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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.
Bilat mammograms: Left breast mass, rule out carcinoma; right breast is normal.
Chest X-Ray: Normal
Liver/spleen scan: Normal
SMA 20: Within normal limits.
Core needle biopsy left breast mass @4:00 position.
Excisional biopsy: L breast; 1.5 x 1.5 cm tumor excised, with sentinel lymph node biopsy X 1 and left axillary LN dissection.
Infiltrating ductal carcinoma, ER/PR positive.
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).
Left breast lumpectomy (excisional biopsy) with sentinel LN biopsy/axillary LN dissection.
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.
Hormone: Arimidex started.