SAINT LOUIS UNIVERSITY

College of Medicine
Department of Surgery
Problem-Based Learning
August 11, 2010

SO, Reda A. Dr.

Depaynos
Med III

1. Impression
• Breast Mass Left, T/C Malignancy
Basis:
o 2-3 cm moveable, slightly tender mass at the left upper outer quadrant
o Firm mass with poorly delineated borders
o Several distinct palpable lymph nodes on the left axilla
o Minimal blood nipple discharge from left breast

Risk factors:
 Family history of breast and ovarian cancers (relatives
on maternal side)
 Menarche at 12 years of age
 Presently irregular menstruation

2. Differential Diagnoses

Fibroadenoma Cysts Cancer

Usual age 15-25, usually 30-50, regress 30-90, most
puberty , and young after menopause common over
adulthood, but up to except with age 50
age 55 estrogen therapy
Number Usually single, may Single or Usually single,
be multiple multiple although may
coexist with other
nodules
Shape Round, disclike or Round Irregular or
lobular stellate
Consistency May be soft, usually Soft to firm, Firm or hard
firm usually elastic
Delimitation Well delineated Well delineated Not clearly
delineated from
surrounding
tissues
Mobility Very mobile Mobile May be fixed to
skin or
underlying
tissues
Tenderness Usually nontender Often tender Usually
 SAINT LOUIS UNIVERSITY
College of Medicine
Department of Surgery
Problem-Based Learning
August 11, 2010

nontender
Retraction Absent Absent May be present
signs

3. Rule out Differential Diagnoses:

• Clinical examination
• A radiological assessment – mammography or ultrasound
• A pathological assessment – cytology or biopsy

4. Based on history alone – test encouraged to patient to have

Palpable Lesions
- FNA biopsy
• Outpatient setting
• 1.5 inches, 22-gauge needle attached to a 10-ml
• Sensitivity and specificity approaches 100%
- Core – needle biopsy
• 14-gauge needle (Tru-Cut needle)
 SAINT LOUIS UNIVERSITY
College of Medicine
Department of Surgery
Problem-Based Learning
August 11, 2010

5. Diagnostic modalities to request

6. Stage of the patient’s disease

Stage IIB T N M
2 1 0

T2 tumor >2cm but not >5cm in

greatest dimension
N1 Metastasis to movable
ipsilateral axillary LN
M0 No distant metastasis

7. Surgical options
 SAINT LOUIS UNIVERSITY
College of Medicine
Department of Surgery
Problem-Based Learning
August 11, 2010

 Extended simple mastectomy

o removes all breast tissue, the nipple-areola complex, skin, and the
level I axillary LN
 Modified radical mastectomy
o removes all breast tissue, the nipple-areola complex, skin, and the
level I and the level II axillary LN
 Halsted radical mastectomy
o removes all breast tissue and skin, the nipple-aroela complex, the
pectoralis major and pectoralis minor muscles, and the level I, II,
and III axillary LN

8. Need to do with the specimen

Pathologic examination of a biopsy can determine whether a lesion is
benign or malignant, and can help differentiate between different types of
cancer.
For example, a pathologist would examine a mastectomy specimen,
even if a previous nonexcisional breast biopsy had already established the
diagnosis of breast cancer. Examination of the full mastectomy specimen
would confirm the exact nature of the cancer (subclassification of tumor and
histologic "grading") and reveal the extent of its spread (pathologic
"staging").