Case Scenar|o

AlLeraLlons ln Cell ulfferenLaLlon neoplasla

Alll klmberly 8eaLrlze C
Almelor napoleon Manuel lll 1
Alvaro lerdlnand Mlguel A
Alvendla !ullus 8lo A
Amar !amle Abegall C
Amor 8yan l
AmoranLo lrancols Cecco M
Andal !ohn ken M
Andaya Anne nlcole u
Ang Charmaln 8
Ang kevln 8oyce C
Angeles khrlsLlne !oy C


lll 1 8LL 2







1) llst Jowo tbe tetms yoo oeeJ to Jefloe ooJ Jefloe eocb ooe of tbem

O Myoma uLerl
O LumpecLomy
O Axlllary lymph node dlssecLlon
O lnfllLraLlng ducLal carclnoma
,oma uter|ne Myoma uLerl or myoma of Lhe uLerlne ls a common benlgn flbrold Lumor of
Lhe uLerlne muscle 1he Lumor develops mosL frequenLly afLer 30 years of age ln women
especlally AfrlcanAmerlcan women who have never been pregnanL Menorrhagla backache
consLlpaLlon dysmenorrhea dyspareunla and oLher sympLoms develop ln proporLlon Lo Lhe
slze locaLlon and raLe of growLh of Lhe Lumor
Lumpectom LumpecLomy ls a Lype of surgery for breasL cancer lL ls consldered breasL
conservlng surgery because only Lhe mallgnanL Lumor and a surroundlng margln of normal
breasL Llssue are removed Lymph nodes ln Lhe armplL (axllla) may also be removed 1hls
procedure ls also called lymph node dlssecLlon

|||ar Lmph Node D|ssect|on Axlllary lymph node dlssecLlon may be done as parL of
alumpecLomy ormasLecLomy ?our surgeon may remove a small group of nodes or all of Lhe
nodes ln your axllla 1hese wlll be senL Lo Lhe paLhology lab where Lhey wlll be carefully
examlned for cancer cells ?ou wlll need Lo know lf your lymph nodes are negaLlve (clear of
cancer) or poslLlve (conLaln cancer) 1hls lmporLanL lnformaLlon affecLs LhesLaglng of your
cancer and lnfluences your LreaLmenL opLlons
Inf||trat|ng Ducta| Carc|noma lnfllLraLlng ducLal carclnoma ls Lhe mosL common lnvaslve
breasL cancer accounLlng for 70 percenL of all cases A very hard lump LhaL has lrregular
borders and seems anchored ln surroundlng Llssues ls characLerlsLlc of lnfllLraLlng ducLal
carclnoma 1he skln over Lhe area or Lhe nlpple may reLracL (pull ln) Cn mammography Lhere
are ofLen mlcrocalclflcaLlons found ln Lhe Lumor area slnce Lhls Lumor has a hlsLory of lnLernal
cell deaLh (necrosls) 1he Lumor varles ln slze and cell dlvlslon Llme wlLh some cells growlng
more rapldly Lhan oLhers

2) llst Jowo oll tbe televoot Joto yoo bove qotbeteJ ftom tbe sceootlo oboot A8

O AdmlLLlng ux lnfllLraLlng uucLal Carclnoma SLage 12n1M0 lncrease ln cell slze
reglonal lymph node meLasLasls presenL no dlsLanL meLasLasls
O 9resence of a 22cm lump on rlghL breasL
O 8lopsy MallgnanL lf your blopsy resulLs ls poslLlve (mallgnanL) cancer was found
O LumpecLomy and axlllary node dlssecLlon 3 of 14 nodes poslLlvereglonal lymph
node meLasLasls presenL
O () 8one scans and C1 scan
O 38 year old lncreaslng age your rlsk of developlng breasL cancer lncreases as you
geL older
O Joman Jomen have many more breasL cells Lhan men 1helr breasL cells are
consLanLly exposed Lo Lhe growLhpromoLlng effecLs of Lhe female hormones
esLrogen and progesLerone
O lamlly hlsLory of myoma uLerl (maLernal) AbouL 3 Lo 10 of breasL cancer cases
are LhoughL Lo be heredlLary resulLlng dlrecLly from gene defecLs (called muLaLlons)
lnherlLed from a parenL
O 9asL medlcal hlsLory of plasLlc surgery for breasL lmplanLs ln AugusL lasL year
Several sLudles have found LhaL breasL lmplanLs do noL lncrease breasL cancer rlsk
alLhough slllcone breasL lmplanLs can cause scar Llssue Lo form ln Lhe breasL
O Marrled wlLh 4 chlldren Jomen who have had no chlldren or who had Lhelr flrsL
chlld afLer age 30 have a sllghLly hlgher breasL cancer rlsk Pavlng many pregnancles
and becomlng pregnanL aL a young age reduce breasL cancer rlsk

