INTRODUCTION
Name : Miss S
Age :
58 years old
Gender : Female
Race : Indian
Occupation : Full-time housewife
Status : Married
Address : Gombak, Selangor
Date of admission : 15 April 2018
Date of clerking : 16 April 2018
CHIEF
COMPLAINT
Patient comes to the hospital due
to breast lump for the past 2 months
HISTORY
OF PRESENTING ILLNESS
Patient was apparently well until 2
months ago, when she noticed a lump at the right breast and right axillary area
when she fell down. At first, the lump at the right breast was as big as a
chicken egg and another lump was about 20 cents coin. Both of the lumps were
progressively increased in size where now the lump at the right breast was as
big as an apple ant another lump was as big as 50 cents coin. Initially, there
was no pain at the lumps, however, two weeks after she noticed it, she started
to have pain at the lumps. It was pricking in nature, intermittent pain, no
radiation, exaggerated by excessive movements of right arm and no relieving
factor. Recently, the pain progressively worsening. There was no skin changes
and no discharge neither from the lumps or the nipple. She went to the
outpatient clinic at HKL and had been given medication which is a cream. Then,
she was referred to the Surgical Out-patient Department (SOPD) at HKL. Fine
needle aspiration cytology (FNAC), mammogram and ultrasound had been done, but
she did not know the result. However, the doctor said she had another small
lump at her left breast as well. After a while, FNAC was done for her left
breast lump. Recently, she had loss her appetite and weight as she noticed that
her clothes were loose than before. She denied of having any fever, back pain,
cough, dyspnoea or abdominal pain.
SYSTEMIC
REVIEW
Respiratory system
|
There were no episodes of cough,
breathlessness or hemoptysis
|
Cardiovascular system
|
There was palpitation but no dyspnea,
orthopnea or chest pain
|
Hepatobiliary system
|
The patient has no jaundice
|
Hemopoietic system
|
This system was intact with no jaundice
or bleeding tendency
|
Neuromuscular system
|
This system was intact with no swelling
and weakness of muscles, bones and joints. There were also no abnormality of
movements and coordination.
|
Urologic system
|
No episode of dysuria or haematuria
|
Gastrointestinal system
|
No abdominal pain, constipation nor
diarrhoea
|
PAST
MEDICAL HISTORY
She is a known case of hypertension
which is diagnosed 20 years ago. Currently she is on antihypertensive drug and
well compliant to medication and follow up. Otherwise, she is not known to have
diabetes mellitus, ischemic heart disease or malignancy.
PAST
SURGICAL HISTORY
She had undergone hysterectomy in 1998
at HKL due to uterus prolapse. There was no complication. Otherwise, she was no
undergo any operation.
DRUGS
AND ALLERGY HISTORY
For the past 20 years, she had been
taking tablet captopril 25mg BD. Otherwise, there is no history of chronic ingestion
of non-steroidal anti-inflammatory drugs (NSAIDS) for any reason. She has no
known allergies towards drugs or foods.
MENSTRUAL
HISTORY
She attained menarche at 12 years
old. Her period was regular every 28 days lasted for 4-5 days. She do not experience
dysmenorrhea, menorrhagia, IMB, dyspareunia or post coital bleeding. She had
her menopause at the age of 50 years old.
PAST
OBSTETRIC HISTORY
Between 1990 to 2000, she has 4
pregnancies. There are 2 girls and 2 boys. All of them were delivered in
Hospital Kuala Lumpur, delivered through SVD.
She had uterine prolapse during her
last delivery in 1998 at HKL and hysterectomy was done. All of them were breast
fed up to 2 years and completed immunization. All children are alive and
healthy. She denied of taking any oral contraceptive pill or hormone
replacement therapy.
PAST
GYNAEOCLOGY HISTORY
There was no previous gynaecology
history such as fibroid, cyst or endometrioma. Pap smear was done last year and
the result was normal. There was no operation done such as D&C or
myomectomy before except hysterectomy.
FAMILY
HISTORY
Her parents were passed away due to
unknown causes. Her father had hypertension and diabetes mellitus while her
mother had hypertension. She is the fourth among five siblings.
