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NYU Medical Grand Rounds Clinical Vignette

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  1. NYU Medical Grand Rounds Clinical Vignette Elizabeth Selden, MD PGY-2 November 8, 2011 UNITED STATES DEPARTMENT OF VETERANS AFFAIRS

  2. 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

  3. 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.

  4. 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.

  5. 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.

  6. 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.

  7. 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.

  8. 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.

  9. 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

  10. 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

  11. 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

  12. 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.

  13. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Preliminary Diagnosis • Bilateral invasive breast cancer, progesterone and estrogen receptor positive, Her2/Neu expression negative

  14. 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.

  15. UNITED STATES DEPARTMENT OF VETERANS AFFAIRS Final Diagnosis • Bilateral invasive breast carcinoma, progesterone and estrogen receptor positive, Her2/Neu expression positive