Mrs. M is an 85-year-old lady who presented to AE of Hairmyres Hospital on 1/10/08 after being referred by her GP for a suspected advanced breast malignancy and a one week's history of low back pain with increasing severity.
She first noticed a lump on the lower outer quadrant of her right breast about a year ago. It was painless and measured approximately 2cm in diameter. She ignored the lump as it did not give her any troubles. Gradually, erythematous skin changes began to form surrounding the lump. With time, the lump progressively increased in size and was not mobile. She declined having any other lumps or local symptoms like skin itch and eczematous changes.
Later, she began to notice discharge from her right nipple which stained her shirt red. Despite all these presentations, she kept it away from her family and everyone else for fear that it might be cancerous. She admitted to self-medication where she had been applying mepore (to absorb leaking fluid from her nipple) and sudocream. Lately, she said that her right nipple had begun to leak foul smelling fluid which was dark in colour and the skin surrounding the lump turned greenish yellow. Recently, she decided to disclose her breast problems during a consultation with her GP for an increasingly aggravating lower back pain.
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The new onset back pain was mainly localised to the lumbar region and was sharp in nature. Upon admission, she said the pain was quite severe scoring 8/10. There was no radiation, any associated muscle weakness or numbness. It was worse on getting up, straightening her back, walking and exertion like coughing. It was slightly eased by lying down. No injuries were noted. She declined having any urinary symptoms but was constipated the last few days prior to admission. She did not complain of any haematuria or PR bleed. She also did not notice any weight loss or change in appetite, rather felt that she had gained some weight possibly due to steroid inhalers for her COPD.
Past Medical History
Chronic obstructive pulmonary disease (COPD) - diagnosed 5 years ago.
Past fracture of lumbar spine (2004)
No significant family history.
No known drug allergy.
Adcal Vit D3
1 Tab, Oral
Twice daily, 2 puffs each
4 times daily
4 times daily
Widowed 15 years ago. Husband died of prostate carcinoma.
Has 2 children who both live in Glasgow.
She lives alone in a double storey house and is finding it more difficult to climb the stairs lately due to her aggravating osteoporosis.
Came from a heavily smoking family and started smoking since she was about 20 years old. Smokes about 10-15 cigarettes a day.
None to note.
None to note. No previous anginal pain.
Slight dyspnoea and wheeze.
None to note.
None to note. No fevers or rigors
None to note.
Very mild pain on her lower back (controlled by analgesias given)
Appeared dyspnoeic (catched her breath from time to time during the interview)
Alert and non-lethargic
Apyrexial (Temperature - 37.1 0C)
Bruised over dorsal surface of both hands (due to repeated venepunctures)
Overweight (BMI - 28.5)
Asymmetry of breasts (Right breast more elevated)
Visible skin changes on the lower outer quadrant of her right breast
Green-yellowish lesion with central puckered skin
Surrounding erythema and satellite erythematous lesion
Spreading into axilla and upper border of right hypochondrium
No nipple retraction
Dark coloured fluid is seen discharging from the right nipple.
Always on Time
Marked to Standard
Supraclavicular and infraclavicular nodes
Lump palpable on lower outer quadrant of right breast localised at site of skin changes. Diameter about 5cm.Hard, craggy, non-fluctuant and immobile.
No other lumps palpable and no lumps could be detected on left breast.
Right axillary nodes palpable most notably on medial aspect of right axillary wall.
None palpable on the left.
Palpable right supraclavicular nodes. Firm and immobile.
Examination of Mrs. M's lumbar spine elicited abnormalities.
Kyphotic posture. Due to lumbar vertebrae fracture, gait is not tested in Mrs. M.
Tenderness over L2-L3.
Decreased flexion and extension of lumbar spine
When hip flexed, pain increase in lumbar spine region.
No other neurological deficit elicited.
No peripheral cyanosis, warm hands
No finger clubbing/ no visible tar stains
No flapping tremor
No central cyanosis (tongue normal colour)
Symmetrical movement of chest wall with respiration
No accessory muscles used in respiration
No visible scars
Central, no tracheal tug
Supraclavicular lymph nodes
Lymphadenopathy on right supraclavicular area
Normal tactile vocal fremitus
Resonant to percussion
Presence of cardiac and liver dullness
Scattered wheeze throughout both lungs
Coarse crackles, more notably on the lung bases.
Hands and nails
Fragile skin (due to aging) with bruises from venepunctures.
No generalised skin pigmentation of haemosiderin
Not jaundiced and non-pallor
No palmar erythema / Non-pallor palmar creases / No dupuytren's contracture /
No finger clubbing, leuconychia, koilonychia
No Kayser-Fleischer rings (brownish green rings)
No xanthelasma or corneal arcus
Good oral hygiene
No glossitis or angular stomatitis or ulceration
No spider naevi
No scars but striae visible
No visible engorged veins or visible peristalsis or arterial pulsation
No caput medusae/ No Cullen's (blue discolouration of umbilicus)/ No Grey-Turner's sign (blue discolouration of flank)
Symmetrical movement of the abdomen with respiration
No enlarged supraclavicular lymph node
No tenderness or guarding
No abnormal masses or organomegaly
Soft, regular liver edge, not enlarged or tender, non-pulsatile
Normal liver span (<13 cm)
No dullness on complete expiration (no splenomegaly)
Absence of shifting dullness (no ascites)
Bowel sounds reduced
135/ 80 mmHg
(regular, normal volume, no rebounding/collapsing pulse)
Hands and nails
Face and tongue
Back of chest
Warm, absence of peripheral cyanosis
No finger clubbing/ splinter haemorrhages/ Osler's nodes/ Janeway's lesions.
No conjunctival pallor
No central arcus or xanthelasma
No central cyanosis
No visible scars or pulsations
Absence of sacral oedema
No pitting oedema
Jugular venous pressure
Not Raised (< 5 cm)
No thrills or left parasternal heave
No murmurs heard
Crackles heard over lung bases
Nothing to note on motor and sensory examination.
MMSE: not carried out.
Cranial nerves intact.
Normal tone throughout upper and lower limbs.
Grade 5 power throughout upper and lower limbs.
Reflexes present throughout upper and lower limbs.
Summary of Problems
1. Advanced fungating breast cancer - Over the past one year, Mrs. M has hidden a fungating lesion on her right breast which was discharging blood stained fluid from her nipple and recently became foul-smelling. Due to lack of awareness compounded with fear, she now presents with an advanced breast malignancy.
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2. Crush fracture of lumbar vertebrae - She presented with a new onset lower back pain with a duration of one week. Given a history of osteoporosis and past fracture of her lumbar spine, it is not known at present if the new fracture is due to an exacerbation of her vertebral osteoporosis or a metastastatic complication of breast carcinoma.
Differentials of clinical breast findings
a) Breast lump:
Breast carcinoma, metastasis to breast from other primary sites, intraductal papilloma
Benign breast disease (e.g. fibroadenomas, cysts, mastitis)
Haematoma, thrombophlebitis, galactocoele
b) Breast skin thickening:
Inflammatory breast CA
In relation to Mrs. M's case, she presented with a right breast lump, surrounding skin changes (erythema and fungating greenish-yellow appearance) and foul-smelling, bloody discharge from her nipple which all point towards a high likelihood of breast carcinoma.
Differentials for Mrs. M's back pain in the lumbar region
Osteoporotic lumbar crush fracture
Metastatic bone disease from breast CA
Non-specific low back pain
Lumbar disc degeneration
Lumbar facet arthropathy, spondylolysis, spondylolisthesis
Benign / malignant primary and neural osseous tumors
Extraspinal causes (eg, ovarian cyst, pancreatitis, ulcer)
Infection (eg, epidural abscesses, peritonitis) â†’ unlikely as Mrs. M was not pyrexic or appeared to be in shock
Aortic aneurysm â†’ likely in the elderly but Mrs. M does not have any pulsating abdominal mass
Aseptic necrosis of the femoral head
Renal infection or stone
Relevant Investigations and Results:
Fasting blood glucose
Lumbar Spine X-ray
Multiple crush fracture
CT chest/ abdomen/ pelvis
Fungating lesion on right breast(Lower outer quadrant) -extending medially (41mm) and laterally (10mm).
