Breast masses, also commonly known as breast lumps, are common complaints by women visiting hospitals. This article focuses on a case where a female patient presented with a breast mass. The article will discuss the differential diagnosis, their epidemiology, and diagnostic tests. It will discuss the standard of care and treatment of carcinoma of the breast, which is the most likely diagnosis.
Mrs. Jennifer Clarke is a 62-year-old Caucasian female who was presented to the hospital with a breast mass. She is married with two children. She had menarche when she was 11 years old. She had her first pregnancy when she was 36 years old and has never had an abortion. She went through menopause when she was 57 years old. Her mother died of breast cancer at the age of seventy and her sister had breast fibroadenoma which was operated on one year before. She is clinically obese and has been undergoing postmenopausal hormone therapy for three years.
On examination, the lump was located below the nipple and close to the skin on the right breast. The lump was on the right breast, single, about 3-4 centimeters, was fixed to the skin, and tender, she said that the lump had been there for two weeks. She had trauma one year before when she hit against a closet.
She had nipple discharge without blood. She had supraclavicular lymphadenopathy with mobile but painful lymph nodes. The size of the breast was slightly larger than the contralateral breast. The nipple was inverted and the skin dimpled. She also complained of mastodynia. The contralateral breast does not have any mass.
Carcinoma of the Breast
The relevant patient findings for carcinoma of the breast include the positive risk factors which were numerous in this patient. The sex of the patient is female. Positive family history of breast cancer can be considered to be the biggest risk factor in this case. The patient is 62 years old which is close to the mean age of diagnosis of carcinoma of the breast (64 years). The patient reached menarche at the early age of eleven. She had her first live birth after 35 years of age.
She is white (Caucasian) and this is a risk factor. She was clinically obese and had been undergoing postmenopausal hormone therapy which is also a risk factor.
The positive pathophysiologic findings include the presence of the lump, with nipple discharge. The breast was tender. Its shape was altered and was larger than the contralateral breast. It was attached to the skin and was not mobile. She had supraclavicular lymphadenopathy which could be an indication of the spread of cancer. Her nipple is also retracted (Robbins & Cotran, 2007).
The most common etiology of fatty necrosis is trauma. Fatty necrosis becomes clinically apparent after 68.5 weeks, and the patient had trauma one year to the time of presentation. The patient experienced trauma when she was hit against a closet, which could have led to fatty necrosis.
The pathophysiologic findings include the presence of the mass, which in fatty necrosis could be single and could sometimes be indistinguishable from cancer. It is usually associated with pain and skin retraction. Nipple retraction is common like in this case. The lesion is fixed to the skin which could be also an indication.
Though rare, breast lymphomas are the most common metastatic tumors of the breast. The pathophysiologic findings in this patient include the enlargement of the breast, presence of the lump, pain, and swelling, skin lesion on the breast, and fluid around it (Kopans, 2007).
The commonest cause of death from cancer in women is breast cancer, with the rates varying worldwide, and the frequency of the disease is increasing even in areas where its rates were low before. The risk factors are linked to estrogen levels with the risk increasing in early menarche, menopause after 55 years of age, and in postmenopausal women.
Childbearing at an early age and more births has been shown to reduce the risk, where breastfeeding could be having a protective function. Oral contraceptives and postmenopausal hormone therapy increase the risk but slightly, and the risk disappears on discontinuation. Alcohol consumption and physical inactivity increase the risk for breast cancer. Mutations in a minority of the cases predispose the individuals to the disease.
The average age of diagnosis of fatty necrosis is fifty years in female patients. The incidence of this disease is approximated to be 0.6 percent in breast diseases which adds up to 2.75 percent of the non-malignant lesions. Breast tumors are associated with fatty necrosis in 0.8 percent. They occur 66.5 weeks after trauma, and they are found after breast reduction surgery in 1 percent of the cases.
Lymphomas of the breast that are primary are rarely seen and they comprise 1.7 to 2.2 percent of all extranodal lymphomas. They make up 0.38 to 0.7 percent of all non-Hodgkin lymphomas. Donna and Joan argued that lymphomas represent the largest number of metastatic tumors to the breast (Domnita and Joan, 1999).
Imaging is invaluable in the diagnosis of breast cancer. Mammography accompanied with ultrasound or an MRI constitutes the imaging. Abdominal ultrasound and a chest x-ray and a whole-body CT scan can also be done. The sensitivity and specificity of these procedures are not available.
