Download insitu and invasive ductal carcinoma

“The Beast, Big C, and The Destructor” are just a few names the patients at
Woodhull Medical and Mental Health Center refer to the world renowned disease,
Cancer. Cancer is the leading cause of death worldwide. This beast knows no face; it
does not discriminate according to gender, age, race, sex or size. It has no bounds. It is
not curable but what is more frightening is that this notorious disease comes in many
forms. According to the National Cancer Institutei the five most common cancer types
reported in the United States are bladder, breast, colon and rectal, endometrial, and renal
cell cancer. Additionally reported is that among women breast cancer is the most vicious
of any other form. The most common type of breast cancer is ductal carcinoma; this
begins in the lining of the milk ducts which are the thin tubes that carry milk from the
lobules of the breast to the nipple.ii With this being the reality, we group two, chose to
study a very unique case of breast cancer. Patient X, a twenty two year old female patient
of Woodhull hospital with third stage ductal carcinoma.
Patient X visited Woodhull hospital for the first time for a general medical
examination on September 18th. Dr. Rizkalla, the visit physician, was informed by the
patient that she has had a benign lump in her right breast for approximately three years
and has had annual sonograms done for early detection. This lump was said to be
enlarging as of recent and discomfort was the patient’s primary complain. When
Dr.Rizkalla examined her she indeed noticed a “large lump” around 9 o’ clock position.
Immediately following the visit the patient was referred to an outpatient facility to have a
mammogram done for an accurate diagnosis.
1
After speaking to Dr. Rizkalla I learned that this was her youngest patient thus far
in her 26 year career as a Primary Care Physician. She also admitted that she was actually
worried about this young lady’s life. She also said “just by the feel of this mass I could
tell that the benign lump she had 3 years back had now matured into something of a great
caliber.” She explained to me that it is quite normal for patients who discover a lump,
cyst or who simply has had a family history of cancer to have a breast ultrasound done
annually. On the other hand, it is extremely rare for a young lady to have a mammogram
done at 22 years of age, so there was no doubt in her mind that this patient’s results were
going to be positive.iii
By October 8th the results were back and Dr. Rizkalla had already a plan in action.
The results simply confirmed her concern. It was revealed that this 22 year old patient
had severe carcinoma. Following the protocol for treating patients with evident
carcinoma a biopsy was performed which reconfirmed this ugly truth. Dr. Jose Ruiz, the
reading pathologist gave Dr. Rizkalla in-depth insight on patient X’s condition. The
diagnosis was Insitu and Invasive Ductal Carcinoma of the breast.
Invasive breast cancer is breast cancer that has spread from where it began in the
breast ducts or lobules to surrounding normal tissue. The insitu component as said by Dr.
Ruiz is “high grade” meaning it has a very high mitotic rate.
Without hesitation Dr. Rizkalla then referred the patient to Dr. Albert Duncan,
who she considers the best surgeon in Brooklyn. Subsequently, patient X visited Dr.
Duncan on October 29th; a consultation then a Modified Radical Mastectomy (MRM)
2
was performed. As described on the Susan G. Komen’s site, a Modified Radical
Mastectomy is a procedure to remove the breast, the pectoralis minor and some lymph
nodes in the adjacent armpit.iv The pectoralis major is a thick triangular, fan shaped
muscle situated at the chest and makes up the breast in females. The pectoralis minor is a
thin triangular muscle that sits just below the pectoralis major. This shows the depth of
the mastectomy.
The results of the mastectomy now gave detailed information about her carcinoma.
Dr. Cesar Rosario the reading pathologist reported that seven out of ten of her axillary
lymph nodes tested positive for malignant carcinoma and 90% of the breast mass also
comprised of malignant carcinoma. What was most alarming was that the cancer had
already fully matured to its third stage.
Sadly, the last visit reported was Friday October 29th. This marks the end of our
testing and treatment for this patient.
One basic fact about cancer is that it could be hereditary. However, more and more
cases are being discovered in patients who have no genetic trace or family history of this
disease. Unfortunately, our patient has a family history of cancer. Both grandfathers of
patient X were diagnosed with thyroid and pancreatic carcinoma.
