Case on the ca breast

Reading File

Asking for Preferences

Finding Sources

Reading File

Finding Sources

Reading File

I now have enough content from Bailey & Love and Schwartz to build a thorough full clinical case. Let me compile it.

Full Clinical Case: Carcinoma of the Breast

PRESENTING COMPLAINT

A 52-year-old postmenopausal woman presents with a painless lump in her right breast noticed 6 weeks ago. She has also noticed dimpling of the overlying skin.

HISTORY OF PRESENTING COMPLAINT

Lump: right upper outer quadrant, noticed incidentally, gradually enlarging
No pain (painless lump is the classic presentation)
Skin dimpling over the lump - noticed for 3 weeks
No nipple discharge
No change in nipple position reported initially

Systemic symptoms (screen for metastatic disease):

No bone pain
No cough or breathlessness
No headache, visual disturbance, or neurological symptoms
No jaundice, abdominal distension, or weight loss
No axillary swelling noticed

RISK FACTOR HISTORY

Risk Factor	Patient Details
Age	52 years - postmenopausal (increasing age = risk)
Menarche	Age 11 (early menarche)
Menopause	Age 52
Parity	Nulliparous (increases risk)
First pregnancy	Never
Breastfeeding	Never
HRT use	On HRT for 12 years (RR = 1.2 for use >10 years)
BMI	32 (obese; RR = 1.29 in postmenopausal women)
Alcohol	2 drinks/day (moderate drinking; RR = 1.32)
Family history	Mother had breast cancer at age 58
Prior breast biopsies	None
Radiation exposure	None

Summary: This patient has multiple risk factors - nulliparity, late menopause, prolonged HRT use, obesity, and family history. The majority of risk factors relate to prolonged oestrogenic exposure of the breast.

(Bailey and Love's Short Practice of Surgery, 28th Ed., p. 952)

EXAMINATION

General

Well-nourished, mildly anxious woman
No jaundice, pallor, or lymphadenopathy in the neck

Breast Examination (with patient sitting, then supine, arms raised)

Inspection:

Asymmetry of the right breast
Skin dimpling in the right upper outer quadrant
No peau d'orange (not inflammatory)
No nipple retraction or discharge
No skin ulceration

Palpation:

Right breast, upper outer quadrant: 3 x 2.5 cm hard, irregular mass
Ill-defined margins
Fixed to the overlying skin (causing dimpling) but mobile on the pectoralis major (no deep fixation at this point)
Contralateral breast: normal
Nipple: no discharge expressed

Axillary examination (right side):

Two palpable firm lymph nodes in the right axilla, mobile, non-matted

Supraclavicular fossa: No nodes palpable

TRIPLE ASSESSMENT

The gold-standard workup for a breast lump is triple assessment: clinical examination + imaging + tissue diagnosis. All three components must agree (concordance).

(Schwartz's Principles of Surgery, 11th Ed., p. 602)

1. Imaging

Mammography (first-line in women >35 years):

Right breast: spiculated mass with irregular margins in the upper outer quadrant
Microcalcifications within the mass
Skin tethering visible on cranio-caudal (CC) view
ACR BIRADS 5 (highly suspicious for malignancy)

Ultrasound (USG) breast:

Hypoechoic irregular mass, taller-than-wide orientation
Posterior acoustic shadowing
Disrupted tissue planes
Right axillary nodes: two nodes with loss of fatty hilum and cortical thickening - suspicious/malignant-appearing

MRI breast (indications here: dense breasts on mammogram, family history of BRCA):

Used to assess extent of disease, multifocality, and contralateral breast
Can reveal additional lesions not seen on standard imaging

(Schwartz's, p. 597-602)

2. Tissue Diagnosis

Core needle biopsy (preferred over FNAC):

Advantage: Provides tissue architecture - can distinguish invasive from in-situ disease
Allows receptor status (ER, PR, HER2) to be obtained pre-operatively
Performed under ultrasound guidance
14-gauge Tru-Cut needle or vacuum-assisted device (8-10 gauge)
A radiopaque clip is placed at the biopsy site

Result: Invasive ductal carcinoma (IDC) of no special type (NST)

Grade II (Elston-Ellis grading: tubule formation + nuclear pleomorphism + mitoses, total score 6-7)
ER positive, PR positive, HER2 negative, Ki-67 = 18%
Molecular subtype: Luminal B (ER/PR+, HER2-, Ki-67 high)

(Bailey and Love's, p. 953; Schwartz's, p. 543)

3. Staging

TNM (AJCC 8th Edition):

T2: tumour >2 cm but ≤5 cm (3 cm here)
N1: movable ipsilateral axillary nodes (2 nodes palpable)
M0: no distant metastasis

