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Vaish Ragavan vr519@ic.ac.uk Neck and Breast Lumps MedEd Y3 Written Exam Lectures 2025SESSION STRUCTURE ✓ Neck Lumps ✓Breast Lumps • Lymphadenopathy •Mastitis • Neck lumps by •Benign breast lumps anatomy •Breast Cancer • Thyroid lumps SBA 1 A 26-year-old male presents to your GP clinic. He says he’s noticed a lump under his jaw for the past 2 months. He went out drinking with his friend last night and the lump has felt painful the morning after. It isn’t normally painful. He doesn’t have any coryzal symptoms at the moment, but he has noticed he has been sweating a lot at night. He doesn’t think he’s lost any weight, but he does feel tired all the time. What is your initial management of this patient? A) Reassure and discharge B) FNA of the neck lump C) Refer for an ultrasound scan D) 2-week wait referral E)Advise him to go to ED immediately Neck Lumps <3wks -> self-limiting infection Intradermal – sebaceous cyst (central punctum), lipoma Extradermal – lymph nodes (85%) – infection, lymphoma, metastases Goitres (8%), other (7%) <- Sebaceous cyst Lipoma (overgrowth of fat cells) -> excisionical Lymphadenopathy Enlarged lymph nodes O/E – rubbery, tender (reactive), mobile, can be firm and matted (malignancy) Types: Reactive – acute viral URTI, tonsilitis, ear infection etc. • Observe, if growing larger after 7 days -> other infective causes (↓) or abscess (Rx: abx +/- referral for incision and drainage) • If caused by bacterial infection: assess need for abx Infected –TB, HIV , EBV, CMV (Inflammatory – SLE, sarcoidosis) Malignancy – lymphomas, leukaemia, metastases Infected Lymphadenopathy Infected –TB, HIV , EBV , CMV • TB – • Tred flags (weight loss, night sweats), extra-pulmonary symptoms • Inv: CXR,sputum – acid-fast bacilli,mycobacteria culture • Rx: RIPE drugs • HIV - • Sexual hx, Fhx (1º HIV), red flags, concordant infections/malignancies • Inv: combination test of both HIV antibodies and p24 antigen • Rx: ART therapy, monitor CD4 and viralload • EBV (glandular fever/infective mononucleosis) – • Contact hx, coryzal symptoms, organomegaly • Inv: FBC and Monospot (heterophile antibody test) • Rx: advise to avoid alcohol and contact sports (splenic ruputure) ^Amoxicillin-induced maculopapular rash in a patient • CMV – with infective mononucleosis • Pregnancy (TORCHinfection), coryzal symptoms (EBV) • Inv: antibody • Rx: (only if immunocompromised/newborn) antivirals Lymphomas B Cell Lymphomas: lymphadenopathy (posterior triangle/inguinal), pruritis, splenomegaly • Hodgkin’s (20%) – Reed-Sternberg cells, bimodal age (20s and >60s), nucleate/multinucleate (‘owl eyed’) cell associated with EBV, pain after drinking alcohol High Grade • Non-Hodgkin’s (80%) VeryAggressive – Burkitt’s • T-cell Lymphomas (rarer) Aggressive – Diffuse Large B-Cell, Low Gradell Inv: PET-CT scan, LN biopsy, BM biopsy Indolent – Follicular, Marginal Zone, Treatment: Chemotherapy, radiotherapy, Small Lymphocytic immunotherapy, stem cell transplants NB: High Grade lymphomas are easier to treat Ann-Arbor Staging Stage 1 – one LN region (LN region can include spleen) Stage 2 – two or more LN regions on the same side of the diaphragm Stage 3 – two or more LN regions on opposite sides of the diaphragm Stage 4 – extra nodal sites (liver, BM) A: No constitutional symptoms B: Constitutional symptoms (Fever, night sweats, weight loss) Emergency Presentations Stridor – harsh, high-pitched inspiratory breathing sound caused by obstruction of larynx or lower bronchi • Can rapidly deteriorate and may need airway management SuperiorVena Cava Obstruction – tumour/LN compression • Upper airway obstruction • Symptoms: SOB, visual disturbances, dizziness, headache • Signs: facial/neck/UL oedema, facial plethora, distended neck/chest