Based on the document you provided, here is a detailed explanation of breast cancer, including

its risk factors, clinical presentations, and diagnostic approach.

1. Risk Factors for Breast Cancer 🧬

Breast cancer risk factors are broadly categorized as hormonal, non-hormonal, and genetic.
Understanding these helps in identifying individuals who may be at higher risk.

Hormonal Factors

These are related to a woman's exposure to estrogen, as prolonged or unopposed exposure can
increase risk.

 Early Menarche & Late Menopause: Starting menstruation before age 12 or

undergoing menopause after age 55 prolongs the duration of a woman's reproductive life,
increasing lifetime estrogen exposure.
 Reproductive History:
o Nulliparity: Never having a full-term pregnancy.
o First Full-Term Pregnancy After Age 30: A first pregnancy at an early age is
protective, while a later first pregnancy increases risk.
o Never Breastfed: Breastfeeding is considered protective against breast cancer.
 Exogenous Hormones:
o Hormone Replacement Therapy (HRT): Use of HRT within the last 5 years is
associated with an increased risk, particularly with combined estrogen and
progesterone formulations.
o Oral Contraceptives (OCPs): There may be a small, temporary increase in risk
with OCP use, which returns to average levels 10 years after cessation.
 Obesity in Postmenopausal Women: After menopause, adipose (fat) tissue becomes a
major source of estrogen, and excess fat can increase circulating estrogen levels,
elevating breast cancer risk.

Non-Hormonal & Genetic Factors

 Radiation Therapy: High-dose radiation to the chest, such as for Hodgkin's lymphoma,
is a significant risk factor.
 Alcohol Abuse: In women, alcohol is known to increase serum estradiol levels.
 Genetics:
o A family history of breast cancer in a first-degree relative (mother, sister,
daughter) is a key indicator.
o A personal history of other cancers, such as endometrial, ovarian, or colon
cancer, also increases the risk.
2. Clinical Presentations & Metastatic Spread 🔍

Breast cancer can present with various signs and symptoms. A painful breast lump is more
commonly associated with benign conditions, while a painless one is more suspicious for
malignancy.

Common Presentations

 Lump or Swelling: The most common sign. A doctor will inquire about when it was
noticed, how it was discovered, its location, and how it has changed over time.
 Nipple Changes: This includes nipple discharge , which can be bloody, serous, or other
colors, and nipple retraction, where the nipple appears pulled inward.
 Skin Changes: Ulceration (open sore), erythema (redness), or a change in the skin's
texture, such as peau d'orange (orange peel-like dimpling).
 Axillary Mass: A palpable lump in the armpit, indicating possible lymphatic spread.

Metastatic Spread

In advanced cases, breast cancer can spread from the breast to other parts of the body.

 Local Spread: The cancer can infiltrate the skin, muscles, and chest wall.
 Lymphatic Metastasis: The cancer travels to nearby lymph nodes, most commonly the
axillary, internal mammary, and supraclavicular lymph nodes .
 Hematogenous (Bloodstream) Metastasis: The cancer cells enter the bloodstream and
can spread to distant organs, most often the bones (leading to bone pain and pathological
fractures), lungs (causing shortness of breath), liver (leading to jaundice), and brain
(causing headaches, nausea, and vomiting).

3. Physical Examination: Inspection & Palpation 🧬

A thorough physical examination is essential to characterize a breast mass. The patient is

examined in different positions to identify subtle changes.

Inspection

The doctor observes the breasts with the patient in three positions: arms by side, arms straight up,
and hands on hips. This helps to identify:

 Symmetry, Size, and Shape: Comparing the affected breast to the unaffected one.
 Peau d'orange: An orange peel-like appearance of the skin, which becomes more
prominent when the patient raises their arms. This is a sign of lymphatic obstruction.
 Skin or Nipple Retraction: The nipple or skin being pulled inward. This is accentuated
when the patient extends their arms forward or leans forward.
  Nipple Discharge or Ulceration: Visually inspecting the nipple for any discharge or
sores.

