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Challenging Cases from the USC Multidisciplinary Breast Conference

Challenging Cases from the USC Multidisciplinary Breast Conference. Stephen F. Sener MD Christy 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.

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Challenging Cases from the USC Multidisciplinary Breast Conference

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  1. Challenging Cases from the USC Multidisciplinary Breast Conference Stephen F. Sener MD Christy A. Russell MD Session II: Challenging Cases

  2. CS • 41F Palpable L breast mass x 2 months

  3. 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

  4. 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

  5. 9/01/2010

  6. 9/01/2010

  7. 10/28/2010 CT CAP

  8. Clinic Photo

  9. Clinic Photo

  10. 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

  11. Path Photo

  12. Path Photo

  13. Path Photo

  14. CS • 41F L breast IDCA with axillary mets • Genetics • L MRM vs Neoadj (1071 Trial?)

  15. 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

  16. 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

  17. CS • In addition to planned radiation therapy and eventual BSO, would you offer further adjuvant systemic therapy? • Yes. Change chemotherapy to include a platinum agent • Yes. Change chemotherapy, but give another regimen without a platinum agent • No. Watch for metastatic cancer.

  18. 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.

  19. 5/12/2012 CT CAP

  20. 5/12/2012 CT CAP

  21. Challenging Cases from the USC Multidisciplinary Breast Conference Stephen F. Sener MD Christy A. Russell MD

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

  23. 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

  24. RN on 9-12-11.

  25. RN on 9-12-11.

  26. RN PMH: none PSH: C-section x1 Med: none • FHx: • Non-contributory • Gynhx: • G3P3 • First pregnancy at 28 • Menarche 14 • Premenopausal

  27. 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 +

  28. 8/16/11 MMG Extremely dense breasts

  29. 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

  30. 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 5 1.7 x 0.9 x 1.2 cm mass in L central breast,BIRADS 4C 1.3 x 1.8 x 0.9 cm mass in L breast @ 3:00, BIRADS 4C 8 mm cyst in R breast @ 2:00, BIRADS 2 abn LN in L axilla BIRADS 4B

  31. RN  Pathology 1 of 4

  32. RN  Pathology 2 of 4

  33. 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.

  34. CTPA 10/12/2011

  35. RN • 40F with multifocal L breast inflammatory CA • Stage cT4dN1M1, ER-/PR-/Her2+.

  36. HER-2+ Inflammatory Breast Cancer M1 • What systemic therapy would you offer this patient? • Trastuzumab + taxane • Trastuzumab + capecitabine • TCH • AC TH • Trastuzumab + lapatinib • Trastuzumab + pertuzumab + docetaxel

  37. 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.

  38. RN on 6-23-12.Local Treatment

  39. CTPA 10/12/2011 CT CAP 6/09/2012

  40. IBC, HER-2+, M1 • What course of treatment would you consider next? • Mastectomy + continue trastuzumab • Continue trastuzumab and add breast XRT • Continue trastuzumab until progression • Continue trastuzumab and add additional chemotherapy

  41. 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.

  42. IBC, HER-2+, M1 Would you offer chest wall and extended nodal radiation? • Yes • No

  43. Challenging Cases from the USC Multidisciplinary Breast Conference Stephen F. Sener MD Christy A. Russell MD

  44. 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.

  45. 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

  46. AG

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