veins, hoarse voice/stridor, cyanosis • Pemberton sign: Lift both arms up -> worsens facial congestion, ^facial swelling due to SVCO cyanosis, resp distress • Inv: CXR, CT chest with contrast • diuretics, benzodiazepines/opioids to manage agitation), dexamethasone, Suspected Leukaemia • inguinal)ed lymphadenopathy (vs lymphoma – posterior triangle or • Bleeding, bruising, bone pain, petechiae, pallor, infection -> Urgent blood test (48h) Lymphoma in young patients (children, under 24s) • Urgent specialist referral (48h) ^Pemberton sign SBA 1 A 26-year-old male presents to your GP clinic. He says he’s noticed a lump under his jaw for the past 2 months. He went out drinking with his friend last night and the lump has felt painful the morning after. It isn’t normally painful. He doesn’t have any coryzal symptoms at the moment, but he has noticed he has beensweating a lot at night. He doesn’t think he’s lost any weight, but he does feel tired all the time. What is your initial management of this patient? A) Reassure and discharge B) FNA of the neck lump C) Refer for an ultrasound scan D) 2-week wait referral E)Advise him to go to ED immediatelyNeck Lumps by anatomy SBA 2 A 63-year-old man presents to his GP after noticing a bulge on the side of his neck. He has a history of hypertension, diabetes and is a smoker. He feels generally well otherwise.You examine the side of his neck and notice a 2cm pulsatile mass under the mandible. What is the most likely diagnose? A) Reactive lymphadenopathy B) Pharyngeal pouch C) Laryngocele D) Carotid artery aneurysm E) Parotid tumour Midline Lumps Adults vs paediatric Adults – thyroid mas, chondroma (benign cartilaginous tumour) Paediatrics (or under 20) • Most likely a dermoid cyst (simple, skin-lined cyst under the skin) • Moves up on tongue protrusion, below hyoid -> thyroglossal cyst (fluid-filled sac resulting from incomplete closure of thyroid's migration path), Developmentally, the • Symptoms: commonly gets infected (abx to clear infection), thyroid starts forming at • Rx: surgery (Sistrunk procedure)eathing, discharge from the skin the base of the tongue before migrating down the thyroglossal duct Submandibular Triangle <20 years -> self-limiting lymphadenopathy >20 years -> malignant lymphadenopathy Not a node -> salivary stone, sialadenitis, salivary gland tumour ^Swollen LN Anterior Triangle Paediatric -> branchial cysts (fluid-filled sac or lump caused by a developmental anomaly) • Just anterior to the SCM, painless, mobile, fluctuant mass • Can become very large if infected, resolve with antibiotics • MRInical dx, but can ix with USS, CT , • Rx: conservative or surgical excision • Ddx: cystic hygroma (transilluminates), thyroglossal cyst (midline, tongue Branchial cysts are most commonly formed from the protrusion) second branchial cleft https://www.youtube.com/watch?v=VyFEY4cR1eI Anterior Triangle Superoposterior area, >40 years old -> parotid tumour Painless, made worse by blowing -> Laryngocele (swelling caused by abnormal dilation of laryngeal saccule) Pulsatile -> carotid artery aneurysm (weakness of the lumen of carotid artery causing bulging) • Most commonly internal carotid • atherosclerosis is a common cause, CT disorders • RF: FHx, HTN, smoking • Increased risk of cerebrovascular accidents • dx: duplex USS or CT/MR angiography • Rx: vascular surgery (open or endovascular) DDx: tortuous carotid artery, carotid body tumours Posterior Triangle Cervical ribs – ‘ribs’ from C7 vertebra • through compression of subclavian arteryndrome Protrude on swallowing (usually left-sided) -> of the oesophagus through the posterior pharyngeal wall) Transilluminates, infants -> cystic hygromas (lymphatic malformation) • Rx: surgery, hypertonic saline sclerosant injection Pancoast tumour (lung cancer in