1. NYU Medical Grand Rounds Clinical Vignette Daniel P. Eiras, MD, MPH PGY2 December 1, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. 49 year old Malaysian woman who presented to the Bellevue Clinic with a right breast mass that she had noticed for one month Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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

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

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

6. Laboratory Findings CBC: within normal limits Basic metabolic panel: within normal limits Hepatic panel: within normal limits U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Breast mass secondary to breast cancer, versus breast cyst, fibroadenoma, or lipoma. Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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

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

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

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

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

13. T2N2M0, stage IIIA, ER-PR-Her2 triple negative, poorly differentiated, invasive ductal adenocarcinoma Working Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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

15. Follow-up Diagnostic Mammogram U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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

17. The patient has been in complete pathological remission for seven months. Interim History U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

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