A 56-year-old hypertensive post-menopausal woman presented with a rapidly enlarging, painless lump in her left breast, which has grown from 2 cm to 6 cm over two years, accompanied by skin changes and a single axillary lump. She underwent radiological tests and biopsy but has no history of breast cancer in her family or signs of metastasis. The provisional diagnosis includes phyllodes tumor or breast tuberculosis, with a noted background of poor socio-economic status and tobacco addiction.

2. Mrs. X
56 years
Female
Gangajalghati, Bankura (Rural)
Home Maker
Muslim
17th May 2020, Surgery
Ward

3. Painless Progressive Lump in the
Left breast
which has been rapidly enlarging
over the last 6 months
2 years

4. • Patient was asymptomatic two years back.
• She first noticed a small lump 2 cm (approx) in diameter, in
the outer part of her left breast.The lump was insidious in
onset and painless to start with, but was associated with
some pricking sensation. It was gradually increasing in size
over the last 1½ years.
• This was followed by a single lump in her left armpit, which
was also gradually increasing in size for the past 1 year.
• She consulted a local homeopathic doctor fearing her
disease and was under medication for the last 8-9 months.

5. •Over the last 6 months there has been a rapid increase in
the size of the swelling.The swelling gradually
progressed to its present size of ~6 cms (diameter) and
became harder and the breast started to feel heavier and
changed shape. She also observed the nipple had drawn
inside. It was accompanied by a dull aching continuous
pain over the Left breast.The pain was relieved with over
the counter medications.
•The skin over the outer aspect of the affected left breast
became discoloured and there was an tiny ulcer which
progressed, with an occasional discharge but healed by
itself.
•No H/O nipple discharge.
•No Lumps in the opposite breast or armpit.
•No H/O trauma to the breast/ or chest wall.

6. • No H/O suggestive of metastasis such as low back or long
bone pain, No H/O fractures, no H/O fever,
breathlessness, jaundice, black-outs/headaches or
convulsions
• She has recently become very weak , has a reduced
appetite and finds it difficult to carry out her daily
activities.
Relevant Medical
and Surgical
HISTORY
• Known Hypertensive on Medication for
4 years. (Losartan)
• No History of : COPD /T2DM/ BA/TB
or exposure toTB contacts/CAD.
• No previous history of any breast or
gynaecological surgery in the past.
• No H/O chest radiation in childhood.

7. PERSONAL
HISTORY
• Married
• Muslim female
• Poor Socio-economic Status (mKPS)
• Mixed regular non vegetarian diet
(decreased appetite)
• Addicted to tobacco (DOKTA)
• Sleep patterns are not altered.

8. MENSTRUAL and
OBSTETRIC
HISTORY
• Attained menarche at the age of 13
years.
• Married at the age of 18 years.
• P2 L 2 A0
• Her age of first childbirth was 20 years.
• Both children (two female) were born by
NormalVaginal Deliveries, exclusively
breast fed for 6 months.
• Both the daughters are free from any
disease at present.
• No history of spontaneous abortions.
• H/O usage of Combined OCPs for 2-3
years after the first childbirth.
• Post Menopausal since the last 3½ years.
• No HRT usage after attaining
menopause.

9. FAMILY
HISTORY
No History of breast cancers in the
family.
No history of ovarian, prostate, colonic,
stomach cancers in the family among
the first or second degree relatives.

10. TREATMENT
HISTORY
• Patient sought medical advice from a
Homeopath when she noticed the
lump.
• Recently Radiological tests and
needle biopsy, have been performed
10 days back.
• Not subjected to any medical
therapy after being admitted to the
hospital, and after the biopsy.
HISTORY OF
ALLERGY
No Known allergy to drugs and
food

11. Summary of History

12. CONSENT

13. • Mental Status- Conscious, alert and Cooperative
• Decubitus of Choice
• Built and Nutrition- Well built, BMI- 20.3
• Karnofsky Performance status – 70 , ECOG- 1
• Pallor- Present
• Icterus , Clubbing , Cyanosis, Edema - Absent
• Tongue – Moist
• Temperature- 38 degree Celsius.
• NeckVeins – Not distended
• Neck Glands- Not enlarged
• Pulse- 110/min, Right arm, sitting position, good volume,
normal character and no asynchrony of peripheral pulses.
• BP- 134/88 mm of Hg in RIGHTARM Sitting Position
• Respiratory Rate – 18 breaths/ min.

