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Hypothetical Chief Complaint

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The incidence of male breast cancer, once thought to be relatively stable, now ... The skin dimpling in breast cancer is due to traction on Cooper's ligaments. ... – PowerPoint PPT presentation

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Title: Hypothetical Chief Complaint


1
Hypothetical Chief Complaint
  • I have left nipple swelling

2
History of Present Illness
  • 75 y.o. male was noted to have a painful left
    nipple swelling on 3/15/06. The nurse noted that
    it was an easily palpable lump, with tenderness
    upon palpation. A surgical consult was sought,
    and suggested to perform mammogram and
    ultrasound.

3
  • Past Medical History
  • Dementia
  • HTN
  • GERD
  • Past Surgical History
  • s/p cholecystectomy
  • s/p peg (12/05)

4
Medications
  • Metoprolol 25 mg BID
  • Senna 8.6 mg QHS
  • Ranatidine 150 mg BID
  • Seraquil 25 mg BID
  • Aricept 5 mg QHS
  • Tyenol 160mg/5mL Q 6 hours (PRN)
  • MVI

5
  • Allergies NKDA
  • Social History No smoking, drinking, or
    drugs
  • Family History No history of cancers

6
  • VS T 98.2 P 80 RR 16 BP 100/50
  • Gen AAO x 3, NAD
  • HEENT NC/AT, PERRLA, EOMI, no LAD, OP clear
  • Neck supple, no thyromegaly
  • Chest CTA b/l, aw entry, left breast mass,
    palpable at about 12 oclock, tenderness on
    palpation
  • CV S1S2 nl, RRR
  • Abd soft, NT/ND, BS, no HSM
  • Extremities WINL
  • Neuro no focal neurological deficit, AAO x 3

7
Labs
  • WBC 7.9 Mg 1.8
  • H/H 11.7/39.8 Phosphorus 2.8
  • Platelets 275 Coags 11.2/25.4/.7
  • Na 139 CXR NAPD
  • K 4.1 EKG NSR _at_ 100 BPM
  • Cl107
  • HCO3 29
  • BUN 25
  • Cr 0.9
  • Glucose 78
  • Ca 8.9

8
Radiographic Labs
  • Mammogram
  • Right breast is fatty with some retroareolar
    densities probably representing mild gynecomastia
  • Density of left breast, which can represent
    gynecomastia, but mass cant be excluded
  • U/S indicated and open excision
  • Impression
  • Changes consistent with gynecomastia
  • R/O mass in left breast approximately at 2
    oclock
  • BI-RADS Score
  • Right breast 2
  • Left breast 0

9
Radiographic Labs
  • Ultrasound of Left Breast
  • In the periareolar region at 12 oclock, 1-2, 3,
    4-5 and 6 positions, hypoechoic density is seen,
    some borders have mass effect.
  • There is a slight vascularity within the lesion,
    which measures 1.5 x .69 cm in the radial plane
    and 1.49 cm in the anteradial plane
  • Some compression is seen consistent with
    gynecomastia
  • BI-RADS Score
  • Left Breast 3

10
Radiographic Labs
  • Left Core Biopsy of Breast Mass
  • Breast tissue showing extensive foci of atypical
    ductal hyperplasia in the background of
    gynecomastia.

11
Breast Cancer
  • Marcella A. Escoto
  • St. Barnabas Scholar
  • MS III

12
Breast Cancer
  • Breast cancer is the most common female cancer in
    the U.S.
  • It is the second most common cause of cancer
    death in women.
  • Lastly, it is the main cause of death in women
    ages 45 to 55.
  • However, male breast cancer is rare in contrast
    to female breast cancer.

