APPROACH TO BREAT LUMP

1. Topic: Approach to a Breast Lump
Date: 17th Mangsir, 2077
Moderator: Prof. Dr. YP Singh
Dr. Suzita Hirachan
1
Presented by: Hari Sedai (Jr. Intern)
Roll no.: 1626
Maharajgunj Medical Campus

2. Surface Anatomy of breast
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3. 3

4. Surgical anatomy of breast
Arterial supply
Venous drainage
Nerve supply 4

5. Lymphatic drainage of the breast
Levels of the axillary nodes (Berg’s levels) (Level I, Level II and Level I5II)

6. Introduction
• Localized swelling, knot, bump, bulge or protuberance in the breast
May appear in both sexes at all ages
• In women, it may be due to infection, trauma, fibro-adenoma, cyst,
fibrocystic conditions or malignancy
In males, commonest cause of breast lump in gynaecomastia
• Can be benign/malignant; solid/cystic
• A breast lump, either self detected, screen detected or clinician
detected, raises the fear of breast cancer in any woman, irrespective
of age 6

7. Clinical approach to breast lump
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Clinical assessment
History
Patient’s particulars
1. Age:
fibroadenoma (<35 yrs)
fibroadenosis (any age, common in middle age)
Inflammatory abscess (young, lactating women)
Ca breast (women >40 years)
2. Social and marital status:
Ca breast and fibroadenosis: more in developed world and
nulliparous, less common in underdeveloped world and multiparous
women

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Chief complaint: Lump/mass/swelling in right/left breast for
……months/years
Other complaints:
Pain in the breast over the swelling
ulceration over the breast
nipple discharge
swelling in the axilla
nipple or areolar deformity or retraction
change in breast size
metastatic features like paraplegia jaundice or breathlessness for
……months/years

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History of presenting illness:
1. Lump/swelling:
Following trauma: Hematoma/fat necrosis
Long history and slow growth: benign conditions
(fibroadenoma/fibroadenosis), atrophic scirrhous Ca-malignant but
slow)
Short history and fast growth: Carcinoma
Any swelling in the opposite breast or axilla

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2. Pain
Painless: Ca breast, but in advanced case pain at back,hip, shoulder due
to metastasis
Painful:
Acute mastitis: throbbing nature when pus is formed
Fibroadenosis: Aggravates during menstruation
3. Ulceration: trauma/malignancy/tuberculosis

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4. Discharge from nipple:
i. Discharge from surface: Paget’s disease, skin diseases (eczema,
psoriasis), chancre
ii. Discharge from a single duct:
Blood stained (intraductal papilloma, intraductal carcinoma, duct
ectasia), serous (any colour): ( fibrocystic disease, duct ectasia,
carcinoma)
iii. Discharge from more than one duct:
Blood stained (carcinoma, ectasia, fibrocystic disease)
black/green (duct ectasia)
purulent (infection, carcinoma)
serous (fibrocystic disease, duct ectasia and carcinoma)
milk (lactation, hypothyroidism, pituitary tumor)

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5. Retraction of nipple:
Long history or since puberty: developmental (circular, can be everted,
no underlying swelling)
Recent history: underlying carcinoma of breast (slit-like, cannot be
everted, underlying swelling palpable)
6. Chest pain, cough, haemoptysis: due to pulmonary metastasis
7. Loss of weight: Carcinoma of breast, TB breast, TB chest wall causing
retro mammary abscess
8. Any pain abdomen/history of jaundice, bone pain
9. Any history of headache, LOC, vomiting and weakness of any limb

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Past history
Recurrent of abscess in congenital retraction of nipple, TB beast,
fibroadenosis
Carcinoma in opposite breast
Personal History
1. Marital status: In unmarried/nulliparous, fibroadenosis and Carcinoma
of breast is common
2. Menstrual history: Relation of lump and pain with menstruation
3. Lactational history: suppurative mastitis common during 1st lactational
period
Obstetric History:
Age of first pregnancy, total number of pregnancy, no. of abortions, mode
of delivery, last child birth, any history of OCP/HRT, breastfeeding

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Family history:
Similar illness or h/o GI or ovarian malignancy in 2-3 generations
Ca breast: recurs in family
Treatment history:
H/O operation in breast
Radiation therapy to the breast or other region of the body, breast biopsy,
lumpectomy, mastectomy, hysterectomy, oophorectomy
Personal history: smoking and alcohol
Menstrual history

