Symbiosis Institute of Health Sciences

“Pathology & Case Presentation Report" ON

"Long-term Progression of Breast Lump: A 6-Year Case Study in a 28-Year-Old
Female"
SEMESTER-3

Submitted by
Namira Sana
PRN: 23040146035
Program: Assisted Reproductive Technology and Embryology

Submitted to
Symbiosis Institute of Health Sciences,
Symbiosis International (Deemed University)
in partial fulfillment of the requirements for the award of the
Degree of Master in Assisted Reproductive technology and Embryology
Batch-2023-25
 INDEX

S.no Content
1. History of patient
2. Clinical examination
3. Investigation
4. Treatment
5. Complication
6. Summary

INTRODUCTION
 Breast cancer
 Breast cancer is a type of cancer that begins in the cells of the breast.
 It can occur in both men and women, but it is far more common in women.
 Breast cancer can develop in various parts of the breast, including the ducts
that carry milk to the nipple (ductal carcinoma), the glands that produce
milk (lobular carcinoma), or in other tissues within the breast.
PATIENT CASE

A 28-year-old female reports with a 6-year history of a gradually enlarging

lump in her left breast. The patient was initially asymptomatic but noticed a
small-sized lump, which has progressed in size over the past six years and
no complaint in right breast or no swelling in right axilla.
HISTORY

 History of present illness

o Duration of Lump: Present for 6 years
o Pain Characteristics: Delicate and intermittent pain associated with
the lump for the past year
o Insidious onset and rapidly progressive in size initially

around 1X1 cm to 4x3 cm now

o The lump is mobile.

o No h/o nipple retraction

o No h/o nipple discharge

o No h/o axillary lymphadenopathy.
o No h/o supraclavicular lymphadenopathy.
 o No h/o distant metastasis such as backache or dyspnea (shortness of
breath)
o No h/o hemoptysis (coughing of blood)
o No h/o headache/seizures

 Past History
o No known medical issues or illnesses reported before the onset of
the breast lump 6 years ago.
o No history diabetes
o No history of hypertension
o No history of emotional or behavioral distress (EBD)
o No h/o of jaundice
o No h/o of TB
o No h/o of trauma to breast
o No h/o irradiation
o No h/o chest pain reported.

 Medication history
o No h/o of taking OCP (oral contraceptive pills)
o No h/o of taking HRT (Hormonal Replacement Therapy)
o No h/o drug allergy

 Family history
o No h/o of breast cancer or related deaths in family
o Father has diabetes mellitus.
o There is no h/o BRCA related malignancies such as pancreatic,
colorectal, prostate or ovarian in the family.
 o Maternal grandmother suffers from hypertension .

 Personal history
o Diet - non-vegetarian
o Bladder habits - normal
o Bowel habits - normal
o Sleep pattern - normal
o No history of any addictions
o No history of smoking
o History of occasional drinking
o No h/o loss of appetite or significant unintentional weight loss
o No h/o any STD

 Menstrual History
o Menarche at the age of 14
o Regular cycles of 4-5 days
o Menstrual cycle of 28-30 days
o No history of heavy bleeding (menorrhagia) or painful bleeding
(dysmenorrhea)
 Past surgical history
o No h/o surgery

 Immunization History
o Up to date with all her vaccines such as tetanus and influenza
o No h/o HPV vaccination.

 Obstetric History
o G4P4
 o P1&4: Older and middle boy child, full term, normal vaginal delivery.
o P2&3: Older and middle girl child, full term, normal vaginal delivery.
o All children were breast fed up to 6 months.
o All the children are healthy
o No h/o abortions

CLINICAL EXAMINATION

Vital Signs

 Temperature - 98 F
 Pulse rate - 78/ min
 Respiratory rate - 19/ min
 Blood pressure - 126/89 mm of Hg
 Weight - 75 kg

GENERAL EXAMINATION

 She was examined in sitting posture in both the hands on the sides in an
adequate day light with proper informed consent and a female attendant.
 Patient was conscious-operative and well oriented with time, place and
person
 Karnofsky performance score = 90
 Well-nourished with a BMI of 30 kg/m² (classified as obese).
 Well-hydrated.
 Afebrile (no fever).
 P- pallor
 I- Icterus
 C- Cyanosis
 C - Clubbing
 L - Lymphadenopathy
 E - Edema
 No PICCLE

LOCAL EXAMINATION
 Examination of Breast - The patient was adequately exposed up to the
waist and examined maintaining proper privacy in the presence of female
attended
 Patient was inspected in sitting position with arms on side, rising arms
above the head and bending forward position
 Right Breast -
o Globular in shape
o Appears larger as compared to left
o Skin appears normal.
o No dilated veins ,scar, ulcer or sinuses seen
o Nipple-areolar complex appears normal.

