A Case Study on Breast Cancer

Submitted by:

Daño, Marielle

Heyrosa, Rusty Vincent E.

Javelona, Jyssa Mae B.

Submitted to:

Mr. Joseph Kirby Moroscallo

Clinical Instructor
 Case #1 A 41-year-old woman underwent an initial screening mammography that revealed
dense bilateral breast tissue. According to the evaluation by the radiologist, the evaluation was
considered incomplete; therefore, additional imaging is recommended BIRADS- The pa ien
past medical history is unremarkable. She has never had previous breast masses, breast
complaints, biopsies, or prior mammography. She is married and had onset of menarche at age
11 and her first child at age 27. Her family history is significant in that her mother died at the
age of 45 from breast cancer. On examination, both breasts are firm but without specific
abnormalities. No dominant masses or axillary adenopathy are appreciated.

 Summary: The patient is a 41-year-old woman with a high-risk profile for breast cancer
based on history of maternal, premenopausal breast cancer, and the findings of bilateral
dense breast tissue, which makes breast examinations and imaging less reliable.
 Most likely diagnosis: Dense breast tissue in a woman with breast cancer with a high-risk
profile.
 Concerns and complications: The pa ien family history suggests a high-risk profile. In
addition, the presence of bilateral dense breast tissue affects the ability to detect
abnormalities by physical examination and mammographic imaging. Furthermore,
increased breast density is shown to correlate with increased risk in breast cancer
occurrence.

Objectives:
1. What is the normal anatomy and physiology of the affected body part?
2. What is the disease's pathophysiology?
3. What assessment and evaluation factors, diagnostic procedures, and imaging techniques
are utilized to detect the disease?
4. What is the recommended Surgical Management for the case?
5. Create a Preoperative, Postoperative, and Discharge Nursing Care Plan.

1. NORMAL ANATOMY AND PHYSIOLOGY OF THE BREAST

The breast is an organ whose structure reflects its special function: milk production for lactation
(breast feeding). The epithelial component of the tissue consists of milk-producing lobules that
link to ducts that go to the nipple. The majority of breast cancers develop from the cells that form
the lobules and terminal ducts. These lobules and ducts are distributed throughout the breast's
background fibrous tissue and adipose tissue (fat). The male breast anatomy is virtually
comparable to that of the female breast, with the exception that male breast tissue lacks the
specialized lobules since males have no physiological necessity for milk production.
ANATOMY:

Breast Mound
The breasts are situated on the front and lateral portions of the thorax. Each breast reaches the second rib
superiorly, the sixth costal cartilage inferiorly, the sternum medially, and the midaxillary line laterally.
Breast form and size are determined by genetic, ethnic, and nutritional variables, as well as the
individual's age, parity, and menopausal state. The breasts might be hemispherical, conical, pendulous,
piriform, or slender and flattened. Each breast has a conical shape with a base diameter of 10-12 cm and a
thickness of 5-7 cm. The majority of breast tissue is generally concentrated in the upper outer quadrant.
This is the quadrant most frequently implicated in breast cancer and most benign breast tumors.

Nipple-areola Complex
In nulliparous women, the NAC is positioned between the fourth and fifth ribs, although its location
fluctuates greatly when the breasts are pendulous. The complex is generally 3-4 cm in diameter and is best
positioned in the center of the breast mound. The areola and nipple are both made up of keratinizing
stratified squamous epithelium with high basal melanin deposition. Melanocytes are abundant in the skin
of the nipple and areola, making them darker than the rest of the breast. The areola is a skin disc that
encircle the base of the nipple and can range in color from pink to dark brown depending on parity and
race. It has sebaceous glands, sweat glands, and visible Montgomery's glands, which open at the areola's
perimeter as Morgagni tubercles and offer lubrication during breastfeeding.
Fascial support and Chest wall
The deep pectoral fascia, which forms the anterior wall of the rectus abdominis sheath, rests on top of the
pectoralis major, serratus anterior, external oblique, and its aponeurosis along the breast's deep surface.
Practical implications stem from the breast's fascial interactions. The anterior layer of the superior
pectoral fascia surrounds the breast ventrally and a posterior layer dorsally. The superficial layer, which
sits just under the dermis, makes it possible to swiftly and in an avascular plane separate skin flaps from
the glandular bulk of the breast. On the back of the breast's posterior surface is the deep layer of the
superficial pectoral fascia, which is thicker than the subcutaneous portion. The deep pectoral fascia and a
layer of filmy areolar tissue are separated by this (retromammary bursa). This may be seen after a
mastectomy and provides for a blood-free plane of dissection. It also permits the breast to move freely on
the fascial layer that lies underneath the pectoralis major and serratus anterior. The usual symptom of a
malignant breast mass's deep tethering results from a cancer's deep penetration into the underlying
pectoralis fascia through this region.

Blood supply and Lymph Nodes

The internal mammary artery, which runs beneath the bulk of the breast tissue, is principally responsible
for the breast's blood supply. The breast tissue receives nutrients from the blood supply, including oxygen.
Breast lymphatic arteries drain into lymph nodes while moving in the opposite direction of the blood
supply. Breast tumors spread to lymph nodes or metastasis through these lymphatic channels. The
majority of lymphatic vessels travel to the axillary (underarm) lymph nodes, whereas the internal
mammary lymph nodes, which are situated deep inside the breast, are served by fewer lymphatic veins.
Understanding this lymphatic outflow is crucial since the first lymph node in the chain of lymph nodes is
frequently affected when a breast cancer metastasizes. A surgeon may remove this lymph node, known as
the "sentinel lymph node," from a breast cancer patient in order to look for metastases.

Parenchyma
The majority of the breast's volume is made up of the breast parenchyma and related fat. There are 15 to
20 lactiferous ducts that originate deep inside the breast lobules and converge radially at the nipple to
make up the fibro glandular tissue, or parenchyma, of the breast. Around the breast, these ducts are not
always spread equally. Typically, the top half of the breast, in especially the upper outer quadrant, has
more glandular tissue than the lower half. Each duct creates a lobe with 20 40 lobules and 10 100 alveoli
per lobe.

Nerve Supply
The somatic sensory nerves and the autonomic nerves that follow the blood vessels are primarily
responsible for the breast's innervation. The lateral branches of the thoracic intercostal nerves feed the
supraclavicular nerves (C3, C4), which are superior and laterally located, with the somatic sensory nerve
supply. The anterior branches of the thoracic intercostal nerves, which pass through the pectoralis major
to reach the breast surface, feed the medial portions of the breast. The second through sixth intercostal
nerves give rise to these lateral and medial cutaneous branches. The intercostobrachial nerve provides the
upper outer quadrant of the breast with the majority of its blood supply (C8, T1). As it passes through the
axilla, it provides the breast a sizable branch. The nerves in the breast can be found in a variety of places.
The nerves ramify inside the breast after passing through the intercostal gaps, sometimes traveling along
the deep fascia and other times penetrating briefly through the breast's tissue.

PHYSIOLOGY:
The breast is a physiological organ designed specifically for the production of milk (lactation), including the
synthesis, secretion, and ejection of milk. The lactiferous ducts and tiny saccules known as alveoli make up
the breasts' secretory organs. These secretory units are controlled by a complicated network of hormones
and growth factors that regulate milk production. Important histologic changes in the breast throughout
pregnancy and the menstrual cycle are caused by the variation of these hormones.

Estrogen. The primary female hormone responsible for breast formation and maintenance is estrogen. It
causes the ductal system to expand and the nipples to mature and protrude, which causes the ductal
epithelium, myoepithelial cells, and surrounding stroma to proliferate.

Progesterone. The ovaries secrete progesterone, which stimulates the growth of the lobuloalveolar
structures and terminal ducts. Similar to oestrogen, it requires the presence of the other hormones, such
as insulin and growth hormones, to react. Estrogen and progesterone both have the ability to increase the
amount of fat and connective tissue in the breast, giving it the rounded shape of a fully grown breast.

Prolactin. The an e io pi i a gland acidophilic cell a e e pon ible fo p od cing p olac in I collaborates with
estrogen during the formation of ducts and with progesterone during the growth of lobuloalveolar.
Prolactin aids in the differentiation of alveolar cells into milk-secreting cells together with cortisol and
insulin. In general, it promotes mammary development and differentiation, which in turn leads to milk
production.
Oxytocin. A peptide hormone called oxytocin is produced in the hypothalamus and released by the
posterior pituitary gland (neurohypophysis). Oxytocin induces myoepithelial cells to contract, which
squeezes milk out of the lobules and into the lactiferous ducts. The act of nursing (the sucking reflex)
stimulates its release.

