Breast Cancer Clinical Case Review

Deborah Toppmeyer, MD, director of the Stacy Goldstein Breast Center and professor of medicine at Robert Wood Johnson Medical School, 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 let me start with our case. This is a 44-year-old pre-menopausal woman with no significant past medical history who presents for evaluation of new liver lesions found incidentally on imaging performed for evaluation of kidney stones. Her last mammogram was approximately two years ago. However, on physical examination, she was noted to have a new mass in the right breast measuring approximately two centimeters. There was no evidence of hepatomegaly.

Additional work up at this point included a bilateral diagnostic 3D mammogram and ultrasound, which demonstrated and confirmed a lobulated mass in the right breast with associated amorphous calcifications at the one o'clock position measuring approximately 2.1 by 2.3 by 2 centimeters. An enlarged axillary lymph node was also noted. Biopsies were recommended and this was classified as a BIRADS 5. The patient subsequently underwent an ultrasound guided biopsy of the right breast mass. Pathology confirmed an invasive ductal carcinoma, which was moderately differentiated. Tubule formation was three. Nuclear pleomorphism was two, and the mitotic rate was one. The tumor was highly ER positive at 95%, but PR negative and HER2 neu negative as well. KI-67 was moderately increased at 15%. The axillary node FNA was positive for metastatic adenocarcinoma.

Additional work up included a bone scan, which was positive for osseous metastases. The patient subsequently underwent a liver biopsy, which confirmed metastatic breast cancer. Again, I feel it's always very important to confirm the metastatic site that the biomarkers are similar to the primary. And indeed pathology confirmed an adenocarcinoma consistent with the patient's breast primary, that was also estrogen receptor positive at a hundred percent, again, PR negative and also HER2 neu negative.

So let's define different endocrine resistant, sensitive metastatic, HR positive breast cancer. So primary endocrine resistant is defined as relapse within two years of adjuvant endocrine treatment. Secondary endocrine resistant is defined as relapse while on adjuvant endocrine therapy, but after the first two years or relapse within 12 months of completing adjuvant endocrine therapy. And this is about 37% of the population. And then endocrine sensitive is relapsed greater than 12 months after completing adjuvant endocrine therapy or de novo patients.

So the basic principle of treatment of hormone-sensitive metastatic breast cancer, and again, luckily the majority of these breast cancers, about 70% are indeed hormone receptor positive. And endocrine therapy is absolutely the cornerstone of treatment for endocrine responsive metastatic breast cancer, except in the setting of rapidly progressing disease or visceral crisis. Again, the fact that a patient has liver metastases, lung metastases does not preclude starting with the optimal targeted therapy, which in this case would be endocrine therapy. Sequential treatment with endocrine therapy is the fundamental approach.

However, as we all know, resistance eventually occurs requiring at some point a transition to chemotherapy. But ideally, in this patient population, we really wanna stretch out endocrine therapy as long as possible before embarking on chemotherapy. We are fortunate to have quite a few new targeted therapies in our clinical armamentarium, which allows us to really prolong this period where patients do not need chemotherapy."