CASE PRESENTATION

SURGERY
HISTORY

 Patient’s name Asiya

 Age :20 years
 Address:Nankana saab
 Mode of admission:Breast clinic, OPD
 Date of admission:20/12/10

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 PRESENTING COMPLAINT
 Lump in right breast-1 year

 History of present illness:
 Patient was alright 1 year back when
she noticed a lump in her right breast that
was initially walnut sized but then gradually
increased in size to involve the whole breast
over 3-4 months duration.
 The lump is not associated with
pain but distortion of nipple.Theres c/o
bloody discharge from the nipple that
stained her clothing.
 There is no c/o fever,weight loss
and anorexia.
 For the past few months patient has
developed complain of headache sudden
onset, stabbing in character increasing in
 Thepatient had presented initially
breast clinic of SGRH where her
FNAC was done.She was diagnosed
to have breast CA.She was given
time for operation but she did not
present.
 His family took her to a pir who did
dam Darood but her condition
worsened.She again presented in
SGRH on 20/12/10.
SYSTEMIC INQUIRY

 CNS: There’s no c/o diplopia, loss of

consciousness,fits or loss of
consciousness
 CVS: There’s no c/o chest pain or
palpitations but there’s c/o exertional
dyspnea.
 RESP:There’s c/o dry cough for 3 months.
 GIT: There’s no c/o abdominal
pain,diarrhea,vomiting or
constipation.There’s no c/o
jaundice,hematemesis or malena.
 GENITO URINARY:There’s no c/o burning
micturition,flank pain,hematuria,dysuria
or pyuria.
PAST HISTORY

 No history of previous
hospitalizations.
 DRUG HISTORY:
 H/O intake of hakeem medications
for 3 months for similar complaints.
 FAMILY HISTORY:
There’s no family history of CA

breast,ovary or uterus.But mother

died of suspected tuberculosis at the
age of 45 years.
 MENSTRUAL HISTORY:
 Age of menarche:13 years
 3/28 days cycle of average
flow, no c/o
 dysmenorrhea
SOCIO ECONOMIC:

 4 Siblings, 2 brothers and 2

sisters.Father is a labourer living in
house.Mother died at the age of 45
yrs when she was 6 months old.
EXAMINATION

A young lady lying comfortably in

bed, well oriented in time, place
and person,co-operative with
following vitals:
 B.P:110/80 mmHg
 pulse:90/min
 Temp:98.6 F
 R/R:16/min
GENERAL PHYSICAL
EXAMINATION
 Pallor +++
 Jaundice –ve
 Cyanosis –ve
 Clubbing –ve
 Pedal edema –ve
 JVP not raised
 Lymph nodes-supra clavicular lymph
nodes are palpable on both sides
LOCAL EXAMINATION

 INSPECTION:
 On inspection, left breast is normal while
right breast shows visible nipple changes
like distortion of its shape,ulceration and
eczematous changes(Paget’s disease of
nipple).
PALPATION:

 There’s 5x5 cm lump involving the whole

of rt breast.It is hard in consistency,non
mobile fixed to the underlying muscle and
overlying skin.
There are fixed matted axillary lymph nodes

on right side.
Supraclavicular lymph nodes are palpable on
SYSTEMIC EXAMINATION

 CHEST:
 Normal vesicular breathing with
no added sounds.
 CVS:
 S1+S2+0
Abdomen:

 no visceromegaly
 no palpable mass
 SD and FT are –ve
 Bowel sounds are audible
CNS:

 Congenital squint otherwise

grossly intact

INVESTIGATIONS

 ROUTINE:
 CBC:
 Hb:12.3g/dL
 TLC:10,000/µL
 PLT:255,000/µl
 DLC:
 Neutrophils:76%
 Lymphocytes:20%
 Monocytes:02%
 ESR:21 mm/1st hour
  RFTs:
 serum creatinine:0.9 mg/dL
 blood urea:17 mg/dL
LFTs:

 TBIL:0.5 mg/dL
 ALT:14 IU/L
 AST:25 IU/L
 ALP:51 IU/L
HBsAg non-reactive

Anti HCV non-reactive


 FNAC done on 16/07/10 shows
proliferative breast disease with
atypia.Tissue biopsy advised.

 TRUCUT BIOPSY on 31/07/10
provides inadequate tissue sample,
malignancy cannot be proved.

 INCISIONAL BIOPSY 24/08/10 shows
Invasive ductal CA Grade II

 Abdominal USG:
 Liver shows an echogenic focus
measuring 8x7 mm noted in right lobe of
liver most likely hemangioma.


 BONE SCAN:
 Shows multiple areas of abnormal
increased uptake of radionuclide involving
12th thoracic,1st lumbar vertebrae,multiple
costo chondral junctions,pelvis multiple
sites,manubrium sternii and proximal end of
both femorii.
stage Description

CANCER
BREAST
FOR
STAGING
TNM
tumor
TX Primary tumor not assesable

T0 No evidence of primary tumor

Tis Carcinoma in situ

T1 Tumor ≤2cm in greatest dimensions
T1a Tumor > 0.1 cm but not > 0.5 cm
T1b Tumor > 0.5 cm but not >1 cm
T1c Tumor > 1cm but not >2 cm
T2 Tumor > 2cm but < 5 cm in greatest dimension

T3 Tumor > 5cm in greatest dimension

T4 Tumor of any size with direct extension in to chest wall or skin
T4a Extension into chest wall(ribs,intercostals, cserratus anterior)
T4b Peau d’ orange, ulceration or satellite skin nodules
T4c T4a + b
T4d Inflammatory breast cancer
 TNM staging for breast
cancer
Lymph nodes
Regional
NX Regional lymph nodes not assessable
N0 No regional lymph node involvement
N1 Metastasis to movable ipsilateral axilliary lymph nodes
N2 Metastasis to same side axilliary lymph nodes fixed to
N3 one anothertooripsilateral
Metastasis to other structures
internal mammary lymph node
with or with out axilliary lymph node involvement or
in clinically apparent clavicular lymph node

Distant Metastases
MX Presence of distant metastasis is not
M0 assessable
No distant metastasis
M1 Existant distant metastases including
ipsilateral supra clavicle nodes
American joint committee on cancer
classification for breast cancer on
TNM CRITERIA
Stage Tumor Nodes Metastasis
0 Tis N0 M0
I T1 N0 M0
IIA T0,1 N1 M0
T2 N0 M0
IIB T2 N1 M0
T3 N0 M0
IIIA T0, 1, 2 N2 M0
T3 N1,2 M0
IIIB T4 Any N M0
Any T N3 M0
IV Any T Any N M1
STAGE OF DISEASE OF
PATIENT
 According to all the investigations
and TNM staging patient has stage
IV disease .
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 PLAN

 Ourplan is to go for neo adjuvant

chemotherapy followed by surgery
and adjuvant chemoradiotherapy.
 MANAGEMENT


 The patient is now receiving
chemotherapy from the oncology
department of our hospital.
 Her workup for chemotherapy is
complete.
 And she has received 2 courses of
chemotherapy.