Challenging Cases from the USC Multidisciplinary Breast Conference

Stephen F. Sener MDChristy A. Russell MD

Session II: Challenging Cases

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)– 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?1. Yes. Change chemotherapy to include a

platinum agent2. Yes. Change chemotherapy, but give another

regimen without a platinum agent3. 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 MDChristy A. Russell MD

RN

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

RN • L 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 • PMH: none

• PSH: C-section x1

• Med: none

• FHx:– Non-contributory

• Gynhx:– G3P3– First pregnancy at 28– Menarche 14– Premenopausal

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 +

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 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 breast @ 3:00, BIRADS 4C8 mm cyst in R breast @ 2:00, BIRADS 2abn 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.

CTPA 10/12/2011

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 + taxane2. Trastuzumab + capecitabine3. TCH4. AC TH5. Trastuzumab + lapatinib6. 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.

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?1. Mastectomy + continue trastuzumab2. Continue trastuzumab and add breast XRT3. Continue trastuzumab until progression4. 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. Yes2. No

Challenging Cases from the USC Multidisciplinary Breast Conference

Stephen F. Sener MDChristy 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

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

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

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?1. Never. No survival benefit to removing the

primary lesion2. Now. Patient continues to have response to

original therapy3. Later, maybe. At time of progression in the

breast.