There is no family history of
chronic disease such as diabetes mellitus, hypertension and ischemic heart
diseases running in the family. There is also no known family history of malignancy
except her little sister who had breast Ca.
SOCIAL
HISTORY
She is a married woman who lived
with her husband and her two children. She is full-time housewife. She neither
smokes nor consumes alcohol.
SUMMARY
Mrs. Selvarani, a 58 years old
Indian woman, known case of long standing hypertension, with family history of
breast lumps, had undergone hysterectomy 20 years ago was admitted to the ward
with complaint of lumps at the both breasts and right axilla for the past two
months which become progressively increased in size and associated with pain,
loss of appetite and loss of weight.
PHYSICAL
EXAMINATION
GENERAL
Patient was sitting comfortably. She
was alert, conscious and oriented to time, place and person. She was not in
pain or in respiratory distress. There was a peripheral cannulation located at
the dorsum of her right hand with no active infusion. The hydration status of
the patient was however good.
VITAL
SIGNS
Blood pressure : 136/84
mmHg
Pulse rate : 72
beats/minute, good volume and regular rhythm
Temperature : 37 ˚C
Respiratory rate : 20
breaths/minute
HAND
Her hand is moist and warm. There
was no palmar erythema, clubbing, peripheral cyanosis, leukonychia and
koilonychia. There was no flapping tremor.
HEAD
There was pink conjunctiva and no
yellow discoloration on sclera.
The tongue was moist, no coated
tongue and it is pink in color. There was no central cyanosis, glossitis and
angular stomatitis.
LOWER
LIMB
There was no pitting oedema
BREAST
EXAMINATION
On inspection of
the breasts, the contours of both breasts were normal. There was a visible lump
at the upper outer quadrant of right breast. There were no skin changes such as
peau’ de orange, skin dimpling, tethering, or puckering, or satellite nodules can
be seen over the lump or other sites of the breasts, and no dilated veins. The
nipple-areolar complex of the right and left breast was normal. The nipple
level was the same. There was no fullness or any skin changes at the axillary
tail and the axillary area for both sides.
Palpation of the
right breast revealed a tender lump at the upper outer quadrant, which was
associated with temperature changes over the skin at and around the lump. The
lump was oval in shaped, firm-hard in consistency, with smooth surface and
well-defined margin. The size was about 4cm in length and 5 cm in width. It was
mobile and did not fix to the muscle or the skin. There was no nipple
discharge.
Palpation of the
left breast revealed a non-tender and small, oval lump at the upper outer
quadrant. It was about 1cm in length and 2cm in width. It was firm, smooth, and
well-defined margin, without any temperature changes. It was mobile and did not
fix neither to the muscle nor the skin. There was no nipple discharge of the
left breast.
On palpation of
the right axillary area, there was a lump which was oval in shaped, firm-hard,
smooth surface, with well-defined margin. It was 2cm in length and 3cm in
width, which was mobile and did not fix to the skin or muscle.
There was no other
lymphadenopathy at the left axillary region, cervical, or supraclavicular lymph
nodes.
RESPIRATORY
EXAMINATION
The chest was normal in shape with
no scars of dilated veins. The chest expansion was equal bilaterally. There is
also equal vocal fremitus and both lungs field were resonance on percussion.
There is equal air entry with no added sounds was heard such as rhonchi or
crepitation.
ABDOMINAL
EXAMINATION
The abdomen was not distended.
There were no abnormal skin changes, scars or dilated veins. The cough impulse
was negative. The abdomen was soft and non-tender. Otherwise there was no
hepatomegaly and splenomegaly. Both kidneys were not ballotable. The bowel
sound was present.
CARDIOVASCULAR
EXAMINATION
The apex beat was palpable at left
5th intercostal space, midclavicular line. There are no thrills or
parasternal heave noted. Both normal heart sounds were heard with no murmurs.
NEUROLOGICAL
EXAMINATION
There was normal motor function of
both upper and lower limb with muscle power of 5 on all limbs. The sensory
parts were also normal with intact cranial nerve function.
