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


– 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:

Breast 1.png

– 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

breast 2

 

– 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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