A long case presenting carcinoma breast. Surgery long case presentation.

1. Welcome to Clinical Case
Presentation
Dr. Md. Tafazzul Hossain Bhuiyan
IMO SU III
DMCH

2. A 62 Year Old Female With Breast Lump

3. Particulars of the patient
• Name: Johura Begum
• Age: 62 years
• Sex: Female
• Address: Shibaloy, Manikgonj
• Marital status: Married
• Occupation: Housewife
• Religion: Islam
• Date of admission: 19/09/2022 at 3.30pm
• Date of examination: 19/09/2022 at 4.00pm

4. Present complaint
• Lump in the right breast for 1 month

5. History of the present complaint
According to the patient’s statement she was relatively well about 1
month back, then she suddenly noticed a lump in upper part of right
breast which was gradually increasing in size. She had no pain and
fever. She had no history of trauma to the breast. She had no complaint
of bone pain, cough, chest pain or weight loss. Her bowel and bladder
habit was normal. She did not give history of diabetes, hypertension or
contact with TB patient.

6. Past medical history
• She had no significant past medical or surgical illness

7. Drug history
• She did not took any medication for this disease

8. Family history
• Her mother died naturally at old age
• She has 2 sisters, none has this type of illness
• 1 daughter is in healthy state

9. Personal history
• She is non smoker, non alcoholic, occasional betel leaf and betel nut
chewer
Socio economic history
• Middle socio economic condition
• Lives in brick built house with tin shed roof, use sanitary latrine,
drinks safe water from tube well

10. Immunization history
• She took BCG vaccine at young age
• She is vaccinated against COVID19

11. Allergic history
• She had no history of allergy to any known medication or food.
Obstetric history
• Married for 50 years
• Para 3(NVD)
• Menarche at 12 years
• Menopause at 40 years

12. Breast feeding history
• She breast fed her 2 sons and 1 daughter
Contraceptive history
• She was use to take contraceptive pill irregularly

13. General examination
• Appearance: normal
• Body build: normal
• Cooperation: co-operative
• Decubitus: on choice
• Nutritional status: average(BMI 25.4)
• Anemia: absent
• Cyanosis: absent
• Jaundice: absent
• Edema: absent

14. General examination (cont)
• Dehydration: absent
• Clubbing: absent
• Koilonychia: absent
• Leukonychia: absent
• Pulse: 96bpm
• BP: 130/80 mmHg
• Respiratory rate: 18bpm
• Temperature: 98⁰F

15. General examination (cont)
• Lymph nodes: accessible nodes are not palpable
• Thyroid: not enlarged
• Skin condition: normal
• Bony tenderness: absent

16. Local examination
Inspection
• Both breasts are normal in size and shape
• Nipples are normal and symmetrical
• No visible lump
• No ulcer or peau d’orange or skin tethering
• No scar mark, engorged vein
• No discharge from nipples

17. Inspection
• Picture was taken with proper
consent of the patient

18. Palpation
• Left breast: normal and no palpable lump
• Right breast:
There is a lump in upper and outer quadrant
Tenderness: no tenderness
Temperature: no local rise of temperature
Consistency: hard

19. Palpation (cont)
Shape: globular
Margin: irregular
Size: about 4 cm in its maximum diameter
Fixity: mobile in all direction and free from underlying structure and
overlying skin
• Axilla: no palpable nodes in any axilla

20. Abdominal examination
Inspection
• Skin normal
• Flanks full
• Umbilicus centrally inverted
• No scar mark
• No visible peristalsis
• No engorged veins
Palpation
• Superficial palpation
• Temp: normal
• Tenderness: absent
• Deep palpation
• Lump: no lump felt
• Liver: not enlarged
• spleen: not enlarged
• Kidneys: non ballotable

21. Abdominal examination (cont)
Percussion
• Percussion note: tympanitic
• Liver dullness: right 5th
intercostal space in mid
clavicular line
• Shifting dullness: absent
Auscultation
• Bowel sound: present
• Hepatic bruit: absent
• Renal bruit: absent

22. Other systemic examination
Respiratory system
• Inspection: normal findings
• Palpation: no abnormality seen
• Percussion: resonant
• Auscultation: breath sound
normal, no added sound
Cardiovascular system
• Inspection: normal findings
• Palpation: no cardiomegaly, no
palpable thrill or murmur
• Auscultation: normal heart
sound, no murmur heard

23. Other systemic examination (cont.)
• Musculoskeletal system: no abnormality or any bony tenderness
found
• Nervous system: normal
• Others systems are apparently normal

24. Salient feature
Mrs. Johura begum, a 62 years postmenopausal, normotensive,
nondiabetic lady was presented with a painless hard lump in upper
and outer quadrant of right breast for 1 month. She had no positive
family history of any malignant diseases. She had no history of trauma
to the breast and no bone pain.

