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

CS 41F Palpable L breast mass x 2 months

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

9/01/2010

9/01/2010

10/28/2010 CT CAP

Clinic Photo

Clinic Photo

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

Path Photo

Path Photo

Path Photo

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

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

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? Yes. Change chemotherapy to include a platinum agent Yes. Change chemotherapy, but give another regimen without a platinum agent 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.

5/12/2012 CT CAP

5/12/2012 CT CAP

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

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.

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

RN on 9-12-11.

RN on 9-12-11.

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

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

8/16/11 MMG Extremely dense breasts

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  Pathology 1 of 4

RN  Pathology 2 of 4

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

CTPA 10/12/2011

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

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

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. 39 39 39

RN on 6-23-12. Local Treatment

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

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

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? Yes 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: L Breast: No masses No skin changes nipple everted No LAD Palpable 2cm mass @ 7:00, attached to chest wall.

AG

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 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.

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

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

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? 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.