A 38-year-old White woman presents to her ob-gyn. She reports finding a lump in her left breast on self-exam 1 month ago. In the past 3 months, she has noticed swelling of the left breast, with thickened, red skin, particularly on the upper outer quadrant. She also reports thick, oozing discharge from the left nipple; occasional breast pain; fatigue; and frequent headaches.

Physical exam reveals dimpling in the upper outer quadrant of the left breast. There is lymphadenopathy in the axial nodes, with swelling particularly evident near the left collarbone.

The patient appears fatigued and slightly jaundiced. Heart, breath, and bowel sounds are largely normal on auscultation. The patient's abdomen appears slightly distended, and there is evidence of minor hepatomegaly on palpation. Laboratory tests are ordered, including a complete blood cell count with differential and a comprehensive metabolic panel. Results reveal elevated aspartate aminotransferase (45 IU/L), alanine aminotransferase (72 IU/L), and alkaline phosphatase (200 IU/L) levels.

The patient has been married for 5 years and has a 3-year-old daughter. She has a BMI of 27, does not smoke, and has no other comorbidities. She reports alcohol consumption of one to two glasses of wine in the evening. Onset of menarche was at 11 years of age. She does not have a family history of breast cancer.