1. Care of Relapsed Breast Cancer MGR R2 황은정 /prof. 김시영

2. 11330557 김ㅇ례 F/59 Admission on 2002.1.10 Chief Complaint Lt. neck mass o/s) 5 개월전 Present Illness 59 세 여자환자로 내원 5 개월전부터 Lt. neck mass 만져지다 내원시 2cm 정도까지 크기 증가하여 neck biopsy 통한 진단과 치료 위해 내원함. fever, night sweats, weight loss 은 없었으며, fever, night sweats, weight loss 은 없었으며, Lt. supraclavicular area 에 위치하며 2cm 정도, soft, movable, tenderness 없으며 skin change 없는 상태였음. 1998 년 3 월 13 일 Breast cancer(invasive ductal carcinoma) stage IIA(T1 N1M0), ER(+), PR(-) 로 Lt. Modified radical mastectomy 시행 받을 당시 Lt. neck LNE(0.5X0.5cm) 있어 biopsy 시행 후 metastatic adenocarcinoma 소견보여 Breast cancer Stage IIIC 로 최종 진단 후, 19 98 년 4 월 9 일부터 7 월 23 일까지 Adjuvant chemotherapy (CEF 1 차 ~6 차 ) 시행 받고 1998 년 9 월 11 일 High dose chemotherapy and PBSCT 시행 후 Tamoxifen 복용하며 2001.3.6 외래 추적 관찰 당시 Neck mass 는 사 라진 상태였음

3. Past medical history –DM/HTN/Tb/Hep (-/-/-/-) –Op Hx (+) 1998.3.13 Lt. modified radical mastectomy d/t Breast cancer Stage IIA –Breast cancer, stage IIIc (T1N3M0), invasive ductal carcinoma ER(+) PR(-) ER(+) PR(-) Personal history –Smoking (-) –Alcohol (-) –Menopause : 5 년전 1998.3.13 Lt. MRM 1998.4.9~1998.7.23 CEF#1~#6 1998.10.08 High dose chemotherapy &PBSCT 1998~2001 Tamoxifen “Complete Remission State”

4. Review of system IGeneral fatigue (+) febrile sense (-) edema(-) weight loss(-) Skin rash (-) itching (-) pigmentation (-) bruise (-) rash (-) itching (-) pigmentation (-) bruise (-) Head & Neck headache (-) sore throat (-) rhinorrhea (-) headache (-) sore throat (-) rhinorrhea (-) Eye & ENT visual disturbance (-) tinnitus (-) nasal obstruction(-) visual disturbance (-) tinnitus (-) nasal obstruction(-)Respiratory cough (-) sputum (-) dyspnea (-) tachypnea (-) cough (-) sputum (-) dyspnea (-) tachypnea (-)Cardiac chest pain (-) palpitation (-) orthopnea (-) chest pain (-) palpitation (-) orthopnea (-)

5. Review of system II Gastrointestinal A/N/V/D/C (-/-/-/-/-) hematemesis (-) melena (-) hematochezia (-) Urinary dysuria (-) frequency (-) urgency (-) residual urine sense (-) flank pain (-) nocturia(-) polyuria (-) Musculoskeletal pain (-) back ache (-) swelling (-) weakness (-) Neurologic syncope (-) seizure (-) dizziness (-) numbness(-)

6. Physical examination I Vital sign 120/80 – 80 회 /min – 20 회 /min – 36.4°c weight : 60kg height : 153cm BMI : 25.6kg/m 2 General alert consciousness acutly ill looking appearance Skin no rash no pigmentation Head & Neck no neck vein engorgement Lt. supraclavicular lymph node enlargement Eye & ENT isocoric pupil with PLR (++/++) whitish sclera pinkish conjunctiva PI (-) PTH (-/-)

7. Physical examination II Thorax clear breathing sound without crackle or wheezing regular heart beat without murmur Breast asymmetric breast no palpable mass no discharge no axillary lymph node enlargement Abdomen soft and flat abdomen normoactive bowel sound no tenderness / rebound tenderness no palpable mass no abdominal bruit no splenomegaly no hepatomegaly Back & Extremities CVA tenderness (-/-) pretibial pitting edema (-/-) Neurologic sensory change (-) motor change (-)

8. Initial lab findingCBC/DC 8300/mm² -13.0g/dl –38.6% -221K (seg 70%) 8300/mm² -13.0g/dl –38.6% -221K (seg 70%) aPTT 27 PT (INR) 13.0(1.00) aPTT 27 PT (INR) 13.0(1.00)Chemistry AST/ALT 97/98IU/LBUN/Cr 12/0.7mg/dL AST/ALT 97/98IU/LBUN/Cr 12/0.7mg/dL ALP/GGT 90/42IU/L Na/K/Cl 141/4.2/106mmol/L ALP/GGT 90/42IU/L Na/K/Cl 141/4.2/106mmol/L Glucose 108mg/dL Ca/P/Mg 8.8/3.2/2.2mg/dL Glucose 108mg/dL Ca/P/Mg 8.8/3.2/2.2mg/dL Prot/Alb 6.5/3.9g/dL Uric acid 5.0mg/dL Prot/Alb 6.5/3.9g/dL Uric acid 5.0mg/dL LD/CK 354/73U/L CRP <0.5mg/dL LD/CK 354/73U/L CRP <0.5mg/dL U/A RBC 2~4/HPF WBC 0~1/HPF RBC 2~4/HPF WBC 0~1/HPF

9. Chest X-ray

10. EKG

11. Problem list #1. Lt. neck mass #2. s/p Lt. MRM d/t breast cancer, stage IIIc

12. Initial assessment and plan for #1 #1. Lt. neck mass

13. Initial assessment and plan for #1 #1. Lt. neck mass Locoregional recurrance breast cancer r/o Other malignancy r/o Infectious lymphadenopathy (Tuberculosis)

15. Initial assessment and plan for #1 #1. Lt. neck mass Locoregional recurrance breast cancer r/o Other malignancy r/o Infectious lymphadenopathy (Tuberculosis) Diagnostic plan FNA CEA, CA15-3 Chest CT, Abdomen CT

16. Initial assessment and plan for #1 #1. Lt. neck mass Locoregional recurrance breast cancer r/o Other malignancy r/o Infectious lymphadenopathy (Tuberculosis) Therapeutic plan locoregional therapy + Systemic chemotherapy locoregional therapy + Systemic chemotherapy Antibiotics therapy, Anti tuberculous drug Excisional biopsy Aspiration Incision and drainage

17. #2. s/p Lt. MRM d/t breast cancer stage IIIc, CR state Initial assessment and plan for #2

18. #2. s/p Lt. MRM d/t breast cancer stage IIIc, CR state Check symptom Physical examination Breast self examination Mammography Pelvic examination Patient education Coordination of care Neck CT or Chest CT d/t resolved Lt neck mass Initial assessment and plan for #2

19. Lt. neck mass FNA 02.1.10 1. SPECIMEN ADEQUACY Satisfactory FNA of breast shows clusters of atypical cells having abundant cytoplasm and large nuclei with prominent nucleoli and mitotic figures Diagnosis : Adenocarcinoma, metastatic Diagnosis : Adenocarcinoma, metastatic

20. Chest CT 02.1.10

21. Bone scan 02.1.22

22. STAGING

23. Staging

25. Stage IIIC T1N3M0

26. #1. Breast cancer, stage IIIC, #1. Breast cancer, stage IIIC, T1N3M0 Chemotherapy 시작 2002.1.12 Taxol #1~#6 3 주 간격 Neck CT f/u

27. Clinical course 1 st relapse DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda ® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin® #10~#31 2002.5.16 : 12.53mmAfter 3 months 2002.8.19 : 19.43mm

28. Clinical course 2 nd relapse DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol ® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin® #10~#31 2002.10.24 : 12.32mm 2003.3.6 : 8.82mm

29. Clinical course 3 rd relapse DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol ® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin® #10~#31 2003.8.19 : 16.2mm 12.53mm

30. 2004.6.22 : 7.0mm Clinical course 4 th relapse DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol ® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin® #10~#31 After 3 months 2004.9.16 : 16.91mm

31. Clinical course 5 th relapse DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol ® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar ® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda ® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin® #10~#31 2005.2.28 : 6.72mm2005.5.2 : 12.11mm

32. Clinical course 6 th relapse DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol ® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda ® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar ® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda ® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin ® #10~#31 2005.7.7 : 15.68mm

33. Clinical course DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol ® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda ® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar ® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda ® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin® #10~#31 200cGy/fx/day Total 60Gy 이상 → Total 58Gy 시행 MassSoftened Size : <5mm 중단 Moist desquamation on Lt neck skin

34. Clinical course 7 th relapse DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol ® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin® #10~#31 2006.6.12

35. Clinical course 8 th relapse DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol ® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda ® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar ® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda ® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin ® #10~#31 2007.5.28

36. Clinical course DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol ® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda ® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar ® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin ® #10~#31 Biopsy 시행 (2007.6.13) Metastatic adenocarcinoma ER(-), PR(-), Her-2 neu(3+)

38. Clinical course DateChemotherapy 2002. 1.12 ~ 2002. 5. 3Taxol® #1~#6 2002. 8.22 ~ 2003. 1.23Xeloda ® #1~#8 2003. 6.30 ~ 2003. 8.12Gemzar® #1~#2 2003. 8.22 ~ 2004. 5.25CMF #1~#10 2004.11. 4 ~ 2005. 4. 7CMF #1~#6 2005. 5. 4Xeloda® #1 2005. 8. 1 ~ 2005. 9.25Radiation therapy 2006. 6.26 ~ 2007. 2. 6CMF #1~#9 2007. 6.14 ~ 2007. 1.28TxH #1~#9 2007.12.26 ~ 2009. 3.18Herceptin® #10~#31

39. 06-8-8 07-7-25 08-5-2309-1-30

40. Multiple lung meta Mediastinal LN