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NYU Medical Grand Rounds Clinical Vignette

NYU Medical Grand Rounds Clinical Vignette. Daniel P. Eiras, MD, MPH PGY2 December 1, 2010. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS. Chief Complaint. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS.

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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Daniel P. Eiras, MD, MPH PGY2 December 1, 2010 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. Chief Complaint UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • 49 year old Malaysian woman who presented to the Bellevue Clinic with a right breast mass that she had noticed for one month

  3. History of Present Illness UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • The patient was in her usual state of health until several months prior to admission when she noticed a painless lump in her right axilla • One month prior to admission, she noticed a second lump in her right breast • Given the above findings she presented to Bellevue Clinic for evaluation

  4. Additional History UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Past Medical History: • G5P3 with two miscarriages • Past Surgical History • None • Social History: • The patient works as a hair stylist. She has no history of tobacco, alcohol or drug use. • Family History: • No history of cancer • Allergies: • No known drug allergies • Medications: • None

  5. Physical Examination UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • General: Comfortable, appears stated age • T: 97.7, BP: 138/90, HR: 74, RR: 16, O2 sat: 98% on room air • Breast Exam: • Palpable 2 x 2.5cm breast mass at the 10 o’clock position • Palpable 3cm oblong lymph node in the right axilla • Remainder of physical exam was normal

  6. Laboratory Findings UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • CBC: within normal limits • Basic metabolic panel: within normal limits • Hepatic panel: within normal limits

  7. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Differential Diagnosis Breast mass secondary to breast cancer, versus breast cyst, fibroadenoma, or lipoma.

  8. Diagnostic Mammogram UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  9. Other Studies UNITED STATES DEPARTMENT OF VETERANS AFFAIRS • Breast ultrasound • 4.1cm lobulated mass in the right axillary tail • 1.7cm irregular mass at the 10 o'clock position in the right breast

  10. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Interim History • A fine needle aspirate of the two masses was performed and was positive for adenocarcinoma • A core biopsyrevealed poorly differentiated invasive ductal carcinoma

  11. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Additional Studies • Immunohistochemistry • -Negative for estrogen and progesterone receptors • -Human Epidermal growth factor Receptor 2 (Her2/Neu) score was 2+ (equivocal) • -Ki-67 proliferation index was 85% (high) • -Fluorescence in situ hybridization for Her2/Neu was negative

  12. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Other Studies • Positron Emission Tomography/CAT Scan • -2 x 1.7cm malignant lesion in the right breast (standardized uptake value 8.5) • -Multiple metastatic lymph nodes • (maximum standardized uptake value 10.4) • -Negative for distant metastases

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Working Diagnosis • T2N2M0, stage IIIA, ER-PR-Her2 triple negative, poorly differentiated, invasive ductal adenocarcinoma

  14. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Interim History • The patient was enrolled in neoadjuvant protocol • She received taxol 30mg/m2 twice a week for 6 weeks, with concurrent radiation therapy for 6 weeks • This was followed by an additional 6 weeks of taxol

  15. Follow-up Diagnostic Mammogram UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  16. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Interim History • The patient underwent a right modified radical mastectomy • Pathology of 11 lymph nodes was negative for tumor • She then began adjuvant chemotherapy twice weekly for four cycles • She received doxorubicin 60mg/m2, cyclophosphamide 600mg/m2 as well as neupogen x 5 for each cycle

  17. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Interim History The patient has been in complete pathological remission for seven months.

  18. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • T2N2M0, stage IIIA, (Surgical staging T0N0M0), ER-PR-Her2 triple negative, poorly differentiated, invasive ductal adenocarcinoma, treated with neoadjuvant chemotherapy, surgery, and adjuvant chemotherapy, now in complete pathological remission.

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