NYU Medical Grand Rounds Clinical Vignette

Daniel P. Eiras, MD, MPH

PGY2

December 1, 2010

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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

Chief Complaint

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DEPARTMENT OF VETERANS

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• 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

History of Present Illness

UNITED STATES

DEPARTMENT OF VETERANS

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Additional History

•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

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Physical Examination•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

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Laboratory Findings

•CBC: within normal limits

•Basic metabolic panel: within normal limits

•Hepatic panel: within normal limits

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• Breast mass secondary to breast cancer, versus breast cyst, fibroadenoma, or lipoma.

Differential Diagnosis

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Diagnostic Mammogram

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Other Studies

•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

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DEPARTMENT OF VETERANS

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Interim History

•A fine needle aspirate of the two masses was performed and was positive for adenocarcinoma

•A core biopsy revealed poorly differentiated invasive ductal carcinoma

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DEPARTMENT OF VETERANS

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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

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DEPARTMENT OF VETERANS

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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

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DEPARTMENT OF VETERANS

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• T2N2M0, stage IIIA, ER-PR-Her2 triple negative, poorly differentiated, invasive ductal adenocarcinoma

Working Diagnosis

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DEPARTMENT OF VETERANS

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• 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

Interim History

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DEPARTMENT OF VETERANS

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Follow-up Diagnostic Mammogram

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DEPARTMENT OF VETERANS

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• 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

Interim History

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• The patient has been in complete pathological remission for seven months.

Interim History

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• 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.

Final Diagnosis

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DEPARTMENT OF VETERANS

AFFAIRS