1. AGE

2. Breast Hx

3. Family History of Breast CA and BRCA

1. Location

2. Changes in size

3. Relationship to menstruation

4. Pain

5. Discharge

Assess estrogen exposure

1. Age at menarche(<12)/menopause (>55)

2. Age at parity (1st >35)

3. Hormone Replacement Therapy

4. Breast Feeding

Physical exam

A) 4 positions: sitting, arms at waist, arms up, supine (arm above head)

B) Express nipple for d/c

C) Examine lymph nodes

Looking for: color, texture, dimpling, edema, ulcers

Observe for 1-2 menstrual cycles

*unless high risk patient

Then Ultrasound if still persistant 

1. Fibrocystic changes

2. Fibroadenoma

Initial workup of breast lump in a patient with a breast lump is...

Cystic feeling mass

1. Ultrasound with FNA 

2. Reassurance 

Initial work up of breast lump in a patient over 30yo 

with Solid mass

1. B/L Mammogram

2. Core biopsy 

- ER/PR/Her2 status

1. Mass post FNA

2. Solid mass

3. Suspicious Mammogram

4. Bloody nipple d/c

5. Skin ulceration

6. Bloody FNA

Galactorrhea 

[image]

N0- no lymph nodes

N1 - mobile lymph nodes

N2 - firm lymph nodes

N3 - + internal mammary lymph nodes

Stage 1 Breast Cancer is ...

5yr survival?

<2cm mass, no LN, no mets

93% 5yr survival

>2cm with mobile lymph nodes

2-5cm with no lymph nodes

72% 5yr survival

2-5cm mass with mobile LN

>5cm mass with no LN

>5cm with mobile mass

Any size tumor with fixed mass

41% 5yr survival

Any size with internal mammary lymph node

Inflammatory breast cancer

Distant metastasis

18% 5yr survival

1. lymph nodes

2. liver

3. lung

4. bone

5. brain

6. adrenals

1. CBC (bone marrow suppresion)

2. LFT (liver METS)

3. CT for METS

4. BRCA testing for possible prophylactic BL mastectomy

benign whirly stromal tissue

Tx:

Observation, or

Elective removal

Patient with painful breast w/menstrual cycle, cystic, nodular fullness...

Dx made with...

Tx is...

fibrocystic disease

Dx: Breast Exam, FNA with straw colored output

Tx: FNA, stop caffeine, OCP, vitamin E, Eve Primrose Oil

MCC mastitis in lactating woman

in non-lactating woman

a. Staph areus

b. polymicrobial

1. Nafacillin

2. FNA for abscess

3. Ductectomy for recurrent mastitis

Core biopsy

or

Excisional biopsy

Since it is smooth and round it may appear to be a fibroadenoma of imaging studies

Phyllodes tumor Tx is

1. Local excision with pathology report

2. if (+) malignant --> simple mastectomy w/ ALND

3. CXR to r/u lung MET

4. If >5cm --> adjuvant chemotherapy

1. ductogram

2. exision of duct/system

Lobular carcinoma in situ

(LCIS)

Dx: incidental on biopsy

- no evidence on imaging

Tx: observation

premalignant lesion --> lumpectomy + XRT

Increases cancer risk by 4-5 of normal population

Comedo, Micropapillar, and Cribiform

Comedo is most aggresive

Lumpectomy + XRT

or

Simple Mastectomy

Padget's Disease

Dx: nipple biopsy

Tx: Excision

Simple Matectomy + SLNB (ALND if +)

or

Lumpectomy w/ XRT + SLNB(ALND if +)

1. chemotherapy

2. hormone therapy

ER+ - tamoxifen

Her2neu+ - herceptin

3.

1. s/p lumpectomy

2. Chest wall invasion

3. >4 lymph nodes

1. +margins

2. tumor size >breast tissue

- big breast get lumpectomies

3. multifocal disease  

1. Long thoracic - winged scapula

2. Thoracodorsal (LATS) lose sensation

3. Medial pectoral

4. Lateral pectoral

Removal of breast tissue, areola, and skin

spares the axillary lymph nodes

Indication:

DCIS with diffuse microcalcifications

or

patients with CI to XRT

(making lumpectomy not an option)

1. Invasive carcinoma (instead of lumpectomy and XRT)

2. Inflammatory breast cancer

1. Arm edema

2. Infections

3. Nerve injury

4. Skin flap necrosis

5. Seroma

6. Phantom Breast

Cyclophosphamide with 5FU and Methotrexate

Used for positive lymph nodes, stage III disease, palliative stage IV disease

Tamoxifen -

Raloxifene - teratogenic

Mammograms q6mo for 2yrs

then yearly

Mammogram

CXR

LFT