CASE SCENARIO

LOCALLY ADVANCED BREAST CARCINOMA

PRESENTED BY -
DR. VAIBHAV THORAT CO-ORDINATOR - DR. I.M. KHAN
DR. SAGAR DILIP RATHOD MODERATOR - DR. D.D. WAGH
 HISTORY
• My patient is , a 44 year old , perimenopausal , married lady ,
resident of wardha , a housewife by occupation , came in with chief
complaints of :

• Lump in the right breast since 6 months

• Ulceroproliferative growth in the right breast since 3 months
• pain in right breast since 3 months
• swelling in right upper limb since 2 months
 HISTORY OF PRESENTING ILLNESS
• Patient was apparently alright 6 months ago , when she noticed a
lump in upper outer aspect of her right breast , while bathing .
• Initially the lump was small in size approximately 2 cm x 2 cm , was
graadually progressive in nature .
• Subsequently pateint developed ulcer over the lump since 3 months
which was initially small in size of approximately 1 cm x 1 cm and
progressed to current size of 9 cm x 7 cm and is involving the whole
breast . It was assocaited with pain and in later course with purulent
discharge.
 HISTORY OF PRESENTING ILLNESS

• not associated with ulceration/foul smell/nipple discharge from

opposite breast

On enquiry ,
• No h/o lumps in opposite breast/axilla
 HISTORY OF PRESENTING ILLNESS

• No h/o previous trauma to breast

• No h/o past episodes of acute pain and redness with fever
• No h/o weight loss/loss of appetite
• No h/o back/hip pain / pain in limbs
• No h/o abdominal pain / distension
• No h/o chest pain , breathlessness or cough
• No h/o headache , giddiness or any obvious neurologiacal deficit
• No h/o Diabetes , TB , Hypertension , Asthma
• No h/o Radiation exposure in the past.
 Menstural & Obstetric history
• perimenopausal , last cycle - 4 monts back
• Menarche : 14 years of age , regular , 5-6 days , normal flow .
• Patient married at age of 19 years
• total no. of children - 4
• First child birth at 20 years - FTND
• Age of the youngest child being 17 years
• All children breast fed upto 11/2 years of age .
• No h/o abortion.
• No past h/o taking oral contraceptive pills / HRT
 Past History
• No h/osmoking or alcohol intake
• No h/o any past interventions / biopsies of the breast .
• No h/o chest irradiation in the past.
• No history of Koch 's/ Koch's contact.
• No h/o any medical or surgical illness.
 Personal History
• Patient takes mixed diet
• No bowel or bladder complaints
• Appetite and Sleep normal
• No h/o allergies
• No h/o addictions.
 Family History
• no history of breast malignancy in any first/second degree relatives.

• No h/o any BRCA related malignancies in the family.

 Sumary of History
• 44 year perimenopausal old lady , presented with lump in her right
breast since 6 months associated with ulcerproliferative lesion since 3
months and assocaited with right upper limb swelling since 2 months.
 General Examination
• The patient has been exmained in a well lit room with due consent ,
adequate exposure , maintaining privacy , in the presence of a female
attendant , in sitting , semi recumbent and supine position.
• The patient is conscious , cooperative , well oriented to time , place
and person .
• Moderately built and overweight , with BMI of 23.40
• Karnofsky Performace score - 80
 General Examination
• patient is afebrilw.
• pulse - 82/minute , in right radial artery , normal in rhythm and volume , no radio-
radial or radio-femoral delay.
• blood pressure - 120/70 mm Hg in the right brachial artery in supine position.
• respiratort rate - 20/minute , thoraco-abdominal , B/L chest expansion is symmetrical
.
• No pallor/icterus/cyanosis/clubbing/edema.
• Axillary lymphadenopathy present , will be discussed with the regional examination.
• no e/o lymphadenopathy elsewhere in body.
• no area of tenderness
 Regional exminations - inspection
• Sitting position , arms by her side
• The right breast is asymmetrically drawn up
• There is an ulceroproliferative fungating growth
present involving the entire right breast of
approximate size 9 cm x 8 cm .
• Right nipple-areola complex is destroyed .
• Four Satellite nodules are visible in the medial
aspect of right breast , lateral to the sternal
border
• Sero-purulent discharge present from the ulcer.
 Inspection
• on bending forward the left breast falls forward freely whereas right
breast does not fall forward .
• no visible fullness in B/L supraclavicuar region seen.
• right sided upper limb edema is seen .

• left nipple areola complex and breast appears to be normal , no

fullness visible in left breast and left axilla .
 Palpation
• Right breast -
Palpable ill-defined lump of approximate size 9 cm x 9 cm is palpated involving whole
breast , with overlying ulceroproliferative growth overlying the lump . it is hard in
consistency
the lump is adhered to the underlying structures and is not freely movable.
Induration is present around the ulcer extending upto lower border of clavicle and
below upto inframammary fold .
generalised tenderness present.
the ulcer bleeds on touch.
there is local rise in temperature
seropurulent discharge is present
 Palapation
• Right Axilla
There is 2 palpable lymph nodes , largest of size measuring 3x2 cm ,
along the anterior axillary fold , non tender , fixed , firm , belonging to
anterior group of lymph nodes .
no other palpabe nodes in right axilla or supraclavicilar region
 Palpation
• Left breast - no palpable lump , NAC normal
• no nipple d/c , no dilated veins
• left axilla - no palpable LN present.
 Systemic Examinaton
• Abdominal examination - no palpable organomegaly, no palpable
lump , no ascitis .

• Respiratory system - Air entry , bilaterally equal

• CVS - s1s2 heard
• CNS - patient is oriented to time , place and person
• P/V - normal
• P/R - normal
 Summary
• 44 year perimenopausal old lady , presented with lump in her right
breast associated with ulcerproliferative lesion since 6 months
assocaited with right upper limb swelling since 2 months

• On examination there was hard , tender lump of about 9 x 9 cm with

fungating ulceroproliferative lesion involving all the quadrants of
right breast . there is restricted mobility (s/o fixity to chest wall)

• Two palpable lymph nodes are present in right axilla , largest

measuring 3x2 cm palpable against anterior axillary fold , with non
piting oedema of the right upper limb.
 Diagnosis
44 year old perimenopausal lady with Locally advanced Breast
Carcinoma of the right breast , T4cN2aM0 , clinical stage IIIB