13
Epidemiology
  • Breast cancer is 100 times more common in females
    than males.
  • In males, breast cancer accounts for breast cancer cases in the U.S. and 0.1 of
    cancer mortality in men.
  • The American Cancer Society estimated that 1,450
    men would have been diagnosed with breast cancer
    in U.S. and 470 would die from this disease in
    year 2004.
  • The incidence of male breast cancer, once thought
    to be relatively stable, now seems substantially
    to be increasing, that has increased from 0.86 to
    1.06 per 100,000 population over the last 26
    years.
  • The median age of onset in males is 65-67 years
    of age.
  • In females, it is estimated that approximately
    211,240 American women would have been diagnosed
    with breast cancer in year 2005, and 40,410 women
    would have died.
  • Breast cancer rates increased by 1.2 per year
    between 1940 and 1980.
  • However, the median age of onset in females is
    45-50 years of age, around 10 years younger than
    males.

14
Back to BasicsANATOMY
  • Basic Structure
  • Composed of glandular, fibrous, and adipose
    tissue.
  • Lies within layers of superficial pectoral
    fascia.
  • Each mammary gland consists of approximately 15
    to 20 lobules, each of which has a lactiferous
    duct that opens on the areola.
  • The breast has ligaments that extends from the
    deep pectoral fascia to the superficial dermal
    fascia that provide structural support referred
    to as Coopers ligaments.
  • The skin dimpling in breast cancer is due to
    traction on Coopers ligaments.
  • The breast frequently extends into axilla as the
    axillary tail of Spence.
  • The breast is also partitioned into 4 quadrants
    by vertical and horizontal lines across the
    nipple
  • Upper inner quadrant (UIQ)
  • Lower inner quadrant (LIQ)
  • Upper outer quadrant (UOQ)
  • Lower outer quadrant (LOQ)

15
Breast Anatomy
16
Quadrants of the Breast
17
Blood and Nerve Supply to the Breast
  • Blood Supply
  • Arterial
  • It is supplied by the axillary artery via the
    lateral thoracic and thoracoacromial branches
  • The internal mammary artery via its perforating
    branches
  • Adjacent intercostal arteries
  • Venous
  • It tends to follow the arterial supply axillary,
    internal mammary, and intercostal veins
  • The axillary vein is responsible for the majority
    of venous drainage
  • The venous drainage is largely responsible for
    metastases to the spine through Batsons plexus.
  • Nerve Supply
  • The breast is supplied by 4 main nerves
  • Long thoracic nerve
  • Thoracodorsal nerve
  • Medial and lateral pectoral nerves
  • Intercostobrachial nerve

18
Lymphatic Drainage to the Breast
  • The lymphatic drainage of the breast is important
    because of its role in the metastasis of breast
    cancer.
  • Lymph tends to pass from the nipple, areola, and
    lobules of the gland to the subareolar lymphatic
    plexus.
  • Most lymph (more than 75), especially from the
    lateral quadrants drain to the axillary lymph
    nodes.
  • The axillary lymph nodes are sub-divided into
    levels
  • Level I (low) lateral border of pectoralis minor
  • Level II (middle) deep to pectoralis minor
  • Level III (high) medial border of pectoralis
    minor
  • Rotters node these nodes lie between the
    pectoralis major and minor muscles.
  • Most of the remaining lymph, particularly from
    the medial quadrants, drains to the parasternal
    nodes or to the opposite breast, while lymph from
    the lower quadrants passes deeply to the inferior
    phrenic nodes.

19
Back to Basics.ANATOMY
20
Risk Factors for Breast Cancer
  • Females
  • Early menarche
  • Late menopause
  • Nulliparity or 1st pregnancy 30 y.o.a.
  • White race
  • Old age
  • Family history of breast cancer
  • Genetic predisposition (BRCA 1, BRCA 2, Li
    Fraumeni Syndrome)
  • Prior personal history of breast cancer
  • DCIS or LCIS
  • Atypical ductal or lobular hyperplasia
  • Males
  • Testicular Abnormalities
  • Undescended testes
  • Congenital inguinal hernia
  • Orchitis
  • Testicular injury
  • Infertility
  • Positive family history
  • Klinefelter Syndrome
  • Elevated endogenous estrogen
  • Previous irradiation
  • Trauma
  • Jewish ancestry