Palpation

The doctor uses the pads of their fingers to feel for a lump in all four quadrants of the breast,
avoiding a pinching motion. The key characteristics to note are:

 Site: The upper outer quadrant (UOQ) is the most common location for breast lumps.
 Tenderness: Whether the lump is painful to touch.
 Consistency: The texture of the lump, described as soft, firm, or hard. Malignant lumps
are typically hard.
 Border & Surface: Malignant lumps often have irregular borders and a nodular or
irregular surface , unlike benign lumps which are usually smooth and well-defined.
 Fixation: Whether the lump is fixed to the overlying skin or underlying chest wall,
which is a highly suspicious sign of malignancy.

4. Differential Diagnosis (DDx) of a Breast Lump 🧬

A breast lump can be due to a variety of conditions, both benign and malignant. The physical
exam helps to distinguish between them.

 Benign Lumps:
o Cyst: A fluid-filled sac. It is typically soft to firm, has a smooth and well-
defined border, and is most common in women aged 35-55.
o Fibroadenoma: A solid, benign tumor. It is often called a "breast mouse"
because it is freely movable (not fixed). It has a rubbery consistency with a
smooth, well-defined border, and is most common in young women aged 15-25.
 Malignant Lumps (Carcinoma):
o A cancerous lump is typically hard, has irregular borders, a nodular surface ,
and may be fixed to the surrounding tissues.

5. Nipple & Areola Complex Findings and Bacterial Mastitis 🚨

Nipple & Areola Complex

Changes in this area can also be a clue to the underlying condition.

 Nipple Discharge:
o Unilateral (Single Duct): Discharge from a single duct, especially if it is blood-
stained, is highly suspicious for an intraductal papilloma or intraductal
carcinoma.
 o Bilateral (Multiple Ducts): Discharge from multiple ducts is typically associated
with benign conditions like duct ectasia or fibrocystic disease.
 Nipple Retraction: A recent, persistent nipple retraction that is slit-like or
circumferential and not present from birth can be a sign of underlying malignancy.
 Paget's Disease: A rare type of breast cancer that starts in the nipple. It can be mistaken
for eczema as it presents as a red, scaly rash, but unlike eczema, it often does not itch and
may be associated with an underlying lump.

Bacterial Mastitis

This is an infection of the breast tissue, often unrelated to cancer, but important to distinguish.

 Causes: Often occurs during lactation (puerperal) due to cracked nipples, but can also be
non-lactational, particularly in periareolar areas.
 Clinical Presentation: Characterized by the classic signs of inflammation: severe pain,
swelling, erythema, and warmth to the touch. If an abscess forms, there will be high-
grade fever and a palpable fluctuant (fluid-filled) swelling.
 Management:
o Cellulitic Stage: Treated with proper antibiotics, a supportive bra, warm
compresses, and analgesics. It is important to empty the breast with a breast pump
to prevent milk stasis.
o Abscess Stage: Requires either repeated aspiration with antibiotic coverage or
incision and drainage (I&D) for large abscesses. An "antibioma" is a hardened
swelling that can form if antibiotics are used without draining the pus.

For a visual guide on how to perform a breast examination, you can watch a video at: [suspicious
link removed]

Excellent — you’ve given me a very detailed revision outline from your surgery notes about
breast cancer (Ca breast) and breast lumps. Let me expand on it so you’ll have:

✅ A clear, structured understanding of the topic.

✅ High-yield must-know facts (for exams and practice).
✅ Extra clinical pearls & connections to related concepts.

🧬 BREAST CANCER (Ca Breast) —

Detailed Review

1. 🔑 Risk Factors for Breast Cancer

Think of 3 broad categories: hormonal, non-hormonal, genetic

(A) Hormonal (↑ Estrogen Exposure = ↑ Risk)

 Early menarche (<12 yrs) → longer estrogen exposure.

