葉 賢, 58y/o, female · 2017-07-21 · rare tumor subtypes cystosarcoma phyllodes angiosarcoma...
TRANSCRIPT
� 葉葉葉葉*賢賢賢賢, 58y/o, female
� Time of admission:97/05/26
� Source of admission: OPD
� Occpation: housewife
� Residence: Kaoshoung
Basic Data
Chief complaint
� an ill-defined mass in right upper quadrant breast
Present illness
� 96-01She first found right breast mass with mild yellow nipple discharge
� 96-07She didn’t go to see the doctor until last July because of increasing nipple discharge
� The patient visited LMD � excision was done, pathology report
revealed benign
Present illness
� A new palpable solid mass was noted in the right breast since last winter
� 長庚 Hospital (97-年初)� Mammogram
� suspected malignancy breast tumor
� 97-05-22 she visited Dr.吳’s OPD for second opinion
� nipple discharge(+),
skin eczema change(-)
tenderness(-), local heat(-)
Skin dimping (-), Nipple retraction (-)
Peau d'orange (-)
Present illness
� Dr.吳's OPD (97-05-22):
� PE:
� R't side breast mass with tenderness
� ill-defined, hard
� in upper outer quadrant
(9 o'clock, 2cm from areola)
� measured about 3cm x 2.5cm
Present illness
� Dr.吳's OPD (97-05-22):
� core needle biopsy :
� (97-05-24) Pathological proved of
infiltrating ductal carcinoma
at Rt breast
� Breast MRI with contrast
Personal History
� contraceptives use : (-)
� Late parity : (-)
� Menopause : 55 y/o
� Drug allergy:denied
� Food allergy:denied
� Smoking:denied
� Alcohol:denied
� Usual medication: nil
� Betel nut chewing:denied
� Social activity:active
� Life style:normal
Family History
� Breast ca(-), colon ca(-), ovarian ca(-)
� Lung cancer(+): her father
past History
� Medical history:Nil
� Surgical history:Nil
PE
� 90 Kg, 162 cm� Vital Signs:stable� clear consciousness, oriented, well-looking� HEENT: grossly normal, pink conjunctiva,
anicteric sclera� Chest: symmetrical expansion,
clear breathing sound� Heart: regular heart beat,
without murmur
PE
� Breast:
� Palpable Mass(+): 3*2.5*2 cm, hard, irregular surface, at right breast, (4cm from areola)
� nipple discharge(+), bloody discharge(-)
� Nipple retraction (-)
� tenderness(-)
� local heat(-)
� skin erythema(-),skin edema(-), nipple eczema(-), Skin dimping (-), Peau d'orange (-)
� Axillary LN (+/-)
PE
� Abdomen:
� soft and flat, OP scar(-)
� bowel sound:normoactive(+)
� RUQ pain(-), Murphy sign(-)
� palpable mass(-), tenderness(-)
� rebounding pain(-), shifting dullness(-)
� Back: knocking tenderness (-)
� Extremities: pitting edema(-)
取樣日期取樣日期取樣日期取樣日期 970527 970619
取樣時間 0955 1338
HBsAg results(0.0-2.0 S/N)
0.5 COI [0.0-1.0]
HBsAg (血液) Negative
Anti-HCV results[0-1.0 S/CO]
0.28 S/CO [0.00-1.00]
Anti-HCV (血液) Negative
CEA (血液) [<4.6 ng/ml] 1.24 ng/ml [<3.40]
CA125 (血液) [<35 U/ml]
8.34 U/ml [<35.00]
取樣日期取樣日期取樣日期取樣日期 970526
取樣時間 1109
Glucose(血液)1 [70-110 mg/dl]
106 mg/dl [55-110]
BUN (血液) [7-18 mg/dl] 15.3 mg/dl [6.0-20.0]
Creatinine(血)[0.5-1.3 mg/dl]
0.4 mg/dl [0.5-1.2]
GOT(血液) [0-40 IU/L] 21 IU/L [<37]
GPT (血液) [0-40 IU/L] 20 IU/L [<41]
Bilirubin T(血)[0.2-1.2 mg/dl]
Na (血液)[135-148 mEq/L]
139 mEq/L [136-145]
K (血液)[3.5-5.3 mEq/L] 3.6 mEq/L [3.5-5.1]
Cl (血液)[98-108 meq/L] 104 mEq/L [98-107]
取樣日期取樣日期取樣日期取樣日期 970526 970526
取樣時間 1109 1109
確認日期 970526 970526
確認時間 1156 1144
WBC [4.0-11.0 x10.e3/uL]
11.49 10^3/uL [4.00-11.00]
RBC [4.2-6.1 x10.e6/uL]
4.49 10^6/uL [4.20-6.10]
HGB [12-18 g/dL] 13.0 g/dL [12.0-