21
Screening for Breast Cancer
  • Breast screening is a method of detecting breast
    cancer at a very early age.
  • There are several methods for to screen for
    breast cancer, and it can begin at a very early
    age.
  • The simple ways to begin to screen for breast
    cancer are
  • Breast Self Examination
  • Mammography
  • Ultrasound

22
Breast Self Examination
  • Breast Self Examination
  • All women should perform a self breast
    examination monthly after the menstrual period,
    when breast swelling and fibrocystic changes are
    less likely to interfere with the detection of a
    lump or mass.
  • This is also followed by a yearly clinical breast
    exam.
  • HOW TO DO THE EXAM
  • First, lift your right hand and place it behind
    your head.
  • Keep the first 3 fingers of your hand firmly
    together.
  • Press the outermost point of your right breast
    (near armpit) firmly in a little circular motion
    with the pads of your fingers. Then continue in a
    large circle all around your breast.
  • Move your finger an inch closer to the nipple and
    feel another circle around the breast. Continue
    circling until you have felt every part of the
    breast, including the nipple.
  • Squeeze the nipple gently to see if any fluid
    comes out.
  • Now change hands and repeat the procedure for the
    other breast.

23
Breast Self Exam (BSE)
24
Mammography
  • 2. Mammogram
  • Mammograms are the most important tools doctors
    have to diagnose and evaluate women who have
    breast cancer.
  • It tends to identify 5 cancers/ 1,000 women
  • It is 85-90 sensitive
  • Gives false positives 10, false negatives 6-8
  • Mammograms are more useful in ages 30 secondary
    to the large proportion of fibrous tissue in
    younger womens breast make more difficult to
    interpret.
  • Recommendation for annual mammograms start at the
    age of 40 however, women with risk factors for
    breast carcinoma should have yearly mammograms
    at an earlier age.
  • The American College of Radiology Diagnostic Code
    interprets the mammograms from negative to highly
    suggestive of malignancy.

25
Mammography
  • American College of Radiology Diagnostic
    Code
  • BI-RADS SCORE
  • 0 incomplete assessment, needs additional
    imaging
  • 1 negative
  • 2 benign finding
  • 3 probably benign recommend short term follow
    up
  • 4 suspicion abnormality consider biopsy
  • 5 highly suggestive of malignancy

26
Ultrasonography
  • Ultrasound is frequently used to evaluate breast
    abnormalities that are found with screening
    mammography or during a physician performed
    breast examination.
  • Ultrasound allows significant freedom in
    obtaining images of the breast from almost any
    direction.
  • However, it is not FDA approved as a screening
    tool for breast cancer. Yet, it is used as a
    first tool in women under 30 years of age when a
    breast abnormality is found secondary to the
    large amount of fibrous tissue found in women of
    this age.
  • Advantages
  • They are good for identifying cystic disease
  • Can assist in therapeutic aspiration
  • It has excellent contrast resolution
  • Disadvantages
  • It lacks spatial resolution (fine detail)
  • It cannot detect most calcium deposits on breast
    tumors
  • It cannot document how much breast tissue has
    been imaged
  • Will not identify lesions

27
Diagnostic Tools for Breast Cancer
  • While physical breast exam, mammography,
    ultrasound, and other breast imaging methods can
    help detect a breast abnormality, biopsy followed
    by pathological analysis is the only definitive
    way to determine if cancer is present.
  • Depending on a number of factors, including how
    suspicious the abnormality appears the size, the
    shape and the location of the abnormality many
    different methods of biopsy can be performed,
    such as
  • Fine Needle Aspiration Biopsy (FNA)
  • Core Needle Biopsy
  • Vacuum-Assisted Biopsy (Mammatome or MIBB)
  • Large Core Surgical (ABBI)
  • Open Surgical (Excisional or Incisional)

