Vanderbilt University School of Medicine
VC3 – 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.

 

 

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Prerequisites

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Describe and discuss:

  • topographic and structural anatomy of the breast
  • physiology, including hormonal changes that affect the breast
  • pathophysiology, including the relevance of benign tissue changes to breast cancer
  • epidemiology of breast disease, including genetic patterns of breast disease

 

Demonstrate:

  • ability to take a medical history
  • ability to conduct a complete history and physical and basic physical examination of the breast and lymph nodes
  • basic communication skills

 

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Apply Medical Knowledge in the Clinical Encounter

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1.     Describe and discuss symptoms and signs indicative of breast disease (pain, nipple discharge, and breast mass).

 

2.     Describe and discuss distinguishing features of these common entities in the differential diagnosis of breast masses:

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

 

3.     Describe and discuss incidence, epidemiology, and risk factors (genetics and environmental) associated with breast cancer.

 

4.     Describe and discuss the general indications, uses, and limitations of mammography.

 

5.     Describe the importance and impact of screening mammography.

 

6.     Describe other evaluation modalities:

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

 

7.     Describe and discuss the following pathological diagnoses, including the biology, natural history, and prognosis of each:

  • infiltrating ductal carcinoma
  • infiltrating lobular carcinoma
  • ductal carcinoma in situ (DCIS)
  • lobular carcinoma in situ

 

8.     Describe and discuss principles of the basic options available for 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.     Describe and discuss the use of tumor, nodes, and metastases (TNM) staging in the treatment of breast cancer.

 

10.  Describe steps in the clinical decision tree that are involved in the work-up of a breast mass.

 

11.  Discuss the rationale for using a team approach 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).

 

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Diagnose

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1.     Obtain, document, and present an age-appropriate medical history, including estimated duration of illness and  breast cancer risk factor assessment.

 

2.     Perform a breast and lymph node exam to establish the diagnosis and severity of disease (can’t do this with exam only).

 

3.     Demonstrate skill in identifying location and character of nipple discharge.

 

4.     Discuss indications to do a more comprehensive examination.

 

5.     Generate a list of the most important and likely types of breast disease, recognizing specific history and physical exam findings that distinguish between causes. Consider benign vs. malignant, abscess. Develop a differential diagnosis for:

  • a 20 year old patient with breast mass
  • a 45 year old patient with breast mass

 

6.     Recommend when to order diagnostic and laboratory tests necessary to determine the type of a patient’s breast disease and be able to interpret them, both prior to and after initiating treatment based on the differential diagnosis. Include consideration of test cost and performance characteristics as well as patient preferences.

  • 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

 

7.     Discuss benign, pre-malignant, and malignant pathology results and the role of hormonal receptor analysis and tumor DNA analysis.

 

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Develop a Management Plan

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1.     Discuss the management of the patient with an abnormal mammogram.

 

2.     Discuss the follow-up for a patient with a benign lesion (alterations in lifestyle, imaging studies, cancer risk).

 

3.     Discuss the role of incision and drainage and antibiotics in breast abscess treatment.

 

4.     Discuss the management of breast cancer including:

  • clinical staging of breast CA
  • therapeutic options for the patient with breast CA
    • 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
    • Given that the patient has viable operative options, discuss how the provider can assist the patient in choosing the appropriate approach for her, taking into account her history, resources, access to care, personal needs, body image issues and preferences

 

5.     Demonstrate knowledge of sterile technique in the operating room and simple wound closure, and the ability to remove sutures and drains.

 

6.     Discuss current 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.     Access and utilize appropriate information systems to ascertain information about health system and community resources.

 

8.     Plan for follow-up.

 

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Differential Diagnosis

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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