What happened, in summary

This 61-year-old man came to emergency care with pain and swelling of the left chest and breast. The lesion had been present for years, but it had recently grown quickly and caused skin ulceration. CT showed a 7.4 cm left chest-wall mass. Ultrasound and mammogram showed suspicious left axillary lymph nodes and a 7.1 cm solid breast mass. Core biopsies from the breast and axillary node showed invasive carcinoma with papillary features and lymph-node metastasis. The tumor was grade 1 but mitotically active, ER-positive and PR-positive at 100% each, and HER2-negative by IHC 1+. CT scans of the abdomen, pelvis, and bone did not show distant disease, and he was clinically staged as Stage IIIB, cT4N1aM0. He received neoadjuvant chemotherapy with adriamycin, cyclophosphamide, and paclitaxel. The response was limited. After chemotherapy, he underwent left radical mastectomy and scout-guided axillary dissection. The main surgical specimen showed encapsulated papillary carcinoma, supported by loss of myoepithelial cells on p63 staining and lack of neuroendocrine differentiation. There was no definite response to presurgical therapy, with overall cancer cellularity of about 95%, and skin ulceration remained. Margins were negative overall, although the tumor was less than 1 mm from the skin margin. The final pathologic stage was ypT4bN1a. He then completed radiation therapy and started tamoxifen for hormone-receptor-positive disease. The limited chemotherapy response made surgery, radiation, and endocrine therapy the main disease-control steps in his treatment sequence after staging. Three years after diagnosis, he was clinically doing well with no evidence of recurrence.