Erwin Hernandez Seng Thai Phou Trang Pham Shane Manalang Y Dinh

A 55 year-old white female police officer presents with complaints of a palpable mass under her left nipple. She states that she discovered this lump a few days ago while taking a shower. She also states that her last mammogram was 3 years ago. Her last menstrual period was 4 weeks ago. She has no significant past medical history and denies smoking, alcohol, or any drug usage.

◦ Clinical Breast Exam ◦ Screening Mammography ◦ Breast Ultrasound ◦ Fine Needle Aspiration (FNA)

 Conduct thorough history.  Breast mass ◦ Palpable mass, typically only in one breast ◦ Family history of breast disease, malignant and/or benign ◦ Menstrual and obstetrical histories are important. ◦ Associated symptoms of pain, nipple discharge, and skin changes (eg, dimpling or inflammation, nipple inversion) ◦ Length of time present

 Perform a thorough breast examination for any patient presenting with a breast complaint and for any older woman presenting with unexplained weight loss, or anorexia.  Breast mass ◦ Firm mass of variable shape and size ◦ Fifty percent of masses found in the upper outer quadrant of the breast ◦ May have associated pain with palpation, but most are painless ◦ Nipple discharge or inversion ◦ Skin retraction or tethering ◦ Axillary lymphadenopathy ◦ Inflammatory changes of the skin (ie, peau d'orange)

As the patient is laying supine during the examination, her hands must be above her head. The area for examination should extend from the clavicle, medially to the midsternum, laterally to the midaxillary line, and to the inferior portion of the breast. Additionally, the examination should include the axillary tail of breast tissue and the axilla to search for palpable lymphadenopathy.

Vertical strip pattern- examines the breast tissue in overlapping vertical strips across the chest wall. The vertical strip method is the superior method for ensuring that all breast tissue is examined, because the examiner is better able to track which areas have been examined, and the entire nipple- areolar complex is included.

 The vertical strip technique entails the use of the pads of the 2nd, 3rd, and 4th fingers held together, making dime-sized circles.  The finger pads begin in each circle using light pressure, then repeat in the same area with medium and deep pressure before moving to the next area for examination.

 Ultrasound is used to distinguish solid from cystic mass and to direct needle aspiration for abscess drainage. Simple cysts are seen on sonograms as round or oval with sharply defined margins and posterior acoustic enhancement. Complex cysts are characterized by a significant solid component, septations, lobulations, varied wall thickness, and the presence of internal debris. Abscesses usually appear as ill-defined masses and have central hypoechoic areas with either septations or low-level internal echoes, and posterior enhancement.  Schedule an outpatient mammography to further characterize the suspected breast mass. The sensitivity of mammography ranges from 74-95%, and specificity ranges from 89-99%. Approximately 5-10% of screening examinations are interpreted as abnormal, but 90% of women with abnormal results do not have breast cancer.

 Ultrasound guided Fine needle aspiration  22 or 25 gauge  Sample sent to pathology lab for analysis.

 Complications Breast mass - Chronic pain, scarring or disfigurement, metastases, postsurgical complications (eg, ipsilateral lymphedema), and death.  Prognosis Breast mass: Prognosis varies from excellent in patients with a fibroadenoma to poor in those with inflammatory breast cancer. Influencing factors include tumor size, histology, nodal involvement, distant metastases, and comorbid conditions.

 Patient Education Instruct all women on the correct way to perform breast self-examination.