28
Fine Needle Aspiration Biopsy
  • Fine Needle Aspiration Biopsy (FNA)
  • It is a percutaneous (through the skin)
    procedure that uses a fine gauge needle (22 or 25
    gauge) and a syringe to sample fluid from a
    breast cyst or remove clusters of cells from a
    solid mass.
  • Advantages
  • Fastest and easiest method of biopsy, where the
    results are easily available.
  • It is excellent for confirming breast cysts
  • Has a low morbidity
  • Only 1-2 false-positive rate
  • Disadvantages
  • The procedure only removes very small samples of
    tissues or cells from breast
  • If the sample is benign fluid, then the procedure
    is ideal. However, if the tissue is solid or a
    cloudy sample, the small number of cells removed
    by FNA only allow for a cytologic (cell)
    diagnosis.
  • False negatives rate up to 10
  • May miss deep masses

29
Core Needle Biopsy
  • 2. Core Needle Biopsy
  • It is also a percutaneous procedure that involves
    removing small samples of breast tissue using a
    hollow core needle.
  • This procedure is usually for palpable lesions.
  • It differs from FNA in that is also uses a larger
    gauge needle (16,14 or 11).
  • Advantages
  • Core needle biopsy usually allows for a more
    accurate assessment of a breast mass than FNA
    because the larger core needle usually removes
    enough tissue for the pathologist to evaluate
    abnormal cells.
  • Disadvantages
  • Still a chance of sampling error
  • Again, like FNA it only removes a sample of the
    mass and not the entire area of concern.

30
Vacuum-Assisted Biopsy
  • 3. Vacuum-Assisted Biopsy (Mammotome)
  • This is a relatively new biopsy that is
    percutaneous procedure that relies on
    stereotactic mammography or ultrasound imaging.
  • Stereotactic mammography involves using computers
    to pinpoint the exact location of a breast mass
    based on mammograms taken from two different
    angles.
  • Vacuum-assisted biopsy is minimally invasive
    procedure that allows for the removal of multiple
    tissue samples.
  • It has been becoming more common that open
    surgical biopsies due to its advantages.
  • Advantages
  • Minimally invasive
  • Usually no significant scarring
  • Does not require stitches
  • No breast deformity
  • Procedure takes less than hour
  • Cost effective

31
Large Core Surgical
  • 4. Large Core Surgical (ABBI)
  • It is a surgical technique that involves removing
    an entire intact breast lesion under image
    guidance.
  • It requires the use of a prone biopsy table and a
    stereotactic mammography.
  • It can remove 5 mm to 20 mm of breast tissue.
  • However, this technique is not widely accepted
    and has bought controversy secondary to that in
    large core biopsy it requires the removal of a
    significant portion of normal breast tissue just
    to reach the lesion.

32
Open Surgical Biopsy
  • 5. Open Surgical Biopsy
  • Traditional open surgical biopsy is the gold
    standard to which other methods of breast
    biopsies are compared.
  • It tends to require a 1.5 cm to 2 cm incision in
    the breast.
  • Excisional Biopsy The surgeon will attempt to
    completely remove the area of concern, often
    along with the surrounding margin of normal
    breast tissue.
  • Incisional Biopsy Similar to excisional biopsy
    except that the surgeon removes only part of the
    breast lesion, usually performed on large
    lesions.
  • Advantages
  • Yields the largest breast tissue sample of all
    breast biopsy methods
  • Gold standard the accuracy is close to 100 for
    a diagnosis
  • Disadvantages
  • Requires stitches and leaves a scar
  • Chances of bleeding, infection, or problems with
    wound healing
  • Mortality risk associated with anesthesia

