Iman Jaramna, 3rd group, 4th year

CASE REPORT
REASONS FOR HOSPITALIZATION

I examined the patient M. A., female, 63 years old, from Sibiu, who presented to the ER on the 13th
of December 2020 for shape distortion of the right breast, nipple discharge and a weight loss of 7
kilograms in the last month. The patient is known for history of Alzheimer’s, therefore she won’t be
able to share the correct information. I decided to collect the requested information from her
daughter, 32 years old who knows her mother’s medical history.

FAMILY HISTORY

Insignificant for current pathology.

PERSONAL PATHOLOGICAL HISTORY

The patient suffered an appendectomy at the age of 14. She has been diagnosed with Alzheimer’s
disease in 2017 and gastritis 4 months ago.

PERSONAL PHYSIOLOGICAL HISTORY

The patient had menarche at the age of 13. She had 2 natural births that went well, without
difficulty, her first pregnancy at 29. Menopause set in at the age of 54.

LIVING AND WORKING CONDITIONS

The patient lives in the city, above average conditions. She worked as a teacher for 30 years and
retired at 55 by choice.

BACKGROUND MEDICATION

1. PANTOPRAZOLE 2x20 mg/day one dose in the morning – gastritis

2. FAMOTIDINE 2x20 mg/ day, 1 in the morning and 1 in the evening. – gastritis
3. DONECEPT 1x10 mg/day, in the evening – Alzheimer’s disease

DISEASE HISTORY

The patient has been registered with Alzheimer’s disease since 2017 and has been diagnosed with
gastritis 4 months ago due to Helicobacter Pylori for which she follows a treatment. She came to our
hospital complaining about shape distortion of the right breast that her daughter noticed during the
last month taking care of her mother, nipple discharge, observed on her clothes for the last 2 weeks
and a weight loss of 7 kg in the last month.

PHYSICAL EXAMINATION
Iman Jaramna, 3rd group, 4th year

GENERAL
GENERAL STATE: lethargy, near-syncope

STATE OF CONSCIOUSNESS: decreased

MENTAL STATE: precarious

WEIGHT: 45 kg

HEIGHT: 160 cm

BMI = 17.6 kg/m2 (Mild thinness)

IDEAL WEIGHT: 55.68 kg

VITAL SIGNS

Body temperature: 37.2

Pulse rate: 70 bpm

Respiration rate (rate of breathing): 17/min

Blood pressure: 120/80

ORGANS AND ORGAN SYSTEMS

Skin: pale, increased capillary refill time, dry skin and mucous membranes, sunken eyes

Ganglio-lymphatic: Enlarged supraclavicular lymph nodes, ipsilateral axilla showed an enlarged

mobile lymph node

Connective-adipose tissue: Poorly represented subcutaneous cellular tissue, weight deficit

Lungs: transmission of vocal vibrations present, palpation of the skin, subcutaneous cellular tissue,
muscles, intercostal nerves, thoracic bones - without pathological elements, extension of the lung
peaks and bases - present, symmetrical, pectoral rumble - normally transmitted throughout the lung
area, normal lung sound throughout pulmonary area, physiological tubal murmur present, vesicular
murmur present throughout the lung area, inhale / exhale ratio - normal (3/1), stetacoustic no
pathology added

Cardio-vascular: normal precordial area appearance, apexian shock visible and palpable in the
left intercostal space V on the mid-clavicle line, cardiac dullness within normal limits, rhythmic, clear,
well-beat heart rate, ventricular rate: 110 bpm, BP: 110 / 65, rhythmic peripheral pulse, poorly
perceptible, veins of normal appearance
Iman Jaramna, 3rd group, 4th year

Digestive: mouth examination: pale lips, no lesions, smooth oral mucosa, pink, normal palatal
arch, smooth, pink, continuous, normal palatal wave , pink pharyngeal mucosa, smooth, moist,
normal looking tongue , normal-looking pharynx, supple abdomen, participates in respiratory
movements, pale skin, no muscle defense, no sensitivity in the appendicular points, nausea, poor
appetite

Liver and spleen: within normal limits, impalpable gallbladder

Muscular system: intact, muscle weakness

Osteo-articular: unmodified peripheral joints, mobile, spine with preserved physiological curves,
painless to palpate, percussion and mobilization, normal joints morphologically and functionally,
examination of the temporomandibular joint without pain

Uro-genital: supple renal lodges, painless on palpation and percussion, impalpable kidneys,
oliguria, clear urine on emission, bilateral negative Giordano maneuver, external genitals of normal
appearance

Central nervous system: A mental status examination revealed average grooming and hygiene,
poor eye-to-eye contact, psychomotor retardation, a calm and quiet demeanor, irrelevant yet
coherent responses to questions and blunted affect. The patient denied experiencing any
hallucinations or other perceptual abnormalities and no overt delusions or obsessions were noted
during his examination.

A cognitive assessment with the mini-mental state examination revealed a score of zero, as the
patient was unable to complete any of the required tasks. While the patient registered three items
correctly, she recalled none. She was unable to do the serial sevens or threes measures of attention
and was unable to read or write.

