Case Presentation 4p7166

CASE PRESENTATION

A.

PATIENT IDENTITY Name : Mrs. S Age : 44 years old Sex : Female Address : Bakung lor Religion : Moslem Marital Status : Married

B.

ANAMNESIS  Main Grievance Having enlargement of mammae  Historical of Present Disease The patient came to the hospital of Arjawinangun because there was a unilateral enlargement of her mammae since 2 months ago. The patient complained of increasingly enlarged mammae. In addition to these symptoms, patient has no other complaints.  Historical of Past Disease  Hipertension (-)  Diabetes Melitus (-)  Historical of Family Disease  Hipertension (-)  Diabetes Melitus (-)  The patient said there was no other family member that have same disease like her

C.

MEDICAL EXAMINATION Present Status General Condition: Moderate Awareness : Composmantis Blood Pressure : 150/100 mmHg Pulse : 72x/minute Breathing : 20x/minute Temperature : 37,4 ºC General Status Head  Form : Normal, Simetrical  Hair : Black colour, No hair fall  Eye  Anemic Conjungtival, -/-

 Icteric Sclera, -/ Light Reflect, (+)  Isocor Pupil, right = left Ear : Normal form, cerumen (-), tympani membrane intac Nose : Normal form, no deviation on septum, epitaction, -/Mouth : Normal

   Neck  Enlargement of lymph nodes (-)  Trachea in the middle  No mass

Thorax  Lungs – pulmonary  Inspection : The right and left of his chest shape is symmetrical  Palpation

: His right and left fremitus tactile and vocal is

symmetrical, crepitus (-), tenderness (-), rebound tenderness (-)  Percussion : The sound of percussion are resonant in both of his lung fields  Auscultation : The sound of his lung is vecular and bronchial 

in the entire of lung field, ronkhi -/-, wheezing -/Heart  Inspection : Ictus cordis is not visible  Palpation : Ictus cortis palpable on the left of midclavicula on ICS line 5  Percussion : Upper limit ICS 3 linea parasternalis sinistra Right limit ICS 4 linea sternalis dextra Left limit ICS 5 linea midclavicula sinistra  Auscultation : Heart sound I – II pure regular, mumur (-), gallops (-)

Abdomen  Inspection : Flat abdomen shape, supple, not visible skin disorders  Palpation : Tenderness (-), rebound tenderness (-)  Percussion : There was a whole field tympanic abdomen  Auscultation : Bowel (+) Normal Ekstremity Superior : Warm akral, edema -/-, CTR <2” Inferior : Warm akral, edema -/-, CTR <2”

Genitalia : Normal D.

INVESTIGATIONS Laboratory Examination  Complete Blood  Leukocytes  Red Blood Cell  Hb  HCT  Platelets  BT  CT

: 6,56 10e3/uL : 4,46 10e6/uL : 10,1 g/dL : 32,5 % : 363.000 10e3/uL : 2’ : 4’

E.

DIAGNOSIS OF WORK Invasive Ductal Carcinoma Mammae Dextra

F.

DIFFERENTIAL DIAGNOSIS

G.

MANAGEMENT PLAN Non-medical:  Radical masectomy Medical:  Cefazolin 2x1  Ketorolac 2x1  Ranitidine 2x1  Amlodipine 1x1

H.

PROGNOSIS Quo ad vitam Quo ad functionam Quo ad sanationam

: Ad Bonam : Ad Bonam : Ad Bonam

LITERATURE REVIEW Background Worldwide, breast cancer is the most frequently diagnosed life-threatening cancer in women and the leading cause of cancer death among women. Breast cancer is malignancy derived from the parenchyma, stroma, mammary areola and

papilla. Breast cancer is malignancy that starts from cells in the breast subsequently grow in the breast tissue. Cancer can begin to grow in the milk glands, milk ducts, fatty tissue and connective tissue on breast. It is particularly common in women, but also can occurs in men. Anatomy Women and men both have breasts, but women have more breast tissue than men. Each breast lies over a muscle of the chest called the pectoral muscle. The female breast covers a fairly large area. It extends from just below the collarbone (clavicle), to the armpit (axilla) and across to the breastbone (sternum).

