This is an extremely pleasant 50-year-old woman with a maternal grandmother with breast cancer at age 50 that is kindly seen at the request of Dr. Chattapadhyay regarding possible radiotherapy for her recently diagnosed DCIS of the left breast. Patient 1st was found to have the interval development on routine screening mammography performed 12/31/2008 of a new cluster of microcalcifications in the upper outer quadrant of the left breast, subsequently undergoing stereotactic core biopsy 1/2/2009 which showed flat epithelial atypia and columnar cell alteration with dystrophic calcifications. Subsequently seen by Dr. Chattapadhyay for a surgical consultation at which time there were no palpable mass, nipple, skin or axillary abnormalities noted. Surgical excision was recommended and subsequently on 3/2/2009 the patient underwent left breast needle localized biopsy. Pathologic specimen on microscopic examination did in fact confirm the presence of atypia but in addition there was ductal carcinoma in situ involving lobules and terminal ducts. Nuclear grade was II, architectural pattern showed some transitory changes with spread into the lobules. Overall size was 1.7 x 1.6, VCS was 0.5 mm on the superficial margin, 4 mm from the inferior margin. The patient is desirous of breast consultation.
REVIEW OF SYSTEMS: See chart documentation.
PAST MEDICAL HISTORY: Noteworthy only in the patient has no known allergies and has not been exposed to therapeutic radiation. She has been on chronic
Wellbutrin. In addition takes Effexor and Lipitor. Generally has been in good health. Does have osteopenia.
SOCIAL HISTORY: The patient is a retired attorney. Has never smoked. Drinks only socially.
FAMILY HISTORY: See present illness.
Risk factors for breast cancer include menarche age 12, did take birth control pills for an extensive period of time, has 2 children both of which were breast fed.
PHYSICAL EXAM: Reveals an extremely well-informed woman in no acute distress.
BP 130/88, weight 123.
SKIN: No nodularity.
HEENT: Head normocephalic. Eyes: PERRLA, sclerae anicteric.
NECK: Thyroid not palpable.
NODES: No significant cervical, supraclavicular or axillary adenopathy.
BACK AND SPINE: No tenderness.
CHEST: Clear to P and A.
HEART: Normal sinus rhythm.
RIGHT BREAST: Nipple everted. No masses.
LEFT BREAST: Nipple everted. No dominant masses. Recent outer quadrant
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incision on the left. Some induration. No masses.
ABDOMEN: Nondistended. Liver percussion to 7-8 cm.
EXTREMITIES: No edema.
NEUROLOGICAL: Grossly intact. Deep tendon reflexes 2+ and symmetrical.
X-rays, lab in past see present illness. Careful review of the mammograms does show the interval development of outer quadrant calcifications, tubular abnormalities. Pathology does show grade II tumor without necrosis and with close inferior margins.
IMPRESSION:
1. Grade II DCIS left breast post excisional biopsy with close surgical margins.
Patient is scheduled for an MRI which we would concur with. She is interested in breast consultation and assuming we do not see other foci on the MRI she is a good candidate for this. However, one would need to consider possible reexcision to obtain better surgical margins. This will be discussed with Dr.
Chattapadhyay.
Told the patient that after we have her MRI we will also attempt to get estrogen receptor status on her biopsy. Patient will be presented to the Combined
Modality Tumor Conference for a joint recommendation.
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