Human placental lactogen (hPL). The maternal placenta produces human placental lactogen, and blood
levels grow throughout pregnancy. During the last few weeks of pregnancy, it reaches its peak and
prepares the breast for milk production. It is associated to breast development and differentiation. After
delivery, its serum levels rapidly decrease.

2. PATHOPHYSIOLOGY:

Breast cancers develop through a series of events that start with an increase in the number of breast cells
and progress to the formation of atypical breast cells, carcinoma in situ, and then invasive malignancy. A
faulty gene interacts with the environment to cause breast cancer. Cancerous cells lose their capacity to
stop dividing, adhere to other cells, and remain in their proper location. Some mutations, including p-53,
BRCA1 and BRCA2, can result in cancer. Either a person inherits or acquires these mutations after birth.
Breast cancer is also caused by other mutations that block the P13K/AKT pathway. These mutations aid in
'apoptosis,' which prevents cancer cells from committing suicide by keeping the pathway activated.
Breast cancers are many types which are mainly invasive (infiltrating) breast cancer, non-invasive (ductal,
lobular), estrogen fueled, inflammatory and metastatic breast cancer, in these types' ductal carcinoma and
invasive breast cancers are more common types accounting for about 15% and 80% respectively.

What assessment and evaluation factors, diagnostic procedures, and

imaging techniques are utilized to detect the disease?

The majority of cancers are difficult to identify in their early stages, but there are a number of
tests that can help. If many invasive procedures are required to confirm the diagnosis and the
necessity for surgical treatment, there may be a significant diagnostic delay. In conclusion, there
are several ways that a cancer diagnosis can be delayed. The patient might overlook or ignore
warning signs of cancer.

Diagnostic test for BREAST CANCER

Breast exam
A breast self-exam is a private examination of your breasts for breast awareness. You can use
your hands and eyes to check if your breasts' appearance and texture have changed in order to
better understand your breasts.

Talk to your doctor about any new breast changes you discover. The majority of medical
organizations do not recommend routine
breast self-exams as part of breast cancer
screening, despite the fact that the majority of
breast changes discovered by a breast
awareness self-exam have benign origins. This
is because there isn't enough proof that breast
self-exams can help prevent cancer or provide
breast cancer patients longer lives.
WHY IS IT DONE?
You can learn more about the typical feel and appearance of your breasts by performing a breast
self-exam for breast awareness. You can let your doctor know if you detect a change in your
breasts that seems odd or if you realize one breast is different from the other.

Mammogram
Mammograms use X-ray images of the breast. Doctors
use mammograms to seek for early signs of breast
cancer. A routine mammogram is the best test doctors
have to find breast cancer early, frequently up to three
years before it can be felt. If you have a problem with
your breast, such as lumps, or if an area of the breast
appears abnormal on a screening mammogram, doctors
may recommend that you get a diagnostic
mammogram. This breast X-ray is very detailed.
HOW IS IT DONE?
Every woman's breast may appear different because
every woman's breasts differ somewhat. The technician cannot tell you the results of your
mammogram. Another X-ray treatment will be performed on the opposite breast. You will then
have to wait while the technician confirms that additional X-rays are not necessary.

Breast MRI (Magnetic Resonance Imaging)

When a woman has a breast MRI, she frequently
lies face down with perforations in the table
allowing viewers to see her breasts. A vein in the
arm must typically be injected with contrast
material before or during a breast MRI in order to
assess breast location and monitor for any
potential movement. The technologist watches the
MRI through a window. The dye could
sharpen photos and make it easier to detect irregularities. Some uses of MRI are the following,
Additional investigation of mammogram anomalies, detection of early breast cancers not picked
up by conventional tests, especially in high-risk individuals and those with dense breast tissue
Biopsy

