Breast Cancer Clinical Case Review

In this video, Coral Omene, MD, PhD, assistant professor of medicine at Rutgers Robert Wood Johnson Medical School, and program director of Breast Cancer Disparities Research in the division of medical oncology at Rutgers Cancer Institute of New Jersey, presents the baseline characteristics of the case.

Editor’s note: The following is an automatically generated transcript of the above video.

“So we know that breast cancer is the most common cancer among women other than skin cancer. About 10 to 15% of all breast cancers are triple-negative. Triple-negative, meaning that the tumors do not express the estrogen receptor, the progesterone receptor, or HER2, which stands for human epidermal growth factor receptor 2 Triple-negative, this subtype of breast cancer happens to be more prevalent among young women of African descent. It is notable that it has aggressive clinical behavior and as such, it has a poor prognosis compared to other subtypes. In fact, the overall five-year relative survival rate for triple-negative breast cancer is about 77% for early stage, 91% survival rate for node negative population, while 65% for node positive population. And while the metastatic disease survival can be as low as 12%, the recurrence rate after surgery is high and can be as high as 25% with a median survival time after metastases of about 13.3 months.

So I'm gonna segue onto our patient case. Once again, this is early-stage triple-negative breast cancer. This patient presented at age of 53. She was postmenopausal. She had no significant medical history except for high blood pressure and anxiety. Of note, she hadn't had any screening mammograms prior to presentation until she self-palpated a mass in her right breast. She denied any associated pain, nipple discharge, or skin changes. On physical exam, it was notable for about a four-centimeter, firm mass at the upper inner quadrant of the right breast. There was no nipple retraction or skin changes. Now what is the workup that one would do when presented with such a patient?

So according to the NCCN, the National Comprehensive Cancer Network Guidelines which we all use in oncology, the standard workup will include not only the history and physical exam, but imaging including diagnostic bilateral mammogram, an ultrasound as necessary, breast MR, a biopsy with a pathology review, and a determination of the tumor ER/PR/HER2 status, as well as genetic counseling and testing especially if the patient is at risk for a hereditary breast cancer, which is known to be the case for triple-negative breast cancer. There is a significant overlap between the subtype and the tumors that arise from a BRCA 1 or 2 mutation. So this patient underwent the necessary work up. She had a bilateral screening 3D mammogram that showed a concerning mass located in the upper inner right breast. She then had a follow-up right breast diagnostic 3D mammogram and ultrasound, which demonstrated a lobulated mass with associated amorphous calcifications at the one o'clock position measuring about 3.2 by 2.5 by 2.7 centimeters with prominent axillary lymph nodes. Biopsies were recommended given the BIRADS 5.

The patient also underwent a bilateral breast MRI that showed an irregular mass measuring 3.8 by 3.6 centimeters. There was no extension to the pectoralis muscle observed, and, once again, there were noted prominent right axillary lymph nodes. She subsequently underwent an ultrasound guided biopsy of the right breast mass as well as the right axillary lymph node.

The pathology of the breast, after reviewed, demonstrated invasive ductal carcinoma, poorly differentiated, with a Nottingham histological score of three, three, and three, grade three, in a fibrous background with patchy necrosis, occupying about 70% of the biopsy. Biomarker showed ER with 0%, PR with 0%, HER2 immunohistochemistry stained zero. Triple-negative ER, PR, and HER2 negative. The proliferation rate of ki67 was high at over 90% and the axillary node FNA returned as positive.

So given it's locally advanced cancer, she underwent staging imaging scans and according to NCC guidelines, this is recommended, as you can see, that one would want to see additional testing that includes chest, abdomen, pelvic CTs, and bone scans as well as, as we have mentioned before, a breast MRI, which she did receive. But this patient, her bone scan and her CT chest, abdomen, pelvis, were all negative for metastases giving her the stage of clinical T2N1, stage III disease. The other considerations in terms of workup include a brain MRI. This is not typically standard to do as an automatic testing. However, should be considered if a patient has any neurological symptoms.

In this case, this patient was neurologically intact. As was mentioned before, genetic testing is very important for this population because if found to harbor the mutation for BRCA 1 or 2, there are implications for risk reduced in surgery and adjuvant therapy choices in this setting. For this patient, she underwent genetic testing and was negative for the BRCA 1 or 2 mutation.”