Case Study: Right

Breast Cancer
(T4NBY:
1 M x)
Patrick Kelvian
Sri herlina Dalimunthe
Putri sion ginting
Leonard owen L

0915061
1015132
1015013
1015119

Preceptor : dr. Antonius kurniawan, sp.b, finacs

RUMAH SAKIT SEKAR KAMULYAN
CIGUGUR-KUNINGAN
2014

Patient Identity

Name
Age
Gender
MR
Religion
Address
Job
Adm. Date
Room
Pre-op diagnose
Post-op diagnose
Operation

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: Mrs. O
61 years old
Female
168990
Moslem
KarangPawitan
Housewife
25th November 2014 , at : 13.31
: Musa 6-2
Right breast cancer (T4N1Mx)
Right breast cancer (T4N1Mx)
Biopsy Incicion

Anamnesis
Chief Complaint: Lump in right breast
Patient came in with a complaint of a lump inside her
right breast, which has seem to show since the past 5
months. Initially, the lump is felt to be the size of a chicken
egg and has grown ever since. The lump is reddish but no
pain is felt.
By the time the lump is realized, the patient went to
doctor A and had it biopsied. Biopsy was repeated in the
following month and the result from the two previous biopsy
showed that the lump was benign. Two weeks after the
biopsy, patient experienced a secretion of a pus from biopsy
scar, which became more and more and spreading.
Patient complained that the lump has been more
painful in the past two months. Pus comes out from biopsy
scar and spreading. Throbbing pain is experienced until now.

Anamnesis
Treatment/Medical Efforts:
Biopsy at doctor A, 2 times, 5 months ago, and is declared
benign. Visited doctor B and is suggested to run another
biopsy.
Medical History:
Has never experienced such illness before.
Suffered hypertension 10 years ago, took medication
(captopril) and control regularly.
Family Medical History:
No family member has ever had a similar complaint.
History of cancer in family is denied.
History of high blood pressure in family (+).

Anamnesis
History of Allergies:
None in food nor medicine.

History of Habit:
Consumed greasy food, not often exposed to radiation.

History of Obstetry and Gynecology

Menarche, 16 years old, one child, gave birth at 20
years old, never used birth control, menopause at 50
years old.

Physical Examination

General condition
Sickness degree
Consciousness
Nutrition status
Skin
cyanotic (-)

: Normal
: Moderate
: Compos mentis
: Overweight
: anemic (-),icteric (-),

Vital Sign
Blood pressure
II)
Heart Rate
Respiration Rate
Temperature

: 190/90 mmHg (Hypertension stage

: 80 x/mnt, regular
: 20x/mnt
: 36,6C

General examination
Head
- Eyes: Anemic conj. -/, icteric sclera -/-,
- Pupil: circle, isokor, diameter 3 mm,
pupilary reflex direct +/+, indirect +/+
Neck:
JVP 5+0 cmH20
Chest
: simetrical movement right=left
- Lung : VBS +/+, Rh -/-, Wh -/
- Heart : irregular rhytm, murmur

 Abdomen:
Inspection : Flat
Auscultation: Bowel sound (+) normal
Percussion : Tympanic, empty traube space,
CVA - /
Palpation : non palpable liver and spleen
Ascites (-) Pain (-). Murphy sign(-)
Anus
: no examination
Genital
: no examination

General Status
Extremity
: warm, CRT <2, Edema -/ Physiological reflex: +/+
Pathological reflex: -/
Motoric
: normal
Sensoric
: normal
Tremor and involuntary movement (-)

Local Status
Mammae dextra lump 17 cm
x 15 cm, hyperemic with
ulceration, physically stiff,
attached to surrounding
tissue, pressure pain (+),
nipple retraction (-).
Lump at axilla sized 4 cm x
3 cm, phisically stiff,
pressure pain (-).

Laboratory and Imaging

USG (Nov 25th 2014)

Hematology (Nov 25th- 26th

2014)

ECG
(Nov 25th 2014)

Resume
Patient female, 61 years old came in with a complaint of a
lump inside her right breast, which has seem to show since
the past 5 months. Initially, the lump is felt to be the size of
a chicken egg and has grown ever since. The lump is
hyperemic but no pain is felt.
By the time the lump is realized, the patient went to
doctor A and had it biopsied. Biopsy was repeated in the
following month and the result from the two previous biopsy
showed that the lump was benign. Two weeks after the
biopsy, patient experienced a secretion of a pus from
biopsy scar, which became more and more and
spreading.
Patient complained that the lump has been more
painful in the past two months. Pus comes out from biopsy
scar and spreading. Throbbing pain is experienced until now.

