NYU Medical Grand Rounds Clinical Vignette Denise Pate MD, PGY-2 January 27, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

A 51-year-old woman presents for consultation after being diagnosed with bilateral breast cancer and undergoing radical mastectomy. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 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.

History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 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.

Additional History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Past Medical History Hypertension Silicon injection Bilateral breasts Past Surgical History None 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 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Atenolol 50mg Daily Allergies: No known allergies

Physical Examination U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS General: Well-appearing woman in no acute distress Vitals: T 98.2F, BP 160/94, HR 92, RR 15 O 2 saturation: 97% on room air Chest: Well-healed bilateral mastectomy The remainder of the physical exam was normal.

Studies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 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)

Imaging Studies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS CT of Chest/Abdomen/Pelvis Multiple small gallstones Radionuclide Bone Imaging, total body No evidence of metastatic bone disease

Pathology results U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS 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

Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Bilateral breast carcinoma

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

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

Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Bilateral, node-positive breast carcinoma, currently disease free for 10 years.