J) wbot fottbet Joto Jo yoo oeeJ to qotbet to estobllsb tbe potboqeoesls of A8s coocet?
wby Jo yoo cooslJet eocb of tbese Joto os televoot?

O lurLher assessmenL of lumps or abnormallLles uslng mammogram and breasL
ulLrasound
DlLrasound uses hlghfrequency sound waves Lo produce an lmage of Lhe
lnslde of your breasLs 1he lmage produced wlll show any lumps or
abnormallLles LhaL are presenL ln your breasLs ?our docLor may also suggesL
a breasL ulLrasound lf Lhey need Lo know wheLher a lump ln your breasL ls
solld or conLalns llquld

O LlfesLyle whlch lncludes eaLlng hablLs dally acLlvlLles carclnogens alcohol lnLake
8lsk lncreases wlLh amounL of alcohol consumed (Cne beer has 13 grams of
alcohol a glass of wlne has 11 grams and a shoL of llquor has 13 grams)
A llfesLyle of lnacLlvlLy lnLake of carclnogenlc foods and noL eaLlng a
balanced and healLhy meal may lncrease Lhe rlsk of developlng abnormal
cells ln Lhe body lncludlng Lhe breasLs

O Lxposure Lo Loxlns and radlaLlon
9rolonged exposure Lo Loxlns and radlaLlon lncreases Lhe rlsk for developlng
abnormal cells ln Lhe body lncludlng Lhe breasLs

O lamlly PlsLory of 8reasL Cancer
8lsk lncreases wlLh number of flrsL degree relaLlves affecLed PeredlLary
breasL cancers accounL for approxlmaLely 3 Lo 10 of all breasL cancers
Speclflc heredlLary predlsposlLlons for breasL cancer such as lnherlLlng a
muLaLlon ln elLher Lhe 88CA1 or 88CA2 gene are noL Laken lnLo accounL ln
rlsk esLlmaLes wlLh Lhe 8reasL Cancer 8lsk AssessmenL 1ool
O Larly Menarche
8lsk lncreases wlLh earller menarche

O LsLrogen Levels / Dse of 1amoxlfen
1amoxlfen ls a medlclne LhaL can reduce Lhe rlsk of developlng breasL cancer
ln hlgh rlsk women lLs beneflL Lo normal rlsk women ls unknown

O lnLake of 8lrLh conLrol pllls
Cral conLracepLlve 8lrLh ConLrol 9llls can sllghLly lncrease your rlsk buL Lhe
exLra cancers are mosLly small and curable and Lhe sllghL rlsk gradually
dlsappears when 8C9s are no longer used

Cverall Lhese flndlngs when gaLhered and esLabllshed may sLrongly lndlcaLe Lhe presence
of cancer cells especlally breasL cancer cells ln our paLlenL A8


4) now Joes A8s tomot Jlffet ftom tbot of bet motbets?

A8's moLher has a uLerlne myoma whlch ls a benlgn (noncancerous) Lumour LhaL grows
wlLhln Lhe muscle Llssue of Lhe uLerus DLerlne myoma range ln slze from larger Lhan a melon Lo
as small as a coln 2030 of women of chlldbearlng age have uLerlne myoma Jhlle many
women do noL experlence any problems sympLoms can be severe enough Lo requlre LreaLmenL
lor example a very large myoma may cause Lhe uLerus Lo sLreLch Lo Lhe slze of a slx or seven
monLh pregnancy Cnce women go Lhrough menopause uLerlne myomas do noL usually cause
any furLher problems

