breast cancer clinical cases daniel a. nikcevich, md, phd smdc cancer center april 20, 2009

Breast Cancer Clinical Cases

Daniel A. Nikcevich, MD, PhD

SMDC Cancer Center

April 20, 2009

Breast Cancer

• Who is the patient?

• Stage of disease.

• Pathology.

• Hormone receptor status.

• Her-2-neu status.

• Genetic risk

• Goals of treatment.

• 60 yo female in excellent health presents to your office with a left breast mass.

• Mammogram shows 2 cm spiculated lesion in UOQ.

• What’s the next step?• Biopsy• Grade 1 infiltrating ductal carcinoma• She’s now s/p lumpectomy and sentinel

lymph-node biopsy

• Stage 1 (T1N0M0) infiltrating ductal carcinoma.• ER+/PR+, her-2-neu negative, grade 1.• How should she be treated?• Hormonal/endocrine therapy

– Tamoxifen– Aromatase inhibitor

• Chemotherapy– Doxorubicin/cyclophosphamide– Cyclophosphamide/methotrexate/flurouracil– Cyclophosphamide/docetaxel

• 5 years of adjuvant hormonal therapy = risk of recurrence of approximately 7% in 10 years.

• 5 years of adjuvant hormonal therapy plus chemotherapy = risk of recurrence of approximately 6% in 10 years.

• Absolute benefit of chemotherapy ~ 1%• So how should your patient be treated?• Hormonal therapy

– Tamoxifen– Aromatase inhibitor

• 76 yo female in excellent health presents to your office with a left breast mass.

• Mammogram shows 2 cm spiculated lesion in UOQ.

• What’s the next step?• Biopsy• Grade 1 infiltrating ductal carcinoma• She’s now s/p lumpectomy and sentinel

lymph-node biopsy

• Stage 1 (T1N0M0) infiltrating ductal carcinoma.• ER+/PR+, her-2-neu negative, grade 1.• How should she be treated?• Hormonal/endocrine therapy

– Tamoxifen– Aromatase inhibitor

• Chemotherapy– Doxorubicin/cyclophosphamide– Cyclophosphamide/methotrexate/flurouracil– Cyclophosphamide/docetaxel

• 5 years of adjuvant hormonal therapy = risk of recurrence of approximately 26% in 10 years.

• 5 years of adjuvant hormonal therapy plus chemotherapy = risk of recurrence of approximately 20% in 10 years.

• Absolute benefit of chemotherapy ~ 6%• So how should your patient be treated?• Hormonal therapy plus chemotherapy

– Tamoxifen or Aromatase inhibitor– Docetaxel plus cyclophosphamide

• 38 yo female with a strong family history of breast cancer presents with mastalgia that developed shortly after the birth of her daughter.

• The breast exam is unremarkable and the mammogram reveals a vague density in the right breast which cannot be identified on ultrasound.

• What is the next step?• MRI• 3 cm mass in the central breast with enlarged

right axillary lymph nodes.• Grade 3 infiltrating lobular carcinoma

• Your patient undergoes a right modified radical mastectomy and axillary lymph node dissection.

• 2.8 cm infiltrating lobular carcinoma• 3/21 lymph nodes + tumor• ER+/PR- and her-2-neu 3+ (positive)• Stage IIIA (T2N1M0) infiltrating lobular

carcinoma.– How should she be treated?

• Hormonal/endocrine therapy– Tamoxifen– Aromatase inhibitor

• Chemotherapy– Doxorubicin/cyclophosphamide– Cyclophosphamide/methotrexate/flurouracil– Paclitaxel

• Trastuzumab

• Estimate of recurrence in 10 years with no therapy = 70%

• Estimate recurrence with tamoxifen = 40%• Estimate recurrence with tamoxifen plus

chemotherapy = 30%• Estimate recurrence with tamoxifen,

chemotherapy, and trastuzumab = 15%• What therapy would you recommend for

your patient?

• She enrolled into a clinical trial and received chemotherapy with doxorubicin, cyclophosphamide, and paclitaxel.

• Also received trastuzumab and lapatinib (an oral drug similar to trastuzumab).

• Now on tamoxifen and doing well 2 years out from her surgery.