apex) Pulsatile -> subclavian artery aneurysm Pharyngeal Pouch Zenker’s diverticulum – herniation of the oesophagus through the posterior pharyngeal wall O/E: posterior triangle; protrude on swallowing (usually left-sided) Symptoms: dysphagia and loss, aspiration -> recurrent chestt infections, halitosis RF: M>F , increasing age fluoroscopy, USSrd – barium swallow, Rx: (<1cm – conservative), surgery – resection of the pharyngeal pouch (endoscopic/open) Thyroid Lumps Diffuse or nodular? • Diffuse – iodine deficiency, congenital, acute thyroiditis, physiological (pregnancy/puberty), autoimmune (Graves', Hashimoto's) • Nodular – multinodular goitre; fibrotic goitre; solitary thyroid nodule Euthyroid, thyrotoxic or hypothyroid? Investigations – 1 line:TSH, USS • If abnormal: T4 autoantibodies Chest X-ray Radionuclide scans FNAand cytology • Hashimoto’s • Tracheal goitres • Hypofunctioning/cold - • Characterise • Graves’ • Metastases > malignancy malignancy • Hyperfunctioning/hot - > adenoma Thyroid Cancer • Papillary (60%) - younger patients; • spread: lymph nodes and lung; • Rx: total thyroidectomy +/- node excision +/- radioiodine; • better prognosis: female, young • Follicular (<25%) - middle-aged; • spread: blood (bone, lungs); • well-differentiated; • Rx: total thyroidectomy + radioiodine ablation • Medullary (5%) - sporadic or part of MEN syndrome; • calcitonin – tumour marker; • pre-op phaechromocytoma screen; • radiotherapyy + node clearance +/- external beam • Lymphoma (5%) - F:M = 3:1; stridor/dysphagia • Anaplastic (rare) - F:M = 3:1; elderly, poor response to Rx Thyroid Surgery Types: • Partial lobectomy or lobectomy (for isolated nodules) • Thyroidectomy: cancers, MNG, Graves’). Pre-operative management • vascularity)PTU to make euthyroid (stop 10 days before surgery – increases • If hyperthyroid -> propranolol • laryngeal nerve injury).irect laryngoscopy pre- and post-op (risk of recurrent • Check serum Ca2+ (and pth if abnormal). Complications • Recurrent laryngeal nerve – hoarseness, vocal changes • Parathyroid gland – hypoparathyroidism (tingling, paraesthesia, etc due to low Ca) SBA 3 A 58 female patient presents to ED with profuse sweating and palpations.A nurse takes her BP and reports it is 210/160.You notice she is also very tall and thin. She explains that her father has also episodes of very high blood pressures and had to have an abdominal surgery to treat the cause. She mentions that he also had small bumps on his tongue and lips. What type of thyroid cancer would she be at greater risk of? A) Follicular B) Papillary C) Medullary D)Anaplastic E)Adenoma SBA 3 A 58 female patient presents to ED with profuse sweating and palpations.A nurse takes her BP and reports it is 210/160.You notice she is also very tall and thin. She explains that her father has also episodes of very high blood pressures and had to have an abdominal surgery to treat the cause. She mentions that she also had small bumps on his tongue and lips. What type of thyroid cancer would she be at greater risk of? A) Follicular B) Papillary C) Medullary D)Anaplastic E)Adenoma SBA 4 A 33-year-old woman presents to her GP . She has had two days of breast pain, fevers and malaise. She is currently breastfeeding. What is the most likely causative organism of her pathology? A) S.Aureus B) S. pneumoniae C) Klebsiella D) E. coli E) C. difficileBreast Anatomy Mastitis and Breast Abscesses Mastitis - inflammation of the breast tissue often secondary to infection – S. aureus • Commonly seen in breast-feeding women breasts – a collection of infective tissue due to an ongoing infection of the Inv: clinical examination, (abscess: USS to diagnose) Rx: Mastitis – OTC analgesia (erythromycin or clarithromycin if pen allergic) flucloxacillin Abscess – US-guided needle aspiration/surgical