Ms. L, age 76, was diagnosed in January 1998 with locally advanced (III-B) breast cancer that was estrogen/progesterone receptor negative and positive for the HER2/neu oncogene. After undergoing a left mastectomy, she received adjuvant chemotherapy with doxorubicin and cyclophosphamide. In 1999, disease recurrence on the chest wall was treated with paclitaxel and trastuzumab, followed by palliative radiation therapy to the chest wall. A left partial acromioplasty was performed in February 2000 to manage extension of the disease from the chest wall. The patient then remained stable until this morning when she awoke with chills and a fever of 102 F. She reported that she had experienced progressive shortness of breath over the past week, which increased dramatically over the past two days to the point where she is dyspneic at rest. She has no cough and says that she stays in bed or on the sofa all day.