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Patient profile:A 55 years old female patient was admitted in female surgical ward on 27/9/11c/o breast pain and nipple discharge o/e T4b , N1 , M0 B.P-130/80 mm hgPast medical history: 8/2/10 no pain/discharge 2 months h/o breast lymphoma gradually increase in size o/e 4x3cm firm mobile skin involvement medial group of nodes positive mobile

Breast lymphoma Poorly differentiated duct cell carcinoma Advised exisional biopsy

13/2/10: Plan for MRM(modified radical mastectomy) B.p:110/80 H.b:9.7mmhg Rbs:105mg/dl Serum.creatine:0.6mg/dl Sr.calcium:9.4mg/dl ALP:112iu/ml No h/o chest pain No h/o DM/HTN Transfuse 2 units PRBS before operation

Risk factors for breast cancer development: Personal history of breast cancer Family history of breast Cancer in first degree relatives Prolifarative bening breast disease Early menarch,late menopause First pregnancy after age 35 Exogenous estrogens Obesity Dietary factors alcohol high fat diet Present medical history:27/9/11:

parameterNormal value Observed valueH.b9.2mg/dl11-16.5g/dlRBS 105mg/dl110-180mg/dlsr. creatinine 0.6mg/dl0.5-0.9mg/dlSr.calcium11mg/dl8.4-10.8mg/dlLDH350U/LAlbumin 4.3g/dl3.5-5.0g/dlT . protiens6.86.8-8.3g/dlSGOT246-38u/lSGPT106-38u/lALP9036-142mu/mlBil . total0.40.5-1.1mg/dl Truent biopsy was done: ER,PR&HER-2nm status RX T.brufen 400mg for four days 5/10/11: T4b N1 MX plan for neo adjuvent therapy 8/10/11: normal sited cardiac chamber sclerotic aortic valve,no RWMA,no MR/TR ,trivial AR,no PAM impaired diastolic compliance normal LV/RV systolic function First cycle of neo adjuent chemotherapy from (9/10/11 to 13/10/11)

Reason for selection of Neoadjuvent therapy:Patient diagnosed with locally advanced breast cancer(stage III disease) have tumors larger than 5 cm or direct tumor involvement of the skin or chest wall.These patients also have extensive lymph node involvement because bulk of disease at the time diagnosis ,surgical management is generally not feasible.Because of success of neoadjuvant therapy in the treatment of locally advanced disease, investigators are beginning to explore the use of neoadjuvent therapy in early stage diseaseThe results from a preliminary study conducted by NSABP indicated that preoperative doxorubicin and cyclophosphamide reduced the size of most tumors and decrease incidence of positive nodes at the time of surgery.

First cycle chemotherapy: DAY 1: ing.dexamethasone 20mg in 100ml of NS over half an hour inj.ondansetron 8mg i.v stat + ranitidine 50mg i.v stat inj.cyclophosphamide 54mg in 100ml NS over15-20min inj.adriamycin 54mg in 100ml NS over 15-20min tab.lorazepam 1mg DAY 2: tab.decadron 8mg Q12 hr + T.ranitidine 150mg Q12 hr tab.ondansetron 8mg Q8 hr + T.lorazepam 1mg HS DAY 3: Same as day 2 DAY 4: Decadron 4mg &same as day 2 DAY 5: Same as day 4

During the cycle the patient developed loose stools, vomiting & nutropenia RX tab.ciprofloxacin 500mg bd 4 days tab.augmentin 625mg tid tab.neurobin od tab.hemsi od 21 days cap.omeprazole20mg tab.emeset 4mg sos for 5 days Discharge on 26/10/11 After 5 days for count PLAN: second cycle was planed from( 1/11/11 to12/11/11) 80% chemotherapy along with GMCSF for all cycles & to start GCSF 24 hr after chemotherapy has been completed for 5 days

Second cycle chemotherapy: DAY 1: ing.dexamethasone 20mg in 100ml of NS over half an hour inj.ondansetron 8mg i.v stat + ranitidine 50mg i.v stat inj.cyclophosphamide 50mg in 100ml NS over15-20min inj.adriamycin 50mg in 100ml NS over 15-20min tab.lorazepam 1mg hs DAY 2: tab.decadron 8mg Q12 hr + tab.ranitidine 150mg Q12 hr tab.ondansetron 8mg Q8 hr + tab.lorazepam 1mg HS DAY 3: Same as day 2 DAY 4: Decadron 4mg &same as day 2 DAY 5: Same as day 4