Adipose Tissue The female breast is mostly made up of a collection of fat cells called adipose tissue. This tissue extends from the collarbone down to the underarm and across to the middle of the ribcage. Lobes, Lobules, And Milk Ducts A healthy female breast is made up of 12–20 sections called lobes. Each of these lobes is made up of many smaller lobules, the gland that produces milk in nursing women. Both the lobes and lobules are connected by milk ducts, which act as stems or tubes to carry the milk to the nipple. These breast structures are generally where the cancer begins to form.

The Lymph System Within the adipose tissue is a network of ligaments, fibrous connective tissue, nerves, lymph vessels, lymph nodes, and blood vessels. The lymph system, which is part of the immune system, is a network of lymph vessels and lymph nodes running throughout the entire body. Similar to how the blood circulatory system distributes elements throughout the body, the lymph system transports disease-fighting cells and fluids. Clusters of bean-shaped lymph nodes are fixed in areas throughout the lymph system and act as filters by carrying abnormal cells away from healthy tissue. The type of breast cancer is generally determined by the origin of the growth of cancer cells, which is almost always in the lobes, lobules, or ducts. When cancer is found in the nearby lymph nodes, it helps doctors identify just how far the cancer has spread. If the nearest nodes contain cancer, additional nodes are usually examined for the presence or absence of cancer cells to understand how

far the disease has progressed.

Epidemiology The final decades of the 20th century saw worldwide increases in the incidence of breast cancer, with the highest rates reported in Westernized countries. Reasons for this trend are largely attributed to introduction of screening mammography. Changes in reproductive patterns—particularly fewer children and later age at first birth—may also have played a role, as may changes in lifestyle factors, including the following: •

Western dietary patterns

•

Decreased physical activity

•

Rising obesity rates

•

More widespread use of exogenous hormones for contraception and treatment of menopausal symptoms

The beginning of the 21st century saw a dramatic decrease in breast cancer incidence in a number of Westernized countries (eg, the United Kingdom, , and Australia). These decreases paralleled those noted in the United States and reflected similar patterns of mammography screening and decreased use of combination HRT. In 2008, there were an estimated 1.38 million new cases of invasive breast cancer worldwide. The 2008 incidence of female breast cancer ranged from 19.3 cases per 100,000 in Eastern Africa to 89.9 cases per 100,000 in Western Europe. With early detection and significant advances in treatment, death rates from breast cancer have been decreasing over the past 25 years in North America and parts of Europe. In many African and Asian countries (eg, Uganda, South Korea,

and India), however, breast cancer death rates are rising. Age-related demographics The incidence rate of breast cancer increases with age, from 1.5 cases per 100,000 in women 20-24 years of age to a peak of 421.3 cases per 100,000 in women 75-79 years of age; 95% of new cases occur in women aged 40 years or older. The median age of women at the time of breast cancer diagnosis is 61 years. Rates of in situ breast cancer stabilized among women 50 years and older in the late 1990s; this is consistent with the proposed effects of screening saturation. However, the incidence of in situ breast cancer continues to increase in younger women. Race- and ethnicity-related demographics In the United States, the incidence of breast cancer is higher in non-Hispanic whites than in women of other racial and ethnic groups. Among women younger than 40 years, African Americans have a higher incidence. In addition, a larger proportion of African-American women are diagnosed with larger, advancedstage tumors (>5 cm) and are more likely to die of breast cancer at every age. According to the American Cancer Society (ACS), breast cancer rates among women from various racial and ethnic groups are as follows: •

Non-Hispanic white: 125.4/100,000

•

African American: 116.1/100,000

•

Hispanic/Latina: 91.0/100,000

•

American Indian/Alaska Native: 89.2/100,000

•

Asian American/Pacific Islander: 84.9/100,000

According to the ACS, death rates from breast cancer among women from

various racial and ethnic groups are as follows: •

Non-Hispanic white: 23.9/100,000

•

African American: 32.4/100,000

•

Hispanic/Latina: 15.3/100,000

•

American Indian/Alaska Native: 17.6/100,000

•

Asian American/Pacific Islander: 12.2/100,000 Breast cancer death rates among women in most racial and ethnic groups in

the US have been declining since the early 1990s, except in American Indian and Alaska Native populations, among whom rates have remained stable.