Resume
Treatment/Medical Efforts:
Biopsy at doctor A, 2 times, 5 months ago,
and is declared benign. Visited doctor B and is
suggested to run another biopsy.
Medical History:
Suffered hypertension 10 years ago, took
medication (captopril) and control regularly.
Family Medical History:
History of high blood pressure in family (+).

Resume

History of Habit:
Consumed greasy food, not often exposed to
radiation.

History of Obstetry and Gynecology

Menarche, 16 years old, one child, gave birth
at 20 years old, never used birth control,
menopause at 50 years old.

Vital Sign

Blood pressure
Heart Rate
Respiration Rate
Temperature

: 190/90 mmHg
: 80 x/mnt, regular
: 20x/mnt
: 36,6C

Local Status
Mammae dextra lump 17 cm
x 15 cm, hyperemic with
ulceration, physically stiff,
attached to surrounding
tissue, pressure pain (+),
nipple retraction (-).
Lump at axilla sized 4 cm x
3 cm, phisically stiff,
pressure pain (-).

Resume
ECG (Nov 25th 2014)
Interpretation : Normal sinus rhytm
Hematology (July 25th 2014)
Hb
: 10.9 g/dl (L)
Ht
: 34 % (L)
Leukocyte
: 13100 /mm3 (H)
USG (Nov 25th 2014)
Result : Normal

Diagnosis pre op
Right Breast Cancer (T4N1Mx)
with
Hypertension stage II

Therapy
Preoperation:

Amlodipine tab 10 mg 1x1

Captopril 3 x 50mg
Postoperation:

Amoxicilin 3x500 mg
Ketorolac 3x1 amp

Operation (November 26

th

2014)

Pre-op diagnose: Ca mammae dextra T4N1M0

Post-op diagnose: Ca mammae dextra T4N1M0
Operation: Biopsy Incision

Pathology Anatomy Result

Invasive ductal right breast cancer grade II

Diagnosis
Right Breast Cancer (T4N1Mx) (Invasive
ductal right breast cancer grade II)
with
Hypertension stage II

Follow up
Date

Subjective

Objective

Assesment

Work-up

Tuesday
25/11/14

There is mass in the

breast with a moderate
pain

BP : 190/90
Pulse : 80
Temp : 36.6
Respi: 22

Ca mammae
dextra T4N1M0

Inf RL 20/mnt
Amlodipine 1x10 mg
Captopril 3 x 50 mg
Lab
ECG
Chest Xray
USG
Planning for operation
tomorrow if blood pressure
stable (26/11/2014)
Fasting

Wednesday
26/11/14
Operation day

There is mass in the

breast with a
continuous moderate
pain

BP : 150/90
Pulse : 80
Temp : 36.7
Respi : 24

Ca mammae
dextra T4N1M0

Infuse RL 20/mnt
Biopsy incision

Thursday
27/11/14
Post op day 1

Pain in the surgical

wound.

BP : 170/90
Pulse : 84
Temp : 36.8
Resp : 24

Ca mammae
dextra T4N1M0

Inf RL 20tts/mnt
Amlodipine 1x10 mg
Captopril 3x50 mg
Amoxicilin 3x500mg
Ketorolac 3x1

Prognosis
Quo ad Vitam
: Ad malam
Quo ad Fuctionam
: Ad malam
Quo ad Sanationam : Ad malam

DISCUSSION

Anatomy and Physiology of the

Mammae

 Mammary gland (glandula mammaria s. mamma) is a

pair organ, which relates to the type of the apocrine
glands of the skin. It mostly occurs at the base on the
large breast muscle (m. pectoralis major), partially on
the front of ridgeshaped muscle (m. serratus
anterior) and crossing the free edgemof breast
muscle, adjoins by its small section to the side of
breast wall. In the average the base of gland reaches
the external edge of sternum.
The mammary gland is usually located at the level of
the III to (VI) VII ribs, and from all sides (except the
nipple and aerola) is surrounded by fatty tissue.
Between both mammary glands there is a deepening
called cavity (sinus mammarum).

