Question

A 75-year-old hypertensive woman has a 2 x 2 cm infiltrating duct cell carcinoma in the subareolar region of the breast. There are no palpable lymph nodes or distant metastases; however, she was treated for pulmonary tuberculosis 20 years ago. The best line of management for her would be:

• A. Modified radical mastectomy followed by radiotherapy
• B. Modified radical mastectomy followed by 6 cycles of chemotherapy
• C. Breast conservation surgery followed by radiotherapy
• D. Modified radical mastectomy followed by hormone therapy

Hint:

Think about which treatments are safe given her old TB and her age.

Answer 1

The Correct Option is D

Step 1: Understanding the Question:
An elderly (75-year-old) patient has a small, node-negative infiltrating duct carcinoma in the subareolar region, with a remote history of pulmonary tuberculosis. The question tests how patient age, tumor location, and past lung disease should modify standard breast cancer treatment.

Step 2: Key Concept or Approach:
Standard therapy for early operable breast cancer is either breast conservation surgery with radiotherapy, or modified radical mastectomy (MRM), both giving equivalent survival. The choice depends on tumor location relative to the breast, and on patient-specific factors. A subareolar tumor is technically and cosmetically harder to conserve, since it usually needs central or nipple-areolar excision and carries a higher local recurrence rate with conservation. Old healed pulmonary tuberculosis is a relative contraindication to chest wall or breast irradiation, because radiation can reactivate quiescent TB foci and worsens pre-existing lung damage, raising the risk of radiation pneumonitis. Elderly patients, whose breast cancers are usually hormone receptor-positive, generally do better with adjuvant hormone therapy such as tamoxifen than with aggressive chemotherapy, which they tolerate poorly.

Step 3: Working Through the Options:
MRM followed by radiotherapy is unwise given her TB history, since radiotherapy risks reactivating old disease in an already compromised lung. MRM followed by 6 cycles of chemotherapy exposes a 75-year-old to significant toxicity for a small, node-negative, likely hormone-sensitive tumor, which is excessive. Breast conservation followed by radiotherapy is unsuitable for two reasons at once: the subareolar location makes conservation technically difficult, and radiotherapy again clashes with her TB history. Modified radical mastectomy followed by hormone therapy avoids the need for radiotherapy altogether, since mastectomy removes the breast tissue and a small node-negative tumor does not routinely need chest wall irradiation, and it uses well-tolerated, effective hormone therapy suited to an elderly, likely receptor-positive tumor.

Step 4: Conclusion:
The best management is modified radical mastectomy followed by hormone therapy.