Etiology Age and gender Increasing age and female sex are established risk factors for breast cancer. Sporadic breast cancer is relatively uncommon among women younger than 40 years but increases significantly thereafter. The effect of age on risk is illustrated in the SEER (Surveillance, Epidemiology and End Results) data, where the incidence of invasive breast cancer for women younger than 50 years is 44.0 per 100,000 as compared with 345 per 100,000 for women aged 50 years or older. The total and age-specific incidence for breast cancer is bimodal, with the first peak occurring at about 50 years and the second occurring at about 70 years. This bimodal pattern may reflect the influence of age within the different tumor subtypes; poorly differentiated, high-grade disease tend to occur earlier, whereas hormone-sensitive, slower-growing tumors tend to occur with advancing age. Family history of breast cancer

A positive family history of breast cancer is the most widely recognized risk factor for breast cancer. The lifetime risk is up to 4 times higher if a mother and sister are affected, and it is about 5 times greater in women who have two or more first-degree relatives with breast cancer. The risk is also greater among women with breast cancer in a single first-degree relative, particularly if the relative was diagnosed at an early age (≤50 years). Despite a history indicating increased risk, many of these families have normal results on genetic testing. A family history of ovarian cancer in a first-degree relative, especially if the disease occurred at an early age (< 50 years), has been associated with a doubling of breast cancer risk. This often reflects inheritance of a pathogenic mutation in the BRCA1 or BRCA2 gene. The family history characteristics that suggest increased risk of cancer are summarized as follows: •

Two or more relatives with breast or ovarian cancer

•

Breast cancer occurring in an affected relative younger than 50 years

•

Relatives with both breast cancer and ovarian cancer

•

One or more relatives with two cancers (breast and ovarian cancer or 2 independent breast cancers)

•

Male relatives with breast cancer

•

BRCA1 and BRCA2 mutations

•

Ataxia telangiectasia heterozygotes (quadrupled risk)

•

Ashkenazi Jewish descent (doubled risk) A small percentage of patients, usually with a strong family history of other

cancers, have cancer syndromes. These include families with a mutation in the PTEN, TP53, MLH1, MLH2, CDH1, or STK11 gene.

To aid in the identification of mutation carriers of BRCA1/2, a number of family history–based risk assessment tools have been developed for clinical use, including the following: •

BRCAPRO

•

Couch

•

Myriad I and II

•

Ontario Family History Assessment Tool (FHAT)

•

Manchester All of these assessment tools are highly predictive of carrier status and aid

in reducing testing costs for the majority of mutation negative families. BRCAPRO, the most commonly used model, identifies approximately 50% of mutation-negative families, avoiding unnecessary genetic testing, and fails to screen only about 10% of mutation carriers. Notably, a significant portion of ovarian cancers not previously considered familial can be attributed to BRCA1 or BRCA2 mutations. This finding has led to the suggestion that women with nonmucinous invasive ovarian cancers may benefit from genetic testing to determine mutation status independent of a strong history or no history of breast cancer. The National Institutes of Health (NIH) provides a Cancer Genetics Services Directory. This is a partial listing of professionals who provide services related to cancer genetics, including cancer risk assessment, genetic counseling, and genetic susceptibility testing. Reproductive factors and steroid hormones Late age at first pregnancy, nulliparity, early onset of menses, and late age of menopause have all been consistently associated with an increased risk of

