Labc case presentation
- 1. CASE PRESENTATION - LABC Presenter – Aakansh Jain Postgraduate student PGIMER & Dr RML Hospital, New delhi SCOPE – MARCH 2017
- 2. Chief complaints Swelling in right breast - 4months Ulceration and pain over swelling in rt breast - 2 week • 40 yr • Hindu lady • Resident of UP • Home maker HISTORY
- 3. History Of Present Illness She noticed a swelling of approx 2 cm in right breast 4 months back Since then it rapidly progressed to current size of approx 10 cm, not associated with pain or fever 2 months later another swelling appeared in right axilla of about 1-2 cm in size, gradually increasing in size No other swelling in opposite breast or axilla
- 4. HOPI cont.. She developed an ulcer in the nipple areola complex 2 weeks back just above the swelling Ulcer was associated with serous discharge It was also associated with pain Pain was localised to region of ulcer, dull aching in character, relieved on taking medication
- 5. • No h/o nipple discharge • No h/o trauma / radiation exposure in past • No h/o chest pain cough/ hemoptysis • No h/o weight loss or appetite • No h/o pain in abdomen or jaundice • No h/o lower back ache, pain in limbs • No h/o headaches / vomiting or weakness of any limbs • Not a known case of HTN/ DM / asthma HOPI cont..
- 6. HOPI cont.. • She gave h/o multiple needle insertions and dry taps from the swelling done by some local practitioner Past History • No past h/o tuberculosis • No past h/o surgical intervention
- 7. Family history • No h/o any breast , ovarian , prostate or GI malignancies in 1st degree relatives or family members
- 8. Menstrual & Obstetric history • Menarche at the age of 12 yrs. • Married at age of 16 yrs. • 1st child at the age of 23 yrs. • She has 4 children and one abortion • All Breastfed for minimum 2 years • Youngest child of age 5 yrs. • No h/o intake of any birth control pills • Has normal menstrual cycles
- 9. Personal History • Vegetarian • Normal sleep pattern • Normal bowel and bladder habit • Non smoker/ non alcoholic • No known allergies
- 10. To summarize….. • 40 yr premenopausal hindu lady presented with rapidly progressing swelling in her right breast for 4 months which is at present of approximately 10 cm and an ulcer over the swelling for last 2 wks associated with serous discharge. • She complained of another swelling in her right axilla for last 2 months. • Negative metastatic and family history.
- 11. General physical Examination • Conscious, oriented to time, place and person • Built average • Performance status - 80 (karnofsky scale), • Well hydrated • Adequately Nourished with BMI – 24.1 kg/m2 • No pallor, clubbing , cyanosis, icterus, pedal edema, generalised lymphadenopathy (axillary LNA in regional examination) Vitals- • PR-80 /min • BP -118/74 mmHg • RR – 16 / min , • Temperature- 98.2° F
- 12. LOCO REGIONAL EXAMINATION INSPECTION Asymmetry noted, with right breast lying at a higher level Visible fullness- right UOQ. Skin- shiny , engorged veins, Peau d’ Orange present An ulcer present over the swelling of size 1*1 cm in UOQ involving NAC, irregular shape, everted edges and floor of pale necrotic tissue. Serous discharge present • No Satellite nodules.
- 13. • On leaning forward the left breast fell more forward • B/L NAC- both present, No nipple discharge. Right NAC was ~3 cm higher than left & retracted. Right nipple involved in ulcer.
- 14. • On raising both arms above head- rt nipple retracted and peau d’ orange becomes more prominent • Axilla, arm and thorax appear normal
- 15. Palpation - Left breast was normal in consistency Right breast- • No local rise of temperature • A swelling of 10*11 cm palpable in right breast mainly in the upper and lower outer quadrant and extending to inner quadrants. • Surface smooth , margins well defined, non tender, hard in consistency, • Fixed to skin and breast tissue, a ulcer present over it, peau d’ orange present. • Neither fixed to chest wall nor to the underlying pectoralis major muscle
- 16. • An ulcer of size 1*1 cm present over the swelling involving nipple areola complex • non-tender , - Irregular margins, - floor covered with necrotic tissue, - everted edges, - base was formed by underlying . lump, - serous discharge oozing from ….ulcer, - there was no nipple discharge on . expression
- 17. Axillary lymph node examination • There were two groups of lymph nodes palpable • One lymph node of 3*2 cm size, hard, nontender, mobile in the central group • Another lymph node of 1.5* 2 cm hard, nontender mobile in anterior group • No supra/infra clavicular lymph adenopathy • No lymph adenopathy in C/L axilla
- 18. Systemic examination • P/A – soft , non tender, no organomegaly, no shifting dullness • DRE- No fissures, fistula/sinus openings No palpable nodule No rectal bleeding • Per vaginal examination - NAD • Spine examination – no spine tenderness • Chest – B/L AE +, no added sounds • CVS – S1S2 heard, no murmur heard
- 19. To Summarize… 40 yr premenopausal lady presented with rapidly progressing right breast swelling currently of size 11 cm associated with serous discharging ulcer and peau d’ orange with I/L two mobile axillary lymph nodes with no clinical evidence of distant metastasis.
- 20. Diagnosis • 40 yr premenopausal lady with locally advance carcinoma of right breast with clinically T4b N1 M0 with stage IIIb
- 21. Investigations • To support diagnosis – B/L mammography with B/l axillary USG • To confirm diagnosis – core needle biopsy, • To stage disease – metastatic workup- • Bone scan • CECT thorax, abdomen and pelvis • LFT, ALP
- 22. Management • Neoadjuvant chemotherapy • MRM + axillary lymph nodal dissection • Radiotherapy to chest wall and supraclavicular LN region + Adjuvant chemotherapy • Hormonal therapy (as per receptor status)
Editor's Notes
- #5: Reddish watery; initially painless
- #7: Radial scar appear as ductal carcinoma in situ grossely
- #8: PTEN cowden syndrome – thyroid malignancy, GI malignancy, breast ,cerebral malignancy % of increased risk if 1* 2* 3* 4*
- #9: LMP – 20 feb 2017
- #10: combined oral contraceptive pill contains estrogen(estradiol) and progesterone (progestin).
- #12: AFTER TAKING INFORMED CONSENT , IN WELL LIT ROOM, IN PRESENCE OF FEMALE ATTENDANT , Bp measured in left brachial artery ECOG- EUROPEAN COOPERATIVE ONCOLOGY GROUP Nutritional status = carbohydrates protein – mid arm circumference, fat -
- #13: I examined the pt in sitting, sitting with hand raise above head , supine, recumbant and bending forward position Left breast -normal in size and shape Left Nipple areola complex normal
- #17: Correction – ulcer to be called pressure ulcer as underlying lump presses to cause skin necrosis, margins to be undermined , probe test positive
- #22: incisional biopsy from ulcer