A biopsy is a process where a small sample of tissue is removed and evaluated in a lab. With the
aid of a specific biopsy needle, breast tissue can be removed for a breast biopsy. A surgical
removal is also an option. Examining any
abnormal cells or cancerous growths. A
procedure can be performed to examine a
palpable lump or mass in the breast, to
examine a mammography problem such as a
cyst or tiny calcium deposits in the breast
tissue, and to assess nipple issues such as a
bloody discharge from the nipple.
TYPES OF BIOPSY
• Fine needle aspiration (FNA) biopsy - A very fine needle is inserted into the lump or other
troublesome region. A tiny sample of tissue or fluid is taken out. There's no need for a cut
(incision). To determine whether the region is a solid lump or a fluid-filled sac (cyst), a FNA
biopsy may be performed.
• Core needle biopsy - A sizable needle is inserted into the bulge or other problematic region.
Cores, which are tiny tissue cylinders, are taken out. No cuts are required.
• Open (surgical) biopsy - It is sliced open at the breast. The lump or region of concern is
partially or completely removed by the surgeon. The lump may occasionally be small, deep,
and difficult to locate. Then wire localization is another technique that might be employed. A
tiny needle with an even smaller wire is inserted into the breast for this purpose.
• Stereotactic biopsy. - Using a computer and the results of a mammography, a 3D picture of
the breast is created using this technique. The biopsy needle is then precisely guided to the
location of the breast lump or other problematic area by the 3D picture.
• Vacuum-assisted core biopsy. - The breast is sliced in a tiny way. Through the cut, a hollow
tube or probe is introduced. With the use of an MRI, X-ray, or ultrasound, the breast lump or
mass is located. It is possible to collect many tissue samples at once inside the tube. It is
possible to collect many tissue samples at once.
• Ultrasound-guided biopsy - The breast tumor or lump is visualized using ultrasound pictures
in this procedure. These pictures aid in pinpointing the precise biopsy site.

SURGICAL TREATMENT FOR BREAST CANCER

The medical staff will nearly always advise surgery to remove the malignancy if it is localized.
When it is technically viable to remove the afflicted tissue, surgery is thought of as the main
treatment for breast cancer. A lumpectomy, which removes a single tumor from your breast, or a
mastectomy, which removes your
entire breast, are two different types of
breast cancer surgery. (For metastatic
breast cancer, which has already
spread to other regions of the body, it
is not a successful treatment.) Breast
cancer surgery is largely a type of
treatment, despite the fact that it can
occasionally be employed for
diagnostic or even cosmetic goals. To
look for evidence of cancer spreading,
exploratory surgery may occasionally
be performed. Breast reconstruction
following a mastectomy can
occasionally be necessary.
MASTECTOMY

The most frequent procedure for breast cancer is a mastectomy, or breast removal surgery. This
is due to the fact that mastectomy can treat
both early-stage and late-stage breast cancer.
Additionally, a preventive mastectomy may
be chosen as a preventative measure by some
patients who are at a high risk of having
breast cancer in the future.
• Total mastectomy - your entire breast is
removed while leaving the chest muscle
intact.
• Double mastectomy - taking both breasts
out. This could be a prophylactic strategy
or it could be essential if the cancer has
already spread to both breasts.
• Skin-sparing or nipple-sparing mastectomy - removing all of your breast tissue while
preserving your skin and, if possible, your nipple for use in your breast reconstruction.
• Modified radical mastectomy - Having your breast tissue and lymph nodes under your arms
removed Often, lymph nodes are where breast cancer spreads first.
• Radical mastectomy - your chest muscles, underarm lymph nodes, and breasts will be
removed. Only when breast cancer has spread to your chest muscles is this unusual procedure
necessary.

Lumpectomy
Only a portion of your breast
tissue is removed during a
lumpectomy, often known as
breast conserving surgery.
This is an alternative method
for treating breast cancer that is in an early stage. Surgery can be performed solely to remove the
tumor's "lump" when it is still reasonably small and hasn't spread. A margin of the surrounding
tissue is also removed during a lumpectomy to ensure that no cancerous cells were accidentally
left behind in your breast.

