What are the risk factors on history and physical exam for female breast cancer?

RAHAB was an ENFP; LMEM

R: Radiation

A: Alcohol

H: History of atypical Hyperphasia

A: Age

B: Breast Cancer (previous history)

E: Estrogen Use (after menopause)

N: Nulliparity

F: Family History

P: Pregancy after 30

LM: Late menopause

EM: Early Menarche

Note: Caucasians have higest incidience, Afterican Americans have higher mortality

Describe the composition and organization of the female.

Understand the anatomic basis for the incidence of breast cancer in each of the four quadrants of the female breast.

Upper Outer Quandrant: Axillary and supraclavicular

Lower Outer Quandrant: Anterior pectoral, axillary, supraclavicular, subperitoneal, lmpathatic plexus

Upper Inner Quadrant: Internal mammary nodes, mediastinal nodes

Lower Inner Quadrant: Internal mammary nodes, subperitoneal lympathatic plexus

Identify the 3 most common symptoms that women complain of when they see a physician for a breast problem.

1. Breast lump (benign or malignant)?

2. Breast pain (Cyclic or noncyclic)?

3. Nipple Discharge (serous or bloody)?

What are the 5 characteristics of benign breast mass?

Benign characteristics

-Fluctuates in size during mentrual cycle

-Well defined borders

-Mobile beneath the skin

-Soft cystic quality

-Tender to palpation

If benign characteristics present, probability of breast cancer drops to 1/10.

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What is the most common cause of bloody discharge from the breast? What is the most common cause of serous discharge? What abnormal condition condition might cause a milky discharge?

Bloody discharge: Benign intraductal papilloma

Serous discharge: Benign intraductal papilloma

Milky discharge: (normal) pregnancy and postpartum

DDx: prolactin secreting pituitary tumor, medications,

Hypothyroidism

Understand the techniques used to properly examine the breasts.

1. Chaperone - female

2. Inspection

Sitting upright, leaning forward and arms over head

Evaluate size, shape symmetry, controu, skin color

Look for retraction signs

3. Palpation (3 min/breast)

Best time is 1 week after onset of last period

Patient sitting up and lying supine

Vertical rows most sensitive for finding mass

Tail of Spence and nipple area included

Sensitivity is 54% and specificity is 94% for CA

4. Initial Breast Examination

Between 20-30 y.o. (part of routine physical)

Every 3 years before 40

Yearly after 40

Identify surface indicators of underlying malignancy during breast examination.

Padget's disease

Inflammatory breast carcinoma (Red swollen breasts)

Gynecomastia

What is significance of breast enlargement in the male patient?

Puberty

Chronic hepatic failure or cirrhosis (Liver)

Pituitary or testicular tumors

Medications (aldosterone or cimetidine and steroids)

What is the proper course of action after finding a dominant breast lump on physical exam.

On finding a breast mass a physician has several options depending on patient’s risk factors and findings:

1. Re-examination in 2-3 weeks

2. Mammogram or Ultrasound or MRI

3. Refer for biopsy

What are the 10 characteristics of malignant breast mass?

REMINDERS: Lack Tenderness and Mobility

-Rock hard consistency

-Enlargement (rapid)

-Mass that is dominant (solitary, 3D mass that is distinct form the surrounding tissues, asymmetric relative to other breast)

-Irregular borders

-Nipple Discharge

-Edmea (peau d'orange)

-Retraction signs

    - Due to traction on Cooper's suspensory ligaments

-Superficial venous pattern (increased)

Lack Mobile and Tenderness

-Non mobile and fixed to underlying tissue

-Non tender to palpation

20% of breast masses are malignant.

What are the three types of palpatation?

Circular, Wedge, and Verticle Strip

Verticle Strip being the most sensitive

How do you increase sensitivity to cancer during palpation of breast exam? Decrease sensitivity?

Increases with duration of exam (3 min / breast) Decreases with large or dense breasts

Padget's disease of the nipple

Underlying ductal carcinoma

(not to be confused with eczema)

~red, scaly, crusty patch involving nipple and areola

Acute mastitis

Lactation

Systemic Signs of Infection: fever, chills, malaise

not to be confused with inflammatory breast carcinoma

~infection of glandular tissue of breast that usually involves one breast at a time: affected area is red, hot, swollen, tender. Axillary lymphadenopathy absent.

inflammatory breast carcinoma

Inflammatory breast carcinoma

~entire breast is affected with redness, warmth, and swelling; Axillary lymphadenopathy is present

No lactation