Breast Lump Approach

– History –

• CC: most likely will present as a breast lump:

1. Breast parenchyma:
   • Lump:
     • Site and location: uni\bi-lateral? Quadrant?
     • Onset and timing: first time? Cyclic? Comes and goes\there all the time?
     • Characteristics:
     • Size (increasing?)
     • Number
     • Painful
     • Aggravating \ relieving factors
   • Pain:
     • Same, do SOCRATES, (don’t forget to ask if it’s cyclic)
2. Nipple-areola complex:
   • Nipple discharge:
     • Uni\bi-lateral?
     • Color?
     • Content: milky or pus?
     • Bloody?
     • Spontaneous or when you squeeze?
     • Same orifice all the time?
   • Nipple\areola changes:
     • Nipple retraction (since childhood or new, bi-\uni-lateral)?
     • Nipple inversion?
     • Paget ds: rash, burning, itching?
3. Skin:
   • Redness?
   • Rash?
   • Dimpling?
   • Ulcers?
   • Peu d’orange\thickening of the skin?

• Associated sx: (mainly to screen for mets):
  • Constitutional sx: fever, wt loss, anorexia, fatigue
  • LN: lumps in the axilla
  • CNS: seizures, headache, blurred vision, N\V
  • Lung: chest pain, SOB, cough, hemoptysis
  • Liver: jaundice
  • Bone: bone pain

• Gynecological Hx:
  • Menstrual cycle:
    • Regular cycles or not?
    • Last period?
    • Recent changes?
  • Age of menarche
  • Age of menopause
  • Number of pregnancies + how old were you when you had your first child?
  • Breastfeeding \ lactation

• PMHx:
  • Previous breast mass
  • Diseases:
    • Chronic ds
    • Benign breast ds (fibroadenoma, fibrocystic changes)
    • Malignancy (breast, ovarian)
  • Medications: HRT, OCP
  • Exposure to chest radiation
  • Trauma to the breast
  • Breast ca screening
  • Previous surgeries or procedures (FNA, biopsy)
  • Allergies

• FMHx:
  • Same complaint?
  • Family hx of malignancy (breast, ovarian, colon, prostate)
    • Who?
    • Breast: bi-\uni-lateral?
    • When were they diagnosed?
    • How were they diagnosed?
    • Outcome?

• Social Hx:
  • Occupation, marital status, children?
  • Smoking, alcohol, recreational drugs?
  • Travel Hx
  • Diet, exercise

 

 – Breast Cancer Risk Factors – 

• Gender
• Age
• Obesity
• Prev Hx (breast malignancy \ pathology, ovarian ca)
• Family Hx (genetic mutations, any malignancy)
• Early menarche
• Late menopause
• Nulliparity
• Age of first preg (>30)
• Not breastfeeding
• OCP\HRT
• Radiation

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– Breast Physical Exam –

1. Inspection of the breast: (while arms are relaxed + pressing on hips + raised above head)
   • Asymmetry
   • Obvious masses
   • Skin changes: redness, dimpling, ulcers, peu d’orange
   • Nipple changes: excoriation, retraction, inversion
   • Describe the lump: 
     • Number: solitary
     • Location: Rt\Lt breast
     • Quadrant
     • Size
     • Shape
     • Surface
     • Border
     • Consistency
     • Mobile or fixed
     • Tenderness
     • Overlying skin
2. Palpation of the breast: (first ask the pt if she has any pain?)
   • Ask the pt to raise her arms above the head
   • Palpation of the breast in a systematic pattern
   • Axillary tail
3. LN examination:
   • Axillary LN
   • Supra\infra-clavicular LN
4. Mets:
   • Lung: auscultate
   • Liver: palpate
   • Bone: palpate vertebral spinous processes 

 

– Imaging –

• < 40: US
• 40: mammogram

Imaging of the breast mass will be reported using the BIRADS:

– Biopsy –

• FNA
• Core needle biopsy
• Excisional biopsy, if indicated;
  • Size: > 4 cm
  • Increasing in size
  • BIRADS 4B and above
  • Radiology-pathology discordance
  • Atypical dutal\lobular hyperplasia
  • “Fibroepithelial” lesion (fibroadenoma vs phyllodes tumor)
  • Papillary lesion

 

– Lymph Nodes Assessment –

• If there’s an enlarged LN (via PE or radio) -> biopsy that LN
• If it’s positive -> do axillary LN dissection (ALND)
• If it’s negative or no enlarged LN -> do sentinel LN biopsy (SLNB)
  • If SLNB is negative -> means no LN involvement
  • If SLNB is positive -> do ALND

 

– Staging –

(if biopsy shows breast ca, otherwise ‘no tissue, no issue’)

• CT of the chest, abdomen, pelvis, brain
• Bone scan

 

– Treatment –

• Surgery:
  • MRM: removes breast tissue and associated LN + leaves skin flap, nerves, muscles
  • BCT:
    1. Lumpectomy w\ wide margin
    2. Axillary LN clearance
    3. Whole breast radiation

• Contraindications to BCT -> do MRM:
  • High tumor-to-breast size ratio
  • Multi-centric tumor
  • Retro-areolar tumor
  • Contraindication to radiation (e.g. prior radiation to chest wall, active skin lesions, pregnancy)

• Neo-adjuvant:
  • Indications:
    • Borderline size -> tumor shrinks -> becomes legible for BCT
    • Large tumors
    • Bulky axilla

 

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