Breast:
 Lump
 Attached to the chest wall and cannot be moved.
 The lump is hard, irregular in shape and very different from the rest of the breast
tissue
 tender, but it is not painful.
 Large
 One
 In the lower right quadrant
 Dimpling of the skin
 Peau d'orange
 Change in size of affected breast
 Inverted nipple
 Discharge from nipple - mostly bloody
Iman Jaramna, 3rd group, 4th year

STAGE DIAGNOSIS

1. HYPERPROLACTINEMIC SYNDROME
Clinically proved by: nipple discharge in the last 2 weeks

2. CACHECTIC SYNDROME
Clinically proved by: weight loss of 7 kg in the last month

3. HYPERTONIC ACUTE DEHYDRATION SYNDROME <5%

Clinically proved by: increased capillary refill time, dry skin and mucous membranes, muscle
weakness, nausea, decreased urine output, sunken eyes

LABORATORY INVESTIGATIONS AND IMAGING

Laboratory results include: hypernatremia 180 mmol/l, BUN and creatinine levels elevated, Hb
135g/l, WBC 24.2x109 , Ht 27%, oliguria, urea 31,3 mmol/l, creatinine 263 umol/l, glucose 95mg/dl,

Tumor markers were also within the normal range: cancer antigen 19-9, 7 IU/mL; cancer antigen 15-
3, 14.7 U/mL; and carcinoembryonic antigen (CEA), 2.2 ng/mL. Other laboratory results were also
unremarkable.

Mammogram and ultrasound revealed a 5.2-cm right breast mass with an enlarged ipsilateral axillary
lymph node. Core biopsy of the mass showed invasive ductal carcinoma, estrogen receptor (ER) 95%
positive, progesterone receptor 85% positive, and HER2 negative. Fine needle aspiration of the
axillary lymph node was positive for adenocarcinoma. Positron emission tomography/computed
tomography was obtained, and revealed multiple 1- to 2-cm, positron emission tomography-avid
pulmonary nodules and enlarged mediastinal and hilar lymph nodes, suspicious for metastases.
Interventional radiology was consulted for core biopsy of one of the pulmonary nodules. The biopsy
confirmed metastatic breast cancer, ER 95% positive, progesterone receptor 90% positive, and HER2
negative.

FINAL DIAGNOSIS

DE NOVO, HR-POSITIVE, HER2-NEGATIVE METASTATIC INVASIVE DUCTAL

CARCINOMA

Metastatic sites include pulmonary nodules and lymph nodes, and metastatic disease has been
biopsy proven.

Clinically: Lump, Dimpling of the skin, Peau d'orange, Change in size of affected breast,
Inverted nipple, Discharge from nipple
Iman Jaramna, 3rd group, 4th year

Investigations: Mammogram and ultrasound revealed a right breast mass with an enlarged
ipsilateral axillary lymph node. Core biopsy of the mass showed invasive ductal carcinoma.
Fine needle aspiration of the axillary lymph node was positive for adenocarcinoma.

HYPERTONIC ACUTE DEHYDRATION SYNDROME <5%

Clinically: pale, increased capillary refill time, dry skin and mucous membranes, sunken
eyes

Investigation: oliguria; hypernatremia

DIFFERENTIAL DIAGNOSIS

1. FIBROADENOMAS
2. CYSTS
3. METASTASIS TO THE BREAST FROM OTHER PRIMARY SITE
4. DUCT ECTASIA
5. FIBROCYSTIC DISEASE
6. PAPILLOMA
7. LYMPHOMA
8. TRAUMATIC FAT NECROSIS
9. INFLAMMATORY CARCINOMA
10. MASTITIS

The goal of treatment is to slow the progression of disease, improve quality of

life, and prolong survival.
TREATMENT

The patient was placed on the combination regimen of letrozole 2.5 mg by mouth daily and
palbociclib 125 mg by mouth daily for 21 days followed by a 7 day rest period (to complete a 28-day
cycle).

FOLLOW-UP

A follow-up complete blood count 4 weeks after treatment initiation was remarkable for an absolute
neutrophil count (ANC) of 1200/mm3 (grade 2 neutropenia). The patient was feeling well and was
afebrile, so palbociclib was continued. Four weeks later, ANC had decreased to 800/mm3, and the
patient remained afebrile. Since this was grade 3 neutropenia, palbociclib was held for 1 week and
was resumed when ANC was >1000/mm3. Otherwise, she tolerated the treatment well with no
other adverse effects. Computed tomography scans of the chest, abdomen, and pelvis were done 3
months after treatment initiation, and showed significant decrease in size of the breast mass, lymph
nodes, and pulmonary nodules.
Iman Jaramna, 3rd group, 4th year

PROGNOSIS

Breast cancer prognostic factors include the following:

1. AXILLARY LYMPH NODE STATUS

2. TUMOR SIZE
3. LYMPHATIC/VASCULAR INVASION
4. PATIENT AGE
5. HISTOLOGIC GRADE
6. HISTOLOGIC SUBTYPES (EG, TUBULAR, MUCINOUS [COLLOID], OR PAPILLARY)
7. RESPONSE TO NEOADJUVANT THERAPY
8. ESTROGEN RECEPTOR/PROGESTERONE RECEPTOR (ER/PR) STATUS
9. HER2 GENE AMPLIFICATION OR OVEREXPRESSION

COMPLICATIONS
1. BONE PAIN

2. SPINAL COMPRESSION

3. HYPERCALCEMIA

4. LYMPHEDEMA

5. WHEEZING

6. CHEST PAIN

7. JAUNDICE