Cn Lhe oLher hand A8 has an lnfllLraLlng ducLal carclnoma ls Lhe mosL common Lype of
breasL cancer lL ls one of several recognlzed speclflc paLLerns of cancer of Lhe breasL lnvaslve
means LhaL Lhe cancer has lnvaded" or spread Lo Lhe surroundlng breasL Llssues uucLal means
LhaL Lhe cancer began ln Lhe mllk ducLs whlch are Lhe plpes" LhaL carry mllk from Lhe mllk
produclng lobules Lo Lhe nlpple Carclnoma refers Lo any cancer LhaL beglns ln Lhe skln or oLher
Llssues LhaL cover lnLernal organs such as breasL Llssue All LogeLher lnvaslve ducLal
carclnoma" refers Lo cancer LhaL has broken Lhrough Lhe wall of Lhe mllk ducL and begun Lo
lnvade Lhe Llssues of Lhe breasL Cver Llme lnvaslve ducLal carclnoma can spread Lo Lhe lymph
nodes and posslbly Lo oLher areas of Lhe body whlch causes mulLlple body malfuncLlons and
problems


5) usloq o flowcbott explolo tbe potbopbysloloqy of A8s bteost coocet to locloJe
o tloloqy ooJ pteJlsposloq foctots
b locol ooJ qeoetol effects
c lotbwoy of Jlssemlootloo


6) lo tbe blstopotboloqlc tepott wbot moJe tbe potboloqlst JeclJe ooJ soy tbot tbe lomp
wos oo lofllttotloq Joctol cA?

8y deflnlLlon lnfllLraLlng ducLal carclnoma one of several recognlzed speclflc paLLerns of
cancer of Lhe breasL lL was known Lo be Lhe mosL common Lype of breasL cancer lL ls so named
because lL beglns ln Lhe cells formlng Lhe ducLs of Lhe breasL

Cn a mammogram lnvaslve ducLal carclnoma ls usually vlsuallzed as a mass wlLh flne splkes
radlaLlng from Lhe edges (splculaLlon) lL may also appear as a smooLh edged lump ln Lhe breasL
Cn physlcal examlnaLlon Lhls lump usually feels much harder or flrmer Lhan benlgn causes of
lumps ln Lhe breasL Cn mlcroscoplc examlnaLlon Lhe cancerous cells lnvade and replace Lhe
normal breasL Llssue

ln Lhe case of A8 her prevlous lmplanLs may conLrlbuLe as a facLor of Lhe lnlLlaLlon of her
carclnoma AnoLher Lhlng ls LhaL based on Lhe deflnlLlon LhaL lnfllLraLlng Ca lnvades and replace
normal breasL Llssue Lhe lnvolvemenL of her lymph nodes may afflrm Lo Lhe sald deflnlLlon of
her condlLlon


7) A8 woots yoo to explolo exoctly wbot 12N1M0 meoos wbot wlll yoo tell bet?

ln dlagnoslng a paLlenL's CA sLage we use a 1nM classlflcaLlon sysLem Je base a paLlenL's
classlflcaLlon accordlng Lo Lhe exLenL of Lhe Lumor (1) Lhe lymph nodes lnvolved (n) and Lhe
spread or meLasLasls (M) of Lhe mallgnanL cells ln your case 12n1M0 means LhaL Lhe Lumor
(12) has spread over an area greaLer LhaL 2cm buL less Lhan 3cm ?our paLhologlsL reporLs Lhe
lnvolvemenL of 3 lymph nodes (n1) and reporLs no dlsLanL meLasLasls or spread (M) whlch was
also conflrmed by your C1 scans and xrays"


) be osks yoo to explolo wbot bet cbooces of sotvlvol ote now wlll yoo explolo?

lL ls good Lo know LhaL Lhe Lype of cancer LhaL you have ls Lhe mosL common Lype of breasL
cancer whlch means LhaL Lhere are a loL of lnLervenLlons and medlcal breakLhroughs made for
Lhls Lype of cancer AnoLher good Lhlng ls LhaL no dlsLanL spread of your carclnoma was
deLecLed and only 3 lymph nodes were lnvolved 8uL sLlll your recovery and recuperaLlon
process depends on how your body wlll compensaLe and how wlll you cooperaLe as parL of Lhe
healLh Leam neverLheless l can say LhaL as of now your chances of survlval are greaL"