breast cancer. Prolonged exposure to elevated levels of sex hormones has long been postulated as a risk factor for developing breast cancer, explaining the association between breast cancer and reproductive behaviors. Clinical trials of secondary prevention in women with breast cancer have demonstrated the protective effect of selective estrogen receptor modulators (SERMs) and aromatase inhibitors on recurrence and the development of contralateral breast cancers. Use of SERMs in women at increased risk for breast cancer has prevented invasive ER-positive cancers. These data estradiol and its receptor as a primary target for risk reduction but do not establish that circulating hormone levels predict increase risk. A number of epidemiologic and pooled studies an elevated risk of breast cancer among women with high estradiol levels. One of the most widely studied factors in breast cancer etiology is the use of exogenous hormones in the form of oral contraceptives (OCs) and hormone replacement therapy (HRT). Data obtained from case-control and prospective cohort settings an increased risk of breast cancer incidence and mortality with the use of postmenopausal HRT. Increased risk of breast cancer has been positively associated with length of exposure, with the greatest risk being observed for hormonally responsive lobular, mixed ductal-lobular, and tubular cancers. Risk is greater among women taking combination HRT than among those taking estrogen-only formulations. Estrogen alone was associated with increased risk (though the increase was consistently less than that associated with combined HRT use). Prior breast health history

A history of breast cancer is associated with a 3- to 4-fold increased risk of a second primary cancer in the contralateral breast. The presence of any premalignant ductal carcinoma in situ (DCIS) or LCIS confers an 8- to 10-fold increase in the risk of developing breast cancer in women who harbor untreated preinvasive lesions. A history of breast biopsy that is positive for hyperplasia, fibroadenoma with complex features, sclerosing adenosis, and solitary papilloma have been associated with a modest (1.5- to 2-fold) increase in breast cancer risk. In contrast, any diagnosis of atypical hyperplasia that is ductal or lobular in nature, especially in a woman under the age of 45 years, carries a 4- to 5-fold increased risk of breast cancer, with the increase rising to 8- to 10-fold among women with multiple foci of atypia or calcifications in the breast. Benign breast lesions, including fibrocystic disease such as fibrocystic change without proliferative breast disease or fibroadenoma, have not been associated with increased risk. Lifestyle risk factors The wide variability of breast cancer incidence around the world (eg, the nearly 5-fold difference between Eastern Africa and Western Europe) has long been attributed to differences in dietary intake and reproductive patterns. In general, rates differ according to the level of industrial development: there are more than 80 cases per 100,000 in developed countries, compared with fewer than 40 per 100,000 in less developed countries. As with cancers of the colon and prostate, diets that are rich in grains, fruits, and vegetables; low in saturated fats; low in energy (calories); and low in

alcohol—the more common pattern in less industrialized countries—are thought to be protective against breast cancer. Obesity Increased risk of postmenopausal breast cancer has been consistently associated with the following: •

Adult weight gain of 20-25 kg above body weight at age 18

•

Western dietary pattern (high energy content in the form of animal fats and refined carbohydrates)

•

Sedentary lifestyle

•

Regular, moderate consumption of alcohol (3-5 alcoholic beverages per week) The Western lifestyle (ie, chronic excess energy intake from meat, fat, and

carbohydrates and lack of exercise) strongly correlates with development of the following: •

Obesity, particularly abdominal obesity

•

Chronic hyperinsulinemia

•

Higher production and availability of insulinlike growth factor (IGF)-1

•

Increased levels of endogenous sex hormones through suppression of sex hormone–binding globulin Studies of dietary fat, total energy, and meat intake levels have largely been

inconsistent in population studies of adult women with regard to risk of breast cancer. In contrast, epidemiologic studies have more consistently found a positive relation between breast cancer risk and early-life exposures such as diet, obesity, and body size (including height). The mechanism of this relation is unknown. Environmental risk factors

A number of environmental exposures have been investigated in relation to breast cancer risk in humans, including the following: •

Tobacco smoke (both active and ive exposure)

•

Dietary (eg, charred and processed meats)

•

Alcohol consumption

•

Environmental carcinogens (eg, exposure to pesticides, radiation, and environmental and dietary estrogens) Of these environmental exposures, only high doses of ionizing radiation to

the chest area, particularly during puberty, have been unequivocally linked with an increased risk of breast cancer in adulthood. Because of the strong association between ionizing radiation exposure and breast cancer risk, medical diagnostic procedures are performed in such a way as to minimize exposure to the chest area, particularly during adolescence. Women with a history of radiation exposure to the chest area should be examined and counseled regarding their risk of breast cancer on the basis of the timing and dose of the previous exposure. A patient treated for Hodgkin lymphoma with Mantel radiation that includes the breasts in the radiation field has a 5-fold higher risk of developing breast cancer. This risk increases markedly for women treated during adolescence[; evidence suggests that cumulative risk increases with age as a function of age of exposure and type of therapy. Current evidence does not a significant and reproducible link between other environmental exposures and breast cancer risk. Thus, a number of factors remain suspect but unproven.

