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Case Study 63: Cancer of the Female Breast

Dec 21, 2019

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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

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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 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 • 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

Grading tumors Nuclear (size/shape) Score 1: little variation in size Score 2: moderate variability, open vesicular nuclei Score 3: lots of variability open nuclei Mitotic Score 1: <7 mitoses Score 2: 8-14 mitoses Score 3: >14 mitoses Tubular differentiation Score 1: > 75% glandular/tubular Score 2: 10-75% glandular/tubular Score 3: < 10% Glandular/ tubular

Staging Cancer • agrdjdytydstasf Stage 0: No Cancer Stage I: IA: Cancer is small, low grade and localized IB: Cancer is large, low grade and localized Stage II: IIA: Tumor is 2-5cm but has not spread IIB: 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

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Case Presentation on Locally Advanced breast Cancer

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Social Work: The Baylor College of Medicine Division of Continuing Professional Development (License Number 7270) is an approved continuing education provider for Social Workers through the Texas State Board of Social Worker Examiners. This activity has been approved for 1 continuing education unit.

Maintenance of Certification (MOC) Recognition Statement: Successful completion of this CME activity, which includes participation in the evaluation component, enables the participant to earn up to 1.0 Part II MOC points in the American Board of Internal Medicine’s (ABIM) Maintenance of Certification (MOC) program. It is the CME activity provider’s responsibility to submit participant completion information to Accreditation Council for Continuing Medical Education (ACCME) for the purpose of granting ABIM MOC credit.

By signing in, you give Baylor College of Medicine permission to share your participation information/completion data with the specialty board referenced above through the ACCME Program and Activity Reporting System (PARS). Your MOC credit equates to the number of CME credits claimed for the activity and pending completion of the post-test with a minimum passing score of 70%. You can access your MOC credit(s) through the ABIM website at www.abim.org.

Activity Director

Benjamin leon musher, m.d., disclosure policy.

Baylor College of Medicine (BCM) is accredited by the Accreditation Council for Continuing Medical Education (ACCME) to provide continuing medical education (CME) for physicians. BCM is committed to sponsoring CE activities that are scientifically based, accurate, current, and objectively presented.

In accordance with the ACCME Standards for Commercial Support, BCM has implemented a mechanism requiring everyone in a position to control the content of an educational activity (i.e., directors, planning committee members, faculty) to disclose any relevant financial relationships with commercial interests (drug/device companies) and manage/resolve any conflicts of interest prior to the activity. Individuals must disclose to participants the existence or non-existence of financial relationships at the time of the activity or within 24 months prior.

In addition, BCM has requested activity faculty/presenters to disclose to participants any unlabeled use or investigational use of pharmaceutical/device products; to use scientific or generic names (not trade names) in referring to products; and, if necessary to use a trade name, to use the names of similar products or those within a class. Faculty/presenters have also been requested to adhere to the ACCME's validation of clinical content statements.

BCM does not view the existence of financial relationships with commercial interests as implying bias or decreasing the value of a presentation. It is up to participants to determine whether the relationships influence the activity faculty with regard to exposition or conclusions. If at any time during this activity you feel that there has been commercial/promotional bias, notify the Activity Director or Activity Coordinator. Please answer the questions about balance and objectivity in the activity evaluation candidly.

All of the relevant financial relationships listed for these individuals have been mitigated.

Disclosures

The following individual(s) has/have reported financial or other relationship(s) with commercial entities whose products/services may relate to the educational content of this activity:

Disclosure:

• Research Support: Merck
• Consultancy: Arimex; Gnubiotics

Planning Committee Members

Tannaz armaghany, m.d..

Nothing to disclose.

Ernest Ramsay Camp, M.D., FACS

Shalini makawita, m.d., m.sc., george van buren, ii, m.d., facs, health topics.

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