• Excisional biopsy - This is a process to remove a tumor so that it can be biopsied. The tumor's
carcinogenic status can be ascertained through laboratory analysis (malignant).
• Wide local excision - a surgical procedure to remove a malignant tumor and the surrounding
tissue. After that, the marginal tissue will be examined for the presence of malignancy.
• Quadrantectomy - a segmental mastectomy that eliminates your duct-lobular system along
with around a fourth of your breast. When the tumor exhibits ductal spread, it is advised.
• Re-excision lumpectomy - a process used after the initial removal of the tumor and its
surrounding margin of tissue. Your surgeon will reopen the surgery site and remove a further
margin of tissue if the marginal tissue tests positive for cancer cells until the tissue is cancer
free.

Lymph node dissection

Cancer in your lymph nodes is a warning indication that it may be moving outside of your breast
because the lymph system is frequently where cancer spreads initially. Your surgeon might take
one or more lymph nodes under your arm that are close to the afflicted breast out and examine
them to find out. The most likely location for breast cancer cells to drain is here.
• Sentinel lymph node biopsy - This test will determine whether cancer has spread to your
lymphatic system. As the first lymph node to filter fluid draining from the afflicted breast, the
sentinel lymph node is a useful sign.
• Axillary lymph node dissection - The surgeon may decide to remove a greater portion of
lymph nodes for analysis if the sentinel node biopsy reveals cancer or if they have another
reason to think you have pervasive
cancer in your lymph nodes.

Reconstructive breast surgery

reconstructive surgery to restore your
breast shape if you are having one or
both of your breasts removed to treat
breast cancer. Immediately after your lumpectomy or mastectomy, surgeons can frequently
reconstruct the breast using plastic surgical procedures. They can also conduct a different surgery
at a later date, perhaps after your chemotherapy or radiation therapy is ended and your tissues
have had a chance to heal.
• Implant reconstruction -The implant consists of a silicone shell that is filled with silicone gel or
saline. The surgeon covers it with your skin, either the skin from your natural breast or a skin
transplant from another area of your body, and inserts it over or under your muscle.
• Autologous or “flap” reconstruction - With this technique, your breast is rebuilt using tissue
from another area of your body.
• Nipple reconstruction - They can create a new nipple out of a skin graft taken from another
area of your body if they were unable to save your old one.

CUES/ EVIDENCES
Subjective:
The patient verbalized “Dili
nalang ko seguro mag
gawas gawas doc oy
mauwaw naman ko kung
tangtangon na akoang
totoy”
The significant others of the
patient reported that the
patient is having self pity
“mo ana man siya doc oy
mas bali pa kuno mamatay
kaysa sa ma buhi nga
kuwang na ang lawas”
Objective:
• Shows hesitation to talk to
other person
• Do not want to talk about
the situation
NURSING CARE PLAN
NURSING SCIENTIFIC BASES
DIAGNOSIS
Low Self-Esteem related Early experiences may
change in physical contribute to having a low
appearance and social role feeling of worth. If a person
change struggled to live up to their
parents' expectations, was
neglected or abused, or
didn't fit in at school, they
may come to have negative
basic beliefs about
themselves. These are
ingrained beliefs that a
person has about oneself.
source: https://
www.healthdirect.gov.au/
self-esteem
GOALS and NURSING RATIONALE EVALUATION
OUTCOME INTERVENTIO N
• To be able to regain the • Spend time with the • Giving the patient enough • The patient was later able
patient’s self worth and patient; allot adequate time time demonstrates the to deal with how her
self-esteem for a measured and calm nurse's interest in and sickness was affecting her
conversation. acceptance of their bodily changes and
feelings. Building self- resumed taking care of
• To be able to express the esteem requires a herself after being able to
feelings of the patient trustworthy relationship, express her sorrow about
about the matter affecting which is essential. her illness.
low self-esteem
• Ensure privacy. • The patient has to be able
to express their feelings
freely and without being
overheard during private
sessions.
• Apply active listening and • These channels of
open-ended questions. communication allow the
patient uninterrupted
expression of interests,
anxieties, and other
feelings. This method will
demonstrate respect for the
patient's skills and assets
in addition to
acknowledging issues and
worries.
 NURSING CARE PLAN
CUES/ EVIDENCES NURSING SCIENTIFIC BASES GOALS and NURSING RATIONALE EVALUATION
DIAGNOSIS OUTCOME INTERVENTIO N

