BREAST LUMP – CLINICAL

ASPECTS , DIAGNOSIS AND

MANAGEMENT

UNDER THE GUIDANCE OF

DR. S.P MUKHIYA PRESENTER
PROFESSOR DR. SONAL RAIKWAR
DR. PRAVEEN VERMA JR III
ASSISTANT PROFESSOR
DEPARTMENT OF GENERAL SURGERY
DEPARTMENT OF GENERAL SURGERY
RDGMC AND CRGH RDGMC AND CRGH
INTRODUCTION
A breast lump is one of the most common complaint that a female
patient presents in the surgery out patient department.
A breast lump , however insignificant it might look or feel , should
always be subjected to careful examination and investigations.
Around 80% of the diagnosis is made with just the history taking and
thorough clinical examination of the patient.
The subsequent slides will be covering the most important clinical
aspects of examination to form a provisional diagnosis followed by
specific investigations and basics of management of a breast lump.
SURGICAL ANATOMY OF THE BREAST AND
AXILLA
 THE AXILLARY LYMPH NODES
SURGICAL GROUP ANATOMICAL
(BY PECTORALIS GROUP
MINOR)

LEVEL 1 ANTERIOR
LEVEL 2 CENTRAL
LEVEL 3 APICAL
LATERAL
ROTTERS LYMPH POSTERIOR
NODES BETWEEEN
PECTORALIS MAJOR
AND MINOR
HISTORY TAKING IN BREAST LUMP
History of Present Illness
Onset – If its acute has a sudden onset or chronic has a insidious
onset.
Progression – Is the swelling progressed slowly over time or has it
progressed suddenly with some drastic changes.
Duration – Is it present there for a long time or has it been there just
for a while.
Negative History – Fever , weight loss , nausea/vomiting , trauma ,
pain in back or pain in upper limbs, nipple discharge and lactation.
 PERSONAL , MENSTRUAL AND OBSTETRIC
HISTORY

Age at menarche
Age at first Live birth
Age at menopause
Regularity of the menses
Lactation
History of exposure to Hormonal pills , HRT and any other significant
drugs that may affect the disease.
Past History – H/O chronic diseases as diabetes, hypertension ,
Hypothyroidism / hyperthyroidism , COPD , CAD.
Family History – h/o similar or any significant diseases in the family.
CLINICAL EXAMINATION
GENERAL EXAMINATION
Routine general examination to be done including vitals and any
significant physical sings.

SYSTEMIC EXAMINATION
All the four systems CVS , CNS , R/S and P/A to be examined
carefully.
LOCAL EXAMINATION OF A BREAST LUMP
 INSPECTION
INSPECTION
COMPARISION OF SKIN OVER THE NIPPLE AREOLAR VISIBLE SWELLING
BILATERAL BREAST BREAST COMPLEX AND
AXILLA
 Comparing the size  Erythema  Shape  Site
and anatomical  Ulcer or discharge  Location  Size
location of the  Peau‘d orange  Discharge  Shape
bilateral breast.  Dimpling of the skin  Axillary lump  Quadrant
 Dilated veins  Axillary ulcer or
 It can be either equal , discharge
pulled up or  Pagets disease
disfigured.
 PALPATION
PALAPTION
A Breast lump is palpated in all of the following positions –

• Supine
• Standing with Hands by the side
• Standing with hands above the shoulders
• Standing with hands over the waist
SIZE AND SITE CONSISTENCY MARGINS MOBILITY AND AXILLARY LYMPH
FIXITY TO NODES
UNDERLYING
STRUCTURES

 WHICH  CYSTIC  DISCRETE  FREELY  NOT PALPABLE

QUADRANT IS  FIRM LUMP NOT MOBILE
INVOLVED  HARD PALPABLE  PALPABLE ON
 PARTIALLY THE SAME SIDE
 WHAT IS THE  PRECISELY MOBILE
APPROX. SIZE PALPABLE AND  PALPABLE ON
OF THE LUMP WELL  FIXED THE
DELINIATED CONTRALATERAL
 IS IT UNIFOCAL WITH SIDE
OR MULTI REGULAR
FOCAL MARGINS  PALPABLE
INFRACLAVICULAR
OR
SUPRACLAVICULAR
NODES
CLINICAL BENIGN BREAST DISEASE MALIGNANT BREAST DISEASE
FEATURES
AGE AT PRE AND PERIMENOPAUSAL PERI AND POST MENOPAUSAL
PRESENTATION WOMEN
PROGRESSION SLOWLY PROGRESSIVE RAPIDLY PROGRESSIVE

