BREAST DISEASE

Risk Factors:
     Personal or family Hx of breast Ca; null parity; delayed childbearing (>30);
     late menopause (>53); No lactation

History:
     Risk factors; Date of mass onset, location & chgs in size
     Tenderness, Menstrual & reproductive Hx; Hormone use
     Nipple discharge;  unilateral bleeding, color of fluid
     Character of menstrual cycle; age at menopause
     Parity and age of 1st pregnancy
     Past Hx of breast biopsies, fibrocystic breast disease, or other benign breast disease

Physical Exam:
     Do complete breast exam with patient sitting and lying supine
     Note: symmetry, contour, nipple position, skin chgs or scars
     Palpate for masses, discharge, arm edema, axillary and supraclavicular nodes
     **Very mobile mass maybe a fibroadenoma

Differential Diagnosis:
     Breast Ca; fibrocystic chgs, fibroadenoma, phyllodes tumor, 
     superficial thrombophlebitis, mastitis, galactocele, duct ectasia, subareolar abscess, 
     fat necrosis, chronic costochondritis

Evaluation of Palpable breast Mass:
     1. Physical characteristics suggest cyst = Fine Needle aspiration
          Insert 22 guage needle and aspirate
               Non-bloody fluid does not need cytology unless recurrent cyst
               Bloody then analyze aspirate and biopsy
     2. Solid Lesion or no fluid obtained when attempting to aspirate
          Insert 22 guage needle with syringe and obtain fine needle aspiration
     3. Recurrent Cyst, residual mass after aspiration or bloody aspirate
          US of breast
               1. Simple cyst = US guided simple aspiration
               2. Fibroadenoma = no need for open biopsy
     4. Mammography should be obtained on any woman over 35 with a palpable mass
          Malignancy suggested by: Stippled calcifications, stellate discrete mass,
          Increased vascularity, asymmetric localized fibrosis, altered subareolar duct
          pattern   
     5. Stereotactic Core Biopsy or Open Biopsy
          Dominant, Solid Breast lesions if Fine Needle is non-diagnostic

Evaluation of Non-Palpable Breast Lesion Detected by Mammography
     Evaluate with Breast Ultrasound
          1. Solid = Mammographic localization then needle localized biopsy
          2. Cystic = follow with self breast exam; physical exam, & mammography
               ** If becomes solid evaluate as a solid mass

TNM Clinical Staging:
     Stage I = Tumor < 2 cm, no nodes, no mets
     Stage II = Tumor < 5 cm, no not fixed, no mets
     Stage III = Tumor > 5 cm; or invasion of skin; or attached to chest wall; 
                or + supraclavicular nodes ; No mets
     Stage IV = Distant Mets

Treatment:
     1. Wide local excision, axillary node dissection followed by radiotherapy And possible
          chemotherapy depending on whether receptors are estrogen sensitive
     2. Modified Radical Mastectomy (pec major & minor are spared); axillary nodes out
     3. Simple Excision
     4. Quadrant Excision