cancer

1. A 53 year old woman with
left chest wall swelling
Dr. Saiful Islam Shahid
Phase B resident
Clinical Oncology
BSMMU

2. Particulars of the Patient
 Name : Mrs Rahima Begum
 Age : 53 years
 Sex : Female
 Religion : Islam
 Marital Status : Married
 Occupation : Housewife
 Address : Village - Birpur, PO - Birpur, Thana - Narsingdi
Sadar, District - Narsingdi

3. Chief Complaints
1. Swelling over previously operated area of left chest wall for 8 months
2. Weight loss for 6 months

4. History of Present Illness
According to the statement of patient, she was reasonably well 13
years ago. In 2010, she was diagnosed as a case of Left Breast
Neoplasm for which she underwent operative procedure. Then she
received chemotherapy for 6 times at 21 days interval in Dhaka
Medical College which was followed by radiotherapy. She completed
her hormone therapy in 2017. After that, she was on regular follow-
up.

5. Swelling over the operative area of left chest wall - 8months
• Gradually increasing in size
• Initially painless
• Occasional dull-aching, non radiating pain
• Relieved after taking Tab. Paracetamol.

6. Weight loss - 6 months
• Unintentional
• Evidenced by loosening of clothes.
• Associated with anorexia, nausea
• Not associated with any polyuria, polydipsia, heat intolerance,
vomting and diarrhoea.

7.  No history of -
• Fever
• Cough
• Hemoptysis
• Shortness of breath
• Yellow discoloration of sclera
and urine
• Abdominal pain
• Abdominal swelling
• Headache
• Seizure
• Bony pain
• Trauma to the chest

8. She is a known case of hypertension for last 7 years which is well
controlled with anti hypertensive medication. There was no history of
any episode of hypertensive emergency.
Her bowel bladder habit is normal.

9. Menstrual History:
She is menopausal for last 6 years.

10. Personal History:
Ex betel nut chewer.

11. Family History:
She is married and lived by 2 sons and 1 daughter.
She has 3 sisters and 2 brothers and they are apparently healthy.
No family history of any breast or ovarian malignancy.

12. Socio-economic history:
She is a housewife and maintains a middle class family. She lives
in a storied building and has access to safe drinking water and
sanitary toilet.

13. Immunization History:
She was not immunized as per EPI schedule.
Received 3 doses of COVID - 19 vaccine.

14. Transfusion History:
History of several times of blood transfusion during management
of Breast neoplasm previously.

15. Drug History:
She takes Tab OLMESARTAN + AMLODIPINE combination for
management of hypertension and occasional PPI for
dyspepsia.

16. Background History
She was diagnosed as a case of Carcinoma Left breast on
2010.
She underwent left sided simple mastectomy with axillary
dissection on 16/11/2010
Histopathology report revealed Infiltrating Ductal Cell
Carcinoma, Grade: 2, Stage : pT3N1Mx
IHC revealed ER :(+) , PR :(+), HER-2 :(-)

17. Then she received 6 cycle of chemotherapy with FAC schedule
upto 12/4/2011 in DMC
Later she received LRRT-50 Gy, 25# (Co-60 machine by 2D
technique) from 15/5/2011 to 19/6/2011
She completed her hormone therapy with Tab TAMOXIFEN on
July, 2017.

18. General Examination
• Appearance : Normal
• Body built : Average
• Co-operation : Co-operative
• Decubitus : On choice
• Nutritional status : Average
• Height : 5 feet 1 inch
• Weight : 52 kg

19. General Examination (contd.)
• Anaemia : (+)
• Jaundice : Absent
• Cyanosis : Absent
• Oedema : Absent
• Dehydration : Absent
• Koilonychia : Absent
• Leukonychia : Absent

20. General Examination (contd.)
• Clubbing : Absent
• Thyroid gland : Not enlarged
• JVP : Not raised
• Skin condition : Normal
• Hair distribution : Normal
• Bony tenderness : Absent

21. General Examination (contd.)
• Pulse : 80 beats/min
• BP : 110/70 mm Hg
• Temp. : 98.5°F
• Resp. rate : 16 breaths/min

22. Local Examination
• There is a swelling over surgical scar mark of mastectomy at left lateral
chest wall. Swelling measures about 4.5 cm X 2 cm, mildly tender, firm
to hard in consistency, surface smooth, margin irregular, fixed with
overlying skin and underlying structures. Local temperature and skin
color is not altered. There is no ulceration and discharge from the
swelling.
• There are multiple, mobile, discrete palpable axillary lymphadenopathy
over right axilla with firm consistency, largest one measuring about 2
cm X 1 cm in anterior group. Lymph nodes were non-tender.

23. Examination of Respiratory System
Inspection:
• Shape of the chest- Normal
• Resp. rate- 16 breaths/min
• Chest movement- Normal and symmetrical
• No visible pulsation
• No suprasternal, intercostal or subcostal indrawing

24. Examination of Respiratory System
Palpation:
• Trachea- Centrally placed
• Apex beat - Present in left 5th intercostal space just medial
to mid-clavicular line
• Chest expansion- normal and symmetrical
• Vocal fremitus- Normal

25. Examination of Respiratory System
Percussion:
• Resonant all over the chest
Auscultation:
• Breath sound- Vesicular with no added sounds
• Vocal resonance- Normal all over both lung field

26. Examination of Alimentary System
 Oral Cavity : Normal findings
 Abdomen :
Inspection:
• Scaphoid and symmetrical in shape,
• Umbilicus centrally placed & inverted,
• Flanks are not full,
• No visible scar mark, peristalsis or engorged vein.

