Challenging Cases from the USC Multidisciplinary Breast Conference
description
Transcript of Challenging Cases from the USC Multidisciplinary Breast Conference
![Page 1: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/1.jpg)
Challenging Cases from the USC Multidisciplinary Breast Conference
Stephen F. Sener MDChristy A. Russell MD
Session II: Challenging Cases
![Page 2: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/2.jpg)
CS
• 41F Palpable L breast mass x 2 months
![Page 3: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/3.jpg)
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
![Page 4: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/4.jpg)
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
![Page 5: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/5.jpg)
9/01/2010
![Page 6: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/6.jpg)
9/01/2010
![Page 7: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/7.jpg)
10/28/2010 CT CAP
![Page 8: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/8.jpg)
Clinic Photo
![Page 9: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/9.jpg)
Clinic Photo
![Page 10: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/10.jpg)
![Page 11: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/11.jpg)
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
![Page 12: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/12.jpg)
Path Photo
![Page 13: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/13.jpg)
Path Photo
![Page 14: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/14.jpg)
Path Photo
![Page 15: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/15.jpg)
![Page 16: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/16.jpg)
CS
• 41F L breast IDCA with axillary mets– Genetics– L MRM vs Neoadj (1071 Trial?)
![Page 17: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/17.jpg)
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
![Page 18: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/18.jpg)
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
![Page 19: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/19.jpg)
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.
![Page 20: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/20.jpg)
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.
![Page 21: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/21.jpg)
5/12/2012 CT CAP
![Page 22: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/22.jpg)
5/12/2012 CT CAP
![Page 23: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/23.jpg)
Challenging Cases from the USC Multidisciplinary Breast Conference
Stephen F. Sener MDChristy A. Russell MD
![Page 24: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/24.jpg)
RN
40 year old female with an erythematous left breast x 1 month.
![Page 25: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/25.jpg)
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
![Page 26: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/26.jpg)
RN on 9-12-11.
![Page 27: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/27.jpg)
RN on 9-12-11.
![Page 28: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/28.jpg)
RN • PMH: none
• PSH: C-section x1
• Med: none
• FHx:– Non-contributory
• Gynhx:– G3P3– First pregnancy at 28– Menarche 14– Premenopausal
![Page 29: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/29.jpg)
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 +
![Page 30: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/30.jpg)
8/16/11 MMG
Extremely dense breasts
![Page 31: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/31.jpg)
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
![Page 32: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/32.jpg)
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
![Page 33: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/33.jpg)
RN Pathology 1 of 4
![Page 34: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/34.jpg)
RN Pathology 2 of 4
![Page 35: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/35.jpg)
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.
![Page 36: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/36.jpg)
CTPA 10/12/2011
![Page 37: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/37.jpg)
RN
• 40F with multifocal L breast inflammatory CA• Stage cT4dN1M1, ER-/PR-/Her2+.
![Page 38: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/38.jpg)
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
![Page 39: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/39.jpg)
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.
![Page 40: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/40.jpg)
RN on 6-23-12.Local Treatment
![Page 41: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/41.jpg)
CTPA 10/12/2011 CT CAP 6/09/2012
![Page 42: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/42.jpg)
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
![Page 43: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/43.jpg)
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.
![Page 44: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/44.jpg)
IBC, HER-2+, M1
Would you offer chest wall and extended nodal radiation?
1. Yes2. No
![Page 45: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/45.jpg)
Challenging Cases from the USC Multidisciplinary Breast Conference
Stephen F. Sener MDChristy A. Russell MD
![Page 46: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/46.jpg)
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.
![Page 47: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/47.jpg)
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
![Page 48: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/48.jpg)
AG
![Page 49: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/49.jpg)
![Page 50: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/50.jpg)
![Page 51: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/51.jpg)
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
![Page 52: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/52.jpg)
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.
![Page 53: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/53.jpg)
CT CAP 11/23/2011CT CAP 8/24/2011
![Page 54: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/54.jpg)
CT CAP 11/23/2011CT CAP 8/24/2011
![Page 55: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/55.jpg)
AG
-39F with L breast IDCA metastatic to bone-only, ER+/PR+/H2N equivocal.-Stage cT4aN0M1, Stage IV.
![Page 56: Challenging Cases from the USC Multidisciplinary Breast Conference](https://reader036.fdocuments.net/reader036/viewer/2022062813/568165a6550346895dd88c58/html5/thumbnails/56.jpg)
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.