 Left Breast Position -

o Slightly displaced laterally
o Size and shape- shrunken as compared to right breast with altered
contour.
 o There is a visible fullness behind nipple-areolar complex and also in
upper outer quadrant
 Skin over the swelling -
o Reddish discoloration of skin over the upper outer quadrant.

 On raising arms above head -

o No dimpling seen
 Nipple:
o Displaced upwards and outwards and deviated to left.
o No retraction with no discharge

 Areola -
o Dark, edema and redness present over peri-areolar region
o No ulcer present
o No visible swelling on inspection of axilla and supraclavicular Lymph
node
 On bending forward -
o Right breast fell forward less than left, no nipple retraction noted.

 Inspection of arm, thorax and shoulder joint.

o Chest did not show any other nodule or ulceration.
o Movement of shoulder joint were in full range and painless.
o There was no edema of the arm

PALPATION

 Right breast-
o Soft, no warmth felt , no tenderness
o No lump was felt
o No discharge from nipple and areola.

 Left breast -
o Warmer as compared to right and non tender.
o There was single lump palpable in the upper outer quadrant
o size - 4x3 cm
o Margins- irregular
o Surface- uneven
o consistency - firm
o The lump was mobile

 Nipple-areolar complex
o No retraction of nipple noted
 o Non-foul smell, no serosanguinous discharge from nipple on
compressing it.
 Areola -
o non-tender
o No serosanguinous ,non-foul smell discharge
o edges- everted
o margins - irregular

 Examination of axilla and neck.

o No lymph nodes were palpable in both axillae and neck.

SYSTEMIC EXAMINATION

 CNS- Conscious, oriented to time, place and person, no abnormalities

detected .
 Examination of spine - Normal, no restricted movements.
 CVS - S1, S2 heard ,no mummer heard
 Respiratory System- B/l air entry present , normal bronchi vesicular breath
sounds heard

Here’s a structured case study including the provisional diagnosis, investigations,

and management plan over days 1, 3, and 5.

PROVISIONAL DIAGNOSIS
 Fibroadenoma:
o Benign breast tumor commonly seen in young women.
 o Longstanding, slow-growing, and painless mass suggests
fibroadenoma over malignancy.

DIFFERENTIAL DIAGNOSIS:
 Phyllodes tumor (though rare, some present similarly)
 Breast cyst
 Ductal carcinoma in situ (DCIS) – low likelihood but to be ruled out
 Lipoma (non-breast tissue origin but benign soft mass)

DAY-WISE PLAN OF INVESTIGATIONS AND MANAGEMENT

Day 1 (Initial Workup)

Clinical Examination:

 Inspection:
o Left breast lump visible but no skin changes (e.g., redness, dimpling).
o No nipple discharge or retraction.

 Palpation:
o Firm, mobile, and well-circumscribed lump (~4 cm) in the upper
outer quadrant of the left breast.
o No palpable lymph nodes in axilla or supraclavicular region.
Blood Tests
 BREAST ULTRASOUND
 Findings:
o Smooth, oval, hypoechoic mass (~4 cm) with well-defined margins.
o No signs of increased vascularity or posterior shadowing.
 BI-RADS Score:
o BI-RADS 3: Probably benign, with a <2% chance of malignancy.
 FNAC (Fine-Needle Aspiration Cytology)
o Cytology Results:
o Stromal and epithelial cells consistent with fibroadenoma.
o No malignant cells detected.
 Review of Results and Planning for
Surgery
 Review of Ultrasound and FNAC Reports
o Confirmed Diagnosis: Fibroadenoma of the left breast (BI-RADS 3).

 Patient Discussion and Counseling

 Options Presented:
o Observation with Follow-up Ultrasound in 6-12 months (if the patient
is asymptomatic).
o Surgical Excision with Mammoplasty to remove the lump and correct
any potential asymmetry.
 Patient's Preference:
o Patient requests surgical excision due to concern about the size and
appearance of the breast and wishes to undergo mammoplasty to
maintain symmetry.

