\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[english]{babel}



\usepackage{float}








\begin{document}

\title{Metastatic breast cancer with a large fungating breast mass in a
developed country: A caveat to our strategy}



\author[1]{Justine Chinnappan}%
\author[1]{Huda Marcus}%
\author[1]{Thair Dawood}%
\author[1]{Ghassan Bachuwa}%
\affil[1]{Hurley Medical Center}%


\vspace{-1em}



  
  \date{May 14, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup








\sloppy


\textbf{Metastatic breast cancer with a large fungating breast mass in a
developed country: A caveat to our strategy}

\textbf{Justine Chinnappan MD\textsuperscript{1}, Huda Marcus
MD\textsuperscript{1}, Thair Dawood MD\textsuperscript{1}, Ghassan
Bachuwa MD, MS, MHSA, FACP, AGSF\textsuperscript{1}}

\textsuperscript{1}Department of Internal Medicine. Michigan State
University at Hurley Medical Center, Flint, MI -- 48502

\textbf{Correspondence:}

Justine Chinnappan, MD

Hurley Medical Center

One Hurley Plaza

Flint, MI -- 48503

1872040319

USA

\textbf{Abstract:}

A 49-years-old female presented with severe persistent headache. Further
evaluation unraveled fungating right breast mass and a new diagnosis of
poorly differentiated invasive ductal carcinoma with brain metastasis as
the cause of the symptoms was made. Diagnosis of breast cancer with
large fungating mass and brain metastasis on presentation in this era is
still shocking. It makes us question the reasons behind these
unfortunate presentations which include but are not limited to:
unawareness about the risk factors, symptoms, complications and the
available screening guidelines, embarrassment from the site of lesion,
or socioeconomic status.

\textbf{Key Clinical Message}

Discussion about breast cancer and screening mammogram at 40-49 years
will create awareness about it and encourage females volunteer any
abnormalities. Breast examination at every annual physical visit should
be encouraged among physicians.

\textbf{Key Words:} Diaphragmatic herniation, caudate lobe of the liver,
posterior mediastinal mass

\textbf{Case History:}

Breast cancer is the most common cancer and is the second most cause of
cancer death in the United States. Despite various measures, there are
still patients presenting in advanced stages of cancer making us wonder
about the effectiveness of these measures in the healthcare system and
the need for further intervention.{[}1,2{]}

Question: What is one of the differential diagnoses of persistent
worsening headache?

\textbf{Answer:}

We present a case of breast cancer with brain metastasis at initial
presentation in a developed country.

A 49-years-old female presented to the emergency department with
progressive worsening of headache of 1 week duration. She also endorsed
a mass in the right breast which started as a lump 10 months ago, which
continued to increase in size, associated with tenderness, episodes of
bleeding and purulent drainage. Other significant histories include
hypertension not on treatment, does not have a primary care physician,
no prior mammogram, 5 healthy living children who were breastfed, no
history of alcohol consumption or smoking, history of pancreatic cancer
in mother at 60's and breast cancer in aunt at 50's and paternal cousin
at 40's. On presentation she was hypertensive, in acute distress due to
pain and examination was significant for a large ulcerated fungating
right breast mass(Figure 1) with multiple right axillary lymphadenopathy
and without neurological deficits.

Ultrasound of the right breast showed 8.6 x 8 cm heterogeneous mass with
blood flow. Computed tomography (CT) of the chest revealed 8.6 x 8.5 cm
mass in the right breast with surrounding skin thickening and right
axillary lymphadenopathy(Figure 2) . Magnetic resonance imaging (MRI) of
head revealed 1.8 x 2.1 cm enhancing left cerebellar lesion with
adjacent vasogenic edema and mass effect on the 4th ventricle(Figure3,
Figure 4). Nuclear medicine bone scan was significant for a single
osseous metastatic lesion in the left femoral neck. Needle biopsy of the
breast tissue confirmed the diagnosis of poorly differentiated invasive
ductal carcinoma which was ER-, PR- and Her-2/neu - with
Ki-67(proliferative index) immunostaining positive in 35\% of tumor
cells. BRCA-2 gene testing was negative. Patient underwent multiple
cycles of stereotactic radiosurgery to the brain and
Pembrolizumab-Gemcitabine-Carboplatin chemotherapy. Follow-up at 15
months with CT of chest, abdomen and pelvis revealed reduction in size
of primary breast mass and right axillary lymphadenopathy but developed
7 new hepatic lesions and abdominal lymphadenopathy. The needle biopsy
of the liver showed metastatic lesion consistent with primary breast
cancer which is triple receptor negative. She continues to receive
chemotherapy with close follow-up.

\textbf{FUNDING:} None.

\textbf{ACKOWLEDGMENT:} None.

\textbf{CONFLICT OF INTEREST:} None.

\textbf{ETHICAL APPROVAL AND CONSENT STATEMENT:} Published with
appropriate informed

written consent from the patient.

\textbf{AUTHOR CONTRIBUTIONS:}

Justine Chinnappan involved in acquisition, draft, and review. Huda
Marcus involved in acquisition, draft, and review. Thair Dawood involved
in conception and review. Ghassan Bachuwa involved in review.

\textbf{DATA AVAILABILITY STATEMENT:}

Data sharing is not applicable to this article as no new data were
created or analyzed in this study.

\textbf{REFERENCES:}

1. Lei S, Zheng R, Zhang S, et al. Global patterns of breast cancer
incidence and mortality: A population-based cancer registry data
analysis from 2000 to 2020. Cancer Commun (Lond). 2021;41(11):1183-1194.
doi:10.1002/cac2.12207

2. Ugalde I, Pirela D. Fungating breast mass in a developed country. BMJ
Case Rep. 2018;2018:bcr2018224727. Published 2018 Apr 26.
doi:10.1136/bcr-2018-224727\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-1/Figure-1}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-2/Figure-2}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-3/Figure-3}

\end{center}
\end{figure}\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/Figure-4/Figure-4}

\end{center}
\end{figure}

\selectlanguage{english}
\FloatBarrier
\end{document}

