Iwao Tanaka, MD

The patient is an 86-year-old woman with a history of right breast infiltrative lobular carcinoma 16 years before presentation.

A 57-year-old man with no stated past medical history presented to the ED with complaints of headache and blurry vision that were getting progressively more severe. These symptoms began about 6 months before presentation. He also noted worsening bloody bowel movements.

Our patient is a 59-year-old man with a history of diabetes and HIV infection. He also has diffuse large B-cell lymphoma, which was diagnosed after presenting with low back pain and having found a bulky left upper quadrant mass. He received etoposide, prednisone, vincristine, doxorubicin and cyclophosphamide (EPOCH) chemotherapy for six cycles followed by involved field radiation to the bulky retroperitoneal mass.

A 64-year-old black man with a history of hepatitis C, a 40 pack-year smoking history and a family history of lung cancer presented with a two-to-three month history of gradually worsening dyspnea on exertion. This was associated with intermittent dry cough with one episode of hemoptysis, decreased appetite and about a 10-lb weight loss during the past two months.

A 63-year-old woman without significant personal past medical history presented to her primary physician with a one-month complaint of palpable right breast mass. The patient was referred to a breast surgeon for evaluation and underwent imaging studies that showed a 4 cm × 3 cm mass in the right upper outer quadrant. Core biopsy of the mass was performed and pathology revealed an invasive lobular carcinoma, classical type.

A 60-year-old woman presented to us with newly diagnosed breast cancer. She had a screening mammogram that revealed loose collections of punctate and linear calcifications on the left breast with ultrasound showing two to three poorly marginated hypoechoic zones. Breast biopsy was consistent with ductal carcinoma in situ with microinvasion. She underwent mastectomy with negative sentinel lymph node biopsy.

A 55-year-old woman presented to our center for restaging PET/CT. Her history was significant for recurrent breast cancer in the mediastinum and lungs. She initially underwent left mastectomy, adjuvant chemotherapy and radiotherapy. She was started on palliative chemotherapy. Her initial staging PET/CT showed subcentimeter medistinal lymph nodes (maximal SUV 8.4), right lower lobe mass 1.4 × 1.2 cm (SUV 5.3), scattered subcentimeter nodules in the lung. Her restaging scan with a PET/CT after chemotherapy showed progressive disease with right axillary lymph nodes measuring 1 cm (SUV 2.0), medistinal lymph nodes measuring 1 cm (SUV 3.6 to 10.1), right lower lobe mass measuring 2.1 × 1.4 cm (SUV 7.1), relatively stable pulmonary nodules and new left pleural effusion.

A 68-year-old woman initially presented with intermittent abdominal pain and persisting left hip pain. She gave a history of early breast cancer and completed five years of tamoxifen one year ago. Her pertinent positive physical exam finding was decreased range of motion of the left hip. A CT chest/abdomen/pelvis showed an anterior mediastinal mass, multiple liver lesions, lytic and blastic lesion of the left 12th rib and multiple lytic lesions of the thoracic and sacral vertebrae. On bone scan, there was uptake in the left 12th rib and left sacroiliac joint (figure 1). A mammogram was negative. A biopsy of the liver lesion revealed an adenocarcinoma, ER-positive, PR-negative and HER2-neu negative. The patient was started on letrozole and zoledronic acid. Eight months later, the CT of the chest/abdomen/pelvis showed progression with increasing size of the mediastinal mass and number of liver metastases. Bone scan showed an interval response. She was started on fulvestrant (Faslodex, AstraZeneca) and noted to have stable disease three months later by tumor markers and PET/CT. Her skeletal system findings on PET/CT were hypermetabolic left 12th rib lesion with a standardized uptake value of 3.6 and hypermetabolic lytic sacral lesion with a standard uptake value of 4.1 (figures 2 and 3, top rows). Five months later, she experienced left forearm pain and there were increasing tumor markers. An X-ray of the forearm was negative and a bone scan showed stable disease in the left 12th rib and left sacrum with no evidence of metastatic disease in the left upper extremity (figure 1). Her skeletal system findings on PET/CT were left 12th rib lesion with a standard uptake value of 6.9 and lytic sacral lesion with a standard uptake value of 8.3 (figure 2 and 3, bottom rows), consistent with progression. Concordant with progression of skeletal metastatic disease, there was progression of mediastinal lymphadenopathy on both PET and CT (figure 4).