Long Case 1 – Breast Cancer

Questions Answers Comment

s
A)Summary A) Diagnosis : Left breast carcinoma with mediastinal LN & lung mets (T4N1M1)
74 years old, Malay lady
K/C HPT
Presented on 4/1/2021 with 1 year history of left breast lump.
On examination, she had left a breast lump size of 10x8cm with peau d'orange and inverted ni
pple. She had no palpable left axillary LN. Examination of the right breast is unremarkable.
Mammogram/ultrasound 4/1/2021 : Suspicious left 7-12OC mass with axillary LN. Indetermin
ate right 7OC lesion.
She defaulted follow up and CT TAP date and went for traditional treatment.
On 6/4/2022, she came with an increasing left breast lump (11x11cm, impending rupture) with
left axillary LN (2cm).
Repeated CT TAP 26/4/2022 : Left breast mass with left axillary & mediastinal LN. Few lung
nodules likely mets. Cardiomegaly with enlarged right atrium.
Case was referred to Oncology. In view of she has moderate to high cardiac issue, she is not fo
r chemotherapy. T. Letrozole 2.5mg od was started on 16/6/2022.
She responded well with T.Letrozole as her lump reduced to 4x4cm.
However, noted from BMD scan 11/1/2023 : Left femoral neck/total hip - osteoporosis. AP spi
ne - osteopenia.
Planned by Oncologist : For IV Zometa 6/12 ly & repeat back BMD scan in 6/12.
 IV Zometa will be started on 10/5/2023.

Introduction
Wash your hands
B) Examination Introduce yourself to the patient including your name and role
checklist
Confirm the patient's name
Briefly explain what the examination will involve using patient-friendly language
Gain consent to proceed with the examination
Adjust the head of the bed to 45 degrees or sit up straight
Adequately expose both breast
Ask if the patient has any pain before proceeding

Inspection
First describe any obvious breast lesion or lump or skin changes, tru cut scar

Go by describing the breast, then nipple areolar complex and finally the axillae

Instruct the patient to elevate both arms over her head to accentuate any skin
changes

Then instruct the patient to put both arms at waist to contract pectoralis muscle
Palpation
BREAST
Warm your hand, stand on patient’s right side
Start with palpating the non-diseased breast, then the diseased breast

Fix one palm on one quadrant and palpate with the other palm on other quadrants

Watch patient’s facial expression. DO NOT CAUSE PAIN!!!( if mild tender, can ask
permission of patient continue examination gently but stop if tenderness+)

Again palpate through the breast, nipple areolar complex and the axillae

lump – site,size,consistency, surface, fixity, tenderness

Check also the tails of Spence

Squeeze the nipple with both palms for any discharge. Note the color and any
retraction

AXILLA
Your right hand holding and supporting patient’s right elbow and let the patient’s
forearm lying on your forearm, with your left hand checking patient’s right axillae

Check anterior, posterior, lateral, medial and finally apical axillae. Repeat the
procedure on patient’s left axillae
 Before palpating the apex of the axillae, warn the patient that it may hurt or feel
ticklish

Note for any lymph node. Describe it as per breast lump

COMPLETE EXAMINATION BY :
palpation of supraclavicular and cervical lymph nodes whilst standing behind the
patient

Check the abdomen for any hepatomegaly or ascites

Check lungs and the spine for any tenderness, deformity

C)Discussion

Q1:What is the most li Q1 :Provisional diagnosis : Right breast carcinoma -cT4cN1M1

kely diagnosis?

Q2 :How will you Q2: Triple assessment

confirm the diagnosis?
History – symptoms, risk factor, symptoms of mets

Mammogram – look for malignant features, multifocal & multicenteric lesion same & opposit
e breast, lymph nodes.
 USG – visualise lesion(hypoechoic) without overlap structures as in MMG & study other smal
l lesions not detected by MMG, examine malignant features of lymph nodes

Biopsy - Trucut - type of malignancy, ER/PR/Her2 status

Q3: What will be your

management for this p
atient?
How do you stage the
disease?

Do you need CT
staging for all breast
cancer patients?
HPE shows :
Left 7-12OC - Invasiv
e carcinoma, NST, gra
de 2. ER/PR positive.
HER2 equivocal (1+ to
2+). FISH negative.
Right 7OC - Usual duc Since patient not fit for neoadjuvant chemo & non operable with distant mets like this case,
tal hyperplasia hormonal is an option.
Aromatase inhibitors are preferred in postmenapausal group.
However, bone density need to be monitored.
In View pt has osteoporesis/osteopenia, AI was discontinued.
Thus Zometa started ( Biphosphonate) to decrease osteoclastic activity.

Other options are radiotherapy for pain & surgical fixation in pathological fractures.
Watch out for hypercalcemia
Q4:What are the other
options of treatment in
metastatic breast ca
with
osteoporesis/osteopeni
a after aromatase
inhibitor?

Does not confer survival benefit, however is done correctly is a useful palliative tool, for
symptomatic locally advanced breast cancer (infection, bleeding, pain) – to achieve better
quality of life.
Tell me about
Screening of Breast
cancer
Is Mastectomy
indicated in stage 4
breast cancer?