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“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 3 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. 5 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. 6 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. 7 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 8