Question

CANCER CASE STUDY:
A routine mammogram showed a large mass in the right breast of Mrs. H., age 42. A biopsy confirmed the presence of a malignant tumor. Mrs. H. was concerned because her mother and aunt had breast cancer. No metastases were detected at this time. A mastectomy was performed and a number of axillary and mediastinal nodes were removed. Pathologic examination showed several nodes from each area contained malignant cells. Given this case was considered to be stage III, it was recommended that Mrs. H. have chemotherapy and radiation treatment following surgery and later have her ovaries removed to reduce her estrogen levels.

Case Study Questions

1. Differentiate malignant and benign tumors.
2. Evaluate how the biopsy was used in diagnosing the cancer.
3. Appraise additional signs and symptoms Mrs. H. may expect to experience should the tumor returns after treatment.
4. Examine the reasons for axillary lymph node dissection. Appraise why it was recommended that the patient continue with chemotherapy and radiation.
5. Differentiate the treatments the patient is receiving, including advantages, disadvantages and overall prognosis of each.

Answer 1

Benign tumors are encapsulated and remain localized to a body part and does not spread to other sites and are amenable to local surgical removal. Example: Adenoma, lipomas, hemangiomas.

Recurrence does not occur and has got a good prognosis.

Malignant tumors invade and destroy adjacent structures and spread to distant sites (metastasis). Example: Sarcoma, Squamous cell carcinoma, Adenocarcinoma, Lymphoma.

There is a tendency to reoccur even after treatment and prognosis can be poor.

Biopsy involves histologic examination of a piece of tissue from the suspected area by a pathologist. It is considered as definitive diagnosis for cancer. A biopsy will determine if the tissue is benign or malignant, the anatomic tissue from which the tumor has formed, and the degree of cellular differentiation of the cancer cells present in the tumor.

Signs & symptoms

The breast cancer can be identified by a lump during breast self-examination.

Nipple discharge, Nipple retraction can occur. In large cancer, infiltration, induration and dimpling or pulling in of the overlying skin can be noted.

Peau d’ orange appearance can occur due to plugging of the dermal lymphatics.

Assess for recurrence of cancer and signs of metastasis to other body parts.

Symptoms or warning signs of a cancer coming back (recurrence) can include:

· Changes in bowel or bladder habits.

· A sore that does not heal.

· Unusual bleeding or discharge.

· Thickening or lump in the breast or other parts of your body.

· Indigestion or difficulty swallowing.

· Noticeable change in a wart or mole.

· Nagging cough or hoarseness.

There are different types of cancer recurrence:

· Local recurrence means that the cancer has come back in the same place it first started.

· Regional recurrence means that the cancer has come back in the lymph nodes near the place it first started.

· Distant recurrence means the cancer has come back in another part of the body, some distance from where it started (often the lungs, liver, bone, or brain).

Axillary lymph node dissection is done to reduce the risk of metastasis. Metastasis primarily occurs through the lymphatic chains, principally from the axilla.

In this case, the pathologic examination of axillary and mediastinal nodes already showed malignant cells.

Chemotherapy and radiation is recommended to prevent distant metastasis and recurrence since the case was considered to be in stage 3, (local metastasis has occurred) based on the pathology report.

Treatment methods

Surgical therapy: it involves breast conservation surgery with axillary lymph node dissection or modified radical mastectomy. The advantage is it removes the cancer cells completely but causes body image disturbances, impaired arm mobility and need for prosthesis. Prognosis is good if combined with radiation and chemotherapy.

Removal of ovaries are advised later to reduce estrogen levels as it has the tendency to promote the growth of cancer cells.

Radiation therapy: is used to destroy the tumor as a companion to surgery. The major side effects that can occur with radiation therapy include fatigue, bone marrow suppression, skin reactions, mucosal reactions, and other systemic effects like pneumonitis, pericarditis, etc. Prognosis is good if combined with surgery.

Chemotherapy: involves the use of chemicals as a systemic therapy for cancer. Side effects include fatigue, anorexia, nausea and vomiting, bone marrow suppression, mucositis and hair loss. The major disadvantage is the body image disturbance that happens due to hair loss. Prognosis is good if combined with surgery.