52 y.o./ female with chief complaint of right breast mass.
4 month prior – noted right breast mass
PE
Right breast mass, 3 cm, solid, hard, ill-defined border, movable, tender, very near subareolar area with no axillary node
Primary and Secondary Clinical Diagnoses?
Primary Clinical Diagnosis: Right breast mass, cancer
Secondary Clinical Diagnosis: Right breast mass, fibroadenoma
Bases for Clinical Diagnoses?
Bases for breast cancer –
Solid mass, hard, ill-defined border in a 52 y.o. patient (pattern recognition of breast cancer and prevalence of cancer in this age group)
Bases for fibroadenoma –
Solid movable mass and prevalence (fibroadenoma is the most common benign solid breast tumor)
Hard consistency and ill-defined border are subjective findings
Need for paraclinical diagnostic procedure?
| Degree of Certainty | Plan of Treatment | |
| Breast Cancer | Not quite certain (70%) – ?hard, ill-defined, and age | Modified radical mastectomy |
| Fibroadenoma | (30%) | Excision |
Yes, need paraclinical diagnostic procedure because of uncertainty of clinical diagnosis at this point and plans of management for both primary and secondary diagnoses are markedly different. Beside, if the mass turns out to be really breast cancer, the plan for modified radical mastectomy is still mutilating calling for a more definitive diagnosis prior to mastectomy.
What is the most cost-effective paraclinical diagnostic procedure?
| Benefit | Risk | Cost | Availability | |
| Biopsy | Direct exam – info (can be informative in 90% or more – can give a more definitive diagnosis of breast cancer in 90% of the time) | Pain on needle puncture or cutting
Scar in open biopsy |
PhP 1,000 | A |
| Mammography | Indirect exam – shadowing (can be informative in 50% of the time) | Radiation
Painful compression |
PhP 1,000 | A |
| Ultrasound | Indirect exam – shadowing (can\t tell whether malignant or benign if solid)
|
None? | PhP 900 | A |
Benefit and cost wise with acceptable risk and availability, biopsy is the option of choice.
Between needle and open biopsy, needle is preferred because information can be gotten in more than 90% of the time. Open biopsy will be informative in 98 to 99% of the time but it is more invasive than needle biopsy.
What to look for in biopsy?
Malignant cells
What are mammographic findings suggestive of breast cancer?
Cluster of microcalcifications
Spiculated mass
What are findings suggestive of benignity in ultrasound of a breast mass?
Cystic nature of the mass
Suppose the result of needle biopsy shows picture consistent with breast cancer.
What is the pretreatment diagnosis?
Right breast mass, breast cancer.
Goal of treatment?
Goal of treatment: to remove the mass with negligible chance of recurrence (local, regional, distant) (with the best survival results)
| Benefit | Risk | Cost | Availability | |
| Surgery | 99% complete removal | Side-effects of operation and anesthesia | PhP 50,000 | Available |
| Chemotherapy | 60% response rate | Side-effects of chemotherapy | PhP 60,000 | Available |
| Radiotherapy | 70% response rate | Side-effects of radiotherapy | PhP80,000 | Available |
Cost in a private setting and includes professional fees
Benefit wise, surgery is the option of choice.
| Survival Rates / Recurrence Rates | |
| Surgery | |
| Surgery + Chemotherapy | |
| Surgery + Radiotherapy |
Pathophysiology
Follow-up
Objectives:
Check results of treatment
Monitor for recurrence
Provide psychosocial support
Frequency of check-up:
ROJ@17nov14
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