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Ix of a Breast Lump: Triple Assessment (Radiology (Over 35 (US +…

- - - - Breast pain
      - Skin or nipple changes
      - Mets
        
        Bones: bone pain, #s
        
        Liver: abdo pain
        
        Brain: headache, seizures
        
        Lungs: dyspnoea
      - Lump
- - - - Send cytology if bloody fluid
      - Core biopsy residual mass
      - Core biopsy if +ve cytology
      - Reassure if clear fluid
- - - - Remaining breast
      - Axilla
      - Supraclavicular fossa
  - - - Palpate / percuss spine for tenderness, masses
      - Examine abdomen for hepatomegaly
      - Percuss and auscultate lungs for signs of mets
  - - - Note asymmetry
      - Describe scar
      - Look at surrounding skin and axilla
      - Evidence of radiotherapy
      - Ask pt. to press her hips: pec major present
      - Arm lymphoedema
- - - - Pt. preference
      - Multifocal disease
      - Large lump in small breast: e.g. >4cm
      - Large area DCIS: e.g. >4cm
      - Nipple involvement
- - - - Explanation including use of suction drain to close cavity and ↓ risk of haematoma or seroma formation
      - There will be an anaesthetised patch of skin in the upper medial part of the arm, Division of intercostobrachial nerve (T1)
      - Mark side prior to anaesthetic
- - - - Hands relaxed by sides
      - Leaning forwards
      - Hands behind head
      - Hands pressing hips
    - - ASym, masses
    - - Scars periareolar, submammary
      - Radiotherapy tattoos
      - Eczema, erythema, ulceration
      - Peau d’orange, dimpling
      - Accessory nipples: look along the milk line
    - - inversion
      - discharge
      - discolouration
      - destruction
  - - - Arm: lymphoedema
      - Abdomen / Suprapubic: DIEP or TRAM flap harvest
      - Back lat-dorsi flap harves
      - Axillae: LN dissection
- - - - Apical
      - Anterior
      - Posterior
      - Medial
      - Lateral
- - - - Delayed
      - ↑ pt. decision time
      - Avoidance of detrimental effects of adjuvant therapy
      - Immediate: single operation
- - - - Pedicled: inf. epigastric A.
        
        Or free: attached to internal thoracic A
        
        No implant necessary and combined tummy tuck
        
        CI if poor circulation: smokers, obese, PVD, DM
        
        Risk of abdominal hernia
    - - Evolution of the TRAM flap
        
        Free: skin and fat only, no muscle
        
        Spares the rectus: ↓ pain and ↓ risk of hernia
        
        May not be possible if small perforators
    - - Pedicled: skin, fat, muscle and blood supply
        
        LD mobilised and tunnelled medially to form neo-breast
        
        Supplied by thoracodorsal A. via subscapular A.
        
        Often augmented with an implant
- - - - Implant leakage
      - Infection requiring removal
      - Capsular contracture
- - - - Recess on back where lat dorsi has been removed
      - Ask pt. to lift head of bead (when lying supine) to see
        recess in the rectus muscle
      - Scars extend over back or abdominal wall
    - - Breast usually lies higher
      - Becker implant may have palpable SC filling port in the axilla
      - Rounder shape than normal breast
    - - Arm lymphoedema
        
        Evidence of radiotherapy
        
        Evidence of axillary clearance / radiotherapy
        
        Note asymmetry
- - - - Thyroid examination
      - Evidence of CLD
      - External genitalia
      - Visual fields
- - - - Testicular atrophy
        
        Post-orchitis
        
        Bilat torsion
        
        Klinefelter’s: XXY
        
        Renal failure
        
        Hyperprolactinaemia
    - - ↑ production
        
        Sex-cord stromal tumours
        
        Lung Ca
      - ↑ peripheral aromatisation
        
        Chronic liver disease
        
        Thyrotoxicosis
  - - - Diazepam
      - Anabolic steroids
      - Marijuana
    - - Spiro
      - Digoxin
      - Captopril
      - Verapamil
      - Ranitidine
- - - - Ductal carcinoma NOS: ~70% of cancers
      - Lobular carcinoma: ~20% of cancers
      - Other: mucinous, medullary, papillary
      - Phylloides tumours
  - - - Irregular, nodular surface
      - Poorly defined edge
      - Hard / scirrhous consistency
      - Painless
      - Fixation to skin or chest wall
      - Nipple involvement
- - - - ANDI: fibroadenosis, cysts
      - Papillomas
      - Cystic disease
  - - - Mastitis
      - Abscess
      - Fat necrosis
      - Duct ectasia and periductal mastitis