These imaging modalities are followed by fine-needle aspiration cytological biopsy (FNAC). Ultrasound-guided FNAC produced 5-22 percent less insufficient aspirations in a study conducted by Houssami, Ciatto & Ambrogetti. Ultrasound-guided FNAC had 14.6 percent better sensitivity than freehand FNAC. Generally, the sensitivity and specificity for FNAC are high and Ultrasound-guided FNAC may not be necessary. Malignant cells are positive findings in cancer patients.
Fatty necrosis is diagnosed by FNAC mainly and it has a sensitivity of 87 percent and a specificity of 99 percent. This test is limited due to frequent collections of inadequate samples which could arise the need to repeat the procedure. Necrotic fat cells are found in positive cases. Core biopsy is another invasive procedure regarded to have more specificity and sensitivity. Imaging studies can also be done. They generally show opaque masses sometimes with calcifications. They include mammography, MRIs, and ultrasound. The sensitivity and specificity of imaging techniques are not available.
Breast lymphomas can also be diagnosed by imaging of the breast. The cost, sensitivity, and specificity of these procedures are not available. Complete Blood Counts are cheap tests of all types of lymphomas. Examination of lymphocytes is done to detect the presence of Reed-Sternberg cells which are found in Hodgkin lymphoma but not on Non-Hodgkin lymphoma. The background in Hodgkin lymphoma has reactive lymphocytes, granulocytes, and macrophages (Robbins & Cotran, 2007).
Standards of Care for Carcinoma of the Breast
Various criteria are used to ensure proper standards of care in breast cancer patients. The diagnostic tests should be scientifically sound so that they can be used consistently and they can be reliable and valid when used in different situations. The strategies used in care should be related to the national goal and represent a leverage goal in the measure, and show that the information provided is useful in health care and to individual patients.
The quality of care measures should have reasonable interpretability of the results of their use and the results obtained should be useful in making decisions and necessary actions in the management of the patient. The quality of care should be feasible in implementation such that the data obtained are available to other health care personnel conducting the management of the patient.
The quality of care should be adaptable, allowing it to be used in various situations. If these criteria are not met, the quality of the measures used could not be useful (Wong et al., 2002). These measures were obtained from “measuring the Quality of Breast Cancer in Women by Schachter, M. AHQR publication, October 2004.
Treatment of Carcinoma of the Breast
After cancer has been staged, the initial step in treatment that follows is to plan for therapy and find out which method gives the best chance for cure or, if it can’t be cured, the best chance for control. What can be termed as a gold standard treatment modality has to involve more than one type of treatment. Surgery usually plays a major role in this. Few cases of breast cancer like the late-stage may not require surgery. Small tumors are removed by lumpectomy while large ones usually require mastectomy for a better prognosis.
Radiation usually follows surgery as an adjuvant. It is invaluable especially when lymph nodes are involved like in this case, which indicates the presence of metastatic cells. This reduces the risk of recurrence. Neoadjuvant radiation is a type of radiation done before surgery. Brachytherapy may follow where a mambo site is placed in the cavity left after surgery.
Neoadjuvant chemotherapy is a form of chemotherapy given before surgery. This shrinks the mass as it slows down the disease process for easy excision. After surgery, adjuvant chemotherapy is usually instituted. This helps eliminate malignant cells in the circulation. HER2-positive tumors have been shown to respond well to trastuzumab. Hormone responsive tumors, positive for estrogen and progesterone receptors, are usually responsive to hormone therapy, and it should be done in these cases. Tamoxifen is given for the first five years and then followed by others like letrozole (Anon, 2002).
Second-line treatment may involve using only one modality in treatment or the use of alternative medicine.
Patient and Family Education
Patient and family education involves teaching them about the risk factors. Factors that can not be changed like age, sex, positive family history, age of onset of menarche, sometimes age of first birth, number of pregnancies, breast density, previous radiations, race, and past medical history should be taught to the patient so that awareness is increased about the disease. This together with teaching the patient the signs and symptoms of the disease goes a long way in making patients seek healthcare early before the disease is difficult to manage.
The patient and family should also be taught about modifiable risk factors like obesity (like the patient in this case), physical inactivity, alcohol consumption, and breastfeeding should also be taught so that they can be managed by the patient and subsequently reduce the chances of getting breast cancer (Anon, 2011).
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Tan et al. (2006). Fat necrosis of the breast – A review. The Breast Vol. 15. No. 1, pp. 313-318.
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