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Examination
Introduction, consent, adequate privacy, female attendant, exposure
upto the waist
General survey: Head to toe examination, PILCCODE
Local examination:
Always examining the non-complaining breast first

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Position
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
Most convenient position: Semi-recumbent position

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Inspection (Done in sitting position)
1. Breast: both breast are inspected for
• Symmetry and position: whether displaced in any direction
• Size and shape: larger/smaller in comparison to normal breast
• Any puckering or dimpling scirrhous carcinoma: breast is shrunken and
drawn towards the growth
• Dimpling of skin

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2. Nipple
a. Presence: present and symmetrical normally
one retracted: underlying carcinoma
Destroyed: Paget’s disease, fungating carcinoma
b. Compare the level of nipples on both sides
Vertical distance: from clavicle, Horizontal distance: from midline
Carcinoma: nipple of affected side drawn towards the normal
Inflammatory fibrosis: Elevation of the normal
Fibroadenoma: Displaced away

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c. Number (accessory nipples found along milk line extending from axilla
to the groin)
d. Size and shape
Prominent: due to underlying swelling e.g., cysts
Recent retraction: Ca breast, occasionally due to chronic
inflammation
Destroyed with red and flat ulcer: Paget’s disease
e. Surface (any crack, fissure, scalliness and eczema)
f. Any discharge from the nipple (check undercloth)
g. Any ulcer over the nipple

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3. Areola
a. Colour (pale pink in young girl, darker in adult and brown in
pregnancy)
b. Size (large in huge swelling of soft fibroadenoma/sarcoma and
decreased in scirrhous carcinoma)
a. Surface and texture ( crack, fissure, ulcer, eczema, swelling and
discharge)
Paget’s disease: bright red in early stage’ later destroyed leaving
red weeping ulcer
Retention cyst: Due to enlarged Montgomery’ tubercles

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4. Skin over the breast
colour and texture: ( red, warm and edematous in acute mastitis)
Engorged vein: cytosarcoma phylloides and rapidly growing sarcoma
Acute lactational mastitis: nipple retraction or puckering
Scirrhous carcinoma of breast: Peau d’ orange
Nodules: often metastatic
Ulceration and fungation: Advanced carcinoma, large soft
fibroadenoma, rapidly growing sarcoma
Swelling in the breast: (position in relation to the quadrant, extent, size,
shape, surface, margin, skin over it, position and extent, floor)

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5. Arm and thorax
Cancer en cuirasse
brawny edema of arm (neopalstic infiltration of the axillary LNs, after
radical mastectomy, cellulitis), swelling/fullness in axilla and
supraclavicular fossa ( Enlarged LNs)
6. Anterior chest wall: nodules
7. If ulcer is present, examining it

25. Findings on inspection
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28. Breast Abscess

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30. Peau d’ orange
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33. Palpation (Done in semi-recumbent position 45 degree)
Normal breast first
Normal breast: firm lobulated impression with nodularity
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hard), sarcoma (variable from place to place)
1. Breast lump:
a. Local temperature and tenderness: warm and tender in
inflammatory, acute mastitis carcinomatosa
b. Site and extent: carcinoma( mostly UO quadrant), fibroadenoma
(lower half>upper half)
c. Number ( multiple on fibroadenosis, most other breast lesion
solitary)
d. Size and shape (globular in fibroadenoma, irregular in carcinoma)
e. Surface (smooth in benign, irregular in carcinoma)
f. Consistency (cystic, firm, hard, stony-hard)
fibroadenosis (firm, shotty), fibroadenoma (firm), carcinoma (stony-

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g. Margin:
Ill-defined in fibroadenosis
Fibroadenoma, carcinoma: well-defined
Fibroadenoma: margin is regular and tends to slip of the palpating
finger (Breast Mouse owing to high mobility in the breast)
Carcinoma: Irregular and doesn’t slip-off
h. Fluctuation
Present in cystic swelling like chronic abscess, lipoma
Absent in very tense cyst

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i. Fixity
• Skin fixity: infiltration by malignant tumour (puckering and
tethering)
• Breast tissue: In-fibroadenoma; lump is easily movable
within breast tissue; in carcinoma, lump is fixed to the
breast tissue and breast tissue moves along with the lump
• Underlying fascia and muscle: ( testing fixity on pectoralis
major muscle and serratus anterior)
• Chest wall: lump fixed, irrespective of contraction of any
muscle

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Examination of the lymph nodes
Examination of the anterior, central, apical lateral, posterior and
supraclavicular lymph nodes
Comparison of the both sides simultaneously
Noting number, size, fixity, tenderness, consistency, matting

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General Examination
Abdomen
Liver: for secondary deposits
Lungs; bones and lumbar spines for tenderness:
metastasis
Rectal and vaginal examination: Krukenberg’s tumour
Provisional diagnosis: …………….