SURGICAL AND ANESTHESIA PLAN

Pre operative procedure
 Patient evaluation: The patient undergoes a thorough evaluation, including
medical history, physical examination, and review of symptoms.
 Imaging: Imaging studies-mammography and ultrasonography are
conducted to assess the extent of the lump and to rule out any other
abnormalities.
 Biopsy: A true cut biopsy has been performed to obtain tissue samples for
pathological examination to confirm the diagnosis.
 Consultation: The patient meets with the surgical team to discuss the
procedure, potential risks, benefits, and alternative treatment options.
 Informed consent: The patient provides informed consent after
understanding the procedure and associated risks.
 Pre-operative medications are given
Drugs used in pre op
 Analgesics: prescribed preoperatively to manage pain and reduce
inflammation.
 Opioid analgesics may be administered for moderate to severe pain relief,
particularly in patients with acute or chronic pain conditions.
 Antibiotics: - administered preoperatively to reduce the risk of surgical site
infections, especially in cases where there is a high risk of contamination or
infection.
 Antiemetics: Antiemetic medications may be given preoperatively to
prevent postoperative nausea and vomiting Common antiemetic include
ondansetron, metoclopramide, and dexamethasone.
 Anxiolytics/Sedatives: Anxiolytic or sedative medications
may be administered preoperatively to alleviate
preoperative anxiety, promote relaxation, and enhance
patient comfort. - Benzodiazepines (e.g., lorazepam,
midazolam) are commonly used for preoperative sedation
 Anticoagulants/Antiplatelet Agents: Depending on the
patient's medical history and risk factors for thromboembolic
events, anticoagulants or antiplatelet agents may be continued or
temporarily withheld preoperatively.
 Other Medications: - Patients with pre-existing medical conditions may
require continuation of chronic medications, such as antihypertensive,
antidiabetic agents, or medications for cardiovascular disease.

ANESTHESIA PLAN
 Type of Anesthesia: General Anesthesia
o General anesthesia is typically preferred for these surgeries to ensure
complete unconsciousness and muscle relaxation.
 Anesthesia Induction:
1. Preoxygenation: 100%oxygen for 3mins.
2. Intravenous Access: Establish intravenous access for drug
administration.
3. Induction Agents: Administer intravenous induction agents such as
propofol to induce unconsciousness rapidly.
4. Neuromuscular Blockade: Administer a neuromuscular blocking agent
(e.g., rocuronium or vecuronium) to facilitate endotracheal intubation
and provide muscle relaxation during surgery.
 AIRWAY MANAGEMENT
 Endotracheal Intubation: Perform direct laryngoscopy or video
laryngoscopy to visualize the vocal cords.
 Inserting an appropriate size endotracheal tube(4) and confirmed
placement using auscultation.
 Mechanical Ventilation: Connected the endotracheal tube to the anesthesia
machine and initiated mechanical ventilation with a mixture of oxygen and
inhalational anesthetic agent isoflurane (sevoflurane or desflurane) to
maintain anesthesia

MAINTENANCE OF ANAESTHESIA
 Inhalational Anesthesia:
 Adjust the concentration of inhalational anesthetic(isoflurane/desflurane)
to maintain adequate depth of anesthesia and hemodynamic stability.
 Monitor depth of anesthesia using a depth of anesthesia monitor (e.g.,
bispectrality index, BIS).
 Analgesia:
o Administer opioid analgesics(fentanyl/morphine) as needed for
intraoperative pain control.
 Muscle Relaxation:
 o Titrate neuromuscular blocking agents to maintain adequate muscle
relaxation throughout the procedure.
 Intraoperative Monitoring:
 Continuous Monitoring:
o Monitor vital signs including heart rate, blood pressure, oxygen
saturation, and end-tidal carbon dioxide (EtCO2) continuously.
o Monitor temperature and urine output to assess for signs of
intraoperative complication.

SURGICAL PLAN
1. Position: Supine.
2. Incision: Surgeon makes a curved or elliptical incision over the left breast,
typically along the natural crease or inframammary fold.
3. Dissection of Breast Tissue: carefully dissects the breast tissue away from
the underlying muscle, including the pectoralis major muscle.
4. Nipple-Areola Complex (NAC) Removal: If indicated, the surgeon removes
the nipple-areola complex en bloc with surrounding tissue.
5. Axillary Lymph Node Dissection: Surgeon performs dissection and removal
of lymph nodes from the left axilla, if necessary for staging and treatment.
6. Hemostasis: Bleeding is controlled using electro cautery, ligatures, or
hemostatic agents to ensure a bloodless surgical field.
7. Closure: The incision is closed in layers using absorbable sutures, ensuring
proper wound approximation and minimizing the risk of complications.
 STEP-BY-STEP SURGICAL PROCEDURE

Step 1: Incision

 The surgeon makes the planned incision (e.g., peri areolar or

inframammary).
 Care is taken to create minimal scarring while maintaining access to the
lump.

