SEER Training Modules
Case #3
Click an information source below to view the case history.
Physical Exam
04/04/XX
Right breast: 4 x 3 cm firm, irregular mass at 1:00 position. No skin changes, no dimpling, no nipple discharge. Freely movable mass.
Left breast: No masses palpated. No palpable lymph nodes in right axilla.
Imaging
04/06/XX
Mammograms: Suspected lesion in right breast. Faint calcifications at mirror image position in left breast.
04/15/XX
Chest X-Ray: Within normal limits.
Laboratory
04/15/XX
SMA 12: fasting blood sugar elevated.
04/30/XX
Estrogen/progesterone receptors: ER mildly positive, PR negative.
Surgical Observations
04/17/XX
Bilateral breast biopsies
04/30/XX
Right simple mastectomy, R sentinel LN biopsy, R TRAM flap reconstruction.
Pathological Reports
04/17/XX
Biopsy, R breast: Intraductal carcinoma of the right breast, comedo type, nuclear grade 3, margins positive.
Biopsy, L breast: Fibrocystic calcifications, no evidence of malignancy.
04/30/XX
R simple mastectomy, R SLN biopsy: Extensive intraductal comedocarcinoma with lobular extension; TS = 4.1 x 3.5 x 3.0 cm; two R sentinel LNs without metastases.
Treatment
04/30/XX
Surgery: Right simple mastectomy with right sentinel lymph node biopsy and right TRAM flap reconstruction.
