M.D. is a 50-year-old woman whose routine mammogram showed a 2.3 × 4.5 cm lobula
ID: 239842 • Letter: M
Question
M.D. is a 50-year-old woman whose routine mammogram showed a 2.3 × 4.5 cm lobulated mass at the 3:00 position in her left breast. M.D. underwent a stereotactic needle biopsy and was diagnosed with infiltrating ductal carcinoma that was both estrogen and progesterone receptor positive. The staging workup was negative for distant metastasis. Her final staging was stage IIB. She had a modified radical mastectomy with lymph node dissection. The sentinel lymph node and 11 of 16 lymph nodes were positive for tumor cells. An implanted port was placed during surgery. She is prescribed a chemotherapy regimen of six cycles of CAF (cyclophosphamide [Cytoxan], fluorouracil [5-FU], and doxorubicin [Adriamycin]).
1. Describe the biopsy technique used to diagnosis M.D.'s cancer. 2.
Discuss the implications of a positive sentinel node.
3. Using the TNM staging system, what would her classification be?
4. What is the significance of her hormone receptor status?
5. Surgical intervention is the primary treatment for breast cancer. Describe the surgical procedure that M.D. had.
6. M.D. asks you why she has to have chemotherapy with so many drugs if the surgeon removed all of the cancer. How would you respond?
7. Compare the drug actions of cyclophosphamide (Cytoxan), fluorouracil (5-FU), and doxorubicin (Adriamycin).
8. List any side effects and special considerations associated with the use of CAF.
9. M.D. is ordered doxorubicin at 75 mg/m 2 . Her height is 5 feet, 7 inches, and her weight is 155 pounds. Calculate the dose she will receive.
10. You have finished teaching M.D. regarding the effects of CAF. You know that she understands instructions regarding cyclophosphamide (Cytoxan) when she states: a. “This medication should be taken with food.” b. “I will drink 2000 to 3000 mL of fluids each day.” c. “Taking this drug at nighttime will reduce nausea.” d. “I will increase my intake of foods with potassium.”
CASE STUDY PROGRESS M.D. has now completed three cycles of CAF. Her last treatment with doxorubicin, cyclophosphamide, and 5-fluorouracil was approximately 12 days ago. She comes to the emergency department with a 2-day history of fever, chills, and shortness of breath. On arrival, she is disoriented and agitated. Vital signs are 86/43, 119, 28, 103.6° F (39.8° C), Sa O 2 85% on room air. Chest x-ray demonstrates diffuse infiltrates in the left lower lung. Her chem 14 is within normal limits, with the exception of BUN 28 mg/dL, creatinine 1.6 mg/dL, and lactic acid 2.4 mg/dL.
11. Interpret M.D.'s CBC results.
12. Calculate M.D.'s absolute neutrophil count (ANC) and describe its significance. Complete Blood Count WBC 1200/mm 3 Neutrophils 34% Segmented (Polys) 30% Bands 4% Lymphocytes 60% Monocytes 3% Eosinophils and basophils 2% Hct 24.9% Hgb 8.7 g/dL Platelets 85,000/mm 3 The infection risk is as follows: Risk AGC (per mm 3 ) Not significant 1500-2000 Minimal 1000-1500 Moderate 500-1000 Severe < 500
13. What is the single most important nursing intervention for a patient with an ANC less than 500/mm 3 ?
14. What are the probable causes of the abnormal laboratory findings listed previously?
15. What is the significance of the lactic acid level?
16. What treatment do you anticipate for M.D.?
17. The physician orders a 500-mL normal saline bolus now, with orders to infuse over 2 hours. You decide to use M.D.'s implanted port for IV access. After accessing the port and connecting the fluid, the infusion pump alarms that the line is occluded. What will you do? M.D. requires endotracheal intubation and spends 3 days in the ICU receiving antibiotics and respiratory support. She is able to be extubated and returns to the oncology unit, where she remains for a few more days before being discharged to home.
Explanation / Answer
Strtctic Brst Bipsy
strtctic brst bipsy is prcdur tht uss mmmgrphy t prcisly idntify nd bipsy n bnrmlity within th brst. It’s nrmlly dn whn th rdilgist ss suspicius bnrmlity n yur mmmgrm tht cn’t b flt in physicl xm. This prcdur will hlp dtrmin whthr yu hv brst cncr r ny thr bnrmlitis in yur brst t b cncrnd but.
mmmgrphy is spcil frm f X-ry usd n th brsts. It’s rcmmndd s prvnttiv scrning tl fr brst cncr in wmn vr th g f 40.
