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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

Elizabeth Selden, MD

PGY-2

November 8, 2011

UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS


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

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.


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.


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


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

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

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.


UNITED STATES

DEPARTMENT OF VETERANS AFFAIRS

Preliminary Diagnosis

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


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.


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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