14. Inspection
(5 positions in inspection) - sitting,arms up, leaning forwards, pressing hips,
supine, Recumbant 45deg

15. Inspection

16. • Both breasts are at the same level, but the Left Breast
is grossly larger, with visibly apparent Peau d orange
appearance.
• Both the inframammary fold appears to be normal.
• No dilated veins over both the breasts & chest wall.
• Left breast has visible fullness on the Outer aspect.
• The skin overly the breast has a 2x1.7cm area of
hyperpigmentation with a scab and crusting.
• Another hyper pigmented (blackish) elliptical area of
skin is seen medial to the previously described scab.
• The Left NAC is drawn up medially, and the left Nipple
is retracted. No visible discharge.
• Healed Core biopsy mark is visible over the swelling.
• No lymphedema noted in either arms.
• Supra clavicular fossae are empty.

18. • The right breast was normal.
• The inspectory findings were confirmed on Palpation.
• There is a slight local rise of temperature over the Left breast.
• The Lump is spherical, 6.2 cms in diameter, hard in
inconsistency, with ill defined margins and slightly tender on
palpation.
• The skin overlying the breast lump is involved with an area of
darkened pigmentation and an firm irregular elliptical scab,
there is no active discharge.
• The lump is not freely mobile within the breast tissue and not
fixed to the underlying muscle or the chest wall.
• Pressure on the nipple areolar complex does not produce any
active discharge and the inverted nipple cannot be everted
during palpation.
Palpation

19. • There is a single mobile Lymph node in the left axilla that
is firm in consistency, 2cmX1cm in dimensions.
• The Right axilla is normal.
• Both the supraclavicular and infra clavicular fossae are
empty.
• Both the shoulder movements are adequate
• Arm diameter is 20cms in the Left arm and 19.2 cm in
the Right Arm.
Regional Examination.

20. ABDOMEN
• Within normal limits.
• No Hepatomegaly or
Splenomegaly
• Normal tympanic note on
percussion
• No free fluid.
• IPS +
• DRE- NORMAL
• PV- Normal

21. CHEST
[CARDIO-VASCULAR
&
RESPIRATORY]
CENTRAL NERVOUS
SYSTEM
&
SPINE
• Clear,Vesicular Breath
Sounds
• Normal Heart Sounds
• No Added Sounds
• Within Normal
Limits

22. CASE SUMMARY
This 56 year old Hypertensive, post-menopausal, (P4 ) lady presented to
us with a swelling in her Left Breast for the last 2 years.The swelling was
about 2 cms (dia) when she first noticed it, it was slow growing &
insidious to start with initially but rapidly increased to its present size ~ 6
cms (dia), over the past 6 months.The affected breast underwent skin
changes.There was a small ulcer on the outer aspect of the left breast,
which occasionally produced a clear discharge.The patient also
experienced a dull aching continuous pain that subsided with
medication.
This was also associated with a single insidious swelling in her armpit
that increased in size since the last one year.The patient was on
homeopathic therapy for the pas 6 months.
She is not symptomatic for any metastatic disease, and has no family
history of breast and related malignancies in the family. She is addicted
toTobacco. Underwent imaging & needle biopsy after hospital
admission.

23. The left breast is grossly enlarged with Peau d’ orange
appearance.
The left nipple is retracted.
There is a 6.2cm lump (diameter) in the upper outer part of the
left breast that is fixed to the skin with an overlying healed hyper
pigmented 2x 1.7cm cm scab from a previous ulcer and a small
satellite nodule adjacent to it.The lump is hard, with poorly
defined margins, not fixed to the deeper muscles or the chest
wall.
There is a single ipsilateral mobile axillary lymph node (2x1cms)
The opposite breast and axilla is normal.
Systemic examination is within normal limits.

24. PROVISIONAL DIAGNOSIS

25. DIFFERENTIAL DIAGNOSIS
• Phyllodes tumour (Cystosarcoma Phyllodes , Brodie’s
sarcoma) of the Left Breast
• Tuberculosis of the Left Breast of the Left Breast
Long standing breast mass
with Rapidly enlarging
Skin Ulcer over the breast
Large breast, Hard lump,
Ulcer
Postmenopausal
Has axillary nodes
No dilated veins / Shiny skin
Lump is not bosselated
Ulcer healed spontaneously
Indian patient
Poor socioeconomic status.
Skin Ulcer over the breast
Breast lump, + Discharging Ulcer
NOTB / CONTACT or pulmonary
TB.
No H/O fever , or evening rise of
temp. (constitutional symptoms)
Ulcer spontaneously healed