Strtctic brst bipsis us mmmgrphic X-rys t lct nd trgt th r f cncrn nd t hlp guid th bipsy ndl t prcis lctin. This tchniqu hlps nsur tht th r tht is bipsid is th xct r whr th bnrmlity ws sn n th mmmgrm. It’s clld strtctic bcus it utilizs tw imgs tkn frm slightly diffrnt ngls f th sm lctin.
ftr th smpl is cllctd, it’s snt t pthlgy lb t dtrmin if thr r cncr clls prsnt.
Brst Cncr Clls in Sntinl Lymph Nd
lrg study fund tht wmn dignsd with rly-stg brst cncr with ccult mtstss in th sntinl lymph nd hd th sm survivl rts s wmn dignsd with rly-stg brst cncr withut ccult mtstss in th sntinl lymph nd.
Th sntinl lymph nd (SLN) is th undrrm (xillry) lymph nd clsst t brst cncr. During surgry t rmv rly-stg brst cncr, th sntinl nd ftn is rmvd nd snt t pthlgist wh dtrmins if thr is cncr in it. Rmving just th sntinl nd is clld sntinl nd bipsy r sntinl nd dissctin.
Sntinl nd dissctin my b dn vn if th sntinl nd lks nrml nd shws n signs f cncr n n ultrsund r x-ry. Dctrs cll this "cliniclly ngtiv." Still, pthlgist my find singl cncr clls r smll grups f cncr clls in sntinl nd tht is cliniclly ngtiv. Ths singl nd smll grups f cncr clls r clld ccult mtstss r micrmtstss. ccult mns th mtstss r hiddn r nt sily sn. Sm dctrs ls lk fr ccult brst cncr mtstss in bn mrrw by ding bn mrrw bipsy.
Bfr this study, it wsn't clr hw imprtnt ccult mtstss in th sntinl lymph nd nd/r bn mrrw r. vn s, mny dctrs blivd tht wmn dignsd with rly-stg brst cncr with ccult mtstss in th sntinl nd nd/r bn mrrw hv wrs prgnsis thn wmn withut mtstss in ithr plc. dctr wh blivs this my rcmmnd mr ggrssiv trtmnt pln if ccult mtstss r fund.
Brst Cncr Stgs
ftr smn is dignsd with brst cncr, dctrs will try t figur ut if it hs sprd, nd if s, hw fr. This prcss is clld stging. Th stg f cncr dscribs hw much cncr is in th bdy. It hlps dtrmin hw srius th cncr is nd hw bst t trt it. Dctrs ls us cncr's stg whn tlking but survivl sttistics.
Th rlist stg brst cncrs r stg 0 (crcinm in situ). It thn rngs frm stg I (1) thrugh IV (4). s rul, th lwr th numbr, th lss th cncr hs sprd. highr numbr, such s stg IV, mns cncr hs sprd mr. nd within stg, n rlir lttr mns lwr stg.
Th stging systm mst ftn usd fr brst cncr is th mricn Jint Cmmitt n Cncr (AJCC) TNM systm, which is bsd n 7 ky pics f infrmtin:
nctyp Dx® Rcurrnc Scr rsults my ls b cnsidrd in th stg in crtin circumstncs.
Th mst rcnt AJCC systm, ffctiv Jnury 2018, hs bth clinicl nd pthlgic stging systms fr brst cncr. Th pthlgic stg (ls clld th surgicl stg) is dtrmind by xmining tissu rmvd during n prtin. Smtims, if surgry is nt pssibl right wy r t ll, th cncr will b givn clinicl stg instd. This is bsd n th rsults f physicl xm, bipsy, nd imging tsts. Th clinicl stg is usd t hlp pln trtmnt. Smtims, thugh, th cncr hs sprd furthr thn th clinicl stg stimts, nd my nt prdict th ptint’s utlk s ccurtly s pthlgic stg.
Numbrs r lttrs ftr T, N, nd M prvid mr dtils but ch f ths fctrs. Highr numbrs mn th cncr is mr dvncd. nc prsn’s T, N, nd M ctgris, s wll s ER, PR, Hr2 sttus nd grd f th cncr hv bn dtrmind, this infrmtin is cmbind in prcss clld stg gruping t ssign n vrll stg. Fr mr infrmtin s Cncr Stging. Dtild xplntins f th TNM ctgris r sn blw. Th dditin f infrmtin but ER, PR, nd Hr2 sttus lng with grd hs md stg gruping cmplx, s, it is bst t sk yur dctr but yur spcific stg nd wht it mns.
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