Examination
of other systems revealed no abnormalities.
PROVISIONAL
DIAGNOSIS
Breast cancer involving axillary
lymph node metastasize
Reasons favoring:
-progressively painful lumps at the
right and left breast which were progressive increased in size.
-tender, hard lumps
-right lymphadenopathy
-family history of breast lumps
DIFFERENTIAL
DIAGNOSIS
1. Breast abscess
2. Breast mastitis
INVESTIGATION
Blood
Investigation
1. Full blood count
Objective: To check for any
sign of anaemia or underlying infection.
Result
|
Normal Range
|
Result
|
Normal Range
|
||
WBC
|
11.9 x 109/l
|
(4.0 – 11.0)
|
Neutrophils
|
8.6 x 109/l
|
(2.0 – 7.5)
|
Hb
|
13.0 g/dl
|
(13.0 – 18.0)
|
72%
|
(40 – 75)
|
|
Plt
|
222 x 109/l
|
(150 – 400)
|
Lymphocytes
|
2.2 x 109/l
|
(1.5 – 4.0)
|
PCV
|
0.40 L/L
|
(0.40 – 0.54)
|
19%
|
(20.0 – 45.0)
|
|
RBC
|
4.5 x 1012/l
|
(4.50 – 6.50)
|
Monocytes
|
0.7 x 109/l
|
(0.2 – 0.8)
|
MCV
|
85 fl
|
(76.0 – 96.0)
|
6%
|
(2.0 – 10.0)
|
|
MCH
|
28.7 pg
|
(27.0 – 32.0)
|
Eosinophils
|
0.3 x 109/l
|
(0.04 – 0.40)
|
MCHC
|
33.7 g/dl
|
(30.0 – 35.0)
|
2%
|
(1.0 – 6.0)
|
|
RDW
|
13.6 %
|
(11.6 – 15.0)
|
Basophils
|
0.0 x 109/l
|
(0.02 – 0.10)
|
MPV
|
11.6 fl
|
(6.3 – 10.2)
|
0%
|
(>0.9)
|
2. Renal profile
Objective: To assess renal function by looking at
the electrolytes levels to rule out renal failure and as a preparation for
operation candidate.
Urea
|
4.4 mmol/L
|
(1.7 – 8.3)
|
Sodium
|
135 mmol/L
|
(135 – 145)
|
Potassium
|
3.5 mmol/L
|
(3.5 – 5.0)
|
Chloride
|
100 mmol/L
|
(96 – 108)
|
Creatinine
|
43 mmol/L
|
(64 – 122)
|
3. Liver function test
Objective: To look for any derangement of liver
function and as a preparation for operation candidate
Result
|
Normal Range
|
|
Total protein
|
78 g/l
|
(66 – 87)
|
Albumin
|
35 g/l
|
(35 – 50)
|
Total bilirubin
|
10 µmol/l
|
(<21)
|
ALP
|
75 u/l
|
(56 – 119)
|
ALT
|
40 u/l
|
(<42)
|
4. PT/ INR/ APTT
Objective: To assess any coagulation defect and as a
preparation for operation candidate.
PT
|
10.9 seconds
|
(10.8 – 14.4)
|
PT normal control
|
12.6 seconds
|
|
PT ratio
|
0.8 seconds
|
|
INR
|
0.82
|
|
APTT
|
24.7 seconds
|
(23.4 – 37.5)
|
APTT normal control
|
28.2 seconds
|
|
APTT ratio
|
0.9
|
Imaging
1. Chest x-ray
Indication: to rule out the
presence of lung metastasis from the malignancy.
It is also as a
baseline investigation for pre-operative assessment.
Impression: No abnormalities
had been identified
2. Bilateral Mammogram
Impression: There is an
ill-defined density seen in both upper outer quadrants. There is a dense lesion
scan in right axillary, represent a lymph node. No clustered
macrocalcification.
3.
Ultrasound both breast
Impression:
i) Right
breast
At 9
o’clock position 3cm from nipple, suspicious lesion measuring 2.5cm x 2.6cm in
size. Another satellite nodule is seen next to it. Axillary nodes seen, largest
suspicious looking measures 2.5cm x 3.0cm.
ii) Left
breast
A
suspicious nodule at 2 o/clock position, 8cm from nipple, measuring 1.2cm x
1.2cm is seen.
