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MORE THAN MEETS THE MAMMOGRAM: THE PALPABLE BREAST MASS

A Clinical Case Presentation

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Grace McRoy, MPH, PA-C

Breast Surgical Oncology

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KNOW YOUR LEMONS

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WHO IS SHE?

  • 53 yo female presenting to my clinic with a painful left breast mass
  • No family history of breast cancer
  • No prior breast biopsies
  • History of bilateral breast reduction
  • No recent breast imaging

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PHYSICAL EXAM

  1. Large firm and fixed left breast mass with overlying skin changes, and nipple retraction
  2. Palpable left axillary lymphadenopathy
  3. Right breast without palpable mass, skin changes, or nipple retraction

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AS A PA, WHERE DO I START?

  • Breast imaging!
  • Symptom management!
  • Support!

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ROADBLOCK…

  • Patient is currently uninsured… what next?
  • Mammogram and ultrasound are $$$
  • How do we get to a diagnosis?

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PROCEDURE TIME

  • I performed punch biopsy x 2 of both the areola and the skin of the breast in clinic
  • Pathology came back a few days later…
    • Moderately differentiated invasive ductal carcinoma, ER/PR+, HER2 1+, Ki67 33%
  • But Grace, what does that mean??

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WHERE DO WE GO FROM HERE?

  • Discuss case at Tumor Board
    • Recommendation: mammogram, breast ultrasound, CT chest/abdomen/pelvis, bone scan
  • Patient to see a medical oncologist, radiation oncologist and surgical oncologist in a multidisciplinary clinic

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ADDITIONAL FINDINGS

  1. Patient was able to enroll with Medicaid and imaging was completed
  2. CT Chest: No evidence of metastatic disease in the lungs
  3. CT AP: Uterine mass- eventually had a complete hysterectomy with gynecology oncology with pathology showing benign findings
  4. Bone scan: No evidence of metastatic disease to the bone
  5. Mammogram and ultrasound: 5.1 cm mass in the left breast, 1.2 cm mass in the left breast, diffuse skin thickening, multiple abnormal lymph nodes with largest measuring 4.5 cm

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Summary: disease limited to the breast and regional lymph nodes

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WHERE ARE WE NOW?

  • Currently receiving chemotherapy
  • Will return to surgical oncology to discuss surgical options once neoadjuvant chemotherapy is complete
    • Likely candidate for mastectomy with ALND

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MY ROLE AS A PA FROM START TO FINISH…

  • First visit: gather a full history, perform a complete breast exam and lymph node evaluation, develop a plan
  • Make sure all imaging is up to date
  • Refer to necessary providers
  • LONG TERM CONTINUITY OF CARE!

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ANY QUESTIONS?

  • Email: gracestewart843@gmail.com