Breast Cancer
Patient Presentation:
J.D., a 44 year old woman presents at the office after noting a non-tender
nodule, about the size of a marble, on her right breast. Pt is G3P2 with
her first pregnancy at age 28. Pt currently is not breastfeeding. Last
menses was 1 week ago and normal. Patient tracked the nodule through the
last menses to see if it resolved but it did not. Pt does regular SBE each
month and noticed the lump in this manner. No h/o breast problems or
symptoms. Patient’s maternal grandmother was diagnosed with breast cancer
at age 75. No other family h/o breast cancer. No recent trauma or h/o
breast implants.
Differential Diagnoses
Breast abscess, fibrocystic breasts, carcinoma
Diagnosis
A careful breast examination was performed to rule out an infection (the
mass would be tender), which it was not. The mass also did not
transilluminate which can be indicative of a cyst. The lymph nodes in the
axilla and neck were not enlarged. The mass was located in the UOQ of her
right breast and was asymmetrical, meaning it was only found on one breast.
It was firm, mobile, and located around 11 o’clock. The provider sent the
patient to a Comprehensive Breast Center for a diagnostic mammogram and
right breast ultrasound. The mammogram showed dense breast tissue with
possible architectural distortion but no malignant calcifications in the
lump. The ultrasound defined the lump as an irregular mass that was 0.8 x
0.7 x 1.9 cm. The radiologist also performed an u/s guided needle biopsy of
the lesion.
Evaluation
J.D. met with the breast surgeon who informed her that the biopsy showed an
infiltrating ductal carcinoma with a small area of ductal carcinoma in
situ. For the next hour or so, the patient was educated on breast cancer
and treatment considerations such as local & systemic therapy;
chemotherapy & hormone therapy; breast conservation & mastectomy;
the difference between invasive cancer and DCIS; pros and cons of various
treatments. She was also given materials to take home and read, discuss her
options, and return to the office in 3 days.
Outcome/Treatment
J.D. decided to have a lumpectomy and sentinel lymph node biopsy. She also
scheduled to see the radiation oncologist. The sentinel lymph node biopsy
was positive, so J.D. returned 3 days later for a standard axillary lymph
node dissection. The final pathology revealed a 1 cm infiltrating ductal
carcinoma with a small area of DCIS. The margins were clear and the
sentinel lymph node & 2 other lymph nodes were positive for microscopic
metastatic disease. Fourteen other lymph nodes were negative. The
consensus for treatment was that she should be offered a regimen of
chemotherapy and breast irradiation.
Case created by Jacqueline Duffey,
2010.