Breast Hx & Exam - CE

History

I- Demographic:

• Name:
• Age:
• Nationality:.
• Martial Status:
• Residency:
• Occupation:

II- Chief of complaint

Main Patient answer why he is on admission:

right breast mass, pain, discharge, mass further workup was requested.

III- History of Present Illness - HOPI

Common complaints of lump, pain, tenderness (mastalgia) - change in breast size, skin with peudorange , nipple retraction (commonly carcinoma), ulceration (paget’s disease) or discharge

Q to ask

• When noticed (duration)?
• How noticed?
• Any change in the lump since first noticed?
• Any change in the breast/nipple?
• Any associated symptom? Pain, discharge
• Any relationship with the menstrual cycle?
• Any history of trauma?

OPERATES:

Onset: at time of pregnancy noticed small lump

Site: on Right breast Upper right quadrant

Progression: Progressively increase after first pregnancy

timing: ?

Associated: No previous breast issues

menstural cycle?

Episode free ?

• Noticed mass 1 month ago on upper right side to axilla

• swelling no pain, minimal discharge watery,

• ulceration

• Nipple discharges (Blood? water?) - bilateral or unilateral?

• Odor

• nipple changes

• color changes

• progression

• (pagematous changes in alveolar - )

• intraductal papilloma - erosion of breast - bleeding from nipples - surgical excision of effected duct.

• image guided local wirezation - do U/S to see which duct cause this bleeding

Associated Symptoms to same system: hemoptysis?… systemic metabolic side effects? such as spine lung liver

know each color fibrocystic disease - green milky -adenoma, prolactinemia, pregnancy

IV- Past History

• Medical: exposure radiation, menopause, menarche, regularity of menustral periods

• Family: postive family history of benign breast lump

• Surgical:

• Medications: HRT medications / contraceptives…

• Allergens: no

• Social History: first child at age of 42

  • No medical hx
  • use of contraceptives
  • previous family hx of breast cancer, and DM
  • no recreational hx,
  • nulliparity risk factors to know
  • 3 years of contraceptive use
  • early menopause (ask age of menarche)
  • Nullaparity
  • famiily hx of genitoutinary cancers - BRCA - HERN2nue?
  • previous cancer
  • protective factors include pregnancy and lactaitonal history

V- Systemic Review

ask for

• Bone (spine)
• Lung
• Liver
• B symptoms

VI- Differential

• Benign (Fibroadenoma, FIbrocyst, Filloid tumour)
• Malignant (Invasive ductal, Ductal…)

VII- Physical Examination

Breast focused Examination

Breast Inspection

***Inspect three levels while on ***

1. At Rest
2. Raised Arm,
3. Arm to waist, and
4. below folds

Comment on

• assymetry - level - visible mass? - s?

• affected areas (unilateral, bilateral? which quadrant?)

• vissible masses

• Dilated veins

• PAC RING

• Discharge,

  • Red: Duct papilloma, carcinoma
  • Yellow/Green: Fibrocystic disease, duct ectasia
  • White/Milky: Galactorrhea

• ulcers

• texture of nipples (peduea orange; thick edematous skin - due lymphatic drainage blockage)

• nipple retraction due mass behind niple - (could be physiological)

  • Carcinoma (retraction)
  • Paget’s disease (ulceration) raised level, retraction, ulceration

• cooper ligament holding structure of breast - skin dimpling - due fibrosis of malignant cells infliltration to cooper ligament

• raise arm and to waist Examine the axilla

• Inspect the supraclavicular area

• infammary lines, protraction of pectrolaris muscle to see any dimpling

Breast Palpation

I- Palpation of Breast

• raise arm
• to waist
• below folds
• Palpate axillary tail (contains breast tissue) infront pectoralis major edge axilla

Palpate the 4 quadrants for any obvious mass or lump. first on normal side fully then compare. palpate with palmar

clockwise palpation to check any masses/tenderness solid hard mass, irregular margin, immobile.

Comment on swelling/lump same as Lesion identification

• Lump characteristics: site, size, shape, surface, mobility, temperature, tenderness, texture, edge, attachment to skin or deep tissue For these characteristics - use the pulp of your fingers\
  • Site: More carcinoma develops in the upper outer quadrant
  • Size: Variable, Large mass - giant fibroadenoma, Phylloides tumor
  • Shape: Well defined - fibroadenoma, ill-defined - carcinoma
  • Mobility: Fibroadenoma freely mobile
  • Temperature: Raised in inflammation, inflammatory carcinoma
  • Tenderness: Inflammatory – abscess
  • Texture: Hard - carcinoma, firm - fibroadenoma, fluctuant - cyst
  • Attachment: Carcinoma, sometimes inflammatory lesions

SSS MATTT

Comment on Skin tethering - tumor infiltration of Cooper’s ligament pulling on the skin. Skin dimples when the tumor is moved to one side or arm raised above the head.

Skin fixation - when the tumor is directly fixed to the skin. The skin cannot be moved/pinched separately.

