History taking , local Examination , Investigations of breast lump

1. BREAST LUMP
NR.Aishwarya

2. Breast anatomy
• Modified sweat gland ( apocrine )
• Rudimentary in males
• Well developed in females
• Extent

4. History
1)Age
fibroadenoma - <35 yrs
fibroadenosis - any age
inflammatory breast abscess ,mastitis – lactating women
carcinoma - > 40 yrs
2)Residence
common in England
rare in Japan
3)Social status
common in developed country, nulliparous women

5. 4) Lump
Following trauma - hematoma, fat necrosis
long history, slow growth - fibroadenosis/fibroadenoma (benign)
Short history , fast growth – carcinoma
5) Pain
painless – carcinoma, long standing cases causes pain in back,hip or
shoulder ( bony metastasis)
painfull - mastitis ( throbbing nature)
fibroadenosis (during menstruation) – cyclical
breast
6) Discharge from nipple
fresh blood- duct papilloma/ carcinoma
Pus - mammary abscess
milk – during lactation , galactocele , mammary fistula
serous / greenish – fibroadenosis / duct ectasia

7. 7) Retraction of nipple
carcinoma
8)Loss of weight
carcinoma/TB breast, TB chest wall causing retro mammary
abscess
9)Past history
recurrence of abscess - congenital retraction of nipple ,Tb,
fibroadenosis
carcinoma recur in opposite breast
10)Personal history
fibroadenosis , carcinoma - unmarried/ nulliparous
suppurative mastitis - lactational period
11)Family history
often recur in family

9. Local examination
1. Sitting position with arms by the side of body: Gives information about
nipples, lump and palpation of axillary lymph nodes
2. Sitting with arms raised over the head: lump/dimple/nipple retraction
becomes more obvious
3. Sitting and leaning forward: fixity of the breast to the chest wall and
pectoralis major muscle
4. Sitting and hand pressed on the waist: abnormal movement of nipple or
exaggeration of skin dimples
5. Patient recumbent with 45 degree head end elevation and both hands by the side
of the head
6. Recumbent position: to palpate the breast lump against the chest wall,
inferior quadrant is seen better

10. Local Examination
INSPECTION
• Breast
i. Position - whether displaced in any direction
ii. Size and shape - whether larger or smaller that its
normal breast
iii. Any puckering or dimpling? In scirrhous carcinoma the
breast may be shrunken and drawn in towards the
growth.

11. Inspection
• Skin over the breast
i. Colour and texture.— In acute mastitis the skin becomes red,
warm and oedematous.
ii. Engorged veins - large soft fibroadenoma (cystosarcoma
phylloides) and in rapidly growing sarcoma , acute lactational
mastitis with huge breast abscess,
iii. Dimple, retraction or puckering - scirrhous carcinoma of the breast,
iv. Peau d' orange - carcinoma of the breast. This is due to blockage of
subcuticular lymphatics with oedema of the skin which deepens the
mouths of the sweat glands and hair follicle

12. v) Nodules may be observed in the breast which are often metastatic,
vi) Ulceration and fungation - late feature of advanced carcinoma of the
breast due to infiltration of the skin by the growth.
Nipple
i. Presence - Are both nipples present and symmetrical / retracted /
destroyed
ii. Position - Compare the level of the nipples on both sides. Nipple may be
displaced - fibroadenoma.
destroyed/ eroded - Paget's disease ,fungated carcinoma
iii. Number – accessory nipple found anywhere along the milk line (ridge)
which extends from the axilla to the groin.
iv. Size and shape - prominent, flattened or retracted
Prominence - cyst.
Slight retraction – puberty , carcinoma
v. Surface - cracks, fissures or eczema

15. Areola
i. Colour - pale pink (young girls)
slightly darker(adult )
brown( pregnancy),
ii. Size - larger (soft fibroadenoma )
Diminution (scirrhous carcinoma)
iii. Surface and texture - crack, fissure, ulcer, eczema, swelling or
discharge. In Paget's disease, the areola becomes bright red in the
early stage and is destroyed leaving a red weeping ulcer
Retention cyst: Due to enlarged Montgomery’ tubercles
Arm and thorax
Brawny edema
Axilla and supraclavicular fossa - inspected for any swelling due to
enlarged lymph nodes

16. PALPATION
• Initially in sitting position, in semi-
recumbent (45°) position and later on in
recumbent position
• palpate the normal breast first then abnormal
i. Local temperature and tenderness - ( back of
the fingers). A warm and tender -
inflammatory
ii. Situation (in which quadrant) - Carcinoma
,Fibroadenosis occurs more often in the
upper and outer quadrant and in axillary tail
iii. Number -majority of lesions -solitary,
fibroadenosis - Multiple lumps can be felt

17. i. Size and Shape - Whether globular (fibroadenoma) or
uneven (carcinoma)
ii. Surface - Smooth surface - benign condition,
uneven surface -carcinoma.
vi. Margin - fibroadenosis the margin is ill-defined.
fibroadenoma (a firm tumour within the soft
tissue) regular margin
carcinoma (stony hard tumour within the soft
surrounding) irregular

18. vii. Consistency - cystic, firm, hard or stony hard
firm, sotty or diffuse India-rubber -
fibroadenosis
encapsulated tumour – fibroadenoma
stony hard - carcinoma.
viii. Fluctuation - cystic swelling ,abscess , lipoma
The clinician stands behind the patient, who
sits on a stool. His two hands should go above the
patient's shoulder. With one hand he holds the cyst
and with index finger of the other hand gentle tap is
made on the centre of the cyst.
ix. Transillumination ( dark room) The torch is
placed on the under-surface of the breast so that
the light is directed through the breast tissue to the
examiner.
Fat (translucent) ,solid tumour (opaque)

19. x. Fixity to the breast tissue - This is demonstrated by
holding the breast tissue with one hand and gently
moving the tumour with other hand.
- Fibroadenoma - 'Breast mouse'.
- carcinoma-fixed
xi. Fixity to the underlying fascia and muscles - restriction
in mobility indicates fixity to the pectoral fascia and
pectoralis major.
xii. Chest wall: lump fixed, irrespective of contraction of
any muscle

21. Examination of lymph node
• Examination of the anterior, central, apical,lateral,
posterior and supraclavicular lymph nodes
• Comparison of the both sides simultaneously
• Note number, size, fixity, tenderness, consistency, matting

24. INVESTIGATION
• Mammography
soft tissue radiographs are taken by placing in direct contact with
ultrasensitive film and exposing it to low voltage,high amperage xrays
dose – 0.1 cGy hence very safe
sensitivity increases as breast become less dense
• Ultrasound
useful in young women with dense breast
differentiate cyst from solid lesion
helps to localise impalpable areas of breast
• MRI
Determine whether mammograhic lesion at the site of previous surgery due
to scar or recurrence
To assess the multifocality and multicentric in lobular cancer
screening tool for high risk women
assess the extent of high grade ductal carcinoma in situ

27. • Needle biopsy/ cytology
obtained using 21G or 23G needle with multiple passes
through lump ,aspirate smeared on to slide which air dried or
fixed
FNAC - least invasive ,rapid, very accurate
false negative can occur
cannot differentiate invasive & insitu disease
• Large needle biopsy with vacuum system
obtained using 8G or 11G needle allows more extensive
biopsy taken
management of microcalcification or compete excision of
fibroadenomas

28. Triple assessment

29. Thank you