Click an information source below to view the case history.
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.
Mammogram: Suspected malignant lesion of right breast.
Chest X-Ray: No evidence of metastatic lesions.
scan: No evidence of skeletal metastases.
SMA 20: WNL
ERA/PRA: Both are negative
Right breast biopsy
Right simple mastectomy with lymph node dissection.
R breast bx: Intraductal carcinoma; 1 cm lesion located 1 cm from nipple in upper outer quadrant.
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.
Surgery: Right breast excisional biopsy; 9/20/XX Right simple mastectomy with right axillary lymph node dissection.
Chemotherapy: Adriamycin/Cytoxan followed by Taxotere.
Radiation: Beam radiation to right chest, total dose 6000 cGy.