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Teachable Moment
Less Is More
October 2017

Unnecessary Staging Imaging in Early-Stage Breast Cancer: A Teachable Moment

Author Affiliations
  • 1Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas
  • 2Parkland Hospital, Dallas, Texas
  • 3Division of Hematology Oncology, University of Texas Southwestern Medical Center, Dallas
JAMA Intern Med. 2017;177(10):1516-1517. doi:10.1001/jamainternmed.2017.2785

A woman in her 60s with impaired glucose tolerance and osteoarthritis of the knees presented to her primary care clinician after routine screening mammography revealed a 1-cm area of calcification at the 9-o’clock position of the right breast. Ultrasonography of the right breast and axilla identified an 8 × 6 × 8-mm hypoechoic mass with indistinct margins in the corresponding area, without evidence of axillary lymphadenopathy. She otherwise had no complaints, reported no personal or family history of cancer, and took no scheduled medications. Examination revealed symmetric breasts without palpable masses or lymph nodes, and no skin or nipple changes. A biopsy of this mass revealed invasive ductal carcinoma (estrogen receptor positive and human epidermal growth factor receptor 2 positive). She was diagnosed with clinical T1N0M0 (stage 1A) breast cancer. Routine laboratory analysis noted no abnormalities. Multimodality staging imaging, including a nuclear bone scan and contrast-enhanced computed tomography (CT) scans of the chest, abdomen, and pelvis revealed no clear evidence of metastasis, but a 1.8-cm left adrenal gland nodule was noted. A magnetic resonance scan of the abdomen was performed to better define this nodule, and results indicated a likely adenoma. Results of biochemical testing (dexamethasone suppression test and measured levels of plasma metanephrines), performed to evaluate the functionality of the adrenal lesion, were negative.

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