BENIGN BREAST DISEASE Clinical Case presentation

Overview

This teaching case presentation covers the evaluation of a breast lump and the clear presentation of a surgical case. A third-year medical student presents a 21-year-old woman with a painless, mobile lump in the upper outer quadrant of her left breast. A senior surgical mentor guides her through the history, breast anatomy, examination technique, differential diagnosis, investigations, and management.

Case Summary

• The patient noticed the lump while bathing about three months before presentation. It remained roughly the same size for two months, then grew during the month before assessment.
• The lump was not painful, including during menstruation. She reported no nipple discharge, fever, recalled trauma, loss of appetite or weight, or symptoms suggestive of distant disease.
• Her history included regular menstruation, no prior similar breast problem or breast procedure, and no known breast cancer in first-degree relatives.
• Examination found a firm, mobile mass of approximately 3 × 4 cm in the upper outer quadrant of the left breast. There was no skin fixation, nipple discharge, or palpable axillary or supraclavicular lymphadenopathy. The other breast and general systemic examination were unremarkable.
• The leading clinical impression was a benign breast lump, most likely a fibroadenoma. The discussion emphasizes that history alone cannot establish the diagnosis; the clinical examination and appropriate investigations must also be considered.

Main Teaching Points

1. Present the History Selectively and Logically

The mentor advises students to give a concise case summary rather than reciting every detail. A useful sequence is:

• Identify the patient and state the main complaint, its location, and duration.
• Describe when the lump appeared, whether it has changed in size, and whether it is painful or related to menstruation.
• Ask about trauma, fever, nipple discharge, and previous breast symptoms or procedures.
• Ask about systemic symptoms that could suggest spread, such as bone pain, breathlessness, chest pain, jaundice, or neurological symptoms.
• Review relevant medication and exposure history, including hormonal medication and previous radiotherapy.
• Include menstrual, pregnancy, and lactation history, along with a specific family history of relevant cancers. The mentor cautions against writing only “nothing significant”; pertinent negatives should be stated.
• End the history with a brief provisional impression—not a definitive diagnosis before examination.

The mentor notes that the upper outer quadrant contains a relatively large amount of breast tissue, making it a common site for breast lumps. The axillary tail of the breast, or tail of Spence, is also relevant to examination.

2. Know the Anatomy and Clinical Correlations

The session reviews the breast as a modified sweat gland with glandular parenchyma and supporting stroma. The mentor discusses lobes, lobules, ducts, Cooper’s ligaments, the nipple and areola, and Montgomery glands. The breast is divided into four quadrants, with the nipple–areolar region also treated as a central area.

Other anatomy points include:

• Blood supply, including branches of the lateral thoracic and internal thoracic arteries and intercostal vessels.
• Axillary lymph-node levels in relation to the pectoralis minor muscle, described using the Berg classification.
• The axillary tail and its relevance to breast examination.
• Congenital or accessory breast tissue along the milk line, and conditions such as polymastia, amastia, and Poland syndrome.

3. Conduct a Systematic Breast Examination

The mentor stresses consent, adequate exposure and lighting, and explaining the examination to the patient. A chaperone should generally be noted where appropriate.

Inspection positions discussed:

• Sitting with arms relaxed.
• Sitting with arms raised above the head.
• Leaning forward to assess whether the breast moves freely or appears fixed to the chest wall.

Inspection should include symmetry, breast position and contour, skin colour and texture, visible veins, dimpling or puckering, ulcers, swelling, the nipples and areolae, and the inframammary folds. Raising the arms can make a subtle lump more visible and helps show the folds beneath the breasts.

Palpation positions discussed:

• A semi-recumbent position, described as useful for routine palpation.
• Supine positioning, particularly for large or pendulous breasts or in patients with obesity.

For a lump, document its quadrant and clock-face position, dimensions, and distance from anatomical landmarks. Describe its shape, surface, borders, consistency, tenderness, mobility, and relationship to the skin, breast tissue, pectoralis major, and chest wall. The mentor recommends saying hemispherical rather than spherical when the full circumference of a lump cannot be assessed.