One 12 mm chest and right axillary node.
Several tiny nodules on both lungs (Largest on right middle lobe 3-4 mm, the rests <2mm).
No mediastinal lymphadenopathy.
Abdomen and pelvis grossly normal.
Probable osteoporotic collapse (L2-L4)
Core Biopsy of right fungating breast CA (Clinically P5)
Oestrogen and progesterone receptors - >90% of tumour cell nuclei strongly +ve
Allred score 5+3 = 8
Invasive CA (poorly differentiated ductal CA)
No in-situ CA
No vascular invasion
Core biopsy B5b
Initial Treatment of Acute Problems:
Provide adequate analgesia
Perform routine bloods, ECG, CXR and lumbar spine X-ray (to determine if there is lumbar fracture)
Perform CT scan of chest, abdomen and pelvis
Perform core biopsy of right breast lesion
Perform bone scan to determine if there are focal hot spots indicating bony mets from primary breast CA
Further Management Option:
Physiotherapy / Occupational Therapy assessment
Give low molecular weight heparin to prevent DVT from restricted mobility due to lumbar spine fracture
Conservative management of lumbar spine fracture (pain relief, bracing and rehabilitation). Consider thoraco-abdominal-sacral orthosis. Early mobilization is important to prevent secondary complications of immobility.
Core biopsy confirmed invasive ductal carcinoma - Discuss management options with patient. Address to Mrs. M' s fears of a cancer diagnosis.
Breast cancer is the commonest cancer in women. 
Breast lumps can be classified into:
Aberrations of normal development and involution
Benign neoplasms - e.g. fibroadenoma (most common).
Malignant neoplasms -non-invasive and invasive malignant tumours.
Prognostic Factors 
Following surgery, a number of prognostic factors determines outcome and plan adjuvant therapy.
Type of tumour
Tumour grade - well differentiated (Grade I) do better than poorly differentiated (Grade III)
Axillary lymph node status - 1 node +ve (80% survival at 5 years); 4 nodes +ve (50% survival at 5 years)
Presence or absence of lymphovascular invasion
Hormone receptor status - ER+ve have better prognosis and responds to tamoxifen.
Factors 2-4 combine to form the Nottingham Prognostic Index (NPI): 
NPI = 0.2 x size (cm) + grade + nodal status
NPI Score 10 Year Survival
2.41 - 5.4 50% to 85%
Pathologically, breast carcinomas are divided into 2 main types:
Non-invasive / Carcinoma in-situ
Malignant cells remain within basement membrane.
Ductal carcinoma in situ (DCIS)
Lobular carcinoma in situ (LCIS)
Paget's disease of nipple
Malignant cells extend beyond basement membrane.
Invasive ductal carcinoma
Invasive lobular carcinoma
Mucinous / colloid
Classical presentation may include the following where breast asymmetry is the commonest.
Adapted from Ref 
Signs and symptoms
Nodular, irregular, immobile and non-fluctuant with menstrual cycle are normally malignant.
Skin tethering or dimpling due to fixation to overlying skin or underlying pectoral muscle.
Peau d' orange - swollen, pitted skin overlying breast CA due to lymphatic obstruction.
Nipple eczema - Paget's
Due to contraction of intramammary ligament (Cooper's)
Non-cyclical breast pain
Late stage presentation.
Bone - pathological fractures
Liver- jaundice, hepatosplenomegaly
Lungs - dyspnoea, pleural effusion
Comparison of the Patient's Presentation to Classical Presentation:
Mrs. M presented with a hard, immobile lump on the lower outer quadrant of her right breast (measuring about 5 cm now). There are visible skin changes surrounding the lump which are typical of advanced breast cancer i.e. erythema and fungating greenish-yellow appearance. She also complained of bloody nipple discharge which is purulent and foul-smelling indicating that the intraductal lesion is undergoing inflammatory changes. In summary, Mrs.M's presentation is classical of advanced fungating breast carcinoma. It is little wonder that she does not experience any breast pain as only 2.7% of patients with mastalgia have cancer. (1)
How this case relates to the GMC themes in 'Tomorrow's Doctors':
Theme 2: Treatment & Theme 11: The Individual In Society
The diagnosis of discrete breast lumps is based on triple assessment:
1) Clinical examination - palpation
2) Radiological imaging
Mammography in older patients (above age 35).
