A 40-year-old Hindu lady presented with a rapidly enlarging swelling in her right breast reaching 10 cm in size over 4 months, along with an ulcerating node. Examination found a hard, fixed breast mass with peau d'orange appearance and serous discharge from the ulcer, as well as two mobile axillary lymph nodes. She was diagnosed with locally advanced carcinoma of the right breast, stage IIIb. Further tests and treatment including chemotherapy and surgery were planned.

1. CASE PRESENTATION - LABC
Presenter – Aakansh Jain
Postgraduate student
PGIMER & Dr RML Hospital,
New delhi
SCOPE – MARCH 2017

2. Chief complaints
Swelling in right breast - 4months
Ulceration and pain over swelling in rt breast - 2 week
• 40 yr
• Hindu lady
• Resident of UP
• Home maker
HISTORY

3. History Of Present Illness
 She noticed a swelling of approx 2 cm in right breast
4 months back
 Since then it rapidly progressed to current size of
approx 10 cm, not associated with pain or fever
 2 months later another swelling appeared in right
axilla of about 1-2 cm in size, gradually increasing in
size
 No other swelling in opposite breast or axilla

4. HOPI cont..
 She developed an ulcer in the nipple areola complex
2 weeks back just above the swelling
 Ulcer was associated with serous discharge
 It was also associated with pain
 Pain was localised to region of ulcer, dull aching in
character, relieved on taking medication

5. • No h/o nipple discharge
• No h/o trauma / radiation exposure in past
• No h/o chest pain cough/ hemoptysis
• No h/o weight loss or appetite
• No h/o pain in abdomen or jaundice
• No h/o lower back ache, pain in limbs
• No h/o headaches / vomiting or weakness of any
limbs
• Not a known case of HTN/ DM / asthma
HOPI cont..

6. HOPI cont..
• She gave h/o multiple needle insertions and dry taps
from the swelling done by some local practitioner
Past History
• No past h/o tuberculosis
• No past h/o surgical intervention

7. Family history
• No h/o any breast , ovarian , prostate or GI
malignancies in 1st degree relatives or family
members

8. Menstrual & Obstetric history
• Menarche at the age of 12 yrs.
• Married at age of 16 yrs.
• 1st child at the age of 23 yrs.
• She has 4 children and one abortion
• All Breastfed for minimum 2 years
• Youngest child of age 5 yrs.
• No h/o intake of any birth control pills
• Has normal menstrual cycles

9. Personal History
• Vegetarian
• Normal sleep pattern
• Normal bowel and bladder habit
• Non smoker/ non alcoholic
• No known allergies

10. To summarize…..
• 40 yr premenopausal hindu lady presented
with rapidly progressing swelling in her right
breast for 4 months which is at present of
approximately 10 cm and an ulcer over the
swelling for last 2 wks associated with serous
discharge.
• She complained of another swelling in her
right axilla for last 2 months.
• Negative metastatic and family history.

11. General physical Examination
• Conscious, oriented to time, place and person
• Built average
• Performance status - 80 (karnofsky scale),
• Well hydrated
• Adequately Nourished with BMI – 24.1 kg/m2
• No pallor, clubbing , cyanosis, icterus, pedal edema,
generalised lymphadenopathy (axillary LNA in regional
examination)
Vitals-
• PR-80 /min
• BP -118/74 mmHg
• RR – 16 / min ,
• Temperature- 98.2° F

12. LOCO REGIONAL EXAMINATION
INSPECTION
Asymmetry noted, with right
breast lying at a higher level
Visible fullness- right UOQ.
Skin- shiny , engorged veins,
Peau d’ Orange present
 An ulcer present over the
swelling of size 1*1 cm in UOQ
involving NAC, irregular shape,
everted edges and floor of
pale necrotic tissue.
 Serous discharge present
• No Satellite nodules.

13. • On leaning forward the left breast fell more forward
• B/L NAC- both present, No nipple discharge. Right NAC was ~3 cm
higher than left & retracted. Right nipple involved in ulcer.

14. • On raising both arms
above head- rt nipple
retracted and peau d’
orange becomes more
prominent
• Axilla, arm and thorax
appear normal

15. Palpation - Left breast was normal in consistency
Right breast-
• No local rise of temperature
• A swelling of 10*11 cm palpable in
right breast mainly in the upper
and lower outer quadrant and
extending to inner quadrants.
• Surface smooth , margins well
defined, non tender, hard in
consistency,
• Fixed to skin and breast tissue, a
ulcer present over it, peau d’
orange present.
• Neither fixed to chest wall nor to
the underlying pectoralis major
muscle

16. • An ulcer of size 1*1 cm present
over the swelling involving
nipple areola complex
• non-tender ,
- Irregular margins,
- floor covered with necrotic tissue,
- everted edges,
- base was formed by underlying
. lump,
- serous discharge oozing from
….ulcer,
- there was no nipple discharge on
. expression

17. Axillary lymph node examination
• There were two groups of lymph nodes
palpable
• One lymph node of 3*2 cm size, hard,
nontender, mobile in the central group
• Another lymph node of 1.5* 2 cm hard,
nontender mobile in anterior group
• No supra/infra clavicular lymph adenopathy
• No lymph adenopathy in C/L axilla

18. Systemic examination
• P/A – soft , non tender, no organomegaly, no
shifting dullness
• DRE- No fissures, fistula/sinus openings
No palpable nodule
No rectal bleeding
• Per vaginal examination - NAD
• Spine examination – no spine tenderness
• Chest – B/L AE +, no added sounds
• CVS – S1S2 heard, no murmur heard

19. To Summarize…
 40 yr premenopausal lady presented with rapidly
progressing right breast swelling currently of size
11 cm associated with serous discharging ulcer and
peau d’ orange with I/L two mobile axillary lymph
nodes with no clinical evidence of distant metastasis.

20. Diagnosis
• 40 yr premenopausal lady with locally
advance carcinoma of right breast with
clinically T4b N1 M0 with stage IIIb

21. Investigations
• To support diagnosis – B/L mammography with
B/l axillary USG
• To confirm diagnosis – core needle biopsy,
• To stage disease – metastatic workup-
• Bone scan
• CECT thorax, abdomen and pelvis
• LFT, ALP

22. Management
• Neoadjuvant chemotherapy
• MRM + axillary lymph nodal dissection
• Radiotherapy to chest wall and supraclavicular
LN region + Adjuvant chemotherapy
• Hormonal therapy (as per receptor status)