Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Daniel P. Eiras, MD, MPH
PGY2
December 1, 2010
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• 49 year old Malaysian woman who
presented to the Bellevue Clinic with a right
breast mass that she had noticed for one
month
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
•CBC: within normal limits
•Basic metabolic panel: within normal limits
•Hepatic panel: within normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Differential Diagnosis
• Breast mass secondary to breast cancer, versus
breast cyst, fibroadenoma, or lipoma.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Diagnostic Mammogram
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Working Diagnosis
• T2N2M0, stage IIIA, ER-PR-Her2 triple
negative, poorly differentiated, invasive ductal
adenocarcinoma
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Interim History
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Follow-up Diagnostic Mammogram
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Interim History
• 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
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Interim History
• The patient has been in complete pathological
remission for seven months.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• 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.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS