Case Study: It's a Lump, but is it Breast Cancer?

[EDNURSE20, BSN]

Reasons for breast lumps are essentially any hormonal changes like menopause, pregnancy, contraception, Breast feeding or periods. 

Non cancerous lumps could be cysts, lipoma or fibrocystic changes  

signs of cancer I picked up on, other than the lump, are family hx, the pt age and early onset of mensuration. I’m sure there are more. 

for the examination:

- as for the breast themselves, no pain or nipple changes but is there a rash? Or any change to size/shape?

- I would do a pregnancy testing, unlikely but to rule it out

- menopause is more likely, regular menses? Hot flashes? Wt gain? Mood changes? 

- bloods, fbc, crp, fsh, tsh, u+e’s, hb1ac, lipids

- mammogram. 

Considering the pt age and family hx alone, I would be concerned about breast ca. But I feel like for a case study this is to obvious. 

[Workitinurfava, BSN, RN]

She should start getting mammograms due to her family history.

[mom_e_bizcut, LPN]

How about the physical exam? Is the lump soft and pliable, can it be moved around? A mammogram will most certainly be ordered either way, but if the lump is hard and immovable it may be a more immediate appointment or they could possibly do an ultrasound right there depending on the resources available at the office. Any recent illness or allergic reactions? Blood work may be needed as well assuming standard tests prior to test for change in BRCA1 or BRCA2 genes, but with family history I guess that could be an earlier option.

[SafetyNurse1968, ADN, BSN, MSN, PhD]

Thank you so much for your questions and comments! Here is the first update:

Finding a lump in your breast can be frightening — but although breast cancer is the most common cancer found in women, most breast lumps are not cancer. In fact, more than 80 percent of them end up being benign

Breast lumps can be caused by:

• Breast cancer
• Breast cysts (fluid-filled sacs in breast tissue that are usually benign)
• Fibroadenoma (a solid, benign mass most common in young women)
• Fibrocystic breasts (lumpy or rope-like breast tissue)
• Galactocele (a milk-filled cyst that's usually harmless)
• Injury or trauma to the breast
• Intraductal papilloma (a benign, wartlike growth in a milk duct)
• Lipoma (a slow-growing, doughy mass that's usually harmless)
• Mastitis (an infection in breast tissue that most commonly affects women who are breast-feeding)

Risk Factors

Most breast cancers are found in women 50 years or older. Most of us have some risk factors, but most women don’t get breast cancer. Risk factors include getting older, early menstruation and menopause after age 55

Other risk factors for breast cancer:

• close relatives who were diagnosed with breast cancer before the age of 45 – especially if more than one relative was diagnosed
• changes in BRCA1 and BRCA 2 genes
• Ashkenazi Jewish heritage
• radiation therapy to the breast or chest during childhood
• history of breast cancer or other health problems like in situ carcinomas, atypical ductal hyperplasia or atypical lobular hyperplasia
• dense breasts on a mammogram
• lack of physical activity, being overweight or obese after menopause, taking hormones, first pregnancy after 30, not breastfeeding, never having a full-term pregnancy, drinking alcohol and smoking

Review of Systems: only abnormal values presented

Lymph nodes/neck: one movable, firm, non-tender axillary lymph node of approximately 1.5 cm palpated under left arm

Breast exam:

• Symmetric breasts
• No dimpling or erosion of skin, no nipple retraction or discharge, no erythema, discoloration or swelling
• Multiple, diffuse, small (0.4-1.2 cm) mobile, apparently cystic lesions palpable throughout both breasts.
• One 2 cm mass palpated in upper outer quadrant of left breast, mass is firm and not fixed to the chest wall and is not tender to the touch.

