SYB Case 2

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SYB Case 2

• By Amy

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History

• 63 y/o female
• History of left breast infiltrating duct
  carcinoma s/p mastectomy in 1996 and chemotherapy
• ER negative, PR negative, HER-2/Neu negative

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Focal opacity in the right anterior lung base and
small opacity in the left lateral lung base -
likely atelectasis but cannot r/o metastases
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nodule in the left upper lobe - increased in size
nodule in the left upper lobe - decreased in size
Interim decrease in size in all but one
metastatic lung nodules.
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Surgical clips in left axilla
Left sternal lesion with increased sclerosis
Lesions involving anterior aspect of the left
second and third ribs are slightly more prominent
on this exam
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Stable to slightly smaller size of mediastinal
lymph node
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Breast Cancer

• Most common female cancer in the U.S.
• Infiltrating ductal most common type (70-80)
• Second most common cause of cancer death in women
• Main cause of death in women ages 45-55

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Most common sites of metastasis

• Bone most common, particularly the spine, ribs,
  pelvis, proximal long bones, and skull
• Liver
• Lungs
• Brain
• Subcutaneous tissues

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TNM Breast Cancer Staging

• Primary tumor (T)
• TX  Primary tumor cannot be assessed
• T0  No evidence of primary tumor
• Tis  Carcinoma in situ
• T1  Tumor 2 cm or less in greatest dimension
• T2  Tumor more than 2 cm but not more than 5 cm
  in greatest dimension
• T3  Tumor more than 5 cm in greatest dimension
• T4  Tumor of any size with direct extension to
  (a) chest wall, (b) skin, (c) both chest wall and
  skin, or (d) inflammatory carcinoma
• Regional lymph nodes (N) Clinical classification
  
• NX  Regional lymph nodes cannot be assessed (eg,
  previously removed)
• N0  No regional lymph node metastases
• N1  Metastasis to movable ipsilateral axillary
  lymph nodes
• N2  Metastasis to ipsilateral axillary lymph
  nodes, or in clinically apparent ipsilateral
  internal mammary nodes in the absence of evident
  axillary node metastases
• N3  Metastasis to ipsilateral infraclavicular
  lymph nodes with or without clinically evident
  axillary lymph nodes, or in clinically apparent
  ipsilateral internal mammary lymph node(s) and in
  the presence of clinically evident axillary lymph
  node metastases, or metastasis in ipsilateral
  supraclavicular lymph nodes with or without
  axillary or internal mammary nodal involvement

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TNM Staging contd.

• Regional lymph nodes Pathologic classification
  (pN) - Classification is based upon axillary
  lymph node dissection /- sentinel lymph node
  dissection.
• pNX  Regional lymph nodes cannot be assessed
  (eg, previously removed, or not removed)
• pN0  No regional lymph node metastasis no
  additional examination for isolated tumor cells
  (i.e. single tumor cells or small clusters not
  greater than 0.2 mm, usually detected only by
  immunohistochemical or molecular methods but
  which may be verified on hematoxylin and eosin
  stains)
• pN1  Metastasis in 1 - 3 ipsilateral axillary
  lymph nodes and/or in internal mammary nodes with
  microscopic disease detected by sentinal lymph
  node dissection but not clinically apparent
• pN2  Metastasis in 4 - 9 axillary lymph nodes or
  in clinically apparent internal mammary lymph
  nodes in the absence of axillary lymph nodes
• pN3  Metastasis in 10 or more axillary lymph
  nodes, or in infraclavicular lymph nodes, or in
  clinically apparent ipsilateral internal mammary
  lymph nodes in the presence of one or more
  positive axillary nodes or in more than three
  axillary lymph nodes with clinically negative
  microscopic metastasis in internal mammary lymph
  nodes or in ipsilateral supraclavicular lymph
  nodes
• Distant metastasis (M)
• MX  Distant metastasis cannot be assessed
• M0  No distant metastasis
• M1  Distant metastasis

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Stage Groupings by TNM Classification

• Stage 0  Tis N0 M0
• Stage I  T1 N0 M0 (including T1mic)
• Stage IIA  T0 N1 M0 T1 N1 M0 T2 N0 M0
• Stage IIB  T2 N1 M0 T3 N0 M0
• Stage IIIA  T0 N2 M0 T1 N2 M0 T2 N2 M0 T3 N1
  M0 T3 N2 M0
• Stage IIIB  T4 Any N M0
• Stage IIIC  Any T N3 M0
• Stage IV  Any T Any N M1

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Metastatic work-up

• Physical Exam - skin, breasts, lymph nodes, and
  abdomen
• Diagnostic bilateral mammography (/- ultrasound)
• Blood tests CBC, LFTs
• Chest imaging
• CT scanning of the liver and pelvis and
  radionuclide bone scans have a low diagnostic
  yield in women with early stage (TI-II N0-I)
  breast cancer and are not routinely necessary
• Chest CT is performed for radiation planning in
  women, but is not necessary for routine staging
  of the thorax in women with early stage disease
• Staging CT of the abdomen and pelvis and a
  radionuclide bone scan is more likely to
  influence therapy in patients with stage III
  disease and are therefore recommended in these
  patients

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Management of Metastatic Breast Cancer

• Relapses are most common in the initial 5 years
  after treatment for early stage disease, but can
  occur up to 30 years later
• Prognostic factors include the interval between
  initial therapy and relapse, number of metastatic
  sites, presence/absence of visceral involvement,
  age and stage at diagnosis, and hormone receptor
  status
• Patients with metastases are unlikely to be cured
  of their disease by any means
• Complete remissions from chemo are uncommon
• Serial plain radiographs, CT scans, or MRI allow
  assessment of tumor response
• Plain radiographs showing sclerosis of previously
  lytic lesions is highly indicative of response,
  while enlargement of the lytic area suggests
  progression
• In pts with mainly sclerotic lesions, serial
  plain films are less helpful because the healing
  cannot be observed

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References

• UpToDate all accessed 1/25/09
• Hirsch, A., et al. Management of locoregional
  recurrence of breast cancer after breast
  conserving therapy.
• Bleiweiss, I. Pathology of breast cancer The
  invasive carcinomas.
• Esserman, L., and Joe, B. Diagnostic evaluation
  and initial staging work-up of women with
  suspected breast cancer.
• Hurria, A., and Come, S. Follow-up for breast
  cancer survivors Recommendations for
  surveillance after therapy.
• Hayes, D. General principles of management of
  metastatic breast cancer.