`

the case of a 53 year old menopausal female from novaliches, quezon city

CC Breast Mass, Right Breast Mass, Right Solitary, hard, non-tender breast mass, Right Lower Outer Quadrant

HPI
1 Month PTA

Patient palpated a mass on her right breast Non-Neoplastica small Patient palpated a mass about the size of Fat Necrosis on her rightmarble located on the Lower Outer Quadrant breast about Fibroadenoma the size of a small tenderness, discharge or erythema marble (-) Chronic Breast located on the Lower Abscess Outer Quadrant Neoplastic (-) tenderness, discharge or erythema

In the Review of Systems, try to elicit the following: SSx of Metastasis Bone pain Shortness of breath Lack of appetite Weight loss Neurological pain or weakness, headaches

On Examination of the Breast, take note of the following: Mass Size Consistency Mobility Discharge Skin changes Erythema Induration Skin Dimpling Nipple Retraction

ROS

No weight loss, loss of appetite No headache, vomiting No dyspnea, difficulty of breathing No chest pain, orthopnea No palpitations, PND No abdominal pain, diarrhea, constipation No dysuria, frequency, urgency No edema, cyanosis (-) DM, HTN, PTB, Asthma No previous surgery (-) History of Breast Cancer

PMHx FMHx PSHx

Non-smoker, non-alcoholic drinker

Findings
Conscious, coherent, ambulatory

BP CR RR

100/70 mmHG 89 beats/min 14 breaths/min

Normotensive Normal Normal

Pink palbebral conjunctivae, anicteric sclerae (-) NAD, TPC, CLAD Right Breast: Pendulous breast with 2x2cm mass, non-tender, fixed, hard, (-) discharge, orange-peel (-) palpable right axillary lymph nodes Left Breast: Unremarkable

Findings
SCE, (-) retractions, resonant, CBS, (-) crackles, wheezes AP, NRRR, no murmur, AB at 5th ICS, LMCL Flabby abdomen, NABS, soft, non-tender, liver and spleen not enlarged (-) pallor, cyanosis, edema DRE unremarkable

Fat Necrosis Fibroadenoma

Rule In Solitary nontender firm mass Solitary nontender firm mass Solitary nontender firm mass Dominant solitary nontender mass

Rule Out (-) Hx of Trauma, Scar, Hematoma ** R/O through Excisional Biopsy ** Usually found in a young woman with large breasts ** R/O (-) Fever ** Biopsy to distinguish from carcinoma (-) Involvement of the Suspensory Ligaments - retraction, revealed by dimpling, deviation of the nipples, fixation to the pectoral muscles (-) Involvement of the Lactiferous Tubules Flattening of the nipple, bloody or clear discharge (-) Lymphatic obstruction edema of the skin, peau dorange (-) Lymphatic spread Regional lymphadenopathy

Chronic Breast Abscess Breast Carcinoma

Breast Mass, Right, Probably Malignant

Resource Allocation for Diagnosis and Pathology

Level of Resources Basic

Clinical History Physical examination Clinical breast examination Fine-needle aspiration biopsy (1) Surgical biopsy (Incision/Excision) (2)

Pathology Imaging and Laboratory Tests Interpretation of biopsies Cytology report categorizing cells as malignant, benign or not diagnostic Surgical or pathology report categorizing lesion as malignant vs. benign, invasive vs. in situ and describing tumor size, lymph node status, histologic type, tumor grade and margin status Determination and reporting of ER and PR status Determination and reporting of margin status

Limited

Core needle biopsy Image-guided sampling (ultrasonographic + mammographic)

Enhanced

Maximal

Preoperative needle localization under mammographic or ultrasound guidance Stereotactic biopsy Sentinel node biopsy

Onsite cytopathologist

Diagnostic breast ultrasound +/- diagnostic mammography Plain chest radiography Liver ultrasound Blood chemistry profile/CBC Diagnostic mammography Bone scan

HER-2/neu status IHC staining of sentinel nodes for cytokeratin to detect micrometastases

