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Surgery -Assessment of Breast Pathology
The fundamental principle of breast evaluation is Triple Assessment: This includes a physical examination, subsequent radiological imaging, and biopsy (either fine needle or core biopsy).
Clinical assessment
Placement and examination
Breasts are optimally assessed in a semi-recumbent position followed by an upright position. Initially, the arms are positioned at the sides in a semi-recumbent posture. Subsequently, they ought to be examined in an upright position, with hands placed on the hips (first in a relaxed state and subsequently applying forceful pressure on the hips to engage the pectoral muscles), and ultimately abducted gradually above the head.
Inspection is essential and should focus on the following aspects.
• comprehensive symmetry and placement. Are the breasts of identical size? Is there a deformity resulting from an underlying disease? Is the position standard? • Dermal appearance. Is the skin erythematous or edematous? Is there a fixed form of lymphoedema in the skin known as 'peau d’orange'? Are there any scars from prior surgery?
• Dermal adhesion. Is the skin mobile when the arms are elevated? Tethering indicates the presence of underlying intraparenchymal scarring or a tumor.
Nipples. Are the nipples retracted, displaced, or ulcerated (indicative of retroareolar tumor or infection)? Is there any excretion?
Palpation
For palpation, the hands should be repositioned to the hips, and the patient may recline in a semi-recumbent position once again. Employ the flat surfaces of all four fingers simultaneously. Initially palpate the 'normal' breast. Be systematic and avoid 'kneading' the breast. A typical sequence is: upper outer quadrant; lower outer quadrant; lower inner quadrant; higher inner quadrant; center (retroareolar) region; supraclavicular fossa; and axillary region. Essential characteristics to consider comprise:
• Tangible mass. Is it hard, uneven, and fixed (cancer) or smooth, spherical, and movable (cysts or fibroadenoma)? Diffuse nodularity. Characteristic of a benign condition. Discharge from the nipple upon probing of the central region. Blood indicates a tumor; pus indicates an infection; serous or milky fluid may be inconsequential.
• Axillary and supraclavicular lymphadenopathy. Is it multifocal and attached (cancer)? Ultrasound Imaging
• Simple to execute and devoid of discomfort— often conducted at a breast outpatient clinic. Avoids radiation exposure in young women.
• Extremely adept in distinguishing between solid tumors and cysts. Mammography is utilized for both population screening and diagnostic evaluation. Very unpleasant for the majority of women and entails a minimal radiation exposure.
• Capable of detecting imperceptible lesions
. • Capable of recognizing premalignant lesions, such as ductal carcinoma in situ (DCIS). Mammographic characteristics indicative of malignancy encompass spiculated microcalcifications, irregularities, and stellate outlines.
Biopsy Aspiration cytology
• Well-tolerated, facile to execute, and rapid to report—typically conducted within half a day at the breast outpatient clinic. • Lacks histological data; offers solely cellular information and depends on cellular atypia for malignancy diagnosis. • Fails to distinguish between invasive and in situ cancer. • Occasionally therapeutic for cysts. High sensitivity and specificity.
Guided core biopsy
• Conducted under ultrasound or mammographic supervision utilizing a Trucut® needle or comparable instrument. Can be performed under general anesthesia or local anesthesia. Delivers precise histological data—facilitates cancer grading. Capable of distinguishing between invasive cancer and carcinoma in situ. Extremely delicate and specific.
Alternative (less frequently utilized)
Computed tomography (CT) scanning is beneficial for evaluating significant local invasion and for regional and systemic staging.
CT positron emission tomography (PET) imaging
Valuable for examining ambiguous lesions and detecting unrecognized metastatic illness.
Magnetic Resonance Imaging (MRI) scanning
Periodically employed for diagnostic purposes, such as in women with breast implants.
Essential topics—breast anatomy
The breast consists of epithelial ductal tissue, epithelial secretory lobules, adipose tissue, and connective tissue. It is segmented into four quadrants and a peri- / retroareolar central zone for the clinical characterization of anomalies. The arterial supply originates from segmental perforators of the internal thoracic artery (ITA). Lymphatic drainage is crucial in the therapy of breast cancer.
• Non-pathological lymphatic drainage predominantly occurs to the axillary nodes.
• The medial half may occasionally drain to the internal mammary nodes. Axillary lymph nodes are categorized into three levels: Level 1 is located inferior to the pectoralis minor, Level 2 is situated posterior to it, and Level 3 is positioned superior to the pectoralis minor.