25. Salient feature (cont)
On examination the lump was about 4 cm in its maximum diameter,
margin was irregular, mobile, non tender and no local rise of
temperature. There were no skin changes over the lump. There was no
nipple discharge. Left breast was normal and there was no axillary
lymphadenopathy. Her all vital parameters were normal. Other
systemic examination were normal.

26. Provisional diagnosis

27. Carcinoma right breast
(T2N0Mx)

28. Differential diagnoses
• Phyllodes tumor
• Traumatic fat necrosis

29. Investigations
• Mammography : right breast is predominantly fatty. A radio opaque
shadow is seen in upper and inner quadrant of right breast. No micro
or macro calcification is noted. Overlying skin and soft tissue appears
normal.
• Impression: suspicious mass in right breast. Right axillary
lymphadenopathy
• Category: BIRADS 4

30. Mammography

31. USG of both breast and axilla
• A fairly solid mass lesion with lobulated margin is noted in right breast
at 12o’ clock position
• No abnormal micro or macro calcifications could be noted
• A lymph node <1cm demonstrated in right axillary region
• Impression: Right upper mid quadrant (12o’ clock) solid mass with
enlarged right axillary lymph node most likely malignant

32. USG of both breast and axilla

33. Core biopsy and histopathology
• Gross: specimen consists of 3 linear pieces of tissues.
• Microscopic examination: section shows core of breast tissue. It
reveals an invasive ductal carcinoma. The tumor shows mild
desmoplastic changes. Nottingham histologic score: 6
• Histologic grade II
• Lymphovascular invasion: not identified
• Perineural invasion: absent
• Diagnosis: Invasive ductal carcinoma, NOS, grade II

34. Immunohistochemistry
• Estrogen receptor (ER): positive
• Progesterone receptor(PR): positive
• HER-2: negative
• Ki67: immunoreactive in 12% tumor cells

35. Histopathology &
immunohistochemistry

36. Investigations
Investigations Date Reports
CBC 19/09/22 Hb- 14.1gm/dl, WBC- 12,490/cmm, PLT-216*10^3/mm3
S. glucose 19/09/22 7.2 mmol/l
S. creatinine 19/09/22 1.24 mg/dl
S. ALT 24/09/22 41U/L
S. electrolytes 19/09/22 Na+ 143, K+ 4.6, Cl- 106 mmol/L
Blood grouping Rh
typing
19/09/22 A+ve
ECG 19/09/22 Normal
HBsAg and Anti HCV 19/09/22 Negative
CXR PA view 19/09/22 Normal study
USG of WA 26/09/22 Fatty liver

37. Clinical diagnosis
• Invasive ductal cell carcinoma (right breast) grade II, NOS
(T2N0M0)

38. Management
• Counselling
• Preoperative assessment
• Multidisciplinary approach
• Operation of the patient
• Adjuvant chemotherapy
• Rehabilitation and psychological support

39. Operation note
• Date and time: 28/09/22 at 1.50pm
• Name of operation: modified radical mastectomy with axillary
clearance of right breast
• Indication: Carcinoma of right breast with rt axillary
lymphadenopathy
• Incision: transverse elliptical incision
• Anesthesia: GA

40. Operation note (cont)
• Findings: a lump present in upper and outer quadrant, right axillary
lymphadenopathy
• Procedure: with all aseptic precaution proper painting and draping
was done. Incision was given. Modified radical mastectomy was done.
Axillary clearance was done. Two negative suction drain was kept.
Skin was closed.
• Specimen sent for histopathology

41. • Patient was discharged in 3rd post operative day
• With advice to consult with dept of radiotherapy with histopathology
report

42. Histopathology of specimen
• Invasive ductal carcinoma
• Grade 2( Nottingham modification of Bloom Richardson system)
• Lymphovascular invasion: not identified
• Perineural invasion: not identified
• Tumor extension: skin: free of tumor
• Nipple and areola: free of tumor
• Other quadrants: free of tumor

43. Histopathology (cont.)
• Resection margin: deep resection margin clear
• Peripheral resection margin clear
• Lymph nodes(17): reactive hyperplasia, no metastasis seen
• Pathological staging: pT2N0Mx
• Diagnosis: Invasive ductal carcinoma, NST grade 2

44. Final histopathology report

45. Final diagnosis
• Invasive ductal carcinoma (right breast), Grade II, NOS
(T2N0M0)

46. Thank you