A 72 years old white woman presented at the specialized outpatient clinic for breast diseases in the Deventer Hospital in Deventer, The Netherlands. Two weeks earlier, she had discovered a local swelling in her right breast, located behind the nipple. There was no retracted nipple, nor excretion from the nipple. The skin had been red for a while, but this had disappeared spontaneously. The woman was postmenopausal, had given birth to 4 children to whom she had breastfed two. Her family history is relevant for breast cancer, her daughter had breast cancer when she was thirty-five years old. The patient history mentioned a cholecystectomy, hysterectomy and appendectomy and hypertension and atrial fibrillation. She had used some medication against hypertension, an anticoagulant and a tranquilizer.
Physical examination revealed an elastic swelling, located centrally in the right breast, measuring about five centimetres across, without fixation to the skin or pectoralis major muscle fascia. The tumour appeared malignant. No abnormalities were observed in the left breast, nor in axillar or supraclavicular lymph nodes. A digital mammogram was performed and showed a mass of 32 millimetres with spiculated margins, positioned five centimetres behind the nipple. Ultrasound of the lesion confirmed this. The radiologist classified the mass as a suspicious abnormality (figure ). A fine-needle aspiration (FNA) of the swelling was taken. The pathology report confirmed the presence of a malignancy. The pathologist described atypical epithelial cells with polymorphism of the nucleoli, and the conclusion was adenocarcinoma of the breast. An additional ultrasound of the right axilla was performed. It showed a lymph node of 1.5 centimetre, without pathological characteristics. The patient and her family were informed thoroughly about the different treatment possibilities. The decision was made to perform a mastectomy and a sentinel node procedure.
Under the nipple, subcutaneously, 44 megabecquerel Technetium99 nanocolloid was injected five hours before the operation. However on the scan made just before the operation, there was no sentinel node visible. At the beginning of the operation patent blue dye was injected to locate the sentinel node. During the operation three blue lymph vessels were seen. There were, however, more enlarged lymph nodes without blue coloring but with pathologic aspect. It was decided to perform a regular lymphadenectomy of the axilla, without removing the highest level nodes. The postoperative course was uncomplicated. She left the hospital five days after the operation, the drains were removed prior to discharge. Pathological examination showed a locally cornified squamous cell carcinoma with a mitosis activity index of more than 20 (figure ). The conclusion was a radical excision of a moderate differentiated squamous cell carcinoma of the breast, with a size of four centimeters. The Bloom Richardson score was eight, this means high grade malignant. In the preparation eleven lymph nodes were found of which two had metastasis of squamous cell carcinoma. There was no metastasis in the lymph nodes located right underneath the axillary vein. Hence, the tumour was classified as pT2N1Mx breast carcinoma. Determination of the hormone receptors showed positivity for estrogen receptor, the progesterone receptor identification was negative. There was no amplification of the her2neu receptor.
The case was discussed in the multidisciplinary oncology conference. The decision was made to treat this patient according to the Dutch national guidelines for adjuvant treatment with breast carcinoma, just like an adenocarcinoma. Patient was thus started on hormonal therapy: intitially tamoxifen 20 mg daily for two and a half year and an aromatase inhibitor hereafter for the same period. The patient had no other complaints or signs of another tumour.
Clinical course
A year after the operation there were no indications for relapse nor for metastasis or a skin tumor. The tamoxifen was replaced by an aromatase inhibitor because of side-effects, mostly nausea.
Almost two years after the operation she visited the outpatient medical oncology clinic because of fatigue, anorexia and weight loss. Laboratory investigation showed hypercalcemia. Further evaluation with bone scintigraphy and an ultrasound of the liver showed both, bone and liver metastases. The metastatic disease in the lever was proven by FNA. She was briefly admitted to the clinical ward and was transferred to a hospice facility, where she died shortly afterwards.
1,3 Mans Hofstee,2 and Mike SL Liem1
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