 Late menopause (>55 yrs).
 Nulliparity (never pregnant).
 Never breastfed → breastfeeding is protective.
 First pregnancy >30 yrs → early full-term pregnancy is protective.
 Exogenous hormones
o HRT (combined estrogen + progesterone) = ↑ risk.
o OCPs → slight ↑ risk (esp. recent use <10 yrs), but risk returns to baseline after
10 yrs off.
 Obesity (postmenopausal) → adipose tissue converts androgens → estrogens.

(B) Non-hormonal

 Radiation exposure (e.g. mantle radiotherapy for Hodgkin’s lymphoma).

 Alcohol abuse → increases circulating estrogen.

(C) Genetic

 Family history → esp. first-degree relatives (mother, sister, daughter).

 Associated cancers: ovarian, endometrial, colon (Lynch syndrome).
 BRCA1, BRCA2 mutations → very high risk.

🔑 Must know for exams:

 Most important modifiable risk = alcohol, obesity, HRT.

 Most important non-modifiable risk = female sex, age, family history.

2. 🧬 Clinical Presentation of Breast Cancer

Common Presentations

 Breast lump → most common.

 Nipple changes → retraction, discharge (esp. bloody).
 Skin changes → ulcer, erythema, peau d’orange (orange peel appearance).
 Axillary mass → enlarged lymph nodes.
 Pain → more often benign, but can occur in cancer.

Advanced/Metastatic Features
  Bone pain, fractures → bone metastasis.
 Breathlessness → pleural effusion, lung metastasis.
 Jaundice → liver metastasis.
 Neurological signs → headache, vomiting, raised ICP (brain mets).

3. 🧬 Spread of Breast Cancer

1. Local spread → skin, nipple, chest wall, muscle.
2. Lymphatic spread
o Axillary LNs (most common).
o Internal mammary nodes.
o Supraclavicular nodes.
3. Hematogenous spread
o Bone (vertebrae, femur, ribs, skull).
o Lungs, liver, brain.

🔑 Mnemonic for distant mets = BBLL → Bone, Brain, Liver, Lung

4. 🧬 Breast Examination
(A) Inspection

 Patient positions:
1. Arms by side
2. Arms raised
3. Hands on hips
 Look for:
o Symmetry, breast size & shape.
o Skin: edema, peau d’orange (lymphatic obstruction).
o Retraction of skin or nipple.
o Ulceration.
o Nipple discharge.

(B) Palpation

 Use flat fingers, quadrant by quadrant.

 Describe lump:
o Site (upper outer quadrant most common).
o Tenderness.
o Consistency (soft, firm, hard).
o Border (regular vs irregular).
 o Surface (smooth vs nodular).
o Fixity (to skin, muscle, chest wall).

(C) Special Checks

 Axillary & supraclavicular lymph nodes.

 Neurological exam of upper limb → brachial plexus involvement.

5. 🧬 Differentiating Breast Lumps (Benign vs Malignant)

Feature Benign (Fibroadenoma, Cyst) Malignant (Ca Breast)
Age Young (15–25 yrs) Older (>40 yrs)
Consistency Smooth, rubbery (FA), cystic Hard, irregular
Mobility Mobile (“breast mouse”) Fixed
Surface Smooth Irregular, nodular
Borders Well-defined Ill-defined
Pain May be painful Usually painless

🔑 Most common benign tumor = Fibroadenoma (“breast mouse”).

🔑 Most common malignant tumor = Invasive ductal carcinoma (NST).

6. 🧬 Nipple Discharge — Important DDx

 Bloody → carcinoma, intraductal papilloma, duct ectasia.
 Serous → fibrocystic disease, duct ectasia, carcinoma.
 Green/black → duct ectasia.
 Purulent → infection/abscess.
 Milky → galactorrhea (physiological, pituitary prolactinoma, drugs).