• 58 yo retired nurse comes to your clinic with a c/o persistent right shoulder pain.

• Plain films show a lytic lesion in proximal right humerus, and bone scan indicates other sites of suspected disease.

• Biopsy of right humerus shows moderately-differentiated adenocarcinoma– ER+/PR+, her-2-neu negative

• Mammogram shows 1 cm lesion in left breast– Biopsy shows similar findings to bone biopsy

• What is the stage of disease?

• Stage IV (T1NXM1)

• Metastatic breast cancer is incurable

• What are the goals of therapy?

• Palliation– Symptom relief– QOL

• Prolong survival

• How should your patient be treated?• Hormonal/endocrine therapy

– Tamoxifen– Aromatase inhibitor– Fulvestrant

• Chemotherapy– Doxorubicin/cyclophosphamide– Cyclophosphamide/methotrexate/flurouracil– Epirubicin– Paclitaxel– nab-paclitaxel– Docetaxel– Carboplatin– Gemcitabine– Vinorelbine– Capecitabine– Ibexapilone– Bevacizumab

• Bone-only breast cancer is often an indolent disease.

• Does she have a clinical trial option?• This patient has been treated on study with

anastrozole, an aromatase-inhibitor, plus zoledronic acid.

• She is pain-free and with excellent QOL, four years from diagnosis.

• I use chemotherapy for metastatic breast cancer in setting of visceral crisis and/or rapidly progressive disease.

• 46 yo teacher who feels well and is asymptomatic has her annual screening mammogram.

• New collection of microcalcifications in UOQ left breast.

• Next step?

• Ultrasound guided biopsy.

• Biopsy reveals 0.6 cm ductal carcinoma in situ. No evidence of invasive disease.

• How should your patient with DCIS be treated?• Breast conservation or simple mastectomy.• Your patient opts for breast conservation and

has lumpectomy.• 0.8 cm ductal carcinoma in situ. No invasive

disease.• Grade 1.• ER+/PR+. Her-2-neu not performed.• TisNXM0 (Stage 0).

• Now what?• DCIS is breast cancer, but is non-invasive breast

cancer.• Would typically recommend adjuvant whole-

breast XRT and 5 years of tamoxifen.• Goal of therapy is to reduce risk of local

recurrence and reduce risk of developing new invasive carcinoma.

• No role for chemotherapy in DCIS.• Trastuzumab only in context of clinical trial

(NSABP B-43)

• 62 yo retired male develops persistent soreness behind right nipple after a snowmobile accident.

• What’s next?

• Physical examination.

• 1.5 cm retroareolar mass and 1 cm right axillary lymph node.

• Now what?

• Diagnostic mammogram.

• 2 cm mass identified.

• Ultrasound guided biopsy shows grade 3 infiltrating ductal carcinoma.

• Your patient goes to right modified radical mastectomy and axillary lymph node dissection.

• 2.2 cm infiltrating ductal carcinoma.

• 4/23 lymph nodes + tumor.

• ER+/PR-, her-2-neu negative.

• Stage IIIB (T2N2M0).

• How should this 62 yo male with breast cancer be treated?

• Biology and clinical behavior of male breast cancer is considered to be similar to female breast cancer.

• Male breast cancer treated identical to female breast cancer.

• ALL men with breast cancer should have genetic counseling and consider BRCA gene mutation testing.

• How should this 62 yo male with breast cancer be treated?

• He was treated with chemotherapy.– Doxorubicin plus cyclophosphamide followed by paclitaxel.

• Adjuvant post-mastectomy XRT.– Survival benefit for XRT in patients with 4 or more involved

axillary lymph nodes.

• Will complete 5 years tamoxifen this year.• Patient does possess deleterious BRCA mutation.• Two daughters also possess same deleterious BRCA

mutation.

Breast Cancer

• 6 patients with breast cancer– 3 women with invasive breast cancer– 1 woman with metastatic breast cancer– 1 woman with DCIS– 1 man with invasive breast cancer

• Who is the patient?• Stage of disease.• Pathology.• Hormone receptor status.• Her-2-neu status.• Genetic risk• Goals of treatment.

• Questions?

• dnikcevich@smdc.org