27. Palpation:
• No tenderness,
• No organo megaly
Percussion:
• Tympanic
Auscultation:
• Bowel Sound : present

28. Examination of CVS
No abnormalities were detected.

29. Examination of Nervous System
• Higher psychic function - Normal
• Cranial nerves - Intact
• Motor system examination - Normal
• Sensory system examination - Normal
• Cerebellar function test - Normal
• Signs of meningeal irritation - Absent

30. Salient Feature :
Mrs. Rahima Begum, 53 years old, hypertensive, non diabetic patient,
hailing from Narsingdi, came to our hospital with the complaints of
swelling over previously operated area of left chest wall for 8 months
and weight loss for 6 months.
According to the statement of patient, she was reasonably well 13
years ago. In 2010, she was diagnosed as a case of Left Breast
Neoplasm for which she underwent operative procedure.

31. Then she received chemotherapy for 6 times at 21 days interval in
Dhaka Medical College which was followed by radiotherapy. She
completed her hormone therapy in 2017.
Then 8 months ago, she noticed a small swelling over her left chest wall
which was gradually Increasing in size. Swelling was initially painless
but later became associated with occasional dull - aching, non -
radiating pain which was relieved after taking Tab Paracetamol.

32. She also complained of unintentional weight loss for last 6 months
which was evidenced by loosening of clothes. Weight loss was
associated with anorexia, nausea but was not associated with any
polyuria, polydipsia, heat intolerance, vomiting and diarrhoea.
She is a known case of Hypertension for last 7 years which is well
controlled with anti hypertensive medication. Her bowel bladder habit
is normal.

33. On general examination, she is mildly anemic. Vitals are within normal
limit. On local examination, There is a swelling over mastectomy scar
mark at left lateral chest wall. Swelling measures about 4.5 cm X 2 cm,
mildly tender, firm to hard in consistency, surface smooth, margin
irregular, fixed with overlying skin and underlying structures.
There are multiple, mobile, discrete palpable axillary lymphadenopathy
over right axilla with firm consistency, largest one measuring about 2 cm
X 1 cm in anterior group.
Systemic examination of this patient did not reveal any abnormality.

34. Provisional Diagnosis
?

35. Provisional Diagnosis
Chest wall recurrence of left breast neoplasm

36. Differential Diagnosis
?

37. Differential Diagnosis
Sarcoma (Soft / Bony)

38. Investigations
Complete blood count (23/11/22) :
Hb% : 10.4 gm/dl
ESR : 56 mm in 1st hr
WBC : 9,400 per cumm
Neutrophils : 52%
Lymphocytes : 41%
Monocytes : 04%
Eosinophils : 03%
Basophils : 00%

39. Investigations
• Serum creatinine (23/11/22):
0.63 mg/dl Normal range (0.6-1.3mg/dl)
• SGPT (23/11/22):
19U/L Normal range (14-63U/L)
• Serum Electrolytes (23/11/22):
Na: 134 mmol/L
K : 4.7 mmol/L
Cl:102 mmol/L
• CA 15-3 : 18.6 U/ml

40. Imaging:
• USG of both breast(6/9/2022) : SOL (5 cm X 2.5 cm) in left chest wall
Right axillary lymphadenopathy
• Mammography of right breast(18.9.2022): Right axillary
lymphadenopathy (BIRADS - 1)
• USG of whole abdomen : Fatty change in liver (Grade 1)

41. Axillary lymph node biopsy : (2/10/2022)
Chronic non-specific lymphadenitis

42. Whole Body 18F-FDG PET-CT scan (15/11/22):
• Hypermetabolic (SUV max:5.6) irregular lobulated hyperdense soft tissue
mass at the surgical site invoving underlying pectoral muscles-suggests
locoregional recurrence.
• Multiple enlarged FDG avid(SUV max:2.7) right axillary lymph node –
suggesting metastasis.
• One ill-defined hyperdense lesion in left lower lung (SUV max2.7) - likely
inflammatory.
• No other suspicious lesion or appreciable abnormal FDG uptake elsewhere in
the body surveyed.

45. Core biopsy from swelling : (24/11/2022)
Features are suggestive of Sarcoma

46. MRI of Chest: (18/12/2022)
• Soft tissue intensity lesion(CC-2.4cm AP-4.6cm &TD-4.5cm) at left
lateral chest wall involving underlying pectoralis muscle - possibly
recurrence.
• Bilateral axillary lymphadenopathy. (Largest one 2.3 x1.5 cm in right
axilla)

48. After availability of these reports, Wide Local Excision of left
chest wall swelling was done on 27/12/2022 by general surgery
department of BSMMU.

49. Post operative Histopathology report(9/1/23)
Pleomorphic Rhabdomyosarcoma

51. Review of Histopathology report : (4/2/23)
Suggestive of Metaplastic duct cell carcinoma with frank
rhabdomyosarcomatous and chondrosarcomatous elements.

53. Immunohistochemistry : (6/2/2023)
• Vimentin : Positive
• Desmin : Positive
• SMA : Positive
• S-100 : Negative
• Myogenin: Negative
Dx : Compatible with Pleomorphic Rhabdomyosarcoma

55. Working Diagnosis

56. Key Questions:
• What should be the ideal diagnosis?
• What should be our next steps of management?