Clinical Vignette #1 by olk11750


									   Clinical Vignette #1
                Provided by Barbara Sharp, MD

                                                The patient is a 79 year old female with no
                                                specific breast concerns. Her daughter was
                                                recently diagnosed with breast cancer at age
                                                53. (see 1 a, b/RCC and RMLO)
                                                Standard routine screening views in the
                                                craniocaudal (CC) and mediolateral oblique
                                                (MLO) projections using full field digital
                                                technique reveal suspicious nodularity
                                                inferomedially in the right breast (see ar-
                                                (see 1 c,d/RCC and RML)
                                                Diagnostic spot magnification views in the
                                                craniocaudal (CC) and mediolateral (ML)
                                                projections reveal a suspicious spiculated 5
                                                mm nodule at the inferomedial aspect of the
                                                right breast (see arrows) and clustered cal-
                                                cifications in the lateral right breast which
                                                were mildly suspicious (see oval)
                                                (see 1 e,f)
                                                Ultrasound confirms a suspicious
                                                hypoechoic mass with shadowing at the
                                                inferomedial, 4:00 position of the right breast,
                                                close to the chest wall.
                                                A) Ultrasound guided core biopsy at 4:00
                                                   revealed invasive ductal carcinoma
                                                   with a prominent tubular pattern.

                                                B) Stereotactic core biopsy of
                                                   microcalcifications revealed atypical
                                                   ductal hyperplasia.

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     Clinical Vignette #2
                  Provided by Barbara Sharp, MD

                                                  Dense breast parenchyma reduces mammographic sensitivity.
                                                  All new palpable lumps should be evaluated with ultrasound
                                                  in addition to mammography.
                                                  A 42 year old female presented for a diagnostic bilateral
                                                  mammogram because she discovered a pea-sized lump in her
                                                  left breast six months previously.
                                                  (see 3 a – CC, 3b – MLO)
                                                  Craniocaudal and mediolateral oblique standard views dem-
                                                  onstrate extremely dense breast parenchyma. A “bb” was
                                                  placed over the palpable lump. No definite mammographic
                                                  abnormalities are seen.
                                                  (see 3c, 3d)
                                                                 Spot magnification views of the palpable lump
                                                                 demonstrate no definite abnormality. Some
                                                                 calcification does not definitely correspond to
                                                                 the site of the lump marked with a “bb”.
                                                                 (see 3 e,f)
                                                                 Ultrasound reveals a hypoechoric mass at 11:30,
                                                                 6 cm from the nipple, measuring 10 x 4 x 8 mm
                                                                 in size.
                                                                 Pathology: Ultrasound core biopsy revealed
                                                                 invasive well differentiated ductal carcinoma (6
                                                                 mm) with scattered foci of lowgrade ductal
                                                                 carcinoma in situ. The patient had a left breast
                                                                 MRI with enhancement of the known cancer
                                                                 and a benign appearing nodule near the nipple.
                                                                 The patient underwent mastectomy and had 2
                                                                 benign axillary lymph nodes.

24    Fall 2005   Northeast Florida Medicine                                                www . DCMS online . org
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    for breast cancer: first results of the HERA trial. American          report of overall survival [Abstract # 510]. Pro Am Soc Clin
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19. Bonneterre J, Thütlimann B, Robertson JF, et al. Anastrozole          doxorubicin, paclitaxel, and the combination of doxorubicin
    vs. tamoxifen as first-line therapy for advanced breast cancer        and paclitaxel as front-line chemotherapy for metastatic breast
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    Arimidex Randomized Group Efficacy and Tolerability                   92.
    (TARGET) study. J Clin Oncol 18(22):3748-57, 2000.
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20. Nabholtz JM, Buzdar A, Pollak M, et al. Anastrozole is superior       doxorubicin as first-line single-agent chemotherapy for
    to tamoxifen as first-line therapy for advanced breast cancer         metastatic breast cancer: a European Organization for Research
    in postmenopausal women: results of a North American multi-           and Treatment of Cancer Randomized Study with cross-over.
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    18(22):3758-67, 2000.
                                                                      27. Blum JL, Savin MA, Edelman G, et al. Long term disease
21. Mouridsen H, Gershanovich M, Sun Y, et al. Phase III study            control in taxane-refractor metastatic breast cancer treated
    of letrozole vs. tamoxifen as first-line therapy of advanced
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    breast cancer in postmenopausal women: analysis of survival
    and update of efficacy from the International Letrozole Breast
    Cancer Group. J Clin Oncol 21(11):2101-9, 2003.                   28. Harris L, Batist G, Belt R, et al. Liposome-encapsulated
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     Clinical Vignette #3
                  Provided by Barbara Sharp, MD

                                                                                                              Continued on page 43

42    Fall 2005   Northeast Florida Medicine                                                                      www . DCMS online . org
                                            Clinical Vignette #3 - Captions
                  Continued from page 42
  A 75 year old female presented with a history of left              the mass. An elliptical area of enhancement anterior to the
  lumpectomy for DCIS in 1998. She has a family history of           mass, separated by 2 cm of intervening tissue was seen.
  breast cancer in mother who was diagnosed at age 38. This          The patient underwent bilateral simple mastectomy. A 1.2
  patient presented with a new palpable lump at the                  cm invasive colloid carcinoma was found on the right. On
  lumpectomy site.                                                   the left, poorly differentiated invasive cancer spanning a 5 cm
  (see 6 a-d/Rcc, Lcc, RMLO and LMLO)                                area was found. Right sentinel nodes were negative. Left
                                                                     axillary node dissection was performed in 1998.
  Bilateral standard craniocaudal (CC) and mediolateral ob-
  lique filmscreen mammograms were obtained. A new spicu-            This case illustrates that breast MRI is useful in delineating
  lated mass measuring 3.5 cm was noted in the upper outer           the full extent of disease and can identify additional sites of
  left breast, corresponding to the palpable abnormality (see        disease in the ipsilateral breast in 16% of patients (range 6-
  arrows, L CC and MLO views)                                        34%). If a patient survives her first cancer, she has a risk for
                                                                     a second cancer which increases 1% each year up to a 15% risk.
  Also noted was a new coarse cluster of calcifications in the
  right mid-breast, slightly lateral to the plane of the nipple      The occurrence of cancer in the contralateral breast; either in
  (see arrows) (see 6e)                                              patients with a history of prior breast cancer or in patients
                                                                     in whom the contralateral cancer is detected during initial
  Left breast sonogram is remarkable for a 3.4 x 3.2 cm
                                                                     screening, is not common. The incidence of a synchronous
  hypoechoic mass with lobular borders.
                                                                     contralateral cancer is between 3 and 6%.
  Left breast ultrasound guided core biopsy demonstrates
  invasive moderate to poorly differentiated ductal carcinoma.
  Right breast stereotactic biopsy of clustered calcifications was
  remarkable for invasive colloid carcinoma with lymphatic
  invasion. (see 6f, LMRI)
  The patient then underwent left breast MRI which demon-
  strated a 3.7 cm suspicious mass enhancing in the upper
  outer left breast. A nodular area of enhancement was also
  seen along the lateral margin of the mass and additional
  nodules are noted along the superior and inferior aspect of

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