The patient is a 62 year old white male with a past history of alcohol abuse who presented with a one year history of pruritis in the right subareolar region. Approximately seven months ago he noted the development of a subareolar mass with subsequent ulceration. He was seen by a dermatologist and a breast biopsy was performed. This was found to be poorly differentiated adenocarcinoma with lymphatic invasion. Mammograms were then performed revealing a 2 cm mass in the right subareolar region without associated calcifications. Chest X-ray and liver function studies were unremarkable. Bone scan revealed no evidence of metastatic disease. Physical exam was notable for a firm 2 cm right subareolar mass with excoriation and ulceration of the overlying skin. A clinically positive right axillary lymph node was also noted.
A right modified radical mastectomy was performed and pathologic review of the surgical specimen revealed a 2 cm invasive ductal carcinoma with high nuclear and histologic grade and lymphatic invasion. The surgical margins were negative. Estrogen and progesterone receptors were positive. Axillary lymph node dissection revealed 5/18 nodes positive for tumor.
The patient then underwent postoperative chemotherapy consisting of four cycles of cytoxan and adriamycin. He was also started on Tamoxifen therapy. After completion of his chemotherapy, the patient then underwent adjuvant radiation therapy. The right chest wall was treated to a total dose of 5000 cGy in 200 cGy fractions using 6 MV photons via opposed tangential fields with 1 cm of bolus used daily. The right supraclavicular region was treated to a total dose of 4600 cGy in 200 cGy fractions using 6 MV photons using a single anterior field prescribed to a depth of 3 cm. A posterior axillary boost was also delivered to bring the total axillary midplane dose to 4600 cGy. The patient tolerated his therapy well and remains clinically without evidence of disease.