Part A: Describe the clinical presentation of the patient.
Madam Li is a 60-year-old lady whose chief complaint is a mass located in the right breast. The mass was discovered 6 months ago, and it steadily increased in size without fluctuation ever since. The lesion was painless and was associated with redness and occasional bleeding in the last 4 months. However, other changes such as nipple discharge or the presence of other lumps were not noticed by her. Madam Li also reported a loss of appetite and a 10-pound weight loss since a year ago, but she did not have any fever, bone pain or shortness of breath.
Regarding her gynaecological history, the age of menarche and menopause were 11 and 52 years old respectively. She is nulliparous, and she never took any oral contraceptive pills or hormone replacement therapy. The breast mass was her first episode, and she had no trauma, breast disease or breast investigations previously, including biopsy or mammogram. She had no previous exposure to high doses of ionising radiation.
Her other medical history includes hypertension and hyperlipidaemia, which are controlled by medication. She was hospitalised previously due to shingles last year, and tuberculosis infection when she was 22 years old. Currently, she is not taking any supplements or Chinese medicine and has no drug allergy. She has a negative family history of cancer, including breast and ovarian cancer. She is a non-smoker and a non-drinker, and she lives alone.
On inspection, there is a mass located in the upper inner quadrant of the right breast. There is erythema on the skin surface, although other skin changes including bleeding, peau d’orange, ulceration, or skin tethering are absent even after the patient raises her arms. The mass is more prominent after the patient tenses the pectoralis major, suggesting the mass is located superficial to the muscle layer. There are no visible nipple changes such as nipple discharge, retraction, discolouration or skin changes.
From palpation, there is no abnormality detected in the left breast. On the right breast, the mass is located at 2 o’clock position and 3cm away from the nipple. The mass measures 3cm by 2cm, and it is irregular oval shaped. There is no increase in warmth palpable, and the mass is non-tender. The surface and the border are irregular, and the consistency is stony hard. The mass is immobile even when the patient is relaxed, and it is fixed to the skin.
Examination of the axillary lymph nodes revealed a single mass, which is likely to be an enlarged lymph node, in the right axilla. The mass is located in the posterior group of lymph nodes, and it is smooth, hemispherical and measures 1cm x 1cm in size. The mass is non-tender, immobile, and the consistency is firm.
There are negative findings from the examination of supraclavicular and cervical lymph nodes, and there are no pleural effusion, bony tenderness or hepatomegaly that can be detected.
Part B: What are the possible causes for his/her complaints?
The characteristics of the mass, including irregularity, immobility, hardness, association with erythema, and increase in size over the past few months, suggest it is more likely to be a malignant lesion than a benign one. Hence, the top differential diagnosis is breast cancer. This is supported by the presence of loss of appetite and loss of weight, and positive breast cancer risk factors from her history, including her age, menarche before 12 years old, and no previous pregnancy. The diagnosis of breast cancer can also explain the axillary mass on the ipsilateral side, as it can be lymph node metastasis.
Although an irregular hard mass attached to the skin is highly suspicious of breast cancer, there are also other conditions that can present with similar features. For example, breast fat necrosis can present as a firm mass that is non-tender, irregularly shaped, and erythema of the skin over the lump. A negative history of a trauma preceding the onset of the lesion does not rule out fat necrosis completely, because the traumatic event may be unnoticeable to the patient, such as from wearing a seatbelt. However, the axillary mass is less likely to be caused by fat necrosis unless the patient had trauma to both the breast and axilla simultaneously.
Although rare, tuberculosis of the breast is another possibility, especially when Madam Li has a past history of tuberculosis, and the mass can be an extra-pulmonary presentation of a tuberculosis flare-up. The presentation of breast tuberculosis is usually a mass that is irregular, hard and fixed to the skin like breast carcinoma (1). Also, since breast tuberculosis is usually as a result of an extension from the axilla, this can also explain the axillary mass as well. However, this cause is not likely since breast tuberculosis usually affects young females, and is often painful, which does not match with Madam Li’s case.