Conclusion
For
urgent biopsy of both breast nodules and right axillary nodes.
Breast Biopsy(Right)
Impression:
Macroscopic- Specimen labelled as core biopsy, consists of 5 strips of tissue
measuring 5-10 mm in length. Entirely submitted in 1 block.
Microscopic- Section shows 4-5 strips are infiltrated by malignant epithelial
cells. These malignant cells are arranged in clusters, strain or singly
distributed. These tumor cells display pleomorphic, hyperchromatic or vesicular
nuclei with prominent nucleoli. Mitotic figures are also noted.
▲Diagnosis
Core biopsy of
right breast lump: Infiltrating ductal carcinoma
Breast Biopsy(Left)
Impression:
Macroscopic- Specimen labelled as left breast ultrasound guided biopsy consisting
of two fragmented strips of tissue measuring 13mm to 15mm in length. Entirely
submitted in 1 block.
Microscopic- Sections show 2
fragmented strips of fibrofatty tissue infiltrated by malignant epithelial
cells in sheets and cords. These malignant cells exhibit mildly pleomorphic and
hyperchromatic nuclei with prominent red nucleoli. Mitoses are frequently seen.
No tubular formation or any intravascular permeation noted. The surrounding
stroma is infiltrated by lymphocytes.
▲Diagnosis
Ultrasound
guided biopsy of left breast lump: Infiltrating ductal carcinoma
FINAL DIAGNOSIS
Infiltrating
ductal carcinoma with lymph node metastasis
PRINCIPLE OF MANAGEMENT
Treatment of breast cancer has two basic
principles which are to reduce the risk of local recurrence, and the risk of
metastatic spread.
Surgery is still a central role for the
management of breast cancer. For this case which is infiltrating ductal carcinoma,
surgery is the best and hopes the only option for the treatment. Before any
operation being done, it is important to stage the cancer first so therefore we
can select the most suitable type of operation for the patient, either a total
mastectomy or a wide local excision for breast conservation.
In this case, the biggest lump was
measured 2.5cm x 2.6cm, which involved mobile ipsilateral axillary lymph node
metastasis, without any evidence of distant metastasis. Therefore, based on TNM
staging (Tumor-Node-Metastasis), this cancer is T2, N1, and M0, and can be
classified in stage IIB of breast cancer. Based on the staging, the most
suitable treatment for this patient is a mastectomy with axillary clearance.
Adjuvant therapy, which is chemotherapy
and radiotherapy are also important as excision of a breast cancer without
these leads to and unacceptable local recurrence rate. Chemotherapy can be done
by using a regimen such as a 6-monthly cycle of cyclophosphamide, methotrexate,
and 5-fluorouracil (CMF). This therapy has been proved to reduce the risk of
relapse for 25% over a 10-15 years period. For radiotherapy of the chest wall
after mastectomy, this treatment had been largely abandoned except in cases of
extensive local disease with infiltration of the chest wall, and the tumour is
a high-grade, large, heavily node positive of if there is extensive
lymphovascular invasion. Hormone therapy such as anti –estrogen (Tamoxifen),
LHRH agonists, or oral aromatase inhibitors can be considered as it can reduce the
risk of recurrence.
However, it is currently considerably more
expensive. Counseling of the patient about the risk and complications of the
operation is compulsory. Breast reconstruction with nipple reconstruction after
the operation can be offered based on
patient preference. Counseling before the reconstruction is important so
that the patient expectations of cosmetic outcome are not realistic. Follow up
after the operation is important as the objectives of follow up are; to provide
patient with support and counseling, detect potentially curable conditions such
as local recurrence of cancer in the breast, to detect new cancers in the
opposite breast, to manage patients in whom metastatic disease develops, and to determine the outcome. The suggested
follow-up schedule is as follows; 3-monthly for the first 2 years, 6-monthly
for the next 3 years, and yearly after that.
