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3/3/2014
1
Tumor Board with Navigation
Session #53
Moderator: Tina Rizack, MD, MPHWith
Dennis R Holmes, MD, FACSReshma Jagsi, MD
Jessica Lapise, MS, CGCGary Levine, MDWilliam Sikov, MD
Heather Coelho, RN, BSN, OCN, CBPN‐IC
Case #1
• 42 year old female with an extensive family history of breast cancer
– PMH: negative
– G1P1 (10 yo old son)
– OCPs age 16‐20 and then 21 to 35
– Family history;• Paternal grandmother with bilateral breast cancer in 50s and ovarian cancer age 66
• Paternal great aunt breast cancer in 50s, died in 60s– Daughter with premenopausal breast cancer
• Paternal aunt with bilateral breast cancer (ILC) in 60s– Had BSO due to mother/s history– Known BRCA2 8765delAG
• Father died age 50: renal cell cancer 40s and lung cancer• Paternal uncle age 70: melanoma age 49
– BRCA2 mutation diagnosed 7/2011 with site specific testing done by ob/gyn
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Case #1
• BRCA management
– BSO 2012
– Breast MRI 2012: negative
• Desires prophylactic mastectomy
• Mammogram pre‐op
Breast MRI
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Case #1 mammogram
Biopsy
• ADH
• She undergoes a bilateral nipple sparing mastectomy with immediate reconstruction
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Pathology
• Left breast:
– Grade 2 IDC measuring 0.4 cm
– ER 76‐90% strong / PR neg <1%
– HER‐2 neu 3+
– DCIS and ADH
• Right breast: benign
• Left axillary FNA: negative
• Undergoes 12 weeks of chemotherapy with TH with 9 more months of herceptin
Case #2
• 34 year old female• Self palpated mass in left breast
• PMH: – Idopathic lymphedema of LLE with intermittent swelling
– Exercise induced asthma
• Social: married, physician.• GynHx: GO and desires fertility
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• Family hx:
– Paternal aunt with breast cancer in her 40s
– PGM died 50s unknown causes
– Maternal GM breast cancer in 70s
Case #2 imaging
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Ultrasound
MRI
Case #2 biopsy
• Ultrasound guided biopsy
• IDC grade 3 no DCIS no LVI
• ER >90% strong/PR+ 76‐90% strong
• HER2 2+ FISH negative, ratio1.22
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• Referred to REI
– Develops ovarian hyperstimulation syndrome
– Suffers a LLL PE started on anticoagulation
– BRCA negative
• Completes neoadjuvant therapy with TC
• What surgery would you recommend?
• Bilateral nipple spearing mastectomy with SLN biopsy
– Right breast benign
– Left 1.2 cm residual IDC with close margin <0.5 mm grade 2 +LVI
– Repeat HER2 is 3+
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• Surgery– Bilateral nipple sparing
mastectomy– Left sentinel lymph node
biopsy– Pathology:
• Right breast benign• Left
– 1.2 cm IDC– Grade 2– No LVI– Negative margins– DCIS 1.5 cm, grade 3 – Posterior margin 0.5 mm
• Stage ypT1cN0• HER2 repeated according to new
CAP guidelines– 3+
Case #3
• 54 year old male with a right palpable breast mass– PMH: clear cell renal cell cancer s/p right nephrectomy2006DMIIHTNRemoval of a skin cancer from his leg (SCC)asthmasleep apneadivericulitis s/p segmental colon resectionMorbid obesity 450#
– PE: 4‐5 cm mass above the nipple‐areolar complex at 12 ‘clock
• Family History:
– Sister with uterine cancer in 40s, 7 other siblings with no cancer
– Father had brain tumor
– Patient with 3 daughters
– Puerto Rican decent
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Genetics Consult
• BRCA 1 and 2 negative
• Insurance would not cover BART
Mammogram
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Ultrasound
Surgery
• Mastectomy SLN biopsy
– pT1cN0
• 1.5 cm
• Grade 2
• 0/3 positive nodes
• DCIS grade 2
• Negative margins
• No LVI
• Pt started on tamoxifen
• Tolerated well
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Case #4
• 35 yo G2P2 currently lactating– Pumps breast milk for 17 month old and self palpated a mass in her left breast
– PMH: • kinked aorta and palpitations
• History of C. difficle in 2002
• Jehovah’s witness
– GynHx: menses 13, OCPs age 19‐21 and 23‐28, 1st
child at 30, breast feed both for ~1.5 years
– Family history• Maternal aunt with breast cancer in her 60s
• PE: 4 x 4 cm mass in left breast
Mammogram
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Ultrasound
MRI
Biopsy
• IDC grade 3
• No LVI
• ER/PR/HER2 negative
• DCIS
• FNA axillae
– Positive
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Neoadjuvant Treatment
• Treated on CALGB 40603: standard arm• Bilateral mastectomy and left axillary dissection with expanders
– Develops post op hematomas requiring removal of expanders and evacuation of clot
– Severe anemia
• Final pathology: ypT1aN2a– 1 mm focus of IDC in left breast – Extensive LVI and tumor emboli– DCIS grade 3, 1.5 cm– Negative margins– 4/8 positive nodes
• Largest 1 cm• Extracapsular extension
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