33
Staging of Breast Cancer
  • TNM Staging for Breast Cancer
  • Tx Cannot assess primary tumor
  • T0 No evidence of primary tumor
  • T1
  • T2
  • T3 5cm
  • T4 any size, with direct extension into the
    chest wall or with skin edema or ulceration
  • Nx Cannot assess lymph nodes
  • N0 No nodal metastasis
  • N1 Movable ipsilateral axillary nodes
  • N2 Fixed ipsilateral axillary nodes
  • N3 Ipsilateral internal mammary nodes
  • Mx Cannot assess metastasis
  • M0 No metastasis
  • M1 Distant metastasis or supraclavicular nodes

34
Staging System for Breast Cancer
35
Treatment
  • The primary goal of local therapy is to provide
    optimal control of the disease in the breast and
    regional tissue while providing the best possible
    cosmetic result.
  • The different types of treatment may include
    surgery, radiation therapy, adjuvant
    chemotherapy, adjuvant endocrine therapy, or a
    combination of modalities.

36
Surgical Treatment
  • The optimal surgical approach is determined by
    the following factors
  • Disease stage
  • Tumor size
  • Tumor location
  • Breast size and configuration
  • Number of tumors in the breast

37
Surgical Treatment
  • Radical mastectomy Resection of all breast
    tissue, axillary nodes, and pectoralis major and
    minor muscles.
  • Modified radical mastectomy Same as radical
    mastectomy except pectoralis muscles left intact.
  • Simple mastectomy Resection of all the breast
    tissue, except pectoralis muscle left intact and
    no axillary node dissection.
  • Lumpectomy and axillary node dissection
    Resection of mass with rim of normal tissue and
    axillary node dissection good cosmetic result.
  • Sentinel node biopsy Recently developed
    alternative to complete axillary node dissection.
  • Lymph nodes are identified on pre-operative
    scintigraphy and blue dye is injected in the
    periareolar area.
  • Axilla is opened and inspected for blue and/or
    hot nodes identified by a gamma probe.
  • When sentinel node is positive, an axillary
    dissection is completed.
  • When sentinel node is negative, axillary
    dissection is not performed unless axillary
    lymphadenopathy identified.

38
Breast Cancer
  • There are many different types of breast cancers,
    and they can be distinguished by the following
  • Infectious/Inflammatory Disease
  • Mastitis
  • Fat Necrosis
  • Benign Disease
  • Fibroadenoma
  • Cystosarcoma Phyllodes
  • Intraductal Papilloma
  • Gynecomastia
  • Atypical Ductal Hyperplasia
  • Pre-Malignant Disease
  • Ductal Carcinoma In Situ (DCIS)
  • Lobular Carcinoma In Situ (LCIS)
  • Malignant Disease
  • Infiltrating Ductal Carcinoma
  • Infiltrating Lobular Carcinoma
  • Paget Disease (of the Nipple)

39
Infectious/Inflammatory Breast Disease
  • Mastitis
  • It is usually caused by S. aureus or
    Streptococcus spp.
  • It commonly occurs during early weeks of breast
    feeding, in which there is focal tenderness with
    erythema and warmth of overlapping skin.
  • Diagnosis Ultrasound can be used to localize an
    abscess
  • Treatment Continue breast feeding and recommend
    breast pump as an alternative.
  • If cellulitis would perform wound care and IV
    antibiotics, and if abscess would do incision and
    drainage followed by IV antibiotics.
  • Fat Necrosis
  • It usually presents as a firm, irregular mass of
    varying tenderness, with a history of a local
    trauma elicited in 50 of patients.
  • The exam represents irregular mass with no
    discrete borders that may or may not be tender.
  • Diagnosis and Treatment Excisional biopsy with
    pathologic evaluation for carcinoma.

