Ms. B, aged 65 years, had had no medical care in 45 years. She had a long history of abuse and was embarrassed to see a provider because of her bruises. Her husband had died a year earlier. She reported that she had been feeling ill recently.
Ms. B came to the medical center wanting to establish care with a female clinician. She had seen my picture in the paper and decided to make an appointment.
Ms. B’s medical history showed tobacco abuse for 50 years. In addition, she reported having been physically abused by her husband and sexually abused by her father. She had unintentionally lost 165 pounds in the past two years. Her income was very limited. With no family or friends and no means of transportation, Ms. B had to beg for a ride to go anywhere. She had never had blood work done, and had never had a mammogram or a colonoscopy.
Ms. B reported feeling “not right” on the day she came in for a consult. She also reported the presence of a mass on her right breast for the past seven years, which seemed to be shrinking. At the time of this visit, no shortness of breath, chest pain, headaches, fever, chills, appetite change, nausea, vomiting, dysphagia or change in bowel or bladder habits was reported.
Clinicians immediately looked at Ms. B’s vital signs. BP was 162/110 mm Hg, indicating stage 2 hypertension. Pulse was 114 beats per minute, respiration rate 20 breaths per minute, temperature 97.4°F, and oxygen saturation 97% on room air.
On examination, Ms. B was malodorous, disheveled and quite anxious. She was alert and oriented to person, place and time. Her respirations were easy and nonlabored. Ms. B had severe gingivitis with numerous dental caries. Her eye contact was poor. There were no breath sounds on the left side of the chest cavity. Right lung field breath sounds were present.
Ms. B’s left breast was without any lumps, bumps or masses. Her right breast had a 10- × 8-cm hard, nontender mass, causing nipple retraction and dimpling. Several satellite nodules were noted as well. No supraclavicular or axillary adenopathy was appreciated. The patient’s abdomen was soft and nontender without organmegaly.
3. Diagnostic Tests
Ms. B’s WBC was 13,300/mL, hemoglobin 8.8%, hematocrit 28.1%, platelets 782, mean corpuscular volume 77.9 fL, albumin 2.8 g/dL, calcium 10.6 mg/dL, and vitamin D <4.0 pg/mL. Cancer antigen was 15-3, 19.3, carcinoembryonic antigen, 6.3. Urinalysis showed blood, protein, leukocyte esterase, bacteria, and WBC.
Chest CT showed an aortopulmonary window mass measuring 5.0 × 5.8 × 5.2 cm and obstructing the left mainstem bronchus, with severe compression of the left pulmonary artery; a left pleural effusion; and a T12 and left kidney lesion.
Mammogram showed asymmetrical breast tissue, a large right breast mass with skin thickening and nipple retraction. In the left breast a 6.0 × 3.0 × 6.0 mm nodule was present, with a concern for malignancy.
A PET/CT showed a T7 lesion. Radiotracer uptake was noted at the left lung and right breast. There was no uptake in the abdomen or pelvis. MRI of the brain showed no acute process with mild atrophy.
Bronchoscopy performed for biopsy of the lung mass showed a left fungating mass, obstructing the left mainstem bronchus, growing into the trachea. A needle biopsy of the right breast mass was attempted but was unsuccessful. This was followed by an open biopsy.
Ms. B was diagnosed with breast cancer that had metastasized to the lung. Lung biopsy showed a moderate differentiated invasive squamous cell carcinoma. The open breast biopsy showed invasive lobular carcinoma, ER positive, PR positive, and HER2/NEU negative.
Ms. B came to the clinic with deep-seated mistrust of people in general. Her vague complaints were of concern, and combined with her assessment findings, led to an extensive workup. She had two separate cancers. She was also anemic and had a urinary tract infection, uncontrolled hypertension, hypovitaminosis, gingivitis, and very limited resources with no support system.
Ms. B’s prognosis was poor. Lung cancer is the leading cause of cancer death in the United States. The American Cancer Society (ACS) had estimated 221,000 new cases with 156,900 deaths for 2011.1 Squamous cell cancer of the lung use to be the most common histologic cell type before the 1980s.1 It is highly associated with smoking. Adenocarcinoma is now the most common histologic type.1 This is thought to be associated with the introduction of low-tar filter cigarettes. Normal treatment options can be surgery, chemotherapy, and/or radiation.
Invasive lobular breast cancer makes up 8% of all breast cancers.2 This type of cancer usually metastasizes to unusual locations and often occurs bilaterally. The most common type of breast cancer occurs in the breast ducts.3 Risk factors include prior chest-wall radiation, prolonged hormone replacement, early menarche, advanced age, family history with an increased risk with a relative diagnosed at a younger age, and genetics.
A surgeon, oncologist, and radiation oncologist were contacted to evaluate Ms. B. She was not a surgical candidate for the lung cancer. The oncologist recommended giving the patient carboplatin (Paraplatin) and paclitaxel (Taxol). Mastectomy with lymph-node dissection was indicated for the invasive breast cancer. Mastectomy was not feasible, however, while Ms. B was getting chemotherapy secondary to wound healing.
Any treatment chosen would only be palliative in nature. Hospice was discussed at length, but Ms. B was not ready for such a step. She decided to begin with radiation therapy for the lung cancer, followed by chemotherapy. It was estimated that Ms. B had another six months to live at most. A hospice referral was done as follow-up to provide ample support.
Angela York, FNP-C, is a certified family nurse practitioner at United Health Care/Evercare in Colorado Springs, Co.
1. Jemal A, Bray F, Center MM, et al. Global cancer statistics. CA Cancer J Clin 2011;61:69-90.
2. Pestalozzi BC, Zahrieh D, Mallon E, et al. Distinct clinical and prognostic features of infiltrating lobular carcinoma of the breast: combined results of 15 International Breast Cancer Study Group clinical trials. J Clin Oncol 2008;26:3006-3014.
3. Li CI, Uribe DJ, Daling JR. Clinical characteristics of different histologic types of breast cancer. BR J Cancer 2005;93:1046-1052.