Grandmother told she has BC and now they don't know what it is

MEDICAL ONCOLOGY CONSULTATION

Reason for Referral: breast cancer

90 year old female

Patient initially presented to general surgery in 8/2018 with abnormal R breast lump.

Mammogram and ultrasound done 8/2018 confirmed 1.9cm oval mass in R breast, s/p biopsy

FINAL PATHOLOGIC DIAGNOSIS
BREAST, RIGHT, 2:00, 1.9 CM MASS (RADIOLOGY PERFORMED ULTRASOUND GUIDED
NEEDLE CORE BIOPSY):
- MODERATELY DIFFERENTIATED INVASIVE DUCTAL CARCINOMA.
- NOTTINGHAM COMBINED HISTOLOGIC GRADE 2 OUT OF 3:
- TUBULE FORMATION: 3 OUT OF 3.
- NUCLEAR PLEOMORPHISM: 2-3 OUT OF 3.
- MITOTIC COUNT: 1 OUT OF 3.
- COMBINED SCORE: 6-7 OUT OF 9.
- NO CARCINOMA IN SITU IDENTIFIED.
- INVASIVE TUMOR SIZE: AT LEAST 1.4 CM.
- LYMPHOVASCULAR INVASION: NOT IDENTIFIED.
- NECROSIS: FOCALLY IDENTIFIED.
- MICROCALCIFICATIONS: NOT IDENTIFIED.
- BREAST RECEPTOR MARKERS (ER, PR, AND HER2): PLEASE SEE THE ADDENDUM REPORT.

BREAST RECEPTOR MARKERS
Date Ordered: 8/17/2018

INTERPRETATION
BLOCK:
1
ESTROGEN RECEPTOR (ER):
Interpretation: Negative
0% immunoreactive cells present
Intensity of staining: Absent
Scoring performed in invasive carcinoma
No internal control is present; however, the external control tissue on the same slide is positive.
PROGESTERONE RECEPTOR (PR):
Interpretation: Negative
0% immunoreactive cells present
Intensity of staining: Absent
Scoring performed in invasive carcinoma
No internal control is present; however, the external control tissue on the same slide is positive.
HER2 IHC:
Negative (0, absent or incomplete, weak staining in <=10% of invasive tumor cells)

8/27/18: discussed at breast conference. Recs: proceed with needle loc and SLNbx

9/21-9/22/18: admitted for Afib

CXR - hazy R lung base opacities, aspiration and/or pneumonia

CT thorax no contrast - multiple lung nodules measuring up to 2.2 cm, mediastinal, hilar and supraclavicular LAD, pleural and pericardial effusions, R breast mass

10/3/18, s/p US-guided bx of R supraclavicular LN

FINAL PATHOLOGIC DIAGNOSIS
LYMPH NODE, ULTRASOUND-GUIDED (RADIOLOGY PERFORMED) FINE NEEDLE ASPIRATION, SUPRACLAVICULAR AREA, RIGHT:
- STATUS POST ULTRASOUND-GUIDED NEEDLE BIOPSY 1.9 CM MASS 2:00 RIGHT BREAST (BPMS18-17034)
- EXTENSIVELY NECROTIC TISSUE SHOWING FEATURES OF METASTATIC, POORLY DIFFERENTIATED CARCINOMA (SEE COMMENT)

COMMENT
The findings are consistent with metastatic tumor. The overall morphologic as well as a minimal histochemical staining profile of this lesion is not specific and the site of origin of this lesion is not apparent The findings do not appear to support metastatic breast cancer. The possibility that this represents metastatic breast cancer is not completely ruled out but is not favored. Differential diagnosis includes, but is not limited to lung, proximal gastrointestinal tract, gynecologic or pancreaticobiliary tract. Two (2) other pathologists have reviewed this case and concur with this interpretation

SUBJECTIVE/ROS:

Weight loss, gradually, about 30lbs over the past year

Progressive fatigue over the past month, but still remains relatively active

Occasional SOB and dry cough

Denies bone pain, headaches, dizziness

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Gen: elderly, pleasant, NAD

HEENT: no palpable LAD

CVS: irregularly irregular

Lungs: decreased breath sounds at bases

Abd: soft, NT, ND, +palpable hard mass 2-3cm in LLQ along surface of skin

Ext: no edema

Breast: left breast --> palpable hard mass, 3-4cm at 4 o'clock

Labs:

WBC'S AUTO 9.4 10/02/2018

HGB 11.0 10/02/2018

HCT AUTO 34.0 10/02/2018

PLT'S AUTO 295 10/02/2018

CREAT 0.80 09/22/2018

ALT 12 04/11/2014

AST 16 04/11/2014

CA 8.7 09/21/2018

ALB 3.3 09/22/2018

No results found for this basename: ca153

No results found for this basename: CA125

No results found for this basename: IRON, IBC, FESAT, FERRITIN

No results found for this basename: B12

No results found for this basename: Folate

No results found for this basename: HAV, HAVG, HAVIGM, HBSAG, HBVSAB, HBCAB, HCV, HCVPCR, HCVPCRQL, HCVPCRQN, HAVIGG, HCVPCRLOG, HAVAB, HBCIGM, HCVAB, HCVGENO

Imaging: reviewed

Pathology/Procedures:

EGD, 5/2017:

IMPRESSION:

Mild gastritis and duodenitis s/p biopsies

Unremarkable esophagus

Suspect dysphagia is oropharyngeal in nature.

FINAL PATHOLOGIC DIAGNOSIS
STOMACH, ANTRUM AND BODY, BIOPSY:
- GASTRIC OXYNTIC AND GLANDULAR MUCOSA WITH FOVEOLAR HYPERPLASIA AND MINIMAL
ACUTE INFLAMMATION; SEE COMMENT.
- NO HELICOBACTER, INTESTINAL METAPLASIA, OR DYSPLASIA SEEN.

ASSESSMENT:

90 year old female with hx smoking, hyperlipidemia, A.fib on pradaxa and aspirin, osteoporosis, osteoarthritis of bilateral knees

R breast mass --> moderately differentiated invasive ductal carcinoma, ER/PR/HER 2 negative

Pulmonary nodules, mediastinal/hilar/supraclavicular lymphadenopathy, pleural/pericardial effusion

S/p R supraclavicular LN FNA --> metastatic poorly differentiated carcinoma, extensively necrotic tissue, with minimal IHC staining profile, not supportive of breast cancer. Ddx includes lung, proximal GI, gynecologic or pancreaticobiliary

Explained to patient and daughter today that although we may be dealing with a diagnosis of triple negative breast cancer with visceral mets, this is not definitely supported on the recent R supraclavicular lymph node biopsy and limited IHC staining profile. There is a possibility that given her smoking history, she may have another primary malignancy such as lung cancer. This will guide management.

PLAN:

- CT neck/C/A/P to complete workup and evaluate for repeat biopsy for additional tissue

- bone scan to r/o bone mets

- genetics referral

- baseline labs, including tumor markers

RTC 2 weeks