CARCINOMA OF THE BREAST – A CASE STUDY
This is the case of a fifty-three year old female who discovered a mass in her right breast in May of 1985. A mammogram ordered by her treating physician reported findings suspicious for malignancy. An excisional biopsy of the breast mass was done on 6/1/85 revealing an infiltrating ductal adenocarcinoma. Following surgery, the patient was prescribed a course of radiation therapy. She received only three of her scheduled radiation treatments and was subsequently lost to follow-up. This patient received no other form of treatment in the management of her disease.
She next sought medical attention for her condition in August of 1986 – some fourteen months later. At this time the patient presented to the Drs. Pérez García with complaints of pain, swelling, and ulceration in her right breast with foul smelling discharge. She also complained of pain, swelling, and immobility in her right arm, frequent low-grade fevers, and a weight loss of thirty pounds (fourteen kg) over the previous two months.
The patient appears older than her stated age. She is pale and weak and in moderate distress due to pain in her right breast and arm. Height: 5 feet 4 inches (1.62 m). Weight: 165 lbs (73.4 kg). Blood pressure: 170/110 mm Hg. Pulse: 80/ min. and regular. Temperature: 37.6o C. Respirations: 16/min. Head & Neck: Poor oral hygiene with multiple dental caries and missing molars. Bilateral tender cervical lymphadenopathy with two 1 cm lesions on the right, and three 1 cm lesions on the left. Chest: There is a 3 cm node palpable in the right supraclavicular fossa which is tender. The lung fields are clear. The heart sounds are normal, without murmurs or extra sounds. The heart rate and rhythm are normal. Breasts: The right breast is extensively involved with a neoplastic/inflammatory process, principally in its upper outer quadrant. There is an approximately 6 – 8 cm mass in the breast which is contiguous with tumor mass involving the patient’s right axilla. The breast mass is firm, tender, and adherent to the underlying fascia. The overlying skin is erythematous and ulcerated around the areola, with a foul smelling whitish discharge. The left breast and axilla are normal. Abdomen: Soft without masses or organomegaly. The bowel sounds are normal. Pelvic exam: Normal introitus. Cervix appears normal. Uterus anteverted and anteflexed. There are no adnexal masses or tenderness. Extremities: There is obstruction to venous/lymphatic outflow from the right upper extremity due to axillary involvement with tumor. The right arm is swollen in its whole extent and has a dark reddish-brown discoloration. The arm is immobilized in extension with slight flexion at the elbow.
Central nervous system: Grossly normal.
Hgb 12.0 gm%. Hct 39%. RBC 3.2 x 106/mm3. WBC 12,300/mm3 with a normal differential count. Glucose 70 mg%. Sodium 134 meq/L. Potassium 4.2 meq/L. Chloride 98 meq/L. BUN 18 mg%. Creatinine 1.1 mg%. Calcium 8.0 mg%. Phosphorous 3.9 mg%. Cholesterol 200 mg%. Total protein 5.8 gm%. Albumen 3.2 gm%. Globulin 2.4 gm%. Bilirubin (total) 0.4 mg%. SGOT 38 mU/L. LDH 140 mU/L. Alkaline phosphatase 50 mU/L. Urinalysis showed a trace of protein and 5 – 10 WBC/HPF. The chest xray was normal. The patient refused all other investigations ordered (bone scan, brain scan, liver-spleen scan,).
As best as could be determined from the available clinical and laboratory data, this patient had a Stage IIIB recurrent carcinoma of the breast (T4C N2 M0). On August 19, she began a series of weekly treatments with IPT during which she received the following medications: regular insulin – 15 units IV; Genoxal (Schering – cyclophosphamide 500 mg/25 ml) 1.0 ml IV; Methotrexate (Lederle – methotrexate 50 mg/20 ml) 3.0 ml IV; and Fluorouracil (Roche -5-fluorouracil 200 mg/10 ml) 5.0 ml.
Upon completion of twelve weekly treatments with this regimen, the patient was relieved of all her complaints and abnormal physical findings. There was no more pain in her right breast or arm, and the ulcerated area around the areola had healed leaving some residual thickening in the skin. There were no palpable masses in either breast, and no palpable cervical or supraclavicular lymphadenopathy. The pretreatment involvement of the patient’s right axilla with tumor had resolved completely, and there was a concomitant return to normal size, color, and functional capacity of the affected arm.
During the entire course of this patient’s treatment, she experienced no adverse reactions from the chemotherapeutic agents used, nor from the insulin administration. A control mammogram done on October 28, 1986, reported “…a slight thickening in the skin in the right retroareolar area. Actually no calcifications or tumor masses are identified. It is considered that there exists a notable improvement and/or cure” (figure I.3). This patient continues with regular follow-up examinations, and to date (4/92) has shown no evidence of recurrence of her disease.
May 23, 1985. (translation)
In the right retroareolar region, in the midline between the quadrants, is seen a dense tumor approximately 2 cm. in diameter with a diffuse inferior border, and without any precise calcifications. There is increased vascularization of this area. There is evidence of moderate bilateral ductal ectasia and fibrocystic breast disease.
The first possibility is cancer of the right breast.
Moderate bilateral fibrocystic disease.
Possible bilateral ductal ectasia.
Macroscopic description : In the intraoperative period, one segment of breast tissue measuring 2 cm in its greatest diameter was received. Slices of this revealed a central gray zone being 0.5 cm in its greatest dimension. On frozen section, an invasive ductal carcinoma was identified. The surgical suite was informed. Afterwards, various segments of breast and adipose tissue of normal appearance were received measuring 2 cm in greatest dimension. All the tissue received is included for study by stained section.
Microscopic Section: The presence of a malignant neoplastic process of epithelial origin, and of the size described, is confirmed. There is no capsule, but its margins are well defined. There is proliferation of epithelial cells of ductal origin and invasion of the fibrous stroma where there is a desmoid reaction. There is also perivascular and perilymphatic infiltration. The segments of fatty tissue received last contained no tumor.
DIAGNOSIS: Infiltrating ductal carcinoma of the right breast.
October 26, 1986. (translation)
This control examination shows a slight thickening of the skin in the right retroareolar area, very likely in relation to the treatment performed. No actual calcifications or tumor lesions are identified. It is considered that there exists a notable improvement and/or cure. In addition, there is evidence of moderate bilateral fibrocystic disease and the beginnings of fatty infiltration.