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Medical Grand RoundsMedical Grand RoundsClinical VignetteClinical VignetteNovember 12th, 2008November 12th, 2008

Jon-Emile Kenny M.D.Jon-Emile Kenny M.D.

Chief ComplaintChief Complaint

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

History of Present IllnessHistory of Present Illness

Patient first noticed the mass 2 years prior and Patient first noticed the mass 2 years prior and went to an outside hospital for evaluation. went to an outside hospital for evaluation.

At that time, review of systems was non-At that time, review of systems was non-contributory. contributory.

History of Present IllnessHistory of Present Illness

A fine needle aspiration and core biopsy of an A fine needle aspiration and core biopsy of an axillary lymph node and breast mass revealed axillary lymph node and breast mass revealed poorly differentiated invasive ductal poorly differentiated invasive ductal adenocarcinoma. adenocarcinoma.

The carcinoma was estrogen receptor-negative, The carcinoma was estrogen receptor-negative, progesterone-receptor negative and HER2 progesterone-receptor negative and HER2 receptor positive. receptor positive.

History of Present IllnessHistory of Present Illness

A staging CT scan was significant for probable A staging CT scan was significant for probable liver and bone metastases. liver and bone metastases.

The patient was lost to follow up until her current The patient was lost to follow up until her current presentation. presentation.

On presentation, the patient complained of On presentation, the patient complained of significant pain of her left breast. She noted that significant pain of her left breast. She noted that her breast had become ulcerated over the her breast had become ulcerated over the previous weeks to months, but only recently had previous weeks to months, but only recently had started to have foul-smelling discharge.started to have foul-smelling discharge.

HistoryHistory

Past Medical History:Past Medical History:– nonenone

Past Surgical History: Past Surgical History: – nonenone

HistoryHistorySocial Hx:Social Hx: Pt. had lost her home in the Pt. had lost her home in the

interim and was living with family.interim and was living with family.Family Hx:Family Hx: Non-contributoryNon-contributoryAllergies: Allergies: No known drug allergiesNo known drug allergiesMedications:Medications:

nonenone

Review of Systems: Review of Systems: – Chronic fatigueChronic fatigue– Remainder of review of systems negativeRemainder of review of systems negative

Physical ExamPhysical ExamGeneral:General: middle-aged female in no acute distress, middle-aged female in no acute distress,

sitting comfortably, Alert and Oriented x3.sitting comfortably, Alert and Oriented x3.

T:97.3T:97.3ooF BP:132/76 HR:75 RR:18 F BP:132/76 HR:75 RR:18 OO22:99%RA:99%RA

Breast:Breast: Left breast completely ulcerated, crater-like Left breast completely ulcerated, crater-like with granulation tissue without discharge. Left with granulation tissue without discharge. Left lymphadenopathy of axilla. lymphadenopathy of axilla.

The remainder of the physical exam was normalThe remainder of the physical exam was normal

Working DiagnosisWorking Diagnosis

Locally advanced, invasive ductal Locally advanced, invasive ductal adenocarcioma.adenocarcioma.

LaboratoryLaboratory

WBC 10.7 mmWBC 10.7 mm33 (nl 4.5-11) (nl 4.5-11)

Hemoglobin 6.3 g/dL (13.5-16.5), MCV 63.0Hemoglobin 6.3 g/dL (13.5-16.5), MCV 63.0

Coagulation studies normalCoagulation studies normal

Liver enzymes normalLiver enzymes normal

Basic Chemistries normalBasic Chemistries normal

CEA 1.8 (nl < 5)CEA 1.8 (nl < 5)

CA 27.29 was 339.4 (nl < 40)CA 27.29 was 339.4 (nl < 40)

ImagingImaging

Chest XR:Chest XR: Bilateral pulmonary nodular densities Bilateral pulmonary nodular densities

Bone Scan:Bone Scan: Suspicion for bone metastases in Suspicion for bone metastases in T4/5 spinous process.T4/5 spinous process.

Chest CT: Chest CT: Innumerable lung, liver and osseous Innumerable lung, liver and osseous metastasesmetastases

Abdomen/Pelvis CT:Abdomen/Pelvis CT: New lytic lesions in L4, New lytic lesions in L4, multiple liver and bone lesions.multiple liver and bone lesions.

Hospital CourseHospital Course

The patient was admitted and was transfused for The patient was admitted and was transfused for her anemia. Her tumour was biopsied, but her anemia. Her tumour was biopsied, but deemed inoperable by the surgical service deemed inoperable by the surgical service because of bleeding risk.because of bleeding risk.

She received a course of antibiotics for super-She received a course of antibiotics for super-infection of her breast mass.infection of her breast mass.

She was seen by radiation oncology for She was seen by radiation oncology for palliative XRT and received Trastuzumab palliative XRT and received Trastuzumab (Herceptin) chemotherapy.(Herceptin) chemotherapy.

Pt. was discharged with Oncology follow up.Pt. was discharged with Oncology follow up.

Follow-upFollow-up

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

Final DiagnosisFinal Diagnosis

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