A 64-Year-Old Man With Back Pain After Mastectomy

Avan Armaghani, MD


April 16, 2019

Update: The image originally associated with this Case Challenge was mirrored (reversed) and incorrectly suggested the patient's left breast was affected. The image has been removed to avoid any confusion, as the text correctly describes a right mastectomy.

Editor's Note:
The Case Challenge series includes difficult-to-diagnose conditions, some of which are not frequently encountered by most clinicians but are nonetheless important to accurately recognize. Test your diagnostic and treatment skills using the following patient scenario and corresponding questions. If you have a case that you would like to suggest for a future Case Challenge, please contact us.


A 64-year-old, generally healthy man presents with right lower back pain. Approximately 7 years prior, he had presented to his primary care physician after noticing a lump in his right breast 4 months before. Although he did not have any other constitutional symptoms, including fever, chills, chest pain, shortness of breath, nausea, vomiting, or diarrhea, he was concerned because the lump had increased in size.

A core needle biopsy of the right breast mass and other investigations revealed he had stage IIA estrogen receptor–positive HER2 negative breast cancer. The patient underwent right mastectomy and then started tamoxifen adjuvantly.

Now, 2 years after the completion of 5 years of tamoxifen therapy, the patient describes concerning right lower back pain. The rest of his medical and surgical history is unremarkable. He does not have a family history of breast cancer or other cancers. He works as an electrician and lives in the Cayman Islands with his wife. He has two children. He admits to drinking alcohol, but only in moderation (2-3 drinks 1-2 days per week, maximum).


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