Week 4 - Breast change

Question 1

Mrs. JM is a 45 year old woman, primary school teacher, living in Weipa.

Take a history of this patient.

HPC:
• ‘Odd change in my left breast when I was showering last week”
• Duration: Noticed it 8 days ago.
• “My breast feels a bit thicker - points to upper outer quadrant*
- Commonest location of malignancy.
• No pain, nipple discharge or trauma to breast.
- No pain - inflammatory disorders less likely.
- 3 types of discharge - blood (papilloma), pus (duct ectasia) and milk (excess prolactin - pituitary tumours). No discharge in malignancy.
• Menstrual cycle - regular. Mastalgia - not usually, some times*
- Pain in breast mid cycle - suggestive of fibrocystic disease.
• LMP - about 4/52 ago, K due now.
• Age of menarche: 13 years* Parity: None* (failed IVF/infertility)
- Early menarche, late menopause, nil parity - risk factors for cancer due to excess oestrogen.
• Appetite, weight: stable
- To exclude malignancy.
• Was on COCP* ages 17-30 yrs.
- Relationship to OCP and cancer*
• Cervical smear - never*
• Never had mammogram/breast USS* ‘I check regularly’*

Answer 1

HPC:
• Site
• Onset - when did you first notice?
• Character - describe the change/lump i.e. hard, mobile/fixed, single/multiple.
• Timing - have you ever experienced anything like this before?
• Associated symptoms i.e. pain, nipple discharge/bleeding, trauma to breast, tenderness, change in size/texture over time (i.e. thickening of breasts)

Malignancy:
• Weight loss, fatigue, loss of appetite

Fibrocystic disease:
• Mastalgia - pain (firm, tender) in breast during mid cycle

PMHx:
• Past medical history of any cancer?
• Menstrual cycle - regular/any changes? pain mid cycle?
• Age of menarche?
- Early menarche a risk factor.
• Menopausal?
- Late menopause a risk factor.
• Do you have children, how many pregnancies have you had? Age of first pregnancy?
- Nulliparity/late first pregnancy a risk factor.

PSHx:
• Any recent surgeries?

Medications:
• Any regular medications? i.e. OCP.

Allergies:
• Agent, reaction, treatment.

Immunisations:
• E.g. Fluvax, pneumococcal.
• Screening - mammogram, pap smear? i.e. when was last one, regular check ups, past abnormalities. Do you conduct regular self examinations of breasts?

FHx:
• Family history of any breast/ovarian cancer (and age affected)?

SHx:
• Background
• Occupation
• Education
• Religion
• Living Arrangements
• Smoking
• Nutrition i.e. obesity is a risk factor.
• Alcohol/recreational drugs i.e. heavy alcohol use.
• Physical activity

Systems Review:
• General - weight change, fever, chills, night sweats?
• CVS - chest pain, palpitations, orthopnoea/PND?
• RS - dyspnoea, cough, sputum or wheeze?
• GI - vomiting, diarrhoea, indigestion, dysphagia, change in bowel habit, abdominal pain?
• UG - dysuria, polyuria, nocturia, urgency, incontinence, urine output?
• CNS - heachaches, nausea, trouble with hearing or vision?
• ENDO - heat/cold intolerance, swelling in throat/neck, polydipsia or polyphagia?
• HAEM - easy bruising, lumps in axilla, neck or groin?
• MSK - painful or stiff joints, muscle aches or rash?

Question 2

Perform a physical examination on this patient.

Answer 2

Introduction:
• Wash hands.
• Name, patient preferred name.
• Explain procedure - breast exam 3 parts and pelvic exam 3 parts.
• Any questions?
• Any pain or discomfort - can stop at any time?
- May be some discomfort at some stages of the examination but I will warn you before and let me know if you would like to me to stop.
• Verbal consent.
• Ask patient if they need to go to bathroom - empty bladder.
• Ask patient if they would like a chaperone.

Breast Exam - 3 Parts
1. Lymph nodes (patient sitting on edge of bed clothed) - patient rests arm on you.
• Supraclavicular/infraclavicular (patient shrugs shoulders).
• Anterior (pectoral)
• Posterior (subscapular)
• Lateral
• Central (patient relaxes arm down).

2. Breast inspection with arm movements (ask patient to remove top).
   • Hands on hips, move shoulders forward and back.
   • Raise arms upward and back down.
   • Checking for symmetry, discharge, visible masses, teathering of skin etc.
   • Once complete, ask patient to cover up and lay down on bed.
3. Breast palpation (patient lying down on bed).
   • Ask patient to remove drape/top on one side.
   • Linear method - superficial and deep palpation. Keep fingers in contact with skin, skip nipples.
   - Ask patient if they check their breasts regularly - inform patient they should check breasts once a month (e.g. in bed or shower) - should wait for a few days after period so not painful or if post-menopausal can check anytime.
   • Nipple palpation - “I am now going to examine nipples” - rocking motion above/below and side to side.
   • Nipple discharge - “I am now going to check for any discharge. - 2 fingers above/below and side to side - push down and pull skin apart.
   • Ask patient to cover back up and rest while you prepare for pelvic exam.

Question 3

What is your provisional and differential diagnoses?

Answer 3

• Provisional diagnosis: Breast cancer.
• DDx:
- Benign proliferation.
- DCIS.
- Fibrocystic disease.

Question 4

What investigations would you carry out on this patient?

Answer 4

• Mammogram.

• Better than breast USS.
• <35 yrs - favour USS first (more fibrous).
• > 35 yrs - favour mammogram first (more fatty).

• FNAB.

• Biopsy - FNA vs. core biopsy.
• Favour core biopsy for anything solid/large amount of tissue.
• Favour FNA for anything cystic.

• Breast USS - confirm mass.
- Can guide FNA in.

• CT scan - staging.

• Bone scan.
• Liver or lung mets.
• PET scan.
• Biopsy + immunohistochemistry (HER2)*
• MRI occasionally done on specialist advice e.g. BRCA1 diagnosis with dense breast. Too expensive to use as a routine test.

Question 5

What treatment does this patient require?

Answer 5

Triple test:
• Clinical assessment.
• Imaging - mammogram vs USS.
• Biopsy.