Anyone who is too short of time to read some speculative random thoughts on surgery should skip this contribution. For those that have the time, I hope the following item is of interest.
Last year I missed a breast cancer in a young woman for several weeks, both on palpation and on initial open excision, when all I removed was the overlying pseudo-lipoma. Much vexed by this, I thought about palpation of the breast, but a letter on the subject to the local medical journal was rejected, apparently on the advice of a breast surgeon. (He sai dthat the tracing technique I described was obvious and well-known from its use for varicose ulcers). I’ve also added a little on the nature of palpation as a process.
World-wide, millions of women are shown breast self-examination by their medical advisors. Nowhere, it seems, are women taught about the various types of normal lumps there, ones which do not change over months or years. If they don’t learn to identify these, they are less likely to identify abnormal lumps [unsupported assertion]. Neither women nor physicians have a systematic approach to the normal lumps in the breast, which I believe are:
2. The circular shoulder of breast tissue under the edge of each areola, around the core of soft fat through which the milk ducts pass.
3. The axillary tail in some women.
4. Normal tissue with a fine soft granular texture, like cooked rice.
5. Normal tissue with a coarser soft texture of fatty lobules, smaller than jelly-beans.
6. Fine horizontal ridges of firmer breast tissue in the upper and outer parts of the breast in some women.
7. A more constant horizontal ridge of tissue above the lower margin of each breast, in older women.
8. Normal axillary lymph nodes, palpable in many women, with a characteristic flip or flick felt by the patient, when examined by another person or by themselves.
Once identified, such lumps change little over months or years (unlike the lumps of fibroadenosis), and will be easy to recognise again. Of course, to avoid disasters, ANY dubious or worrying lump or change in the breast must be investigated in the accepted way.
Often it is a problem for the doctor to get the patient to feel the same lump (or vice versa). One technique is for the first examiner to keep one fingertip flat on the lump (or one on each side of it if wider), and for the second examiner to rest their fingertip(s) lightly on the nail(s) of the first. As the first person draws the finger(s) away, the other should be able to identify the lump with less difficulty.. The first person should also indicate the direction in which to move the finger to feel the lump most easily,(either from side to side or along its length), or whether to dip each of the two fingers in turn, to feel the lump more easily by displacing it against the non-dipping finger.
Often a nervous and tense patient has to be persuaded to relax, and to press much more lightly. Typically this should be with a force of about 0.2 N (Newton) (the weight of 20 ml of watery liquid, or two to three plastic ball-point pens) rather than the ten or twenty times that force exerted by a nervous palpator.
Recording these findings for future comparisons (or for location of a lump when the patient is already sedated or anaesthetised) can be inadequate and unreliable from diagrams, and sometimes waterproof markings wash off or have not been put on.
These findings can be recorded in more accurate detail than usual by tracing them and a few landmarks (sternal and epigastric notches, inframammary fold, areola & nipple, any scars, prominent ribs) onto a large sheet of thin kitchen wrap plastic placed widely over the breast. The plastic is then photocopied at the lightest setting (to avoid streaky shadows of creased plastic), and the A4 paper copy has the various features labelled, to which proposed lines of incisions can also be added. This is photocopied a second time after adding the patient ID, the date, and which breast. Copies can be run off for the medical record, the referring doctor, and the patient (and her partner, if wanted). An alcohol swab is useful for cleaning any marking ink accidentally transferred onto the glass surface in the photocopier.
This low-tech technique (a Gladwrappogram) is immediate, accura, valid, cheap and easy to understand, and easy to copy and use for comparison weeks or months later. The one-to- one scale is far more accurate, clearer and easier to use than either Polaroid photos or the usual simple diagrams.
Similar techniques makes it easier to keep track of moles or other skin or subcutaneous lesions for repeated observation or later treatment The future? Perhaps direct photocopying of the breast, with lumps marked, will prove feasible, like the reputed assograms supposed to have been carried out at bibulous office parties.
It is hard to imagine something like plaster of Paris being sufficiently reactive to show the impressions of subcutaneous lumps. At the present time, robotic tactile sensing is limited to static measurements, without regard to the consistency of the material being assessed. This contrasts with feeling with the fingers, which repeatedly press on and lift off in small movements at closely spaced points to assess consistency, its variation, especially when non-linear, the definition of its edges, and the shape of areas of differing consistency. This gives information about elastic and plastic properties and mobility, aided by horizontal movements of the fingertips.
Until the day comes that a machine can sense and integrate this information usefully, the reliability of palpating abnormal breast lumps (and lumps in other parts of the body e.g. prostate) may improve through more detailed awareness of the varying consistency of the normal tissue.
The above comments were compiled with the collaboration of my colleague, but responsibility for the wilder flights of imagination is mine.