Nyu medical grand rounds clinical vignette
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NYU Medical Grand Rounds Clinical Vignette. Elizabeth Selden, MD PGY-2 November 8, 2011. 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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Nyu medical grand rounds clinical vignette

NYU Medical Grand Rounds Clinical Vignette

Elizabeth Selden, MD

PGY-2

November 8, 2011

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS


Chief complaint

Chief Complaint

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


History of present illness

History of Present Illness

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 illness1

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.


History of present illness2

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.


History of present illness3

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.


History of present illness4

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.


History of present illness5

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.


Additional history

Additional History

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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


Additional history continued

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


Physical examination

Physical Examination

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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


Diagnostic tests

Diagnostic Tests

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

  • 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.


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Preliminary Diagnosis

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


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Outpatient Course

  • 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.


Nyu medical grand rounds clinical vignette

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Final Diagnosis

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


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