Vamsee Torri, MD

A 43-year-old woman was referred to our hospital with history of left breast multifocal ductal carcinoma in situ for which she underwent bilateral mastectomy and reconstruction in 2006. Her family history was significant for breast cancer: Her sister was diagnosed at age 38, maternal aunt at age 36 and maternal cousin at age 25. All died from metastatic disease. She was positive for BRCA2 mutation, at which time she opted for left mastectomy and prophylactic right mastectomy. She now presents with palpable mass in the left axilla and underwent an FNA of the mass, which showed moderate cellularity composed of polymorphous population of lymphocytes, predominately small lymphocytes, with no evidence of malignant cells. She later underwent an ultrasound of the left axilla that showed a 2.7 cm × 2.2 cm × 0.9 cm lobulated mass representing lymph node with an echogenic fatty hilum.

A 54-year-old woman was initially diagnosed with left breast cancer 11 years ago. Based on left lumpectomy, axillary lymph node dissection and imaging she was staged as cT2N1M0. Her tumor was ER/PR negative and HER2-neu low. She received adjuvant chemotherapy with doxorubicin and cyclophosphamide followed by paclitaxel. She received radiation to left breast, supraclavicular and intramammary lymph nodes.

A 55-year-old woman presented to our center for restaging PET/CT. Her history was significant for recurrent breast cancer in the mediastinum and lungs. She initially underwent left mastectomy, adjuvant chemotherapy and radiotherapy. She was started on palliative chemotherapy. Her initial staging PET/CT showed subcentimeter medistinal lymph nodes (maximal SUV 8.4), right lower lobe mass 1.4 × 1.2 cm (SUV 5.3), scattered subcentimeter nodules in the lung. Her restaging scan with a PET/CT after chemotherapy showed progressive disease with right axillary lymph nodes measuring 1 cm (SUV 2.0), medistinal lymph nodes measuring 1 cm (SUV 3.6 to 10.1), right lower lobe mass measuring 2.1 × 1.4 cm (SUV 7.1), relatively stable pulmonary nodules and new left pleural effusion.

A 76-year-old woman was referred to oncology with new palpable left axillary lymph node. Her past medical history was significant for marginal zone lymphoma that was diagnosed in 1999 (received chemotherapy), hypertension and type 2 diabetes. Her ECOG performance status was 2 and physical exam was significant for 1.5 cm left axillary lymph node. Her labs showed white blood cell count of 5.9, hemoglobin of 13.4, platelets of 232, Bun/Cr 22/0.9 and LDH 574.

A 68-year-old woman initially presented with intermittent abdominal pain and persisting left hip pain. She gave a history of early breast cancer and completed five years of tamoxifen one year ago. Her pertinent positive physical exam finding was decreased range of motion of the left hip. A CT chest/abdomen/pelvis showed an anterior mediastinal mass, multiple liver lesions, lytic and blastic lesion of the left 12th rib and multiple lytic lesions of the thoracic and sacral vertebrae. On bone scan, there was uptake in the left 12th rib and left sacroiliac joint (figure 1). A mammogram was negative. A biopsy of the liver lesion revealed an adenocarcinoma, ER-positive, PR-negative and HER2-neu negative. The patient was started on letrozole and zoledronic acid. Eight months later, the CT of the chest/abdomen/pelvis showed progression with increasing size of the mediastinal mass and number of liver metastases. Bone scan showed an interval response. She was started on fulvestrant (Faslodex, AstraZeneca) and noted to have stable disease three months later by tumor markers and PET/CT. Her skeletal system findings on PET/CT were hypermetabolic left 12th rib lesion with a standardized uptake value of 3.6 and hypermetabolic lytic sacral lesion with a standard uptake value of 4.1 (figures 2 and 3, top rows). Five months later, she experienced left forearm pain and there were increasing tumor markers. An X-ray of the forearm was negative and a bone scan showed stable disease in the left 12th rib and left sacrum with no evidence of metastatic disease in the left upper extremity (figure 1). Her skeletal system findings on PET/CT were left 12th rib lesion with a standard uptake value of 6.9 and lytic sacral lesion with a standard uptake value of 8.3 (figure 2 and 3, bottom rows), consistent with progression. Concordant with progression of skeletal metastatic disease, there was progression of mediastinal lymphadenopathy on both PET and CT (figure 4).

A 37-year-old woman was diagnosed with bilateral synchronous invasive lobular breast cancer, ER/PR-positive and HER-2/neu negative. Her initial mammogram showed a 2.5-cm mass in the left breast and 1.5-cm axillary lymph node. On PET/CT there was 2.3-cm left subareolar enhancing mass with an standardized uptake value of 7.7, 1.5-cm left axillary lymph node with an standardized uptake value of 5.3 with no evidence of distant metastasis. MRI breast showed 3.5 × 3.5 cm, 1 × 0.8 cm and 1.3 cm masses in the upper outer quadrant of left breast and 3.5 × 2 cm mass in the upper inner quadrant of right breast. The patient received neoadjuvant chemotherapy with four cycles of dose-dense doxorubicin and cyclophosphamide followed by four cycles of dose-dense paclitaxel with good clinical response.

A 40-year-old woman presented to our hospital with a painless right axillary mass with duration of two months. Her history included stage IIA right breast cancer diagnosed 18 months prior. She underwent mastectomy and sentinel lymph node sampling followed by immediate transverse rectus abdominis muscle reconstruction. The tumor was a multifocal, moderately differentiated infiltrating lobular carcinoma with extensive ductal carcinoma in situ, and nonsentinel lymph node from the right axillary tail of the breast was positive for macrometastasis. The tumor was ER-positive, PR-positive and HER-2/neu-negative. She received adjuvant chemotherapy with four cycles of dose dense doxorubicin and cyclophosphamide and is currently on adjuvant hormonal therapy with tamoxifen.