Case Presentation dense breasts and no mammographic correlate to - PDF document

§ 45 year old premenopausal woman presents to clinic with a new palpable left breast mass at 2 o’clock 3 cm from the nipple. § Diagnostic mammogram showed extremely Case Presentation dense breasts and no mammographic correlate to the palpable finding. October 10, 2019 § Screening mammogram 2 years ago was Jo Chien, MD unremarkable. Amie Lee, MD Jasmine Wong, MD 1 2 What Additional Imaging Should be Done? A) Ultrasound § Targeted ultrasound of the breast showed a 1.3 cm mass at 2 o’clock 3 cm from the B) 3D mammogram nipple at the site of palpable mass § Ultrasound guided core biopsy of the mass C) MRI showed a ER/PR positive (95%) Her2 negative grade 2 IDC. D) PET CT scan E) No further imaging needed since mammogram was negative 3 4 1 | [footer text here]

Should a Breast MRI be performed? § Patient elects to undergo a partial A) Yes mastectomy and sentinel lymph node biopsy § Surgical pathology showed a 1.5 cm grade B) No 2 ER/PR positive (95%) Her2 negative IDC with negative margins, 1 positive sentinel C) It’s complicated… lymph node (3mm) and 2 negative sentinel lymph nodes 5 6 What adjuvant systemic therapy should be How should the positive sentinel lymph offered? node be managed? A) Completion axillary lymph node dissection A) Chemotherapy B) Mastectomy B) Endocrine Therapy C) Surveillance ultrasounds of the axilla C) Chemotherapy followed by hormone therapy D) No further surgical management, refer to radiation oncology D) Need more information – send molecular E) Repeat sentinel lymph node biopsy profiling 7 8 2 | [footer text here]

Which adjuvant systemic therapy do you recommend? A) Chemotherapy § Medical oncology sends a MammaPrint test – results show low risk signature B) Tamoxifen C) Ovarian suppression D) Aromatase inhibitor E) Ovarian suppression and aromatase inhibitor 9 10 Which of the following options would be inappropriate to recommend? § The patient is risk averse and elects to start on ovarian suppression and letrozole. A) Hold AI for 2 weeks then try a different one, continue OS § She develops intolerable joint pain and vaginal dryness, and would like to discontinue B) A trial of E-string for vaginal dryness her hormone therapy due to her side effects. § She is exercising 5 days a week and doing C) A trial of duloxetine for joint pain acupuncture weekly D) Stop OS, continue with AI alone E) Switch to tamoxifen alone 11 12 3 | [footer text here]

What Surveillance Imaging Should This Patient Have? A) Annual Bilateral Screening Mammograms B) Annual Breast MRI C) 3D Screening Mammogram and Breast MRI, alternating every 6 months D) Annual Screening Mammogram and Breast Ultrasound 13 14 4 | [footer text here]