Although all three differential diagnoses have similar presentations and match the presentation of Madam’s Li breast lump, further investigations can differentiate between the three causes. These include radiological assessment and histopathological assessment, which are part of the triple assessment.
Part C: Suppose the patient suffered from the top differential diagnosis (from part B), how would you manage this patient with the most up-to-date and best evidence-based approach?
The management of breast cancer depends on the Tumour, Node and Metastasis staging according to The AJCC 8th edition staging system, and they can be evaluated by completing the triple assessment. In addition, Madam Li has a suspicious axillary lymph node, and thus CT or PET scan and bone scan should be performed to determine whether there is any distant metastasis. Such staging system allows us to stratify the patients into three large groups with each group having a different management approach. The three groups are: early breast cancer (stages I, IIA or IIB (T2N1)); locally advanced breast cancer (stages IIB (T3N0), or IIIA to IIIc); and metastatic breast cancer (stage IV). In earlier stages the management is by curative intent, whereas for later staged cancer, palliative care is given. (2)
In Madam Li’s case, since she presented with breast lesion associated with a suspicious axillary mass, but without other symptoms or signs of distant metastasis, the patient most likely has non-inflammatory locally advanced breast cancer. The management of this group of patients can include neoadjuvant therapy, surgery, and adjuvant therapy. Neoadjuvant chemotherapy is usually recommended for locally advanced breast cancer, as it can shrink the size of a tumour, and thus allowing more patients to be eligible for more conservative surgery at the breast and axilla regions (3). However, for patients with a hormone-responsive tumour and contraindications for chemotherapy, neoadjuvant hormonal therapy is an alternative.
Surgical management of breast cancer is divided into breast and axillary surgery. For the breast, options include breast conserving therapy (breast conservation surgery with adjuvant radiotherapy) and mastectomy. Whereas for the axilla, this includes sentinel lymph node biopsy (SLNB) or axillary dissection. The selection depends on the patient and tumour factors, and the patient’s choice. For example, breast conservation surgery is less favourable if the patient has contraindications for radiotherapy, which is mandatory after breast conservation surgery; or if the tumour is multicentric, has characteristics of inflammatory breast cancer, or invades into the skin or muscle (4). Since the Madam Li’s breast mass is immobile and appears fixed to the skin, it may suggest there is an invasion into the skin and thus mastectomy is more appropriate. After the mastectomy, a breast reconstruction is an option which can improve her quality of life after the surgery (5). Regarding the axillary surgery, since the patient has a positive axilla lymph node that is a macrometastasis (>2mm), axillary dissection should be performed instead of SNLB, because axillary dissection is associated with improved survival and reduced axillary recurrence for macrometastasis (6).
Due to the presence of a positive axillary lymph node, adjuvant therapy can be considered if there are no contraindications, since they can reduce the recurrence rate and improve survival (7-9). The types of adjuvant therapy available include chemotherapy and radiotherapy (7), and if the cancer is positive for hormonal receptors or HER-2 receptor, then endocrine therapy and targeted therapy are recommended for Madam Li as well. For example, if the cancer is ER/PR positive, then the patient is eligible for hormonal therapy such as tamoxifen and aromatase inhibitors (8). If the cancer is HER2-positive, then targeted therapy such as Herceptin can be administered (9).
Part D: What is/are the interesting point(s) during the management of this patient?
There are two main reasons why I selected this case. First of all, breast cancer is the most common site for cancer in females, and the third most common cancer for both sexes in Hong Kong in 2015. Hence I wanted to take this opportunity to gain a deeper understanding of the clinical presentations and management of breast cancer.
Secondly, since the management for this patient was modified radical mastectomy with the breast reconstructed by a latissimus dorsi flap, it is an example of how treatment can improve not only the patients’ physical wellbeing, but also improve the social and mental well-being as well. The breast reconstruction surgery was important for the patient, since the breasts are one of the gender-defining characteristics, and she thought that the loss of one breast would be equivalent to a loss of part of her identity. Also, she feared that the disfiguring appearance from the mastectomy would be an obstacle for socialising, as people may discriminate against her appearance. Hence it is interesting to see how one surgical procedure can greatly improve the quality of life of a patient.