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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