risk).You will see these repeatedly in the breast clinic so make sure you develop a system for how to approach this finding. Other presentations (e.g. nipple discharge, breast pain) will also frequently appear in the breast clinic so establish a system for these symptoms.
Uses ionizing radiation to create images of breast tissue looking for characteristic masses and microcalcifications. It is also used as the primary breast cancer screening tool in the UK.
Is often used for younger women as their breasts are more dense, which makes mammography less effective. US and mammography will sometimes take place in the same patient.
Uses a small hollow needle to remove breast tissue that can be analysed to obtain a histological diagnosis.
Include mastectomy, wide local excision, breast reconstruction, axillary clearance, and sentinel lymph node biopsy.
Learn to assess the patients and plan appropriate investigations. (See Table 32.1)
Table 32.1 Regional anatomy of the breast
| Arteries | Internal mammary (most), lateral thoracic, thoracoacromial, posterior intercostal |
| Veins | Axillary, subclavian, intercostal, internal thoracic |
| Lymphatics | Axillary, parasternal, inferior phrenic nodes |
| Nerves | 4th–6th intercostal nerves |
| Breast boundary | Clavicle superiorly, latissimus dorsi laterally, sternum medially, and inframammary fold inferiorly |
| Axillary boundary | Axillary apex superiorly, axillary fascia basally, pectoral muscles anteriorly, latissimus dorsi/teres major/subscapularis posteriorly, serratus anterior + first four ribs medially, humeral bicipital groove + biceps laterally |
| Axillary contents | Axillary artery/vein/lymph nodes, intercostobrachial + long thoracic nerves, infraclavicular part of brachial plexus’ to ‘thoracodorsal nerve |
Most patients with breast symptoms are referred to the breast clinic. Beware: patients with query breast cancer are referred to the one-stop breast clinic under the 2-week rule pathway.
Key features of the history include duration and timing of symptoms. You will certainly be expected to know about the risk factors for developing breast cancer: History ALONE:
• History of breast cancer/family history (BRCA genes)/HRT ± oral contraceptive pill.
Ask about family history in a first-degree relative (including the age at which they were diagnosed). These risk factors all heighten exposure to oestrogens (
breast cell proliferation risk of cancer).
Most patients in the breast clinical will undergo the ‘triple assessment’ of clinical examination, radiological imaging, and histological investigation. It is rare that a GP or even a breast specialist will consider a defined breast lump as warranting anything less than a full triple assessment.
Every breast examination should be performed with a chaperone present regardless of the examiner’s sex and patient’s age. Patients are typically anxious so be extra cautious to remain respectful throughout the examination. The patient should be positioned ideally at 45° with their arm above their head. The reason for this position is that it reduces the distance between the examiner’s hand and the chest wall therefore making it easier to detect any abnormal areas. The breast tissue is examined with the most sensitive part of the hand, the fingertips. Following examination of breasts, it is essential to examine both axillae.
Examination findings should be documented on a scale of 1–5 with the prefix ‘E’:
It is highly likely that you will encounter patients in clinic who are found to have a new diagnosis of breast cancer. The most common presentation is a solitary lump. Note its size, consistency, and fixation. Typically the cancer is a firm mass, which demonstrates tethering to the skin. It may also present with features of local advancement demonstrating skin ulceration, erythema, puckering, dimpling, or peau d’orange. Nipple changes include retraction, discharge, and dry scales. It is essential that if you find such a mass, an examination of the axilla is performed to identify any axillary nodes. The alternative method of presentation is detection of cancer in the screening programme.
Following examination, the patient will proceed to have a mammogram ± target US to the area of concern or a target US only if <35 years of age. This is because mammograms are not typically performed due to the density of the breast tissue in the <35 age group, rendering the mammogram of limited value. The mammogram consists of two views: mediolateral oblique (MLO) view and the craniocaudal (CC) view. The mammogram and US are classified 1–5 with the prefix M and U for mammogram and US respectively (i.e. M5 signifies a malignant tumour on mammogram). In certain cases the breast tissue is further evaluated with MRI. This is useful for assessing indeterminate breast masses, breast lumps post previous surgery to distinguish between scar tissue and breast tumours, and for screening women at high risk (i.e. those with a strong family history).
