SEER Training Modules
Case #5
Click an information source below to view the case history.
Physical Exam
09/08/XX
Right breast: 2 cm mass present for 2-3 weeks prior to admission; discovered by patient. Associated with slight discomfort but no pain. No tenderness; peau d'orange noticed overlying the mass. No nipple discharge. Mass freely movable. No bone pain.
Left breast: No masses palpated. No palpable lymph nodes.
Imaging
09/12/XX
Mammogram: Suspected malignant lesion of right breast.
09/13/XX
Chest X-Ray: No evidence of metastatic lesions.
10/01/XX
scan: No evidence of skeletal metastases.
Laboratory
09/13/XX
SMA 20: WNL
09/14/XX
ERA/PRA: Both are negative
Surgical Observations
09/14/XX
Right breast biopsy
09/20/XX
Right simple mastectomy with lymph node dissection.
Pathological Reports
09/14/XX
R breast bx: Intraductal carcinoma; 1 cm lesion located 1 cm from nipple in upper outer quadrant.
09/20/XX
R mastectomy: No residual tumor at original biopsy site; no infiltration to pectoralis muscle or fascia. Metastatic carcinoma to 2 of 13 right axillary lymph nodes.
Treatment
09/14/XX
Surgery: Right breast excisional biopsy; 9/20/XX Right simple mastectomy with right axillary lymph node dissection.
11/2/XX
Chemotherapy: Adriamycin/Cytoxan followed by Taxotere.
03/21/XX
Radiation: Beam radiation to right chest, total dose 6000 cGy.