During follow-up, history taking and
physical examination should be carried out. Blood tests and diagnostic imaging
have not been found to improve survival or quality of life more than does
physical examination for detecting distant metastases. The patient is also must
be advised to carry out monthly breast self-examination.
DISCUSSION
The final
diagnosis which is infiltrating ductal carcinoma of breast with lymph node
metastasis has been made based on the triple assessment; clinical assessment
which is complete history taking and thorough physical examination,
radiological examination which is mammogram and ultrasound, and histopathology
assessment which is FNAC and core biopsy. This triple assessment is very
effective for any case with breast disease, and the predictive value of this
combination should exceed 99.9%.
From the history of
the patient, the lumps which are progressively increase in size and develop
pain, is a common symptom in breast disease and it is not suggest breast
cancer. However, because of the present of 1st degree family history
of breast lumps, breast cancer should be suspected. On physical examination,
the lumps were hard, tender, and mobile, without involvement of any skin
changes such as peau’ de orange, skin puckering or tethering, nipple retraction
or discharge, or satellite nodules. Theoretically, these lumps can be due to
many types of breast disease, and it is not particular for breast cancer.
However, the present of axillary lymphadenopathy is very suggestive for breast
cancer; specifically for the one which is already metastasize to the regional
lymph nodes. Based on the radiological examination, suspicious lesions at the
upper outer quadrant of both breasts has been detected which measuring more
than 2cm, and with satellite nodules. A suspicious lesion of lymph node is also
has been detected. From this radiological assessment, breast cancer should be
considered in the first place. Based on the histopathology assessment, the
results showed that it is confirmed that the provisional diagnosis is breast
cancer. For other investigations that had been done such as full blood count,
renal profile, liver function test, coagulation profile, and chest x-ray, they
are important for assessing the health condition of the patient to sit for an
operation.
Breast
cancer is the most common cause of death in middle-aged women worldwide. Many
risk factors have been identified for a person, especially women, to develop
breast cancer. Based on demographical factors, breast cancer is in general more
common in developed countries, especially in the Western world, although it is
uncommon in Japan. For gender, woman has 99% of risk to develop breast cancer,
and in male, the risk is below 1%. Breast cancer is more common in the age
above 35 years old, and it is rare below the age of 20. Based on medical
conditions, a woman who has early menarche (<12 years old) and late
menopause (>52 years old) have higher risk to develop breast cancer, as she
exposes to oestrogen for a longer period. Woman who has previous breast cancer
at contralateral breast, or breast atypical hyperplasia, or exposed to
radiation is known to have higher risk to have breast cancer. Breast cancer is
also commoner in nulliparous women, or women who has late 1st
pregnancy (>30 years old). Early 1st pregnancy (<20 years old)
and breast feeding have been recognized as a protective factor for breast
cancer. Women who take oral contraceptive pill (>5 years) or hormone
replacement therapy (>10 years) are known to have higher risk of developing
breast cancer. Based on family history, a woman with 1st degree
relatives that has breast cancer or ovarian cancer, with proved genetic basis
of BRCA-1, BRCA-2 or p53 mutation, has higher risk to get breast cancer. Based
on the environmental factors, smoking, alcohol consumption, high fat diet, and
postmenopausal obesity are known as the risk factors for breast cancer.