18.0]
HCT [37-52 %] 37.3 % [37.0-52.0]
MCV [80-99 fL] 83.1 fL [80.0-99.0]
MCH [26-34 pg] 29.0 pg [26.0-
34.0]
MCHC [31-37 g/dL]
34.9 g/dL [33.0-37.0]
RDW [11.5-14.5 %]
13.1 % [11.5-14.5]
PLT [130-400 x10.e3/uL]
274 x10^3 /uL [130-400]
MPV [7.2-11.1 fL] 10.00 fL [7.20-
11.10]
RDW-SD 39.3 fL
PDW 11.4 fL
%NEUT [40-74 %] 69.2 % [40.0-74.0]
%LYM [19-48 %] 25.9 % [19.0-48.0]
%MONO [2.0-10.0 %]
3.2 % [2.0-10.0]
%EOS [0-7 %] 1.4 % [0.0-7.0]
%BASO [0-1.5 %] 0.3 % [0.0-1.5]
Blood grouping (血液)
O
Rh type (血液) Positive
Bleeding time(血)
Mammography in 長庚 Hospital
R’t side breast outer quadrant ill-defined hyperdensity lesion about 3cmx2cm
Mammography in 長庚 Hospital
Breast Imaging Reporting And Data System (BIRADS): category V
97-05-22 Breast MRI(R’t breast)
Early phase subtraction
remarkable ill-defined heterogenous mass with high and iso-hyperintense mass(3.45x2.45x1.51cm) noted at lateral (9 'o'clock from nipple) of Rt breast
� There are two individual hyperintense spots noted inside the lesion, at Rt lateral aspect
Late phase subtraction
� Rapid of initial rise and wash out of delayed phases
� Highly suspect malignancy
� Non specific LN with preserved of hilar fat
97-05-26 Breast echo
97-05-26 Breast echo
(9,4), irregular heterogenous hypoechoic mass 32.0mmx19.0mmx32.3mm (BIRADS V)
Operation note
� OP date : 97-5-27
� OP method :
� R’t side Modified radical Mastectomy
� OP finding :
� Ill-defined hard mass
� LN(+)
� Clinical: T2N0M0 (IIA)
� Surgical: T2N1M0 (IIB)
Pathology 97-06-02
� Pathologic Staging (pTNM)
� Primary Tumor (pT): pT2: Tumor more than 2.0 cm but not more than 5.0 cm in greatest dimension
� Regional Lymph Nodes (pN): pN0: No regional lymph node metastasis histologically) (Specify: Number examined: 18 ; Number involved: 0 )
� Distant Metastasis (pM): pMX: Cannot be assessed
� Stage Groupings Stage IIA : p T2 pN0 MX
� Estrogen receptor (+)
� Progesterone receptor (+)
� HER-2/neu (-)
Clinical course
� 97-年初 長庚長庚長庚長庚HospitalMammography revealed malignancy
� 97-05-22 OPDcore needle biopsy, breast MRI
� 97-05-24 Pathological proved of invasive ductal carcinoma at Rt breast
� 97-05-26 admission, sono, CXR
� 97-05-27 operation (R’t side Modified radical Mastectomy)
� 97-06-02 Pathological proved of No regional lymph nodemetastasis
Differential & Diagnosis
� Fibrocystic change
� Fibroadenoma
� Phyllodes tumor(=Cystosarcoma phyllodes)
� Intraductal papilloma
Fibrocystic change
� Etiology
� more than 50 percent of women of reproductive age have fibrocystic changes
� imbalance between estrogen and progesterone
� Symptoms
� painful breast tissue before menses
� report improvement during menstruation
� Clinical
� fibrotic tissue may be palpated and is generally found in the upper outer quadrants of the breast
� cysts are more frequent in women in their 30s and 40s
� A nonbloody, green or brown nipple discharge may be present
Fibroadenoma(juvenile fibroadenomas)
� Etiology
� most common breast lesion in adolescents ( 20-25 y/o)
� Symptoms
� typically asymptomatic
� may cause discomfort for a few days before the onset of menses
� Clinical
� PE: rubbery, well circumscribed, and mobile
� average size is 2 to 3 cm (range 1 to 10 cm)
� most frequently found in the upper, outer quadrants
� recurrent or multiple in 10 to 25 percent of cases
� Ultrasonographic : reveals a solid avascular mass that is well circumscribed.
