SURGERY CASE 2 Rogelio, Graciella; Roque, Marianne; Ruanto, Teresa; Sabalvaro, Dyan Dr. Dakila Delos Angeles

Pink is pretty but breast cancer is not Pink is pretty but breast cancer is not! Prevention and NOT early detection is the best cure! Eliminate the cause and eradicate the disease! – Philippine Breast Cancer Network

A 45-year old female consults because of a L breast mass. A year PTC, she noticed a mass underneath the L nipple measuring initially at 1 X 1 cm. With progressive increase in the size of the mass, she comes for consult. On PE, the L breast has a 2 X 2 cm. hard, non-tender, & movable mass with irregular margins underneath the nipple. Axilla is negative for any masses. The R breast and the rest of the PE are normal.

45 y/o, F CC: Left breast mass

1 year PTC - mass underneath the L nipple measuring initially at 1 X 1 cm. PROGRESSIVE CONSULT

Physical Exam (+) L breast: 2x2 cm, hard, non-tender, movable mass with irregular margins underneath the nipple (-) axillary masses R breast – UNREMARKABLE Other systems – UNREMARKABLE

MISSING DATA Patient’s age of menarche Is the patient already in her menopausal stage? If yes, at what age did she have her menopause? - Because the female hormone estrogen stimulates breast cell growth, exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. - too early menarche (<12 y/o) or too late menopause (> 55 y/o) Radiation therapy to the chest – having radiation therapy to the chest area as a child or young adult as treatment for another cancer significantly increases breast cancer risk. The increase in risk seems to be highest if the radiation was given while the breasts were still developing (during the teen years). Sabiston Textbook of Surgery, 18th edition www.breastcancer.org

MISSING DATA Patient’s weight - being overweight is associated with increased risk of breast CA especially after menopause. Fat tissue is the body’s main source of estrogen after menopause, when the ovaries stopped producing the hormone. More fat tissue means having higher estrogen levels, increase risk of breast CA Was there a use or exposure of exogenous hormone? Any prolonged use of oral contraceptives? - Because the female hormone estrogen stimulates breast cell growth, exposure to estrogen over long periods of time, without any breaks, can increase the risk of breast cancer. Smoking history? Alcohol intake? - Alcohol can limit your liver’s ability to control blood levels of the hormone estrogen, which in turn can increase risk. Sabiston Textbook of Surgery, 18th edition www.breastcancer.org

MISSING DATA Obstetric history: Parity? Was she breast-feeding her child/children? FAMILY HISTORY: First degree relatives (mothers, sisters, and daughters) of patient with breast cancer? Distant relatives with breast cancer? When is the onset of breast cancer – premenopausal ? Bilateral breast cancer? The absolute risk of breast cancer is much higher for women who have inherited mutations in the genes known as BRCA1 or BRCA2. Sabiston Textbook of Surgery, 18th edition www.breastcancer.org

Left breast mass probably malignant WORKING DIAGNOSIS Left breast mass probably malignant

Progressing increase of the size of the mass hard, non-tender, & movable mass with irregular margins underneath the nipple On average, an individual woman has 1-in-8 chance of developing breast cancer over an 80-year lifespan The absolute risk of developing breast cancer during a particular decade of life is lower than 1 in 8. From age 40 to 49, absolute risk is 1 in 69, or 1.4% The absolute risk of developing breast cancer during a particular decade of life is lower than 1 in 8. The younger you are, the lower the risk. For example: From age 30 to 39, absolute risk is 1 in 233, or 0.43%. This means that 1 in 233 women in this age group can expect to develop breast cancer. Put another way, your odds of developing breast cancer if you are in this age range are 1 in 233. From age 40 to 49, absolute risk is 1 in 69, or 1.4%. From age 50 to 59, absolute risk is 1 in 38, or 2.6%. From age 60 to 69, absolute risk is 1 in 27, or 3.7%.

PHILIPPINE BREAST CANCER NETWORK FACTS FROM THE PHILIPPINE BREAST CANCER NETWORK Fact # 1 All women are at risk. Approximately 70% of breast cancers occur in women with none of the known risk factors.   Fact # 2 Only about 5% of breast cancers are inherited. About 80% of women diagnosed with breast cancer will be the first to be victims in their families. Fact # 3 Breast cancer is the leading killer of women ages 35 to 54 worldwide. More than a million women develop breast cancer without knowing it and almost 500,000 die from it every year.  http://www.pbcn.org/page5.html

PHILIPPINE BREAST CANCER NETWORK FACTS FROM THE PHILIPPINE BREAST CANCER NETWORK Fact # 4 One out of four who are diagnosed with breast cancer die within the first five years. No less than 40% die within ten years.   Fact # 5 The incidence of breast cancer has been rising for the past 30 years. And the supposed authorities and experts that should know, don't know why. Fact # 6 Risk factors are not necessarily causes of breast cancer. Enough evidence exist linking environmental pollution and contamination to cause breast cancer. Fact # 7 Mammography fails to detect as much as 20% of all breast cancer  and as much as 40% in women under the age of 50. http://www.pbcn.org/page5.html