10) wbot oteos of tbe obove ossessmeot cooceto yoo? xplolo
o wbot ls tbe potbopbysloloqlc bosls of obootmol floJloqs?

at|gue uurlng chemoLherapy Lhe red blood cell counL comes down Lhus anaemla can be one
of Lhe reasons CLher Lhan chemoLherapy you are undergolng any oLher LreaLmenL llke
radlaLlon LhaL Lhere ls also Lhe chance of feellng faLlgue uue Lo loss of appeLlLe Lhe body
becomes weak Lhus leadlng Lo faLlgue SLress Lenslon and depresslon regardlng Lhe success of
Lhe LreaLmenL slde effecLs eLc can also lead Lo faLlgue Age facLor also plays an lmporLanL role
as Lhe energy level ls less as you grow old

eddened ora| mucosa soreness lL ls caused by Lhe free radlcals produced by Lhe
chemoLherapeuLlc drug 1hls free radlcals damage Lhe unA of Lhe cells lL lncreases Lhe
lnflammaLory cyLoklnes and beglnnlng Lhe cardlnal slgns of lnflammaLlon 8eddenlng and
soreness of Lhe mucosa ls manlfesLed by Lhe paLlenL lnLerleukln 1and 1umor necrosls lacLor
alpha ls malnly lnvolved ln Lhe process


11) lotmolote yoot Jlscbotqe ploo fot A8 wbot televoot beoltb teocbloqs wlll yoo qlve?

nurslng care should be planned Lo promoLe paLlenL comforL provlde paLlenLs and Lhelr
famllles wlLh lnformaLlon relaLed Lo paln conLrol provlde lnformaLlon abouL and asslsLance
wlLh behavloral and physlcal lnLervenLlons prevenL and allevlaLe slde effecLs of pharmacologlc
Lheraples and promoLe paLlenL compllance wlLh Lherapy and requlred followup

1 Lxplaln Lo Lhe paLlenL Lhe full beneflL of radlaLlon LreaLmenLs lnsLrucL her Lo reporL
long Lerm adverse effecLs
2 Lmphaslze Lhe lmporLance of keeplng followup appolnLmenLs wlLh Lhe physlclan
3 8efer Lhe paLlenL Lo a supporL group such as Aruga and kyLhe loundaLlon
4 lnsLrucL paLlenL for proper skln care and managemenL
9revenL lncreaslng lrrlLaLlon and avold scraLch
uo noL use any perfumed soap olnLmenLs or deodoranL
Dse baby powder or malze sLarch
Jear loosecloLhes and coLLon made raLher synLheLlc maLerlals
Cpen Lo fresh alr buL noL dlrecL Lo sunllghL
1each paLlenLs abouL skln careskln emulslon cream for dry and paln
managemenL and anLlbloLlc spray for molsL desquamaLlon
3 Lnsure Lhe paLlenL has Lhe ablllLy Lo manage lncreaslng slde effecLs posLLreaLmenL
a laLlgue
Lncourage paLlenL Lo resL and llmlL dally acLlvlLles
b nausea and vomlLlng
LaL small frequenL meals
1ake anLlnausea or anLlemeLlc medlcaLlons lf necessary
SLlmulaLe appeLlLe
LaL nuLrlLlous and hlgh proLeln snacks
Avold faLLy or greasy foods
uo mouLh care regularly
1ake nuLrlLlonal supplemenLs
c SLomaLlLls
Avold lrrlLanLsalcohol Lobacco splcy acld foods or hoL drlnks
LaL sofL or llquld dleL
MouLh care wlLh sallne or waLer frequenLly
d Alopecla
CenLly brush and comb lnfrequenLly shampoo
Avold Lhe use of halr colorlng and chemlcal
Clve psychologlcal supporL for change of body lmage
Clve advlce for uslng wlg lf necessary
e 8one marrow suppresslon
Cbserve slgns and sympLoms of bleedlng anemla and lnfecLlon
f ularrhea
urlnk plenLy of flulds Lo avold dehydraLlon
Avold mllk or dalry producLs
Avold foods hlgh ln flber
Avold hlgh faL splcy and gas formlng foods
LlecLrolyLe replacemenLpoLasslum