7. 🧬 Special Breast Cancer Types / Signs

 Paget’s disease of the nipple → eczematous nipple lesion, may destroy nipple,
associated with underlying carcinoma.
 Inflammatory carcinoma → rapid progression, peau d’orange, very aggressive.
 Phyllodes tumor → large, rapidly growing, mostly benign but can be malignant.
8. 🧬 Mastitis vs Carcinoma (Important Differentiation)
 Mastitis / Breast abscess (usually lactational):
o Pain, redness, warmth.
o Fever, fluctuant swelling (if abscess).
o Tx → antibiotics, drainage if abscess.
 Inflammatory breast cancer:
o Rapidly progressive redness, swelling, peau d’orange.
o No fever, systemic signs of infection absent.
o Very poor prognosis.

9. 🔑 Must-Know Exam Facts

1. Most common cancer in women worldwide = Breast cancer.
2. Most common site in breast = Upper outer quadrant.
3. Most common histology = Invasive ductal carcinoma (NST).
4. Most common benign breast condition = Fibrocystic change.
5. Painless hard lump in elderly woman = carcinoma until proven otherwise.
6. Peau d’orange = lymphatic obstruction by carcinoma.
7. Bloody nipple discharge in elderly = carcinoma until proven otherwise.
8. Inflammatory breast carcinoma = most aggressive form.
9. Axillary lymph nodes = most important prognostic factor in early breast cancer.

✅ In short:
When approaching a breast lump → take history → examine → think benign vs malignant →
check for local + systemic spread → confirm with investigations (FNAC/core biopsy,
mammogram, USG).

Would you like me to also create a step-by-step flowchart (“Approach to a Breast Lump”) —
starting from history → exam → DDx → investigations → management? That’s very exam-
friendly and helps with quick recall.

The document you provided outlines the diagnostic and management strategies for breast cancer,
from initial investigations to surgical and adjuvant therapies.

1. Investigations for Breast Cancer 🔬

A diagnosis of breast cancer is based on a triple assessment: a combination of clinical
examination, imaging studies, and pathology. The positive predictive value of this approach is
very high, at 99.9%.

A. Imaging Studies

 Mammography: This is the primary screening tool. It uses low-dose X-rays to create
images of the breast. It's more sensitive in older women because their breasts are less
dense. Signs of cancer on a mammogram include a solid mass with or without stellate
(star-like) features, asymmetric tissue thickening, and clustered micro-calcifications.
 Ultrasound (U/S): A useful tool for differentiating between solid and cystic masses,
especially in younger women with dense breast tissue, which can be difficult to interpret
on a mammogram. U/S can also guide biopsies and identify impalpable lesions. On U/S,
a cyst appears with a well-circumscribed wall, smooth margins, and an echo-free center.
A cancerous mass, however, typically has irregular walls and a characteristic acoustic
enhancement.
 Ductography: This involves injecting a radio-opaque dye into a breast duct, followed by
a mammogram. It's primarily used to investigate blood-stained nipple discharge .
 MRI: A powerful imaging tool, often used for staging and assessing the extent of disease.

B. Pathology

 Fine Needle Aspiration Cytology (FNAC): This is a minimally invasive technique that
uses a thin needle to extract cells from a mass for microscopic examination. While it can
confirm the presence of malignant cells, it cannot distinguish between invasive cancer
and non-invasive (in-situ) disease.
 Core Biopsy: This uses a larger needle to obtain a tissue sample, which is more
definitive. It can differentiate between invasive and in-situ cancer and allows for pre-
operative assessment of hormone receptors (e.g., estrogen, progesterone), which is crucial
for guiding hormonal therapy.

C. Workups

 Routine Workup: Includes a complete blood count (CBC) to check for anemia, which
may be a sign of advanced disease.
 Metastatic Workup: Performed when metastasis is suspected. This includes:
o Lab Studies: An elevated alkaline phosphatase (ALP) level can suggest bone or
liver metastasis.
o Radiological Studies: A chest X-ray (CXR) to check for lung metastasis, an
abdominal U/S for liver metastasis, and a bone scan if the patient is symptomatic
or has an elevated ALP.

