الأربعاء، 4 يناير 2012

Breast surgery







1  A discrete breast lump does not need reviewing, it needs
referring.
2  Breast lumps in young women probably are not cancer, but
may be.
3  Do not ignore breast lumps in pregnant women: their
relatively poor prognosis is due to delay in diagnosis.
4  Skin dimpling or retraction is usually caused by breast
cancer.
5   All spontaneous nipple discharge (bloody or not) should be
evaluated.
6   An inflamed breast may be an inflammatory carcinoma, not
infection.
7   A complaint of a change in breast size or shape may signify
malignancy.
8  Unilateral nipple inversion of recent onset may be caused
by an underlying carcinoma.
9   An axillary mass could be breast cancer even with a normal
breast examination.
10  Men also get breast cancer.

________________________________________________________________________
 
N O T E S

1 Breast lump
Approximately one in ten patients with a discrete breast lump
has cancer. Benign lumps are common but so are cancers,
particularly in postmenopausal women. All lumps undergo
triple assessment in the breast clinic: clinical examination, im-
aging and cytology or pathology. Clinical examination alone is
not enough, as some cancers may be missed.
Action: Refer urgently to the breast unit.


2 Breast lumps in young women
Every breast unit in the country diagnoses patients with breast
cancer in their twenties and thirties. A delay in referral can
directly lead to a poor prognosis. Any young patient with signs
or symptoms of breast cancer should not be reassured or
reviewed, but referred.
Action: Refer urgently to the breast unit.


3 Breast lumps in pregnancy
There is significant evidence that, stage for stage, age for age,
breast cancer diagnosed during pregnancy has the same prog-
nosis as that diagnosed in non-pregnant women. The anecdotal
poor outcome is due to the well-documented delay in diagno-
sis that occurs, both because of reluctance by the physician to
refer and reluctance, once referred, to perform the appropriate
diagnostic investigations. Breast lumps are not a normal side-
effect of pregnancy.
Action: Refer urgently to the breast unit.


4 Skin dimpling and retraction
Skin dimpling and retraction rarely occur in the setting of
benign breast disease. A malignancy or the surrounding reaction can cause retraction of Cooper’s ligaments, which attach to the skin. In addition, cancer can involve skin directly. Often the
patient has not noticed the underlying lump, and complains of
the skin changes only.
Action: Refer urgently to the breast unit.

5 Nipple discharge
The diagnosis of pathologic nipple discharge is a clinical one.
Bloody discharge is never normal. Ductal carcinoma must be
suspected. In addition, spontaneous, unilateral discharge,
which is serous or watery, can also be caused by intraductal
pathology and warrants further investigation. While only 10%
of pathologic nipple discharge cases are malignant, all spon-
taneous discharge should be evaluated.
Action: Refer urgently to the breast unit.

6 Inflamed breast
Breasts can go red and hard with infection (acute mastitis) and
also with a rapidly progressing inflammatory breast cancer.
The diagnosis can be made with time and response to antibiotics but much more quickly by urgent referral for triple assessment.
Action:       Give appropriate antibiotics and refer urgently to the
breast unit.

7 New breast asymmetry
Sometimes a woman or physician will notice a swelling or
shrinking of one breast or flattening of the breast with arm
movement and no evidence of a mass. Lobular cancers can be
very infiltrative and yet might not produce a mass. Cancer or
its fibrous reaction can cause retraction of Cooper’s ligaments
causing a shape change in the breast. Every breast exam
should include visual inspection with the arms in various
positions.
 
Action: Refer urgently to the breast clinic.

 
8 Nipple inversion
Many women have long-standing bilateral nipple inversion of
many years’ history and this is not suspicious. What should
arouse suspicion is a unilateral inversion of recent onset, which
may signal an underlying cancer.
Action: Refer urgently to the breast clinic.

9 Axillary mass
Breast cancer can present as an axillary mass from metastasis
to the lymph nodes. Palpable axillary lymph nodes should
generally be regarded as suspicious, particularly if large or
hard. Often investigation reveals a breast mass or mammo-
graphic lesion. Occasionally, however, no abnormality can be
found and an ‘unknown primary’ should be considered. Cat
scratches or infected wounds of the arm or hand may also
result in swollen lymph nodes. Infection will often cause ten-
der lymph nodes or an erythematous lymphatic channel, and
the primary site can often be identified. Other malignancies
such as lymphoma can also present as an axillary mass.
Action: Examine lymph nodes elsewhere. Refer urgently to the
breast unit.

10 Male breast cancer
Men rarely get breast cancer but when they do, it usually
manifests itself as a painless lump under, or adjacent to, the
nipple. The lump needs triple assessment to make the diagnosis.
Action: Refer urgently to the breast unit.




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