Breast lump

Breast lumps are very common, the majority of which will be benign.  However, given that 1 in 9 women will develop breast cancer at some stage in their life, an accurate and organised assessment of any abnormality in the breast is very important.

Breast Screening (Scotland) (http://www.nsd.scot.nhs.uk/services/screening/breastscreening/breastfaqs.html)

  • Offered to all women over the age of 50-70.  NB Appointments can also be made by patients or by GPs.
  • Mammography
  • Any patients with suspicious results will be sent to the one-stop clinic within 3-weeks for further assessment

One-stop clinic

  • Consultant breast surgeon will see every patient for history and examination
  • Imaging
    • If >40, a mammogram is the modality of choice
    • If <35, an ultrasound is the modality of choice
    • If <40 and >35, both may be required.
      • All results are reviewed by a radiologist during the clinic
  • Pathology
    • Most commonly, a core biopsy will be taken during the clinic and sent to pathology for assessment (this will take 1-3 weeks for results) as this will give a definitive diagnosis
    • Occasionally, fine needle aspiration will be done there and then in the clinic (As far as I know, they don’t routinely do this in Tayside)
  • Based on these results, further testing (MRI) may be required.

Presentation

  • History
    • Most patients present with a palpable mass.  Ask about duration, speed of growth etc
    • It is important to ask about any association symptoms
      • Pain; nipple discharge; skin dimpling; inflammation; nipple inversion
    • A family history of breast cancer is important.  It is also important to ask about menstrual and obstetric history.
  • Examination of the breast
    • Important points
      • ALWAYS offer a chaperone
      • Try and use appropriate language (examine not feel)
      • Allow the patient to undress and prepare in private (or with chaperone if they wish)
    • Inspection
      • Inspect first with the patient’s hands by their side:
        • look for any nipple abnormality (inversion/discharge etc) and any skin changes (Peau d’orange; tethering; rash) and any visible lumps
        • check symmetry (NB most breasts are not completely symmetrical, though if there is a gross abnormality that could be of concern, it is appropriate to ask the patient whether this is new)
      • Also inspect with the patient with her hands on her hips, squeezing inwards (may bring out any abnormalities in deeper tissue)
      • Also with her hands behind her head.  (also look into the axilla)
      • Remember to inspect under the breast
    • Palpation
      • Ask if there is any pain and examine this area last.
      • Examine all of the areas of the breast (either divided into quadrants + tail or as a clock face + tail)
        • Do NOT use the fingertips but the flat pads of the fingers/hand
        • Remember also to examine under the nipple
        • NB the breast can feel a bit lumpy- if you feel a lump, carry on to finish the examination, then come back to this at the end for a more detailed assessment
      • Repeat on the other breast
    • Lymph node exam
      • If you are examining the right axilla, support the patient’s arm with your right hand/arm and examine with the left (opposite) hand, and vice versa
      • You would also examine the subclavicular nodes
  • Record
    • Size; location; shape; surface; texture; mobility

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