breast lump (nandinii)
DESCRIPTION
TRANSCRIPT
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
4
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
5
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
6
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
11
Enlargement
A normal duct cells
B basement membrane (duct wall)
C lumen (center of duct)
Illustration © Mary K. Bryson
Ductal Carcinoma in situ (DCIS)
12
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)
13
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
14
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
17
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