excision and drainage Encourage to continue breast-feeding from both breasts SBA 4 A 33-year-old woman presents to her GP . She has had two days of breast pain, fevers and malaise. She is currently breastfeeding. What is the most likely causative organism of her pathology? A) S. Aureus B) S. pneumoniae C) Klebsiella D) E. coli E) C. difficile Duct ectasia Papilloma Fibroadeno Fibrocystic breast Breast cyst Fat necrosis ma changes Pathology Blockage of Wart-likegrowth in Overgrowth Changes in breast tissue Fluid-filled sacFibrosis and ABCmillaryducts mamillary ducts of tissue associated with menstrual calcification as a part of *Papillomatosis: surrounding cycle, which resolve once after injury to normal breast multiple papillomas a lobule menstruation begins breast tissue changes - associated with associated with atypical hyperplasia ageing (cancer risk) Breast Behind the nipple Behind the nipple Firm, Generalised lumpiness of Discrete, Firm lump in area lump smooth, breast tissue; can present round, of trauma mobile lump as individual cysts fluctuant lump, not attached to the skin Nipple Green/brown/bl Clear or bloody None Nipple discharge None Nipple retraction changes oody discharge, discharge uncommon depending on nipple retraction location Pain? Uncommon Uncommon None Common Uncommon Uncommon Age 45-55 35-55 Younger 35-55 >35 Any age (<30) Inv Triple assessment Triple assessment Breast Mammogram/USS Triple Triple assessment ultrasound assessment Treatment None Vacuum-assisted Observation OTC pain relief FNA(part of None excision ix) Benign breast lumps ^Duct ectasiaBenign breast lumps <- Breast cyst (USS) Fat necrosis (mammogram) -> Breast Cancer Most common cancer in women RF: Female, increased oestrogen exposure, more dense breast tissue, obesity, smoking, family history (first-degree relatives), COCP – small increase but normal ten years after stopping, HRT BRCA genes • BRCA1 – 70% risk of breast cancer by 80, 50% ovarian cancer, increased risk of bowel and prostate cancer • BRCA2 – 60% risk of breast cancer by 80, 20% ovarian cancer Clinical Signs • Hard, irregular, painless lump • Fixed in place or tethered to skin or chest wall • Nipple retraction • Skin dimpling or oedema – peau d’orange • Lymphadenopathy – axillary <- peau d’orange with nipple retraction Types of Breast Cancer • breast ductstal carcinoma, non-specific type (most common) – originates from • microcalcification on mammogram, 30% malignancy risk, Rx: surgery +/-as hormonal therapy • lobules, lobular carcinoma (10-15% breast cancers) – originates from breast • breast biopsy, 30% malignancy risk, Rx: core biopsy with wide margins,dentally on rarely surgery +/- hormonal therapy • and tenderness with peau d’orange, doesn’t resolve with antibioticss, swelling • breast cancer involving nipple (DCIS/invasive breast cancer)nipple/areola, Types of Breast Cancer Invasive ductal carcinoma Invasive lobular carcinoma Paget’s disease of the nipple NICE Referral Criteria 2 week wait: Consider 2 week Non-urgent: wait: • =/>30 with • Skin changes • <30 with unexplained suggesting unexplained breast lump with breast cancer breast lump with or without pain • =/>30 with or without pain • =/>50 with nipple unexplained lump changes in axilla (discharge, retraction) Triple Assessment Clinical Imaging – USS or Biopsy – FNA or assessment mammography core biopsy • History and • USS – in younger • Cystic lump – examination women (<35) FNA • Mammograph - • Solid lump – core >35 biopsy • MRI – further assessment of size/features of tumour Breast Cancer Staging TNM staging and number staging Number: TNM: Stage 0 – carcinoma in situ T1 - =/< 2cm Stage 1 – confined to breast, mobile T2 – 2cm – 5cm Stage 2 – confined to breast, mobile + LNs in T3 - >5cm ipsilateral axilla Stage 3 – tumour fixed