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Case Presentation
Case Presentation
Case Presentation
SURGERY
HISTORY
No history of previous
hospitalizations.
DRUG HISTORY:
H/O intake of hakeem medications
for 3 months for similar complaints.
FAMILY HISTORY:
There’s no family history of CA
INSPECTION:
On inspection, left breast is normal while
right breast shows visible nipple changes
like distortion of its shape,ulceration and
eczematous changes(Paget’s disease of
nipple).
PALPATION:
on right side.
Supraclavicular lymph nodes are palpable on
SYSTEMIC EXAMINATION
CHEST:
Normal vesicular breathing with
no added sounds.
CVS:
S1+S2+0
Abdomen:
no visceromegaly
no palpable mass
SD and FT are –ve
Bowel sounds are audible
CNS:
ROUTINE:
CBC:
Hb:12.3g/dL
TLC:10,000/µL
PLT:255,000/µl
DLC:
Neutrophils:76%
Lymphocytes:20%
Monocytes:02%
ESR:21 mm/1st hour
RFTs:
serum creatinine:0.9 mg/dL
blood urea:17 mg/dL
LFTs:
TBIL:0.5 mg/dL
ALT:14 IU/L
AST:25 IU/L
ALP:51 IU/L
HBsAg non-reactive
FNAC done on 16/07/10 shows
proliferative breast disease with
atypia.Tissue biopsy advised.
TRUCUT BIOPSY on 31/07/10
provides inadequate tissue sample,
malignancy cannot be proved.
INCISIONAL BIOPSY 24/08/10 shows
Invasive ductal CA Grade II
Abdominal USG:
Liver shows an echogenic focus
measuring 8x7 mm noted in right lobe of
liver most likely hemangioma.
BONE SCAN:
Shows multiple areas of abnormal
increased uptake of radionuclide involving
12th thoracic,1st lumbar vertebrae,multiple
costo chondral junctions,pelvis multiple
sites,manubrium sternii and proximal end of
both femorii.
stage Description
CANCER
BREAST
FOR
STAGING
TNM
tumor
TX Primary tumor not assesable
Distant Metastases
MX Presence of distant metastasis is not
M0 assessable
No distant metastasis
M1 Existant distant metastases including
ipsilateral supra clavicle nodes
American joint committee on cancer
classification for breast cancer on
TNM CRITERIA
Stage Tumor Nodes Metastasis
0 Tis N0 M0
I T1 N0 M0
IIA T0,1 N1 M0
T2 N0 M0
IIB T2 N1 M0
T3 N0 M0
IIIA T0, 1, 2 N2 M0
T3 N1,2 M0
IIIB T4 Any N M0
Any T N3 M0
IV Any T Any N M1
STAGE OF DISEASE OF
PATIENT
According to all the investigations
and TNM staging patient has stage
IV disease .
PLAN
The patient is now receiving
chemotherapy from the oncology
department of our hospital.
Her workup for chemotherapy is
complete.
And she has received 2 courses of
chemotherapy.