Transcript Journal Club - NYU Langone Medical Center

NYU Medical Grand Rounds
Clinical Vignette
Denise Pate MD, PGY-2
January 27, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
A 51-year-old woman presents for consultation
after being diagnosed with bilateral breast
cancer and undergoing radical mastectomy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient was in her usual state of health until 1
year prior to presentation when she felt a mass in her
right breast in the 6 o’clock position.
• A mammogram was performed but was unreadable
secondary to previous silicon injections.
• A bilateral breast MRI was performed and was
suspicious for bilateral malignancies.
• Biopsies of both breast masses were benign.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• One year later, the patient presented with soreness and
numbness of her left arm.
• A biltateral scintimammogram was performed and was
suspicious for malignancy of the left breast.
• Lumpectomy demonstrated malignancy was present.
• A modified bilateral radical mastectomy was performed,
and she now presents for further care.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
Past Medical History
• Hypertension
• Silicon injection
• Bilateral breasts
Past Surgical History
• None
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Family History
• Breast cancer in:
• Sister
• Two first cousins
Social History
• Born in Philippines
• Works as an attorney
• Lifetime non-smoker
• Rare alcohol use
• Denies illicit drug use
Outpatient Medications
Atenolol 50mg Daily
Allergies: No known allergies
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
General: Well-appearing woman in no acute distress
Vitals: T 98.2F, BP 160/94, HR 92, RR 15
O2 saturation: 97% on room air
Chest: Well-healed bilateral mastectomy
The remainder of the physical exam was normal.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Studies
• CBC: Within normal limits
• Basic Metabolic Panel: Within normal limits
• Hepatic Panel: Within normal limits
• CA 15-3: 10.9 U/ml (0-30 U/ml)
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Imaging Studies
• CT of Chest/Abdomen/Pelvis
• Multiple small gallstones
• Radionuclide Bone Imaging, total body
• No evidence of metastatic bone disease
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Pathology results
• Left breast:
• Invasive ductal carcinoma with comedocarcinoma
• 4/6 axillary lymph nodes were positive
• Right breast:
•Fibrocystic disease with a focus of comedocarcinoma
• 2/19 axillary lymph nodes were positive
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
Bilateral breast carcinoma
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Oncologic Course
• Further testing demonstrated the tumor was:
• Estrogen Receptor positive
• Progesterone Receptor positive
• HER2 positive
• 3+ by immunohistochemistry, bilaterally
• The patient underwent chemotherapy with adriamycin
and cyclophosphamide, followed by further treatment
with paclitaxel and trastuzumab (Herceptin).
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Oncologic Course
• Additional adjuvant radiation therapy was performed.
• The patient was then treated with tamoxifen for 5 years
without evidence of recurrence.
• After this time, she was switched to letrozole (Femara).
• 10 years after her initial diganosis, the patient remains
disease-free.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
Bilateral, node-positive breast carcinoma,
currently disease free for 10 years.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS