NYU Medical Grand Rounds Clinical Vignette

Elizabeth Selden, MD

PGY-2

November 8, 2011

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Patient NR is a 51 year old woman from the Philippines who presents for follow-up after recently diagnosed breast cancer status-post bilateral mastectomies

Chief Complaint

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Patient reports having had silicone injections in both breasts at age 20.

• Her older sister, who had undergone similar injections, developed breast cancer and underwent bilateral mastectomies.

• As a result, the patient has always been very conscious of any breast problems.

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

• One year prior to presentation, the patient’s gynecologist palpated a firm, non-mobile mass in her right breast on routine screening and patient was sent for bilateral MRIs.

• MRI revealed a suspicious lesion in the right breast as well as a slightly less suspicious lesion in the left breast.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

• Patient underwent biopsy of right breast and fine-needle aspiration of left breast.

• Pathology showed fibrocystic changes, but was otherwise negative.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

• Nine months prior to presentation, patient began experiencing new soreness and numbness of her left arm and noted a new mass in the inner superior quadrant of her left breast.

• She was sent for scintimammogram with Tc99 sestamibi which indicated an abnormality, but again fine needle aspirates were negative.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

• Despite negative FNA, patient insisted on a biopsy.

• She underwent incisional biopsy of the mass in her left breast.

• Frozen pathology of the biopsy was positive.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

History of Present Illness

• Patient underwent bilateral mastectomies which revealed a 2cm invasive cancer in the left breast and a 0.8cm cancer in the right breast.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History• Past Medical History:

• Hypertension

• Gynecologic history:• Menarche at age 17• No hormonal intake• Four children, first child born at age 25• Currently peri-menopausal

• Past Surgical History:• No additional surgical history

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Additional History continued• Social History:

• Denies tobacco, alcohol, drugs

• Family History:• Sister: breast cancer at age 41; two

cousins with breast cancer

• Allergies: No Known Drug Allergies

• Medications: Atenolol 50 mg daily

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Physical Examination

• General: Well appearing, normal weight, no distress

• Vital Signs: T: 98 BP:160/94 HR: 92 RR: 18 O2 sat: 99%

• Chest: bilateral mastectomy scars, with 2cm area that failed to close on left; mild chest wall edema

• Remainder of the physical exam normal

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

Diagnostic Tests

• Pathologic specimens from mastectomies and lymph node dissection revealed four positive nodes on the left and three on the right.

• Receptor status revealed positive estrogen and progesterone receptors, and Her2/neu expression negative.

•CT scan was done which was only notable for cholelithiasis.

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Bilateral invasive breast cancer, progesterone and estrogen receptor positive, Her2/Neu expression negative

Preliminary Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• On further testing, molecular pathology revealed Her2/Neu expression.

• Patient received adjuvant chemotherapy with doxorubicin and cyclophosphamide, followed by paclitaxel.

• She also received four doses of trastuzumab.

• Patient has been in remission now for 12 years.

Outpatient Course

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS

• Bilateral invasive breast carcinoma, progesterone and estrogen receptor positive, Her2/Neu expression positive

Final Diagnosis

UNITED STATES

DEPARTMENT OF VETERANS

AFFAIRS