Ketty Badrinath, M.D.
62 yr old Female was found to have a right breast abnormality on a screening mammogram. This mammogram was repeated which revealed an abnormality measuring 1.5 cm suspicious of malignancy in the upper outer quadrant of the right breast. She underwent a needle localization biopsy of this abnormality revealing infiltrating ductal carcinoma and DCIS.
PMHx: History of benign disease in left breast.
PSHx: Excision of breast lumps in left breast. Benign.
Meds: Vit E and calcium
Social: She is a widow. Menarche at 14 yrs of age and menopause at age 55. She is grii pii. (No hx of tobacco or alcohol consumption.) (BCP x 2 yrs. No hx of ERT. )
Family Hx: No family history of any type of cancer.
Review of Systems: Negative.
PEx: Was within normal limits except for mild echymosis and vague palpable abnormality at the biopsy site.
Recommendation: She was advised lumpectomy and sentinel node biopsy pending further recommendations after sentinel node biopsy and ER, PgR data.
Pathology: Infiltrating ductal carcinoma long with DCIS. T 1 C, N 1 , M x . Margins of resection clear.
ER: 90% positive
Final Recommendation: Adjuvant chemotherapy followed by Adjuvant Radiotherapy and Tamoxifen.
Follow-up: Eight years later, the patient presents with metastases to liver, bones and brain. Patient and family decided to go into hospice.