First Oncology Consultation

Clinician Specialty: Oncologist Patient name and age: Jane Doe, 62 years old Referring Doctor: Dr. Sarah Chen Copy Doctor: Dr. Michael Green Oncology diagnosis and ICD-10 code: Invasive ductal carcinoma of breast, Stage IIB (C50.911) Stage: Stage IIB Date of diagnosis: 1 November 2024 Social history: Married, lives with husband. Works as a retired teacher. Occasional social drinker, non-smoker. No illicit drug use. Allergies: Pencillin (rash, pruritus) (T42.0X5A) Smoking history: Never smoked (Z87.891) Alcohol history: Occasional social drinker, 1-2 units per week (Z72.89) Previous medical history: Hypertension (I10), Type 2 Diabetes Mellitus (E11.9) Previous surgical history: Appendectomy (2005), Cholecystectomy (2015) Family history: Mother diagnosed with breast cancer at age 70. Father died of myocardial infarction at age 65. Current illness: Patient presented with a palpable lump in her right breast approximately three months ago. Mammogram and subsequent biopsy confirmed invasive ductal carcinoma. She reports no nipple discharge or skin changes. Occasional mild breast pain, but denies systemic symptoms like weight loss or fever. Presenting complaints: Right breast lump, mild breast pain. Surgery to date for current referral: Core needle biopsy of right breast mass on 15 October 2024. Clinical examination: General: Well-nourished, no acute distress. Vital signs stable. Breasts: Right breast, 2.5 cm firm, mobile mass palpable in the upper outer quadrant, non-tender. No skin dimpling, erythema, or nipple retraction. Left breast, no palpable masses or abnormalities. Axillary lymph nodes: No palpable lymphadenopathy in either axilla. Supraclavicular nodes: Not enlarged. Special investigations: Mammogram, Ultrasound of breast, CT chest/abdomen/pelvis, Bone scan. Imaging: Mammogram: Irregular speculated mass, 2.3 cm, in the right upper outer quadrant. BI-RADS 5. Ultrasound: Corresponding hypoechoic mass with ill-defined margins. No suspicious axillary lymph nodes identified. CT chest/abdomen/pelvis: No evidence of distant metastases. Bone scan: No evidence of bony metastases. Histology: Invasive ductal carcinoma, oestrogen receptor positive, progesterone receptor positive, HER2 negative. Blood results: Full blood count: WNL. Liver function tests: WNL. Renal function tests: WNL. Tumour markers (CA 15-3): Within normal limits. NGS: No specific actionable mutations identified in BRCA1/2, TP53, or ATM. Testing for PIK3CA mutation pending. Assessment: 62-year-old female with newly diagnosed Stage IIB (T2N0M0) hormone-receptor positive, HER2-negative invasive ductal carcinoma of the right breast. Patient is otherwise fit and well with controlled co-morbidities. Risk of recurrence is moderate based on tumour characteristics. Plan: 1. Discussion at multidisciplinary team meeting. 2. Recommend neoadjuvant chemotherapy given tumour size, followed by lumpectomy and sentinel lymph node biopsy. 3. Consider genetic counselling. 4. Commence endocrine therapy following surgery. 5. Follow-up appointment in 2 weeks to discuss MDT recommendations and treatment plan in detail. Prescribe antiemetics and instruct on potential chemotherapy side effects. Key takeaway: Patient requires neoadjuvant chemotherapy followed by surgery and endocrine therapy for Stage IIB breast cancer.