Case Report on Breast ca - PowerPoint

Document Sample
Case Report on Breast ca - PowerPoint Powered By Docstoc
					A CASE ON

Advanced Breast Adenocarcinoma

THE PATIENT

Clinical Abstract

GENERAL DATA M.S., 65 y/o female, married, Catholic, Filipino, retired government employee, born on April 24, 1941, currently residing at San Pedro, Laguna, was admitted for the first time at Asian Hospital and Medical Center on June 13, 2006.

CHIEF COMPLAINT Enlarging mass at the right breast

Clinical Abstract HISTORY OF PRESENT ILLNESS 1 ½ years PTC • Circular mass at the right breast, 1 cm x 1 cm • Not painful or troublesome • No note of any nipple discharge or skin dimpling • No consult was done 1 month PTC • Mass enlarged, now 10 cm x 8 cm • It is hard, fixed, and irregular • Breast assymmetry

Clinical Abstract
PAST MEDICAL HISTORY 1999, had hysterectomy at PGH OB/GYNE HISTORY Menarche at age 12, Menopause at age 55 FAMILY HISTORY (-) Family hx of HPN, DM, PTB, breast cancer PERSONAL SOCIAL HISTORY Non-smoker, Non-alcoholic beverage drinker

Clinical Abstract

REVIEW OF SYSTEMS (+) malaise, (+) joint pain

PHYSICAL EXAM (+) Palpable axillary lymph nodes at the right axilla (+) Palpable mass at the right breast, 10 cm x 8 cm, hard, fixed and irregular

Diagnostic Procedures

MAMMOGRAPHY Clusters of microcalcifications Breast asymmetry Irregular areas of increased density FINE NEEDLE ASPIRATION BIOPSY (FNAB) Atypical Ductal Hyperplasia
MODIFIED RADICAL MASTECTOMY (MRM) Invasive Ductal Carcinoma, 10 cm x 8 cm, T4N1M0 (Stage IIIB)

Laboratory Workup
ESTROGEN RECEPTOR (ER) TEST 80% 3+ Positive

COMPLETE BLOOD COUNT (unremarkable) BLOOD CHEMISTRY (unremarkable)

Definitive Diagnosis

Invasive Ductal Carcinoma, 10 cm x 8 cm, T4N1M0 (Stage IIIB)

OVERVIEW OF BREAST CANCER

Breast Cancer
• Malignant proliferation of epithelial cells lining the ducts and lobules of the breast.

LOBULES

DUCTS

Breast Cancer
• Most common cause of cancer in women

• Hormone dependent disease • Female to male ratio - 150:1 • Risk factors 1. Early menarche (≤ 12 y/o) 2. Late menopause (> 52 y/o) 3. Late first full term pregnancy (>30 y/o) 4. Inherited gene abnormalities (BRCA-1, BRCA-2)

Breast Cancer
• Types

1. Ductal Carcinoma In Situ (DCIS) 2. Lobular Carcinoma In Situ (LCIS) 3. Invasive Ductal Carcinoma (IDC) 4. Invasive Lobular carcinoma (ILC) • Benign mass: firm,rubbery,frequently painful, mobile • Malignant mass: painless, hard, irregular, fixed

Breast Cancer
• Staging Stage 0 Stage 1
Stage IIA

TIS N0 M0 T1 N0 M0
T0 N1 M0 T1 N1 M0 T2 N0 M0

Stage IIIA

T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1/N2 M0 T4 AnyN M0 AnyT N3 M0 AnyT AnyN M1

Stage IIIB

Stage IIB

T2 N1 M0 T3 N0 M0

Stage IV

Breast Cancer

PRIMARY TREATMENT  SURGERY Lumpectomy Simple Mastectomy Modified Radical Mastectomy Radical Mastectomy

Breast Cancer
ADJUVANT THERAPY
 RADIOTHERAPY

 CHEMOTHERAPY 1. Alkylators - damages proteins that control growth in the genes of the tumor cells 2. Antimetabolites – acts as false buildings blocks in the cancer cell’s genes 3. Antibiotics – include potent inhibitor of gene replication 4. Antimiotic agents – rob cellular genes of the ability to reproduce themselves during division 5. Antimicrotubules – Interfere with cell structure and cell division

Breast Cancer
 HORMONAL THERAPY 1. Aromatase Inhibitors – reduce the amount of estrogen produced 2. SERMs – block estrogen receptors in the cancer cells 3. ERDs – destroy the estrogen receptors in the cancer cells 4. Ovarian shutdown – addresses the fact that the ovaries are the major source of estrogen  IMMUNE THERAPY – Appropriate only for women with advanced breast cancer who have a particular cancer gene called HER2/neu that is being overexpressed

ADJUVANT THERAPY FOR THE PATIENT

Pertinent Findings in the Patient
Clinical • Breast mass at the right breast, 10 cm x 8 cm • Mass is hard, fixed, and irregular

Physical Examination • Palpable axillary lymph nodes, right side

Pertinent Findings in the Patient
Diagnostic

• Invasive Ductal Carcinoma, T4N1M0 (Stage IIIB) • Estrogen Receptor 80%, 3+, positive Personal History • Patient is postmenopausal • Patient had hysterectomy • Patient has arthritis

