Patient profile:

A 55 years old female patient was admitted in female

surgical ward on 27/9/11
c/o
breast pain and nipple discharge
o/e
T4b , N1 , M0
B.P-130/80 mm hg

Past medical history:

8/2/10
no pain/discharge
2 months h/o breast lymphoma gradually increase in size
o/e
4x3cm firm mobile
skin involvement
medial group of nodes positive mobile

Breast lymphoma
Poorly differentiated duct cell carcinoma
Advised exisional biopsy
13/2/10:
Plan for MRM(modified radical mastectomy)
B.p:110/80
H.b:9.7mmhg
Rbs:105mg/dl
Serum.creatine:0.6mg/dl
Sr.calcium:9.4mg/dl
ALP:112iu/ml
No h/o chest pain
No h/o DM/HTN
Transfuse 2 units PRBS before operation

Risk factors for breast cancer

development:

Personal history of breast cancer

Family history of breast Cancer in first degree relatives
Prolifarative bening breast disease
Early menarch,late menopause
First pregnancy after age 35
Exogenous estrogens
Obesity
Dietary factors alcohol high fat diet

Present medical history:

27/9/11:

parameter

Normal value

Observed
value

H.b

9.2mg/dl

11-16.5g/dl

RBS

105mg/dl

110-180mg/dl

sr. creatinine

0.6mg/dl

0.5-0.9mg/dl

Sr.calcium

11mg/dl

8.4-10.8mg/dl

LDH

350U/L

Albumin

4.3g/dl

3.5-5.0g/dl

T . protiens

6.8

6.8-8.3g/dl

SGOT

24

6-38u/l

SGPT

10

6-38u/l

ALP

90

36-142mu/ml

Bil . total

0.4

0.5-1.1mg/dl

Truent biopsy was done:

ER,PR&HER-2nm status
RX
T.brufen 400mg for four days
5/10/11:
T4b N1 MX
plan for neo adjuvent therapy
8/10/11:
normal sited cardiac chamber
sclerotic aortic valve,no RWMA,no MR/TR ,trivial AR,no PAM
impaired diastolic compliance
normal LV/RV systolic function
First cycle of neo adjuent chemotherapy from (9/10/11 to
13/10/11)

Reason for selection of Neoadjuvent

therapy:

Patient diagnosed with locally advanced breast

cancer(stage III disease) have tumors larger than 5 cm or
direct tumor involvement of the skin or chest wall.
These patients also have extensive lymph node
involvement because bulk of disease at the time
diagnosis ,surgical management is generally not feasible.
Because of success of neoadjuvant therapy in the
treatment of locally advanced disease, investigators are
beginning to explore the use of neoadjuvent therapy in
early stage disease
The results from a preliminary study conducted by NSABP
indicated that preoperative doxorubicin and
cyclophosphamide reduced the size of most tumors and
decrease incidence of positive nodes at the time of surgery.

First cycle chemotherapy:

DAY 1:
ing.dexamethasone 20mg in 100ml of NS over half an hour
inj.ondansetron 8mg i.v stat + ranitidine 50mg i.v stat
inj.cyclophosphamide 54mg in 100ml NS over15-20min
inj.adriamycin 54mg in 100ml NS over 15-20min
tab.lorazepam 1mg
DAY 2:
tab.decadron 8mg Q12 hr + T.ranitidine 150mg Q12 hr
tab.ondansetron 8mg Q8 hr + T.lorazepam 1mg HS
DAY 3:
Same as day 2
DAY 4:
Decadron 4mg &same as day 2
DAY 5:
Same as day 4

During the cycle the patient developed loose stools, vomiting &
nutropenia
RX
tab.ciprofloxacin 500mg bd
4 days
tab.augmentin 625mg tid
tab.neurobin od
tab.hemsi od
21 days
cap.omeprazole20mg
tab.emeset 4mg sos for 5 days
Discharge on 26/10/11
After 5 days for count
PLAN:
second cycle was planed from( 1/11/11 to12/11/11)
80% chemotherapy along with GMCSF for all cycles & to start GCSF
24 hr after chemotherapy has been completed for 5 days

Second cycle chemotherapy:

DAY 1:
ing.dexamethasone 20mg in 100ml of NS over half an hour
inj.ondansetron 8mg i.v stat + ranitidine 50mg i.v stat
inj.cyclophosphamide 50mg in 100ml NS over15-20min
inj.adriamycin 50mg in 100ml NS over 15-20min
tab.lorazepam 1mg hs
DAY 2:
tab.decadron 8mg Q12 hr + tab.ranitidine 150mg Q12 hr
tab.ondansetron 8mg Q8 hr + tab.lorazepam 1mg HS
DAY 3:
Same as day 2
DAY 4:
Decadron 4mg &same as day 2
DAY 5:
Same as day 4

