BREAST AND ENDOCRINE
CASE 37: aSSeSSment oF a breaSt lump
history
A 47-year-old female presents to the breast clinic complaining of a painful lump in her left breast. She has not noticed any nipple discharge, skin changes or changes in her breast shape. Her mother was diagnosed with breast cancer at 50 years of age. She has recently been through a divorce and has no children. She is a non-smoker and has been previously fit and healthy.
examination
A 4-cm irregular lump is found adjacent to the nipple in the left breast. The lump is hard in consistency and only mildly tender on palpation. It is slightly mobile with no tethering of the overlying skin. It does not appear deeply fixed. There are palpable left-sided axillary lymph nodes which are mobile. The right breast and axilla are normal. Abdominal and skeletal examinations are normal.
INVESTIGATIONS
a mammogram of the breast is shown in Figure 37.1.
Questions
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How should this lump be assessed? |
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What are the risk factors for |
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developing breast cancer? |
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TowhatagegroupdoestheUKoffer |
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a breast screening programme? |
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What is a sentinel lymph node |
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biopsy? |
Figure 37.1 mammogram of the left breast.
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100 Cases in Surgery
ANSWER 37
Breast cancer is the commonest form of cancer amongst women. Any women presenting with a breast lump should undergo triple assessment:
•Clinical assessment (history/examination)
•Mammography and/or ultrasound
•Fine-needle aspiration cytology (FNAC) or core biopsy
The incidence increases with age, but at menopause the rate of increase slows. Risk factors for developing breast cancer include:
•Oestrogen exposure, unopposed by progesterone
•Nulliparous women in developed countries
•Mutations in the BRCA1 and BRCA2 genes
•Early menarche/late menopause
•Family history
•Saturated dietary fats
•Previous benign atypical hyperplasia
The breast screening programme was set up by the Department of Health in 1988 and is offered to women between the ages of 50 and 70 years. All women now have two views of the breast taken at every screen – craniocaudal and mediolateral views. It has reduced mortality rates in the 55–69-year age group.
In patients without systemic disease, surgery is potentially curative. Treatment options include mastectomy or breast-conservation surgery, such as wide local excision or quadrantectomy. Axillary lymph node status is a good prognostic indicator for breast cancer and is helpful in delineating further treatment pathways. Management of the axilla is controversial. Options include axillary node sampling, clearance or sentinel node biopsy. The sentinel node is the first lymph node the breast lymphatics drain to before reaching the axilla. Sentinel lymph node biopsy is an alternative to axillary sampling or clearance, which provides information on the probable tumour status of other axillary lymph nodes. The technique involves injection of a technetium-based radioisotope into the breast, often in combination with a dye. The sentinel node is detected with the use of a gamma camera or direct visualization on dissection (the dye is usually blue) before excision.
KEY POINT
• all patients presenting with a lump in the breast should undergo triple assessment.
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Breast and Endocrine
CASE 38: breaSt lump on SelF-eXamination
history
A 33-year-old woman is referred to the breast clinic after noticing a painless lump in her right breast during self-examination. She reports no associated nipple discharge or skin changes and is currently mid-menstrual cycle. She has a 3-year-old daughter and has no family history of breast disease. She smokes 15 cigarettes per day.
examination
On examination of the right breast, a 3-cm lump is found in the upper outer quadrant. It is rubbery in consistency, mobile and non-tender. There are no skin changes. There is no evidence of lymphadenopathy in either axillae or supraclavicular fossae. The left breast is normal and abdominal examination is unremarkable.
Questions
•What are the possible diagnoses?
•What is the likely diagnosis in this patient?
•How should this be confirmed?
•How should the patient be managed?
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100 Cases in Surgery
ANSWER 38
The most likely diagnosis is a benign fibroadenoma. They are most commonly seen between the ages of 15 and 35 years. The fibromatous element is the dominant feature. They tend to grow slowly and occasionally can grow to >5 cm, where they are termed giant fibroadenomata. Fibroadenomata are often multiple and bilateral and are often referred to as ‘breast mice’ because they are extremely mobile. On examination, they tend to be spherical, smooth and sometimes lobulated with a rubbery consistency. The differential diagnosis includes fibrocystic disease (fluctuation in size with menstrual cycle and often associated with mild tenderness), a breast cyst (smooth, well-defined consistency like fibroadenoma but a hard as opposed to a rubbery consistency) or breast carcinoma (irregular, indistinct surface and shape with hard consistency).
Confirmation of the diagnosis should be with FNAC or excision biopsy. If FNAC is performed, treatment options include wide local excision or observation, depending on patient wishes. Malignant change occurs in 1 in 1000.
KEY POINT
• a diagnosis of benign fibroadenoma should be confirmed by triple assessment.
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