SYB Case 2 By: Amy

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

Focal opacity in the right anterior lung base and small opacity in the left lateral lung base - likely atelectasis but cannot r/o metastases

nodule in the left upper lobe - increased in size Interim decrease in size in all but one metastatic lung nodules. nodule in the left upper lobe - decreased in size

Left sternal lesion with increased sclerosis Surgical clips in left axilla Lesions involving anterior aspect of the left second and third ribs are slightly more prominent on this exam

Stable to slightly smaller size of mediastinal lymph node

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

Most common sites of metastasis Bone – most common, particularly the spine, ribs, pelvis, proximal long bones, and skull Liver Lungs Brain Subcutaneous tissues

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

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 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 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

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

Metastatic work-up Physical Exam - skin, breasts, lymph nodes, and abdomen Diagnostic bilateral mammography (+/- ultrasound) Blood tests – CBC, LFT’s 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

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

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.