12) A8 comes fot bet scbeJoleJ followop oppolotmeot be oppeots vety ooxloos wbeo
oskeJ sbe tells yoo lve beeo wottleJ oboot my Jooqbtets wbot lf tbey qet bteost
coocet? wbot coo l Jo to belp tbem? wbot ls yoot tespoose? wbot lotetveotloos coo
yoo Jo to belp?

lf Lhe paLlenL asked you abouL Lhelr daughLer acqulrlng Lhe breasL cancer afLer her dlagnosls
Lhe nurse should be cerLaln answerlng Lhe rlsk facLors lnvolved ln havlng Lhe dlsease 1he rlsk
facLors lnvolved ln Lhe case are
a 99 occur ln lemale
b lncreaslng age
c Pavlng flrsL degree relaLlve wlLh breasL cancer(lncreased rlsk Lwofold) havlng Lwo
(lncreased rlsk by flvefold) 1he rlsk ls hlgher lf Lhe relaLlve ls premenopausal aL Lhe Llme
of Lhe dlagnosls
d Pormonal lacLors
1ell Lhe paLlenL LhaL lL ls noL necessary LhaL lf she acqulred Lhe dlsease lL wlll be
Lransferred Lo her daughLer Some cases are famlllal buL lL depends on case Lo case basls
Ma'am Lhough you have Lhe breasL cancer lL ls noL necessary LhaL your daughLers wlll also
acqulre lL 1here ls a probablllLy buL lL ls noL cerLaln lL can also be prevenLed 1ell Lhe paLlenL Lo
educaLe her daughLer abouL conducLlng a selfbreasL examlnaLlon every monLh ln order Lo
observe any dlscrepancles or any slgns of Lhe dlsease 1he paLlenL Leachlng should lnclude
a 8reasL SelfLxamlnaLlon afLer mensLruaLlon (3
Lh
Lo 7
Lh
day)
b lnsLrucL Lhe paLlenL on how Lo do 8SL and reLurn demonsLraLes
c Mammography Screenlng should be done 10 years earller Lhan Lhe age aL whlch Lhe
youngesL famlly member develops breasL cancer buL noL before 23 years old
d ConLlnue breasLfeedlng (by Lhe daughLer) lf Lhe daughLers are lacLaLlng moLhers already

1J) oo osk bet wbetbet sbe bos otbet poestloos be tells yoo sbe ls wottleJ oboot tbe
bteost coocet comloq bock ooJ woots to koow wbetbet sbe woolJ bove to qo tbtooqb
tbe cbemotbetopy ooJ toJlotbetopy oll ovet oqolo wbot coo yoo Jo ooJ wbot wlll yoo
tell bet?

8reasL cancer can recur aL any Llme buL mosL recurrences occur ln Lhe flrsL Lhree Lo flve
years afLer lnlLlal LreaLmenL 8reasL cancer can come back as a local recurrence (ln Lhe LreaLed
breasL or near Lhe masLecLomy scar) or as a dlsLanL recurrence somewhere else ln Lhe body
1he mosL common slLes of recurrence lnclude Lhe lymph nodes Lhe bones llver or lungs

lf she had a lumpecLomy local recurrence ls usually LreaLed wlLh masLecLomy slnce
radlaLlon Lherapy cannoL be dellvered Lwlce Lo Lhe same area lf Lhe lnlLlal LreaLmenL was
masLecLomy recurrence near Lhe masLecLomy slLe ls LreaLed by removlng Lhe Lumor whenever
posslble usually followed by radlaLlon Lherapy ln elLher case hormone Lherapy and/or
chemoLherapy may be used afLer surgery and/or radlaLlon Lherapy lf breasL cancer ls found ln
Lhe oLher breasL lL may be a new Lumor unrelaLed Lo Lhe flrsL breasL cancer 1reaLmenL would
lnclude a lumpecLomy or masLecLomy and someLlmes sysLemlc Lherapy


14) A8 seems to Jo floe fot o wblle Oo bet olotb mootb followop vlslt sbe tells yoo sbe bos
beeo bovloq beoJocbes fot tbe post few weeks net Mkl loJlcotes sbe bos metostosls to
tbe btolo be ooJetqoes o booe mottow ttoosploot oofottoootely lt folleJ to stop bet
coocet be Jles ot tbe oqe of J9 leovloq bebloJ foot cbllJteo oqes 4 tbtooqb 14

