Surgery

45 year old woman with breast mass

Grace Huang on May 26, 2013

45 year old woman with no significant past medical history comes in because she noticed a lump in her breast for the first time yesterday while performing a self breast exam. The mass is about 1 centimeter in diameter and is nontender. The patient reports that she has neither personal history of malignancy nor family history of malignancy. She denies recent unintentional weight loss.

Which of the following, if they were true of this patient, would be most concerning for breast cancer?

Expand all answers
Breast cancer in paternal aunt and mom, both after the age of 60
Bilateral breast cancer in mom at the age of 60
Correct. Bilateral breast cancer, breast cancer in premenopausal women, and breast cancer in men are concerning for BRCA1/2 mutations, which confer high risk of getting breast cancer.


20 pack year history of tobacco
Oral contraceptive use

Which of the following physical exam findings are most concerning for breast cancer?

Expand all answers
Tender, mobile mass with other smaller, tender masses throughout the breast.
This finding is more typical of fibrocystic changes.


Well circumscribed, mobile mass.
This finding is more typical of fibroadenoma.


Single, nonmatted, palpable lymph node in axilla.
Though this could be significant for cancer, an isolated enlarged lymph node may also be secondary to an infection.


Nontender, irregular mass associated with skin dimpling.
Correct. Skin dimpling is due to cancerous invasion of ligaments of the breast that may cause dimpling; therefore, it is important to inspect the breast carefully, asking patients to extend arms above their head, behind the back, and with their arms at their hips with shoulder shrugged to assess for changes.


Physical Exam

General: well appearing in NAD
Breast Exam: nontender, firm, irregular mass palpated at 2 o’clock region 1 cm from nipple of left breast . No palpable lymph nodes in the axillary, cervical, or supraclavicular regions.

Which imaging studies would be most appropriate for her as a next step?

Select all that apply
Expand all answers
Diagnostic mammogram
Correct. Diagnostic mammogram includes focused views, which would help characterize the suspicious mass.


Screening mammogram
Correct. Screening mammogram includes views of contralateral breast, allowing us to check for a potential breast cancer on the other side that may not be palpable on physical exam.


MRI
Breast ultrasound

Screening mammogram shows microcalcifications in left breast. Core needle biopsy is performed which shows ductal carcinoma and patient is H2N positive and ER-/PR-.  Patient also undergoes sentinel lymph node biopsy, which is negative.  Due to her small breast size, she decides to pursue simple mastectomy followed by radiation and Trastuzumab.

Which of the following are contraindications to receiving radiation?

Select all that apply
Expand all answers
History of myocardial infarction 10 years ago
Previous radiation to the same body part
Pregnancy
History of pulmonary embolism
Lupus
Relative contraindication. Patients with lupus are more apt to have exaggerated scarring and healing response.


45 year old woman with no significant past medical history comes in because she noticed a lump in her breast for the first time yesterday while performing a self breast exam. The mass is about 1 centimeter in diameter and is nontender. The patient reports that she has neither personal history of malignancy nor family history of malignancy. She denies recent unintentional weight loss.

Which of the following, if they were true of this patient, would be most concerning for breast cancer?

Expand all answers
Breast cancer in paternal aunt and mom, both after the age of 60
Bilateral breast cancer in mom at the age of 60
Correct. Bilateral breast cancer, breast cancer in premenopausal women, and breast cancer in men are concerning for BRCA1/2 mutations, which confer high risk of getting breast cancer.


20 pack year history of tobacco
Oral contraceptive use

Which of the following physical exam findings are most concerning for breast cancer?

Expand all answers
Tender, mobile mass with other smaller, tender masses throughout the breast.
This finding is more typical of fibrocystic changes.


Well circumscribed, mobile mass.
This finding is more typical of fibroadenoma.


Single, nonmatted, palpable lymph node in axilla.
Though this could be significant for cancer, an isolated enlarged lymph node may also be secondary to an infection.


Nontender, irregular mass associated with skin dimpling.
Correct. Skin dimpling is due to cancerous invasion of ligaments of the breast that may cause dimpling; therefore, it is important to inspect the breast carefully, asking patients to extend arms above their head, behind the back, and with their arms at their hips with shoulder shrugged to assess for changes.


Physical Exam

General: well appearing in NAD
Breast Exam: nontender, firm, irregular mass palpated at 2 o’clock region 1 cm from nipple of left breast . No palpable lymph nodes in the axillary, cervical, or supraclavicular regions.

Which imaging studies would be most appropriate for her as a next step?

Select all that apply
Expand all answers
Diagnostic mammogram
Correct. Diagnostic mammogram includes focused views, which would help characterize the suspicious mass.


Screening mammogram
Correct. Screening mammogram includes views of contralateral breast, allowing us to check for a potential breast cancer on the other side that may not be palpable on physical exam.


MRI
Breast ultrasound

Screening mammogram shows microcalcifications in left breast. Core needle biopsy is performed which shows ductal carcinoma and patient is H2N positive and ER-/PR-.  Patient also undergoes sentinel lymph node biopsy, which is negative.  Due to her small breast size, she decides to pursue simple mastectomy followed by radiation and Trastuzumab.

Which of the following are contraindications to receiving radiation?

Select all that apply
Expand all answers
History of myocardial infarction 10 years ago
Previous radiation to the same body part
Pregnancy
History of pulmonary embolism
Lupus
Relative contraindication. Patients with lupus are more apt to have exaggerated scarring and healing response.


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