CT scanning, PET scan, MIBI scan, breast MRI

Shyyan R, Masood S, Badwe RA, Errico KM, Liberman L, Ozmen V, Stalsberg H, Vargas H, Vass L. Breast cancer in limited-resource countries: diagnosis and pathology. Breast J 2006 Jan-Feb;12 Suppl 1:S27-37. [45 references]

Comparison of Paraclinical Diagnostic Procedures in Patients with a Palpable Breast Lump in which a More Definitive Diagnosis is Needed in a Patient Suspected to have a Breast Cancer
(Goal: to be more definite on the diagnosis of a palpable breast lump suspected of cancer)

Procedures FNAB

Benefit Direct examination and Sampling Diagnostic yield and accuracy rate of more than 90%

Risk Pain Hematoma No Scar

Cost Php 1,500

Open Biopsy

Direct examination and sampling Diagnostic yield and accuracy rate of more than 98%

Pain Hematoma Side effects of Anesthetic agents Scar

Php 8,000

Lecture: Dr. Reynaldo Joson, September 25, 2006

Actual Procedures Done on the Patient CBC, Blood Chemistry Normal Estrogen and Progesterone Receptor - Positive (+) Her2-neu IHC 2+ Her2neu FISH Negative

Excision Biopsy Invasive Ductal Carcinoma August 23, 2006 (s/p Excision) Invasive Ductal Carcinoma, Right breast mass, grade II Measuring 2x1x1cm Modified Radical Mastectomy (after 2 wks) September 14, 2006 (s/p MRM) No residual tumor seen Skin, nipple, and basal line of resection are negative for malignant cells All (0/12) lymph nodes are

Primary Tumor (T) Tx T0 TIS T1 T2 T3 T4 Cannot be assessed No evidence of primary tumor Carcinoma in situ Tumor 2cm Tumor > 2cm but 5cm Tumor > 5 cm Extension to chest wall, inflammation, satellite lesions, ulcerations Mx M0 M1 Nx N0 N1 N2 N3

Regional Lymph Nodes (N) Cannot be assessed No regional lymph nodes Metastasis to movable ipsilateral nodes Metastasis to matted or fixed ipsilateral nodes Metastasis to ipsilateral internal mammary nodes Distant Metastasis (M) Cannot be assessed No distant metastasis Distant Metastasis (includes spread to ipsilateral supraclavicular nodes)
HPIM 16th ed

Stage Grouping Stage 0 Stage I Stage II A TIS N0 M0 T1 N0 M0 T0 N1 M0 T1 N1 M0 T2 N0 M0 T2 N1 M0 T3 N0 M0 T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1,N2 M0 T4 Any N M0 Any T N3 M0 Any T Any N M1
HPIM 16th ed

Stage II B Stage IIIA

Stage III B Stage IV

Scarff, Bloom and Richardson grade Grade I - well differentiated (3-5) Grade II - moderately differentiated (6-7) Grade III - poorly differentiated (8-9)

HPIM 16th ed

Diagnostic tests to rule out metastasis Stage I, II Complete Blood Count Liver Function Tests Chest X-Ray

Bigger, More Advanced Bone Scan Liver Scan

Diagnosing Nodal Metastasis in Invasive Ductal Carcinoma ALND Axillary Lymph Node Dissection Axillary Lymph Node Dissection - traditional procedure to detect lymph node metastasis, and potentially therapeutic for the regional control of axillary metastases Sentinel Lymph Node (SLN) Biopsy - most women with early-stage breast cancer arecancer in - minimally invasive alternative to stage breast node negative, node-negative patients in these women exposes clinically and axillary dissection - them tometastasis-free SLN in 6570% of patients benefit yields the complications of this procedure, with no - associated with significant long-term no further axillary - if SLNs are histologically negative, morbidity. surgery would be performed - associated with reduced arm morbidity and better quality of life - treatment of choice for patients who have early-stage breast cancer with clinically negative nodes

SLNB

Local/regional treatments: 1. Mastectomy + radiation therapy 2. Breast-conserving surgery Lumpectomy (also called "wide resection," "partial mastectomy," or "quadrantectomy") + radiation therapy to the remainder of the breast tissue Women who didn't get radiation after lumpectomy were shown to have a 40% greater risk of the cancer coming back in the same breast These two options are considered equally effective for women with a breast cancer measuring about four centimeters or less. For women with a single tumor larger than about four centimeters, breast preservation therapy may still be an option if chemotherapy is able to shrink the cancer substantially BEFORE surgery.

