Cancer Information Management

Date of admission: 8/05/2022

Date of discharge: 8/10/2022

HISTORY & PHYSICAL

Date: 08/05/2022

Reason for consult: Pre-op evaluation and medical management follow up.

HISTORY OF PRESENT ILLNESS: Patient is a 63 year old resident of Silver Hills Nursing

Home, who was seen for an ulcerating right breast lesion. Because of her prior history of paranoid

schizophrenia, the patient has been difficult to manage from the onset permitting very little

examination of the lesion. However, with cooperation from the family, who has power of

attorney, they have arranged for admission for modified radical mastectomy. Also, further exam

of the other breast and also removal or biopsy of lesion on the face at the same time, as the patient

would not permit any further physical exam.

PAST MEDICAL HISTORY: Severe schizophrenia since her teen years. She recently

was hospitalized at Greenleaf and had medications adjusted. She provides very little in the way

of history and the sister who is here is unable to provide much. Obesity, questionable vascular

heart disease. Post-menopausal.

FAMILY HISTORY: Positive for diabetes.

REVIEW OF SYSTEMS: Very limited from the patient as she is guarded about her answers.

Exam is limited as the patient is reluctant to have any body system examined.

BREASTS: Not examined as patient would not permit.

IMPRESSION: 1. Schizophrenia, paranoid.

2. Right beast lesion, causing skin ulceration.

3. Possible diabetes mellitus.

4. Possible hypertension.

OPERATIVE REPORT

Date: 08/08/2022

PROCEDURE: Right modified radical mastectomy.

INDICATIONS: This 63 year old white female with psychosis since her teens. She has a

fungating mass of the right breast.

After adequate general endotracheal anesthesia was obtained, the patient was given a gram of

Ancef IV and the left breast was examined. No palpable masses were noted there. An elliptical incision was made in the skin around the right breast and dissection was carried up to the clavicle superiorly, medially to the sternum, inferiorly to the inferior costal margin and laterally to the latismus dorsi muscle. As the axilla was cleared, the thoracodorsal and long thoracic nerves were each individually identified and preserved and lymph node bearing tissue was swept anteriorly from them up to the axillary vein.

A large node was noted near the apex of the axilla and was felt to be consistent with

node metastasis. Blood vessels feeding this tissue were ligated with hemoclips and the breast

and axillary dissection was sent on irrigation. Subcutaneous tissue was then closed with running

0-Vicoryl suture and the skin was closed with staples. Each drain was sutured to the skin using

2-10 silk and placed to grenade suction. Patient tolerated this procedure well and was taken to

recovery in stable condition.

PATHOLOGY REPORT

Date of Report: 08/08/2022

MATERIAL/TISSUE SUBMITTED

Right breast & axillary contents

CLINICAL HISTORY/CLINICAL DIAGNOSIS

Right breast fungating mass

ADDITIONAL MICROSCOPIC OBSERVATIONS

Immunoperoxidase stains with adequate controls are performed on block #20. Estrogen Receptor: Positive, 95%, Allred score 8. Progesterone Receptor: Positive, 15%, Allred score 3. HER2 by IHC: Positive, 3+. HER2/neu by FISH was not performed.

GROSS EXAMINATION

Omitted.

MICROSCOPIC EXAMINATION

Omitted.

FINAL DIAGNOSIS:

Right breast:

A. Invasive, ductal carcinoma of the breast, 6.7 cm maximal tumor diameter, in the upper inner quadrant.

B. A carcinoma in situ component is not identified.

C. Nottingham grade 2.

D. Two foci of separate and distinct invasive carcinoma w/ductal and lobular features. One focus measuring 1.0 cm is identified in the upper outer quadrant and a second focus measuring 0.8 cm is identified in the retroareolar region. See comment.

E. All margins negative. Tumor extends within 2.5 mm of the deep surgical margin.

F. Lymphovascular invasion: Small vessel invasion of lymphatics is identified.

G. Six of fourteen axillary lymph nodes contain metastatic ductal adenocarcinoma. The largest tumor deposit is 1.3 cm.

COMMENT

Two separate and distinct types of invasive carcinoma are identified in the right breast. The large and dominant pattern is invasive ductal carcinoma, which has eroded through the skin causing ulceration. Two foci of invasive carcinoma with ductal and lobular features are also identified.

DISCHARGE SUMMARY

Date: 08/10/2022

Patient is a 63 year old severely schizophrenic female with breast cancer on the right eroding through the skin. Due to her psychiatric condition, close follow up with her family practice doctor was required. During her admission she was also diagnosed with diabetes. Patient underwent a right modified radical mastectomy on the 8th of August. She had Jackson Pratt drain placed in the operative area postoperatively. The patient did remarkably well post op with minimal complaints of pain. Glucose control was a bit of a problem with her going into the mid 200 range post op. This was brought into good control by the first postoperative day and by day two, she was suitable for discharge. Patient was also seen by a medical oncologist who started her on an aromatase inhibitor and Herceptin as of today, due to her positive markers. Arrangements were made for her transfer back to the nursing home on the 10th of August. Her medial JP drain was putting out very minimal amounts by that time and it was discontinued prior to discharge. She was given prescription for Darvocet for pain. She will follow up a week after discharge at Surgical Clinic.

End