Painful axillary mass in a middle-aged woman

Abstract

CLINICAL PRESENTATION: (Dr. J. McNeil) A 57-yearold African-American woman was seen in the surgery clinic because of a painful left axillary mass that had been present for 6 weeks. During that time, the mass had markedly increased in size and had developed a foul-smelling purulent drainage. A mammogram performed 4 years earlier had been interpreted as normal, and no family history of breast disease existed. The patient’s medical history included hypertension and 10-packyears of tobacco abuse. She denied previous surgery. A review of systems was significant for a 30-pound weight loss over 5 months associated with intermittent fevers, chills, and night sweats. In addition, the patient described chronic fatigue and generalized myalgias. On physical examination, the patient was alert, oriented, and afebrile with stable vital signs. Her examination was significant for a 10 3 12-cm fungating mass located in the lateral aspect of her left breast with extension into the axilla (Fig. 1). The right breast and the remainder of her examination were unremarkable. Laboratory evaluation revealed a white blood cell count of 30,300, a hematocrit of 31.3 and a platelet count of 965,000. The serum chemistries included sodium 127, potassium 3.1, chloride 87, bicarbonate 23, and a calcium increased to 14.2. All renal and liver function tests were within the normal range. The patient was hospitalized for further management, including pain control, intravenous antibiotics, and treatment of the hypercalcemia. A computed tomography (CT) scan of the chest was obtained (Fig. 2). The left breast mass measured 12 3 12 cm and showed evidence of marked necrosis. Involvement of the underlying musculature as well as adjacent axillary lymphadenopathy appeared to exist. Two cystic areas suggestive of either necrotic lymph nodes or fluid collections were also visualized. Thoracic and abdominal CT imaging studies showed no evidence of distant metastases. Likewise, a bone scan and spine films were negative for definitive bony metastases. The patient underwent ultrasound-guided drainage of 500 ml of serosanguinous fluid, and a core biopsy specimen was obtained. Pathologic examination confirmed a grade 3 invasive ductal carcinoma. The tumor was estrogen receptor negative, progesterone receptor negative, borderline positive for c-erbB2/HER-2 oncoprotein, and positive for p53 tumor suppressor gene product. The Ki67 proliferation index was 53%. The medical oncology service was consulted, and chemotherapy was initiated with cyclophosphamide and doxorubicin. The patient was subsequently discharged on her eighth hospital day.