Breast Lump: Clinical Approach😍

Breast Disorders: Clinical Approach

Work Up of Breast Disorders

• NOTE
• PET scan would never be an answer → WHEN DIAGNOSIS IS TO BE MADE.
• ONLY USED IN STAGING

Clinical Signs

Triple Assessment → 99.9%

1. History & Clinical Examination
• Use the dial clock method to document lesion location.

2. Radiological Imaging
• <40 years: Ultrasound (USG)
• D/t ↑ density
• >40 years: Mammogram

3. Histopathological Examination
• FNAC
• Core needle biopsy is the standard.
• Lymph node biopsy is contraindicated in case of a palpable lymph node.

ANS

1. Bilateral Mammography

2. PET Scan

3. Biopsy of the breast mass

4. USG guided biopsy of the lymph node

Imaging & Screening

BIRADS Score (Breast Imaging Reporting and Data System)

• Modalities → USG, MRI, Mammogram

Score	Inference	Management	Mnemonic
0	Incomplete/ Inconclusive	Additional imaging needed	Zero has no value unless something is added.
1	Negative	No Bx; Follow up in 1 year	1 laid horizontally = minus sign.
2	Benign lump like fibroadenoma	No Bx; Follow up in 1 year	"B" is 2nd alphabet → B = Benign.
3	Probably Benign	Follow up in 6 months (Risk of cancer <2%)	ㅤ
4	Suspicious	Core Needle Biopsy	ㅤ
ㅤ	4a: Low suspicion	ㅤ	ㅤ
ㅤ	4b: Moderate suspicion	ㅤ	ㅤ
ㅤ	4c: High suspicion	ㅤ	"Four" rhymes with "core" → Core needle biopsy.
5	Highly suggestive of malignancy	Core Needle Biopsy	"High five" emoji.
6	Biopsy proven malignancy	Surgical excision when appropriate	6 flipped = "P" → P = Proven.

Screening Guidelines (ASBRS)

• Average Risk:
• 25–39 years
• Clinical breast examination every 1–3 years
• ≥ 40 years of age
• Annual mammography

• Higher than Average Risk:
• ≥ 21 years
• Consult healthcare professional every 6–12 months
• Imaging
• Annual MRI or mammogram at
• 25 years → 3D mammography at 30 years
• BRCA mutation.
• Prior chest wall radiation
• OR
• 10 years before age of youngest affected family member
• Whichever is earlier
• Annual 3D mammography/MRI at 35 years
• Strong family history.
• Predicted lifetime risk >20%
• By Gail, BRCA pro model

• Stop screening when:
• Life expectancy becomes <10 years.

High-Risk Patients for Breast Cancer

• Known gene mutation
• BRCA1, BRCA2, TP53, PTEN, In woman or first-degree relative

• Family history
• Two first-degree relatives with breast cancer
• With or without known gene mutation

• Chest irradiation
• Exposure between 10–30 years of age

• Past breast cancer
• Biopsy-proven breast cancer

• Risk models
• ≥ 20% lifetime risk of breast cancer

Mammograph

• Popcorn calcification: Fibroadenoma

• Spiculated mass: Malignancy.

• Breast X-ray.

• Radiation exposure: 0.1-0.2 cGy.

• Machine identified by compression plates.
• Compression is a must.
• Makes breast density and thickness uniform.
• Improves penetration.
• Prevents overlapping of tissue.
• Allows for better screening.

• Contraindicated in acute painful conditions.
• Mastitis.
• Breast abscess.

Views:

• Craniocaudal:
• Left and Right breast seen.



 

• Mediolateral oblique:
• Axillary lymph nodes also seen.
• Maximum breast tissue is seen.

Microcalcification:

• Highly suspicious of cancer.

• Needs biopsy.

• Corresponds to BIRADS 5.

• In decreasing order of risk of malignancy-
• Cluster microcalcification (maximum risk)
• Linear microcalcification
• Segmental microcalcification
• Diffuse microcalcification (minimum risk)

• Note
• Microcalcification → Suggests Malignancy
• Popcorn calcification → Fibroadenoma

Ivory vertebrae.

• Seen in
• Pagets disaese
• Hodgkins Lymphoma
• Blastic mets
• Breast Ca
• Prostate Ca
• HOD Page il Ivory kuthi vach

Q. Benign or malignant?:

• Malignancy:
• Irregular/spiculated margins.
• Taller > Wider.

MRI

• Kinetic Curves can be performed.

Type 2

• Mnemonic: 2 → Plateau

Type 3 curve:

• Rapid Wash in and Rapid Washout.

• Suggestive of Malignancy.

Simple breast cyst

• Fluid-containing lesion.

• Exhibits Posterior Acoustic Enhancement.

Indications:

• Screening for young > 25 years & high-risk patients.

• Imaging of choice (IOC) for breast implants.

• Detection of recurrence vs. scar tissue.

• Most sensitive for Ductal Carcinoma In Situ (DCIS).

Breast Implant Rupture Findings:

Intracapsular: 

Extracapsular: 

• Snowstorm (USG).

Biopsy Techniques

• Punch Biopsy:
• Used for skin lesions/cancers.
• Paget's disease of the breast.

• Incisional Biopsy (Tru-cut/Core needle):
• IOC for most breast lesions.
• A 14 G biopsy gun is typically used.

Foramen of Langer