1. Challenging Cases from the USC Multidisciplinary Breast Conference
Session II: Challenging Cases
Challenging Cases from the USC Multidisciplinary Breast Conference
Stephen F. Sener MD
Christy A. Russell MD

2. CS
41F Palpable L breast mass x 2 months

3. CS 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 ca
Gyn Hx:
G6 P4, miscarriage 1, abort 1
First Pregnancy: 23
Breast Feeding: 3 yrs total
Menarche: 13
Menopause: pre
OCP / HRT Hx: 10-12yrs of ocp

4. CS
Physical Exam
L 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 x3
R Breast: no masses, no nipple retraction/discharge, no skin changes. No ax LAD

5. 9/01/2010

6. 9/01/2010

7. 10/28/2010 CT CAP

8. Clinic Photo

9. Clinic Photo

11. CS 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 4c
Core Bx (9/2/2010)
L breast: IDCA poorly differentiated, BRS 9/9
L axilla: c/w met IDCA
ER-, PR-
Her2: Neg

12. Path Photo

13. Path Photo

14. Path Photo

16. CS 41F L breast IDCA with axillary mets Genetics
L MRM vs Neoadj (1071 Trial?)

17. CS Patient offered neoadjuvant chemotherapy trial – denied
Patient offered ACOSOG 1071 trial – agreed
Summary: cT2, N1, M0 triple negative multicentric infiltrating ductal breast cancer.
Strong family history: genetic counseling

18. CS
Patient 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 trial
Pathology: ypT2 (2.5 cm), N1 (1/31), M0

19. CS
In addition to planned radiation therapy and eventual BSO, would you offer further adjuvant systemic therapy?
Yes. Change chemotherapy to include a platinum agent
Yes. Change chemotherapy, but give another regimen without a platinum agent
No. Watch for metastatic cancer.

20. CS
Unfortunately, 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.

21. 5/12/2012 CT CAP

22. 5/12/2012 CT CAP

23. Challenging Cases from the USC Multidisciplinary Breast Conference
Stephen F. Sener MD
Christy A. Russell MD

24. 40 year old female with an erythematous left breast x 1 month.RN
40 year old female with an erythematous
left breast x 1 month.

25. RN L Breast: R Breast: Large palpable density in central breast ~12cm
Skin thickening and edema at 6:00
2.5cm LN palpable
R Breast:
No masses
No LAD

26. RN on

27. RN on

28. RN FHx: Gynhx: PMH: none Non-contributory PSH: C-section x1 Med: none
G3P3
First pregnancy at 28
Menarche 14
Premenopausal 28

29. RN MMG/US 8/16/11 RIGHT: 2:00 posterior depth 8mm cyst BR2
LEFT: 2.9x2.3x3.1cm mass 6o’clock posterior depth BR5
LEFT: 1.1x0.8x1.8cm mass 12o’clock posterior depth BR5
LEFT: 1.7x0.9x1.2cm mass central anterior depth BR4C
LEFT: 1.3x1.8x0.9cm mass 3o’clock posterior depth BR4B
LEFT: axillary tail LN BR4B
Core bx 8/22/11
LEFT: 6:00- poor diff IDCA BRS 8/9 DCIS 3/3
LEFT: 12:00- poor diff IDCA BRS 8/9
ER-, PR-, HER2 + 29 29 29

30. 8/16/11 MMG
Extremely dense breasts

31. 8/16/11 MMG & U/S: 3.1 x 2.9 x 2.3 cm mass in L breast @ 6:00,
BIRADS 5
1.1 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

32. 8/16/11 MMG & U/S:
3.1 x 2.9 x 2.3 cm mass in L 6:00, BIRADS 5
1.1 x 0.8 x 1.8 cm mass in L 12:00, BIRADS 5
1.7 x 0.9 x 1.2 cm mass in L central breast, BIRADS 4C
1.3 x 1.8 x 0.9 cm mass in L 3:00, BIRADS 4C
8 mm cyst in R 2:00, BIRADS 2
abn LN in L axilla BIRADS 4B

33. RN  Pathology 1 of 4

34. RN  Pathology 2 of 4

35. RN 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. 35 35 35

36. CTPA 10/12/2011

37. RN 40F with multifocal L breast inflammatory CA
Stage cT4dN1M1, ER-/PR-/Her2+. 37 37 37

38. HER-2+ Inflammatory Breast Cancer M1
What systemic therapy would you offer this patient?
Trastuzumab + taxane
Trastuzumab + capecitabine
TCH
AC TH
Trastuzumab + lapatinib
Trastuzumab + pertuzumab + docetaxel

39. RN 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 wks
CT scan on : Marked improvement in pulmonary metastases.
BRCA-negative.
Axilla cN0. 39 39 39

40. RN on 6-23-12. Local Treatment

41. CTPA 10/12/2011
CT CAP 6/09/2012

42. IBC, HER-2+, M1 What course of treatment would you consider next?
Mastectomy + continue trastuzumab
Continue trastuzumab and add breast XRT
Continue trastuzumab until progression
Continue trastuzumab and add additional chemotherapy

43. RN
Patient was taken to total mastectomy. She continues on single agent trastuzumab.
SURGICAL PATH
6/21/12 SurgPath:
ypT0Nx: No residual cancer, microcalcifications in benign small ducts.

44. IBC, HER-2+, M1
Would you offer chest wall and extended nodal radiation?
Yes No

45. Challenging Cases from the USC Multidisciplinary Breast Conference
Stephen F. Sener MD
Christy A. Russell MD

46. AG
39 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 in
Biopsy of bone c/w breast cancer, ER/PR+, HER-2 FISH ratio 1.8.
Zoledronic acid from 1-12.

47. AG R Breast: L Breast: No masses No skin changes nipple everted No LAD
Palpable 2cm 7:00, attached to chest wall.

48. AG

51. AG PMH: Stage IV Breast CA s/p XRT PSH: lipoma removal x2
8/2011 PSF T11-L3
Meds: leuprolide, tamoxifen, morphine, Ca2+, oxycodone, zoledronic acid.
FHx:
P Gma: B breast 60, esophageal CA
P uncle: prostate CA
Mother: cervical CA
Gyn hx:
G4P4
1st 16
premenopausal
Menarche at 13
H/o breastfeeding
No OCP

52. AG
Patient 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.

53. CT CAP 8/24/2011
CT CAP 11/23/2011

54. CT CAP 8/24/2011
CT CAP 11/23/2011

55. AG
-39F with L breast IDCA metastatic to bone-only, ER+/PR+/H2N equivocal.
-Stage cT4aN0M1, Stage IV.

56. AG
With 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 lesion
Now. Patient continues to have response to original therapy
Later, maybe. At time of progression in the breast.