LUMP PROTOCOL

● Duration: When? Congenital or acquired

● Mode of onset: Sudden  Trauma, infections; insidious  Neoplastic
● Progression
● Assoc Symptoms: Pain, disfigurement, pressure effects (depending on loc)
● Disappearance in different manoeuvres
● Other lumps
● Secondary changes
● Wt loss

Past Hx:
● Previous surgery
● TB
Personal Hx:
● Smoking, Pan
Family Hx:
● TB
● Hx of swellings in other family members: Neurofibromatosis

EXAMINATION
General appearance
A spherical shaped swelling present infront of right knee joint with normal coloured
overlying & surrounding skin. No visible scar mark, pulsations or dilated veins. It is of
normal temp, non-tender, soft with well defined margins smooth surface and size is 4x5 cm.
Overlying skin is mobile & it is mobile in both planes, non-fluctuant, non-reducible,
non-compressible and transillumination is absent. Distal neurovascular status is normal with
no regional lymph node enlargement. Percussion note is dull with no audible bruit.

ULCER PROTOCOL
Hx
● Duration
● Mode of onset
● Progression
● Discharge
● Other ulcers

Past Hx:
● DM
● Varicose veins

EXAMINATION

An oval shaped ulcer of 3 x 5 cm present about 2 cm above the right medial maleolus with
clear watery discharge, sloping edges, granulating/ necrotic floor, surrounding skin is
erythematous. Local temp is raised, it is tender, bleeds on pressure, with hard base, can be
mobilized on overlying structures in both the planes. Distal neurovascular status is intact and
proximal lymph nodes are enlarged (Pulses are week on right side). Other limb is normal.
 Breast:
Follow up:
■ 3 monthly for 1 year,
■ 6 monthly for 1 year
■ And than 1 yearly.
On each follow up visit
● Do a physical examination including the chest wall axilla and
supraclavicular fosse.
● Also examine the chest, abdomen, spine and bones for
recurrence.
● Take a chest x-ray and do USG abdomen if clinically
indicated.
NOTE
● 80% of recurrences occur in the first 2 years. Perform a bone scan after the
surgery only if clinically indicated.
● Perform mammogram of contra lateral breast if patient is above 45 yrs of age.

TREATMENT:
● Premenopausal women with tumour less than 1cm with no nodal involvement
surgery only will suffice.
● All other patients require adjuvant therapy.
● Hormonal therapy only in those patients who are receptor positive and in low risk
group of node negative patients.
● Radiotherapy to the axilla and supra clavicular region if
inadequate clearance i.e.
no. of L.N removed is less than 15.
And 3 or more L.N are involved.
Surgery is a better option for management of axilla.
● Radiotherapy to chest wall in all the patients with tumour more than 4 cm in size
and after BCT.
● Tamoxifen is indicated in only those patients who are ER/PR positive whether pre
or post menopausal. 35% response is seen if only ER or PR positive but up to 80%
response is seen if both are positive.
● For pre menopausal patient use CAF and for post menopausal use CMF
chemotherapy.
● For stage IIIB give 3 to 4 cycles of pre operative neo adjuvant chemotherapy.
● Aromatase inhibitors had a better response than Tamoxifen. But more costly.
● Bisphosphonates reduce the risk of bone mets. And also reduce chances of
pathological fractures.