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Right breast: 5 x 3 cm mass noted on physical exam by family physician. No pain or tenderness; no nipple discharge; no skin changes. Slight nipple retraction; freely movable mass.
Left breast: No masses palpated
No enlarged lymph nodes bilaterally
Chest X-Ray: Within normal limits
Bone Scan: No evidence of skeletal mets; questionable early stage osteophytosis
Thoracic and lumbar spine: Negative for metastases
SMA 12: Within normal limits
Estrogen receptor assay: Positive for estrogen receptors
Biopsy right breast mass
Right modified radical mastectomy
Biopsy right breast mass: Adenocarcinoma of right breast, margins involved.
R MRM: Infiltrating duct carcinoma of right breast with dermal invasion; no evidence of tumor in 32 regional lymph nodes; tumor is attached to fat; tumor size is 5.5 x 4.0 x 4.0 cm; lesion is located at 12:00; differentiation is grade 2.
Surgery: Right modified radical mastectomy with axillary lymph node dissection.
Hormone: Arimidex started.