General Surgery
Breast
MBBS surgery notes on breast disease: triple assessment, benign lumps and breast cancer staging and treatment, mapped to NMC codes SU25.1 to SU25.5.
MedNext Academy | 3 min read
Breast
MBBS surgery notes on breast disease: triple assessment, benign lumps and breast cancer staging and treatment, mapped to NMC codes SU25.1 to SU25.5.
This chapter covers benign and malignant breast disease. It centres on the triple assessment of a breast lump, the features that raise suspicion of cancer, and the modern principles of breast conserving surgery and axillary staging.
High-yield: Breast
- The triple assessment of a breast lump combines clinical examination, imaging and needle biopsy or cytology.
- Mammography is the imaging of choice in women over about 35 years, while ultrasound is preferred in younger dense breasts.
- A fibroadenoma is the commonest benign breast lump in young women and is smooth, firm and highly mobile, earning the name breast mouse.
- A breast cyst is a smooth, fluctuant, sometimes tender swelling common around the perimenopause.
- A fibroadenosis or fibrocystic change causes lumpy, tender breasts that vary with the menstrual cycle.
- A duct papilloma is the commonest cause of blood-stained nipple discharge from a single duct.
- Breast cancer is the commonest cancer in women, and most are invasive ductal carcinomas.
- Suspicious features of a breast lump include a hard irregular fixed mass, skin dimpling, nipple retraction and peau d orange.
- Peau d orange is caused by dermal lymphatic obstruction and indicates locally advanced disease.
- Breast cancer spreads to the axillary lymph nodes, and axillary staging guides treatment and prognosis.
- Oestrogen and progesterone receptor and HER2 status determine the use of hormonal therapy and targeted agents.
- Sentinel lymph node biopsy stages a clinically negative axilla and avoids the morbidity of full clearance.
- Breast conserving surgery with radiotherapy gives survival equal to mastectomy for suitable early tumours.
- Paget disease of the nipple is an eczema-like change that signals an underlying breast malignancy.
- The commonest cause of breast lymphoedema and a stiff arm after treatment is axillary clearance and radiotherapy.
Triple assessment of a breast lump
- **Clinical:** History and examination of the lump, skin, nipple and axilla.
- **Imaging:** Mammography over about 35 years; ultrasound in younger dense breasts.
- **Pathology:** Core needle biopsy, or fine needle aspiration cytology, for tissue diagnosis.
- **Suspicious signs:** Hard fixed irregular mass, skin dimpling, nipple retraction and peau d orange.
NMC competencies in this chapter
- **SU25.1:** Assessment of the breast and triple assessment
- **SU25.2:** Benign breast disease
- **SU25.3:** Breast cancer: presentation and diagnosis
- **SU25.4:** Staging and management of breast cancer
- **SU25.5:** Adjuvant therapy and follow-up in breast cancer
Frequently Asked Questions
What is the triple assessment?
The combined evaluation of a breast lump by clinical examination, imaging with mammography or ultrasound, and tissue diagnosis by core biopsy or cytology, which together give a reliable diagnosis.
What is the commonest benign breast lump in young women?
A fibroadenoma. It is smooth, firm and very mobile, earning the nickname breast mouse, and is confirmed on triple assessment.
What features suggest breast cancer?
A hard, irregular, fixed lump with skin dimpling, nipple retraction, bloody single-duct discharge or peau d orange, the last indicating locally advanced disease.
Is breast conserving surgery as safe as mastectomy?
For suitable early tumours, breast conserving surgery combined with radiotherapy gives survival equal to mastectomy, with a better cosmetic outcome.
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