Cancer Information Management

MAMMOGRAPHY REPORT (Mammo done at another hospital)

Date: 12/20/2022

Diagnosis: 0.8 cm mass in upper outer portion of right breast. Left breast is benign.

PATHOLOGY REPORT (Outpatient biopsy performed at another hospital)

Date: 01/05/2022

Specimen:

Breast needle core biopsy

Final Diagnosis:

Right breast, upper outer quadrant, core biopsy: Infiltrating ductal carcinoma, grade 1.

Admission Date: 1/29/2022

Discharge Date: 1/30/2022

HISTORY & PHYSICAL

Date: 01/29//2022

HISTORY OF PRESENT ILLNESS: Patient with biopsy proven right breast cancer, here for definitive treatment.

PHYSICAL EXAM: No masses palpated in either breast. Axilla negative.

IMPRESSION: Localized rt breast cancer. Will proceed with lumpectomy.

OPERATIVE REPORT

Date: 01/29/2022

Preoperative Diagnosis: Abnormal mammogram. Biopsy revealed invasive ductal carcinoma, and complete excision was recommended.

Operation: Right breast lumpectomy, wire localized. Sentinel lymph node biopsy

(Body of operative report omitted – no pertinent findings)

PATHOLOGY REPORT

Date: 01/29/2022

Specimen(s) received: Right partial breast. Right axillary sentinel node biopsy.

Clinical History: UOQ mass found on screening mammography.

Diagnosis: A. Right breast tissue demonstrating carcinoma in-situ and infiltrating duct carcinoma. Size of infiltrating portion of tumor is 1.2 x 0.5 x 0.5 cm, surgical resection margins are free of tumor. Nottingham Score: Glandular (Acinar) Tubular Differentiation: 3, Nuclear Pleomorphism: 2, Mitotic Rate: 1. Overall Grade: 2. Extra piece of breast tissue, right, demonstrating benign fibrocystic disease with microcalcifications. No lymphovascular invasion is identified. B. 3 right sentinel lymph nodes examined, no malignancy identified in 3 nodes. ER: positive, 90%, Allred score 8. PR: positive, 86%, Allred score 7. HER2 HercepTest (IHC): 2+/equivocal. HER2 FISH: negative. Ki-67: 15.8%.

MEDICAL ONCOLOGY CONSULT (Staff physician’s office)

Date: 02/14/2022

I saw the patient in my office today. This is a lady who had a lumpectomy on 01/29/2022. She was found to have a combination of ductal carcinoma in situ and invasive cancer. She had a sentinel lymph node dissection and had negative lymph nodes. Her Oncotype DX recurrence score was 5, which showed her to be at low risk. I therefore recommended no chemotherapy. We had a long discussion regarding the pros and cons of adjuvant hormone therapy. I went ahead and arranged for her to see the radiation therapist and I would like to see her after completion of radiation to initiate therapy.

RADIATION ONCOLOGY CONSULT (Radiation therapy center is part of the reporting facility)

Date: 03/09/2022

Clinical History: Patient is a 55 year-old woman that I am seeing for consideration of radiation therapy as part of conservative breast management. Patient was noted to have some new microcalcifications in the upper outer quadrant of the right breast. Lumpectomy demonstrated a mixture of ductal carcinoma in-situ and infiltrating ductal carcinoma. It did stain strongly for Estrogen and Progesterone receptors and HER2/neu was negative. Her lumpectomy and sentinel lymph node biopsy was performed on 01/29/2022. Patient has healed well from her surgical incision. She describes no skin changes or nipple discharge.

Assessment: I have advised 35 treatments of breast radiation to decrease her recurrence. The logistics, side effects of radiation therapy to the breast region were discussed in great detail over 55 minutes. She had numerous questions that were answered. She appears to understand. She had elected to proceed. We will have her come for simulation and planning in a few days.

RADIATION TREATMENT SUMMARY

Date: 06/14/2022

The patient was treated to the right breast to 5040 cGy given at 180 cGy per fraction per day. She was treated in a 3-D conformal fashion with 18 MV photons. The right breast lumpectomy site was boosted to an additional 1260 cGy given at 180 cGy per fraction per day using 18 MV photons and a 3-D technique with blocking to shield nontarget tissues. Thus, the total dose received by the target volume was 6300 cGy. The patient was given 35 treatments over 51 elapsed days. The dates of treatment were 04/24/2022 through 06/14/2022.

RADIATION TREATMENT FOLLOWUP NOTE

Date: 7/15/2022

The patient is a very pleasant 55-year-old woman with a history of a right breast cancer, status post lumpectomy and lymph node biopsy. She did not receive chemotherapy as Oncotype DX showed her to be at low risk. She finished radiation therapy last month. She presents today in one month follow-up.

Since the patient was last seen in this department, she states she has been doing very well. She states her medical oncologist started her on Arimidex on 7/10/2022 and feels she is tolerating this very well. She is very pleased. She denies headaches, nausea, vomiting, or bone pains. She states that she always has some achiness in her knee. She states that she will be seeing her medical oncologist again this fall after her mammogram, which she has already ordered.

The patient is free of recurrence. We will see her back in one year.