If popular opinion were true that young women are not prone to developing breast
cancer, then patient X would not have been a part of the statistics. Here we have a case of
uniqueness, a 22 year old young lady visiting her primary care physician for a general
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examination with a chief complaint of pain in the breast, just to discover a few weeks
later that she has a life threatening disease which has no cure. This case however is quite
rare, because according to the Young survival coalition sitev in the in the United States
each year, approximately 70 thousand men and women age 15 to 39 are diagnosed with
cancer. Breast cancer accounts for roughly 15% of all cancers in this age group. Women
ages 15 to 54 die more frequently from breast cancer than any other cancer.vi In 2009, the
American Cancer Societyvii predicted more than 190,000 new cases of breast cancer in
women. They estimated that roughly 18,600 of these women would be younger than 45
years old. Compared to older women, young women generally face more aggressive
cancers and a lower survival rate,viii because more and more evidence tells us that breast
cancer before age 40 differs biologically from the cancer faced by older women.ix
Diagnosing breast cancer in younger women (under 30 years old) is more difficult,
because their breast tissue is generally denser than the breast tissue in older women. By
the time a lump in a younger woman's breast can be felt, the cancer often is advanced.
In addition, breast cancer in younger women may be aggressive. Women who are
diagnosed with breast cancer at a younger age are more likely to have a mutated (altered)
BRCA1 or BRCA2 gene.
Delays in diagnosing breast cancer also are a problem. Many younger women who
have breast cancer ignore the warning signs; such as a breast lump or unusual nipple
discharge -- because they believe they are too young to get breast cancer, luckily patient
X was wise enough to visit a doctor when she noticed a change in her “benign” lump.
4
Many women assume they are too young to get breast cancer and tend to assume a
lump is a harmless cyst or other growth. Some health care providers also dismiss breast
lumps in young women as cysts and adopt a "wait and see" approach but not Dr.
Rizkalla!
No effective breast-cancer screening tool yet exists for women ages 40 or younger.
Young women with breast cancer struggle with many issues either not present or much
less severe in the lives of older women. These issues could include; the possibility of
early menopause, effects on fertility, questions about pregnancy after diagnosis, concerns
about body image and challenges to financial stability.x
In essence, it is important to note that cancer no longer only attacks the elderly but
any age group can fall victim to this chronic disease. It is therefore important to have
regular checks done especially if your family history of developing cancer. As Patient X
is a prime example. Had it not been for the level of interest she took in her health the
detection would not have been made hence treatment would have been delayed.
i
National Cancer Institute
http://www.cancer.gov/
publishe October 22, 2012
ii
Ronald L. Eisengberg. Nancy M. Johnson. Comprehensive Radiologic Pathology. 5 th ed. St. Louis, ,Missouri: Jeanne
Olsen
iii
Dr. Rizkalla MD
iv
Susan G. Komen
http://ww5.komen.org/BreastCancer/Mastectomy.html accessed January 2013
v
young survival.org
vi
young survival.org
vii
American Cancer Society. (2009). Breast Cancer Facts and Figures 2009-10. Atlanta, GA: American Cancer Society, Inc.
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viii
Young survival.org
ix
Partridge, A.H. et al. (2009). Breast Cancer in Younger Women. In J. Harris (Ed.), Diseases of the Breast (pp. 1073-1083).
Philadelphia, PA: Lippincott Williams & Wilkins.
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References
1. National Cancer Institute. Availed at http://www.cancer.gov/ accessed October 22 nd, 2012
2. Ronald L. Eisengberg. Nancy M. Johnson. Comprehensive Radiographic Pathology. 5 th ed. St.
Louis, Missouri, Jeanne Olson
3. Susan G. Komen. Avaible at http://ww5.komen.org/BreastCancer/Mastectomy.htm/
Accessed January 2013
4. American Cancer Society. (2009). Breast Cancer Facts and Figures 2009-10. Atlanta, GA:
American Cancer Society, Inc.
5. Partridge, A.H. et al. (2009). Breast Cancer in Younger Women. In J. Harris (Ed.), Diseases of
the Breast (pp. 1073-1083). Philadelphia, PA: Lippincott Williams & Wilkins.
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New York City College of Technology
INSITU AND INVASIVE DUCTAL CARCINOMA
GROUP 2
Renee` Anthony
Geneen Abdallah
Kedisha Symister
Christina Maffeo
Neha David
Edith Seweryn
Christopher Choi
Aleem Khan
Prof: Z Vinokur
Fall 2013
Date: 12/03/2013
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