A Multidisciplinary Approach in Management of Breast Cancer: Case Study and Literature Reviews

doi:10.4236/jct.2013.47A002

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Journal of Cancer Therapy, 2013, 4, 7-11

http://dx.doi.org/10.4236/jct.2013.47A002 Published Online August 2013 (http://www.scirp.org/journal/jct) 7

A Multidisciplinary Approach in Management of Breast

Cancer: Case Study and Literature Reviews

Andee Dzulkarnaen Zakaria*, Nur Farhana Abd Salam, Wan Zainira Wan Zain,

Mohd Nizam Hashim

School of Medical Sciences, Universiti Sains Malaysia, Kubang Kerian, Kelantan, Malaysia.

Email: *[email protected]

Received May 14th, 2013; revised June 16th, 2013; accepted June 24th, 2013

tion License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly

cited.

ABSTRACT

The diagnosis of breast cancer can cause a significant anxiety in someone’s life. The care of the breast cancer patient

requires in many centres. The care of breast cancer patient is undertaken as a joint venture between the surgeon, medical

oncologist, radiotherapist, pathologist and allied health professionals such as the clinical nurse specialist as well as

counsellors. This is a case of a 39-years-old Malay woman presen ted to HUSM with a history of ulcerating breast lump

with bloody pus discharge on the right breast. An initial mammogram study showed lesion suspicious of malignancy,

and histopathological examination was consistent with invasive ductal carcinoma. She received neoadjuvant chemo-

therapy before proceeding to right modified radical mastectomy with axillary clearance and immediate chest wall re-

construction. Detailed discussion on the diagnosis, treatment, surgical intervention and progress of the p atient with ref-

erence to available literature reviews are presented.

Keywords: Breast Cancer; Multidisciplinary Approach; Reconstructive Surgery

1. Introduction

A 39-years-old single, nulliparous Malay woman, came

to our institution with a complaint of right breast lump

since one year duration. She has no family history of

breast cancer and other malignancies such as ovarian,

endometrial and colorectal cancer. Her past medical his-

tory is unremarkable. She attained menarche at the age of

12. She was initially presented with a lump located at the

right upper outer quadrant, about the size of a peanut. It

was described as a single lump, round in shape and soft

in consistency. However, there were no complaints of

tenderness, skin changes on the breast area or any nipple

discharges. She only went to a tertiary centre as she felt

that the breast lump is getting slightly bigger around 4

months after the initial presentation. Several investiga-

tions were done for her, including mammogram study

(Figure 1). The initial analysis of the imaging study was

graded according to the Breast Imaging Reporting and

Data System (BIRADS) as BIRADS 4. The core biopsy

revealed an infiltrating ductal carcinoma (Figure 2) with

positive estrogen and progesterone (ER/PR). cERB was

found to be not overly-expressed.

The final diagnosis of breast cancer was revealed to

(a) (b)

Figure 1. Mammogram in (a) medio-lateral oblique (MLO)

and (b) cranio-caudal (CC) view showing lesions suspicious

of malignancy located at the upper outer quadrant of the

right breast. It was classifie d as BIRAD S 4.

*Corresponding a uthor.

A Multidisciplinary Approach in Management of Bre a st Cancer: Ca se Study and Literature Reviews

(a) (b)

Figure 2. (a) Sections showed fibrocollagenous tissue infil-

trated by malignant cells arranged mostly in cords and

strands. Tubular formation is more than 75%; (b) The cells

display mild to moderate pleomorphism with vesicular or

hyperchromatic nuclei. Mitoses are 7/10 in high power field.

Both (a) and (b) showed features consistent with infiltrating

ductal carcinoma.

her. She wa s given the option of sur gery how ever she did

not come for the follow up. Instead, she went to tradi-

tional healers; however, there was no history of manual

manipulation or massage done over the lump area. The

lump continued to grow progressively. About 3 months

prior to current admission, she started to experience an

intermittent throbbing pain over the lump area. Initially,

she was able to tolerate the pain. However, the pain be-

came progressively worse and started to affect her daily

activity.

