General Surgery · Year 3 · from General Surgery

Case 1: Invasive Ductal Carcinoma

Patient Demographics

  • Age: 54 years
  • Sex: Female
  • Occupation: High school teacher

Chief Complaint

"I found a lump in my right breast during my monthly self-exam."

History of Present Illness

The patient noticed a firm mass in her right breast 3 weeks ago during routine self-examination. The mass is not painful and has not changed in size since she first noticed it. She has not noticed any nipple discharge, skin changes, or axillary lumps. Her last mammogram was 14 months ago and was reported as normal. She is postmenopausal with her last menstrual period at age 51.

Past Medical History

  • Hypertension
  • Hyperlipidemia
  • Menarche at age 12
  • G2P2, first pregnancy at age 28
  • Menopause at age 51
  • Never used hormone replacement therapy
  • No prior breast biopsies

Family History

  • Mother: Breast cancer at age 62, died at age 70 from metastatic disease
  • Maternal aunt: Ovarian cancer at age 58
  • Father: Prostate cancer at age 75, currently alive
  • No known BRCA mutations in family

Medications

  • Lisinopril 10 mg daily
  • Atorvastatin 20 mg daily

Social History

  • Non-smoker
  • Occasional wine (2-3 glasses per week)
  • Regular exercise

Physical Examination

  • Vitals: BP 128/78 mmHg, HR 72 bpm
  • Breast examination:
  • Right breast: 2 cm firm, irregular, fixed mass in the upper outer quadrant at 10 o'clock position, approximately 3 cm from the nipple
  • No skin dimpling, peau d'orange, or nipple retraction
  • No nipple discharge
  • Left breast: No masses, normal appearance
  • Axillary examination:
  • Right: One palpable lymph node, 1 cm, mobile, non-tender
  • Left: No palpable nodes
  • Supraclavicular: No palpable nodes

Diagnostic Workup

Diagnostic Mammogram:

  • Right breast: 2.2 cm spiculated mass at 10 o'clock, 3 cm from nipple
  • Associated pleomorphic microcalcifications
  • BI-RADS Category 5 (highly suspicious for malignancy)
  • Left breast: No suspicious findings

Breast Ultrasound:

  • Right breast: 2.1 x 1.8 x 1.5 cm hypoechoic, irregular mass with acoustic shadowing
  • Right axilla: 1.2 cm lymph node with thickened cortex, loss of fatty hilum

MRI Breast (bilateral with contrast):

  • Right breast: 2.3 cm enhancing mass with washout kinetics
  • No additional suspicious lesions in either breast
  • Chest wall not involved

Core Needle Biopsy Results:

  • Breast mass: Invasive ductal carcinoma, Nottingham Grade 2
  • ER: Positive (95%)
  • PR: Positive (80%)
  • HER2: Negative (IHC 1+)
  • Ki-67: 18%
  • Axillary lymph node: Metastatic carcinoma consistent with breast primary

Staging Workup

  • CT Chest/Abdomen/Pelvis: No evidence of distant metastases
  • Bone scan: No osseous metastases
  • Clinical Stage: cT2N1M0 (Stage IIB)

Multidisciplinary Tumor Board Discussion

  • Patient discussed at breast tumor board
  • Oncotype DX testing recommended given ER+ disease
  • Options presented: neoadjuvant chemotherapy vs. surgery first
  • Patient preference: proceed with surgery

Genetic Counseling and Testing

Given family history of breast and ovarian cancer:

  • BRCA1/BRCA2 testing performed
  • Result: BRCA2 mutation positive

Surgical Planning

Given BRCA2 mutation and patient preference after extensive counseling:

  • Right mastectomy with sentinel lymph node biopsy
  • Contralateral prophylactic mastectomy offered and accepted
  • Immediate reconstruction planned with tissue expanders

Operative Procedure

  • Bilateral skin-sparing mastectomies
  • Right sentinel lymph node biopsy (3 nodes removed)
  • Immediate reconstruction with bilateral tissue expanders
  • Sentinel node frozen section: 1/3 positive for macrometastasis
  • Completion axillary lymph node dissection performed (Level I/II)

Pathology Results

  • Right breast: 2.4 cm invasive ductal carcinoma, Grade 2
  • Margins: Negative (closest margin 0.8 cm)
  • Lymph nodes: 2/14 positive for metastatic carcinoma (no extracapsular extension)
  • Left breast: No malignancy
  • Final Pathologic Stage: pT2N1aM0 (Stage IIB)

Adjuvant Treatment Plan

  • Oncotype DX recurrence score: 22 (intermediate)
  • Recommended treatment:
  • Adjuvant chemotherapy (TC x 4 cycles)
  • Radiation therapy to chest wall (given positive nodes)
  • Endocrine therapy (aromatase inhibitor for 5-10 years)

Teaching Points

  1. Triple assessment: clinical exam, imaging, and biopsy
  2. BI-RADS classification guides management
  3. Multidisciplinary tumor board essential for treatment planning
  4. BRCA testing indicated with suggestive family history
  5. Surgical options include breast conservation vs. mastectomy
  6. Adjuvant therapy based on stage and tumor biology

Clinical Image

Image Description: Mammogram demonstrating a spiculated mass characteristic of invasive breast carcinoma. The irregular borders with radiating spicules and associated microcalcifications are highly suspicious features classified as BI-RADS 5.

Attribution: Image from Wikimedia Commons, Category:Mammography images of breast cancer. Source: https://commons.wikimedia.org/wiki/Category:Mammography

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