Lesions of concern are biopsied using the core biopsy technique. This involves cores of tissue being removed from the area of concern through a 14 G needle connected to a mechanical gun. Similarly to the other components of the triple assessment, the biopsy is classified from 1 to 5 with the prefix B. The alternative to core biopsy is FNA of the lesion. This is performed less frequently but is able to differentiate between a solid or cystic lesion. This involves a 21 G needle attached to a syringe being introduced into the lesion with suction applied. The aspirate from the lesion is then sent for cytology. The cytology of the lesions is again classified from 1 to 5 but on this occasion with the prefix C.
Breast cancer is the second most common cancer in females accounting for 31% of all new cases of cancer in females and affects 1:9 women. Breast cancer is derived from the epithelial cells lining the ducts and from the acini forming lobules. Therefore the most common form is invasive ductal followed by invasive lobular carcinomas. If the cancer does not breach the basement membrane, this is an in situ carcinoma such as DCIS (ductal carcinoma in situ).
These account for 5–10% of breast carcinomas with 60% of these associated with breast cancer genes: BRCA1 and BRCA2. These are tumour suppressor genes located on chromosome 17q and 13q respectively. If either of these genes is mutated, this results in an risk of developing breast cancer.
You will encounter the description of the grade of the tumour in the pathology report from the biopsy and will hear about this in the MDT meeting. The grade of the tumour relates to the degree of differentiation of the tumour cells. This is dependent on the degree of tubule formation, nuclear pleomorphism, and the mitotic count. In simplistic terms, the lower the tubule formation, the greater the nuclear pleomorphism and the higher the mitotic count can all contribute towards a higher grade. The pathologist then derives these features from the specimen and classifies the tumour according to a grade:
Grade 2: moderately differentiated.
Grade 3: poorly differentiated.
Receptor status is in reference to the receptors on the surface of breast cancer cells. This refers to the oestrogen (ER) and progesterone receptor (PR) status, and the c-erbB2 receptor status (HER2). This description will subsequently guide further treatment for the cancer.
The stage is according to the TNM classification. This consists of the size of the tumour (T), whether the tumour has spread to the lymph nodes (N), and whether the tumour has metastasized (M). This is then incorporated into the Union for International Against Cancer Control (UICC) classification to stage the tumour.
Options include both surgical and medical treatment with the main decision regarding treatment decided in the MDT meeting.
Is not essential for all patients and the MDT team will determine its use, for each individual patient. Typically patients with high-grade disease, axillary or distant metastatic disease will be a candidate for cytotoxic agents. Combination therapy is required for these patients as cancer cells within metastasis may be at different stages of their cell cycles. The common combination therapy is referred to as FEC. This consists of (1) 5-fluorouracil (antimetabolite), (2) epirubicin (anthracycline), and (3) cyclophosphamide (alkylating agent). These agents can also be used as neoadjuvant to reduce the tumour size or in metastatic disease. Alternative agents such as paclitaxel (taxane) can also be used in metastatic disease particularly in disease that is resistant to anthracyclines or in relapse of disease post anthracycline treatment.
Should be administered to all patients who have undergone breast-conserving surgery and is also an option for axillary disease.
Is a hormonal agent that acts by binding to ERs to block the effect of endogenous oestrogen on disease progression. Tamoxifen displays benefits in both pre- and postmenopausal women with maximum benefit from a daily dose given for 5 years.
Prevent the aromatization of androgens to oestrogen in peripheral tissue such as the adrenal cortex and adipose tissue. Hence, it is only of value in postmenopausal women as the majority of oestrogen is derived from the ovaries in premenopausal women. The most common aromatase inhibitors you will encounter are anastrozole or letrozole.
Is commonly known as Herceptin®, a monoclonal antibody and is used in HER2-positive cancers. It can be used in metastatic disease in combination with taxanes.
Patients who have had breast-conserving surgery are at risk of developing recurrence. Patients who have had a mastectomy are also at risk of developing breast cancer on the contralateral side. Follow-up typically includes an annual mammogram with routine breast examination. Other investigations are only performed if a patient complains of symptoms that could be suggestive of metastatic disease.
