckering= multiple dimples,

teethering= induced dimpling & mass can be moved for limited distance independent of skin (d.t. infiltration or fibrosis of Cooper's ligs)

fixation= mass can not be moved independent of skin (d.t. infiltration of skin)

How to differentiate causes of nipple retraction? Cong.→ can be everted, cancer→ can not

Causes of nipple discharge? Bl.→duct papilloma or carcinoma, watery or green→fibroadenosis, black→ obstructed duct, milk→ lactation or  gonorrhea, yellow= pus→ acute or chr. Mastitis,

N.B. duct ectasia ← any discharge except bl.

How to examine post-mastectomy case?

Insp: (in all positions as breast)

skin→ scars, dilated vs, ulcers or nodules= recurrence, radiotherapy marks: erythema & ink marks (recent) or telangectasia (previous)

Ms (axillary folds): ant.= pectoralis major & post. = latissmus dorsi

Ms examination: pectoralis maj., L.D., serratus ant.

Palpation: continue as breast examination