BREAST CANCERR.NANDINII

GROUP K1

Overview:

Anatomy

Breast Cancer

-Definition

-Classification

-Symptoms

-Diagnosis

-Treatment

Case Write up

Female Breast Anatomy

milk-producing glands situated on the front of the chest wall.

rest on the pectoralis major muscle - supported by Cooper’s ligaments.

Each breast contains 15-20 lobes arranged in a circular fashion.

The fat that covers the lobes gives the breast its size and shape.

Each lobe comprises many lobules, at the end of which are glands where milk is produced in response to hormones

Ducts

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Areola

Lobes, lobules, and bulbs areLinked by a

network of thintubes (ducts)

Ducts carrymilk from bulbs

toward dark areaof skin in thecenter of the

breast (areola)

Ducts join togetherinto larger ducts ending

at the nipple, wheremilk is delivered

Lymphatic System

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Lymph ducts: Drain fluid that carries white blood cells (that fight disease) from the breast tissues into lymph nodes under the armpit and behind the breastbone

Lymph nodes: Filter harmful bacteria and play a key role in fighting off infection

A network of vessels

Lymph ductLymph node

Breast Cancer

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 Cancer that forms in tissues of the breast, usually the ducts (tubes that carry milk to the nipple) and lobules (glands that make milk). It occurs in both men and women, although male breast cancer is rare. 

Breast cancer is second only to lung cancer as a cause of cancer deaths in American women

EPIDEMIOLOGY:

Estimated new cases and deaths from breast cancer in the United States in 2013:

New cases: 232,340 (female); 2,240 (male)

Deaths: 39,620 (female); 410 (male)(Source: National Cancer Institute)

In MALAYSIA:

National Cancer Registry (NCR 2006) reported 3,525 female breast cancer cases

The most common diagnosed cancer in women & 29.9 % of all new cancers

Overall Age-Standardised Incidence Rate: 39.3 per 100,000 population(Source: CPG)

Classification

Breast Disease:

Benign:

-Low Risk lesion: Fibrocystic changes, Cyst, Fibroadenoma

-Mod Risk lesion: Atypical ductal hyperplasia, Atypical lobular hyperplasia

-High Risk lesion: LCIS, DCIS (premalignancy)

Malignant

- Invasive carcinoma: infiltrating ductal carcinoma, infiltrating lobular carcinoma

- Inflammatory carcinoma

Type

Benign Conditions

Fibrocystic changes: Lumpiness, thickening and swelling, often associated with a woman’s period

Cysts: Fluid-filled lumps can range from very tiny to about the size of an egg

Fibroadenomas: A solid, round, rubbery lump that moves under skin when touched, occuring most in young women

Normal Breast

Breast profile

A ducts

B lobules

C dilated section of duct to hold milk

D nipple

E fat

F pectoralis major muscle

G chest wall/rib cage

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Enlargement

A normal duct cells

B basement membrane (duct wall)

C lumen (center of duct)

Illustration © Mary K. Bryson

Ductal Carcinoma in situ (DCIS)

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Illustration © Mary K. Bryson

Ductal cancer cells

Normal ductal cellCarcinoma refers to any

cancer that begins in the skin or other tissues that cover internal organs

Invasive Ductal Carcinoma (IDC – 80% of breast cancer)

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The cancer has spread to the surrounding tissues

Illustration © Mary K. Bryson

Ductal cancer cells breaking through the wall

Range of Ductal Carcinoma in situ

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Illus

trat

ion

© M

ary

K.

Bry

son

Invasive Lobular Carcinoma (ILC)

15Illustration © Mary K. Bryson

Lobular cancer cells breaking

through the wall

RISK FACTOR

Signs and Symptoms

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Most common: lump or thickening in breast. Often painless

Change in color or appearance of areola

Redness or pitting of skin over the breast, like the skin of an orange

Discharge or bleeding

Change in size or contours of breast

DIAGNOSIS TRIPLE ASSESSMENT

STAGING

Staging

0 Ca in situ

1 T1 without nodes or mets

2 T1-2 + N1 or T3+N0

3 T1-4, N2-3

4 M1

TUMOR NODES METASTATIC

Tx : could not assessed • Nx : could not assessed Mx : could not assessed

T0 : no evidence of primary tumor

N0 : no regional lymph nodes metastatic

M0 : no distant metastatic

T1s : carcinoma in situ N1 : movable ipsilateral axillary lymph nodes

M1 : distant metastatic

T1 : < 2 cm N2 : fixed ipsilateral lymph nodes

T2 : 2-5 cm N3 : ipsilateral internal mammary lymph nodes

T3 : > 5 cm

T4 : extension to chest wall or skin

PRINCIPLES OF TREATMENT

MANAGEMENT(Algorithm for operable breast cancer)

MANAGEMENT(Algorithm for locally advanced breast cancer)

CASE WRITE UP

E, a 49 years old Siamese female was admitted electively to Hospital Tuanku Fauziah on 2nd March 2013 for swelling of left breast associated with pain for 2 weeks of duration.

HISTORY OF PRESENTING ILLNESS Left sided breast lump since 2010 MVA. Initially size of lump was the size of a 1 cent coin

increasing in size for the past few months to a 10 cent coin.