40
Mastitis Fat Necrosis
41
Benign Breast Disease
  • Fibroadenoma
  • It is a fibrous stroma surrounds duct-like
    epithelium and forms a benign tumor that is
    grossly smooth, white, and well-circumscribed.
  • It typically more common in blacks, and occurs in
    the late teens to early 30s.
  • This disease is also estrogen-sensitive, which
    has increased tenderness during pregnancy.
  • The breast exam shows smooth, discrete, circular
    and mobile mass
  • Diagnosis FNA
  • Treatment Observation

42
Benign Breast Disease
  • Cystosarcoma Phyllodes
  • It is a variant of fibroadenoma, in which the
    majority are benign
  • The patients tend to present later than those
    with fibroadenoma
  • They tend to be indistinguishable from
    fibroadenoma by ultrasound or mammogram, but can
    only be distinguished on their histologic
    features (phyllodes has more mitotic activity).
  • The breast exam shows large, freely movable mass
    with overlying skin changes.
  • Diagnosis Biopsy with pathologic evaluation
  • Treatment
  • Small Tumors Wide local excision with a least a
    1 cm margin
  • Larger Tumors Simple mastectomy

43
Cystosarcoma Phyllodes
44
Benign Breast Disease
  • Intraductal Papilloma
  • It is a benign local proliferation of ductal
    epithelial cells, that has unilateral
    serosanguineous or bloody nipple discharge.
  • Patients usually present with subareolar mass
    and/or spontaneous nipple discharge.
  • In examination one must radially compress breast
    to determine which lactiferous duct express fluid
  • Diagnosis Definitive diagnosis by pathologic
    evaluation of resected specimen.
  • Treatment Excise affected duct

45
Benign Breast Disease
  • Gynecomastia
  • It is the development of female-like breast
    tissue in males, which can either be physiologic
    or pathologic.
  • There is at least a 2 cm of excess subareolar
    breast tissue present to make the diagnosis.
  • The causes can be medications, illicit drugs,
    liver failure, increased estrogen, and/or
    decreased testosterone.
  • Treatment Treat underlying cause if specific
    cause identified if normal physiology is
    responsible, only surgical excision.

46
Benign Breast Disease
  • Atypical Ductal Hyperplasia (ADH)
  • It is the name given to a condition that can
    occur in the lining of the milk ducts in the
    breast.
  • This typically is benign in both males and
    females but can be at risk for developing cancer
    hence, further studies are needed.
  • In women, this disease rarely proceeds on towards
    cancer, and it is not cancer.
  • In men however, when ADH is diagnosed with a
    background of gynecomastia there is a 4-5 times
    increased risk for the development of invasive
    breast carcinoma.
  • Diagnosis Biopsy
  • Treatment Observation, or surgical resection

47
Atypical Ductal Hyperplasia
48
Pre-Malignant Disease
  • Ductal Carcinoma In Situ (DCIS)
  • It is the proliferation of ductal cells that
    spread through the ductal system but lack the
    ability to invade the basement membrane. It
    arises from the inner layer of epithelial cells
    in major ducts.
  • More than ½ the cases occur after menopause, in
    which there is a palpable mass some of the times.
  • Diagnosis Clustered microcalcifications on
    mammogram, malignant epithelial cells in breast
    duct on biopsy.
  • Risk of invasive cancer There is increased risk
    in ipsilateral breast, usually same quadrant
    where infiltrating ductal carcinoma is most
    common histologic type.
  • Treatment
  • If small (follow-up or radiation
  • If large ( 2 cm) Lumpectomy with 1 cm margins
    and radiation
  • If breast diffusely involved Simple mastectomy

49
Ductal Carcinoma In Situ
50
Pre-Malignant Disease
  • Lobular Carcinoma In Situ (LCIS)
  • It is a multi-focal proliferation of acinar and
    terminal ductal cells, which arises from cells of
    the terminal duct-lobular unit.
  • The vast majority of the cases occur prior to
    menopause, and one usually does not feel a
    palpable mass.
  • Diagnosis Typically a clinically occult lesion
    undetectable by mammogram and incidental on
    biopsy.
  • Risk of invasive cancer There is an equally
    increased risk in either breast, infiltrating
    ductal carcinoma associated with simultaneous
    LCIS in the contralateral breast in over ½ the
    cases.
  • Treatment None, bilateral mastectomy an option
    if patient is at high risk.

