Clinical Case 2: High-Risk Early-Stage HR+ Breast Cancer

Transcript:

Rachel Layman, MD: Let’s switch gears and talk about another case. I have a patient who is a 42-year-old premenopausal woman who presents to the clinic to discuss the management of screen-detected right breast cancer. She has an ECOG performance status of 1. Her past medical history is only significant for GERD [gastroesophageal reflux disease] and environmental allergies. Past surgical history, [was] just a tonsillectomy as a child. On gynecologic history, she is G2 P2 [gravida 2, para 2] and her first pregnancy was at age 27. She had menarche at age 13. She is not on oral contraceptives at the time but has been on them for about 12 years in the past. On family history, her paternal grandmother had breast cancer diagnosed at age 73. By the time the patient has seen you in clinic, she had already had genetic testing and this was negative for mutations. On social history, she’s married, she does not smoke, and she drinks about 1 alcoholic beverage per week. Her medications are just as-needed medications of famotidine or Claritin as needed, and she has no known drug allergies.

She had a gonadal biopsy of a suspicious lesion in the upper outer quadrant of the right breast that was detected on her screening mammogram. The biopsy revealed a grade 2 invasive ductal carcinoma with associated DCIS [ductal carcinoma in situ]. The estrogen receptor was 95%, progesterone receptor 60%; HER2 was negative, 1+ by IHC [immunohistochemistry]. The Ki-67 was 20%. On physical exam, she had some subtle thickening but not a distinct mass in the upper outer quadrant of the right breast. There was also a well-healed biopsy site. You could palpate 1 palpable right axillary lymph node; it was about 1 cm. She did have a prior ultrasound of the breast and axilla. The left side was unremarkable. On the right side, there was a hypoechoic mass located at 10 o’clock, measuring approximately 4 cm by 4 cm with associated microcalcifications. The breast was heterogeneously dense. There was 1 suspicious axillary lymph node identified that measured 1.2 cm by 1 cm.

Given this, ultrasound-guided fine needle aspiration of the right axillary lymph node was performed, and this was positive for carcinoma. When she saw you, she had already had surgery. She had a right breast lumpectomy and axillary lymph node dissection. This revealed grade 2 invasive ductal carcinoma associated with intermediate-grade DCIS. The invasive component measured 3.6 cm. The margins were widely negative by greater than 1 cm for both the invasive and in situ carcinoma. Three of the 14 lymph nodes are positive for carcinoma and the largest focus was 1.1 cm. There was no extranodal extension. Her AJCC [American Joint Committee on Cancer] anatomic stage was IIB T2NI.

Transcript edited for clarity.