1. Clinical Correlations The NYU Internal Medicine Blog A Daily Dose of Medicine http://clinicalcorrelations.org

2. Medical Grand Rounds Clinical Vignette November 12th, 2008 Jon-Emile Kenny M.D.

3. Chief Complaint 55 year old female presents with a large, ulcerating breast mass and associated supraclavicular and left axillary lymphadenopathy.

4. History of Present Illness Patient first noticed the mass 2 years prior and went to an outside hospital for evaluation. At that time, review of systems was non- contributory.

5. History of Present Illness A fine needle aspiration and core biopsy of an axillary lymph node and breast mass revealed poorly differentiated invasive ductal adenocarcinoma. The carcinoma was estrogen receptor-negative, progesterone-receptor negative and HER2 receptor positive.

6. History of Present Illness A staging CT scan was significant for probable liver and bone metastases. The patient was lost to follow up until her current presentation. On presentation, the patient complained of significant pain of her left breast. She noted that her breast had become ulcerated over the previous weeks to months, but only recently had started to have foul-smelling discharge.

7. History Past Medical History: –none Past Surgical History: –none

8. History Social Hx: Pt. had lost her home in the interim and was living with family. Family Hx: Non-contributory Allergies: No known drug allergies Medications:none Review of Systems: –Chronic fatigue –Remainder of review of systems negative

9. Physical Exam General: middle-aged female in no acute distress, sitting comfortably, Alert and Oriented x3. T:97.3 o F BP:132/76 HR:75 RR:18 O 2 :99%RA T:97.3 o F BP:132/76 HR:75 RR:18 O 2 :99%RA Breast: Left breast completely ulcerated, crater-like with granulation tissue without discharge. Left lymphadenopathy of axilla. The remainder of the physical exam was normal

10. Working Diagnosis Locally advanced, invasive ductal adenocarcioma.

11. Laboratory WBC 10.7 mm 3 (nl 4.5-11) Hemoglobin 6.3 g/dL (13.5-16.5), MCV 63.0 Coagulation studies normal Liver enzymes normal Basic Chemistries normal CEA 1.8 (nl < 5) CA 27.29 was 339.4 (nl < 40)

12. Imaging Chest XR: Bilateral pulmonary nodular densities Bone Scan: Suspicion for bone metastases in T4/5 spinous process. Chest CT: Innumerable lung, liver and osseous metastases Abdomen/Pelvis CT: New lytic lesions in L4, multiple liver and bone lesions.

13. Hospital Course The patient was admitted and was transfused for her anemia. Her tumour was biopsied, but deemed inoperable by the surgical service because of bleeding risk. She received a course of antibiotics for super- infection of her breast mass. She was seen by radiation oncology for palliative XRT and received Trastuzumab (Herceptin) chemotherapy. Pt. was discharged with Oncology follow up.

14. Follow-up Patient has been seen in clinic and is at her baseline. Biopsy has confirmed what was found at the outside hospital. She continues XRT and Trastuzumab (Herceptin) chemotherapy.

15. Final Diagnosis Metastatic HER2 positive, estrogen-receptor negative, progesterone-receptor negative ductal adenocarcioma.