Step 2: Dissection and Exposure of the Lump

 The surgeon uses scalpel and blunt dissection to reach the lump without
damaging surrounding tissue.
 Hemostasis (control of bleeding) is maintained using electrocautery.
 The surgeon identifies the lump (fibroadenoma) and separates it from the
surrounding breast tissue.

Step 3: Excision of the Fibroadenoma

 The lump is completely excised along with a small margin of healthy tissue
to ensure complete removal.
 The excised lump is sent for intraoperative frozen section analysis to
confirm that the tissue is benign.
 If the frozen section shows any suspicious features, the surgeon may take
wider margins or proceed with additional surgery.
Step 4: Reshaping the Breast (Mammoplasty)

 After lump removal, the surgeon reshapes the remaining breast tissue to
restore natural symmetry.
 Techniques used for reshaping:
o Tissue rearrangement: The remaining glandular tissue is repositioned
to maintain the breast’s contour.
o Nipple-areolar complex positioning: Adjustments may be made to
ensure proper alignment with the opposite breast.
o Skin tightening: Excess skin may be removed to avoid sagging,
especially in cases of large lumps or if the patient has ptosis
(drooping).

Step 5: Hemostasis and Drain Placement

 The surgical site is inspected for bleeding, and hemostasis is achieved using
electrocautery.
 If significant fluid or blood accumulation is expected, a drain (e.g., Jackson-
Pratt drain) is placed to prevent postoperative seroma or hematoma.

Step 6: Closure of Incisions

 The incision is closed in layers:

o Deep layers: Closed with absorbable sutures to support the breast
tissue.
o Skin: Closed with non-absorbable sutures, staples, or surgical glue to
minimize scarring.
o If a periareolar incision was used, special care is taken to align the
edges for an aesthetic result.
 Post operative care
 The patient is transferred to the recovery room for monitoring
 Pain medications(opioids) are administered as needed for post-
operative pain management.
 The wound is monitored for signs of bleeding or infection.
 Instructions for post-operative care, including wound care and activity
restrictions, are provided to the patient.

 Pain Management
o Analgesics: Oral painkillers such as acetaminophen or ibuprofen
are prescribed.
o Antibiotics: A short course of antibiotics may be given to prevent
infection.
 Drain Management (if applicable)
o The patient or caregiver is instructed on how to care for the drain.
o Drains are usually removed within 3-5 days, depending on output.

 Wound Care
o Keep the incision clean and dry.
o Change dressings regularly, as advised by the surgeon.
o Sutures are removed after 7-10 days if non-absorbable.
  Activity Restrictions
o Avoid heavy lifting or strenuous activities for 2-4 weeks to allow
proper healing.
o Avoid sleeping on the affected side during the first few weeks.

 Follow-Up Appointments
o 1-Week Follow-Up: Assess wound healing and remove sutures if
needed.
o 6-Week Follow-Up: Evaluate the cosmetic outcome and assess for
any complications like seroma, hematoma, or asymmetry.
o 6-Month Follow-Up: An ultrasound may be performed to check
for any recurrence or residual tissue.

Post-Surgery Medication List

1. Pain Management
a. Paracetamol (Tylenol, Panadol): 500-1000 mg every 6-8 hours as
needed
b. Ibuprofen (Advil, Motrin): 400-600 mg every 6-8 hours with food
c. Tramadol (Ultram): 50-100 mg every 6 hours as needed
2. Antibiotics
a. Amoxicillin-Clavulanate (Augmentin): 500-875 mg every 12 hours for
5-7 days
b. Cephalexin (Keflex): 500 mg every 6 hours for 5-7 days
3. Antiemetics
a. Ondansetron (Zofran): 4-8 mg every 8 hours as needed
 SUMMARY

A 28-year-old female presented with a gradually enlarging lump in her left breast,
noted over six years. The lump was firm, mobile, and approximately 4 cm in size,
with no symptoms in the right breast or axilla. Investigations, including a breast
ultrasound and fine-needle aspiration cytology (FNAC), confirmed a diagnosis of
benign fibroadenoma.

Surgery was performed under general anesthesia, involving excision of the

fibroadenoma and mammoplasty for breast reshaping. Postoperative care
included pain management with paracetamol, ibuprofen, and tramadol, alongside
antibiotics (amoxicillin-clavulanate and cephalexin) to prevent infection.

Follow-up appointments were scheduled for one week and six weeks post-
surgery. Histopathology confirmed the benign nature of the fibroadenoma, and
the patient reported satisfaction with both the cosmetic outcome and her
recovery. This case illustrates effective management of a fibroadenoma through
therapeutic and aesthetic interventions, addressing both health and cosmetic
concerns.