Previously, non -tender on palpation till 2 weeks ago No discharge flowing from nipples No skin changes involved Claims occasional pain on sternal edge that radiates to

back since breast lump present Loss of appetite for 1 month of duration

HISTORY OF PRESENTING ILLNESS Otherwise:

-no clear loss of weight,

-no shortness of breath during exertion or resting,

-no bone pain, no fever, no upper respiratory tract symptoms,

-no abdominal pain

-no altered bowel habit No history of any breast disease prior to this. On follow up with KK Kodiang since 2010. Investigations

carried out and patient was admitted electively for surgical intervention.

PAST MEDICAL HISTORY

1. Bronchial Asthma

- On MDI Salbutamol

- MDI Betamethasone

 

2. Acute gastritis

Done oesophagogastroduodenoscopy (OGDS) in 2009

Diagnosed to have: Gastritis, Helicobacter pylori negative

PAST HOSPITAL ADMISSION

-History of lower segment caesarean section (LSCS) done twice

-History of appendectomy done -History of intestinal obstruction secondary to

adhesion resolved with conservative care (2009) -History of motor vehicle accident with fracture

on upper limb (2010)

FAMILY HISTORY

No history of breast cancer or any other cancer running in the family

No family member or DM, HPT, IHD

SOCIAL HISTORY

4th child from 5 siblings Patient is married with 2 children.

Nonsmoker and non-alcoholic. Allergic to seafood.

PRESENT STATUS

(03/03/2013: 8.00 pm) Vital signs Conscious level : Alert and conscious HR : 82x/min RR: 18x/min BP: 125/96 mmHg Temperature : 370C

GENERAL STATUS Head: No abnormality observed Neck: No increased JVP, No enlarged lymph nodes Thorax: Double rhythm no murmur. Vesicular breath

sound without added sounds Breast : View localized status Abdomen: Surgical scar seen. Abdomen soft nontender Upper limb: No abnormalities Lower limb: No abnormalities

Localized StatusSymmetrical-Size-Shape-Position

 Both breasts are symmetrical in size.Same shape of breast: Round with no visible lumps seen

Skin No visible skin abnormalities. No nodulesNo ulceration & fungationNo texture difference between breastNo puckering/dimplingNo engorged veinsNo skin discoloration

Nipples & Areolae Nipples present at both sides. Not retracted/ destroyedNo accessory nipplesNipples dark brown in colorCentral in positionAreolae smooth with nipple protruded out in the middleNo discharge seen

Hands by side /Hands slowly raised above head

Lymph node enlargement not visibleNo distended veinsNo muscle wasting

Hand pressed hips No tethering to the skinUnsure if fixated to underlying muscles

LOCALIZED STATUSLump-Temperature-Tenderness-Site-Size-Shape-Surface-Margin-Consistency-Relation to the skin-Relation to underlying muscle

 WarmPresent on left breastLeft upper outer (towards the medial line/border upper and lower) quadrant1.5cm x 1.5cmRoundSmoothWell demarcatedHardMobileNot fixated

Nipple-Retracted nipple-Feel breast deep to the nipple-Press for discharge -Appearance -Character -Color

 Nipple not retracted after releaseCould feel the presence of lump NoneNoneNone

Axilla & cervical lymph nodes-Site-Surface-Consistency-Tenderness-Conglumeration

 Not enlarged----

INVESTIGATIONS FINDINGS FROM PREVIOUS INVESTIGATIONS:

Mammography (June 2012)

Left sided breast cyst

Fine Needle Aspiration Cytology ( 14/02/2013)

Atypical suspicious of malignancy

(C4 = cells suspicious but probably malignant)

LAB INVESTIGATIONS

Full blood count

Renal profile

Liver function test

Chest radiograph

Electrocardiogram

Histopathology examination

REVIEW OF INVESTIGATIONS

Full blood count, Renal profile & Liver Function test were mostly in normal range. No significant finding

Chest X-ray : Shows mild cardiomegaly ECG: Sinus rhythm. No significant changes

Chest X-ray

DIAGNOSIS:

Breast carcinoma Fibroadenoma Fibrocystic Cyst

WORKING DIAGNOSIS: Breast carcinoma

Stage 1 (T1N0M0)

PLAN

Wide local excision of left breast lump Vital signs monitoring Review investigations For anesthesiology to review for general anesthesia Keep nil by mouth starting from 12 midnight Intra venous drip 4 pint – 2 pint Normal Saline and 2

pint Dextrose 5%

POST OPERATION ASSESSMENTPRESENT STATUS (04-03-2013: 9.30 pm)

Vital Signs:

Conscious level : Alert and conscious

HR : 72x/min

RR: 16x/min

BP: 122/73 mmHg

Temperature : 370C

Subjective:

Patient complained of pain at the operation site. Pain score 3/10

Patient vomited 2 episodes.

No fever.

Objective:

Operation site bandage not soaked.

Operation site slightly inflamed. But no signs of pus or active infection.

Assessment:8 hours post wide local excision for Left breast atypia.To give analgesic to ease pain.To give antiemetic for vomiting.

 

Plan:Tablet Paracetamol 1gm QIDCapsule Tramal 50mg TDSTablet Maxolon 10mg Stat & PRNIntra venous drip 4 pint – 2 pint Normal Saline and 2 pint Dextrose 5%Continue vital sign monitoring.To inform if wound soaked