A week prior to admission, bloody pus discharges

started to ooze out from the skin overlying the lump. The

discharge was yellowish in colour with streak of blood.

On top of that, the severity of the pain over the lump area

was becoming unbearable, and she finally went to the

emergency in our ce n tre for further treat ment.

2. Physical Examination

On examination, there was a 10.0 × 8.0 cm fungating,

ulcerating mass located mainly at the upper outer quad-

rant of the right breast (Figure 3). The shape was round

and the margin is regular with “sloping edge”. The floor

of the ulcer is yellowish in colour with contact bleeding.

Serous and bloody discharge was also seen and the dis-

charge was foul smelling. Peau d’ orange skin change

was observed. The nip ple-areolar complex was normal .

Lymph node examination revealed lymphadenopathy

at anterior axillary line. The characteristic of the lymph

node is single, round in shape, mobile, smooth surface,

regular margin with firm consistency. The size is at 2 × 3

cm.

The abdominal examination was normal with no or-

ganomegaly detected. Examination of other systems was

normal.

3. Investigations

Several blood investigations were done for this patient

including full blood count, blood urea and serum elec-

Figure 3. The fungating, ulcerous lesion is seen occupying

parts of the upper quadrant of the right breast. Peau d’

orange skin change can be observed. The nipple-areola com-

plex is normal.

trolyte, serum calcium and liver function test. The level

of white cell count, level of alkaline phosphatase (ALP)

as well as serum calcium was found to be elevated, how-

ever other results were normal.

Blood and swab culture was also performed and there

was no grow th so far.

Imaging studies such as X-ray and CT scan were also

done. The X-ray was normal with no evidence of metas-

tasis to the lungs. CT scan was also normal with no evi-

dence of distant metastasis to the vertebra and other or-

gans such as the liver (Figure 4).

4. Management

Her hydration was maintained by administration of in-

travenous fluids. Intravenous antibiotic was also pre-

scribed to cover infection in view of the raised white cell

count. IV Unasyn (Ampicillin and Sulbactam) 1.2 mg

was given three times Fentanyl patch 12.5 mg was also

given every 72 hours to reduce the pain. Daily dressing

was done with normal saline and Bactigrass dressing.

Patient was reviewed by the oncology team and neoad-

juvant therapy was planned. A combination of taxane-

based agent, adriamycin and anthracyclin dosage of 60

mg/ m2 (TAC) regimen was used. After 6 cycles of che-

motherapy was completed, she underwent right modified

radical mastectomy with axillary clearance and immedi-

ate chest wall reconstruction with unilateral pedicled

transverse rectus abdominis muscle (TRAM) (Figure

5).

5. Progress

After the operation, her condition is stable and she is

healing well. The skin flap over the defect area is viable

and healing well with no complications noted so far such

A Multidisciplinary Approach in Management of Bre a s t Cancer: Case Study and Literature Revi ews 9

(a)

(b)

Figure 4. (a) Plain CT scan (b) Contrast-enhanced CT scan

(CECT). Both showed no evidence of distant metastasis. The

breast mass can be clearly demonstrated in both images.

as infection and wound dehiscence. Upon discharge, she

is given appointment dates for follow up at our general

surgery as well as the oncology clinic.

6. Discussion

A study by A. Jemal et al. (2008) revealed that breast

cancer is the most common site-specific cancer in wo-

men and is the leading cause of death from cancer for

women aged 20 - 59 years. It accounts for 26% of all

newly diagnosed cancers in females and is responsible

for 15% of the cancer related deaths in women [1,2].

The risk factors for breast cancer may be divided into

several categories such as demographic, estrogen expo-

sure, lifestyle, personal breast characteristics, familial and

inherited genetic mutations, and radiation exposure. Risk

is generally grouped as minor and major. Minor risk fac-

tors increase a woman’s lifetime risk from 12% to ap-

proximately 15%. A woman’s age is the strongest risk

factor for breast cancer with 85% of women with breast

cancer was noted to be more than 40 years old [2,3].

