Oncology H & P

Oncology diagnosis and stage: Invasive Ductal Carcinoma, Stage IIB (T2 N1 M0) Reason for current consultation: Follow-up appointment to discuss recent imaging results and develop a definitive treatment plan. History: - 58 years old - Patient presents with a several-month history of a palpable lump in the left breast, initially noticed during a self-examination. No associated pain or nipple discharge. Reports increasing fatigue over the past 3 months. - The lump is described as firm, non-tender, and approximately 3 cm in diameter, located in the upper outer quadrant of the left breast. Duration is approximately 4 months, with gradual enlargement. No specific alleviating factors; worsening was noted with initial discovery and slight growth since. - Lump has slowly increased in size since first noticed. Initial self-palpation revealed a smaller, less distinct mass. - No previous similar episodes. Patient had a benign fibroadenoma removed from the right breast 10 years ago, with no recurrence. - Impact on daily activities is moderate due to increased anxiety and fatigue. Unable to maintain usual exercise routine. - No associated focal neurological symptoms. Systemic symptoms include mild, unexplained weight loss (2kg in 3 months) and persistent fatigue. Physical Examination: - Vital signs: BP 130/80 mmHg, HR 72 bpm, RR 16 bpm, Temp 36.8°C, O2 Sat 98% on room air. - General physical examination findings: Well-nourished female, appearing anxious but in no acute distress. No obvious cachexia. Lymph nodes in the axilla and supraclavicular regions were palpable on the left side; one firm, mobile lymph node approximately 1.5 cm in the left axilla. No skin changes, oedema, or ulceration. - System-specific examination findings: - Breast Exam: Left breast reveals a 3x3 cm firm, irregular, non-tender mass at 2 o'clock, approximately 3 cm from the areola. Skin overlying the mass is intact, no dimpling or retraction. Nipple is everted, no discharge. Right breast unremarkable. - Respiratory: Clear to auscultation bilaterally. - Cardiovascular: S1/S2 normal, no murmurs. - Abdominal: Soft, non-tender, no organomegaly. Investigations: - Mammogram (15 October 2024): Irregular, high-density mass with spiculated margins in the left breast, upper outer quadrant. BI-RADS 5. - Ultrasound (18 October 2024): Confirmed a 3.2 cm hypoechoic mass in the left breast with angular margins and posterior shadowing. Also noted an enlarged left axillary lymph node (1.8 cm) with thickened cortex. - Core Needle Biopsy (25 October 2024): Histopathology confirmed invasive ductal carcinoma, oestrogen receptor positive, progesterone receptor positive, HER2 negative. - PET-CT Scan (28 October 2024): Demonstrated avid uptake in the left breast mass and the left axillary lymph node. No distant metastatic disease identified. Impression: - Likely diagnosis: Invasive Ductal Carcinoma of the left breast, Stage IIB (T2 N1 M0). - Differential diagnoses: Fibroadenoma (less likely given imaging and biopsy), benign cyst (ruled out by biopsy), phyllodes tumour. Management Plan: - Investigations planned: Pre-operative blood work (FBC, U&Es, LFTs, coagulation screen), ECG. - Treatment planned: 1. Neoadjuvant chemotherapy for 4-6 cycles (e.g., Adriamycin and Cyclophosphamide followed by Paclitaxel) to downstage the tumour and assess pathological response. 2. Following chemotherapy, surgical intervention will be planned, likely lumpectomy with sentinel lymph node biopsy, or mastectomy if tumour response is insufficient or patient preference. 3. Adjuvant radiation therapy post-surgery if lumpectomy is performed. 4. Endocrine therapy (e.g., Tamoxifen or Aromatase Inhibitor) for 5-10 years given ER/PR positivity. - Other relevant actions such as counselling, referrals, or lifestyle recommendations: - Referral to oncology nurse specialist for patient education and support. - Referral to genetic counselling for BRCA testing given family history of breast cancer (maternal aunt at age 62). - Nutritional counselling to address fatigue and weight management. - Emotional support referral to cancer support group.