A 55-year-old with a palpable mass in the right breast

She is post-menopausal. Breast carcinoma can occur at any age but frequency increases at 40 years. A new breast mass in a post-menopausal woman is cancer unless stated otherwise. She is less likely to be affected by masses that affect premenopausal women such as fibroadenoma and fibrocystic disease.

• Location of the mass
• Since when has the mass been present
• Rate of growth: rapid vs gradual
• Is the mass painful?
• Is the mass ulcerated?
• Are there any other skin changes?
• Does the mass shift position within the breast?
• Is there nipple retraction?
• Is there nipple discharge?
• Is there a mass in the opposite breast?
• Common causes of breast pain include: the luteal phase of the menstrual cycle, pregnancy, hematoma, cysts, mastitis, abscess, galactocele, and nipple fissure Malignant masses are commonly painless Hard fibroadenoma AKA breast mouse is commonly associated with shifting position Swelling found in both breasts include fibroadenoma, fibrocystic change and 3% of breast carcinoma

• Her Last Normal Menstrual Period
• Her First Menstrual Period
• Her Parity and Last Delivery
• Her breastfeeding History
• History of Oral Contraceptive Use or Hormonal Replacement Therapy
• History of Breast or Ovarian Malignancy in her sister or mother
• History of trauma to the breast
• History of breast cancer

All breast masses that persist through one complete menstrual cycle, and all masses in post-menopausal women require evaluation. Remember that a normal mammogram or non-visualization of a palpable mass by ultrasound does not exclude cancer

There is a 5x risk for breast carcinoma with a family history of breast or ovarian cancer. Additionally, there is a very high risk of BRCA1 and BRCA2 mutations

Nulliparous women and women who do not breastfeed have an increased risk of breast cancer

• History of Fever
• History of Purulent Discharge
• History of weight loss
• History of swelling in the armpits or neck
• History of shoulder pain, back pain, or abdominal swelling
• History of coughing up blood or breathlessness
• History of yellow discoloration of the eyes
• History of weakness, impaired sensation, headache, or blurry vision
• Fever, pain, and purulent discharge would indicate an infective process

• Sitting with hands on the hips
• Sitting with hands overhead
• Supine with hands overhead

The best time to examine the breast is 5 to 7 days after the onset of menses. The breasts may be engorged before menses, and during pregnancy making examination more painful and less accurate.

Both breasts are examined sequentially both sitting and supine

Pressing the hands on the hips may bring out dimpling by putting tension on the breast ligaments arising from the pectoralis major fascia

Raising the hands overhead stretches the ligaments of Cooper causing the skin or nipples to retract. It also allows us to expose the undersurface of the breast and examine the axilla

Inspection of the breast

• Compare breast position
• Obvious mass
• Visible swelling in the axilla or neck
• Swelling of the arms

Swelling of the arms may due to lymphatic spread, post-operative axillary vein thrombosis or lymphedema following radical lymphadenectomy of the axillary nodes

Inspection of the skin over the breast

• Ulceration
• Dimpling or retraction
• Peau d’ orange
• Dilated veins

Ulceration is seen in a fungating carcinoma, cystosarcoma phyllodes and a rapidly growing fibroadenoma due to pressure atrophy

Try to pass a probe beneath the skin. It is possible to do so in benign conditions but impossible in malignancy

Peau d’Orange is a pitted appearance caused by cutaneous edema. The pitted marks are attachments or openings of follicles and sweat glands where the skin is firmly attached. It is seen in inflammatory carcinoma due to blockage of the lymphatic ducts.

Dilated veins may indicate Mondor’s disease, a huge abscess, phyllodes tumor or sarcoma

Inspection of the nipples

• The presence or absence of nipples
• Position
• Number
• Retraction
• Cracks and Fissures
• Discharge

Circumferential retraction may indicate breast cancer – the tumor infiltrates and shortens major ducts causing retraction Slit-like retraction may indicate duct ectasia w/ periductal mastitis Bilateral nipple retraction may be congenital Unilateral nipple retraction may indicate carcinoma or may follow fibrosis of a chronic abscess For discharge ask the patient to express. Also check whether retraction reverts as the attempt to express.

Inspection of the Areola

• Redness
• Shininess
• Oedema

Differentiate between eczema and Paget’s disease when examining the Areola Paget’s disease is Unilateral and occurs commonly in older women, there is no itching and vesicles and there may be destruction of the nipple and underlying lump Eczema is bilateral and occurs commonly in younger women. There is itching and vesicles. There is no destruction of the nipple and underlying lump. Unlike Paget’s disease, it has a quick response to local steroids

Bimanual palpation should be performed with the patient lying supine with the ipsilateral arm raised above her head

Palpation of both breasts

• Locate the mass
• Warmth
• Tenderness

Palpation of the mass

• Number of masses
• Location
• Size in 3 dimensions
• Shape
• Margins
• Consistency
• Fluctuation
• Tenderness
• Fixity to skin
• Fixity to breast tissue
• Fixity to chest wall

Mass with irregular surface and ill-defined margins may indicate breast carcinoma

Mass with well-defined margins and globular in shape are benign processes such as breast cysts and fibroadenoma

A cyst is a collection of fluid in a cavity lined by epithelium or endothelium

Breast cysts are fluctuant. They can also occur in fibroadenomas, cystic degeneration in malignancy, chronic abscesses

Fibromas have a firm consistency

Fibroadenomas are hard and feel like a pellet (diffuse shotty feel)

Carcinomas are usually hard to stony hard

Cysts, lipomas, and abscesses are soft in consistency

For fixity, pinch the skin over the mass and see whether it moves. Breast cancer, traumatic fat necrosis, and chronic abscesses are usually firmly tethered to the skin

Palpation of the axilla

• Lymphadenopathy
• Are the lymph nodes discrete or matted?
• Are there fixed or mobile lymph nodes?
• Is there tenderness?
• What is the consistency of the lymph nodes?