Katz et al. stressed again that approximately 15% to

Figure 5. Patient few days after the operation. The flaps are

healing wel l wi th no complications observed.

20% of breast cancers are associated with a familial or

inherited risk. (Thus, 80% to 85% of women have no

significant familial risk factors.) By far the most common

is the mutations in the BRCA 1 and 2 genes. Less com-

mon include the Li-Fraumeni syndrome, associated with

the p53 gene, and Cowden syndrome, associated with the

PTEN gene [3,4].

There have been numerous classifications of breast

A Multidisciplinary Approach in Management of Bre a st Cancer: Ca se Study and Literature Reviews

carcinoma including histopathology classification, gene

profiling and receptors present and also clinical staging.

Based on histological classification, infiltrating ductal

carcinoma is the most common breast malignancy, ac-

counting for 75% of cases. Approximately 10% of infil-

trating ductal carcinomas are of a uniform histologic pic-

ture and are then classified as medullary, colloid, co-

medo, tubular, or papillary carcinomas [3,4].

In order to reach a final diagnosis, the triple assess-

ment method should be applied in any patient who pre-

sents with breast lump or other symptoms suspicious of

carcinoma. The triple assessment consists of clinical as-

sessment (history taking and physical examination), im-

aging studies as well as histopathology studies. This ap-

proach can increase the positive predictive value (PPV)

to exceed 99.9% [5].

In terms of treatment of cancer of the breast, the basic

principles are to reduce the chance of local recurrence

and the risk of metastatic spread. Treatment of early stage

of breast cancer will usually involve surgery with or

without radiotherapy. In an event where there are ad-

verse prognostic factors such as lymph node involvement

that increase the likelihood of metastatic relapse, sys-

temic therapy such as chemotherapy or hormone therapy

is added. At the other end of spectrum, locally advanced

or metastatic disease is usually treated by systemic ther-

apy to palliate symptoms, with surgery playing a much

smaller role as mentioned by Williams et al. [5].

Kaufmann, M. et al. stated that neoadjuvant chemo-

therapy (also called as primary systemic therapy or in-

duction therapy) is standard management for women who

have locally advanced or inflammatory breast cancer but

can be applied to all women who may require postopera-

tive chemotherapy for early-stage breast cancer. Dis-

ease-free survival and overall survival are equivalent

between patients treated with neoadjuvant chemotherapy

and patients treated with the same regimen postopera-

tively. There are various advantages that can be derived

from this approach. Preoperative chemotherapy can offer

women less morbid surgical treatment by down-staging

both the primary breast tumor and axillary metastases.

Finally, clinicians can be informed of the chemosensitiv-

ity of the tumor by looking at the response to chemo-

therapy, and can predict long-term outcome for women

who have br e ast cancer [ 6].

Kaufmann, M. et al. also stated that in terms of the

regimen of neoadjuvant, anthracycline-based regiment is

the most extensively studied regimen. The typical ap-

proach consists of at least four to six cycles of an an-

thracycline-based regimen, usually adriamycin and cy-

clophosphamide, with or without the addition of tax-

ane-based agents [6]. Several studies including by Bear,

H.D., et al. in 2003 have reported higher pathologic clini-

cal response rates and rates of BCS with the addition of

preoperative docetaxel. Nonetheless, taxane and anthrax-

cycline regimens appear to be the most successful [7].

Mastectomy is indicated in for large tumors, multifo-

cal disease, central tumors beneath or involving the nip-

ple, local recurrence or patient’s reference. The radical

Haslted mastectomy is no longer indicated as it caused

excessive morbidity with no survival benefit. The modi-

fied radical (Patey) mastectomy is more commonly per-

formed. The excised mass is composed of the whole

breast, a large portion of the skin, the centre which over-

lies the tumor but which always include the nipple, and

all the fat, fascia and lymph nodes of the axillary [5].

Few studies look at the psychological and social ad-

justments to mastectomy in 160 women, who were fol-

lowed at intervals of 3, 12, and 24 months after surgery.

