Transcript Journal Club

NYU Medical Grand Rounds
Clinical Vignette
Todd Cutler, MD
PGY3, Class of 2012
January 24, 2012
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Chief Complaint
• Our patient is a 39 year-old woman who
presents with a mass in her left breast.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient’s mother was diagnosed with
breast cancer at age 32 and died of disease at
age 43.
• Her maternal grandmother was diagnosed
with breast cancer at age 50 and her maternal
great-grandmother had breast cancer at an
unknown age.
• Given the patient’s family history she began
yearly mammogram surveillance at age 34.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• A mammogram and breast sonogram
performed at age 38 showed no evidence of
disease.
• Months afterwards, she palpated a mass in
her left breast which prompted her to see her
doctor.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
History of Present Illness
• The patient had a mammogram which showed
the mass to be a well-circumscribed 7mm
lesion.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Additional History
•Past Medical History:
• Fibroids
• Depression
•Past Surgical History:
• Tonsillectomy at age 19
•Social History:
• No tobacco use and occasional alcohol use
• Works as legal assistant
•Family History:
• As reported
• Ashkenazi Jewish family
•Allergies:
• No known drug allergies
•Medications:
• Provigil 200mg once daily
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Physical Examination
•General: Well-appearing, no distress
•Vital Signs: T:98.3 BP:128/89 HR:84 RR:16
and O2 sat:99%
• Palpable, firm and discrete left breast mass
in 10 o’clock region, no skin changes
• Remainder of physical exam was normal
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Laboratory Findings
• Complete blood count was within normal limits
• Basic metabolic panel was within normal limits
• Hepatic panel was within normal limits
• CEA, CA 27.29 and CA 125 were within
normal limits
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Differential Diagnosis
• Benign breast disease (e.g. fibroadenoma,
cyst) versus breast cancer
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• An ultrasound-guided biopsy was performed
and, on pathology, the lesion was found to be
invasive ductal carcinoma of the breast.
• She had a lumpectomy and sentinel node
biopsy which showed a T1bN0Mx stage 1
invasive ductal carcinoma.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• Biomarker stainings were negative for
estrogen, progesterone and HER-2/neu
receptors and Ki-67 was 70 to 80%.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• She was referred for genetic testing was
found to be have the BRCA1 mutation
187delAG.
• She was informed that she was at increased
risk of recurrent and contralateral breast cancer
as well as ovarian cancer.
• She declined prophylactic bilateral
mastectomy as well as oophorectomy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• She received six months of chemotherapy
with four cycles of adriamycin and cytoxan
followed by taxol plus carboplatin.
• Afterwards she received local adjuvant
radiation therapy.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Clinical Course
• For five years following her initial
diagnosis and treatment she has had
regular diagnostic imaging by MRI and
mammograms as well as regular
transvaginal ultrasounds.
• Despite extensive counseling, she does
not wish to have risk reducing surgery.
• Today she remains free of recurrence.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS
Final Diagnosis
• Invasive ductal carcinoma of the breast –
in remission.
UNITED STATES
DEPARTMENT OF VETERANS AFFAIRS