Mammary gland is located on the right and left

hermithorax with the
following limits:
Superior limit: 2nd or 3rd rib
Inferior limit: 6th or 7th rib
Medial limit: edge of the sternum
Latera limitl: anterior axillary line
There are 3 main parts in the mammary gland:
Corpus (body), the part which is enlarging
Areola, which is the darker area in the middle
Papilla, or nipple, which is a prominent part at
the top of the breast

Vascularisation

Note: Physiology of Mammary

Gland
There are two hormones which acts in breast development
process:
Estrogen (ductal development)
During pregnancy, large amounts of estrogen is secreted
by the placenta so that the breast ductal system grows
and branches. Simultaneously, breast stroma is also
enlarging and large amount of fat is present in the
stroma. There are at least four other important hormones
in the growth of the ductal system including growth
hormone, prolactin, adrenal glucocorticoids and insulin.

 Progesterone (Lobule-alveolar system development)

Progesterone is required in the post-development of the
breast milk-secreting organ. Once the duct system has
evolved, progesterone works synergistically with
estrogen and all other hormones, the growth of breast
lobules, with alveolar budding and growth of secretion
properties from alveoli cells.

DEFINITION
Cancer isa term used for diseases in which abnormal cells divide
without control and are able to invade other tissues
Ca mammae is a malignant tumor that starts in the cells of the
breast. A malignant tumor is a group of cancer cells that can grow
into (invade) surrounding tissues or spread (metastasize) to distant
areas of the body.

Histopathology Classification
According to WHO dan Japaneese Breast Cancer
Society (1984) Histological Classification of Breast
Tumor
Malignant (Carcinoma)
Non Invasive Carcinoma
Non invasive ductal carcinoma
Lobular carcinoma in situ
Invasive Carcinoma
Invasive ductal carcinoma
Papillobular carcinoma
Solid tubular carcinoma
Scirrhous carcinoma

Grading-based Classification
Grade I
Grade II
Grade III

well-differentiated
moderately differentiated
poorly differentiated

TNM
Classification

Risk Factors
The main risk factor for breast
cancer is hormonal and genetic.

Other Risk Factors

Gender
Age
Age of Menarche
Age when giving first birth
Relatives with breast cancer
Estrogen exposure

Contralateral breast carcinoma or

endometrium
High-fat diet
Obesity
patient
Excercise
Does not breastfeed
Smoking

How to Diagnose?

Physical diagnosis
X-ray photo
Cytology
Histopathology
Lab check

Supporting Examinations

Ultrasonography
Doppler ultra sound
Mammography
Lab:

CEA (Carcino Embryonic Antigen)

MCA (Mucinoid-like Carcino Antigen)
CA 15-3 (Carbohydrat Antigen)
BRCA1 kromosom 17q

Biopsy (closed and open)

Therapy
6 types of standard treatments frequently used:
Surgery
Sentinel lymph node biopsy followed by surgery
Radiation therapy
Chemotherapy
Hormone therapy
Targeted therapy

Surgery
Lumpectomy: a surgery to remove the tumor (lump)
and a small amount of normal tissue around it.
Partial mastectomy: a surgery to remove the breast
that has cancer and some normal tissue around it. The
top layer of the chest muscles below the cancer
infected area may also be removed. This procedure is
also called a segmental mastectomy.

 Total mastectomy: a surgery

to remove the entire breast
that has cancer. This
procedure is also called a
simple mastectomy. Some of
the lymph nodes under the
arm may be taken for biopsy
at the same time or after.
This is done through a
separate incision.

 Modified radical
mastectomy: a surgery to
remove the entire breast
that has cancer, along
with lymph nodes under
the arm, upper layer of
the chest muscles, and
sometimes the part of the
chest wall muscles.

Radiation Therapy
Radiation therapy is a cancer treatment that uses
high-energy x-rays or other types of radiation to
destroy cancer cells or keep cancer cells to grow.
There are two types of radiation therapy:
External radiation therapy
Internal radiation therapy

Chemotherapy
Chemotherapy is a cancer treatment that uses
drugs to stop the growth of cancer cells, either by
killing the cells or stopping them from multiplying.
The way the chemotherapy is given depends on
the type and stage of the cancer being treated.