� Mammography is not indicated : because the large amount of glandular tissue present in adolescents
Fibroadenoma(juvenile fibroadenomas)
� All presumed fibroadenomas <5 cm can be safely observed with serial examinations.
� Most fibroadenomas decrease in size and some completely disappear with time
� Giant fibroadenoma
� Giant fibroadenomas grow rapidly to greater than 5 cm
� may compress or replace normal breast tissue
� Giant fibroadenomas should be excised because they cannot be easily distinguished from phyllodes tumors by physical examination, ultrasonography, or mammography
Phyllodes tumor
� Etiology
� rare primary tumor that typically occurs in older women(42 to 45)
� girls as young as 10 years of age
� Symptoms
� with a large breast mass that is usually painless
� skin may be shiny and stretched from rapid growth
� A bloody discharge may be present
� Clinical
� Ultrasonographic findings : suggest phyllodes tumors that include lobulations, a heterogeneous echo pattern, and an absence of microcalcifications
Phyllodes tumor
� most are benign(80~90%), but still have chance to be malignancy
� recommended treatment is excision
� criteria used for classification of benign versus malignant tumors
� The degree of stromal cellular atypia
� Mitotic activity (mitotic figure > 3/10 HPF )
� Infiltrative as compared to circumscribed tumor margins
� Presence or absence of stromal overgrowth (ie, presence of pure stroma devoid of epithelium)
Intraductal papilloma� Etiology
� rare benign breast tumor (1.2%)
� arising from proliferation of mammary duct epithelium
� typically presents in women between 20~40 y/o
� Symptoms
� clinical presentation : bloody nipple discharge, breast enlargement.
� bilateral in approximately one-fourth of patients
� Clinical
� PE: well-circumscribed nodules may be palpated under the areola or in the ducts at the periphery of the breast
� Cytology of the nipple discharge : demonstrates ductal cells, which differentiates it from fibrocystic disease
� Excision may be indicated to confirm the diagnosis and is curative
Final diagnosis
� PE
� Mammography
� core needle biopsy
� MR Image
� Sono
� Invasive ductal carcinoma
Discussion
Clinical
� Malignant masses
� Hard
� Painless : Malignant masses are painful in only 10-15% of patients.
