This is an 86-year-old Caucasian male with a 20 year history of right-sided breast cancer. He presented to the emergency department with complaints of an ulcerated, hemorrhaging right anterior chest mass. Patient was noted to be a poor historian with a history of dementia. He was alert and oriented only to person and time.
Pertinent surgical history included a right total mastectomy 20 years ago. Patient did not receive adjuvant radiation, chemotherapy, or hormone therapy post-operatively. He also refused further medical care. Per the family, the patient developed a mass on his anterior chest wall approximately two years ago. The mass progressed in size, began to ulcerate and eventually the patient was brought to the emergency department after it began to bleed.
The patient's past medical history also includes bipolar disorder, dementia, and hypertension. His surgical history is significant for a right-sided mastectomy. Current medications include: Lithium 300 mg daily. He has no known drug allergies. His mother had colon cancer, otherwise, no family history of breast cancer. Patient is married and has been retired since the age of 62. His wife suffers from new onset dementia, atrial fibrillation, chronic anemia, chronic kidney disease one son has history of bipolar disease, but is functional, and helps his parents with some of the activities of daily living. His second son lives out of state. The family has the support of a family-friend who has been helping the family through the years. Patient has a remote history of smoking cigarettes and cigars, but denies use of alcohol or recreational drugs.
Vital signs on day of admission were normal with a temperature of 97.4°F, pulse of 80, respiratory rate of 14, pulse oximetry of 100% on room air. Blood pressure was elevated at 162/88. Examination findings were remarkable for a right-sided pedunculated 8 cm × 7 cm mass with a cauliflower-like appearance. The mass was ulcerated, erythematous, malodorous, and with scant bleeding (Figures 1 &2).
Laboratory studies showed a white blood cell count 6,500, hemoglobin 12.4, hematocrit 36.2 and platelet count 178,000. Chemistry profile revealed a creatinine of 1.72 and glucose 106. The remainder was within normal limits.
An initial chest X-ray revealed findings suspicious for prior right-sided mastectomy, as well as a prominent superior mediastinum suggesting a nonspecific mediastinal mass or adenopathy. A CT chest showed a soft tissue mass in right chest wall measuring 5.2 × 2.75 × 5 cm with post-operative changes of the right axilla. CT Head showed no intracranial hemorrhage, mass effect or shift. CT abdomen and pelvis confirmed the anterior chest wall mass, but there was no evidence of metastatic deposits within the abdomen or pelvis. A bone scan also ruled out metastatic disease.
An incisional biopsy of the right breast mass was performed. Pathology returned features consistent with recurrent moderately differentiated duct carcinoma of the breast with ulceration of overlying epithelium. Nottingham combined histologic grade was T3N3M1. Breast studies returned estrogen receptor positive and progesterone receptor positive. HER-2/neu by FISH methodology was normal.
Patient was discharged to a skilled nursing facility and started on hormone therapy with tamoxifen 20 mg daily with one course of palliative radiation. An oncology evaluation determined that patient is not a candidate for curative treatment. During an initial meeting with the family at the nursing home, the family verbalized concerns over the patient's primary caregiver's well being and state of health and stated she was not able to properly care for her husband. Hospice care was recommended, and family agreed. Currently the patient is in a skilled nursing facility with hospice. His wife has been admitted to the same nursing facility due to general deconditioning.