Management  of a Patient with Breast Mass
by Charity M. Cordero-Tumangday, M.D.
Surgery Resident, Year I

Case of a 61/F with a gradually enlarging R breast mass noted since 5 months ago.

Establishing rapport with the patient and her relatives is first step towards a successful management of the case. After such is accomplished, my next move would be to verify the existence of the chief complaint and thereafter formulate a diagnosis.

On breast examination, I palpated an 8x7 cm movable, nontender, hard mass on the  upper outer quadrant of the R breast. I didn’t note any skin involvement. By location I’m pretty sure that the mass is coming from breast tissue. Almost instinctively, my primary concern is to determine the nature of  the mass—whether it is benign or malignant. The mass being hard and  the age of the patient make me suspicious that it is a malignant one. (my primary diagnosis). I proceeded with palpation of the opposite breast, both  axillary and supraclavicular lymph nodes and I did not find any mass. I could ask for the presence of  known risk factors like family history, but these data, though pertinent will not rule in or rule out my primary impression.
 
As good clinical practice, I know I have to have at least a second diagnosis. In this case, if  it’s not malignant, then it must be benign— giant fibroadenoma. The mass being movable and  the absence of  axillary lymph node involvement are findings compatible with a benign process such as fibroadenoma . An inflammatory disease is quite unlikely in the absence of pain, erythema, tenderness, or pus-formation.

Because I’m not a certain about my first diagnosis. I feel the need for a  paraclinical diagnostic  procedure.  The result of which would dictate my plan of management. I would recommend a fine needle aspiration biopsy at this point. The other options I would  offer to the patient include excision of  the mass, frozen section, possible MRM . I personally do not want to bring a patient to the OR not knowing whether she would still have her breast after the operation. If  this is indeed a malignancy I  would want to bring the patient to OR for MRM, mentally prepared and convinced that it is her best chance of survival.  But of course the option is with the patient  and she agreed on an FNAB.

If the tumor turns out to be benign the options I would offer to my patient would be (1) breast mass excision with nipple conservation (2) mastectomy (considering the size of the mass). If  it is malignant  as I expected,  the primary treatment  I would recommend is a modified radical mastectomy. 

The FNAB showed Ductal Carcinoma. The biggest hurdle to tackle at this point is how to break the news to the patient and her relatives. It is a difficult thing to do but it has to be done. I believe that no patient should be deprived of the information concerning the true nature of his or her illness. Especially if  he or she will undergo surgery for that disease.  After an informed consent is secured and the patient psychologically prepared for the operation, the important tasks to handle preoperatively include evaluation of the patient’s general health status and her capacity to undergo the stress of surgery. I would also do a mammography of  the contralateral breast. It is also important to prepare the patient financially or at least give them an idea how much the hospitalization would cost them.  

Intraoperatively, the important points to consider is to determine the extent of the disease, the status of the axillary lymph nodes, to extirpate all breast tissue and axillary content while preserving the axillary vein, thoracodorsal vessels and nerves, the long thoracic and intercostobrachial nerves. In this particular case, there was note of involvement of the axillary lymph nodes. Hemostasis, placement of a JP drain and closure of the wound using Vicryl 4-0 subcuticular sutures followed.

Relief of pain is of great importance in the post-op management. I will also intruct patient on JP drain care, exercise of the R upper extremity and I would also start her on Tamoxifen 20 mg OD. I will tell her that there are no food restrictions and that she can take a bath. I will instruct her on proper wound care. If no complications ensue, I plan to discharge the patient on the 2nd or 3rd post-op day, to remove the JP drain once output goes below 50 cc/day and to have her follow up on out-patient basis after 7 days. I will instruct her to secure the  histopathology of the surgical specimen.

On follow-up, I would inquire of any problems/questions/concerns from the patient. I will check the histopathology report to confirm if the lines of resection are clear of tumor and if the lymph nodes are pathologic. If the lines of resection are positive for tumor, I would recommend post-operative radiation therapy. I will encourage her to comply with Tamoxifen 20 mg once daily for at least 5 years. 

Follow-up plan: 
	Second follow-up 30 days after the operation, then every 6 months for the next two years. If no recurrence or complications ensue, I will have her follow-up annually after the second year. The surveillance would entail a yearly mammogram of the contralateral breast, monthly personal self-breast examination. Any work-up for metastasis would be symptom-directed. I will also encourage an annual gynecologic evaluation since she’ll be taking Tamoxifen. I will inform the patient as to where she can reach me for any questions or undue development.