51
Lobular Carcinoma In Situ
52
Malignant Disease
  • Infiltrating Ductal Carcinoma
  • This is the most common invasive cancer in both
    males and females (80 of cases).
  • It is the most common in perimenopausal and
    postmenopausal women.
  • Presentation A hard, fixed mass, peau d
    orange overlying the skin, ulceration of
    overlying skin, bloody nipple discharge, inverted
    or retracted nipple.
  • The ductal cells tend to invade stroma in various
    histologic forms described as scirrhous,
    medullary, comedo, colloid, papillary, or
    tubular.
  • Medullary Invasive breast cancer that forms a
    distinct boundary between tumor tissue and normal
    tissue.
  • Colloid Formed by mucus producing cancer cells
  • Can have metastasis to axilla, bones, lungs,
    liver and brain.

53
Infiltrating Ductal Carcinoma
54
Malignant Disease
  • Infiltrating Lobular Carcinoma
  • It is the second most common type of invasive
    breast cancer (10 of cases).
  • It originates from terminal ducts cells and, like
    LCIS, has a high likelihood of being bilateral.
  • 20 of infiltrating lobular carcinoma have
    simultaneous contralateral breast cancer.
  • Tends to present as an ill-defined thickening of
    the breast.
  • Like LCIS, lacks microcalcifications and is often
    multi-centric
  • Tends to metastasize to the axilla, meninges, and
    serosal surfaces.

55
Infiltrating Lobular Carcinoma
56
Malignant Disease
  • Paget Disease (of the Nipple)
  • It is usually 2 of invasive breast cancers
  • They are usually associated with underlying LCIS
    or ductal carcinoma extending within the
    epithelium of the main excretory ducts to skin of
    nipple and areola.
  • Presentation Tender, itchy nipple with or
    without a bloody discharge with or without a
    subareolar palpable mass
  • Treatment Usually requires a modified radical
    mastectomy.

57
Paget Disease of the Nipple
58
Metastasis
  • Breast cancer tends to metastasize to the
    following places
  • Lymph nodes (most common)
  • Lung/pleura
  • Liver
  • Bones
  • Brain

59
Prognosis
  • Approximately 50 of patients with operable
    breast cancer develop recurrent disease unless
    they receive adjuvant chemotherapy or hormone
    therapy. Prognostic factors include
  • Tumor size Tumors larger than 5 cm are
    associated with a decreased survival rate and
    increased recurrence rate.
  • Axillary node status
  • Histopathology
  • Hormone receptor status
  • Oncogenic expression

60
5 Year Survival Rate According to Stage
61
Summary
  • Breast cancer is the most common female cancer,
    in contrast to male where it is rare, with a
    ratio of 1001.
  • When performing an initial evaluation of patients
    with possible breast disease
  • Remember to have a complete medical history,
    including risk factors, such as
  • Ask when first menarche, first child, any history
    of breast cancer, when did menopause happen, how
    old is the patient, any previous breast biopsy,
    etc.
  • Be sure to inquire about any history of nipple
    discharge, or any changes in the size, shape,
    symmetry, or contour of the breasts.
  • Remember to inspect and palpate all four
    quadrants of the breast, the axillary lymph
    nodes, and the nipple-areolar complex for any
    discharge.
  • Screening test of choice Mammogram
  • Diagnostic Test Biopsies
  • Treatments Surgical, Hormonal, Adjuvant Therapy
    Chemotherapy, Radiation Therapy

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Surgical Specimen of Left Mastectomy
  • Gynecomastia with atypical ductal hyperplasia
  • Note
  • The breast shows duct hyperplasia with periductal
    edema
  • Some ducts show atypical micropapillary
    hyperplasia
  • Few ducts show disorderly proliferation of
    epithelial cells nearly fills the duct
  • Focal duct dilation and apocrine metaplasia are
    also present
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