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
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
CS MMG/UTZ (9/1/2010) – 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
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
CS In addition to planned radiation therapy and eventual BSO, would you offer further adjuvant systemic therapy? 1.Yes. Change chemotherapy to include a platinum agent 2.Yes. Change chemotherapy, but give another regimen without a platinum agent 3.No. Watch for metastatic cancer.
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.
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 breast @ 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 breast @ 3:00, 8 mm cyst in R breast @ 2:00, abn LN in L axilla
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 breast @ 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 breast @ 3:00, BIRADS 4C 8 mm cyst in R breast @ 2:00, BIRADS 2 abn LN in L axilla BIRADS 4B
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.
RN 40F with multifocal L breast inflammatory CA Stage cT4dN1M1, ER-/PR-/Her2+.
HER-2+ Inflammatory Breast Cancer M1 What systemic therapy would you offer this patient? 1.Trastuzumab + taxane 2.Trastuzumab + capecitabine 3.TCH 4.AC TH 5.Trastuzumab + lapatinib 6.Trastuzumab + pertuzumab + docetaxel
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 6-9-2012: Marked improvement in pulmonary metastases. –BRCA-negative. –Axilla cN0.
IBC, HER-2+, M1 What course of treatment would you consider next? 1.Mastectomy + continue trastuzumab 2.Continue trastuzumab and add breast XRT 3.Continue trastuzumab until progression 4.Continue trastuzumab and add additional chemotherapy
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.
IBC, HER-2+, M1 Would you offer chest wall and extended nodal radiation? 1.Yes 2.No
Challenging Cases from the USC Multidisciplinary Breast Conference Stephen F. Sener MD Christy A. Russell MD
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 10-11. Biopsy of bone c/w breast cancer, ER/PR+, HER-2 FISH ratio 1.8. Zoledronic acid from 1-12.
AG R Breast: – No masses – No skin changes – nipple everted – No LAD L Breast: – Palpable 2cm mass @ 7:00, attached to chest wall. – nipple everted – No skin changes – No LAD
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 CA @ 60, esophageal CA - P uncle: prostate CA - Mother: cervical CA Gyn hx: – G4P4 – 1st child @ 16 – premenopausal – Menarche at 13 – H/o breastfeeding – No OCP
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.
AG -39F with L breast IDCA metastatic to bone-only, ER+/PR+/H2N equivocal. -Stage cT4aN0M1, Stage IV.
AG With ongoing clinical response to systemic hormonal therapy and zoledronic acid, when would you consider resection of the primary lesion? 1.Never. No survival benefit to removing the primary lesion 2.Now. Patient continues to have response to original therapy 3.Later, maybe. At time of progression in the breast.