3090D553-9492-4563-8681-AD288FA52ACE

Editor's Note:

The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to recognize accurately. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a Case Challenge, please contact us.

Background

A 68-year-old woman presents to the emergency department with nausea, vomiting, and diffuse abdominal pain. She reports a 30-lb weight loss over the past 3 to 4 weeks. She has had intermittent nonbloody, nonbilious vomiting and poor oral intake. She reports having bowel movements and flatus. She denies any pruritus, shortness of breath, chest pain, fevers, or chills.

Two years prior, the patient was diagnosed with and treated for breast cancer. She was asymptomatic at the time of the mammography screening but had a family history that included two sisters who were diagnosed with breast cancer, at ages 60 and 65 years. Also, both her brother and father had prostate cancer. The screening mammogram showed evidence of calcifications approximately 1.9 cm in the lower-inner quadrant of her right breast, with a rating of BIRADS 4. This finding was new compared with her previous mammogram 1 year prior.

The patient subsequently underwent diagnostic mammography with stereotactic core needle biopsy, which yielded pathology consistent with a grade 2 invasive ductal carcinoma with foci of ductal carcinoma in situ; thus, her breast cancer was determined to be clinical stage 1a/T1a/cN0/M0. Hormonal testing revealed strong estrogen receptor (ER) positivity, with 51%-100% of cells staining positive. It also revealed negative progesterone receptor (PR) receptivity, with less than 1% of cells staining, and negative HER2/neu findings.

Due to the high risk associated with her family history, the patient underwent diagnostic bilateral breast MRI. A lesion consistent with the calcifications seen on the mammogram was revealed at the 4-o'clock position, with a new suspicious lesion at the 8-o'clock position, measuring 4 mm. Based on her family history of malignancy, the patient underwent further genetic testing. Myriad 25-gene testing, including BRCA1 and BRCA2 testing, yielded negative findings. The patient opted for breast conservation with postoperative radiation and adjuvant systemic treatment.

The patient subsequently underwent a 3-needle localized right lumpectomy (2-needle localization bracketing the area of cancer in the additional 8-o'clock position, with additional needle localization of the 4-o'clock mass) with sentinel lymph node biopsy and possible axillary node dissection. The pathology of the surgical specimen was consistent with a 3.5-cm invasive ductal carcinoma, grade 2, with a positive inferior margin and close anterior and lateral margins. Sentinel nodes revealed evidence of one node with 0.1-mm micrometastasis and three negative nodes. The pathology of the lesion at the 8-o'clock position showed findings consistent with intraductal papilloma.

The patient was upstaged to a T2/N1mic/M0 stage IIB cancer, with an oncotype score of 26. She subsequently underwent adjuvant chemotherapy with docetaxel anhydrous, cyclophosphamide, and pegfilgrastim and postchemotherapy reexcision of her margins, with all new margins reported as negative. A follow-up mammogram performed 1 year later—approximately 10 months prior to her current presentation for nausea, vomiting, and abdominal pain—revealed no abnormal findings.

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