Symptoms and Signs

Early breast cancers may be asymptomatic, and pain and discomfort are typically not present. If a lump is discovered, the following may indicate the possible presence of breast cancer: •

Change in breast size or shape

•

Skin dimpling or skin changes

•

Recent nipple inversion or skin change, or nipple abnormalities

•

Single-duct discharge, particularly if blood-stained

•

Axillary lump To detect subtle changes in breast contour and skin tethering, the examination

must include an assessment of the breasts with the patient upright with arms raised. The following findings should raise concern: •

Lump or contour change

•

Skin tethering

•

Nipple inversion

•

Dilated veins

•

Ulceration

•

Mammary Paget disease

•

Edema or peau d’orange The nature of palpable lumps is often difficult to determine clinically, but the

following features should raise concern: •

Hardness

•

Irregularity

•

Focal nodularity

•

Asymmetry with the other breast

•

Fixation to skin or muscle (assess fixation to muscle by moving the lump in the line of the pectoral muscle fibers with the patient bracing her arms against her hips) A complete examination includes assessment of the axillae and supraclavicular fossae, examination of the chest and sites of skeletal pain, and abdominal and neurologic examinations. The clinician should be alert to symptoms of metastatic spread, such as the following:

•

Breathing difficulties

•

Bone pain

•

Symptoms of hypercalcemia

•

Abdominal distention

•

Jaundice

•

Localizing neurologic signs

•

Altered cognitive function

•

Headache The clinical evaluation should include a thorough assessment of specific risk

factors for breast cancer such as age related, lifestyle, use of estrogenprogesterone hormone replacement therapy (HRT), current or recent oral contraceptive use, and reproductive history.

Pathophysiology The current understanding of breast cancer etiopathogenesis is that invasive cancers arise through a series of molecular alterations at the cell level. These alterations result in breast epithelial cells with immortal features and uncontrolled growth.

Genomic profiling has demonstrated the presence of discrete breast tumor subtypes with distinct natural histories and clinical behavior. The exact number of disease subtypes and molecular alterations from which these subtypes arise remains to be fully elucidated, but these generally align with the presence or absence of estrogen receptor (ER), progesterone receptor (PR), and human epidermal growth factor receptor 2 (HER2). This view of breast cancer--not as a set of stochastic molecular events, but as a limited set of separable diseases of distinct molecular and cellular origins--has altered thinking about breast cancer etiology, type-specific risk factors, and prevention and has had a substantial impact on treatment strategies and breast cancer research. Evidence from The Cancer Genome Atlas Network (TCGA) confirms the following 4 main breast tumor subtypes, with distinct genetic and epigenetic aberrations: •

Luminal A

•

Luminal B

•

Basal-like

•

HER2-positive

It is noteworthy that the basal-like breast tumor subgroup shares a number of molecular characteristics common to serous ovarian tumors, including the types and frequencies of genomic mutations. These data the evidence that some breast cancers share etiologic factors with ovarian cancer. Most compelling are the data showing that patients with basal-type breast cancers show treatment responsiveness similar to that of ovarian cancer patients. The various types of breast cancers are listed below by percentage of cases:

•

Infiltrating ductal carcinoma is the most commonly diagnosed breast tumor and has a tendency to metastasize via lymphatics; this lesion s for 75% of breast cancers

•

Over the past 25 years, the incidence of lobular carcinoma in situ (LCIS) has doubled, reaching a current level of 2.8 per 100,000 women; the peak incidence is in women aged 40-50 years

•

Infiltrating lobular carcinoma s for fewer than 15% of invasive breast cancers

•

Medullary carcinoma s for about 5% of cases and generally occurs in younger women

•

Mucinous (colloid) carcinoma is seen in fewer than 5% of invasive breast cancer cases

•

Tubular carcinoma of the breast s for 1-2% of all breast cancers

•

Papillary carcinoma is usually seen in women older than 60 years and s for approximately 1-2% of all breast cancers

•

Metaplastic breast cancer s for fewer than 1% of breast cancer cases, tends to occur in older women (average age of onset in the sixth decade), and has a higher incidence in blacks

Mammary Paget disease s for 1-4% of all breast cancers and has a peak incidence in the sixth decade of life (mean age, 57 years).

