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MEDICAL GRANDROUNDS

MEDICAL GRANDROUNDS. JYN A. CABAL M.D. March 15, 2007. OBJECTIVES:. To present a case of invasive ductal carcinoma To give new updates regarding breast cancer diagnosis and management. General Data. L.H. 54 year-old Female Single Nulliparous. First Cycle of Chemotherapy. 8 weeks PTA.

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MEDICAL GRANDROUNDS

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  1. MEDICAL GRANDROUNDS JYN A. CABAL M.D. March 15, 2007

  2. OBJECTIVES: • To present a case of invasive ductal carcinoma • To give new updates regarding breast cancer diagnosis and management

  3. General Data • L.H. • 54 year-old • Female • Single • Nulliparous

  4. First Cycle of Chemotherapy

  5. 8 weeks PTA (+) mass on right outer upper quadrant R breast on routine x-ray mammography Consult done, on P.E.: (+) 6.5 cm mass on right outer upper & lower quadrant in largest diameter, no skin lesions, dimpling, nipple discharge or inversion History of Present Illness

  6. 6 weeks PTA 4 weeks PTA MR mammography breast core needle biopsy: Invasive Ductal Ca Grade III R modified radical mastectomy

  7. MR MAMMOGRAPHY Scanty fibroglandular tissue, both breasts 2.4 x 3.6 x 3.7 cm enhancing lobulated mass on upper outer quadrant of R breast, highly suspicious of malignancy 0.6cm x 0.6 cm enhancing nodule in 6 o’ clock position of L breast

  8. CORE NEEDLE BIOPSY • INVASIVE DUCTAL CA, GRADE III • IMMUNOHISTOCHEMISTRY (IHC) ER 1+, PR 2+, HER-2/neu 3+

  9. Histopathology Invasive Ductal Ca Nuclear Grade III Histologic Grade III 3.9 cm in widest diameter Axillary LN Negative (19 LN)

  10. Histopathology - Stanford • Estrogen receptor 3+, 95% • Progesterone Receptor 3+, 30% • HER-2/neu (-) for FISH (Fluorescence In Situ Hybridization)

  11. ER Assay

  12. PR Assay

  13. IHC – Her-2

  14. DIAGNOSTICS • CT Scan of whole abdomen – fatty infiltrating changes in the liver • Bone Scan – no evidence of metastatic disease to the bone

  15. DIAGNOSTICS • CBC Hgb – 12.8 Lymphocytes - 35 Hct – 37 PC – 297 T WBC – 5300 Segmenters - 53

  16. Past Medical History • (+) Hypertension for 4 years on Irbesartan 150 mg OD • 1993 -- (+) L ovarian cyst excision  borderline serous papillary tumor -- (+) TAH-BSO given Premarin as hormone replacement therapy x 2 years

  17. Personal/Social History • Single • Nulliparous • Non-smoker • Non-alcoholic beverage drinker

  18. Menstrual History • Menarche at age 17 • Surgical menopause at age 41

  19. Family History • (+) Colon Cancer, RCC – mother, 90y/o • (+) Gastric Cancer – father, deceased • (-) Breast Cancer • (+) HPN – maternal side • (-) Diabetes Mellitus • (-) Asthma

  20. (-) weight loss (-) anorexia (-) headache (-) fever (-) dyspnea (-) cough (-) chest pain (-) palpitations (-) orthopnea (-) dysphagia (-) constipation (-) diarrhea (-) dysuria Review Of Systems

  21. Physical Examination • General awake, conscious, coherent, not in cardiopulmonary distress • BP- 120/70 HR- 70 RR- 36.2 T- 36.5 • Wt- 68 kilos Ht- 167 cms. BSA- 1.77 • BMI- 24.4 (overweight)

  22. Necktrachea midline, freely movable, thyroid not palpable; no lymphadenopathy Breast(+) 15 cm incisional scar on R ant chest wall, no lymphadenopathy, no skin lesions; L breast: no mass, skin dimpling, nipple discharge Chest and Lungssymmetric chest expansion, tactile fremitus symmetric, resonant percussion throughout, no crackles, no wheezes

  23. HeartApex beat and PMI at 5th intercostal space, LMCL; S1 heard best at apex, S2 heard best at base, no murmurs; regular rhythm Abdomen full, soft, nontender; liver, spleen, and kidney not palpable