TABLE 1: Suggested Approach to Adjuvant Therapy
Age Group LN Status ER Status Tumor Recommendation

Premenopausal
Premenopausal

(+)
(-)

Any
Any

Any
>2 cm, or 1-2 cm with other poor prognostic variables

Multidrug chemo + Tamoxifen if ER(+)
Multidrug chemo + Tamoxifen if ER(+)

Postmenopausal Postmenopausal

(+) (+) (-) (-)

(-) (+) (+) (-)

Any Any

Multidrug chemotherapy Hormonal therapy with or without chemotherapy Hormonal therapy

Postmenopausal

>2 cm, or 1-2 cm with other poor prognostic variables >2 cm, or 1-2 cm with other poor prognostic variables

Postmenopausal

Consider multidrug chemotherapy

Why add chemo?

“It has been usual to give chemotherapy to postmenopausal patients who have no medical contraindications and who have more than one positive lymph node. Tamoxifen is given subsequently.” (Harrison)

TABLE 2: Most commonly used Chemotherapy Drugs
Drugs

CYCLOPHOSPHAMIDE
(Cyclophar)

METHOTREXATE
(Pfizer Methotrexate)

FLUOROURACIL (5-FU)
(K.U. Fluorouracil)
600 mg/m2, IV Antimetabolite; inhibits nucleotide and nucleic acid synthesis by acting as false building blocks in cancer cells’ genes, causing it to die as it gets ready to divide

DOXORUBICIN
(Doxorubicin meiji)

Dose MOA

100 mg/m2/d, PO Alkylator; damages proteins that control growth in the genes of the tumor cells

40 mg/m2, IV Antimetabolite; inhibits nucleotide and nucleic acid synthesis by acting as false building blocks in cancer cells’ genes, causing it to die as it gets ready to divide

60 mg/m2, IV Antibiotic; potent inhibitor of gene replication

TABLE 2: Most commonly used Chemotherapy Drugs
(continuation)
Drugs

CYCLOPHOSPHAMIDE
(Cyclophar)

METHOTREXATE
(Pfizer

FLUOROURACIL (5-FU)
(K.U.
Fluorouracil)

DOXORUBICIN
(Doxorubicin meiji)

Methotrexate)

ContraIndication/s

Severe myelosuppression

Pregnancy; severe renal or hepatic disorders

Pregnancy; lactation

Myelosuppression, stomatitis, pregnancy; lactation Hepatic and cardiac failure, elderly

Precautions

WBC count should be controlled during treatment and performed once a week every two weeks

Infection, peptic ulcer, ulcerative colitis, debility, extreme youth or old age

Poor nutritional state, severe surgical pus, hepatic impairment, history of heart disease, pregnancy, monitor hepatic function

TABLE 2: Most commonly used Chemotherapy Drugs
(continuation)
Drugs

CYCLOPHOS PHAMIDE
(Cyclophar)

METHOTREXATE
(Pfizer

FLUOROURACIL (5-FU)
(K.U. Fluorouracil) Nausea, vomiting, stomatitis, leucopenia, anemia, thrombocytopenia, alopecia

DOXORUBICIN
(Doxorubicin meiji)

Methotrexate)

Adverse Reactions

GI upsets and alopecia, bone marrow damage

Leucopenia, thrombocytopenia, mouth ulceration, diarrhea, stomatitis, liver & kidney damage, osteoporosis, pulmo & neuro rxns, GI upsets Effects enhanced by PABA, chlorampenicol, phenytoin, probenecid, salicylates, sulfoamides, tetracyclines; Fatal toxicities with NSAIDS

Alopecia, stomatitis, myelosuppressio, GI disorders, palpitation, arrhythmia, buring sensation in the mouth Cardiac toxicity may be enhanced by cyclophosphamid e-induced cystitis

Drug Interactions

May potentiate hypoglycemic effects of sulfonylureas, allupurinol, suxamethonium

Bone marrow depressing cytostatic agents

TABLE 3: Most commonly used Adjuvant Chemotherapy Regimens for Breast Cancer
Regimen Dose Schedule Cycle Interval (days) Cycles

CMF (standard) Cyclophosphamide Methotrexate 5-Fluorouracil CMF (for node-negative px) Cyclophosphamide Methotrexate 5-Fluorouracil CAF Cyclophosphamide Doxorubicin (Adriamycin) 5-Fluorouracil

100 mg/m2/d, PO 40 mg/m2, IV 600 mg/m2, IV

For 14 days Days 1 and 8 Days 1 and 8

28 28 28

6 6 6

600 mg/m2, IV 40 mg/m2, IV 600 mg/m2, IV

Day 1 Day 1 Days 1 and 8

21 21 21

12 12 12

100 mg/m2/d, PO 30 mg/m2, IV 500 mg/m2, IV

For 14 days Days 1 and 8 Days 1 and 8

28 28 28

6 6 6

ALGORITHM: Suggested Approach to Hormonal Therapy
Patient Estrogen Receptor (-) Estrogen Receptor (+)

