Approaching A Breast Case

There are 7 steps that you must do when you are dealing with a breast case.
1. History
2. Examination
3. Diagnosis
4. Clinical Stage
5. Investigations
6. Treatmant
7. Follow up

History must cover all the followings:
1. Presenting complaints
2. Risk Factors
3. History suggesting metastasis
4. Constitutional symptoms

Presenting Complaints
Common complaints that a patient will come with are: Palpable mass, Nipple Discharge, Pain, Skin Changes
In Nipple discharge:
- Is it unilateral or bilateral?
- Is it unifocal or bifocal (Uniductal of polyductal)?
- Colour: Serous, Yellowish, Milky, Bloody
Any women despite of age with complaint of bloody nipple discharge, CONSIDER CARCINOMA unless proven otherwise
- Expressed or spontaneous?

Painful breast/Mastalgia
Is it cyclical or non-cyclical?
- cyclical: It is in particular day of menstrual cycle every cycle. Its significant is that it is hormonal related
- non-cyclical: Consider infection as a differential diagnosis

Risk Factors

  • Hormone related:
    • endogenous:
      • early menarche
      • late menopause
      • age at first pregnancy (>30 is a risk factor)
      • Has she breast fed her child? For how long? (Breast feeding less than 6 months or never breast fed her child is a risk factor)
    • exogenous: OCP? HRT?
  • Family history:
    • Breast cancer: 1st degree relatives (6 fold increased risk); 2nd degree relatives (3 fold increased risk)
    • Ovarian cancer
    • Colorectal cancer

- brain: seizure, syncope, giddiness, headache etc.
- lung: hemoptysis, SOB, etc
- liver: palpable liver, mass in liver, etc (REMEMBER, we need only 10% of the liver to be functional, thus jaundice will appear in very advanced disease)
- bone: Urinary incontinence, bone pain (esp. backache), muscle weakness, paraplegia

Constitutional symptoms: In advanced disease
- Loss of weight and appetite

- Same as the approach in swelling examination
- Palpate the breast in circular pattern, whether clockwise or anticlockwise from the nipple area towards the periphery. Remember to palpate the tail and lymph nodes in the axilla. Press the nipple with firm pressure for nipple discharge.

Clinical Staging: TMN Classification
- T0: No palpable mass
- T1: <2 cm
- T2: 2-5 cm
- T3 >5 cm
- T4: Skin/chest wall involved irrespective to size
Lymph Nodes:
- N0: No palpable LN in ipsilateral axilla
- N1: Palpable MOBILE ipsilateral LN
- N2: Palpable FIXED ipsilateral LN
- N3 Palpable Supreclavicular, axillary, inframammary LN
- M0: No metastasis (NOT IN CLINICAL STAGING)
- M1: Distant metastasis
- Mx: Unable to assess

1. Imaging: Ultrasound (Usually done in pts <35 yrs), Mammography (Usually done in pts >35 yrs)
2. Specimen: FNAC (Cytology), Biopsy
3. Abdominal Ultrasound: To detect signs of liver metastasis such as mass in liver, ascites
4. Chest X ray: To detect signs of lung metastasis such as cannon ball lesion, pleural effusion
< Bone and brain are only investigated if it is symptomatic>

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