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This case study examines the diagnosis and pathology of breast cancer in a 53-year-old menopausal female from NovaLiches, Quezon City. The study includes details on the patient's history, physical examination findings, diagnostic procedures, and staging.
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` Breast Cancer the case of a 53 year old menopausal female from novaliches, quezon city tubal.tuliao.umag.uy.valencia.verde.villanueva.vizconde.wee.wylengco.zapanta
CC • Solitary, hard, non-tender breast mass, Right Lower Outer Quadrant • Non-Neoplastic • Fat Necrosis • Fibroadenoma • Chronic Breast Abscess • Neoplastic Breast Mass, Right HISTORY Breast Mass, Right HPI 1 Month PTA Patient palpated a mass on her right breast about the size of a small marble located on the Lower Outer Quadrant (-) tenderness, discharge or erythema Patient palpated a mass on her right breast about the size of a small marble located on the Lower Outer Quadrant (-) tenderness, discharge or erythema
HISTORY In the Review of Systems, try to elicit the following: SSx of Metastasis Bone pain Shortness of breath Lack of appetite Weight loss Neurological pain or weakness, headaches On Examination of the Breast, take note of the following: Mass Size Consistency Mobility Discharge Skin changes Erythema Induration Skin Dimpling Nipple Retraction
HISTORY ROS No weight loss, loss of appetite No headache, vomiting No dyspnea, difficulty of breathing No chest pain, orthopnea No palpitations, PND No abdominal pain, diarrhea, constipation No dysuria, frequency, urgency No edema, cyanosis PMHx (-) DM, HTN, PTB, Asthma No previous surgery FMHx (-) History of Breast Cancer PSHx Non-smoker, non-alcoholic drinker
Findings Conscious, coherent, ambulatory Pink palbebral conjunctivae, anicteric sclerae (-) NAD, TPC, CLAD Right Breast: Pendulous breast with 2x2cm mass, non-tender, fixed, hard, (-) discharge, orange-peel (-) palpable right axillary lymph nodes Left Breast: Unremarkable PHYSICAL EXAMINATION
PHYSICAL EXAMINATION Findings SCE, (-) retractions, resonant, CBS, (-) crackles, wheezes AP, NRRR, no murmur, AB at 5th ICS, LMCL Flabby abdomen, NABS, soft, non-tender, liver and spleen not enlarged (-) pallor, cyanosis, edema DRE unremarkable
IMPRESSION Breast Mass, Right, Probably Malignant
WORK-UP Shyyan R, Masood S, Badwe RA, Errico KM, Liberman L, Ozmen V, Stalsberg H, Vargas H, Vass L. Breast cancer in limited-resource countries: diagnosis and pathology. Breast J 2006 Jan-Feb;12 Suppl 1:S27-37. [45 references]
WORK-UP Comparison of Paraclinical Diagnostic Procedures in Patients with a Palpable Breast Lump in which a More Definitive Diagnosis is Needed in a Patient Suspected to have a Breast Cancer (Goal: to be more definite on the diagnosis of a palpable breast lump suspected of cancer) Lecture: Dr. Reynaldo Joson, September 25, 2006
WORK-UP • Excision Biopsy – Invasive Ductal Carcinoma • August 23, 2006 (s/p Excision) • Invasive Ductal Carcinoma, Right breast mass, grade II • Measuring 2x1x1cm • Modified Radical Mastectomy • (after 2 wks) • September 14, 2006 (s/p MRM) • No residual tumor seen • Skin, nipple, and basal line of resection are negative for • malignant cells • All (0/12) lymph nodes are negative for malignant cells • T2NOMx Actual Procedures Done on the Patient CBC, Blood Chemistry – Normal Estrogen and Progesterone Receptor - Positive (+) Her2-neu – IHC 2+ Her2neu – FISH Negative • Actual Procedures Done on the Patient • CBC, Blood Chemistry – Normal • Excision Biopsy – Invasive Ductal Carcinoma • August 23, 2006 (s/p Excision) • Invasive Ductal Carcinoma, Right breast mass, grade II • Measuring 2x1x1cm • Modified Radical Mastectomy (after 2 weeks) • September 14, 2006 (s/p MRM) • No residual tumor seen • Skin, nipple, and basal line of resection are negative for • malignant cells • All (0/12) lymph nodes are negative for malignant cells • T2NOMx • Estrogen and Progesterone Receptor Positive (+) • Her2-neu – IHC 2+ • Her2neu – FISH Negative
STAGING HPIM 16th ed
STAGING HPIM 16th ed
Histopathologic Grading Scarff, Bloom and Richardson grade Grade I - well differentiated (3-5) Grade II - moderately differentiated (6-7) Grade III - poorly differentiated (8-9) HPIM 16th ed
WORK-UP Diagnostic tests to rule out metastasis Stage I, II • Complete Blood Count • Liver Function Tests • Chest X-Ray Bigger, More Advanced • Bone Scan • Liver Scan
