A very rare surgical case report

1. P.G. Department of Shalya Tantra
NIA, Jaipur

2. PRESENTED BY
Dr. Alok Kumar
Ph.D. Scholar
P.G. Dept. of Shalya Tantra N.I.A. Jaipur

3. A. Particulars of the patient
A 64 Year old female came
to NIA shalya tantra OPD
on 15/09/2015

4. B. Chief complaint
Itching with mild
discharge from a
eczematous lesion at rt.
Nipple and areola
--------4 yrs

5. C. History of present illness
According to patient she was asymptomatic before 4 after
that she got a minor trauma on her rt. Breast. After some
time she suffered from severe itching in her Rt. Nipple and
spread into surrounding areolar area. After sever itching
some watery some time red discharge comes from that
lesion. She also complain of burning sensation after
itching and the lesion becomes Red (erythematous). The
lesion progreses very slowly in size.The above complain
sometime subside spontaneously and aggravate itself but
doesn’t resolve completely. She also complain some
scaling from the lesion occaisionly.The severity of disease
has no relation with the change in weather.

6. D. Past history

7. E. Family History
No significant H/O similar complaints in family

8. F. Personal history
Addiction- No
Bowel habit- regular
Socioeconomic status- Lower middle class
Religion-Hindu, vegetarian taking spicy food
Occupation- house wife
Marital status-Married she has 8 child 5 male and 3
female all are live and healthy.
Non lactating, menopausal around 4 yrs back
H/O excessive bleeding during Menstruation period 4
yrs back so she got hysterectomy.

9. General Physical Examination
Built- Average
Pallor- -ve
Cyanosis- -ve
Icterus- -ve
Clubbing- -ve
B.P- 100/70 mmHg
PR- 84/min
Temp.-Afebrile
R/R- 20/min
Gait N
Lymphadenopathy -no palpable lymph nodes
Teeth - Yellow dicolouration

10. Systemic Examination
1. CNS Examination
Consciousness- Fully Conscious
Orientation- Well oriented to T, P, P.
Speech – Normal
Sensory System- WNL
Motor System – WNL

11. CVS System
Inspection- B/L symmetrical chest wall, No cyanosis, No pallor, No
clubbing
Palpation- No any tenderness
Percussion- Dull note
Auscultation- Heart sounds normal, no murmurs.

12. Respiratory System
Inspection- B/L symmetrical chest wall on
respiration, no dilated veins, scar of previous surgery
at left breast. An eczematous lesion at nipple and
areola at rt. Breast. Rt. Nipple is retracted.
 Palpation- no Tenderness
 Percussion- B/L Resonant
 Auscultation- B/L air entry equal , no added sound

13. GIT system
Abdominal Examination
 Inspection- Normal movement with respiration, no
dilated veins, scar of previous surgery
 Palpation- soft , Liver non-tendor and spleen not
palpable, no any lump or lymph node felt on
palpation
 Percussion- Tympanic sound noted
 Auscultation- normal bowel sound

14. Urogenital system
No relevant complain of this system
No menstruation cycle.

15. Local Examination
Position – Supine/sitting Position
Inspection
Both the nipples are at same level, scar of previous surgery at left
breast. An eczematous lesion at nipple and areola at rt. Breast. Rt.
Nipple is retracted. The lesion has scales and mild erythma. No
dialeted veins on breast.
Palpation
On palpation the lesion is non tendor , cold and mild indurations up-
to areola, nipple is retracted, no lump palpated in both the breast. The
lesion is free no sign of fixicity. No edema palpated.
No any lymph node palpable in brachial, pectoral sub-scapular,
central , apical, supra-clavicular and cervical group on both side

17. Diffrential diagnosis
Eczema of nipple
Paget’s disease
Psoriasis
Drug eruption
Irritant contact dermatitis
Mammary duct ectasia
Tokar cells
Cutaneous melanoma
Nipple duct adenoma
Bowens disease (SSC)

18. Provisional Diagnosis
Paget’s disease
Itching +nt
Scaling +nt
Unilateral +nt
Spread from nipple to areola +nt
Patients age >50 yrs +nt
Non lactating +nt
Destruction of nipple +nt

19. Investigations
CBC -WNL
ESR- 05
Rbs-93mg%
B.Urea-45
S.C.-0.6
HBsAg, HIV. -ve
MAMOGRAPHY - Advised
HISTOPATHOLOGICAL EXAMINATION OF LESION
Advised.

20. Diagnosis
Awaited for report of epidermal smear and
histopathological report.

21. Treatment
Lumpectomy/Mastectomy
Chemotherapy
Radiotherapy
Adjuvant treatment

22. Prognosis
 The presence of three factors for the prognosis has been suggested, whether
there is a palpable mass of the disease, whether lymph nodes are positive and
whether there is an underlying malignant cancer. If there is none of these, the
five- and 10-year survival is 85% and 80% respectively, with adjuvant
chemotherapy even 95% and 90%. If there is a palpable mass, it is 32% and
31% respectively, with adjuvant chemotherapy (40% and 35%).Positive lymph-
nodes have been positively associated with a palpable mass and affect the
prognosis to be now just 28% survival after 10 years (vs 79% without palpable
mass and without affected lymph-nodes).[
Involvement of the lymph nodes
does not directly cause any harm, but is merely an indicator of systemic
spread.Furthermore, patients with an identifiable associated underlying breast
tumor have a survival rate of 38-40% at five years and a survival rate of 22-33%
at 10 years. The death rate of metastatic breast carcinoma in patients with
mammary Paget's disease and underlying cancer is 61.3%, with a 10-year
cumulative survival rate of 33%.