JUANICO, CLAREEN MAE T.

15/07/2020

ASSIGNEMENT
1. How do you perform a proper physical examination of the breast?
Proper examination of the breast inspection starts by introducing your self to the patient and
explain to her what you are about to do and how you are going to do it. In a sitting position, tell the
patient to position her arms by her side, straight up in the air, and her hands or her hips. The doctor
should note for the symmetry, size, and shape of the breast. Evidence of edema (peau d'orange), nipple
or skin retraction, or erythema must also be noted. With the arms extended forward and in a sitting
position, the woman leans forward to check for skin retraction. Upon palpation breast should be carefully
palpated. Patient is in supine position with a pillow supporting the ipsilateral hemithorax. Physician then
gently palpates using the palmar aspect of her finger, the breast from the ipsilateral side, then examine all
quadrants of the breast from the sternum laterally to the latissimus dorsi muscle and from the clavicle
inferiorly to the upper rectus sheath. The breast then can be cupped or molded in the surgeon's hands to
check for retraction. Checking of lymphadenopathy then is performed, the upper arm and elbow are
supported while the surgeon stabilizes the shoulder girdle. Using gentle palpation, the surgeon assesses
all three levels of possible axillary lymphadenopathy. Supraclavicular and parasternal sites are also
palpated.
2. Enumerate and elaborate on the different diagnostics done for metastatic workup of
breast cancer.
Axillary nodal metastasis is the most important prognostic factor predictive of recurrence and
survival of breast cancer patients. In early stages Chest X‐ray (CXR) and Ultrasound scan (USS) of thhe
abdomen are used for those who are asymptomatic for metastatic disease with normal blood tests.
Onther imaging modalities done stage breast cancer include Computed Tomography (CT), Positron
emission tomography (PET), Magnetic Resonance Imaging (MRI), and Bone Scintigraphy. Chest X ray is
done to check for opacities in the lungs that may indicate breast metastases to the lungs. A bone scan,
also called bone scintigraphy, is an imaging test used to determine whether breast cancer has traveled to
the bones. Bone scan uses radiotracers that are injected to the blood stream. This radiotracers are then
taken up by abnormal active bone production in areas of tissue damage. After 2-4 hours radioactive
substance has been absorbed and the body can now be scanned. Areas of extra bone activity such as in
breast cancer can be detected. Chest X rays, are used to detect if there is metastases to the lungs as it
will manifest with nodule like infiltrates in the xray film. Chest-abdomen-pelvis computed tomography (CT)
scan is also standard imaging procedure for oncologic staging. It is widely available and allows evaluation
of several anatomic structures such as lymph nodes, abdominal organs, lung and bony structures to
detect metastases of malignancies such as in breast cancer. Positron Emission Tomography, is used to
detect areas with cancer by obtaining multiple images. Special dye containing radioactive tracers are
swallowed. These tracers are either swallowed or injected into a vein in your arm depending on what part
of the body is being examined. Radioactive Tracers that are sugar containing will be absorbed in areas
with higher chemical activity. Areas are then highlighted that are suspiciously active and this is indicative
of cancer metastases. Whole-body MRI is the diagnostic tool, both for early detection of bone
metastases, as well as for simultaneous detection of metastases to other common sites (liver and brain)
of breast cancer.

For laboratories, the levels of liver enzymes (special proteins involved in vital chemical reactions)
and bilirubin, to evaluate liver function but this should be correlated with an imaging modality such that of
an ultrasound of the abdomen. Levels of potassium, chloride, creatinine and urea nitrogen levels, reflect
the health of the liver and the kidneys during and after treatment. Calcium levels may also be determined
for abnormal activity of the bone.
 3. What is the role of LDH in breast cancer?

LDH plays a central role in anaerobic glycolysis. It catalyzes the reversible conversion of pyruvate
into lactate. It is comprised six tetrameric isoenzymes with a tissue-specific expression regulated by both
physiological and pathological conditions. In cancer,   LDHA gene expression is upregulated to maintain
glycolysis as an alternative source of energy during hypoxic conditions. Different pathways are able to
regulate LDH levels. As it regulates cellular metabolism it is also known as marker of tissue damage. Its
increased is indicative that there is cell death or necrosis .Beyond its role in regulating cellular
metabolism, LDH is a well-known marker of tissue damage. Many pathological conditions, including
cancer, present with LDH elevation due to acute cell death or necrosis.