2. Management of Breast Cancer 🧬

The management of breast cancer is tailored to the stage of the disease, with different approaches
for early and advanced cases.

A. Early Breast Cancer (Stage I & IIA)

 Surgical Management:
o Mastectomy: The removal of the entire breast tissue. It's indicated for large
tumors, central or multifocal tumors, or based on patient preference. A modified
radical mastectomy is the most common type, which removes the entire breast
and axillary lymph nodes while preserving the pectoral muscles. The radical
mastectomy is now obsolete.
o Breast-Conserving Surgery (BCS): This involves removing only the tumor
along with a margin of healthy tissue (lumpectomy). It's an option for smaller
tumors (<4 cm) and is followed by radiation therapy to reduce the risk of
recurrence.
 Sentinel Node Biopsy: This is the standard procedure for managing the axilla in early
breast cancer without clinically palpable lymph nodes. The sentinel node is the first
lymph node to which cancer cells are likely to spread. A blue dye or radioisotope is
injected to locate this node. If it tests positive for cancer, an axillary lymph node
dissection is performed.
 Adjuvant Treatment: This is given after surgery to kill any remaining cancer cells.
o Radiotherapy: Often given after breast-conserving surgery to the remaining
breast tissue. It's also used if the tumor margins are positive, the pectoralis major
muscle is involved, or for inner quadrant tumors.
o Chemotherapy: Uses drugs to kill cancer cells, especially for more aggressive
tumors.
o Hormonal Therapy: Used for hormone receptor-positive tumors (e.g., estrogen
receptor-positive) to block the effects of hormones that fuel cancer growth.

B. Advanced Breast Cancer

For advanced disease, the focus of management shifts to palliation, aiming to relieve symptoms
and improve quality of life. Treatment typically involves hormonal therapy with or without
radiation therapy.

Perfect 👍 — you’ve shared the Investigations and Management parts for Breast Cancer
(BRCA). Let me now explain everything in detail, clarify why each test/management step is
important, and add must-know clinical pearls that are exam-relevant and clinically important.

🔍 Investigations in Breast Cancer

Breast cancer diagnosis follows the principle of Triple Assessment, which has a PPV (positive
predictive value) of ~99.9% when all three components agree:
 1. Clinical assessment (Hx + Examination)
2. Radiological imaging (mammography/ultrasound/MRI)
3. Pathology (FNAC or core biopsy)

1. Imaging
🧬 Mammography

 Definition: X-ray of the breast (craniocaudal + mediolateral oblique views).

 Best in: Women >40 yrs (breast tissue is less dense).
 Findings in cancer:
o Solid irregular mass ± stellate/spiculated margins
o Clustered microcalcifications (esp. DCIS)
o Asymmetric thickening/density of breast tissue

⚠️ Exam Point: Mammography is less sensitive in young women (<35 yrs) due to dense
glandular tissue.

🧬 Ultrasound (U/S)

 Best for young women (dense breast).

 Findings:
o Cyst → well-circumscribed, smooth walls, echo-free center
o Benign solid mass → round/oval, smooth contour, well defined
o Malignant mass → irregular margins, posterior acoustic shadowing

⚠️ Pearl: U/S is also used to guide FNAC/core biopsy.

🧬 Ductography (Galactography)

 Contrast injected into lactiferous duct → followed by mammogram.

 Indication: Blood-stained nipple discharge (suspicion of intraductal papilloma or
intraductal carcinoma).

🧬 MRI

 Useful in:
 o High-risk women (BRCA mutation carriers)
o Inconclusive mammography/US
o Multifocal/multicentric disease
o Implant evaluation

⚠️ Pearl: MRI is very sensitive but not very specific → can lead to false positives.

