Week 4 discussion comment.
Make a comment using your own words in each discussion but please provide at least one reference for each comment.
Do a half page for discussion #1 and another half page for discussion #2 for a total of one page.
Provide the comment for each discussion separate.
Discussion #1
Case Study
CM is a 43-year-old female who presents with concerns regarding two painless right-breast lumps that she detected four months ago. She missed an appointment for evaluation by her primary-care provider at that time and presents today with reportedly no change in these findings since that time. There has been no breast discharge, bleeding, overlying skin changes, lymphadenopathy, or fevers; she denies recent or past breast trauma. She did, however, undergo a stereostatic breast biopsy three years ago that demonstrated atypical lobular hyperplasia, and there is a known family history of breast cancer (mother, diagnosis at age 48). Current review is significant for a 10-pound weight loss due to diminished appetite over the last two months. Amenorrheic x three years; no current hormonal-replacement therapy or previous oral-contraceptive use; had levonorgestrel implantation at age 28, removed at age 33 and has only used condoms since, but nothing now as she is not sexually active.
• Discuss the questions that would be important to include when interviewing a patient with this issue, including any risk factors she may have.
The history of the current concern is potentially the most important component of the patient encounter with questions about the exact location of the masses on the breast, if the masses are bilateral of unilateral, duration of her symptoms, presence/absence of pain, whether the masses change in sensation/size, if the patient has ever had a history of similar complaint before and if so what the outcome of the treatment was (Kosir, 2019, para. 10). Any symptoms the patient has experienced along with the discovery of the masses is also vital to determine what might be changing with the patient’s health; nipple discharge/quality of the nipple discharge, weight loss, and/or fatigue that cannot be explained by exertion or sleep pattern change (Kosir, 2019, para. 11).
CM reports that she discovered the 2 “lumps” in the right breast only approximately 4 months ago and did not receive any care as of yet, there has not been an evolution of the 2 painless masses, and she has not has nipple discharge/bleeding/ skin changes of the breast/ swollen lymph nodes/ fevers/ or traumatic injury to her breasts; however she has risk factors that are significant to diagnosing her complaint: she is female, over the age of 40, and her mother was diagnosed with breast cancer at age 48. Rationale for highlighting these factors are revealed in the Surveillance, Epidemiology and End Results, or SEER, data: “the incidence of invasive breast cancer for women younger than 50 years is 44.0 per 100,000”, “lifetime [cancer] risk is up to 4 times higher if a mother and sister are affected”, and among women who have the first-degree relative cancer link there is a significantly stronger risk of cancer “ if the relative was diagnosed at an early age (≤50 years)” (Chalasani, 2020, para. 2-4).
• Describe the clinical findings that may be present in a patient with this issue.
It would be more common to find an asymptomatic patient who was alerted to the masses during a screening, but if the patient did have symptoms it would be more common to present with a painless, palpable mass (Chalasani, 2020, para. 3). Patients with the following findings need to be considered for cancer as opposed to a benign condition: “change in breast size or shape, skin dimpling or skin changes, recent nipple inversion or skin change, or nipple abnormalities, single-duct discharge, particularly if blood-stained, axillary lump” (Chalasani, 2020, para. 3).
CM has none of the alarm sign findings specific to the 2 masses in her right breast, but the 10- lb. weight loss and diminished appetite may be significant (Kosir, 2019, para. 11). She also has known
atypical lobular hyperplasia, which is an uncommon proliferative type of lesion that could be a sign that cancer will develop within the ducts; these lesions do not have well defined management guidelines but monitoring via imaging studies is vital (Clauser et al., 2016, para. 1).
• Are there any diagnostic studies that should be ordered on this patient? Why?
CM reports not keeping her appointment 4 months ago when the 2 breast masses were found, and she does not report having had follow up for the biopsy findings 3 years ago. I would order an ultrasound for CM to determine if the lesions are cystic or solid due to the likelihood that cystic masses are benign (Kosir, 2019, para. 18). A cystic lesion is aspirated if they are causing symptoms and a solid lesion would require an MRI and guided biopsy for assessment of the mass at a cellular level; for CM I would choose to aspirate any cystic mass and send the fluid for cytology based upon her history and any solid mass requires a biopsy that could show what lack of serial monitoring since the last biopsy 3 years ago has missed (Kosir, 2019, para. 18-20).
• List the primary diagnosis and three differential diagnoses for this patient. Explain your reasoning for each.
The primary diagnosis is lobular carcinoma in situ (LCIS), pleomorphic type, which is “a proliferation of cancer cells lining the lobules” because CM has multifocal masses, known lobular hyperplasia, and no obvious involvement of other tissues as evidenced by lack of lymphedema, fever, and pain of any type (Kosir, 2019, para. 6-8). I do think her masses are cancerous, however because of her first-degree relative with cancer before age 50, weight loss, and history.
The first differential diagnosis is fibroadenoma because these present as painless masses (Kosir, 2019, para. 6). This does not fit due to the fact that they usually form during a woman’s reproductive years and CM is postmenopausal; in older women the masses grow over time and hers have not changed (Kosir, 2019, para. 6). The next differential diagnosis is phyllodes tumor because this is the most common type of tumor among women aged 40-60 years old, but the most common presentation is a single larger mass as opposed to two smaller masses (Miller, 2019, para. 13). The third differential is fibrocystic disease which can cause nodules to be palpable in the breasts, this is less likely due to the fact that there is no reported tenderness, heaviness, and symptoms usually decrease after menopause occurs (Kosir, 2019, para. 4).
• Discuss your management plan for this patient, including pharmacologic therapies, tests, patient education, referrals, and follow-ups.