WORK-UP Diagnosing Nodal Metastasis in Invasive Ductal Carcinoma ALND Axillary Lymph Node Dissection • - traditional procedure to detect lymph node metastasis, and potentially therapeutic for the regional control of axillary metastases • - most women with early-stage breast cancer are node negative, and axillary dissection in these women exposes them to the complications of this procedure, with no benefit • - associated with significant long-term morbidity. Axillary Lymph Node Dissection SLNB Sentinel Lymph Node (SLN) Biopsy • minimally invasive alternative to stage breast cancer in clinically node-negative patients • yields metastasis-free SLN in 65–70% of patients • if SLNs are histologically negative, no further axillary surgery would be performed • associated with reduced arm morbidity and better quality of life • treatment of choice for patients who have early-stage breast cancer with clinically negative nodes
Local/regional treatments: 1. Mastectomy + radiation therapy 2. Breast-conserving surgery Lumpectomy (also called "wide resection," "partial mastectomy," or "quadrantectomy") + radiation therapy to the remainder of the breast tissue Women who didn't get radiation after lumpectomy were shown to have a 40% greater risk of the cancer coming back in the same breast These two options are considered equally effective for women with a breast cancer measuring about four centimeters or less. For women with a single tumor larger than about four centimeters, breast preservation therapy may still be an option if chemotherapy is able to shrink the cancer substantially BEFORE surgery. TREATMENT
TREATMENT Suggested Approaches to Adjuvant Therapy Check Serum Tumor Markers HPIM 16th ed, p.521
TREATMENT • For years, tamoxifen was the hormonal medicine of choice for all women with hormone-receptor-positive breast cancer • In 2005, the results of several major worldwide clinical trials showed that aromatase inhibitors worked better than tamoxifen in post-menopausal women with hormone-receptive-positive breast cancer • Aromatase inhibitors are now considered the standard of care for post-menopausal women with hormone-receptor-positive breast cancer • Tamoxifen remains the hormonal treatment of choice for pre-menopausal women
The patient underwent modified radical mastectomy. Histopathology results showed the patient to be on T2NOMx. The patient is at Stage IIA. PROGNOSIS
PROGNOSIS • Modified radical mastectomy continues to be appropriate for some patients, but breast conservation therapy is now regarded as the optimal treatment for most. Six prospective randomized trials have shown no difference in survival when mastectomy is compared with conservative surgery plus radiation for Stage I and Stage II breast cancer(Table 1). Adapted from Winchester DP, Cox JD. Standards for diagnosis and management of invasive breast carcinoma. CA Cancer J Clin 1998;48:85.
PROGNOSIS • Recurrence • Most recurrences occur in the first three to five years after initial treatment. • Breast cancer can come back as a local recurrence (in the treated breast or near the mastectomy scar) or as a distant recurrence somewhere else in the body. • The most common regions that breast cancer may spread to in order of frequency are: Bone, Lung and Liver. • Approximately 25% of breast cancers spread first to the bone. The bones of the spine, ribs, pelvis, skull, and long bones of the arms and legs are most often affected. • Between 60% and 70% of women who die from breast cancer have eventually had it spread to their lungs. • In 21% of cases, the lung is the only site of metastasis (spread) The most common signs of lung metastases are: shortness of breath and dry cough. In some cases, women will not experience any symptoms; cancer will only be detected by chest X-ray or CT scan. http://www.imaginis.com/breasthealth/bcrecurrence.asp
PROGNOSIS • Recurrence • Chest wall recurrence (CWR) after mastectomy occurs in 5% to 40% of breast cancer patients and is generally believed to forecast a grim outcome. These recurrences are often followed by distant metastasis and death • Patients with initial node-negative disease who develop CWR after 24 months have an optimistic prognosis, especially if they are treated with radiation • Presence of estrogen and progesterone receptors in the cancer cell is another important prognostic factor, and may guide treatment • Hormone receptor positive breast cancer is usually associated with much better prognosis compared to hormone negative breast cancer • HER2/neu status has also been described as a prognostic factor. Patients whose cancer cells are positive for HER2/neu have more aggressive disease Annals of Surgical Oncology, 10(6):628–634 www.emedicine.com
PROGNOSIS Metastasis should be assessed since breast cancer can spread to the lungs. The patient’s chest x-ray showed a pulmonary nodule which maybe a sign of metastasis. In addition the patient is already taking anti-metastasis medication. However histopathologic studies showed no nodal involvement. Thus a biopsy of the pulmonary nodule is needed for definitive staging. The presence of metastasis will classify the patient as Stage 4.
