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Case #2

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Expand Physical Exam

06/04/XX

Left breast: Lump in LOQ present for three months. Firm, hard, with chronic intermittent pain. No skin lesions; no nipple discharge or retraction. Mass is freely movable; TS = 2.0 cm.
Right breast: Within normal limits. No organomegaly, no palpable lymph nodes bilaterally.

Expand Imaging

06/01/XX

Bilat mammograms: Left breast mass, rule out carcinoma; right breast is normal.

06/11/XX

Chest X-Ray: Normal

06/30/XX

Liver/spleen scan: Normal

Expand Laboratory

06/11/XX

SMA 20: Within normal limits.

Expand Surgical Observations

06/12/XX

Core needle biopsy left breast mass @4:00 position.

06/20/XX

Excisional biopsy: L breast; 1.5 x 1.5 cm tumor excised, with sentinel lymph node biopsy X 1 and left axillary LN dissection.

Expand Pathological Reports

06/12/XX

Infiltrating ductal carcinoma, ER/PR positive.

06/20/XX

Exc. Bx: Infiltrating duct carcinoma, WD, left breast, lower outer quadrant; TS: 1.5 x 1.5 cm, confined to breast tissue, surgical margins negative. One (1) sentinel lymph node and 6 axillary lymph nodes all showing no evidence of malignancy (0/7).

Expand Treatment

06/20/XX

Left breast lumpectomy (excisional biopsy) with sentinel LN biopsy/axillary LN dissection.

07/14/XX-08/28/XX

Radiation: External beam to left breast: 5040 cGy in 29 Fx, then 1000 cGy boost dose in 5 Fx for total dose 6040 cGy in 34 Fxs.

09/01/XX

Hormone: Arimidex started.