Subjective: risk for infection related to One of the body's first lines • Vital signs that are within • For dressing changes, • Pathogens are less likely • The patient's temperature is
The patient verbalized Inadequate primary of defense against hazardous the normal range and a wound care, intravenous to be transferred to or now normal, there are no
“Doc sakit kaayo akong defences: broken skin, germs is the skin, which acts lack of symptoms of therapy, and catheter spread among patients longer any
samad ug tinahian sa pag injured tissue and Self Care as a barrier. Skin tissue infection, such as handling, uphold stringent when using aseptic irregularities at the site of
opera” Deficit contains specialized swelling, redness, and asepsis. method. One of the best the incision, and the
immune cells that aid in the purulent discharge from ways to stop an infection patient can now
defense against invaders. non-intact skin areas, from spreading is to break understand why taking
“Doc mura man ug init The skin, however, is home show that the patient is the chain of infection. care of oneself is
akong pamati” to a variety of communities clear from infection. important for preventing
of helpful bacteria known as • Make sure all items are • This lessens or gets rid of infection.
the skin microbiota. • The patient expresses their adequately sterilized or microorganisms.
Objective: Commensals are the name comprehension of the disinfected before usage.
• slightly elevated for these bacteria that behavioral and sanitary
temperature 37 degree naturally invade the skin. precautions needed to • Before making touch with • Microorganisms are
celsius avoid infection. the patient, wash your successfully removed
• integrity impairment due hands or practice good from hands using friction
to incision • The patient verbally hand hygiene. and running water.
• Increased white blood acknowledges the Between procedures,
cells count presence of infection washing lowers the chance
symptoms that should be of spreading infections
reported to a healthcare from one body part to
professional for treatment. another.

• Inform customers and SOs • The likelihood of

(significant others) about transmission is decreased
• source:https:// the proper ways to clean, by knowledge of methods
www.nih.gov/news- events/ sanitize, and sterilize to lessen or eradicate
nih-research- objects. germs.
matters/skinmicrobes-
immune-
response#:~:text=Skin%
20is%20a%20barrier%2
0that,known%20as%20t
he%20skin%20microbio ta.
Discharge Plan

MEDICATION - Give acetaminophen (Tylenol) or ibuprofen for pain instead of narcotic pain medicine.

EXERCISE - Pump It Up - this exercise helps reduce swelling after surgery by using your muscles as a
pump to improve the circulation in your affected arm (on the same side as your surgery).
- Shoulder Circles – this exercise can be done sitting or standing. It’s a good warm-up exercise
and can help relieve tension in your shoulders.
- Arm Lift - this exercise can be done sitting or standing. It helps improve movement in your
shoulders.
- Shoulder Blade Squeeze - this exercise can be done sitting (without resting your back on the
chair) or standing. It helps to stretch your chest muscles.
TREATMENT - Instruct patient to take medication exactly as directed and not to skip doses.
- Encourage patient to perform lifestyle modifications.
ENVIRONMENT - Don't soak in a tub, hot tub, or pool until your healthcare provider says it's OK.

- Take your temperature each day for 7 days after the surgery.

HEALTH TEACHING - Avoid strenuous activity, heavy lifting and vigorous exercise until the stitches are removed.
Tell your caregiver what you do and he or she will help you make a personal plan for "what
you can do when" after surgery.
- Walking is a normal activity that can be restarted right away.
FOLLOW UP - Follow-up appointments are generally made before surgery with your physician and a nurse.
Your sutures will be removed in approximately 10 to 14 days. Call the Breast Care Center if
you do not have or remember your appointment.
- Your dressing will be changed or removed at your post-operative visit.
- The pathology results from your surgery should be available within one week after your
surgery.
DIET - You may resume your regular diet as soon as you can take fluids after recovering from
anesthesia.
- We encourage eight to 10 glasses of water and non-caffeinated beverages per day, plenty of
fruits and vegetables as well as lower fat foods. Talk with us about recommendations for
healthy eating.
- A nutritionist is available for consultation in the Breast Care Center. Call the front desk to
schedule an appointment.
PREVENTION - Keep Weight in Check
- Be Physically Active
- Eat Your Fruits & Vegetables – and Limit Alcohol (Zero is Best)
- Don’t Smoke
- Avoid Birth Control Pills, Particularly After Age 35 or If You Smoke
- Avoid Menopausal Hormone Therapy
- Tamoxifen and Raloxifene for Women at High Risk