ASSOCIATED CYCLICAL MASTALGIA MAY BE ULCERATION , NIPPLE DISCHARGE

SYMPTOMS PRESENT
CONSISTENCY SOFT / FIRM HARD

MARGINS AND SMOOTH SURFACE , WELL IRREGULAR MARGIN AND

SURFACE DEFINED SURFACE
MOBILITY FREELY MOBILE (BREAST RESTRICTED OR FIXED MOBILITY
MOUSE)
NIPPLE AREOLAR NORMAL MAYBE DISPLACED OR
COMPLEX DISFIGURED
AXILLARY LYMPH RARELY PALPABLE PALPABLE
NODES
DIFFERENTIAL DIAGNOSIS
BENIGN BREAST DISEASES CARCINOMA BREAST

 FIBROADENOMA BREAST  INFILTERATUNG DUCTAL CARCINOMA

 FIBROCYSTIC DISEASES  INFILTERATING LOBULAR CARCINOMA

 DUCT PAPPILOMA  CARCINOMA PHYLLODES

 PHYLLODES TUMOUR  INFLAMMATORY CARCINOMA

INVESTIGATIONS
IMAGING IN A BREAST LUMP
MAMMOGRAPHY

X Ray of the breast.

Two views – craniocaudal (CC) and mediolateral oblique (MLO).
3D Mammogram/ Breast tomosynthesis is the latest form.
Used as diagnostic tool for women >40yrs.
Grading system used – BIRADS ( Breast Imaging Reporting And
Data System)
NORMAL MAMMOGRAM OF THE BREAST
POPCORN BROKEN NEEDLE LEAD PIPE MICROCALCIFICATION IN
CALCIFICATION CALCIFICATION IN CALCIFICATION IN MALIGNANCY
IN A DUCT ECTASIA FAT NECROSIS
FIBROADENOMA
USG BREAST
Diagnostic modality for young women who have dense breast tissue.
To differentiate between solid and cystic lesions.
Investigation of choice in pregnancy with breast lump.
BIRADS SCORING SYSTEM
MRI
MRI IS THE INVESTIGATION OF CHOICE IN THESE CONDITIONS

Patients with breast implants

Suspicion of DCIS
To identify local/scar recurrence after surgery
Screening modality for young high risk patients
Pregnancy
Palpable axillary lymph nodes in absence of a palpable breast lump.
FNAC AND HISTOPATHOLOGY FOR A BREAST LUMP

Fine Needle Aspiration Cytology is the study of cells from a breast

lump .

A 22 Gauge needle is used to extract the cells , they are fixed and then
visualized for any atypia.

Histopathology is the cornerstone in diagnosis and management of a

breast lump.
CRITERIA FOR SCREENING WOMEN
FOR BREAST LUMP

 KNOWN CASE OF BRCA 1 AND BRCA 2 MUTATION

 FIRST DEGREE RELATIVE WITH BRCA 1 OR BRCA 2 GENE MUTATION
 HISTORY OF RADIATION EXPOSURE TO CHEST WALL IN YOUNGER
AGE
 PATIENTS OF LI FRAUMENI AND COWDEN SYNDROMES
 PERSONAL HISTORY OF DCIS , ATYPICAL DUCTAL OR LOBULAR
CARCINOMAS
 UNEVENLY DENSE BREASTS ON MAMMOGRAM
Early screening starting at the age of 25 years (very high risk patients)
I.O.C – MRI breast

Screening starting at the age of 35 years (moderate risk patients)

I.O.C – USG breast

Routine screening starting at the age of 45 years

I.O.C – Mammography
MANAGEMENT OF A BREAST LUMP
 BENIGN BREAST DISEASES
Benign breast diseases are nothing but Proliferative and involutory
changes seen in the breast under the influence of various hormones
that affect a female during different physiological conditions as
puberty , pregnancy , lactation and menopause.

