1. CASE: BREAST CANCER Alegre. Almora. Alonzo. Amaro. Amolenda. Anacta. Andal. Ang. Ang. Ang.

2. General Information 45-y/o F Chief Complaint: Left breast mass.

3. History 1yr PTC Noticed a mass underneath the L nipple measuring initially at 1 X 1 cm. progressive increase in the size of the mass Other relevant data should be taken from the history; Family history; menstrual history; pregnancy; lactation. Menarche; menstrual cycles Sexual History Previous pregnancies Family history of breast cancer Consult

5. Personal risk factors: Gender – Females have a 100-fold increase in risk as compared to males. Age – breast cancer risk increases with age – 96% of breast cancers occur in women age 40 and older (ACS, 2003-2004). Race – Caucasian women have a greater risk of breast cancer than other racial groups. Prolonged exposure to endogenous estrogen and progestins Exposure to exogenous combined estrogen and progestin therapy in hormone replacement therapy for postmenopausal women Breast Cancer Diagnostic Algorithms for Primary Care Providers (Third Edition, June 2005)

6. Alcohol use – greater than 27 drinks per week. (Gronbaek, 2004.) Obesity – obese women with BMI >30 had estrogen concentrations between 60% and 219% higher then thin women Radiation exposure to the upper torso – e.g. treatment of Hodgkin’s lymphoma. Breast Cancer Diagnostic Algorithms for Primary Care Providers (Third Edition, June 2005)

7. Risk Factors Increase number of menstrual cycles (increased estrogen exposure) – Early menarche, nulliparity late menopause Pregnant or Lactating Women – During pregnancy, breast grows secondary to estrogen, progesterone, HPL, prolactin (low levels) – After pregnancy, progesterone drops, increasing effects of prolactin

8. Family History One or more first- or second-degree relatives with breast cancer at an early age (less than 40-50 years of age). Breast cancer and a second primary cancer in a close relative, especially ovarian cancer. – Other cancers w/ a genetic risk include: thyroid, colorectal, prostate, endometrial, pancreatic, adrenocortical carcinoma, melanoma, childhood sarcoma, leukemia/lymphoma, and brain tumors. Male breast cancer in a close relative. Two or more relatives with breast cancer at any age. Breast Cancer Diagnostic Algorithms for Primary Care Providers (Third Edition, June 2005)

9. Physical Exam L breast – 2 X 2 cm. hard, non-tender, & movable mass with irregular margins underneath the nipple. Axilla is negative for any masses. The R breast and the rest of the PE are normal.

10. Personal Risk Factors 45y/o F – 35% benign – 25% cyst – 9% fibroadenoma – 31% other benign lesion

11. Breast Mass Benign round or oval shape circumscribed margins width-to– AP dimension ratio greater than 1.4 Malignant irregular shape microlobulated or spiculated width-to–AP dimension ratio of 1.4 or less Rhabar, et al. Benign versus Malignant Solid Breast Masses: US Differentiation. December 1999 Radiology, 213, 889-894.

12. Working diagnosis Malignant breast lesion – (2 X 2 cm. hard, non-tender, & movable mass with irregular margins underneath the nipple) Clinical stage – T1N0M0 T1: Tumor 2.0 cm or less in greatest dimension N0: No regional LN metastasis M0: No distant metastasis