BREAST LUMP in Right Breast in 42 year old Patient noticed LUMP 3 months ago

DIET & DRUGs: High in Fatty foods, Alcohol, Smoking, Physical inactivity, High BMI ( 3% increase risk of Breast Ca with every 1 kg/m2 increase in BMI), current medications, Hormone therapy, Radiation or chemotherapy

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DAY 1, Task 1 2 3, 4 & 5, Breast Lump, Group 6.
Dr Tayyab Razzaq, Dr Sumyya Azam,
Dr Wajahat, Dr Anum Afaq, Dr Asad Ali, Dr M.Moiz, Dr Saniya Qamar, Dr Sidra Arshad, Dr Sidra Farooq, Dr Sana Iqbal, Dr Arz Muhammed
Submitted by Dr Sarah Shahab on behalf of Gr.6
AUGUST 4th, 2023

PALPATION: CBE of both breasts, chest, axilla, regional lymph nodes( in the the week fell.menses),
INSPECT asymmetry, masses, skin inflammation, Nipple DC, retraction or inversion

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HISTORY OF BREAST LUMP: Naila describes her lump as hard, painless & rapidly increasing in size
Most palpable breast lumps are benign . Important points in HISTORY any change in size change relative to menstrual cycle, the duration of lump, any pain/swelling size same or increasing Consistency Hard, indurated, mobile/immobile, fixed to underlying tissue or muscle, Tener/ Non-tender Any overlying skin changes

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Nipple D/C : Color straw or bloody--red, brown or black
Any Retraction / inversion of Nipple, any PAIN ( Breast Abscess)

Menstrual cycle & relation of Lump relative to m.cycle

MENSTRUAL History: Early MENARCHE, late MENOPAUSE, fluctuations in Menstrual cycle

FAMILY h/o Breast Ca which is +ive, or of Fibroadenoma,
Fibrocystic disease, Mastitis, Breast Abscess

Previous MEDICAL h/o Breast cysts, Injury, prev.surgery,
infections, intra-ductal Papilloma, Lipoma

Constitutional symptoms: Fever, fatigue, weight loss, anemia

Swelling of part or all of the breast, swelling in axilla
SKIN overlying; is it thickened, flaky, discolored, pu'de orange, erythematous

H/o Breast feeding, Number of children, SOCIO-ECONOMIC status

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RED FLAGS: Hard, fixed, immobile lump, irregular shape, unilateral lump, increasing size ( as in Naila), Nipple changes D/C, any new or worsening pain, axillary L.N. enlargement, Personal or Family H/O Br. Ca ( sister +ive), young age, skin erythema, dimpling, a new breast lump or assoc. with axillary L.N

REFER if any of above RED FLAGS +ive or mass > 5 cms, rapidly enlarging mass, non-tender, fever, wt. loss, fatigue, anemia, distortion of breast architecture or skin, bloody nipple DC or retraction, all new lumps must be assessed

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Naila is obese ( 3% incr. risk with every 1 kg/m2 increase in BMI), nipple inversion +ive, lump is rapidly increasing, FH of Breast Ca +ive in sister who died

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INVESTIGATIONS: After CBE, Ultrasound for benign breast masses, DIAGNOSTIC Mammogram, New PEM Mammogram, MRI, BIOPSY, Tissue studies FNA & Core Needle Biopsy CNB, Excisional Biopsy is the GOLD standard of evaluation

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SURGERY: lumpectomy, Mastectomy, with or without LYMPH Nodes excision, Chemotherapy, Radiotherapy

GENETIC Testing: BRACA1 & BRACA2 to plan Rx, ER/PR ( Biomarkers- Estrogen/ Progesterone Receptors) & HER2 for prognosis & Rx

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TRIPLE Test: is a combination of CBE, IMAGING & TISSUE SAMPLING (FNA) DIAGNOSTIC Accuracy is 100%. TTS score on a 3 point scale when 1= Benign, 2= suspicious, 3=Malignant. A TTS of 3 or 4 indicated a benign lesion, a TTS of 5 needs an excisions biopsy for Diagnosis, TTS of 6 or more means possible malignancy requiring Surgery. If TTS is 3, FOLLOW-UP in 4-6 weeks

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BI-RADs SCORING: A score of BI-RADs 0 means incomplete assessment. BI-RADs 1 is negative for cancer & routine annual screening should be done. BI-RADs 3 is Probably BENIGN as in our patient Naila but she is Obese, +ive FH of Breast Ca is sister--so she should have U/S, Mammogram, FNA & CNB, excisional Biopsy. If Benign lump, then FOLLOW-UP with a scan in 4-6 weeks. Then on in 6 months or earlier as indicated. BI-RADs 4 is Probably Malignant, BI-RADs 5 is Malignant, BI-RADs 6 is Biopsy proven Malignancy so REFER to ONCOLOGIST/SURGEON

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REFERENCES: UK Statistics Authority; 2017. ( Series No. 35).

REFERENCES: Robinson D, Bell J, Moller H, Salman A. District General Hospital breast unit. Breast. 2018; 15(2):173-180. (PubMed)

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