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Breast Mass

Breast Mass. Identifying information. D.B. 45 years old Female Married Housewife Kapasigan , Pasig City. Chief complaint . Breast mass, right . History of the present i llness. 1 year PTA. Breast mass, right Hard, marble-sized

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Breast Mass

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  1. Breast Mass

  2. Identifying information • D.B. • 45 years old • Female • Married • Housewife • Kapasigan, Pasig City

  3. Chief complaint Breast mass, right

  4. History of the present illness 1 year PTA • Breast mass, right • Hard, marble-sized • No breast pain, nipple discharge, changes in the appearance of the breast • Enlargement of breast mass • 25 centavo coin • Unrecalled antibiotics w/o relief 4 monthsPTA

  5. History of the present illness 1 month PTA • Progressive enlargement of breast mass • Tomato-sized • Breast pain • Sharp, “kirot,” 3/10 • Localized on breast mass • Few days before menses, lasting a few minutes • Spontaneous relief • Core needle biopsy: Invasive Ductal CA • Advised surgery Admission

  6. Review of systems • General: (+) anorexia, (-) weight loss, fever, weakness, fatigue • HEENT: (+) headache, (-) dizziness, enlarged LN • Pulmonary: (-) dyspnea, hemoptysis, cough, wheezing • Cardiovascular: (-) palpitations, chest pains, orthopnea • Gastrointestinal: (-) jaundice, abdominal pain, nausea, vomiting, changes in bowel movement, tea-colored urine • Genitourinary: (-) nocturia, dysuria, frequency, hematuria • Musculoskeletal/Dermatologic: (+) myalgia, (-) back pain, arthralgia, rashes, pruritus • Endocrine: (-) excessive sweating, heat/cold intolerance, polyuria, excessive thirst

  7. Past medical history • No hypertension, diabetes mellitus, asthma • No allergies • No previous hospitalizations • Removal of “pugita,” left eye (2003)

  8. Obstetric and gynecologic history • G4P3 (3,0,1,3) • Menarche at 13 years old • ~28-30 day cycle • Regularly menstruating • 3 days, consuming 3 regular pads/day • (-) dysmenorrhea • LMP: February 13, 2012 (PMP: January 15, 2012) • Oral contraceptive pills (1986-2000) • Injectables (2009-2011)

  9. Family history • Hypertension- mother, father • Asthma- siblings • Cancer • Bone cancer- uncle • Unrecalled cancer- aunt • No diabetes mellitus, PTB

  10. Personal and social history • Housewife, mother • Married to an electrician, OFW • Lives with husband and youngest child • Nonsmoker • Occasional alcoholic beverage drinker • No history of illicit drug use

  11. Physical examination • Conscious, coherent, cooperative • Vital signs • 120/80 mmHg • 86 beats/ min • 20 breaths/min • 36.5C • VAS 0/10 • Weight 59 kilos, Height 153 cm • BMI 25.2 kg/m2 (overweight)

  12. HEENT • Anictericsclerae, pinkish conjunctivae, no • No tragal swelling or tenderness • No nasal discharge • Pinkish lips, moist oral mucosa, no lesions or sores, no tonsillopharyngeal congestion • No cervical lymphadenopathies, non-palpable thyroid gland

  13. Breast • No lesions or scars on the chest • Symmetrical breasts • Pinkish-brownish nipple, no skin dimpling/ retractions • 7 cm x 5 cm mass on the upper outer area of the right breast • Hard, non-tender • Well-circumscribed • Movable • Smooth borders • 11 to 2 o’clock position • No enlarged axillary or supraclavicularlymph nodes • No nipple discharge

  14. Pulmonary • Symmetric chest expansion, no retractions • Equal tactile fremiti • No dullness on percussion • Good air entry, clear breath sounds

  15. Cardiovascular • Adynamicprecordium • PMI at 5th ICS, left MCL • Normal rate and regular rhythm, distinct S1/S2, no murmurs • No carotid bruits

  16. Abdomen • Soft, flabby abdomen without scars • Normoactive bowel sounds • Tympanitic • No tenderness • Non-palpable liver edge • No masses • (-) CVA tenderness

  17. Extremities • No rashes/ skin lesions • Warm extremities • Good skin turgor • Full and equal pulses • No cyanosis, no clubbing • CRT < 2 seconds

  18. Neurologic • Awake, alert, well-groomed • Oriented to 3 spheres • GCS 15 • No cranial nerve deficits • MMT: 5/5 • DTRs: 2+

  19. 45/ F, G4P3, housewife

  20. Initial impression Breast cancer, right

  21. Differential diagnoses • Breast cyst • Common in those in their 40s, perimenopausal • Cyclic breast pain • Breast mass • Firm • Well-demarcated • Mobile

  22. Differential diagnoses • Fibroadenoma • Common in the those <30 years • Breast mass • Usually solitary • Rubbery • Round or lobulated • Nontender • Mobile

  23. Diagnostics • Ultrasound of the breast • Solid vs. cystic • Fine needle aspiration • Diagnostic and therapeutic for breast cysts • If suspected cyst proves to be a solid lesion, then material for biopsy may be obtained instead.

  24. Management of solid breast masses. (Harris et. al., 2000. Diseases of the Breast. p.43)

  25. Biopsy (Large bore needle) Invasive ductal carcinoma, Nottingham combined histologic grade III

  26. Tumor staging (TNM )

  27. Tumor staging (TNM )

  28. Tumor staging (TNM )

  29. Preoperative diagnosis • Invasive ductal carcinoma, Stage IIB, T3 N0 M0

  30. Invasive ductal carcinoma • Most common malignant tumor (80%) • Most often present as a palpable mass or mammographic abnormality • Feel like a hard, bumpy, movable, irregularly-shaped lump beneath the areola

  31. Risk factors • Reproductive factors • Age at menarche • Menstrual cycle characteristics • Pregnancy and age at first full-term pregnancy • Nulliparous • Late age at first full-term pregnancy • Number and spacing of births • Lactation/ breastfeeding • Age at menopause

  32. Risk factors • Oral contraceptives • Duration of use • Use before a first full-term pregnancy or at an early age • Postmenopausal hormone use • Dietary factors • Dietary fat intake • Obesity • Dietary fiber • Vitamin A • Alcohol: >1 drink/day

  33. Risk factors • Physical activity: >3 hours/week • Ionizing radiation • Environmental pollution • Organochlorines • Active and passive smoking • Silicone breast implants • Family history (mother and sister, first degree relative) • Jewish heritage • Benign breast disease

  34. Invasive ductal carcinoma • Has a tendency to metastasize via lymphatics • Lymph nodes • Contralateral breast • Liver • Lungs • Bones (vertebra) • Brain

  35. Diagnostics

  36. Diagnostics • Chest x-ray • Normal chest findings • ECG • Non-specific ST-T wave changes

  37. Modified radical mastectomy • To avoid ay chance of local/regional recurrence • To maximize options for breast reconstruction • Most widely used surgical procedure to treat operable breast cancer • Removes the breast, surrounding tissue and nearby lymph nodes • Leaves the pectoralis major intact • Avoids disfiguring hollow defect below the clavicle

  38. Prognosis • Five-year survival rates are highly correlated with tumor stage: • Stage 0: 99-100% • Stage I: 95-100% • Stage II: 86% • Stage III: 57% • Stage IV: 20%

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