Muscle attachment - patient’s both hands resting on hips, test lump mobility before & after muscle contraction (ask the patient to press against hips).

superior inferiot movement of pectrolaist major if theres mass fixed to muscle

II- Palpation of aeoral complex

• Any retraction/ulceration
• Palpate for a mass underneath the affected nipple
• Nipple discharge - blood (red), serum (brown, green, straw-coloured), pus, milky
• Pathological discharge: Bloody, spontaneous, unilateral
• Discharge spontaneous or on pressure of a segment of the areola
• Any mass associated with the discharging duct

III- Palpation of lymph nodes

Shake hands hold it with patient with your dominant hand, palpate with your left resting on forearm to relax pectoralis major for palpation

• Axilla, supraclavicular, infraclavicular lymph nodes

• Patient sitting upright

• Rt. Axilla: Hold the patient’s right elbow in your right hand. Palpate the axilla with your left hand. For the apex of the axilla, press the finger pulp upward and medially.

• Lt. axilla - reverse

• Palpate for supraclavicular, infraclavicular lymph nodes

• Size, number, and fixation of lymph nodes

• Examine the arm for any swelling

if contracted lymph nodes will go inside

Axilla contents

• branches brachial plexus
• axillary vessels
• fibro fatty tisues, to give shape

Examine the following anterior group lymphndode behind pectrolist press gently circular movement to feel it promiment

posterior group infront lattismus dorsi

medial on ribs

lateral on head of humerous

apical against center of axilla

infra supra clavical palpate

Complete examination with

• Chest: any Lung effusion
• Abdomen: hepatomegaly, ascites
• Spine: pain, tenderness, limitation of movement
• B symptoms

Summarize Findings

…

Differential, Impression, most likely diagnosis

• Breast cancer

  • commonly at 1st pregnancy over 40 years or nulliparous women with early menarche and late menopause or wit hHRT medication, obesity which promotes hormones, or diet of saturated fat. brca1 and 2

• fibroadenoma (more commonly 15-25 years old)

  • smoth, freely mobile mass, regress mostly. <4cm reassurance and follow up if over 4 cm excision is done

Investigations

Diagnosis is done with triple assessment

• clinical evaluation with history and exam

• radiological evaluation: U/S mammoraphy, MRi, Ct scan staging

• Cytological/histological

• FNAC, Core biopsy, Open biopsy

• mammography (more fatty - old age 40 and above)

• U/S (more dense - young) differentiate cyst, mass, suspicious LN

• Chest X-ray.
• Bone scan (spine).
• CT scan.
• Ultrasound (liver).
• CT abdomen.
• If early stage: Bone profile, LFTs.

grade of mammorgam birad 1-6 scores classifcation - indications for biopsy depending on features of the mass

5-6 likely only for biopsy (in this case) Do fine needle aspiration / core needle biopsy

• Core bipsy?, receptors, ER, Progestrin, HER
• FNAC - breast cancer cell not diagnostic

invasive ductul carcinoma grade 2

• CT abd chest, all
• Nuclear PET Scan

Sentinel Lymph Node Biopsy:

• Sentinel lymph node collects lymph from all breast lymph nodes and enters the axilla.
• Blue dye or radioactive isotopes are injected to identify the sentinel node.
• Allows for targeted lymph node removal and reduces the risk of lymphedema.

Adrenal Gland:

• May produce estrogen from androgens.

Staging

• TNM Classification:
  • T (Tumor Size):
    • T1: < 2cm
    • T2: 2-5cm
    • T3: > 5cm
    • T4: Any size with invasion (edema, ulcer, skin changes, peau d’orange).
  • N (Lymph Node Involvement):
    • N0: Non-palpable.
    • N1: Any palpable, mobile lymph node.
    • N2: Fixed lymph node.
    • N3: Supra/infraclavicular spread.
  • M (Distant Metastasis):
    • M0: No distant metastasis.
    • M1: Distant metastasis to any structure.

Biopsy

• FNA: (Differential not specified).

• Core biopsy: Can differentiate invasion of submucosa and mucosa (in situ). Malignant if spread to vessels.

• Sentinel Lymph node during surgery - vessels will be visible - it will hold the coloring filters it, where it would be location of the sentinel - inject isiotiopes use pencil to check - will give sound

Treatment/Management Plan

calcification, structure, surgical plan for calcification mastectomy in this case due prophylaxis to positive genetic makeup

lobectomy if only lump mass found at place.

Treatment Plan:

• Multidisciplinary team approach.

Systemic Therapy:

• Chemotherapy: If breast receptors are not responsive to estrogen.
• Targeted Therapy: Immune therapy (e.g., Her2 targeted therapy) with antibodies and chemotherapy.
• Hormonal Therapy: Tamoxifen.

Surgical Management:

• Breast: Lumpectomy, mastectomy (with or without breast preservation).
• Axilla: Axillary lymph node dissection.

Historical Approach:

• Radical mastectomy (no longer standard practice).

Surgical Cleaning:

• Performed on the patient.

Axillary Lymph Node Removal:

• May result in edema.

before surgery - neo adjuvant therapy post surgery treatment - adjuvant therapy

• axilla is negative in all imaging - take sentinel lymph node biopsy (first group of LN, pick with gamma probe, then study when frozen - check if theres metases for indicatiative axilla dissection) - sentinel is used when no evidence but cancer

• 2 & 3 suspectious LN - METS - Axillary dissection

Note