2. Pathology (Tissue Diagnosis)

🧬 FNAC (Fine Needle Aspiration Cytology)

 Least invasive method

 Can confirm malignancy
 Limitation: Cannot distinguish invasive carcinoma vs DCIS (in-situ).

🧬 Core Needle Biopsy

 Preferred over FNAC

 Provides tissue architecture → distinguishes invasive vs in-situ
 Allows ER/PR/HER2 receptor testing (important for treatment planning).

⚠️ Exam Pearl: Always do core biopsy when planning surgery, since receptor status guides
therapy.

3. Routine Workups
 CBC → anemia (chronic disease, metastasis to marrow)
 Liver function tests → ALP raised in liver/bone metastasis

4. Metastatic Workups
 Chest X-ray → lung metastasis
 Abdominal U/S → liver metastasis
 Bone scan → if bone pain or ↑ ALP
 CT/MRI Brain → if neurological symptoms (brain mets)
🧬 Management of Breast Cancer
A. Early Breast Cancer (Stage I, II-A)
🧬 Surgery

1. Mastectomy
o Simple mastectomy → removal of entire breast tissue
o Modified radical mastectomy (Patey’s) → breast + axillary dissection +
pectoralis minor removal (pectoralis major preserved)
o Radical mastectomy (Halsted’s) → obsolete

Indications for mastectomy:

o Large tumor relative to breast size

o Central tumor involving nipple–areola
o Multifocal tumor
o Local recurrence after breast-conserving surgery (BCS)
o Patient preference

2. Breast Conserving Surgery (BCS) = Lumpectomy + Axillary clearance + Radiotherapy

o Indicated for tumor <4 cm, localized, well-differentiated
o Always followed by radiotherapy to reduce recurrence risk

⚠️ Exam Pearl: Both mastectomy and BCS have equal survival rates if combined with proper
adjuvant therapy.

🧬 Sentinel Lymph Node Biopsy (SLNB)

 Standard for axillary staging in early breast cancer (clinically node negative).
 Sentinel node detected with blue dye/radioisotope .
 If +ve → axillary lymph node dissection (ALND).

B. Adjuvant Therapy
1. Radiotherapy
 o After BCS (mandatory)
o After mastectomy if:
 Tumor >5 cm
 Positive margins
 Axillary nodal involvement
 Pectoralis muscle involvement
2. Chemotherapy
o Indicated in high-risk tumors, LN positive, HER2+ cancers
o Regimens: Anthracycline/taxane-based
3. Hormonal Therapy
o Tamoxifen (SERM) → premenopausal women (ER+ tumors)
o Aromatase inhibitors (letrozole, anastrozole) → postmenopausal women
o Ovarian suppression (GnRH agonists, oophorectomy) → in young high-risk
women
4. Targeted Therapy
o Trastuzumab (Herceptin) → HER2 positive tumors

C. Advanced/Metastatic Breast Cancer

 Goal: Palliation, not cure
 Hormonal therapy → first choice in ER/PR+
 Chemotherapy → for hormone-negative or resistant disease
 Radiotherapy → for bone pain, brain metastasis, chest wall recurrence
 Bisphosphonates/Denosumab → reduce skeletal complications in bone mets

📌 Must-Know High-Yield Facts

✅ Triple Assessment = Gold standard (PPV ~100%)
✅ Mammography → look for spiculated mass + microcalcifications
✅ FNAC vs Core Biopsy → FNAC cannot differentiate invasive vs in-situ
✅ BCS + Radiotherapy = equivalent survival to mastectomy
✅ Sentinel LN biopsy = standard for axillary staging
✅ Hormonal therapy depends on menopausal status (Tamoxifen vs Aromatase inhibitors)
✅ Trastuzumab → only for HER2+ tumors
✅ Commonest metastasis site → Bone (lumbar vertebrae, femur, ribs, skull)
👉 Would you like me to also make you a quick revision table (one -page format) summarizing
Risk factors + Investigations + Management that you can use for last-minute exam prep?