Ultrasound in younger patients (below age 35) due to dense breast tissues.
MRI useful in symptomatic patients with breast implants.
3) Biopsy, usually ultrasound guided
Fine needle aspiration cytology (FNAC)
Core biopsy - provides histological diagnosis and distinguished between invasive and in-situ carcinoma.
Repeat core biopsy
Benign (definite lesion)
Reassure unless radial scar
Suspicious or atypical
Repeat core or open biopsy
Concern whether sample is adequate
Lesions adequately sampled
Investigation of a breast mass : Adapted from Ref (1)
The principles of management are:
Control disease in affected areas
Prevent and treat local disease in early breast CA
Control metastatic disease
a) Breast conserving surgery - involves lumpectomy (WLE), quadrantectomy, or segmental mastectomy with or without axillary dissection and adjuvant radiation therapy.
Fisher et al found that this is as effective as mastectomy for small operable breast cancer.
b) Radical (Halsted) mastectomy
Removal of entire breast used to be the preferred in the past combined with axillary clearance +/- breast reconstruction.
c) Surgery to axilla
Axillary node status is most important prognostic indicator in treatment of invasive breast CA.
Axillary sampling - involves removal of a minimum of 4 nodes for histology. If any of the 4 nodes are +ve, further treatment either axillary clearance or radiotherapy is required.
Axillary clearance - currently, level II dissection is performed where nodes up to axillary vein and beneath pec minor are removed. This results in more breast lymphoedema.
Sentinel lymph node biopsy (SNLB) - first lymph node draining the cancer field is identified, excised and examined for metastatic involvement. This prevents extensive axillary surgery if no node involvement found.
d) Breast reconstruction
Either done during mastectomy or delayed to a later date.Typical reconstructions use latissimus dorsi or rectus abdominis, augmented where necessary with silicone implant.
Adjuvant Systemic Therapy
Reduces risk of relapse by 30-40%.  The choice of therapy depends on NPI.
a) Adjuvant chemotherapy - currently used for most pre-menopausal with high-grade tumours, axillary spread and hormone receptor -ve, but without evident distant mets. 
Most widely used regimen is CMF (cyclophosphamide, methotrexate, 5-fluorouracil).
The effect of chemotherapy on advanced fungating breast tumours has been widely studied, and generally, it has been found to be effective for reducing the tumour size and healing the fungating wound. 
b) Adjuvant hormonal therapy
Tamoxifen (oestrogen receptor blocker) reduces recurrence by 25%/ year and mortality by 17%. Tamoxifen is most helpful in node +ve and ER+ve women and is recommended for 5 years.
In post-menopausal women, aromatase inhibitors (anastrozole, letrozole and exemestane) and progestogens (megestrol) can be used.
Humanised monoclonal antibody trastuzumab, raised against HER-2, increases rate and duration of response of patients with metastatic disease (HER-2 +ve) when combined with chemo.
d) Adjuvant radiotherapy
Following WLE, radiotherapy significantly reduced recurrence within the breast. Recent studies shown that pre-menopausal women receiving adjuvant chemotherapy, post-mastectomy radiotherapy may also improve survival. 
In metastatic or advanced breast cancer, primary aim is palliation either by hormonal or chemotherapy.
Mrs. M presents with an advanced fungating invasive ductal carcinoma which further reduces her treatment options. However, she should still be allowed to make active decisions about her treatment. With an ER+ve tumour from core biopsy, she may be a candidate for hormone therapy. The best adjuvant treatment option for her can be more accurately determined by NPI which is only possible post-operatively. Given her advance age and pre-existing COPD, surgery is a definite contraindication. Therefore, it is most important that Mrs. M is provided with adequate information about all the available options for her case and her decision given the utmost respect.