In the breast clinic, the main purpose is to identify any new cases of breast cancer. However, in the majority of patients this is frequently excluded following triple assessment. The following are some differentials you ought to know about.
Typically develop from whole breast lobules and present as a painless solitary mass. They are frequently encountered in women aged <25 years. Treatment options include leaving them alone or excision depending on patient choice/symptoms. Their sizes may correlate with menstrual cycles and grow/shrink during the month.
Are distended and involuted lobules that are most common in perimenopausal women. Patients frequently complain of breast pain and tenderness over the site of the cyst. These cysts can be aspirated with or without US guidance and re-examined to ensure resolution.
The subareolar ducts can dilate and result in persistent nipple discharge. Duct ectasia can be treated conservatively. If the nipple discharge is particularly troublesome then ducts can be excised.
Can typically be cyclical or non-cyclical (i.e. dependent on the menstrual cycle). If the patient’s assessment has not identified any underlying pathology, the patient can be reassured regarding the findings. Evening primrose oil may improve symptoms.
Frequently a patient with a breast abscess may present in the ED. Depending on the level of sepsis (fever, inflammatory markers (CRP and WCC)) the patient may require admission for IV antibiotics or for potential drainage as an emergency. Alternatively, they may be referred to the next clinic appointment within the next few days. Breast abscesses may be lactational or non-lactational. A lactational breast abscess is predominantly caused by Staphylococcus aureus whereas a non-lactational breast abscess is associated with smoking. The optimal management is recommendation of the cessation of smoking, antibiotic therapy, and US evaluation. Following this, the breast abscess should be drained repeatedly via US guidance until resolution. If possible, incision and drainage of a breast abscess should be avoided unless necessary due to scarring of the breast and the risk of developing a mammary duct fistula.
The aetiology of these rare tumours is frequently unknown. They are predominantly benign breast tumours but can be malignant on occasion. Their typical age of onset is after the age of 40. They may present with rapid growth resulting in venous engorgement and potentially ulceration of the breast. The aim of management is to remove them with a clear macroscopic margin.
This can occur following trauma to the breast. Fat necrosis of the breast can produce a mass, which can appear similar on examination to a breast cancer. It is therefore important to proceed with imaging and not be dismissive of any bruising. The vast majority of cases are treated conservatively and it is predominantly a self-resolving condition.
Involves the removal of all the breast tissue with an ellipse of skin and the nipple. This is typically indicated for patients who would prefer a mastectomy, tumours ≥4 cm, central tumours, and for those with multi-focal disease. Preoperative counselling is required since this can psychologically affect patients. Those with genetic risks may also want to pursue prophylactic bilateral mastectomies which require multiple consultations.
Includes the removal of clinically palpable tumours with an appropriate (ideally ≥10 mm) margin of normal breast tissue. The mainstay of this treatment is that the removal of the cancer will leave an appropriate cosmetic appearance of the breast after the surgery.
For clinically impalpable tumours it is necessary for the radiologist to place a wire into the tumour either by US or mammography guidance. A subsequent incision is then made close to the wire and breast tissue encompassing the tumour is removed.
You will see this procedure combined with breast surgery (i.e. mastectomy or breast-conserving surgery) or in isolation. This is a diagnostic procedure and not a therapeutic one. The basis of this is to identify the draining lymph node of the breast cancer. Prior to the procedure, a radioactive substance tagged with technetium-99m is injected in proximity to the tumour. Following this before the start of the operative procedure, patent blue dye is injected close to the previous injection site. The purpose of the sentinel lymph node biopsy is to find the draining lymph node either via visual inspection (the draining node will be blue) or through a gamma probe. Upon removal of the node, this sentinel node will be sent to the pathology laboratory to establish whether it is positive for axillary nodal disease. If further treatment will be required then the patient will be booked for an axillary clearance.
Again, this is a procedure you will encounter during the breast surgery attachment. This involves the removal of all of the axillary nodes and is also termed a level III axillary clearance. The axillary nodes are described in relation to the pectoralis minor muscle in the axilla (see Fig. 32.1).