Suggested Approaches to Adjuvant Therapy

Age Group Lymph Node Status Positive Negative Endocrine Receptor (ER) Status Any Any Any Tumor Recommendations

Pre-menopausal

Check Serum Multidrug chemotherapy Tumor Markers ER(+) + Tamoxifen if

Multidrug chemotherapy + Tamoxifen if ER(+) Multidrug chemotherapy Tamoxifen with or without chemotherapy Tamoxifen

>2 cm, or 1-2 cm with other poor prognostic variables Any Any >2 cm, or 1-2 cm with other poor prognostic variables >2 cm, or 1-2 cm with other poor prognostic variables

Post Menopausal

Positive Positive Negative

Negative Positive Positive

Negative

Negative

Consider multidrug chemotherapy

HPIM 16th ed, p.521

 For years, tamoxifen was the hormonal medicine of choice for all women with hormone-receptor-positive breast cancer In 2005, the results of several major worldwide clinical trials showed that aromatase inhibitors worked better than tamoxifen in post-menopausal women with hormone-receptive-positive breast cancer Aromatase inhibitors are now considered the standard of care for post-menopausal women with hormone-receptor-positive breast cancer

Tamoxifen remains the hormonal treatment of choice for pre-menopausal women

The patient underwent modified radical mastectomy. Histopathology results showed the patient to be on T2NOMx. The patient is at Stage IIA.
Disease Stage Stage 0 Stage I Stage II Stage III (locally advanced) Stage IV (metastatic) 5-year Survival Rate 99% 85-95% 65-75% 45-50% 20-30%

 Modified radical mastectomy continues to be appropriate for some patients, but breast conservation therapy is now regarded as the optimal treatment for most. Six prospective randomized trials have shown no difference in survival when mastectomy is compared with conservative surgery plus radiation for Stage I and Stage II breast cancer (Table 1).

Adapted from Winchester DP, Cox JD. Standards for diagnosis and management of invasive breast carcinoma.

Recurrence Most recurrences occur in the first three to five years after initial treatment. Breast cancer can come back as a local recurrence (in the treated breast or near the mastectomy scar) or as a distant recurrence somewhere else in the body. The most common regions that breast cancer may spread to in order of frequency are: Bone, Lung and Liver. Approximately 25% of breast cancers spread first to the bone. The bones of the spine, ribs, pelvis, skull, and long bones of the arms and legs are most often affected. Between 60% and 70% of women who die from breast cancer have eventually had it spread to their lungs. In 21% of cases, the lung is the only site of metastasis (spread)
The most common signs of lung metastases are: shortness of breath and dry cough. In some cases, women will not experience any symptoms; cancer will only be detected by chest X-ray or CT scan.

http://www.imaginis.com/breasthealth/bcrecurrence.asp

Recurrence Chest wall recurrence (CWR) after mastectomy occurs in 5% to 40% of

breast cancer patients and is generally believed to forecast a grim outcome. These recurrences are often followed by distant metastasis and death Patients with initial node-negative disease who develop CWR after 24 months have an optimistic prognosis, especially if they are treated with Annals of Surgical Oncology, 10(6):628634 radiation Presence of estrogen and progesterone receptors in the cancer cell is another important prognostic factor, and may guide treatment

Hormone receptor positive breast cancer is usually associated with much better prognosis compared to hormone negative breast cancer
HER2/neu status has also been described as a prognostic factor. Patients whose cancer cells are positive for HER2/neu have more aggressive disease www.emedicine.com

Metastasis should be assessed since breast cancer can spread to the lungs. The patients chest x-ray showed a pulmonary nodule which maybe a sign of metastasis. In addition the patient is already taking antimetastasis medication. However histopathologic studies showed no nodal involvement. Thus a biopsy of the pulmonary nodule is needed for definitive staging. The presence of metastasis will classify the patient as Stage 4.