18/11/11:
H.b:8.6
Serum creatinine:0.6mg/dl
Total count:5600
Monocytes:3.5
Lymphocytes:19.8
Neutrophils:76.7
Third cycle of chemotherap was planed from 22/11/11 to
27/11/11

Third cycle chemotherapy:

DAY 1:
ing.dexamethasone 20mg in 100ml of NS over half an hour
inj.ondansetron 8mg i.v stat + ranitidine 50mg i.v stat
inj.cyclophosphamide 54mg in 100ml NS over15-20min
inj.adriamycin 54mg in 100ml NS over 15-20min
tab.lorazepam 1mg
DAY 2:
tab.decadron 8mg Q12 hr + T.ranitidine 150mg Q12 hr
tab.ondansetron 8mg Q8 hr + T.lorazepam 1mg HS
DAY 3:
Same as day 2
DAY 4:
Decadron 4mg &same as day 2
DAY 5:
Same as day 4

Patient was started on filgrastim from second day of

chemotherapy as adviced after taking two doses.
Patient had total count 34,600/cum
Filgrastim was stopped patient was asymptomatic throuh
out the cycle .
RX
CAP.omeprazole 20mg bd
T.neurobin od

21 days

T.hemsi od
T.emeset 4mg sos
Plan: After 5 days for counts (2-12-2011) reassessment of
breast mass. Further management ( surgery/
chemotherapy).

2 DEC 2011:
B.P: 110/80 mm hg;
Plan: Salvage mastectomy on 13-12-2011;
Hb : 9.5 mg/dl;
TC : 3100 cells/cum;
DC Neutrophils: 69%;
Platelets: 3,56,000 cells/cum;
Sr.Creatinine: 0.6 mg/dl.
5 DEC 2011;
B.P : 110/70 mm hg;
Hb : 9.4 g/dl;
MPV : 6.6 fl;
TC : 3600 cells/cum;
RBC : 3.4x 10^12 cells/l
Neutrophils : 66.6 %;
PCV : 28.3
Sr.Creatinine : 0.5 mg/dl
Rx
RDWA : 79.1 fl
cap omeprazole 20
mg for 1 week
bland diet

13 DEC 2011:
received 3 cycles of neoadjuvant chemotherapy with 80% AC
regimen
Patient has responded for treatment.
O/E :
Tumour size reduced; fixed to the overlying skin and no lymph node
palpable;
Salvage mastectomy
Rx
inj. T.T 0.5ml start IM;
Inj. Cefazoline 1g stat IV;
Tab. Ranitidine 50 mg hs oral;
Tab. Diazepam 5mg hs oral;
14 DEC 2011:
post operative medication
RX
inj. Cefazolin 500mg i.v Q 8 H
inj. Pantaprazole 40mg i.v OD
inj. Tramadol 50mg i.v Q 8 H
inj. Dalteparin 2500 units s/c

operation record:
whole breast including nipple areole & pectoral
fascia dissected off from pectradis.Interpectoral tissue taken
out.
Axillary dissection done upto axillary vein above LD muscle
laterally long thoracic nerve &thoracodorsal complex.
15 DEC 2011:
H.B:8g/dl;
RX
inj. Diclofenac 75mg bd i.m;
16 DEC 2011:
RX
Tab. Livogen bd;
Tab. Vit c;
inj. Cefazoline 500mg tid i.v;
inj. Pantaprazole 40mg od i.v;

Brand
name

Inj.
voveran

Generic
name

Dose

R .O.
A

Inj.dalteparin

2500 iu

s.c

Inj. diclofenac

75mg

i.m

bd

1718/12/11

500mg

i.v

tid

1721/12/11

oral

bd

1722/12/11

oral

tid

1722/12/11

Inj.cefazol Inj. cefazolin

in
Tab.livoge Tab.ferrous
n
sulfate+folic
acid
Tab. Vit c

frequen Time
cy
regimen
1718/12/11

Cap.omez

Cap.omeprazo
le

20mg

oral

bd

1721/12/11

T.brufen

Tab.ibuprofen

400mg

oral

bd

1922/12/11

i.v

od

17&20/12

Patient
on 22/12/11
Inj. was discharged
Inj.pantaprazol
40mg
pantop
e

Risk factors for breast cancer

development:

Personal history of breast cancer

Family history of breast Cancer in first degree relatives
Prolifarative bening breast disease
Early menarch,late menopause
First pregnancy after age 35
Exogenous estrogens
Obesity
Dietary factors alcohol high fat diet