One in four women was reported to be in a state of de-

pression and associated with marital and sexual problems

2 years after the initial therapy. The distress that comes

from mastectomy may be more pronounced in younger

women, as a result of significant treatment-related dis-

tress and changes in bod y image and sexuality during th e

course of the illness as observed by Fobair, P. et al. [8].

According to Nahabedian, M.Y., et al., patients under

50 years of age have a 4.3-fold greater likelihood of un-

dergoing mastectomy followed by breast reconstruction

than older patients [9]. The reasons behind this is de-

scribed by Peppercorn, J., et al., which include the desire

to achieve adequate breast cosmetic and symmetry, as

well as fear of recurrence due to the fact that breast tu-

mors in young women are more likely to be associated

with high-risk tumor features and poorer prognosis, and

tend to present with a more advanced stage at diagnosis

[10].

Petit, J.Y., et al. showed that immediate breast recon-

struction is now recognized as a safe procedure from the

oncological point of view and is able to offer a series of

advantages, such as better esthetic results compared with

delayed reconstruction, attenuation of the sense of muti-

lation deriving from the mastectomy and a reduction in

surgical times [11]. However, extra care must be taken

in-patient who needs post-operative radiotherapy. Studies

done by Kronovitz, S.J., et al. showed that there is two

main problems exist for performing immediate recon-

struction on patients who will then undergo RT. First, RT

can undo the esthetic result from immediate reconstruc-

tion due to impairment of wound healing process and

capsular contracture phenomena. Secondly, it can create

problem especially when planning and designing the ir-

radiation field. The slope of breast profile after recon-

struction and the non-uniform thickness of the thoracic

wall can cause under dosage radiation and non-homo-

genous of dose within the fields of radiation respectively

[12].

Nahabedian MY et al. emphasized that in 30% of cases,

A Multidisciplinary Approach in Management of Bre a s t Cancer: Case Study and Literature Revi ews

particularly following RT, reconstruction with autologous

tissue is to be preferred [9]. The main myocutaneous

flaps used in breast reconstruction are the transverse rec-

tus abdominis myocutaneous (TRAM) flap introduced by

Hartrampf in 1982 and used both as a pedicle flap or free

(anastomosis between the inferior epigastric artery and

the thoracodorsal artery, subscapular or internal breast),

combined with or without prosthesis [9,13,14].

Pedicle TRAM flap uses abdominal muscle, fat and

skin tissue vascularized by the rectus muscle pedicle to

reconstruct the breast mound. Grossly, in the pedicle

TRAM ﬂap, excess skin, subcutaneous fat and rectus

muscle from the infraumbilical area are transferred

through a subcutaneous tunnel to the ipsilateral or con-

tralateral mastectomy site. The ﬂap is then rotated,

shaped into a breast mound, and sutured; the umbilicus

and the abdominal skin are sutured into its new position

and the abdomen skin is sutured as in an abdominoplasty.

Despite the loss of muscle function after a pedicle TRAM

ﬂap harvest, it is still possible for patients to become

pregnant and carry a pregnancy to term, as well as to

achieve a normal vaginal delivery [15] .

Similar with our patient that in the free TRAM ﬂap the

skin, subcutaneous fat, deep inferior epigastric artery, and

a small portion of the rectus muscle and fascia from the

infraumbilical area are transferred to the chest defect,

were epigastric vessels are reattached to either thora-

codorsal or internal thoracic vessels via microsurgery.

This technique allows the relocation of larger amounts of

tissue with a lesser risk of fat necrosis. Hence, it may be a

better procedure in patients with risk factors such as

smoking, diabetes mellitus, and obesity [15].

7. Conclusion

Multidisciplinary approach is paramount and effective in

breast cancer management. Despite the life changing di-

agnosis of breast cancer, reconstructive surgery opens an

avenue of possibility to encourage surgery when needed,

and improves the qua lity of life, physically and mentally.

8. Consent

Informed consent obtained from patient.

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