Breast problems

Chapter 3 Breast problems



Jane Fox



3.1 Introduction




Physical examination


The fully exposed breasts are examined initially in the seated and then the supine position.


On inspection any asymmetry or alteration in contour of the breasts is noted (Box 3.1). Most differences in size of the breasts are developmental. Accessory nipples may be observed along the milk line between axillae and groins. The most common site is just below the normal breast. Accessory breast tissue is most commonly seen between the true breast and the axilla and may increase in size initially with lactation but is rarely connected to the mammary ducts, although a rudimentary nipple may appear as a pore on the skin.



Localised skin retraction and dimpling is an important sign of infiltration by carcinoma. The breast stroma is traversed by fine fibrous bands that support the breast and have attachments to the dermis and to the fascia over the pectoralis major muscle. Invasive and sclerosing lesions within the breast, by involving these ligaments, can produce tethering and dimpling of the overlying skin.


The patient, while sitting, is asked successively to raise the hands fully above the head, to clasp hands behind the neck, to place hands on hips, to press the hands against the hips and to lean forwards. Asymmetry and distortion by a mass or skin tethering (Fig 3.1) and retraction, are often only detected by movements such as arm elevation or leaning forward, or by tension of the underlying chest muscles. Dermal oedema due to lymphatic obstruction causes a skin appearance resembling orange peel or pig skin (peau d’orange). This sign is a feature of a locally advanced cancer or a local inflammatory lesion such as an abscess or may follow treatment for breast cancer, particularly when the axillary lymph nodes have been dissected and when the patient has received radiotherapy to the conserved breast. Erythematous discoloration of skin may be due to underlying infection, duct obstruction during lactation or, occasionally, inflammatory malignancy. In the areola the nodules of Montgomery’s follicles are seen. These can sometimes become infected. Bilateral nipple retraction may be a developmental anomaly. A recent history of unilateral nipple retraction suggests underlying breast disease, particularly malignancy or periductal inflammation.



Nipple discharge should be induced, if possible, by segmental compression around the areola, or assessed by examining the stain on underclothing. Spontaneous nipple discharge that is bloodstained or a clear sticky yellow fluid is most commonly due to duct papilloma, but occasionally indicative of serious intraduct pathology, particularly ductal carcinoma in situ. Physiological discharge may been seen in young women and during lactation. A thick creamy or green discharge suggests mammary duct ectasia and is rarely spontaneous. Hyperprolactinaemia due to a microadenoma of the pituitary gland is a rare cause of a copious milky discharge and some psychoactive medications may precipitate nipple discharge due to endocrine interactions. Cytological examination of the fluid may aid diagnosis.


Palpation is initially performed with the patient supine. A pillow is placed beneath the shoulder on the side being examined and the arm on that side is abducted with the hand placed behind the head (Fig 3.2). This spreads the breast over a larger area, reducing the depth of the breast tissue and thus facilitating palpation. The whole breast is palpated, including the axillary tail, using the palmar surfaces of the fingers with the hand flat. This avoids mistaking normal fat or glandular tissue for discrete lumps, a mistake that is common if the tips of the fingers are used. The detection of a discrete or dominant lump requires experience in palpating the normal texture of the breast and recognising the normal and cyclical variation. If a lump is discovered or the patient’s suspicion of a lump is confirmed, its physical characteristics are fully assessed. Many dominant lumps in the breast are cystic so that assessment for fluctuation is important; however, fluctuation will not be elicitable with deep cysts. The important physical characteristics of cancer are discreteness and induration. Fixity is usually a late sign except where a cancer is unusually superficial or in the infra-mammary fold of the breast.



Finally the patient is brought back to the seated position to complete the examination. Any lumps are assessed by palpation with one hand, then by both hands compressing the breast between them. Fixation of the lump to the underlying muscle is tested by assessing for change in mobility upon contraction of the pectoralis major muscle. The patient is asked to press her hand against the hip in order to contract the muscle. The axilla is palpated while resting the patient’s forearm on the examiner’s forearm. Palpable nodes are common in the normal axilla; firm nodes of 1 cm or more suggest involvement by metastatic tumour. Enlarged and tender nodes may indicate an inflammatory or infective process. The examination is completed by looking for signs of metastatic disease, palpation for supraclavicular nodes and for hepatomegaly and bone tenderness, particularly in the spine, and auscultation of the chest. A diagramatic record can then be made of the findings (Fig 3.3).