CXR - Pulmonary nodule at the right lung base CT Scan – Pulmonary nodule on the Right Lower Lobe, 1x1cm Advised chemotherapy Enrolled at RIBBON Study, receiving Xeloda and Avastin SURVEILLANCE
SURVEILLANCE Solitary Pulmonary Nodule in the Patient with Breast Cancer Similarly, in a study assessing the role of surgery in the diagnosis and treatment of an SPN among post-surgery breast cancer patients, results showed that histology of SPN was primary lung cancer in 38 patients (n=79), pulmonary metastasis of breast cancer in 27, and benign condition in 14. In a patient with a known extrathoracic malignancy and a solitary pulmonary nodule on the CT scan, the following scenarios have been proposed: Malignant lesions account for 3-10% of CT scan–detected pulmonary nodules. In an older patient, a solitary nodule is more likely to be malignant (lung cancer, in particular); in a younger patient, multiple nodules are more likely to be metastases European Journal of Surgical Oncology, Volume 33, Issue 5, June 2007, pp 546-550 With a history of sarcoma or melanoma, the pulmonary nodule is more likely to be a metastasis In the case of underlying head and neck cancer or breast cancer, a second primary cancer in the lung is more likely With other malignancies, the nodule is equally likely to be a primary lung cancer or metastatic disease Bascom, R. (2006). Secondary Lung Tumors. www.emedicine.com
SURVEILLANCE Solitary Pulmonary Nodule in the Patient with Breast Cancer A solitary pulmonary nodule (SPN) appearing in a patient with breast cancer, either past or present, is most likely to be a second primary cancer originating in the lung rather than a metastasis from the breast cancer. • Patients with breast cancer with SPNs should have a diagnostic workup appropriate for lung cancer (In a study conducted among 1416 breast cancer patients, 42 had a solitary pulmonary nodule either at the time of presentation of their breast cancer or during the follow-up period, Fifty-two percent of the solitary pulmonary nodules proved to be a primary lung tumor, 5% proved to be benign lesions, and only 43% proved to be metastatic breast cancer.). • Since adenocarcinoma has become the most common lung cancer cell type, the usual diagnostic tests may not allow a firm differentiation between primary lung and secondary breast cancer. Therefore if malignancy is proved or suspected, thoracotomy with appropriate resection is the treatment of choice in most patients with breast cancer, even at the initial appearance of the breast cancer. www.emedicine.com
Stress • Uncertainty of the future • Unpredictability of the cancer • Disability • Financial difficulties • Physical appearance • - after mastectomy • - hair loss due to chemotherapy • - skin changes due to radiotherapy • Reduce Stress • Keep a positive attitude • Be assertive instead of aggressive - "Assert" feelings, opinions, or beliefs instead of becoming angry, combative, or passive • Exercise regularly • Eat well-balanced meals • Keep Track of Medical Information • Make use of resources and support services offered by the hospital and community • Learn more about breast cancer to help patient feel more comfortable with treatment BioPsychoSocial Aspect
Thank you! tubal.tuliao.umag.uy.valencia.verde.villanueva.vizconde.wee.wylengco.zapanta || hLPS
RIBBON STUDY The Ribbon 1 Study is seeking approximately 1000 patients over age 18 with metastatic breast cancer who have not previously received chemotherapy for this disease. Individuals who have received chemotherapy prior to being diagnosed with metastatic breast cancer may be eligible for the study as long as they have not been treated with chemotherapy since that diagnosis of metastatic breast cancer. The study will evaluate the safety and effectiveness of bevacizumab, an investigational compound, when combined with chemotherapy, compared to chemotherapy alone, in individuals who have not been previously treated with chemotherapy for metastatic breast cancer. Individuals participating in the study will be randomly assigned to one of two treatment groups: * One group will receive bevacizumab in combination with the standard of care chemotherapy treatment. * One group will receive placebo in combination with the standard of care chemotherapy treatment. Note: The chemotherapy treatment used in both groups is considered the standard of care for metastatic breast cancer. Study participants will be given bevacizumab or placebo once every three weeks until their disease progresses or they experience unacceptable toxicity. The maximum treatment period with bevacizumab is 24 months.