• Level I: inferolateral to pectoralis minor.
• Level II: posterior to pectoralis minor.
• Level III: superomedial to pectoralis minor.
It is imperative that you learn the local anatomy of the axilla because you need to be aware of possible complications (e.g. injury to intercostobrachial nerve (T1–T2) posteromedial paraesthesia of proximal arm/axilla/shoulder).
Fig. 32.1 Axillary lymph nodes and regional anatomy. Reproduced from Seiden, David L. and Corbett, Siobhan, Lachman's Case Studies in Anatomy, 2013, Oxford University Press.
Breast reconstruction following mastectomy can be performed at the time of the oncological clearance (immediate) or months to years later after completion of any adjuvant therapy (delayed). Reconstruction aims to reduce both the aesthetic as well as the psychological morbidity associated with breast cancer. Reconstruction of the breast can be implant based (e.g. using a silicone prosthesis, similar to that used for aesthetic augmentations), which is placed under the muscle to rebuild a breast shape. This is currently one of the most common forms of breast reconstruction. However, on the increase is a sought-after form of breast reconstruction using the patient’s own tissue to form a new breast, which may have a more natural feel or consistency; this is known as autologous reconstruction. This can be achieved by using either a (1) free flap (i.e. using microsurgery to connect the blood vessels, also known as microvascular free tissue transfer) such as a deep inferior epigastric artery perforator (DIEP) or transverse rectus abdominus myocutaneous (TRAM) flap taken from the abdomen and consisting of skin and fat, or (2) pedicled flap (i.e. microsurgical anastomosis of vessels is not required, rather the flap and its main blood supply are moved into the defect) such as the latissimus dorsi (LD) flap (muscle and overlying skin) taken from the side of the back.
Breast surgery does not present too frequently in formal examinations. However, it can appear in the following contexts:
• Taking a history: in this format it is important to be succinct, by establishing the presenting complaint and the associated features. It is then imperative to ask about the risk factors, which demonstrates knowledge of them.
• Explaining to a patient they require triple assessment and what this entails: for it is important to be able to explain the imaging procedures in simple terms and what is involved. For this scenario, it would be sensible for you to practise with a non-medic to ensure the information being explained is well understood.
Breast examination tends to be restricted to OSCEs. It is typical for you to encounter a synthetic breast model, which may or may not be attached to an actor. Although actual female actors may also be present! In either scenario, it is important to treat this as a real patient.
• Introduce yourself, wash hands, and always request a chaperone.
• Ensure that the patient’s dignity is always covered with a sheet.
• Inspection: inspect the breasts at eye level, so kneel down, and put your hands behind your back to avoid any embarrassing gestures!
• Ask the patient to sit up and inspect for scars, skin changes, nipple dimpling, nipple discharge, asymmetry, masses in four positions: (1) arms by their side, (2) leaning forward, (3) hands behind their head, and (4) hands on their waist (tensing pectoralis).
• Palpation: position the patient at 45° with the ipsilateral hand behind their head; expose one breast at a time, examine the normal breast first using the flats of your fingers in a clockwise direction in four quadrants and describing findings using a clock face (Fig. 32.2)
Fig. 32.2 Breast quadrants and frequency of cancers.
Amended with permission from Thomas, James, Monaghan, Tanya, Oxford Handbook of Clinical Examination and Practical Skills (2 ed.), 2014: Oxford University Press.
• If a mass is found, then describe it thoroughly.
• Nipple: allow patient to express discharge (blood (?cancer) vs pus).
• Axillary tail (of Spence): palpate where most cancers occur.
• Lymphadenopathy: support patient’s arm on your shoulder. Palpate all axillary lymph node groups as well as the supraclavicular fossa.
• Exclusion of metastases: palpate liver for masses ± hepatomegaly. Ask patient to lean forward and feel for spinal tenderness.
• Thank the patient, cover her up with a sheet, hands behind your back, and report your findings.
• See Fig. 32.3 for anatomy of breast.
Fig. 32.3 Anatomy of breast. Reproduced from Harvey, James et al, Breast Disease Management: A Multidisciplinary Manual, 2013, Oxford University Press.