Diagnostic tests


Percutaneous aspiration of a breast lump is often part of the routine physical examination, both to obtain a cytological specimen for diagnosis and to definitively treat breast cysts. Simple aspiration of breast cysts is both diagnostic and therapeutic. Cytological examination of the greenish-yellow fluid is not worthwhile, but cytology should be done if the aspirate is bloodstained or if the cyst is recurrent or if an ultrasound shows a complex lesion.



Imaging techniques: mammography, ultrasound


Imaging of breast tissue commonly utilises mammography and ultrasound. Mammography provides the most sensitive and specific method of screening an asymptomatic woman for signs of breast cancer. Examination of a symptomatic patient generally involves both mammography and ultrasound and ultrasound should be regarded as a focused investigation rather than a screening strategy. High-resolution ultrasound is useful in providing diagnostic information about solid and cystic masses and is increasingly used as a clinical tool to differentiate between ‘lumpy normal’ and breast pathology. Mammography is least useful in breasts with dense glandular tissue in women aged under 30 years. Imaging of dense breast tissue, particularly in women identified at high risk of developing breast cancer, is challenging. At present MRI (magnetic resonance imaging) has promising sensitivity and improving specificity and is of particular use in young women at high risk of breast cancer because of a genetic predisposition.


Positive signs of malignancy on mammography include an irregular infiltrating mass and focal pleomorphic microcalcification. Differentiation of mass lesions and calcified lesions uses a combination of mammographic workup including magnification, ultrasound and image-guided biopsy (Fig 3.4).





3.2 Breast pain


Breast pain (mastalgia) is a very common problem and is not often due to malignant disease.






3.3 Breast lump


In most instances a lump in the breast is incidentally found by a woman or her general practitioner and may not be a discrete lesion. The breast consists of fat and glandular tissue arranged between fibrous tissue septa. It can be easy to sense a localised area of resistance that is incorrectly considered to be a lump. Squeezing the breast tissue between finger and thumb accentuates the tendency to produce ‘pseudolumps’.


Confusion can be reduced by the correct method of palpation, which is to palpate gently with the pulps of the fingers with a flat hand. Prodding and squeezing should be avoided in order to better detect the truly dominant lump. Breast examination requires experience before the clinician can be reasonably sure whether a lump is present or not. Greater sensitivity can be achieved by palpation with the breast and fingers lubricated by a thin soap film. Perhaps for this reason, many lumps are first noted by the patient while showering.


If the clinician feels that a lump is not present, the patient can be reassured, but it is important to determine what the patient has identified as a lump, and to consider whether imaging is indicated.


The clinician also may be unsure whether a discrete lump is present or not. When a degree of lumpiness is present, it may be difficult to be sure on the first examination whether there is a dominant swelling in a lumpy breast. In these cases the usual practice is regular review, often timing the next visit at a different time during the menstrual cycle, as lumpiness of breast tissue is commonly a cyclical phenomenon. The natural lumpiness of the breast is least in the early part of the menstrual cycle. Bilateral mammography and ultrasound are also very helpful in these patients.


If the clinician identifies a dominant lump, age is often helpful in suggesting an appropriate differential diagnosis. A variety of common breast changes can be defined by the acronym ‘ANDI’ (abnormalities of normal development and involution). Fibro-adenomas are a developmental abnormality and most commonly present in women in their late teens and 20s and respond to normal growth stimuli. Benign breast cysts are a phenomenon of involution and commonly present between 30 years and menopause. Carcinoma should be considered the most likely cause of a new palpable abnormality in a post-menopausal woman but occurs in young women as well. Thickenings in the region of scars from previous benign breast biopsies can also cause difficulties in diagnosis.


Similarly, a variety of discrete nonpalpable lesions may be detected by screening mammography, although a lump may not be palpable.


Jul 18, 2017 | Posted by in GENERAL SURGERY | Comments Off on Breast problems

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