Vital signs:

• BP 136/85 sitting, RA
• HR 70
• RR 15
• T 98.3oF
• HT 5’ 6”
• WT 135 lbs

Laboratory Test Results:

• Na 139 meg/L (135-145)
• K 4.1 meq/L (3.5-5)
• Cl 107 (101-112)
• HCO3 24 mg/dL (22-32)
• BUN 9 mg/dL (8-20)
• Cr 1.0 mg/dL (0.6-1.2)
• Glu fasting 88 mg/dL (60-110)
• Hb 14.3 g/dL females (12-15.5)
• Hct 37.5% females (35-45%)
• Plt 420,000 cu/mm (150,000-450,000)
• WBC 8.0 x 103/mm3 (4,800- 10,800)
• Neutros 60% (57-67)
• Lymphs 31% (25-33)
• Eos 3% (1-4)
• Monos 6% (3-7)
• AST 38 IU/L (0-35)
• ALT 30 IU/L (7-56)
• Alk phos 97 IU/L
• Albumin 4.0 g/dL (3.4-4.7)

Bilateral mammogram:  There were three 1.0-1.5 cm masses distributed diffusely throughout the right breast and four 0.5-1,0 cm masses in the left breast. There also was a 2.1 cm x 3.0 cm x 3.1 cm mass with irregular borders within the upper outer quadrant of the left breast. Associated with the suspicious lesion was diffuse skin thickening and an enlarged axillary lymph node of approximately 1.5 cm. Seven Y-shaped microcalcifications extending to the nipple were seen in the left breast. There is some evidence of extension of the abnormal mass into the pectoral muscle.

 

Can you identify at least six clinical manifestations that might support a diagnosis of breast cancer?

[SafetyNurse1968, ADN, BSN, MSN, PhD]

Diagnosis:

Core-needle biopsy of large left breast mass: pathology consistent with invasive ductal carcinoma (infiltrating breast carcinoma), tubules observed in 85% of sample, 3-5 cell divisions in high-power observation with mild pleomorphism, tumor positive for estrogen and progesterone receptors.

Ultrasound of left breast and axilla: four cystic lesions in the left breast, solid-appearing, non-cystic mass consistent with cancer in upper outer quadrant, ill-defined mass with abnormal vascularity, the mass measures the same as with the mammogram (2,1x3x3.1 cm), there is some suggestion of skin thickening and mild tissue edema.

Ultrasound of liver: clear

Bone scan: no definitive evidence of bone metastasis, positive for mild degenerative changes consistent with degenerative joint disease.

Invasive ductal carcinoma (IDC), also known as infiltrating ductal carcinoma, is cancer that began growing in a milk duct and has invaded the fibrous or fatty tissue of the breast outside of the duct. IDC is the most common form of breast cancer, representing 80 percent of all breast cancer diagnoses.

As with any breast cancer, there may be no signs or symptoms

Make an appointment to have a breast lump evaluated if:

• The lump feels firm or fixed
• The lump doesn't go away after four to six weeks
• You notice skin changes on your breast, such as redness, crusting, dimpling or puckering
• You have discharge, possibly bloody, from your nipple
• Your nipple is turned inward and isn't normally positioned that way
• You can feel a lump in your armpit and it seems to be getting bigger
• Thickening of the breast skin
• Swelling in one breast
• New pain in one particular location of a breast
• Changes in the appearance of the nipple or breast that are different from the normal monthly changes a woman experiences

Now that you know the patient has IDC – what’s next?

Clinical course: The oncologist met with the patient and together they decided on breast conservation therapy/lumpectomy with sentinel lymph node biopsy, radiation and chemotherapy. The nodes were negative and surgical margins were clear. After radiation treatment, the patient was placed on tamoxifen. She will have follow-up appointments every 3-4 months for the first two years and then every 6 months for the next three years, then annually.

For more information on options for treating IDC, check out https://www.breastcancer.org/symptoms/types/idc/treatment

Treatments for invasive ductal carcinoma (IDC) include surgery, chemotherapy, radiation therapy, hormonal therapy, and targeted therapy.

Surgery is used to treat IDC not only to remove the breast tumor itself, but also to confirm whether or not cancer is in the lymph nodes. Surgery is considered a local treatment because it treats just the tumor and surrounding area. A lumpectomy removes only the tumor (the “lump”) and some of the normal tissue that surrounds it.