PHILIPPINE BREAST CANCER NETWORK FACTS FROM THE PHILIPPINE BREAST CANCER NETWORK Fact # 8 Early detection does not prevent breast cancer. Avoiding and eliminating known causes will prevent breast cancer.   Fact # 9 One out of eight North American women will develop breast cancer. The San Francisco Bay Area has the highest incidence rate in the entire world. Fact # 10 The Philippines has the highest incidence rate of breast cancer in Asia and is today considered to have the 9th highest incidence rate in the world today. "The greatest risk of getting breast cancer tomorrow is being born today in a developing country. The greatest risk of not surviving breast cancer is being a woman in the Philippines." Rosa Francia-Meneses http://www.pbcn.org/page5.html

What is the clinical stage? Why?

N: Palpable Nodes M: Metastasis T: Tumor Size TX: Tumor cannot be assessed T0: No evidence of a tumor Tis: Cancer may be lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS) or Paget’s disease) T1: Tumor is 2 cm or less in diameter T2: Tumor is between 2 and 5 cm in diameter T3: Tumor is more than 5 cm in diameter T4: Tumor is any size, has attached itself to the chest wall and spread to the pectoral (chest) lymph nodes N: Palpable Nodes NX: Lymph nodes cannot be assessed (lymph nodes were previously removed, etc.) N0: Cancer has not spread to lymph nodes N1: Cancer has spread to the movable ipsilateral axillary lymph nodes (underarm lymph nodes on same side of breast cancer) N2: Cancer has spread to ipsilateral (same side of body as breast cancer) lymph nodes fixed to one another or to other structures under the arm N3: Cancer has spread to the ipsilateral mammary lymph nodes or the ipsilateral (same side of body as breast cancer) supraclavicular lymph nodes M: Metastasis MX: Metastatis cannot be assessed M0: No distant metastasis to other organs M1: Distant metastatis to other organs

5-YEAR RELATIVE SURVIVAL RATE (%) STAGE TNM 5-YEAR RELATIVE SURVIVAL RATE (%) Tis, N0, M0 100 I T1, N0, M0 IIA T0, N1, M1 92 T1, N1, M1 T2, N0, M0 IIB T2, N1, M0 81 T3, N0, M0 IIIA T0, N2, M0 67 T1, N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0 IIIB T4, N0, M0 54 T4, N1, M0 T4, N2, M0 IIIC Any T, N3, M0 IV Any T, any N, M1 20 Source: American Joint Commission on Cancer and International Union Against Cancer

If there is a palpable 2 x 2 cm hard L supraclavicular lymph node, what would be the stage? Why?

They connect the breast tissue to other parts of the body. These are the "highways" that carry fluid and blood around the body, bringing in nourishment and removing the waste products of cell life. They connect the breast tissue to other parts of the body. If cancer cells are found in the fluid within lymph channels or blood vessels, the cells may be filtered out and trapped in the lymph nodes. Having cancer cells invade the fluid channels of the breast increases the risk that cancer cells may have also traveled to areas beyond the breast.

N: Palpable Nodes M: Metastasis T: Tumor Size TX: Tumor cannot be assessed T0: No evidence of a tumor Tis: Cancer may be lobular carcinoma in situ (LCIS), ductal carcinoma in situ (DCIS) or Paget’s disease) T1: Tumor is 2 cm or less in diameter T2: Tumor is between 2 and 5 cm in diameter T3: Tumor is more than 5 cm in diameter T4: Tumor is any size, has attached itself to the chest wall and spread to the pectoral (chest) lymph nodes N: Palpable Nodes NX: Lymph nodes cannot be assessed (lymph nodes were previously removed, etc.) N0: Cancer has not spread to lymph nodes N1: Cancer has spread to the movable ipsilateral axillary lymph nodes (underarm lymph nodes on same side of breast cancer) N2: Cancer has spread to ipsilateral (same side of body as breast cancer) lymph nodes fixed to one another or to other structures under the arm N3: Cancer has spread to the ipsilateral mammary lymph nodes or the ipsilateral (same side of body as breast cancer) supraclavicular lymph nodes M: Metastasis MX: Metastatis cannot be assessed M0: No distant metastasis to other organs M1: Distant metastatis to other organs

5-YEAR RELATIVE SURVIVAL RATE (%) STAGE TNM 5-YEAR RELATIVE SURVIVAL RATE (%) Tis, N0, M0 100 I T1, N0, M0 IIA T0, N1, M1 92 T1, N1, M1 T2, N0, M0 IIB T2, N1, M0 81 T3, N0, M0 IIIA T0, N2, M0 67 T1, N2, M0 T2, N2, M0 T3, N1, M0 T3, N2, M0 IIIB T4, N0, M0 54 T4, N1, M0 T4, N2, M0 IIIC Any T, N3, M0 IV Any T, any N, M1 20 Source: American Joint Commission on Cancer and International Union Against Cancer