Case Presentation

By roll no. 81,83,84,85,88,89,93,94

Patient’s Particulars

● Name : Zopari
● Age: 46
● Sex: Female
● Address: Zokhawthar
● Religion : Christian
● Occupation: Shopkeeper
● Marital status: Married
● Date of admission : 29th September 2023
Chief Complaint

● Lump on both sides of breast X 1 yr 3 months

History of presenting illness

● Lump was first noticed on the left side

● Insidious in onset
● Not localised and felt around the upper part of the breast in the outer area
which then progressed towards the inner side
● After a month lump was felt on the right side
● Also not localised
● Associated with discomfort on the right side
● No exacerbating or relieving factor
● Not associated with pain
● Patient also noticed retraction of nipple three months after she
noticed the lump
● There was no dimpling of skin/changes over skin
● No discharge from nipple
● No ulceration over the breast
● No symptoms of metastases
● No history of trauma to the breast
Past medical and surgical history

● Patient is a known case of hypertension and diabetes mellitus

and is on medications.
● Tonsillectomy - 2009
● Hysterectomy - 2018
● Hyperthyroidism - treated
● Estrogen therapy was given for 14years due to early
menopause at 32 years.
● No history of any benign breast disease in the past.
● Diagnosed as Carcinoma of breast Stage IIIa 6 months ago and
has completed 8 cycles of chemotherapy
Menstrual History

● Menarche was attained at 12 years

● Cycle duration : 28 days and 5 days menstruation
● Regular cycles, no complaints of dysmenorrhea
● Menopause was a trained cat 32 years and estrogen therapy
was given after which normal menstruation continued and
hysterectomy was done on 2018 due to pre- cancerous lesion in
cervix.
● She is nulliparous
Personal history

● Diet: Mixed diet, no loss of appetite

● Bowel and bladder: Regular and normal
● Sleep: undisturbed
● Habits: Consumes tobacco and chews betel nut for 26 years
Family History

● No history of similar complaints in any family member

● No h/o breast cancer or other malignancies
● No h/o hypertension ,diabetes mellitus , tuberculosis ,asthma
GENERAL PHYSICAL EXAMINATION
● The patient was examined after taking consent with adequate
exposure under natural lighting.
● She is alert ,conscious and well-oriented to time ,place and
person and was co-operative.
● Pallor-Absent
● Icterus-Absent
● Clubbing-Absent
● Cyanosis-Absent
● Lymphadenopathy-Absent
● Edema- Absent
VITALS

● Pulse-96/min (normal rate ,normal volume ,normal character,

regular rhythm ,no radio-radial and radio-femoral delay and all
peripheral pulses are palpable)
● Respiratory rate-21/min
● BP-103/68mmHg
● Temperature-Normal
● Oxygen saturation -99%
LOCAL EXAMINATION

● Patient is examined in sitting and

recumbent position.

INSPECTION:

● Both the breast are present and

are at the same level.
● Size and shape -normal
● Skin over breast
● Nipple areolar complex:
● Both are present and retracted
● Same level
● Size and shape - normal
● No fissure, crack and discharge
● Supraclavicular fossa: no swelling
● Arm and thorax: no oedema ,no nodules
● Axilla : no swelling
PALPATION:

RIGHT BREAST LEFT BREAST

TEMPERATURE No local rise in No local rise in

temperature temperature
TENDERNESS No tenderness No tenderness

NUMBER Single Single3

SIZE ~3 X 4cm ~5 X 3cm

SHAPE Irregular Irregular

SYMMETRY Asymmetrical Asymmetrical

MARGIN Ill-defined Ill-defined

CONSISTENCY Firm Firm

● FIXITY TO SKIN : Not fixed

● INTRINSIC MOBILITY : Moves along with breast tissue

● FIXITY TO MUSCLES : Restriction of mobility along the line of muscle fibres

PALPATION OF AXILLARY LYMPH NODE

● Level l(anterior ,posterior and lateral) -not palpable

● Level II(central and rotters)- not palpable

● Level III(apical)-not palpable

 SYSTEMIC EXAMINATION:

● GASTROINTESTINAL SYSTEM : Normal bowel sounds heard, no

organomegaly

● RESPIRATORY SYSTEM :Normal vesicular breath sounds , no

adventitious sound.

● CARDIOVASCULAR SYSTEMIC :Normal heart sounds ,no

murmur.
PROVISIONAL DIAGNOSIS

● This is a case of Locally advanced carcinoma of breast.

● STAGE IIIa(T0N2M0)
 INVESTIGATIONS
1.ROUTINE INVESTIGATIONS
Urine : Albumin, sugar, deposits
Blood : Urea, sugar, serum creatinine ,haemoglobin, total leukocyte count,
differential leukocyte count, erythrocyte sedimentation rate
X-RAY chest
ECG all leads

2.SPECIFIC INVETIGATION
FNAC: Using 23G/24G
~Predictive value of FNAC:
Sensitivity (true positive): 80–98%
False negative: 2–10%
Specificity is almost 100% as false positive is very rare.
 BIOPSY
• Core Biopsy (gold standard): Core needle biopsy has become the standard of care for biopsy
of breast lesion
In core needle biopsy a number of wedge of tissue is taken
A histological diagnosis of invasive or noninvasive carcinoma may be made
The tumor grade and any lymphovascular invasion may be assessed
The ER/PR and Her2-neu status may also be assessed in the core biospy
specimen

• Incision Biopsy
• Excision Biopsy
• Wedge Biopsy
MAMMOGRAPHY
Mammogram/USG Breast : Mammography may show a characteristic lesion suggestive of
malignancy.
May detect an impalpable lesion in the opposite breast.

CHARACTERISTICS OF MALIGNANT LESION IN MAMMOGRAPHY

- Architectural distortion of breast tissue

- Duct dilatation
- Dense stellate soft tissue mass with irregular margin and spiky projection
- Microcalcification: In elderly patients few microcalcification may be normal
- Stippled calcification is characteristic

- Increased thickness of skin due to lymphedema

- Nipple retraction may be seen.
TREATMENT

It is usually through a combined approach of:

• Surgery : eg. Breast Conservation Surgery, Modified
Radical Mastectomy
• Radiotherapy
• Hormone therapy
• Chemotherapy