Diagnosis Breast cancer is often first detected as an abnormality on a mammogram before it is felt by the patient or health care provider. Evaluation of breast cancer includes the following:

•

Clinical examination

•

Imaging

•

Needle biopsy

Physical examination The following physical findings should raise concern: •

Lump or contour change

•

Skin tethering

•

Nipple inversion

•

Dilated veins

•

Ulceration

•

Paget disease

•

Edema or peau d’orange

If a palpable lump is found and possesses any of the following features, breast cancer may be present: •

Hardness

•

Irregularity

•

Focal nodularity

•

Fixation to skin or muscle

Screening Early detection remains the primary defense in preventing breast cancer. Screening modalities include the following: •

Breast self-examination

•

Clinical breast examination

•

Mammography

•

Ultrasonography

•

Magnetic resonance imaging

Ultrasonography and MRI are more sensitive than mammography for invasive cancer in nonfatty breasts. Combined mammography, clinical examination, and MRI are more sensitive than any other individual test or combination of tests.

Biopsy Core biopsy with image guidance is the recommended diagnostic approach for newly diagnosed breast cancers. This is a method for obtaining breast tissue without surgery and can eliminate the need for additional surgeries. Open excisional biopsy is the surgical removal of the entire lump.

Management Surgery is considered primary treatment for early-stage breast cancer; many patients are cured with surgery alone. The goals of breast cancer surgery include complete resection of the primary tumor with negative margins to reduce the risk of local recurrences and pathologic staging of the tumor and axillary lymph nodes (ALNs) to provide necessary prognostic information. Adjuvant treatment of breast cancer is designed to treat micrometastatic disease (ie, breast cancer cells that have escaped the breast and regional lymph nodes but which have not yet had an established identifiable metastasis). Adjuvant treatment for breast cancer involves radiation therapy and systemic therapy (including a variety of chemotherapeutic, hormonal and biologic agents). Surgery and radiation therapy, along with adjuvant hormone or

chemotherapy when indicated, are now considered primary treatment for breast cancer. Surgical therapy may consist of lumpectomy or total mastectomy. Radiation therapy may follow surgery in an effort to eradicate residual disease while reducing recurrence rates. There are 2 general approaches for delivering radiation therapy: •

External-beam radiotherapy (EBRT)

•

Partial-breast irradiation (PBI) Surgical resection with or without radiation is the standard treatment for

ductal carcinoma in situ. Pharmacologic agents Hormone therapy and chemotherapy are the 2 main interventions for treating metastatic breast cancer. Common chemotherapeutic regimens include the following: •

Docetaxel

•

Cyclophosphamide

•

Doxorubicin

•

Carboplatin

•

Methotrexate

•

Trastuzumab Two selective estrogen receptor modulators (SERMs), tamoxifen and

raloxifene, are approved for reduction of breast cancer risk in high-risk women. In patients receiving adjuvant aromatase inhibitor therapy for breast cancer who are at high risk for fracture, the monoclonal antibody denosumab or either of the bisphosphonates zoledronic acid and pamidronate may be added to the treatment regimen to increase bone mass. These agents are given along with

calcium and vitamin D supplementation.

Prevention and Control Diatery nutrisionist and cancer expert belive that balance diet and healthy lifestyle generally can decrease the prevalence rate of cancer. An effort to know early about the breast cancer we can do the SADARI examination, clinically observation of breast and mammography for screening are three common things for early diagnosis.

Prognosis Overall, patients with mucinous carcinoma have an excellent prognosis, with better than 80% 10-year survival. Similarly, tubular carcinoma has a low incidence of lymph node involvement and a very high overall survival rate. Because of the favorable prognosis, these patients are often treated with only breast-conserving surgery and local radiation therapy.

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