Therefore benign breast diseases are different for each age group .
Management is largely conservative focusing on providing
symptomatic relief.
A short description of the various diseases and there management is
explained in subsequent slides.
BENIGN BREAST DIAEASES IN MANAGEMENT
WOMEN OF REPRODUCTIVE
AGE GROUP
FIBROADENOMA EXCISION + VIT. E SUPPLEMENTATION

FIBROADENOSIS ANALGESICS + SERMS ( LOW DOSE TAMOXIFEN )

BREAST ABSCESS ASPIRATION F/B INCISION AND DRAINAGE +

ADEQUATE ANTIBIOTIC COVERAGE

GALACTOCOELE ASPIRATION + CABERGOLINE ( TO SUPRESS LACTATION )

DUCT ECTASIA MULTIPLE DUCTS – HADFIELD’S EXCISION

SINGLE DCUT – RACQUET INCISION

FAT NECROSIS ANALGESICS + REASSUARANCE

BENIGN BREAST DIEASES IN WOMEN IN MANAGEMENT
PERI AND POST MENOPAUSAL AGE GROUP

DUCT ECTASIA HADFIELD’S EXCISION + SERM

INTRADUCTAL PAPPILOMAS EXCISION

FIBROCYSTIC DISEASES ANALGESICS + ANTIBIOTICS

 CARCINOMA BREAST
Second most common malignancy diagnosed in women across the
world.

Cancer with one of the highest mortality rates.

Sporadic breast cancer still remains the most common followed by

familial breast cancer.
FAMILIAL BREAST CANCER

Genes involved are BRCA 1 BRCA 2 and Tp 53.

Familial breast cancer is associated with –

• Hereditary Breast Ovarian Cancer Syndrome

• Carcinoma Prostate
• Carcinoma Pancreas
• Colorectal Carcinoma
• Carcinoma Stomach
MANAGEMENT OF WOMEN WITH FAMILIAL BREAST
CANCER

Early screening starting at 25 years and 35 years respectively depending

upon the risk.
Starting low dose Tamoxifen has shown to reduce risk by 47% .
Risk reduction surgeries –

B/L Prophylactic Mastectomy B/L SalpingoOphorectomy

Reduces risk by 95% + Reduces risk by 90%
MANAGEMENT PROTOCOL FOR CARCINOMA BREAST
SURGERY CHEMOTHERAPY HORMONAL RADIATION
THERAPY

 LUMPECTOMY /  TOPOISOMERASE II  ER/PR RECEPTOR  WHOLE BREAST

BREAST INHIBITORS ANTAGONISTS RADIATION
CONSERVATION GIVEN FOR 25 DAYS
SURGERY/  ANTHRAYCLIN  TAMOXIFEN (50-55 CGY)
ONCOPLASTY WITH  ATORUBICIN  RALOXIFEN
SENTINEL LYMPH  ACCELERATED
NODE BIOPSY  MICROTUBULE  HER 2 NU PARTIAL BREAST
INHIBITORS RECEPTOR IRRADIATION
 MODIFIED RADICAL ANTAGONIST (ABPI)
MASTECTOMY  DOCITAXEL 30-35 CGY GIVEN FOR
WITH AXILLARY  PACLITAXEL  TRASTAZUMAB 5 DAYS
LYMP NODE (HERCEPTIN)
DISSECTION  CYCLOPHOSPHAMI  PERTUZUMAB
DE (PERJETA)
 SIMPLE
MASTECTOMY
BREAST CANCER
EARLY BREAST CANCER
EARLY BREAST CANCER WITH POSITIVE
AXILLARY LYMPH NODES
LOCALLY ADVANCED BREAST CANCER
BREAST CANCER WITH DISTANT METASTASIS
MANAGEMENT
ONCOPLASTY / MRM + SLNB +
RADIOTHERAPY
MODIFIED RADICAL MASTECTOMY +
AXILLARY LYMPH NODE DISSECTION +
CHEMOTHERAPY +/- RADIOTHERAPY
NEOADJUVANT CHEMOTHERAPY FOLLOWED
BY
MRM + ALND +RADIOTHERAPY
NEOADJUVANT CHEMOTHERAPY +
RADIOTHERAPY +/- MRM WITH ALND
ONCOPLASTY
THANKYOU