Group I nodes: Pectoral, Subscapular, Brachial

Group II nodes: Interpectoral, Central

Group III nodes: apical and supraclavicular

With the shoulder adducted, forearm flexed and resting over your forearm

Push fingers as high as possible to palpate the central nodes

Run fingers against the anterior axillary fold to palpate pectoral nodes

Run fingers against the humerus to palpate the brachial nodes

Stand behind the patient and run fingers against the posterior axillary fold to palpate the subscapular node

Then palpate the deltopectoral grove and superior to the middle 1/3 of the clavicle

• Fibrocystic change: lumpy breast, upper quadrant, blue-dome appearance of cysts in physical exam
• Fibroadenoma: well-circumscribed mobile, rubbery, encapsulated mass
• Intraductal papilloma: unilateral blood nipple discharge in premenopausal women
• Fat necrosis: trauma to the breast or breast surgery, accompanied by pain
• Abscess: painful mass in lactating breast, erythematous and warm, fever, purulent discharge from the mass or nipple
• Galactocele: painful or painless aseptic mass in lactating breast, neither warm nor erythematous

• Ductal carcinoma in situ: not palpable
• Invasive ductal carcinoma: firm, immobile, discrete mass, nipple retraction, painless
• Invasive lobular carcinoma: firm, immobile, discrete mass, nipple retraction, painless, frequently bilateral
• Mucinous carcinoma: gelatinous well-circumscribed mass
• Inflammatory carcinoma: inflamed, tender, warm, erythematous breast, peau d’orange
• Phyllodes tumor: mobile, slow-growing, firm, rubber, and large

• Invasive Breast Cancer
  • Post-menopausal woman with new palpable breast mass
  • Her risk factors for breast cancer include a family history in a first-degree relative and early menarche
  • The mass is non-tender, hard, ill-defined, immobile, and in the upper outer quadrant

• Mammography
• Core needle biopsy

This is part of the triple assessment of breast cancer – physical examination, imaging, tissue sample for pathology

Imaging is done to rule out malignancy, and multicentricity and to screen women older than 30 years

Mammography is generally for women > 35 years and ultrasound < 35 years due to denser breast tissue. Ultrasound can also be used for needle-guided aspiration

FNAC is performed for cystic masses that are painful or enlarging

MRI is not indicated for the workup of a new breast mass due to its high false-positive rate

• Asymmetry
• Clustered pleomorphic calcifications
• Increasing density
• New mass with irregular borders or spiculations

Metastatic workup

• Liver Function Test: for liver metastasis
• Alkaline phosphatase and serum calcium: for bone metastasis
• Chest X-ray: for pulmonary metastasis

Further Investigations for metastasis

• Abdominal and Chest CT: if abnormal chest X-ray and laboratory values
• Bone scintigraphy: suspicious bone pain or abnormal bone studies
• Brain CT or MRI: new onset headache, visual changes, or seizures
• PET scan

• Breast-Conserving Therapy (BCT): Lumpectomy (Partial Mastectomy) + Sentinel Lymph Node Biopsy (SLNB; 2-4 nodes) + Radiation (to decrease risk of local recurrence)
  • Equal survival to mastectomy
  • High local recurrence rate
• Simple Mastectomy with SLNB only
  • Radiation is not needed in early stage

• Simple mastectomy: if a large primary tumor
• Simple mastectomy with axillary lymph node dissection (SLND): if nodes are enlarged and matted
• Modified radical mastectomy (Mastectomy + ALND)
• Neoadjuvant chemotherapy followed by Modified radical mastectomy, then irradiation: for inflammatory breast cancer

Absolute contraindication

• Multiple primary tumors in 2 or more quadrants
• Diffuse malignant microcalcifications throughout the breast
• History of chest wall irradiation
• Positive margins despite repeat excision
• Early pregnancy (radiation cannot be given during pregnancy)

• Estrogen Receptor Blockers: Tamoxifen, Raloxifene, Fulvestrant
• Aromatase inhibitors: Anastrozole
• HER2/Neu Receptor blocker: Trastuzumab

• Anthracyclines: Doxorubicin, epirubicin, idarubicin
• Alkylating agent: Cyclophosphamide
• Antimetabolites: Methotrexate, 5-FU
• Taxanes: Paclitaxel, Docetaxel

• Carcinoma in situ
• Small (<1 cm) tumor with favorable hormonal and molecular characteristics
• SLNB negative

• Long thoracic
• Thoracodorsal
• Medial pectoral
• Lateral pectoral

• Lymphedema
  • ALND is associated with a greater risk of lymphedema than SLNB
• Lymphangiosarcoma in chronic cases (Stuart Treves syndrome)
  • Has a poor prognosis even after limb amputation

This is why SLNB is very useful. It prevents unnecessary ALND