� Irregular
� Possibly fixed to the skin or chest wall
� Skin dimpling
� Nipple retraction
� Bloody discharge
Risk factor
� Factors with relative risk greater than 4 � Advanced age
� Being born in North America or northern Europe
� High premenopausal blood insulinlike growth factor (IGF)–1 level
� High postmenopausal blood estrogen level
� History of mother and a sister with breast cancer
� Factors associated with a relative risk of 2-4 � High socioeconomic status
� Age at first full-term pregnancy older than 30 years
� History of cancer in one breast
� Any first-degree relative with a history of breast cancer
� History of a benign proliferative lesion, dysplastic mammographic changes, and a high dose of ionizing radiation to the chest
Risk factor
� Factors associated with a relative risk of 1.1-1.9 � Nulliparity
� Early menarche (age <11 y)
� Late menopause (age >55 y)
� Postmenopausal obesity
� High-fat diet/saturated fat–rich diet
� Residence in urban areas and northern United States
� White race - Older than 45 years
� Black race - Younger than 45 years
� History of endometrial or ovarian cancer
� Identified factors with a protective role against breast cancer
� Age at first period older than 15 years
� Breastfeeding for longer than 1 year
� Monounsaturated fat–rich diet
� Physical activity
� Premenopausal obesity
� breast cancer
Image study
� Ultrasonography� Mammography
� Screening mammography� Diagnostic mammography
� Computed tomography (CT scan)� Magnetic resonance imaging (MRI)� Positron emission tomography (PET scan)
� Others
Breast Imaging Reporting and Data System (BIRADS): Final Assessment Category
Category Definition
0 Incomplete assessment; need additional imaging evaluation
I Negative; routine mammography in 1 year recommended
II Benign finding; routine mammography in 1 year
recommended
III Probably benign finding; short-term follow up suggested
IV Suspicious abnormality; biopsy should be considered
V Highly suggestive of malignancy; appropriate action should
be taken
Diagnostic Procedures
� Fine-needle aspiration cytology
� Core needle biopsy
� Mammotome biopsy
� Open biopsy
� Excisional biopsy
� Incisional biopsy
� Wire/needle localization biopsy
Histologic Findings
� Ductal � Intraductal (in situ)
� Invasive with predominant intraductal component: Infiltrating or invasive ductal cancer is the most common breast cancer histologic type, comprising 70-80% of all cases
� Invasive, not otherwise specified
� Scirrhous
� Tubular
� Medullary with lymphocytic infiltrate
� Mucinous (colloid)
� Papillary
� Inflammatory
� Comedo
� Other
Histologic Findings
� Lobular � In situ
� Invasive with predominant in situ component
� Invasive
� Nipple � Paget disease, not otherwise specified
� Paget disease with intraductal carcinoma
� Paget disease with invasive ductal carcinoma
� Undifferentiated carcinoma
� Rare tumor subtypes� Cystosarcoma phyllodes
� Angiosarcoma
� Primary lymphoma
Staging of Breast CancerTNM definitions
� Primary tumor
� TX - Cannot be assessed
� T0 - No evidence of primary tumor
� Tis - Carcinoma in situ, intraductal carcinoma, LCIS, or Paget disease of the nipple with no associated tumor (Note: Paget disease associated with a tumor is classified according to the size of the tumor.)
� T1 - Tumor 2 cm or smaller in greatest dimension
� T1mic - Microinvasion 0.1 cm or less in greatest dimension
� T1a - Tumor larger than 0.1 cm but not larger than 0.5 cm in greatest dimension
� T1b - Tumor larger than 0.5 cm but not larger than 1 cm in greatest dimension
� T1c - Tumor larger than 1 cm but not larger than 2 cm in greatest dimension
� T2 - Tumor larger than 2 cm but not larger than 5 cm in greatest dimension
� T3 - Tumor larger than 5 cm in greatest dimension
� T4 - Tumor of any size with direct extension to (a) chest wall or (b) skin, only as described below (Note: Chest wall includes ribs, intercostal muscles, and serratus anterior muscle, but not pectoral muscle.)
� T4a - Extension to chest wall
� T4b - Edema (including peau d'orange) or ulceration of the skin of the breast or satellite skin nodules confined to the same breast
� T4c - Both of the above (T4a and T4b)
� T4d - Inflammatory carcinoma (Note: Inflammatory carcinoma is a clinicopathologic entity characterized by diffuse brawny induration of the skin of the breast with an erysipeloid edge, usually without an underlying palpable mass. Radiologically, a detectable mass and characteristic thickening of the skin may be present over the breast. This clinical presentation is due to tumor embolization of dermal lymphatics with engorgement of superficial capillaries.)