8tlefly Jlscoss tbe totlooole of oll tbe tbetopeotlc meosotes fot A8s coocet

ad|otherap
O Should be glven followlng masLecLomy or breasL conservlng surgery Lo reduce local
recurrence where Lhe beneflL Lo Lhe lndlvldual ls llkely Lo ouLwelgh rlsks of radlaLlon
relaLed morbldlLy
scho|og|ca| Care
O All women wlLh a poLenLlal or known dlagnosls of breasL cancer should have access Lo a
breasL care nurse speclallsL for lnformaLlon and supporL aL every sLage of dlagnosls and
LreaLmenL
O ConLacL deLalls and lnformaLlon abouL Lhe role of Lhe breasL care nurse should be
avallable Lo Lhe paLlenLs Lhelr famllles and all Lhe members of Lhe mulLldlsclpllnary
Leam lncludlng Lhe prlmary care Leam



Ident|f|ng D|stress
O 1he measuremenL of lLs presence of psychologlcal sympLoms ln women wlLh breasL
cancer should be Lallored Lo Lhe lndlvldual clrcumsLances of Lhe paLlenL %eq pteseoce
of blqb level of Jlsttess ot tlsk foctots fot ptoblems)
O 8reasL cancer servlces should rouLlnely screen for Lhe presence of dlsLress and rlsk
facLors for very hlgh levels of dlsLress from Lhe polnL of dlagnosls onwards (lncludlng
durlng follow up revlew phases)
scho|og|ca| Support for Women w|th 8reast Cancer and the|r am|||es
O Croup psychologlcal lnLervenLlons should be avallable Lo women wlLh breasL cancer
who feel lL would sulL Lhelr needs SupporLlve expresslve Lherapy has been show Lo be
effecLlve ln advanced cancer and cognlLlve behavloral Lherapy for locallzed and
advanced dlsease
Commun|cat|on ,ethods
O Cllnlcal encounLers wlLh women wlLh breasL cancer should faclllLaLe paLlenL cholce
abouL LreaLmenL declslons %ossomloq potleot wlsb to pottlclpote lo tbe Jeclsloo mokloq
ptocess)
O JrlLLen agendas prompL sheeLs declslons alds should be use Lo lmprove
communlcaLlon wlLh women wlLh breasL cancer
at|ent Understand|ng Informat|on D|ssem|nat|on
O valldaLes currenL level of undersLandlng ldenLlfles learnlng needs and provldes
knowledge base from whlch paLlenL can make lnformed declslons
O Pelps wlLh ad[usLmenL Lo Lhe dlagnosls of cancer by provldlng needed lnformaLlon along
wlLh Llme Lo absorb lL
Gu|dance nea|th 1each|ngs
O 9aLlenL has Lhe rlghL Lo know and parLlclpaLe ln declslon maklng AccuraLe and conclse
lnformaLlon helps dlspel fears and anxleLy helps clarlfy expecLed rouLlne and enables
paLlenL Lo malnLaln some degree of conLrol
Nutr|t|on
O 9romoLes well belng faclllLaLes recovery and lL's crlLlcal ln enabllng paLlenL Lo LoleraLe
LreaLmenLs
Chemotherap
O 1o desLroy cancer cells ln Lhe body lncludlng cells aL Lhe orlglnal cancer slLe and any
cancer cells LhaL may spread Lo anoLher parL of Lhe body lor breasL cancer
chemoLherapy can be Laken
4 8LlC8L surgery Lo shrlnk a Lumor down
4 Al1L8 surgery Lo reduce chance of lL spreadlng or comlng back
4 As 18LA1MLn1 for breasL cancer LhaL has spread or come back
Lumpectom
O 1o remove Lhe breasL Lumor and some of Lhe normal Llssue LhaL surrounds lL
O 1o preserve much of Lhe appearance and sensaLlon of Lhe breasL
O 1ogeLher wlLh radlaLlon to ellmloote ooy coocet cells tbot moy be pteseot lo tbe
temololoq bteost tlssoe lL ls called breasLconservlng Lherapy