Hormone Therapy
Hormone therapy is a cancer treatment that
removes or blocks hormones tp stop the cancer
cells to grow.
Estrogen, which makes some breast cancers grow,
is produced mainly by the ovaries.
The treatment to stop the ovaries from producing
estrogen is called ovarian ablation.

Targeted Therapy
Targeted therapy is a type of treatment that uses
drugs or other substances to identify and attack
specific cancer cells without harming normal cells.

Treatment Options for Ductal

Carcinoma In Situ (DCIS)
Breast-conserving surgery and radiation therapy
with or without Tamoxifen.
Total mastectomy with or without Tamoxifen.
Breast-conserving
surgery
without
radiation
therapy.

Treatment Options for Lobular

Carcinoma In Situ (LCIS)
Biopsy to diagnose the LCIS followed by regular
examinations and regular mammograms to find
changes as early as possible. This is called
observation.
Tamoxifen to reduce breast cancer risk.
Bilateral prophylactic mastectomy. This treatment
option is used in women who have high risk of
developing breast cancer. Most surgeons believe that
this is a more aggressive treatment than is needed.

Staging-Based Therapy
Stage I, Stage II, Stage IIIA, and Stage IIIC Operable
Breast Cancer:
Breast-conserving surgery to remove the cancer and
only some surrounding breast tissue, followed by lymph
node dissection and radiation therapy.
Modified radical mastectomy with or without breast
reconstruction surgery.
Sentinel lymph node biopsy followed by surgery.
Targeted therapy as neoadjuvant therapy (to shrink
tumor before surgery).

Adjuvant therapy (treatment given after surgery to

reduce the risk of cancer returning) may include the
following:
Radiation therapy to lymph nodes near the breast and
chest wall after modified radical mastectomy.
Chemotherapy with or without hormone therapy.
Hormone therapy.
Monoclonal antibody therapy with Trastuzumab in
combination with chemotherapy.

Stage IIIB, IIIC inoperable Stage, Stage IV, and

Metastatic Breast Cancer:
Chemotherapy.
Chemotherapy followed by surgery (breast-conserving
surgery or total mastectomy), with lymph node
dissection followed by radiation therapy. Additional
therapy (chemotherapy, hormone therapy, or both)
may be given.
Clinical trials testing new anticancer drugs, new drug
combinations, and new ways to provide treatment.

Stage IV and metastatic breast cancer:

Hormone therapy and/or chemotherapy with or without Trastuzumab.
Monoclonal antibody therapy with Trastuzumab and Pertuzumab
combined with chemotherapy.
Antibody-drug conjugate therapy with Ado-Trastuzumab Emtansine.
Tyrosine Kinase Inhibitor Therapy with Lapatinib combined with
Capecitabine.
Combined with Trastuzumab and Lapatinib treatment.
Radiation therapy and / or surgery for relief of pain and other
symptoms.
Bisphosphonates to reduce bone disease and pain when cancer has
spread to the bone.

Complication
Metastasis
Bleeding
Infection

Prevention
Reduce greasy
food intake
Regular exercise

Prognosis
Major Prognosis factors:
invasive carcinoma or in situ disease
distant metastasis
lymph node metastasis
tumor size
locally advanced disease
inflammatory carcinoma

 Factor prognosis major

Committee on Cancer):

(American

Joint

Stage 0: DCIS atau LCIS 92%

Stage I: invasive carcinoma with a diameter of 2 cm or less (including
carcinoma in situ with microinvasion) without the involvement of the
KGB (or only metastases <0:02 cm in diameter) 87%
Stage II: invasive carcinoma with a diameter of 5 cm or less, three
involved axillary nodes or invasive carcinoma larger than 5 cm
without the involvement of the KGB 75%
Stage III: Invasive carcinoma with a diameter of 5 cm or less, four or
more axillary nodes involved; invasive carcinoma with a diameter
greater than 5 cm and the involvement of the KGB; invasive
carcinoma with a diameter of 10 cm or more, axillary nodes involved;
invasive carcinoma with involvement of the ipsilateral internal
mammary lymph nodes; or invasive carcinoma with skin involvement
(edema, ulceration, or satellite skin nodules), chest wall fixation, or
clinical inflammatory carcinoma 46%
- Stage IV: every breast cancer with distant metastasis 13%

 Minor Prognosis factors:

histology subtype
grading tumor
estrogen and progesterone receptor
HER2/neu
lymphovascular invasion
proliferative rate
DNA content