� Regional lymph nodes
� NX - Cannot be assessed (eg, previously removed)
� N0 - No regional lymph node metastasis
� N1 - Metastasis to movable ipsilateral axillary lymph node(s)
� N2 - Metastasis to ipsilateral axillary lymph node(s) fixed to each other or to other structures
� N3 - Metastasis to ipsilateral internal mammary lymph node(s)
� Pathologic classification
� pNX - Regional lymph nodes cannot be assessed (eg, not removed for pathologic study or removed previously)
� pN0 - No regional lymph node metastasis
� pN1 - Metastasis to movable ipsilateral axillary lymph node(s)
� pN1a - Only micrometastasis (none >0.2 cm)
� pN1b - Metastasis to lymph node(s), any larger than 0.2 cm
� pN1bi - Metastasis in 1-3 lymph nodes, any larger than 0.2 cm and all smaller than 2 cm in greatest dimension
� pN1bii - Metastasis to 4 or more lymph nodes, any larger than 0.2 cm and all smaller than 2 cm in greatest dimension
� pN1biii - Extension of tumor beyond the capsule of a lymph node metastasis, smaller than 2 cm in greatest dimension
� pN1biv - Metastasis to a lymph node 2 cm or larger in greatest dimension
� pN2 - Metastasis to ipsilateral axillary lymph node(s) fixed to each other or to other structures
� pN3 - Metastasis to ipsilateral internal mammary lymph node(s)
� Distant metastasis
� MX - Cannot be assessed
� M0 - No distant metastasis
� M1 - Distant metastasis present (includes metastasis to ipsilateral supraclavicular lymph nodes)
Stage 0 Tis N0 M0
Stage I T1* N0 M0
Stage IIA T0 N1 M0
T1* N1 M0
T2 N0 M0
Stage IIB T2 N1 M0
T3 N0 M0
Stage IIIA T0 N2 M0
T1* N2 M0
T2 N2 M0
T3 N1 M0
T3 N2 M0
Stage IIIB T4 N0 M0
T4 N1 M0
T4 N2 M0
Stage IIIC Any T N3 M0
Stage IV Any T Any N M1
Treatment
� Surgical Treatment for Breast Cancer
� Radical Mastectomy
� Modern Mastectomy
� Wide Local Excision and Primary Radiation Therapy (Conservative Breast Surgery)
� Sentinel Lymph Node Biopsy
� Total or simple mastectomy� Skin-sparing mastectomy
� Modified radical mastectomy
� Breast-conserving treatment (BCT)� Wide local excision
� Postsurgical radiation therapy
� Axillary nodes dissection
� Radiotherapy
� Adjuvant chemotherapy
� Adjuvant hormonal therapy
� Hormonal therapy
� Postmastectomy radiotherapy
Prognosis� The prognosis depending on the number of axillary
lymph nodes involved in patients who received adjuvant chemotherapy is as follows:
� With 0 positive nodes � Recurrence rate at 5 years - Approximately 20%
� Survival rate at 10 years - 65-80%
� With 1-3 positive nodes � Recurrence rate at 5 years - 30-40%
� Survival rate at 10 years - 35-65%
� With 4 positive nodes � Recurrence rate at 5 years - Approximately 44%
� Survival rate at 10 years - Not available
� With more than 4 positive nodes � Recurrence rate at 5 years - 54-82%
� Survival rate at 10 years - 13-24%
Prognosis
� tumor size is highly correlated with lymph node involvement and clinical outcome� Tumor smaller than 0.5 cm - Approximately 20%
� Tumor 0.5-0.9 cm - Approximately 20%
� Tumor 1-1.9 cm - 33%
� Tumor 2-2.9 cm - 45%
� Tumor 3-3.9 cm - 52%
� Tumor 4-4.9 cm - 60%
� Tumor larger than 5 cm - 70%
Prognosis� The 5-year survival rate based on tumor size and axillary
lymph node status is as follows
� Tumor smaller than 2 cm � Negative nodes - 96%
� One to 3 positive nodes - 87%
� Four or more positive nodes - 66%
� Tumor 2-5 cm � Negative nodes - 89%
� One to 3 positive nodes - 79%
� Four or more positive nodes - 58%
� Tumor larger than 5 cm � Negative nodes - 82%
� One to 3 positive nodes - 73%
� Four or more positive nodes - 45%
Prognosis� Cancers overexpressing HER2/neu are frequently poorly
differentiated and lymph node–positive
� HER2/neu overexpression correlates with more aggressive behavior and shortened disease-free survivaland overall survival rates
� EGF receptor familyOverexpression of the EGF receptor family is inversely correlated with ER positivity and is usually associated with a poor prognosis
� S-phaseA high S-phase indicates a rapid proliferation rate and is associated with a worse prognosis.
� DNA ploidy diploid tumors are usually associated with a good prognosis