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Vanderbilt Core Clinical Curriculum

Breast Complaints

Breast complaints are common problems that can be caused by a wide variety of acute and chronic disease processes, many of which can be life threatening.

Required Skills/Procedures:

1. Perform situation-appropriate (problem-focused or complete) history and physical examinations
2. Interpret clinical information to formulate a prioritized differential diagnosis
3. Guide the creation of a patient-specific management plan

Appropriate Setting: Inpatient and Outpatient

Expected level of Responsibility: Direct supervision with real patients

Learning Topics during encounters with a patient with BREAST COMPLAINTS can include:

Medical Knowledge Learning Topics related to BREAST COMPLAINTS

1. Symptoms and signs indicative of breast disease (e.g. pain, nipple discharge, and breast mass)
2. Distinguishing features of these common entities in the differential diagnosis of breast masses:

  • fibroadenomas
  • cysts
  • abscesses
  • fibrocystic disease
  • fat necrosis
  • cancer

3. Incidence, epidemiology, and risk factors (genetics and environmental) associated with breast cancer.
4. General indications, uses, and limitations of mammography.
5. Importance and impact of screening mammography.
6. Other diagnostic interventions for breast complaints, such as:

  • the role of ultrasound, needle aspiration, open biopsy, and mammographic needle localization and biopsy
  • the mechanics and value of the stereotactic or ultrasound-guided core needle biopsy

7. Pathological diagnoses (i.e., infiltrating ductal carcinoma, infiltrating lobular carcinoma, ductal carcinoma in situ (DCIS), lobular carcinoma in situ) and their pertinent biology, natural history, and prognosis
8. Principles of the treatment of breast, cancer such as:

  • surgical options: total mastectomy vs partial mastectomy with post-op XRT
  • lymph node evaluation: sentinel LN evaluation or complete axillary LN dissection
  • reconstructive surgery
  • chemotherapy (adjuvant or neoadjuvant)
  • radiation
  • combination therapy
  • hormonal therapy

9. Use of tumor, nodes, and metastases (TNM) staging in the treatment of breast cancer.
10. Clinical decisions involved in the work-up of a breast mass.
11. Team-based care to facilitate the complex discussions and explanation of options for the newly diagnosed breast cancer patient prior to definitive treatment (e.g., team of oncologist, surgeon, plastic surgeon, and radiation therapist).

Diagnostic Evaluation Learning Topics related to BREAST COMPLAINTS:

1. Age-appropriate medical history taking, documentation and presentation pertinent to breast complaints, including estimated duration of illness and breast cancer risk factor assessment
2. Breast and lymph node physical exam to establish the diagnosis and potential severity of disease
3. Identification of the source and character of nipple discharge
4. Recognition of specific historical, epidemiologic, and physical exam findings that distinguish between types of breast disease (e.g., benign vs. malignant vs. abscess). Consider benign vs. malignant, abscess
5. Diagnostic and laboratory tests and their role in diagnosing breast complaints including test performance, cost, and patient preferences. Tests may include:

  • mammography
  • ultrasound
  • MRI
  • needle aspiration, incision and drainage, and therapeutic not really dx
  • fine needle aspiration cytology this should be separated from needle aspiration
  • core needle biopsy, U/S-guided or stereotactic
  • open biopsy
  • mammographic needle localization and biopsy

6. Benign, pre-malignant, and malignant pathology results and the role of hormonal receptor analysis and tumor DNA analysis

Management Plan Learning Topics related to BREAST COMPLAINTS:

1. Management consideration in the patient with an abnormal mammogram
2. Follow-up planning for a patient with a benign lesion (e.g., alterations in lifestyle, imaging studies, cancer risk).
3. Role of incision and drainage and antibiotics in breast abscess treatment
4. Management of breast cancer, including:

  • clinical staging of breast cancer
  • therapeutic options for the patient with breast cancer
    • role of surgery/when to consult a surgeon for further diagnosis & treatment
    • role of radiotherapy
    • role of chemotherapy (adjuvant or neoadjuvant)
    • role of hormonal therapy
    • surgical options including reconstruction
    • patient counseling regarding surgical intervention, including patient history, resources, access to care, personal needs, body image issues, and preferences

5. Management skills, including sterile technique in the operating room, simple wound closure, and the ability to remove sutures and drains
6. Recommendations for early detection and prevention of breast cancer, including:

  • recommendations for screening mammography
  • concerns related to hormone replacement therapy and breast cancer risk
  • the role of genetic screening

7. Use of appropriate information systems to ascertain information about health system and community resources
8. Follow-up planning

Potential Differential Diagnosis Topics Include:

Breast Pain

  • fibrocystic disease
  • cyst
  • mastitis
  • abscess
  • gynecomastia
  • lactating adenoma
  • costochondritis
  • cardiac disease

Nipple Discharge

  • physiologic discharge
  • papilloma (bloody)
  • prolactinoma (milky)

Abnormal Mammogram

  • calcifications or mass lesion
  • describe features of each c/w benign vs malignant disease

Pathologic diagnosis determined by biopsy

  • atypical ductal hyperplasia
  • radial scar
  • carcinoma in situ
    • lobular
    • ductal
  • cancer

Mass Lesion

  • cyst
  • gynecomastia
  • fibroadenoma
  • desmoid
  • fat necrosis (prior op)

Invasive cancer

  • “no special type”
    • ductal
    • lobular
  • special types
    • inflammatory
    • mucinous
    • tubular