The fundamental principle of breast evaluation is Triple Assessment: This includes a physical examination, subsequent radiological imaging, and biopsy (either fine needle or core biopsy).
Clinical assessment
Placement and examination
Breasts are optimally assessed in a semi-recumbent position followed by an upright position. Initially, the arms are positioned at the sides in a semi-recumbent posture. Subsequently, they ought to be examined in an upright position, with hands placed on the hips (first in a relaxed state and subsequently applying forceful pressure on the hips to engage the pectoral muscles), and ultimately abducted gradually above the head.
Inspection is essential and should focus on the following aspects.
• comprehensive symmetry and placement. Are the breasts of identical size? Is there a deformity resulting from an underlying disease? Is the position standard? • Dermal appearance. Is the skin erythematous or edematous? Is there a fixed form of lymphoedema in the skin known as 'peau d’orange'? Are there any scars from prior surgery?
• Dermal adhesion. Is the skin mobile when the arms are elevated? Tethering indicates the presence of underlying intraparenchymal scarring or a tumor.
Nipples. Are the nipples retracted, displaced, or ulcerated (indicative of retroareolar tumor or infection)? Is there any excretion?
Palpation
For palpation, the hands should be repositioned to the hips, and the patient may recline in a semi-recumbent position once again. Employ the flat surfaces of all four fingers simultaneously. Initially palpate the 'normal' breast. Be systematic and avoid 'kneading' the breast. A typical sequence is: upper outer quadrant; lower outer quadrant; lower inner quadrant; higher inner quadrant; center (retroareolar) region; supraclavicular fossa; and axillary region. Essential characteristics to consider comprise:
• Tangible mass. Is it hard, uneven, and fixed (cancer) or smooth, spherical, and movable (cysts or fibroadenoma)? Diffuse nodularity. Characteristic of a benign condition. Discharge from the nipple upon probing of the central region. Blood indicates a tumor; pus indicates an infection; serous or milky fluid may be inconsequential.
• Axillary and supraclavicular lymphadenopathy. Is it multifocal and attached (cancer)? Ultrasound Imaging
• Simple to execute and devoid of discomfort— often conducted at a breast outpatient clinic. Avoids radiation exposure in young women.
• Extremely adept in distinguishing between solid tumors and cysts. Mammography is utilized for both population screening and diagnostic evaluation. Very unpleasant for the majority of women and entails a minimal radiation exposure.
• Capable of detecting imperceptible lesions
. • Capable of recognizing premalignant lesions, such as ductal carcinoma in situ (DCIS). Mammographic characteristics indicative of malignancy encompass spiculated microcalcifications, irregularities, and stellate outlines.
Biopsy Aspiration cytology
• Well-tolerated, facile to execute, and rapid to report—typically conducted within half a day at the breast outpatient clinic. • Lacks histological data; offers solely cellular information and depends on cellular atypia for malignancy diagnosis. • Fails to distinguish between invasive and in situ cancer. • Occasionally therapeutic for cysts. High sensitivity and specificity.
Guided core biopsy
• Conducted under ultrasound or mammographic supervision utilizing a Trucut® needle or comparable instrument. Can be performed under general anesthesia or local anesthesia. Delivers precise histological data—facilitates cancer grading. Capable of distinguishing between invasive cancer and carcinoma in situ. Extremely delicate and specific.
Alternative (less frequently utilized)
Computed tomography (CT) scanning is beneficial for evaluating significant local invasion and for regional and systemic staging.
CT positron emission tomography (PET) imaging
Valuable for examining ambiguous lesions and detecting unrecognized metastatic illness.
Magnetic Resonance Imaging (MRI) scanning
Periodically employed for diagnostic purposes, such as in women with breast implants.
Essential topics—breast anatomy
The breast consists of epithelial ductal tissue, epithelial secretory lobules, adipose tissue, and connective tissue. It is segmented into four quadrants and a peri- / retroareolar central zone for the clinical characterization of anomalies. The arterial supply originates from segmental perforators of the internal thoracic artery (ITA). Lymphatic drainage is crucial in the therapy of breast cancer.
• Non-pathological lymphatic drainage predominantly occurs to the axillary nodes.
• The medial half may occasionally drain to the internal mammary nodes. Axillary lymph nodes are categorized into three levels: Level 1 is located inferior to the pectoralis minor, Level 2 is situated posterior to it, and Level 3 is positioned superior to the pectoralis minor.
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