18/11/11: H.b:8.6 Serum creatinine:0.6mg/dl Total count:5600 Monocytes:3.5 Lymphocytes:19.8 Neutrophils:76.7 Third cycle of chemotherap was planed from 22/11/11 to 27/11/11Third cycle chemotherapy: DAY 1: ing.dexamethasone 20mg in 100ml of NS over half an hour inj.ondansetron 8mg i.v stat + ranitidine 50mg i.v stat inj.cyclophosphamide 54mg in 100ml NS over15-20min inj.adriamycin 54mg in 100ml NS over 15-20min tab.lorazepam 1mg DAY 2: tab.decadron 8mg Q12 hr + T.ranitidine 150mg Q12 hr tab.ondansetron 8mg Q8 hr + T.lorazepam 1mg HS DAY 3: Same as day 2 DAY 4: Decadron 4mg &same as day 2 DAY 5: Same as day 4

Patient was started on filgrastim from second day of chemotherapy as adviced after taking two doses. Patient had total count 34,600/cum Filgrastim was stopped patient was asymptomatic throuh out the cycle . RX CAP.omeprazole 20mg bd T.neurobin od 21 days T.hemsi od T.emeset 4mg sos Plan: After 5 days for counts (2-12-2011) reassessment of breast mass. Further management ( surgery/ chemotherapy). 2 DEC 2011: B.P: 110/80 mm hg; Plan: Salvage mastectomy on 13-12-2011; Hb : 9.5 mg/dl; TC : 3100 cells/cum; DC Neutrophils: 69%; Platelets: 3,56,000 cells/cum; Sr.Creatinine: 0.6 mg/dl.5 DEC 2011; B.P : 110/70 mm hg; Hb : 9.4 g/dl; MPV : 6.6 fl; TC : 3600 cells/cum; RBC : 3.4x 10^12 cells/l Neutrophils : 66.6 %; PCV : 28.3 Sr.Creatinine : 0.5 mg/dl Rx RDWA : 79.1 fl cap omeprazole 20 mg for 1 week bland diet 13 DEC 2011: received 3 cycles of neoadjuvant chemotherapy with 80% AC regimen Patient has responded for treatment.O/E : Tumour size reduced; fixed to the overlying skin and no lymph node palpable; Salvage mastectomy Rx inj. T.T 0.5ml start IM; Inj. Cefazoline 1g stat IV; Tab. Ranitidine 50 mg hs oral; Tab. Diazepam 5mg hs oral;14 DEC 2011: post operative medication RX inj. Cefazolin 500mg i.v Q8 H inj. Pantaprazole 40mg i.v OD inj. Tramadol 50mg i.v Q8 H inj. Dalteparin 2500 units s/c operation record: whole breast including nipple areole & pectoral fascia dissected off from pectradis.Interpectoral tissue taken out. Axillary dissection done upto axillary vein above LD muscle laterally long thoracic nerve &thoracodorsal complex. 15 DEC 2011: H.B:8g/dl; RX inj. Diclofenac 75mg bd i.m; 16 DEC 2011: RX Tab. Livogen bd; Tab. Vit c; inj. Cefazoline 500mg tid i.v; inj. Pantaprazole 40mg od i.v;Brand nameGeneric nameDose R .O. AfrequencyTime regimenInj.dalteparin2500 iu s.c17-18/12/11Inj. voveranInj. diclofenac75mgi.mbd17-18/12/11Inj.cefazolinInj. cefazolin500mgi.vtid17-21/12/11Tab.livogenTab.ferrous sulfate+folic acidoralbd17-22/12/11Tab. Vit coraltid17-22/12/11Cap.omezCap.omeprazole20mgoralbd17-21/12/11T.brufenTab.ibuprofen400mgoralbd19-22/12/11Inj. pantopInj.pantaprazole40mgi.vod17&20/12Patient was discharged on 22/12/11Risk factors for breast cancer development: Personal history of breast cancer Family history of breast Cancer in first degree relatives Prolifarative bening breast disease Early menarch,late menopause First pregnancy after age 35 Exogenous estrogens Obesity Dietary factors alcohol high fat diet