No benefit from hormonal therapy

Pre-menopausal

Post-menopausal

Invasive Cancer

Noninvasive Cancer

Invasive Cancer

Noninvasive Cancer

Stage I, Stage II
TAMOXIFEN

Stage III, Stage IV
TAMOXIFEN
OR OVARIAN SHUTDOWN

Stages I,II,III
TAMOXIFEN TAMOXIFEN
OR LETROZOLE

Stage IV (Metastatic)
TAMOXIFEN OR LETROZOLE/ ANASTROZOLE/ EXEMESTANE OR FULVESTRANT TAMOXIFEN

TABLE 4: TAMOXIFEN (GYNATAM) vs. LETROZOLE (FEMARA)
Drug
Dose Contraindications

Tamoxifen (Gynatam)
20 mg daily, PO Pregnancy

Letrozole (Femara)
2.5 mg daily, PO Premenopausal endocrine status, Pregnancy, Lactation

Precautions

Leucopenia Thrombocytopenia Increased risk of uterine cancer (‹1% of women) Increased risk of blood clots and cataracts (‹1% of women) Increased risk of stroke (‹1% of women) Fertility issues 20 mg x 100’s (P 4,000)

Creatinine clearance of ‹10ml/min Severe hepatic impairment Bone loss, osteoporosis Increase cholesterol level Increased risk of blood clots Upset stomach and sweating Joint and muscle pain, aggravate arthritis

Side Effects

Cost

2.5 mg x 30’s (P 9,617.15)

S.A.N.E. CRITERIA
CHEMOTHERAPY
Drug Safety Affordability Necessity Efficacy Total

CMF CAF

+++ ++

+++ +

+++ +++

+++ +++

12 9

HORMONAL THERAPY
Drug Safety Affordability Necessity Efficacy Total

Tamoxifen
Letrozole

+++
++

+++
+

++++
++++

+++
+++

13
10

COMPUTATIONS
CYCLOPHOSPHAMIDE Patient’s weight = 54 kg Patient’s height = 157 cm Body surface area = 153 m2

RD: 100 mg/m2/d SD: 50 mg tablet

100 mg/m2 m2 = ht (cm) x wt (kg) 3600

x

1.53 m2

50 mg

= 3 tablets/day

COMPUTATIONS
METHOTREXATE FLUOROURACIL

RD: 40 mg/m2 SD: 50 mg/2 ml vial

RD: 600 mg/m2 SD: 250 mg/5 ml ampule

40 mg/m2

x

1.53 m2

600 mg/m2

x

1.53 m2

50 mg

250 mg

= 1 vial/day

= 3 ampules/day

Take Note… • CMF is given in 6 cycles with a 28-day interval every cycle • Minimum duration of treatment with Tamoxifen is 5 years • Start treatment with Tamoxifen after completing the chemotherapy course

PRESCRIPTION
JERNELYN P. RELOJ, MD General Practitioner Ospital ng Maynila MW 8-10 am 18 June 2006 Patient: M.S. Address: San Pedro, Laguna Age: 65 Sex: F

Rx Cyclophosphamide 50 mg tab (Cyclophar) # 42
Sig: Take 3 tablets orally once a day for 14 days Warning: May cause GI upsets, hair loss Refill: On next visit after 28 days

Lic No 985476 PTR No 70011

PRESCRIPTION
JERNELYN P. RELOJ, MD General Practitioner Ospital ng Maynila MW 8-10 am 18 June 2006 Patient: M.S. Address: San Pedro, Laguna Age: 65 Sex: F

Rx
Methotrexate 50 mg/2 ml vial (Pfizer) #2 Sig: Infuse 1 vial intravenously on day 1 and another vial on day 8 ANST. Warning: May cause nausea, vomiting, headache, drowsiness, blurred vision Refill: On next visit after 28 days
Lic No 985476 PTR No 70011

PRESCRIPTION
JERNELYN P. RELOJ, MD General Practitioner Ospital ng Maynila MW 8-10 am
18 June 2006 Patient: M.S. Address: San Pedro, Laguna Age: 65 Sex: F

Rx
Fluorouracil 250 mg/5 ml ampule (KU Fluorouracil) #6
Sig: Infuse 3 ampules intravenously on day 1 and another 3 ampules on day 8 ANST. Warning: May cause nausea, vomiting, anemia, hair loss Refill: On next visit after 28 days
Lic No 985476 PTR No 70011

PRESCRIPTION
JERNELYN P. RELOJ, MD General Practitioner Ospital ng Maynila MW 8-10 am
18 June 2006 Patient: M.S. Address: San Pedro, Laguna Age: 65 Sex: F

Rx
Tamoxifen 20 mg tab (Gynatam) # 30
Sig: Take 1 tablet orally once a day for 1 month after completing chemotherapy course Warning: May cause hot flushes, nausea, vomiting Refill: On next visit after 1 month

Lic No 985476 PTR No 70011


				
DOCUMENT INFO
Shared By:
Categories:
Tags:
Stats:
views:101
posted:7/4/2009
language:English
pages:36