• D.B.
• 45 years old
• Female
• Married
• Housewife
• Kapasigan, Pasig City
 Breast mass, right
1 year PTA
• Breast mass, right
• Hard, marble-sized
• No breast pain, nipple
discharge, changes in the
appearance of the breast
4 months
PTA
• Enlargement of breast mass
• 25 centavo coin
• Unrecalled antibiotics w/o
relief
1 month PTA
• Progressive enlargement of breast mass
• Tomato-sized
• Breast pain
•
•
•
•
Sharp, “kirot,” 3/10
Localized on breast mass
Few days before menses, lasting a few
minutes
Spontaneous relief
• Core needle biopsy: Invasive Ductal CA
• Advised surgery
Admission
•
General: (+) anorexia, (-) weight loss, fever, weakness, fatigue
•
HEENT: (+) headache, (-) dizziness, enlarged LN
•
Pulmonary: (-) dyspnea, hemoptysis, cough, wheezing
•
Cardiovascular: (-) palpitations, chest pains, orthopnea
•
Gastrointestinal: (-) jaundice, abdominal pain, nausea, vomiting, changes in
bowel movement, tea-colored urine
•
Genitourinary: (-) nocturia, dysuria, frequency, hematuria
•
Musculoskeletal/Dermatologic: (+) myalgia, (-) back pain, arthralgia, rashes,
pruritus
•
Endocrine: (-) excessive sweating, heat/cold intolerance, polyuria, excessive
thirst
• No hypertension, diabetes mellitus, asthma
• No allergies
• No previous hospitalizations
• Removal of “pugita,” left eye (2003)
• G4P3 (3,0,1,3)
• Menarche at 13 years old
• ~28-30 day cycle
• Regularly menstruating
• 3 days, consuming 3 regular pads/day
• (-) dysmenorrhea
• LMP: February 13, 2012 (PMP: January 15, 2012)
• Oral contraceptive pills (1986-2000)
• Injectables (2009-2011)
• Hypertension- mother, father
• Asthma- siblings
• Cancer
• Bone cancer- uncle
• Unrecalled cancer- aunt
• No diabetes mellitus, PTB
• Housewife, mother
• Married to an electrician, OFW
• Lives with husband and youngest child
• Nonsmoker
• Occasional alcoholic beverage drinker
• No history of illicit drug use
• Conscious, coherent, cooperative
• Vital signs
•
•
•
•
•
120/80 mmHg
86 beats/ min
20 breaths/min
36.5C
VAS 0/10
• Weight 59 kilos, Height 153 cm
• BMI 25.2 kg/m2 (overweight)
• Anicteric sclerae, pinkish conjunctivae, no
• No tragal swelling or tenderness
• No nasal discharge
• Pinkish lips, moist oral mucosa, no lesions or
sores, no tonsillopharyngeal congestion
• No cervical lymphadenopathies, non-palpable
thyroid gland
 No lesions or scars on the chest
 Symmetrical breasts
 Pinkish-brownish nipple, no skin dimpling/ retractions
 7 cm x 5 cm mass on the upper outer area of the right breast
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



Hard, non-tender
Well-circumscribed
Movable
Smooth borders
11 to 2 o’clock position
 No enlarged axillary or supraclavicular lymph nodes
 No nipple discharge
• Symmetric chest expansion, no retractions
• Equal tactile fremiti
• No dullness on percussion
• Good air entry, clear breath sounds
• Adynamic precordium
• PMI at 5th ICS, left MCL
• Normal rate and regular rhythm, distinct
S1/S2, no murmurs
• No carotid bruits
• Soft, flabby abdomen without scars
• Normoactive bowel sounds
• Tympanitic
• No tenderness
• Non-palpable liver edge
• No masses
• (-) CVA tenderness
• No rashes/ skin lesions
• Warm extremities
• Good skin turgor
• Full and equal pulses
• No cyanosis, no clubbing
• CRT < 2 seconds
• Awake, alert, well-groomed
• Oriented to 3 spheres
• GCS 15
• No cranial nerve deficits
• MMT: 5/5
• DTRs: 2+
45/ F, G4P3,
housewife
Family history of
CANCER;
Long history of OCP
use
Rapidly enlarging
BREAST MASS;
Cyclic BREAST PAIN
7x5 cm hard,
nontender movable,
well-circumscribed
breast mass,
(-) nipple discharge
(-) enlarged lymph
nodes
 Breast cancer, right
• Breast cyst
• Common in those in their 40s, perimenopausal
• Cyclic breast pain
• Breast mass
• Firm
• Well-demarcated
• Mobile
• Fibroadenoma
• Common in the those <30 years
• Breast mass
•
•
•
•
•
Usually solitary
Rubbery
Round or lobulated
Nontender
Mobile
• Ultrasound of the breast
• Solid vs. cystic
• Fine needle aspiration
• Diagnostic and therapeutic for breast cysts
• If suspected cyst proves to be a solid lesion, then
material for biopsy may be obtained instead.
Solid breast
mass
Clinically
benign
Excisional
biopsy
Mammogram
Clinically
suspicious
Mammogram
+ FNA/ Core
Operation
Management of solid breast masses.
(Harris et. al., 2000. Diseases of the Breast. p.43)
 Invasive ductal carcinoma, Nottingham
combined histologic grade III
• Invasive ductal carcinoma, Stage IIB, T3 N0
M0
• Most common
malignant tumor
(80%)
• Most often present
as a palpable mass
or mammographic
abnormality
• Feel like a hard,
bumpy, movable,
irregularly-shaped
lump beneath the
areola
 Reproductive factors
 Age at menarche
 Menstrual cycle characteristics
 Pregnancy and age at first full-term pregnancy
 Nulliparous
 Late age at first full-term pregnancy
 Number and spacing of births
 Lactation/ breastfeeding
 Age at menopause
 Oral contraceptives
 Duration of use
 Use before a first full-term pregnancy or at an early age
 Postmenopausal hormone use
 Dietary factors
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
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

Dietary fat intake
Obesity
Dietary fiber
Vitamin A
Alcohol: >1 drink/day
 Physical activity: >3 hours/week
 Ionizing radiation
 Environmental pollution
 Organochlorines
 Active and passive smoking
 Silicone breast implants
 Family history (mother and sister, first degree relative)
 Jewish heritage
 Benign breast disease
• Has a tendency to metastasize via lymphatics
•
•
•
•
•
•
Lymph nodes
Contralateral breast
Liver
Lungs
Bones (vertebra)
Brain
CBC and blood typing
Hemoglobin
133 g/L
Hematocrit
0.4
WBC
5.1 x 109/L
Urinalysis
Color
Yellow
Turbidity
Slightly turbid
pH
5.5
Sp. Gr.
1.025
Albumin
Negative
Neut
0.60
Sugar
Negative
Lymph
0.37
Pus
4-8/hpf
RBC
0-2/hpf
Epithelial cells
Few
Bacteria
Occasional
Urates
Few
Mucus
Many
Eos
Platelet
Blood type
0.03
Adequate
A+
 Chest x-ray
 Normal chest findings
 ECG
 Non-specific ST-T wave changes
 To avoid ay chance of local/regional
recurrence
 To maximize options for breast
reconstruction
 Most widely used surgical procedure to
treat operable breast cancer
 Removes the breast, surrounding
tissue and nearby lymph nodes
 Leaves the pectoralis major intact
 Avoids disfiguring hollow defect below
the clavicle
 Five-year survival rates are highly correlated
with tumor stage:





Stage 0: 99-100%
Stage I: 95-100%
Stage II: 86%
Stage III: 57%
Stage IV: 20%