Review Question - QID 104650

This patient is presenting with estrogen receptor (ER) positive breast cancer and is subsequently treated with tamoxifen, which can cause hypercoagulability and deep venous thrombosis.

Breast cancer usually presents with a firm, fixed mass in the breast with irregular borders. It may also present with firm, non-tender axillary lymph nodes if the malignant cells have traveled to the nearby lymph nodes. The management is first mammography, then biopsy, followed by surgical excision and chemotherapy. Tamoxifen is an ER antagonist in the breast; thus, its indication in ER-positive breast cancer. It also upregulates the production of clotting factors causing a hypercoagulable state with deep venous thrombosis and pulmonary emboli being potential complications.

Incorrect Answers:
Answer 2: Endometrial cancer is a possible complication of tamoxifen; however, this post-menopausal woman who was treated for a uterine leiomyoma with a hysterectomy is not at increased risk of endometrial cancer.

Answer 3: Eruption of seborrheic keratoses termed Leser-Trelat sign is a sign of visceral malignancy (such as pancreatic cancer) and warrants workup for an underlying malignancy. Otherwise, seborrheic keratoses are a benign finding in the elderly.

Answer 4: Increased bleeding is a risk factor of warfarin which inhibits the production of vitamin K-dependent clotting factors. The liver will actually produce more clotting factors in the setting of an increased estrogen state.

Answer 5: Osteoporosis is a side effect of letrozole which is an aromatase inhibitor that decreases estrogen levels systemically; however, tamoxifen is actually an ER agonist in the bone.

Bullet Summary:
Tamoxifen can cause a hypercoagulable state leading to deep vein thrombosis and pulmonary emboli.