D.B. D.B. 45 years old 45 years old Female Female Married Married Housewife Housewife Kapasigan, Pasig City Kapasigan, Pasig City.

Breast Mass

Identifying information• D.B.

• 45 years old

• Female

• Married

• Housewife

• Kapasigan, Pasig City

Chief complaint Breast mass, right

History of the present illness1 year PTA • Breast mass, right

• Hard, marble-sized

• No breast pain, nipple discharge, changes in the appearance of the breast

4 months PTA • Enlargement of breast mass• 25 centavo coin

• Unrecalled antibiotics w/o relief

History of the present illness1 month PTA • Progressive enlargement of breast

mass• Tomato-sized

• Breast pain• Sharp, “kirot,” 3/10• Localized on breast mass• Few days before menses, lasting a few

minutes• Spontaneous relief

• Core needle biopsy: Invasive Ductal CA

• Advised surgery

Admission

Review of systems• General: (+) anorexia, (-) weight loss, fever, weakness, fatigue

• HEENT: (+) headache, (-) dizziness, enlarged LN

• Pulmonary: (-) dyspnea, hemoptysis, cough, wheezing

• Cardiovascular: (-) palpitations, chest pains, orthopnea

• Gastrointestinal: (-) jaundice, abdominal pain, nausea, vomiting, changes in bowel movement, tea-colored urine

• Genitourinary: (-) nocturia, dysuria, frequency, hematuria

• Musculoskeletal/Dermatologic: (+) myalgia, (-) back pain, arthralgia, rashes, pruritus

• Endocrine: (-) excessive sweating, heat/cold intolerance, polyuria, excessive thirst

Past medical history• No hypertension, diabetes mellitus, asthma

• No allergies

• No previous hospitalizations

• Removal of “pugita,” left eye (2003)

Obstetric and gynecologic history• G4P3 (3,0,1,3)

• Menarche at 13 years old

• ~28-30 day cycle

• Regularly menstruating• 3 days, consuming 3 regular pads/day• (-) dysmenorrhea

• LMP: February 13, 2012 (PMP: January 15, 2012)

• Oral contraceptive pills (1986-2000)

• Injectables (2009-2011)

Family history• Hypertension- mother, father

• Asthma- siblings

• Cancer• Bone cancer- uncle• Unrecalled cancer- aunt

• No diabetes mellitus, PTB

Personal and social history• Housewife, mother

• Married to an electrician, OFW

• Lives with husband and youngest child

• Nonsmoker

• Occasional alcoholic beverage drinker

• No history of illicit drug use

Physical examination• Conscious, coherent, cooperative

• Vital signs• 120/80 mmHg• 86 beats/ min• 20 breaths/min• 36.5C• VAS 0/10

• Weight 59 kilos, Height 153 cm

• BMI 25.2 kg/m2 (overweight)

HEENT• Anicteric sclerae, pinkish conjunctivae, no

• No tragal swelling or tenderness

• No nasal discharge

• Pinkish lips, moist oral mucosa, no lesions or sores, no tonsillopharyngeal congestion

• No cervical lymphadenopathies, non-palpable thyroid gland

Breast No lesions or scars on the chest

Symmetrical breasts

Pinkish-brownish nipple, no skin dimpling/ retractions

7 cm x 5 cm mass on the upper outer area of the right breast Hard, non-tender Well-circumscribed Movable Smooth borders 11 to 2 o’clock position

No enlarged axillary or supraclavicular lymph nodes

No nipple discharge

Pulmonary• Symmetric chest expansion, no retractions

• Equal tactile fremiti

• No dullness on percussion

• Good air entry, clear breath sounds

Cardiovascular• Adynamic precordium

• PMI at 5th ICS, left MCL

• Normal rate and regular rhythm, distinct S1/S2, no murmurs

• No carotid bruits

Abdomen• Soft, flabby abdomen without scars

• Normoactive bowel sounds

• Tympanitic

• No tenderness

• Non-palpable liver edge

• No masses

• (-) CVA tenderness

Extremities• No rashes/ skin lesions

• Warm extremities

• Good skin turgor

• Full and equal pulses

• No cyanosis, no clubbing

• CRT < 2 seconds

Neurologic• Awake, alert, well-groomed

• Oriented to 3 spheres

• GCS 15

• No cranial nerve deficits

• MMT: 5/5

• DTRs: 2+

45/ F, G4P3, housewife

Initial impressionBreast cancer, right

Differential diagnoses• Breast cyst• Common in those in their 40s, perimenopausal• Cyclic breast pain• Breast mass• Firm• Well-demarcated• Mobile

Differential diagnoses• Fibroadenoma• Common in the those <30 years• Breast mass• Usually solitary• Rubbery• Round or lobulated• Nontender• Mobile

Diagnostics• Ultrasound of the breast• Solid vs. cystic

• Fine needle aspiration• Diagnostic and therapeutic for breast cysts• If suspected cyst proves to be a solid lesion, then

material for biopsy may be obtained instead.

Management of solid breast masses. (Harris et. al., 2000. Diseases of the Breast. p.43)

Biopsy (Large bore needle)Invasive ductal carcinoma, Nottingham

combined histologic grade III

Tumor staging (TNM )

Tumor staging (TNM )

Tumor staging (TNM )

Preoperative diagnosis• Invasive ductal carcinoma, Stage IIB, T3 N0

M0

Invasive ductal carcinoma• Most common

malignant tumor (80%)

• Most often present as a palpable mass or mammographic abnormality

• Feel like a hard, bumpy, movable, irregularly-shaped lump beneath the areola

Risk factorsReproductive factors

Age at menarcheMenstrual cycle characteristicsPregnancy and age at first full-term pregnancy

NulliparousLate age at first full-term pregnancy

Number and spacing of birthsLactation/ breastfeedingAge at menopause

Risk factorsOral contraceptives

Duration of useUse before a first full-term pregnancy or at an early age

Postmenopausal hormone use

Dietary factorsDietary fat intakeObesityDietary fiberVitamin AAlcohol: >1 drink/day

Risk factorsPhysical activity: >3 hours/week

Ionizing radiation

Environmental pollutionOrganochlorinesActive and passive smokingSilicone breast implants

Family history (mother and sister, first degree relative)

Jewish heritage

Benign breast disease

Invasive ductal carcinoma• Has a tendency to metastasize via lymphatics• Lymph nodes• Contralateral breast• Liver• Lungs• Bones (vertebra)• Brain

DiagnosticsCBC and blood typing

Hemoglobin 133 g/L

Hematocrit 0.4

WBC 5.1 x 109/L

Neut 0.60

Lymph 0.37

Eos 0.03

Platelet Adequate

Blood type A +

Urinalysis

Color Yellow

Turbidity Slightly turbid

pH 5.5

Sp. Gr. 1.025

Albumin Negative

Sugar Negative

Pus 4-8/hpf

RBC 0-2/hpf

Epithelial cells Few

Bacteria Occasional

Urates Few

Mucus Many

DiagnosticsChest x-ray

Normal chest findings

ECGNon-specific ST-T wave changes

Modified radical mastectomy To avoid ay chance of local/regional

recurrence

To maximize options for breast reconstruction

Most widely used surgical procedure to treat operable breast cancer

Removes the breast, surrounding tissue and nearby lymph nodes

Leaves the pectoralis major intact

Avoids disfiguring hollow defect below the clavicle

PrognosisFive-year survival rates are highly correlated

with tumor stage:Stage 0: 99-100%Stage I: 95-100%Stage II: 86%Stage III: 57%Stage IV: 20%