1. 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

2. 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 Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. 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 Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. 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. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. 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. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. 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. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. 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. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. 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. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. Additional History 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

10. 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Physical Examination 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Diagnostic Tests 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. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. Bilateral invasive breast cancer, progesterone and estrogen receptor positive, Her2/Neu expression negative Preliminary Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

14. 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. Outpatient Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Bilateral invasive breast carcinoma, progesterone and estrogen receptor positive, Her2/Neu expression positive Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS