Presentation on theme: "Challenging Cases from the USC Multidisciplinary Breast Conference"— Presentation transcript:
1Challenging Cases from the USC Multidisciplinary Breast Conference Session II: Challenging CasesChallenging Cases from the USC Multidisciplinary Breast ConferenceStephen F. Sener MDChristy A. Russell MD
3CS PMH: denies PSH: denies Meds: denies All: NKDA SH: no T/E/D Fam Hx: sister with breast cancer at 27, other sister with ?uterine vs ovarian caGyn Hx:G6 P4, miscarriage 1, abort 1First Pregnancy: 23Breast Feeding: 3 yrs totalMenarche: 13Menopause: preOCP / HRT Hx: 10-12yrs of ocp
4CSPhysical ExamL Breast: mod edematous with hematoma around core bx site at 3 o’clock, palp mobile 2x3cm mass at 2 o’clock, and 1x1cm mass at 3 o’clock w/ overlying hematoma and mild ttp. axillary LAD 1x1cm x3R Breast: no masses, no nipple retraction/discharge, no skin changes. No ax LAD
11CS MMG/UTZ (9/1/2010) Core Bx (9/2/2010) 3.2x2.9x2.4cm mass in left 2 o’clock 4cm from nipple, 1.1cm mass at 2 o’clock 2cm from nipple. 1cm mass at 3 o’clock 3 cm from nipple and enlarged LN, BR 4cCore Bx (9/2/2010)L breast: IDCA poorly differentiated, BRS 9/9L axilla: c/w met IDCAER-, PR-Her2: Neg
18CSPatient received neo-adjuvant AC paclitaxel between 10/10 and 2/11.Genetic testing revealed BRCA-1 deleterious mutation.At completion of chemotherapy, she underwent left MRM and right TM (3/7/11).Sentinel lymph node surgery performed followed by ALND per ACOSOG 1071 trialPathology: ypT2 (2.5 cm), N1 (1/31), M0
19CSIn addition to planned radiation therapy and eventual BSO, would you offer further adjuvant systemic therapy?Yes. Change chemotherapy to include a platinum agentYes. Change chemotherapy, but give another regimen without a platinum agentNo. Watch for metastatic cancer.
20CSUnfortunately, by May 2012, she developed a new left supraclavicular lymph node.Staging workup revealed chest wall recurrence as well as lung metastases.Therapy for metastatic cancer initiated.
318/16/11 MMG & U/S: 3.1 x 2.9 x 2.3 cm mass in L breast @ 6:00, BIRADS 51.1 x 0.8 x 1.8 cm mass in L 12:00,1.7 x 0.9 x 1.2 cm mass in L central breast,1.3 x 1.8 x 0.9 cm mass in L 3:00,8 mm cyst in R 2:00,abn LN in L axilla
328/16/11 MMG & U/S:3.1 x 2.9 x 2.3 cm mass in L 6:00, BIRADS 51.1 x 0.8 x 1.8 cm mass in L 12:00, BIRADS 51.7 x 0.9 x 1.2 cm mass in L central breast, BIRADS 4C1.3 x 1.8 x 0.9 cm mass in L 3:00, BIRADS 4C8 mm cyst in R 2:00, BIRADS 2abn LN in L axilla BIRADS 4B
35RN 40F with multifocal L breast inflammatory CA Stage cT4dN1M1, ER-/PR-/Her2+.Staging:Bone scan-negative.CT scan of chest/abdomen/pelvis demonstrated multiple 1-3 cm scattered pulmonary masses consistent with metastatic breast cancer.353535
37RN 40F with multifocal L breast inflammatory CA Stage cT4dN1M1, ER-/PR-/Her2+.373737
38HER-2+ Inflammatory Breast Cancer M1 What systemic therapy would you offer this patient?Trastuzumab + taxaneTrastuzumab + capecitabineTCHAC THTrastuzumab + lapatinibTrastuzumab + pertuzumab + docetaxel
39RN 40F with multifocal L breast inflammatory CA Stage cT4dN1M1, ER-/PR-/Her2+.Follow-up:Initiated TCH x 6 in 10-11, followed by H q 3 wksCT scan on : Marked improvement in pulmonary metastases.BRCA-negative.Axilla cN0.393939
42IBC, HER-2+, M1 What course of treatment would you consider next? Mastectomy + continue trastuzumabContinue trastuzumab and add breast XRTContinue trastuzumab until progressionContinue trastuzumab and add additional chemotherapy
43RNPatient was taken to total mastectomy. She continues on single agent trastuzumab.SURGICAL PATH6/21/12 SurgPath:ypT0Nx: No residual cancer, microcalcifications in benign small ducts.
44IBC, HER-2+, M1Would you offer chest wall and extended nodal radiation?YesNo
45Challenging Cases from the USC Multidisciplinary Breast Conference Stephen F. Sener MDChristy A. Russell MD
46AG39 year old female with 8 month history of breast mass and recent severe low back pain.Metastases to bone only-spine, ribs, pelvis.posterior spinal fusion T11-L3 in 8-11.XRT to spine inBiopsy of bone c/w breast cancer, ER/PR+, HER-2 FISH ratio 1.8.Zoledronic acid from 1-12.
47AG R Breast: L Breast: No masses No skin changes nipple everted No LAD Palpable 2cm 7:00, attached to chest wall.
51AG PMH: Stage IV Breast CA s/p XRT PSH: lipoma removal x2 8/2011 PSF T11-L3Meds: leuprolide, tamoxifen, morphine, Ca2+, oxycodone, zoledronic acid.FHx:P Gma: B breast 60, esophageal CAP uncle: prostate CAMother: cervical CAGyn hx:G4P41st 16premenopausalMenarche at 13H/o breastfeedingNo OCP
52AGPatient initiated on tamoxifen and luprolide and zoledronic acid in August 2011.Breast mass slowly regresses and scans suggest no new mets and healing of bone mets.Biopsy of the breast reveals residual high-grade infiltrating ductal carcinoma.
55AG-39F with L breast IDCA metastatic to bone-only, ER+/PR+/H2N equivocal.-Stage cT4aN0M1, Stage IV.
56AGWith ongoing clinical response to systemic hormonal therapy and zoledronic acid, when would you consider resection of the primary lesion?Never. No survival benefit to removing the primary lesionNow. Patient continues to have response to original therapyLater, maybe. At time of progression in the breast.