Types
of breast cancer can be divided into two large groups which are non-invasive
(in-situ, where the preinvasive cancer cells are not breached the epithelial
basement membrane) and invasive. This is further divided based on where the
cells cancers arise, which is ductal or lobular in-situ, and invasive ductal or
lobular carcinoma. There are other types of breast malignancy which are
medullary carcinoma, colloid carcinoma (mucinious carcinoma), tubular
carcinoma, and sarcoma. Among all of these, invasive ductal carcinoma is by far
the most common (more than 80%). The invasive types of breast cancer are
developed from the preinvasive or in-situ disease. Like infiltrating ductal
carcinoma, it probably develops in a stepwise fashion from ductal hyperplasia
to ductal atypia, and on to ductal carcinoma in-situ (DCIS). For staging of the
breast cancer, the most common used system is the TNM staging. This staging for
breast cancer is explained as below:
TX = primary tumour cannot be assess
T0 = no evidence of primary tumour
T1 = tumour size <2cm
T2 = 2 – 5cm
T3 = >5cm
T4 = any size with extension to the
chest wall or skin
T4a = extension to the chest wall or skin
T4b = oedema or ulceration or satellite
nodules
T4c = both a & b
T4d = inflammatory carcinoma
NX
= regional lymph nodes cannot be assess
N0
= no regional lymph node metastases
N1
= mobile ipsilateral axillary lymph nodes
N2
= fixed ipsilateral axillary lymph nodes
N3 = metastases to supraclavicular, or
infraclavicular, or internal mammary lymph nodes
with or without axillary nodes
MX
= present of distant metastases cannot be assess
M0
= no distant metastases
M1
= distant metastases
|
For grading of breast cancer, it is
according to the extent to which they resemble normal breast tissue and this
assessment depends on the amount of tubule formation, mitotic figures, and
nuclear pleomorphism. The Bloom-Richardson’s grading is one of the systems for
grading breast cancer.
Breast
cancer spread via direct extension, lymphatic and haematogenous route. Direct
extension to subcutaneous tissue and skin would cause skin dimpling, retraction
of the nipple and eventually ulceration. The tumour can also extend deeply
involves pectoralis major, serratus anterior and eventually the chest wall.
Blockage of dermal lymphatics leads to cutaneous oedema pitted by the orifice
of the sweat ducts, giving the appearance of peau d’orange. The main lymph
channels pass directly to axillary and internal mammary lymph nodes. Later,
spread occurs to the supraclavicular, abdominal, mediastinal, groin and
opposite axillary nodes. Haematogenous spread is most commonly to lungs, liver
and bones. Not forgotten is about the Paget’s disease of the nipple. It is a
superficial manifestation of an underlying breast carcinoma. It presents as an
eczema-like condition of the nipple and areola, which persists despite local
treatment.
For
treatment of breast cancer, it is involved multidisciplinary team approach including
surgeon, oncologist, radiologist, pathologist, and breast care nurses. For
surgical treatment, it can be removal of all the breast tissues which known as
mastectomy or conservative breast cancer surgery, where it is aimed at removing
the tumour plus a rim of at least 1cm of normal breast tissue with conserve the
normal breast tissues, and it is commonly referred to as a wide local excision.
For mastectomy procedure, now it is strictly indicated for large tumours (in
relation to the breast size), central tumours beneath or involving the nipple,
multifocal disease, local recurrence, or for patient preference. The common two
types of mastectomy are the radical Halsted mastectomy, and modified radical
mastectomy known as ‘Patey’ mastectomy. If mastectomy is performed, it is
reasonable to clear the axilla as part of the operation, but if a wide local
excision is planned the surgeon should dissect the axilla through a separate
incision. Sentinel node biopsy also considerable in the management of the
axilla in patients with clinically node-negative disease. Adjuvant therapy such
as chemotherapy, radiotherapy, and hormone replacement therapy are very
important in reducing the risk of recurrence, with involvement of regular
follow-ups and counselling. Breast reconstruction may benefits the patient as
it can improve the quality of life and reduced the psychosocial complications.
It may be carried out as either an immediate or a delayed procedure, but many
experts believe that immediate reconstruction is preferable for the patient and
more economical in health care terms. As the incidence and prevalence of breast
cancer is high, therefore the best way to reduce it is by having
self-examination education program and screening program for breast cancer, as
a preventive method. This can be done by using mammography, as a number of
studies have shown that breast screening by mammography in women over the age
of 50 years will reduce cause-specific mortality by up to 30%. However, the
psychological consequences of false results (positive or negative) need to be
addressed.
REFERENCES
1. Bailey &
Love’s, Short Practice of Surgery, 26th Edition
2. Robin C.N.
Williamson, Bruce P. Waxman, Scott: An Aid to Clinical Surgery 6th
Edition
3. Vinay Kumar, Ramzi
S. Cotran, Stanley L. Robbins, Robbins Basic Pathology 7th Edition
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