Clinical Stage: IIB (T2 N1 M0)

Metastatic workup (T2N1 - early disease, no symptoms):

No contrast CT or bone scan required unless symptomatic or raised alkaline phosphatase
If symptomatic: CT chest/abdomen/pelvis + isotope bone scan
PET-CT can be used in select cases for staging

(Bailey and Love's, p. 954)

Molecular subtypes table:

Subtype	HR	HER2	Ki-67
Luminal A	ER/PR+	Negative	Low
Luminal B	ER/PR+	Negative	High
HER2-enriched	Negative	Positive	High
Triple Negative (Basal)	Negative	Negative	High

(Bailey and Love's, p. 953)

MANAGEMENT

Surgical Options

Breast Conservation Surgery (BCS) vs Mastectomy:

This patient has a 3 cm tumour. BCS (wide local excision with 1 cm clear margins) is feasible.

BCS is contraindicated in:

Multicentric tumour
Diffuse microcalcifications on mammogram
Large tumour-to-breast ratio
Twice positive margins after re-excision
Prior breast/chest wall radiation
Collagen vascular disease (SLE, ankylosing spondylitis)

Assuming this patient has no contraindications: BCS + sentinel lymph node biopsy (SLNB) is appropriate.

Modified Radical Mastectomy (MRM) = mastectomy + level I, II, III axillary clearance - indicated if BCS is contraindicated or patient preference.

Skin/nipple-sparing mastectomy + reconstruction: option if mastectomy needed, tumour >1 cm from skin and >2 cm from nipple.

(Bailey and Love's, p. 958-959)

Axillary Management

SLNB first: injection of blue dye ± technetium-99m-labelled colloid to identify the sentinel node
If sentinel node positive: axillary lymph node dissection (ALND) or axillary radiotherapy
This patient has clinically suspicious axillary nodes - axillary USS + core biopsy of nodes before surgery; if confirmed positive, proceed to ALND

Adjuvant Treatment

1. Radiotherapy:

Mandatory after all BCS (BCS + RT = Breast Conservation Therapy, BCT)
Whole breast RT reduces local recurrence from ~30% to ~10%
Post-mastectomy RT (PMRT) indicated for T3/T4 tumours, ≥4 positive nodes, or positive margins

2. Adjuvant Chemotherapy:

Indicated for Luminal B (high Ki-67), node-positive disease
Regimen: Anthracycline-based (AC) ± taxane (e.g., AC x4 → T x4; or TC x4-6)
Can use Oncotype DX recurrence score to further refine chemotherapy decision in ER+/HER2-/N0 cases

3. Endocrine Therapy (Hormonal Therapy):

Patient is postmenopausal + ER/PR positive - indicated for 5-10 years
Aromatase inhibitor (AI) is preferred in postmenopausal women (Anastrozole / Letrozole / Exemestane)
Tamoxifen alternative (if AI not tolerated)
Extended therapy (up to 10 years) reduces late recurrence in high-risk cases

4. Targeted Therapy:

HER2 negative here - Trastuzumab (Herceptin) not indicated
CDK4/6 inhibitors (e.g., Ribociclib, Palbociclib) used in metastatic Luminal B disease

(Bailey and Love's, p. 960-961; Schwartz's, p. 607-610)

Neoadjuvant Chemotherapy (NACT)

Consider if:

Locally advanced disease (T3, T4 or N2, N3)
To downstage a large tumour and allow BCS
To assess chemosensitivity in vivo

After NACT, offer BCS or mastectomy based on response.

FOLLOW-UP

Clinical examination: every 3 months for 2 years, then every 6 months for 3 years, then yearly
Annual mammogram (both breasts)
Annual MRI if BRCA mutation carrier or implant in situ
Patients with new symptoms during follow-up require full re-evaluation

(Bailey and Love's, p. 960)

SUMMARY BOX

Feature	This Case
Age/Menopausal status	52, postmenopausal
Presentation	Painless lump + skin dimpling
Triple assessment	Spiculated mass + core biopsy: IDC-NST
Receptor status	ER+, PR+, HER2-, Ki-67 18%
Molecular subtype	Luminal B
Histological grade	Grade II
Stage	IIB (T2 N1 M0)
Surgery	BCS + SLNB (± ALND)
Adjuvant RT	Yes (mandatory post-BCS)
Adjuvant chemo	Yes (node-positive, Luminal B)
Endocrine therapy	Aromatase inhibitor x 5-10 years
Targeted therapy	Not indicated (HER2-)

Sources:

Bailey and Love's Short Practice of Surgery, 28th Edition, pp. 952-961
Schwartz's Principles of Surgery, 11th Edition, pp. 543-610

This is a shared conversation. Sign in to Orris to start your own chat.