45. Investigations: Radiological Imaging
1. Mammography
Best for women => 40 years of age
Screening mammography
Diagnostic mammography (for breast lump)
Views (cranio-caudal and mediolateral oblique for screening, 90 lateral
with craniocaudal and spot compression view for diagnosis)
Mammography guided biopsy
Digital mammography
In Ca breast; solid mass with/without stellate feature, asymmetric
thickening of breast mass ,clustered microcalcifications, spiculations, duct
distension are seen
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49. 2. USG of Breast (best for women before 40 years of age)
In Ca Breast; irregular margin, irregular internal echo, irregular posterior
shadowing, non-compressibility and ratio between A-P to width
(lateral/horizontal)>1 is seen
Differentiate solid lesion from the cystic lesion
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3. Histological/cytological analysis
a. FNAC (simple or USG Guided): Done for cytological diagnosis only;
difficult to differentiate between in-situ and invasive breast carcinoma
b. Biopsy:
i. Needle biopsy: core-cut biopsy/core needle biopsy
ii. Frozen section biopsy: if FNAC fails even after two trials, done on
table
i. Open biopsy: When FNAC is inconclusive and facility of frozen section
is not available
Incisional biopsy: for mass >5 cm
Excisional biopsy: for mass < 5 cm with negative margin
c. Cytological examination of nipple discharge or cyst-fluid

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Baseline investigations
Full blood count, urea, creatinine, electrolytes
Urinalysis
Serum calcium
Chest x-ray
ECG
LFT
Urinary steroids( aetiocholanolone) : low level is seen in urine in Ca
breast

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For investigations of staging of breast cancer
• Chest x-ray, CT Chest
• USG abdomen and pelvis
• X- ray spine
• Bone scan and skeletal bone survey
• MRI breast
• Tumour marker: CA-15/3, CEA
• PET scan
• Estrogen and progesterone receptor study
• Sentinel LN biopsy
TNM Staging if Breast cancer

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Management
• Simple cysts are aspirated to dryness and require no further
treatment if they do not recur
• Pathological cysts require surgical excision
•A solid lesion requires a firm diagnosis, necessitating histological
examination
•Benign solid lesions may be managed expectantly, provided
regular follow-up is undertaken
•Malignant solid lesions are referred to a multidisciplinary team for
further management

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Treatment
a. Benign lesion: Excision biopsy
b. Cyst: Excision biopsy
c. Abscess: incision and drainage
d. Traumatic fat necrosis: no treatment needed after diagnosis
confirmed
Cryoablation, Laser Interstitial Thermotherapy, Vacuum assisted biopsy
and Radiofrequency ablation can also be done in case of fibroadenoma

60. -Webster incision(circumareolar)
-Galliard Thomas ( Submammary)
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61. d. Carcinoma
1. Local/regional:
Surgery
• Simple (total) mastectomy
• Skin sparing mastectomy
• Extended total mastectomy
• Breast conservation surgery (BCS)
• Modified radical mastectomy (MRM) (Patey’s, Scanlon, Auchinloss)
• Halsted (radical mastectomy)
• Extended radical mastectomy
• Superradical mastectomy
• Toilet mastectomy
Radiotherapy 61

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2. Systemic
Cytotoxic chemotherapy (paclitaxel, epirubicin, docetaxel)
Hormonal therapy (tamoxifen, letrozole)
Immunotherapy (transtuzumaab, lapatinib)
3. Hypercalcemia due to tumour lysis syndrome
IV/oral inorganic phosphate
Furosemide large doses
Adequate hydration

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References
• Bailey and Love’s short practice of surgery, 27th edition
• SRB maula of surgery, 5th edition
• A manual of clinical surgery by S Das
Thank You!!!