In a Sentinel lymph node biopsy, the surgeon looks for the very first lymph node — the “sentinel node” — that filters fluid draining away from the area of the breast that contains the cancer. If cancer cells are breaking away from the tumor and traveling away from your breast through the lymph system, the sentinel lymph node is more likely than other lymph nodes to contain cancer. The surgeon uses a special radioactive substance or dye to identify that first node and the couple of nodes where it drains. These nodes are then removed and sent for examination by a pathologist. If the lymph nodes are cancer-free, no further surgery is necessary. If cancer is found, then more lymph nodes in the armpit need to be removed, either now or at a later date.

Radiation therapy is most often recommended after surgeries that conserve healthy breast tissue, such as lumpectomy and partial mastectomy.

If the IDC is larger than 1 centimeter in diameter and/or has spread to the lymph nodes, chemotherapy is usually recommended or, at the very least, seriously considered. When chemotherapy is given after surgery, it is called “adjuvant therapy.” In cases where the tumor is large, or breast cancer cells have traveled to many lymph nodes or other parts of the body, chemotherapy may be given before surgery to shrink the cancer. This approach is called “neoadjuvant therapy.” In either case, chemotherapy will be given in cycles, usually with a day (or days) of treatment followed by a period of “off” days. The exact schedule can vary depending on the medication or medications used. An entire course of chemotherapy usually takes about 3 to 6 months.

Hormonal therapy for IDC is recommended if the cancer tested positive for hormone receptors, Hormonal therapy, also called anti-estrogen therapy or endocrine therapy, works by lowering the amount of estrogen in the body or blocking the estrogen from signaling breast cancer cells to grow. For small tumors, it’s common for hormonal therapy (adjuvant treatment) to be given after other treatments. Tamoxifen acts like estrogen and attaches to the receptors on the breast cancer cells, taking the place of real estrogen. As a result, the cells don’t receive the signal to grow. Tamoxifen can be used to treat both pre- and postmenopausal women. Other examples of SERMs are Evista (chemical name: raloxifene) and Fareston (chemical name: toremifene).

 

References

Breast lumps https://www.mayoclinic.org/symptoms/breast-lumps/basics/causes/sym-20050619

Invasive ductal carcinoma https://www.hopkinsmedicine.org/breast_center/breast_cancers_other_conditions/invasive_ductal_carcinoma.html

Risk factors for Breast Cancer at a Young Age https://www.CDC.gov/cancer/breast/young_women/bringyourbrave/breast_cancer_young_women/risk_factors.htm?s_cid=byb_sem_013

Treatment for IDC https://www.breastcancer.org/symptoms/types/idc/treatment

 

[allnurses Admin Team]

THANK YOU, @SafetyNurse1968. Great Case Study!!

Here are the responses from members who came to the Admin Help Desk  for the 10th Case Study Investigation (CSI).

 

spotangel

Questions

What are the possible reasons for this lump?

The lump can be benign or cancerous.

It could be breast cancer, breast cyst or a Fibroadenoma

Is it just another cyst?

Could be or not. A cyst  is fluid filled painless and movable. Need further tests to r/o cancer.

How many reasons for breast lumps can you come up with off the top of your head?

Infection/ Abcess

Trauma

Fibroadenoma

Sebaceous cyst

Fibrocystic breast

Fat necrosis and lipoma

Intraductal papilomas

How many risk factors for breast cancer can you spot?

Age

Hereditary predisposition

Family history of breast cancer mother and grand mother

Infrequent breast exams and mammograms

What labs do you want?

BRCA 1 & 2, Baseline labs CBC, BMP,PT/PTT,TYPE AND SCREEN, LFT

What other diagnostic tests should we run?

Breast ultrasound,digital mammogram,manual physical exam and breast exam by a provider, MRI if required

Based on the exam, tests and results a clearer picture will emerge on if this is cancer or not.

 

mom_e_bizcuit

Clinical signs: 1.) lump is firm 2.) irregular 3.) surrounding skin tissue hardening 4.) lump extends to muscle 5.) Platelets on the higher side??? Considered WBC being in upper normal but probably not that so I don't have a 6th one ?

 

?COMING SOON: CSI installment #11?