Breast Conference 7/13/2011

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• 51 AAF presenting with abnormal mammogram

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• Menarche: 12 y • G1P1 (40y), breastfeeding: none• OCP: none• HRT: none• Premenopausal

• Hx breast bx: none • Hx breast Ca: none• Fhx: aunt – breast ca, father – prostate ca, grandmother – colon ca• Shx: caffeine(-), soy(-), tobacco(-), ETOH(-)• Bra: 40DD

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• PMH: none • PSH: none• Meds: Lorazepam• NKDA

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• PE:– Right breast:

no masses, no skin changes– Left breast:

hard mass 12:00, diameter 2cm– Left axillary lymphadenopathy

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• Radiology:– Screening mammogram: lt. breast asymmetry,

enlarged LN– Diagnostic mammogram: lt. breast nodular

densities, enlarged LN– US: lt. breast 0.9*0.8*0.8cm lesion, 1.9*1.1*1.5cm

axillary LN– MRI: lt. breast 11-12:00, 1.1*2.2*1.1cm lesion,

axillary adenopathy– PET/CT: lt. breast and axillary hypermetabolic

activity

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• Pathology:– Breast lesion: Invasive Ductal Carcinoma, grade 3

ER(-) PR(-), HER2(+1)– Axillary lesion: metastatic Ductal Carcinoma

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• Clinical stage IIb: T2N1M0

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• Surgery – lumpectomy + ALND• Medical oncology – • Radiation oncology – • Plastic surgery – • Genetics – • Psychosocial –

• First mention in publication – Oct 2005• Mostly Basal-like carcinoma, but also Claudin low and

Normal-like• Basal-like: triple negative + CK5 or EGFR

• 15% of invasive Breast Carcinoma• High grade, larger• More likely to be node negative• Young, African American and Hispanic women• Earlier menarche, higher BMI, higher parity, lower

duration of breast feeding• Adverse prognosis• Distant relapse is uncommon after 3-5 years from

diagnosis

• Breast tumors are heterogeneous• Cells of origin of different tumors correspond with

normal mammary cells in the differentiation path

• Triple Negative tumors possess phenotypic characteristics of mammary stem cells

• Basal-like carcinoma probably arises from luminal progenitor cells, which express both luminal and basal markers

Visvader, 2009

• >75% of tumors in BRCA1 pts are Triple Negative, Basal-like or both

• Tumors in women with BRCA1 mutation have similarities in morphology and gene expression with Basal-like cancer

• Rapid growth• Over-represented in

woman with interval cancers

• More likely to recur locally than ER+ cancer

• Treatment:– Patients do not benefit from endocrine therapy

– No specific chemotherapy

– Use of targeted agents is investigated – bevacizumab, cetuximab , PARP inhibitors

Multidisciplinary Breast Cancer Conference

Laleh Amiri

7-13-2011

Case CB• 48 y/o f.• 1/18/2011 screening mgm : calcifications in both

breasts + a mass in the L breast. • 4/5/2011 diagnostic mgm & US with comparison

to old films: 2 new clusters of calcifications in the LUI Q @3:00 & 10:00 + cyst.

• 5/6/11 stereotactic bxs :sclerosing adenosis and calcifications + focal atypical lobular hyperplasia in 3:00 bx site.

• 6/21/11 excisional biopsy: focal ALH.

• All: Gluten• Med: MVI• PMH: h/o depression. vitamin D deficiency. • PSH: Cholecystectomy, rhinoplasty,

hemorrhoidectomy• GynHx:G1P1, first birth @38, 1st menstrual

period:13, OCP <1y, LMP 6/23/11. • FHx: PGM BC 60s. 1st cousin with mBC 40s. • SoHx: Born in Ireland. Married,8 y/o son.

lives in Rockville. works for FDA. Drinks rarely. Never tob.

• ROS: negative• Ph/EX: negative

Questions

• Does she really have ALH?

• Was excisional biopsy necessary?

• What is her risk for developing IDC?

• Management of ALH?

• Role of MRI for screening?

Questions

• Does she really have ALH?

• Was excisional biopsy necessary?

• What is her risk for developing IDC?

• Management of ALH?

• Role of MRI for screening?

Breast J. 2007 Jan-Feb;13(1):55-61.

Breast J. 2007 Jan-Feb;13(1):55-61.

Questions

• Does she really have ALH?

• Was excisional biopsy necessary?

• What is her risk for developing IDC?

• Management of ALH?

• Role of MRI for screening?

Questions

• Does she really have ALH?

• Was excisional biopsy necessary?

• What is her risk for developing IDC?

• Management of ALH in premenopausal woman?

• Role of MRI for screening?

NSABP P1

Fisher J Natl Cancer Inst, 2005

NSABP P1

Fisher J Natl Cancer Inst, 2005

Fisher J Natl Cancer Inst, 2005

Benefits and risks associated with tamoxifen use for breast cancer riskReduction.

NSABP P1

NSABP P1

Fisher J Natl Cancer Inst, 2005

Questions

• Does she really have ALH?

• Was excisional biopsy necessary?

• What is her risk for developing IDC?

• Management of ALH?

• Role of MRI for screening?

American Cancer Society Guidelines

CA Cancer J Clin 2007;57:75–89

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