Evaluation of breast disease : Positioning, inspection, Palpation, Investigations

February 22, 2013 | By | Reply More

Evaluation of breast disease : Positioning, inspection, Palpation, Investigations

Positioning and inspection
Breasts are best examined semirecumbent and then sitting upright. Initially the arms are by the side, semirecumbent. After initial inspection they should be positioned ‘hands on hips’ sitting upright (initially relaxed and then with forced pressure on the hips to tense the pectoral muscles) and finally abducted slowly above the head. For palpation, the hands should return to the hips and the patient may lie back semirecumbent again.
Inspection is critical and should concentrate on the following.
  • Overall symmetry and position. Are the breasts the same size? Is there deformity due to underlying disease? Is the position normal?
  • Skin appearance. Is the skin erythematous or oedematous? Is there fixed lymphoedema of the skin (‘peau d’orange’)? Are there scars from previous surgery?
  • Skin tethering. Does the skin move freely as the arms are raised? (Tethering is suggestive of underlying intraparenchymal scarring or tumour.)
  • Nipples. Are the nipples indrawn, deviated, or ulcerated (suggestive of retroareolar tumour or infection)? Is there any evidence of discharge?
Palpation
Use the flat of the fingers and use all four fingers at once. Palpate the ‘normal’ breast first. Be methodical and don’t ‘knead’ the breast. A common routine is: upper outer quadrant; lower outer; lower inner; upper inner; central (retroareolar); supraclavicular fossa; axilla. Features to look for include the following:
  • Palpable mass. Is it hard, irregular, and tethered? (cancer), or smooth, rounded and mobile (cysts or fibroadenoma)?
  • Diffuse nodularity. Typical of benign disease.
  • Nipple discharge on palpation of the central area. Blood suggests tumour; pus suggests infection; serous or milky may not be relevant.
  • Axillary and supraclavicular lymphadenopathy. Is it multiple and tethered (cancer)?
Investigations
Ultrasound
  • Easy to perform and painless—often done in breast outpatient clinic.
  • Avoids radiation dose in young women.
  • Highly sensitive for differentiating between solid tumours and cysts.
Mammography
  • Used both for population screening and diagnostic testing.
  • Uncomfortable for most women and involves a low radiation dose.
  • Able to identify impalpable lesions.
  • Able to identify premalignant lesions (e.g. ductal carcinoma in situ).
  • Mammographic features of malignancy include: spiculated microcalcification; irregularity; stellate outline.
Aspiration cytology
  • Almost painless, easy to perform, and quick to report on—often done in one half day during breast outpatient clinic.
  • Does not provide histology: provides only cellular information and relies upon cellular atypia for a diagnosis of malignancy.
  • Does not differentiate between invasive and in situ carcinoma.
  • Occasionally therapeutic for cysts.
  • Good sensitivity and specificity.
Guided core biopsy
  • Performed under ultrasound or mammographic guidance using a Trucut® needle or similar device.
  • Can be done under general or local anaesthetic.
  • Provides actual histology information—allows cancers to be graded.
  • Able to differentiate between invasive and carcinoma in situ.
  • Highly sensitive and specific.
CT scanning
  • Relatively non-specific for local breast pathology.
  • Useful for assessment of extensive local invasion and regional and systemic staging.
MRI scanning
  • Occasionally used for the assessment of local breast pathology.
Key revision points—anatomy of the breast
  • Breast comprises epithelial ductal tissue, epithelial secretory lobules, fat, and connective tissue
  • The areola is the pigmented area around each nipple
  • The arterial supply is from segmental perforators from the internal thoracic artery (ITA)
  • Lymphatic drainage—important in breast cancer management
    • Non-pathological lymph drainage is almost entirely to the axillary nodes
    • Medial half can occasionally drain to internal mammary nodes
    • Lymph nodes are divided into three levels (1, below; 2, behind; 3, above pectoralis minor)

Category: Surgery

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