to muscle, may have T4 – cancer spread to chest wall fixed LNs and skin involvement larger than N0 – no nodal involvement tumour N1 – involvement of LNs in ipsilateral axilla Stage 4 – complete fixation to chest wall + N2 – fixed LNs in ipsilateral axilla distant metastases Additional investigations done for staging – N3 – supraclavicular LNs LN biopsy, CTThorax, abdomen and pelvis, M0 – no distant metastases isotope bone scan M1 – distant metastasesBreast Cancer Staging SBA 5 A 62-year-old is diagnosed with invasive ductal carcinoma of the breast.The tumour in her right breast, 3cm in size and not tethered to the chest wall. She is oestrogen and progesterone receptor positive and HER2 negative. She has two positive lymph nodes in her right axilla and they are mobile. After a discussion with the MDT and the patient, it is decided she will have chemotherapy before a wide local excision and axillary node clearance.Then, she will have radiotherapy and start anastrozole. Which option below best summarises this patient’s management? A)WLE with adjuvant chemotherapy and neo-adjuvant radiotherapy and hormonal therapy B)WLE with neo-adjuvant chemotherapy and adjuvant radiotherapy and hormonal therapy C)WLE with adjuvant chemotherapy, radiotherapy and hormonal therapy D)WLE with neo-adjuvant chemotherapy, radiotherapy and hormonal therapy E)WLE with adjuvant chemotherapy, radiotherapy and neo-adjuvant hormonal therapy Breast Cancer Management Surgery is the mainstay • Wide local excision (lumpectomy) – tumour less than 5cm and localised to one area of the breast • Mastectomy – larger tumours or widespread disease • Breast reconstruction also offered • Axillary clearance – risk of chronic lymphoedema Adjuvant – tx after surgery to reduce recurrence • Radiotherapy – given afterWLE and after mastectomy for higher risk tumours Neo-adjuvant – tx before surgery to shrink tumour Receptor Status Oestrogen, progesterone and HER2 receptor status Oestrogen-positive (hormonal): • Tamoxifen: pre-menopausal, blocks oestrogen receptors • of androgens to oestrogenstrozole): post-menopausal, blocks conversion • of the hypothalamusrelin): suppresses oestrogen production at the level • Ovarian ablation: surgically (laparoscopic oophorectomy) or via radiotherapy HER2-positive (biologics): trastuzumab (Herceptin), pertuzumab (Perjeta) • Monoclonal antibody that blocks HER2 receptors Triple negative: worse outcomes, Rx: chemo + immunotherapy SBA 5 A 62-year-old is diagnosed with invasive ductal carcinoma of the breast.The tumour in her right breast, 3cm in size and not tethered to the chest wall. She is oestrogen and progesterone receptor positive and HER2 negative. She has two positive lymph nodes in her right axilla and they are mobile. After a discussion with the MDT and the patient, it is decided she will have chemotherapy before a wide local excision and axillary node clearance. Then, she will have radiotherapy and start anastrozole. Which option below best summarises this patient’s management? A)WLE with adjuvant chemotherapy and neo-adjuvant radiotherapy and hormonal therapy B) WLE with neo-adjuvant chemotherapy and adjuvant radiotherapy and hormonal therapy C)WLE with adjuvant chemotherapy, radiotherapy and hormonal therapy D)WLE with neo-adjuvant chemotherapy, radiotherapy and hormonal therapy E)WLE with adjuvant chemotherapy, radiotherapy and neo-adjuvant hormonal therapy Breast Cancer Screening Mammogram every 3 years for woman aged 50 – 70 years Early detection – 1 in 100 women diagnosed through screening High-risk patients – offered screening at an earlier age based on genetic testing or lifetime risk • Test is either MRI or mammography depending on age • join routine screening pathwayent screening orQuestions? Thank you for listening Email: vr519@ic.ac.uk