CXR - Pulmonary nodule at the right lung base CT Scan Pulmonary nodule on the Right Lower Lobe, 1x1cm Advised chemotherapy Enrolled at RIBBON Study, receiving Xeloda and Avastin

Solitary Pulmonary Nodule in the Patient with Breast Cancer Similarly, in a study assessing the role of surgery in the diagnosis and treatment of an SPN among post-surgery breast cancer patients, results showed that histology of SPN was primary lung cancer in 38 patients (n=79), pulmonary metastasis of breast cancer in 27, and benign European Journal of Surgical Oncology, Volume 33, Issue 5, June 2007, pp 546-550 condition in 14. In a patient with a known extrathoracic malignancy and a solitary pulmonary With a history of sarcoma or melanoma, the pulmonary nodulehave been proposed: nodule on the CT scan, the following scenarios is more likely to be a metastasis

In the case of underlying head and neck cancer or breast cancer, a second primary cancer in the lung is more likely With other malignancies, the nodule is equally likely to be a primary lung cancer or metastatic disease

Malignant lesions account for 3-10% of CT scandetected pulmonary nodules. In an older patient, a solitary nodule is more likely to be malignant (lung cancer, in particular); in a younger patient, multiple nodules are Bascom, R. (2006). Secondary Lung Tumors. www.emedicine.com more likely to be metastases

Solitary Pulmonary Nodule in the Patient with Breast Cancer A solitary pulmonary nodule (SPN) appearing in a patient with breast cancer, either past or present, is most likely to be a second primary cancer originating in the lung rather than a metastasis from the breast cancer.
Patients with breast cancer with SPNs should have a diagnostic workup appropriate for lung cancer (In a study conducted among 1416 breast cancer patients, 42 had a solitary pulmonary nodule either at the time of presentation of their breast cancer or during the follow-up period, Fifty-two percent of the solitary pulmonary nodules proved to be a primary lung tumor, 5% proved to be benign lesions, and only 43% proved to be metastatic breast cancer.). Since adenocarcinoma has become the most common lung cancer cell type, the usual diagnostic tests may not allow a firm differentiation between primary lung and secondary breast cancer. Therefore if malignancy is proved or suspected, thoracotomy with appropriate resection is the treatment of choice in most patients with breast cancer, even at the initial appearance of the breast cancer.
www.emedicine.com

Reduce Stress - Keep a positive attitude - Be assertive instead of aggressive "Assert" feelings, opinions, or beliefs Stress of becoming angry, instead - Uncertainty or passive combative, of the future - Unpredictability of the cancer Exercise regularly - Disability Eat well-balanced meals - Financial difficulties Keep Track of Medical - Physical appearance Information - Make use of resources and support - after mastectomy services offered to chemotherapy - hair loss due by the hospital and community - skin changes due to radiotherapy - Learn more about breast cancer to help patient feel more comfortable with treatment

Thank you!
tubal.tuliao.umag.uy.valencia.verde.villanueva.vizconde.wee.wylengco.zapanta || hLPS

The Ribbon 1 Study is seeking approximately 1000 patients over age 18 with metastatic breast cancer who have not previously received chemotherapy for this disease. Individuals who have received chemotherapy prior to being diagnosed with metastatic breast cancer may be eligible for the study as long as they have not been treated with chemotherapy since that diagnosis of metastatic breast cancer. The study will evaluate the safety and effectiveness of bevacizumab, an investigational compound, when combined with chemotherapy, compared to chemotherapy alone, in individuals who have not been previously treated with chemotherapy for metastatic breast cancer. Individuals participating in the study will be randomly assigned to one of two treatment groups: * One group will receive bevacizumab in combination with the standard of care chemotherapy treatment. * One group will receive placebo in combination with the standard of care chemotherapy treatment. Note: The chemotherapy treatment used in both groups is considered the standard of care for metastatic breast cancer. Study participants will be given bevacizumab or placebo once every three weeks until their disease progresses or they experience unacceptable toxicity. The maximum treatment period with bevacizumab is 24 months.