The discussion distinguishes several assessments:

• Skin fixation: Try to lift and move a skin fold over the lump.
• Possible fixation to breast tissue: Move the lump while holding the surrounding gland tissue.
• Pectoralis major fixation: Assess with the muscle tensed, such as when the patient presses her hands against her hips.
• Chest-wall fixation: Observe whether the breast and lump move forward when the patient leans forward.

The examination should also include axillary and supraclavicular lymph nodes, followed by a relevant general systemic examination. The mentor recommends using the pads of the middle fingers to palpate the axillary groups systematically.

4. Recognize Relevant Signs and Differential Diagnoses

The session discusses several alternatives to fibroadenoma:

• Fibroadenosis: May be associated with cyclical mastalgia and a less discrete or more irregular feel than a typical fibroadenoma.
• Breast abscess or mastitis: Considered when inflammatory features such as pain, warmth, or fever are present. The mentor also discusses fluctuation as a sign of a drainable abscess.
• Duct papilloma: Classically associated in the discussion with bloody nipple discharge; duct imaging and surgical treatment options are mentioned.
• Phyllodes tumour: Discussed as a possible cause of a large breast mass, sometimes with a lobulated or “hilly” surface, variable consistency, and prominent superficial veins.
• Malignancy: May be suggested by fixation, skin or nipple changes, suspicious lymph nodes, or systemic features.

The mentor explains that trauma can draw attention to a pre-existing lump, while traumatic fat necrosis can itself produce a firm mass. Other topics include duct ectasia, cyclical mastalgia, and the potential significance of accessory breast tissue.

For nipple discharge, the mentor distinguishes physiological patterns—typically bilateral, from multiple ducts, and not spontaneous—from pathological patterns, which are more concerning when unilateral, spontaneous, bloody, and from a single duct. The session also introduces a “seven Ds” mnemonic, attributed to Clinical Surgery by Norman Browse: depression, destruction, deviation, discharge, discoloration, displacement, and duplication. Recent nipple retraction is contrasted with longstanding congenital inversion.

5. Investigations and Management

Ultrasound, mammographic appearances, and fine-needle aspiration cytology (FNAC/TAPB) are discussed in relation to confirming a likely fibroadenoma. The session briefly mentions the BI-RADS system and benign “popcorn” calcification versus microcalcification associated with malignancy.

For a fibroadenoma, the mentor describes management as dependent on the clinical context, growth, symptoms, cosmetic concerns, and cytology. Options discussed include observation and surgical removal by enucleation or excision. The presenter is advised to describe the approach used at her own institution rather than list unfamiliar procedures. The mentor states that a fibroadenoma does not itself degenerate into a malignant tumour.

For a phyllodes tumour, the discussion includes wide local excision, with mastectomy mentioned for selected large or recurrent cases. These are teaching points from the session, not individualized medical advice.

Presentation and Examination Advice

• Summarize key positive and negative findings instead of reading the entire history aloud.
• Give the provisional diagnosis only after presenting the clinical evidence, and retain appropriate diagnostic uncertainty.
• Use consistent, precise descriptions and a simple breast diagram to mark the lump’s location.
• Answer questions in a logical sequence, beginning with the patient’s age and clinical presentation.
• Communicate calmly and clearly. The mentor notes that confidence and a structured presentation help students recall and convey what they know.

Speakers and Sources Featured

• Miss Lekhana — Third-year medical student who presents the case; her name is also transcribed in variant forms in the subtitles.
• Senior surgical mentor / professor — Leads the discussion and teaching. The subtitles render the name inconsistently as “Shiniasim Sur” and “Srinivasan.”
• Session host/moderator — Introduces the session and participants and gives closing remarks.
• Other participants — Contributors or attendees identified in the subtitles include Kishan and Ravish Bunny; other students and chat participants are also referenced.
• Teaching reference: Clinical Surgery by Norman Browse, cited for the “seven Ds” nipple mnemonic.