Case Study 63: Cancer of the Female Breast

1. Case Study 63: Cancer of the Female Breast By Robyn Schwartz

2. Case Background • 46, premenopausal • Dense breasts • Has noticed cysts in the past • Noticed new lump in upper right quadrant • Did not resolve • Got bigger • Denied lumps in axillary

3. Patient history • Happily married for 21 years • 3 kids (3, 8, and 10) • Does breast self exams • Normal pap 2 years ago • Has Asthma and hypertension • Exercises • No tobacco, alcohol or illegal drugs

4. Risk Factors • All 3 kids born after the age of 35 • First period at 11yr old • Dense breasts • Cysts already develop regularly • Family history of breast cancer • Paternal grandmother diagnosed at age 45 before menopause • Mother diagnosed at age 45 before menopause. Died at age 73 from reoccurrence of breast cancer

5. Breast Cancer: What is it? • Uncontrolled division of abnormal cells in the breast • Caused by specific mutations • BRCA1 and BRCA2 • TP53

6. Our patient: Mammogram • 2.3cm x 2.9cm x 3.2cm mass • Irregular borders • Skin thickening • Enlarged axillary lymph node • 6 Y-shaped microcalcifications extended toward nipple • Abnormal mass into pectoral muscle

7. Grading vs Staging • How far the cancer has spread • I, II, III, IV • Based on • Size of tumor • Invasive vs non invasive • Spread to lymph nodes • Spread to other parts of the body • How abnormal the cells are • 1, 2, 3,4 • Based on • Tubule formation • Size and shape of cells • Mitotic division • Measures the likely aggressiveness of the cells

8. Grading tumors Nuclear (size/shape) Score 1: little variation in size Score 2: moderate variability, open vesicular nuclei Score 3: lots of variability open nuclei Mitotic Score 1: <7 mitoses Score 2: 8-14 mitoses Score 3: >14 mitoses Tubular differentiation Score 1: > 75% glandular/tubular Score 2: 10-75% glandular/tubular Score 3: < 10% Glandular/ tubular

9. Staging Cancer • agrdjdytydstasf Stage 0: No Cancer Stage I: IA: Cancer is small, low grade and localized IB: Cancer is large, low grade and localized Stage II: IIA: Tumor is 2-5cm but has not spread IIB: Tumor is 2-5cm but has spread to lymph nodes Stage III: Tumor is larger than 5cm and has spread to multiple lymph nodes Stage IV: Cancer has spread to other parts of the body

10. Our Patient: Biopsy and ultrasound • Ultrasound: • Non-cystic mass, solid appearing • Abnormal vascularity • Some skin thickening and mild tissue edema • Biopsy: • Consistent with infiltrating breast cancer • 3-5 divisions per high power field • Mild pleomorphism • Positive for estrogen and progesterone receptors

11. Grade and Stage • Grade 1 • Mitotic score: 1 (<7 divisions) • Glandular Score: 1 (75% glandular) • Nucleic Score: 1 (not much change) • Total score: 3 • 10 year survival rate 90% • Stage IIB • Small • Spread to 1 lymph node • 5 year survival rate of 71%

12. Our Patient: Treatment • Breast conservation therapy • Lump removal • Radiation • Lymph node biopsy • Tamoxifen • Estrogen receptor blocker • Helps stop growth of cancer cells

13. Our Patient: Follow Up • 6.5 years cancer free • 80 months later, complained of • bone pain in lower back • Headache

14. Test Results • Bone scan • Lesions in lumbar spine without fracture • Chest X-Ray • 3 small nodules in upper lobe of left lung • Brain MRI • Small mass in right frontal lobe • Abdominal CT • Negative • Blood tests • CEA elevated by 2-fold • CA27-29 concentration elevated by 2-fold

15. Diagnosis, Outlook, and Treatment • Stage IV Breast cancer • 13% 10-year survival rate • Treatments • Chemotherapy • taxanes • Hormone Therapy • Targeted therapy • HER2 targeted therapy • Slow growth • Manage Bone Metastasis • Biophosphonates • Slow destruction

16. How to Prevent cancer • Exercise • Eat well • Don’t smoke • Do regular breast self exams • Report anything suspicious immediately • Check family history