  24. Lymphaticno palpable lymph nodes in neck, supraclavicular, axillary, epitrochlear, or inguinal areas Musculoskeletalmuscles appear symmetric with appropriate and equal strength bilaterally, full range of active and passive motion

  25. Salient Features • 54 year old • Female • Single • Nulliparous • History of HRT use • History of family cancer

  26. Admitting Impression INVASIVE DUCTAL CARCINOMA, RIGHT BREAST STAGE II-A ESSENTIAL HYPERTENSION, controlled

  27. Doxorubicin (Adriamycin) 60 mg/m IV Cyclophosphamide 600 mg/m IV

  28. INVASIVE DUCTAL CARCINOMA

  29. Age Current or prior hormone replacement therapy Ethnicity/race Family history of breast cancer Early menarche Late menopause Older age at first live childbirth Atypical Hyperplasia/LCIS Genetic mutations such as BRCA ½ genes Prior thoracic RT BMI Alcohol consumption RISK FACTORS

  30. Risk Factor – HRT Use • Women 50-64 years of age showed an association between current use of estrogen-only HRT and increased risk of breast cancer (Beral V. Lancet. 2003;362:419-427) • Nurses’ Health Study demonstrated a significantly increased breast cancer risk after long term use (20 years or longer) of estrogen alone (Chen WY, Manson JE, Hankinson SE, et al. Arch Intern Med. 2006;166:1027-1032)

  31. Breast Cancer Work Up History and P.E. Breast Imaging: Mammogram Breast ultrasound Magnetic Resonance Imaging

  32. Breast Cancer Work Up Breast Biopsy Tumor tests: Estrogen receptors Progesterone receptors HER-2/neu/cerb-b2 Other tests: CBC, platelet count, CXR, liver function tests, CT Scan, PET Scan

  33. MRI in Patients with Breast Cancer: Current Applications • Detects cancer that is occult on conventional imaging such as mammography and sonography • In preoperative evaluation, it can detect multifocal and multicentric disease that was previously unsuspected which facilitates accurate staging

  34. For patients who have undergone lumpectomy, it can be helpful in assessment of residual tumor load • Can be helpful to diagnose recurrence when conventional imaging and P.E. are non-confirmatory

  35. Can assess response to neoadjuvant chemotherapy for locally advanced breast ca

  36. Patient selection for preoperative breast MRI: • Young patient • Patient with dense or moderately dense breasts • Patients with difficult tumor histologic findings such as infiltrating lobular carcinoma and tumors with extensive intraductal component in which tumor size assessment is difficult

  37. Tumor Tests • ESTROGEN and PROGESTERONE RECEPTORS - are parts of cells that attach to hormones estrogen and progesterone; serve as “welcome mats” - Hormone Receptor Assay: ER (+) and PR (+) – response rate of 70% ER (+) and PR (-) – response rate of 30% ER (-) and PR (-) – response rate of 10% - tumors that lack either or both of these receptors are more likely to recur than tumors that have them

  38. Tumor Tests • HER-2/neu/cerb-B2 oncogene - codes for a surface membrane receptor that interacts with an unidentified growth factor and is frequently amplified in human breast carcinoma - mapped to chromosome 17

  39. TESTS for HER-2/neu • IMMUNOHISTOCHEMISTRY - test that detects HER-2/neu protein on the surface of the cell by staining the cell with antibodies - can be 0, 1+ (negative), 2+ (borderline), 3+ (positive) - if IHC 2+, have the tissue tested with FISH test

  40. Tests for HER-2/neu • FLOURESCENCE IN SITU HYBRIDIZATION (FISH) - gold standard for confirmatory testing - measures HER-2 gene abnormality - “paints” the HER-2 genes inside the cell so they may be accurately counted - may be (+) or (-) ** All in all, IHC has been shown to miss 15-20% of positive specimens compared with less than 5% with FISH

  41. Only tests IHC 3+ or FISH (+) respond well to therapy that work against HER-2

  42. Risk Categories for Node Negative Breast Cancer (Alberta Breast Cancer Program 2006)

  43. Surgical Procedures of Breast Ca • Lumpectomy/Breast Conservation Therapy • Simple Mastectomy • Modified Radical Mastectomy • Radical Mastectomy

  44. Surgical Procedures of Breast Ca

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