Afterconeneedlebiopsy,mammography,andconfirmationofLCISamultidisciplinaryteam that “typically includes a breast surgical oncologist, medical oncologist, and radiation oncologist plus other experts in cancer (tumor board)” would be established to help her (Kosir, 2019, para. 45). Genetic testing for BRCA abnormalities is advised for her due to family history, chest x-ray, CBC, hepatic panel, and serum calcium levels will investigate the possibility of metastatic disease (Kosir, 2019, para. 47-51). The treatment plan would include a lumpectomy with radiation. There is not an established treatment guideline for LCIS but this plan of diagnostics/surgical intervention/ and radiation treatment has produced better survival rates than combinations of lumpectomy alone/mastectomy/radiation/or observations only (Cheng et al., 2017, para. 1). Tissue removed during the lumpectomy will be examined for appearance/number of cancer cells or graded; TNM staging can help develop what type of care is needed (Kosir, 2019, para. 58-59). LCIS management with lumpectomy and radiation can be augmented by use of the medication tamoxifen or raloxifene because CM is postmenopausal (Kosir, 2019, para. 96). CM should learn that tamoxifen can cause cataracts, CVA, and blood clots; raloxifene carries a lower risk of endometrial cancers (Kosir, 2019, para. 123-125). Breast cancer survivors have different follow-up guidelines than women without a history. The National Comprehensive Cancer Network (NCCN) and the American Cancer Society/American Society of Clinical Oncology (ACS/ASCO) both have a stepwise approach to history and physical examinations, mammography, MRI, lab draws, pelvic exams, imaging studies, and tumor marker testing based upon years since diagnosis and intervention, and the patient should seek consultation with any new onset of symptoms that cancer has returned (Chalasani, 2019, Table 1).
Discussion #2
1. The history of the current problem and knowing the family history is an important component of the patient encounter with questions about the exact location of the masses on the breast, if the masses are bilateral of unilateral, duration of her symptoms, presence/absence of pain, whether the masses change in size, if the patient has ever had a history of similar complaint before and if so what the outcome of the treatment was. Have you had a mammogram? Any symptoms the patient has experienced along with the discovery of the masses is also important to determine what might be changing with the patient’s health; nipple discharge/quality of the nipple discharge, and/or fatigue that cannot be explained by exertion or sleep pattern change. Do you exercise? Do you smoke or drink alcohol? Has she followed up with her not having a period for 3 years. Does she have any pelvic pain or history of ovarian cancer? Do you have any children? The risk factors she has is that her mother was diagnosed with breast cancer at the age of 48, she is over the age of 40, and her history of atypical hyperplasia (Myers & Walls, 2020).
2. The clinical findings that could be present is a painless palpable mass. Skin dimpling, skin changes to the breast, change is size of the breast size or shape. Nipple inversion or discharge – especially bloody discharge and axially lump. Unexplained weight loss.
3. She found the 2 masses 4 months ago and did not keep her appointment with her PCP and it did not say she followed up after having the biopsy 3 years ago. I would order an ultrasound and mammogram since she has the history of atypical lobular hyperplasia that was not followed up with. Atypical lobular hyperplasia (ALH) means that there is an overgrowth of abnormal-looking cells in one or more lobules. The ultrasound would determine if the mass is solid or cystic and a mammogram can not see through dense breast tissue (John Hopkins Medicine, 2020).
4. The primary diagnosis is lobular carcinoma in situ (LCIS). LCIS is not a true breast cancer. LCIS rarely develops into cancer, but it does raise the lifetime risk of breast cancer. I chose this as the primary diagnosis because she has the 2 masses and has a known history of lobular hyperplasia. There is no known involvement of other tissues, no fever, no lymphedema, and no pain is noted with her masses (Myers & Walls, 2020). CM has unexplained 10 pound weight loss, amenorrheic x 3 years and her mother had breast cancer at the age of 48 increases her chances of the masses being cancerous.
The first differential diagnosis is fibrocystic disease. This can cause palpable nodules in the breast. This diagnosis is less likely because she has no complaint of pain, she does not have thinking or changes to her skin, and fibrocystic breast changes occurs after menopause. The second differential diagnosis is fibroadenoma. This diagnosis presents with painless masses but the masses grow in fibroadenoma but hers did not change in size and they usually occur in the reproductive years and she has been amenorrheic x three years. The third differential diagnosis is phyllodes tumor. This type of tumor is more common in women ages 40 to 60 years of age. The 2 small masses make this unlikely since phyllodes tumor is a larger single mass (John Hopkins, 2020).
5. The management would be performing core needle biopsy to confirm LCIS and to determine if its cancerous. Some doctors recommend the removal of the mass by having surgery since it can turn into cancer. Treatment is to observe by performing monthly breast self-exams, clinical breast exams every year by a health care provider, screening mammograms every year. Preventive therapy by taking a medication to reduce your risk of breast cancer. Selective estrogen receptor modulator (SERM) drugs work by blocking estrogen receptors in breast cells so that estrogen isn’t able to bind to these receptors. This helps reduce or prevent the development and growth of breast cancers. Tamoxifen is used in reducing the risk of breast cancer in premenopausal women and postmenopausal women (Myers & Walls, 2020). Education would be to aim for at least 30 minutes of exercise on most days of the week, maintain a healthy weight, dont smoke, drink alcohol in moderation and limit hormone therapy for menopause. Encourage her to go to all her appointments. Do self breast exams monthly and if she notices any changes in her breasts she needs to follow up with her doctor. A referral to a surgeon may be needed if a lumpectomy is needed.