Case Study 63: Cancer of the Female Breast

Case Study 63: Cancer of the Female Breast

By Robyn Schwartz

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

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

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

Breast Cancer: What is it?• Uncontrolled division of abnormal cells in the breast• Caused by specific mutations

– BRCA1 and BRCA2– TP53

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

Grading vs Staging • 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

• 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

Grading tumorsMitotic

Score 1: <7 mitosesScore 2: 8-14 mitoses Score 3: >14 mitoses

Nuclear (size/shape)Score 1: little variation in sizeScore 2: moderate variability,

open vesicular nuclei Score 3: lots of variability

open nuclei

Tubular differentiationScore 1: > 75% glandular/tubularScore 2: 10-75% glandular/tubularScore 3: < 10% Glandular/ tubular

Staging Cancer

• agrdjdytydstasfStage 0:

No CancerStage I:

IA: Cancer is small, low grade and localizedIB: Cancer is large, low grade and localized

Stage II:IIA: Tumor is 2-5cm but has not spreadIIB: 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

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

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%

Our Patient: Treatment

• Breast conservation therapy– Lump removal

• Radiation • Lymph node biopsy• Tamoxifen– Estrogen receptor blocker– Helps stop growth of cancer cells

Our Patient: Follow Up

• 6.5 years cancer free• 80 months later, complained of – bone pain in lower back– Headache

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

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

How to Prevent cancer

• Exercise• Eat well• Don’t smoke• Do regular breast self exams– Report anything suspicious immediately

• Check family history