– History –
- CC: most likely will present as a breast lump:
- 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)
- Lump:
- 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?
- Nipple discharge:
- 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
- Menstrual cycle:
- 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
– Breast Physical Exam –
- 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
- 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
- LN examination:
- Axillary LN
- Supra\infra-clavicular LN
- 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:
- Lumpectomy w\ wide margin
- Axillary LN clearance
- 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
- Indications: